Lone Star Ranch Rehabilitaion and Healthcare Cente

Based on observations, interviews and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 grease traps reviewed in that:<BR/>The grease trap was not being used <BR/>Used grease was disposed of via a plastic bag into the dumpster<BR/>This failure could place residents at risk of infection and vermin from improperly disposed of used grease. <BR/>The Findings were:<BR/>Observation and interview with the DM on 2/22/23 at 9:25 AM revealed no grease traps behind the dumpsters. The DM stated the grease traps stored behind the dumpster had been stolen approximately 1 year ago. When asked how used grease was disposed of, the DM stated, we put it in a plastic trash bag and throw it in the dumpster (the DM demonstrated to this surveyor how this was accomplished, simulating water for grease). The DM stated she had made the MS and the ADM aware of the stolen grease traps a year ago, but nothing had been done about it. The DM also stated she did not follow up with the MS or ADM because she thought they would take care of it. The DM stated she was unaware of any other means of grease disposal.<BR/>Interview with COOK A and COOK B on 02/22/23 at 09:30 AM, both stated they did not know what the procedure was for the disposal of used grease. <BR/>Observation and interview with the ADM on 02/22/23 at 10:30 AM regarding the grease traps stated, we have a grease trap. The ADM showed this surveyor the access point and clean out located in the ground behind the facility for disposal and pick up of used grease. The ADM stated grease was to be poured into the 3-compartment sink which drained into the underground grease trap. The ADM stated she did not know why the kitchen staff responsible for the disposal of used grease were unaware of the procedure. The ADM stated the grease trap had been there for at least a year.<BR/>Record review of the facility policy titled, Sanitization dated 10/2022 stated: The food service area shall be maintained in a clean and sanitary manner. 13) Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #1 and Resident #2) of 2 residents reviewed for medical records.LVN A failed to document a verbal and physical altercation on 10/08/25 between Resident #1 and Resident #2 in a timely manner in Resident #1's progress notes.LVN A failed to document a verbal and physical altercation on 10/08/25 between Resident #1 and Resident #2 in a timely manner in Resident #2's progress notes.LVN B failed to document injury assessments on Resident #1 in a timely manner.RN C failed to document injury assessments on Resident #1 in a timely manner. These failures could put residents at risk of improper care based on inaccurate or incomplete documentation.Record review of Resident #1's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His relevant diagnoses included unspecified dementia with agitation (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with restless behaviors like pacing and rocking, as well as verbal or physical aggression like shouting or combativeness), mood disorder due to known physiological condition with depressive features (a mental health condition characterized by a disturbance in mood (like depression or mania) that is directly caused by a medical or physiological condition), and cognitive communication deficit (difficulty with communication).Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #1's progress notes reflected the following entries:Created date: 10/08/25 at 12:54 PM; Effective date: 10/08/25 at 12:50 PM by the MDS nurse, [PA-C] informed of incident with other resident and gave new order to increase Depakote 125mg PO TID. Order carried out and RP notified and agreed to medication increase. Floor nurse along with DON and Admin made aware of new order.Created date: 10/13/25 at 4:49 PM; Effective date: 10/08/25 at 4:46 PM by LVN A, CN was at nurses station and heard the resident in a verbal altercation with another resident in the hallway. CNA stated this resident was hit with a walker in the face by another resident passing him by. CNA separated both residents to de-escalate the situation. Resident stated, I don't know what happened, but he hit me. CN performed a head-to-toe assessment on the resident for any injuries. Resident had redness to the left eyebrow and under his left eye. Resident stated he had pain to the area. CN administered Tylenol to relieve the pain. RP, DON, ADMN and MD were notified.Created date: 10/15/25 at 4:05 PM; Effective date: 10/10/25 at 4:03 PM by LVN B, The resident with no noted injuries from altercation on 10/08/25, no bruising, nor redness noted to face nor upper body, the resident has no recollection of the incident.Created date: 10/16/25 at 5:24 AM; Effective date: 10/10/25 at 9:21 PM by RN C, No evidence of bruising or redness noted to face, or upper torso present from altercation on 10/08/25. No indication of pain. Continue plan of care.Created date: 10/15/25 at 4:07 PM; Effective date: 10/11/25 at 4:00 PM by LVN B, The resident with no noted bruising nor redness to face nor upper body from altercation on 10/08/25, no c/o of pain voiced denies pain when asked. The resident does not remember anything about the altercation.Created date: 10/16/25 at 5:25 AM; Effective date: 10/11/25 at 8:15 PM by RN C, No evidence of bruising or redness noted to face or upper torso present from altercation on 10/08/25. No indication of pain. Continue plan of care.Created date: 10/15/25 at 4:10 PM; Effective date: 10/12/25 at 1:07 PM by LVN B, The resident does not have any noted bruising nor redness to the face nor upper body from the altercation on 10/08/25, denies pain when asked, no c/o of pain voiced. the resident has no recollection of the altercation.Created date: 10/16/25 at 10:26 PM; Effective date: 10/12/25 at 10:30 PM by RN C, No evidence of bruising or redness noted to face or upper torso present from altercation on 10/08/25. No indication of pain. Continue plan of care.Record review of Resident #2's admission record reflected n [AGE] year-old male admitted to the facility on [DATE]. His relevant diagnoses included Alzheimer's disease with early onset (progressive brain disorder that slowly destroys memory and thinking skills) and unspecified dementia, unspecified severity, with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with behavioral disturbances such as depression, agitation, and wandering).Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #2's progress notes reflected the following entry:Created date: 10/13/25 at 4:51 PM; Effective date: 10/08/25 at 4:50pm by LVN A, CN was at nurses station and heard the resident in a verbal altercation with another resident in the hallway. CNA stated this resident hit the other resident with a walker in the face as he passed the other resident. CNA separated both residents to de-escalate the situation. When asked what happened the resident stated, I am tired of him cussing at me (in spanish). CN performed a head-to-toe assessment on the resident for any injuries. No visible injuries or pain noted at this time. RP, DON, ADMN and MD were notified. CN call MD's office to request an order for a UA and labs. MD agreed STAT. Labs and urine have been collected. Pending results. Resident was placed on a 1:1 monitoring plan.In an interview on 11/26/25 at 3:25 PM, LVN B stated she was told in report about Resident #1 and Resident #2's altercation. LVN B stated, The nurse heard yelling, and she saw [Resident #2] hit [Resident #1] with his walker. [Resident #1] may have Tourette's because he will just be walking down the hall and say curse words. [Resident #2] is sensitive to other's words, so they keep [Resident #1] and [Resident #2] away from each other. LVN B stated she forgot to document the follow ups on 10/10/25, 10/11/25 and 10/12/25. She stated she was off on 10/13 and 10/14 and documented them on 10/15. LVN B stated she was advised the documentation was not done in morning report on 10/15/25. She stated she did the documentation and also told RN C that it needed to be done during report at shift change that evening. LVN B stated if something was not documented, it did not happen. She stated if things were not documented accurately and timely, it could lead to residents not receiving the care they needed. She stated documentation in-services were conducted at least every 3 months, and the last one was in October. She stated when that type of incident occurred, the nurse did a physical aggression-received report for the victim and physical aggression- initiated report in incident/ risk management reports which gave the steps to follow and progress notes were part of those steps. LVN B stated Resident #2 had not had any other incidents of physical aggression.In an interview on 11/26/25 at 4:18 PM, Resident #1 stated he felt safe in the facility and was not afraid of anyone. Resident #1 could not recall ever being hit by anyone or anything.In an interview on 11/26/25 at 4:24 PM, Resident #2 stated he did not remember hitting Resident #1 with his walker. He stated he was friends with Resident #1 and would never hit him. He stated he felt safe in the facility. In a telephone interview on 11/26/25 at 5:10 PM, LVN A stated she did not see the incident happen. She stated she heard something in the hallway, walked toward it, and asked the hospice CNA that was close by what happened. The hospice CNA told her Resident #1 and Resident #2 had a verbal altercation then Resident #2 picked up his walker and smacked Resident #1 in the face with it. LVN A stated she saw a red mark on Resident #1's face. LVN A stated she did put a progress note in, but she did not sign and lock it because she was told the DON needed to see it first. LVN A stated she was off from 10/10/25 to 10/12/25, and on 10/13/25, she went into her progress notes and signed/locked it so it would show up. She did not lock it on 10/08/25 because she was waiting on the DON to read it and approve it. LVN A stated there were no other issues between Resident #1 and Resident #2. She stated Resident #1 cursed and made inappropriate remarks all the time even with redirection. LVN A stated they automatically did an incident report that showed up in progress notes once it was copy/pasted at the end of the incident report. She stated it was important to document things when they happened so that details would not be forgotten and so that others knew what was going on with the resident. She stated she did not recall the last in-service for documentation.In a telephone interview on 11/26/25 at 5:43 PM, RN C stated she was told by the nurse she relieved (LVN B) to go back and make sure there was documentation of Resident #1's injury assessments from the altercation on 10/08/25. RN C stated she was told there was an altercation between Resident #1 and Resident #2, but was not aware Resident #1 had been hit since he did not have any injuries or any changes in behavior. Resident #1 and Resident #2 had not had any altercations prior to or since that incident and staff made sure they were apart. RN C stated it was important to document things so other staff were aware of what was going on with the resident and could provide appropriate care. In an interview on 11/26/25 at 6:05 PM the ADON stated it was important to document incidents accurately and timely to ensure the resident got the care/treatment necessary. The ADON stated when nurses were initially hired, she did a skills check off with them which included documentation. She stated nurse skills were also done annually and as needed. The ADON stated LVN A saved the initial progress note on 10/08/25 but she did not sign it, so it did not show up in the progress notes for that day. She stated annual evaluations and skills check offs were done quarterly. In an interview on 11/26/25 at 6:39 PM, the MDS nurse (who was acting DON) stated it was important to document things as they happened for the safety of the residents, to note interventions, and so other staff were aware of what was going on with the resident. She stated nurses had been educated and in-serviced that they were to document for 72 hours for any issues/incidents. The MDS nurse stated if things were not documented, the resident was at risk of not getting the care they needed. She stated nurses were in-serviced on documentation upon hire, annually, and as needed.Record review of the facility's Policy for Resident Incident and Visitor Accident Report dated 06/05/25 reflected in part: .3. Pertinent documentation must be completed:. d. Nurse Progress Notes. g. Follow up documentation every shift for 72 hours or more frequently if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the right to be free from abuse for two (Residents #2 and #3) of 4 residents reviewed for abuse. <BR/>The facility failed to ensure Resident #2 was free from abuse. On 05/09/25, Resident #1 slapped Resident #2 in the face twice with an open hand because Resident #2 would not give Resident #1 her napkin. <BR/>The facility failed to ensure Resident #3 was free from abuse. On 05/10/25, Resident #1 grabbed Resident #3 ' s arm and slapped it four times with an open hand, once with each word, while she said, I told you so. <BR/>This failure could place residents at risk for abuse and psychological harm. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet dated 06/27/22 with an original admission date of 03/18/22 revealed a [AGE] year-old female with diagnoses including Alzheimer ' s, (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, Diabetes, high blood pressure, major depression, anxiety disorder, and abnormalities of gait and balance. <BR/>Record review of Resident #1's quarterly MDS Assessment, dated 03/15/25, reflected a [AGE] year-old female who admitted on [DATE]. Her BIMS score of 03 indicated the resident had severe cognitive impairment with physical behavioral symptoms such as hitting or scratching occurring 1 to 3 days. She required supervision for oral hygiene and eating, moderate assistance with upper body dressing, and maximal assistance with toileting, showering, lower body dressing, footwear, and personal hygiene. She could walk, reposition herself, and transfer with supervision. She did not utilize a wheelchair or walker. She was frequently incontinent of bladder and bowel. She was taking an antidepressant and insulin. <BR/>Record review of Resident #1's Care Plan dated 07/02/22, reflected Resident #1 had potential to be physically aggressive r/t Dementia, Depression, and Poor impulse control Date Initiated: 01/10/2023 Revision on: 01/10/2023. Resident #1 had a behavior problem r/t yelling, hits, throws things and uses abusive language due to Alzheimer's with poor cognition. RP often will refuse to allow treatment or medications for the behaviors. 05/05/25 altercation with Resident #2. 05/10/25 altercation with Resident #3 Date Initiated: 01/13/23 Revision on: 05/14/25. Resident #1 was placed on 1:1, psyche services contacted, and new orders for medication were received and implemented. 05/10/25 Removed from situation, placed on 1:1, new order for Depakote 125mg twice a day for mood stabilizer. Consent was obtained from the RP when she came in to visit the resident. Date Initiated: 05/10/25. 05/05/25 Resident removed from the situation. Placed on 1:1 observation, social worker trying to get the resident to a local Psych Hospital. <BR/>Date Initiated: 05/06/25. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 01/13/23. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 07/10/22. The resident uses antidepressant medication (Prozac) r/t Depression Date Initiated: 07/10/22 Revision on: 10/31/22. She resided in the memory care locked unit. <BR/>Record review of Resident #2's face sheet dated 04/18/25 with an original admission date of 08/31/23 revealed a [AGE] year-old female with diagnoses including dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, anxiety disorder, depression, and abnormalities of gait and balance. <BR/>Record Review of Resident #2's admission MDS Assessment, dated 05/01/25, reflected her BIMS score of 03 indicated the resident had severe cognitive impairment. She required supervision with eating, lower body dressing, personal and oral hygiene, toileting, transferring, and repositioning. She required moderate assistance with upper body dressing and footwear. She utilized a manual wheelchair and could propel herself. She was frequently incontinent of bladder and bowel. She took antianxiety and antidepressant medications. <BR/>Resident #2's admission care plan dated 04/18/25 reflected Resident #2 was an elopement risk/wanderer r/t poor cognition and psychosis. Date Initiated: 04/18/2025 Revision on: 04/18/2025. She resided in the memory care locked unit. <BR/>Record review of Resident #3's face sheet dated 06/19/23 revealed a [AGE] year-old female with diagnoses including dementia and early onset Alzheimer ' s (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety and mood disorders, major depression, and lack of coordination. <BR/>Record Review of Resident #3's quarterly MDS Assessment, dated 02/06/25, reflected her BIMS score of 05 indicated the resident had severe cognitive impairment. She required set-up with eating. She required maximal assistance with oral hygiene. She was dependent for dressing, personal hygiene, and toileting. She was independent for walking, transferring, and repositioning. She did not utilize a wheelchair. She was frequently incontinent of bladder and bowel. She took antipsychotic, antianxiety, anticonvulsant (seizure), and antidepressant medications. <BR/>Resident #3's care plan dated 04/18/25 reflected Resident #3 was on palliative care with hospice services due to end stage disease process of Alzheimer's. Expected physiological signs of weight loss, skin breakdown or pressure injury, dehydration, fecal impaction and gradual /rapid loss of the ability to move about or become bedfast is expected. Date Initiated: 07/02/23 <BR/>Revision on: 07/22/23. Dignity will be maintained, and the resident will be kept comfortable and pain free with in one hour of intervention over the next review period Date Initiated: 07/02/2023 Target Date: 06/11/2025. I/my family, anticipate that I will remain LTC (Long Term Care) after respite stay is completed so that all of my needs can be met on a daily basis with safety. Date Initiated: 07/02/23 Revision on: 07/02/23. The resident is physically aggressive r/t dementia, depression, poor impulse control. Date Initiated: 07/22/23 Revision on: 07/22/2023. She resided in the memory care locked unit. <BR/>Observation of Resident #1 in the memory unit on 05/13/25 at 2:30 pm revealed she was in the restroom. Upon leaving the restroom, she was ambulatory with a slow gait and could walk without assistive devices. She made her way with the hospitality aide at her side to one of the sofas in the memory care activity room. She sat down without difficulty or losing her balance. The hospitality aide sat down beside her. She was talkative with the hospitality aide while sitting on the couch. She was touching herself in between the legs and smiling. She was trying to take her pants down even though she just came out of the restroom. She told the hospitality aide she needed to use the restroom again for a bowel movement. She was saying she forgot toilet paper when she was sitting on the couch. <BR/>In an interview with the hospitality aide, she said she was currently 1:1 with Resident #1 because she either fell recently or hit someone else. She said she had worked at the facility for 4 weeks and said Resident #1 did not hit others very often. <BR/>In an interview with LVN A on 05/13/25 at 5:54 pm, she said she worked at the facility for 3 years and was familiar with all of the residents in the memory unit, as she only worked in the memory unit. She said Resident #1 got physical faster and would usually strike first. She said Resident #1 got agitated for no obvious reason-she saw her hitting a window with a belt one time. She said she was not at the facility during the incident between Resident #1 and Resident #3, but she heard Residents #1 and #3 were arguing and one hit the other and Resident #1 was put on 1:1 and she has stayed on 1:1 status ever since. She said the doctors were also making medication changes on Resident #1. <BR/>In an interview with the SW on 05/14/25 at 9:30 am, she said she had worked at the facility since June 2025. She said on 05/10/25 she called the RP to discuss Resident #1's behavior. She said the local psychiatric hospital called the daughter to tell her they could meet Resident #1's needs and the RP told them her mother did not need psychiatric care, and she demanded to speak with the doctor's there. The SW said she received a phone call from the local psychiatric hospital and was told the RP would not let the intake specialist at the local psychiatric hospital get a word in to explain the procedures and the phone call ended there. She said the local psychiatric hospital called her (the SW) and told her they had been aggressively spoken to by the RP and the local psychiatric hospital closed out the referral. The SW said a meeting was held with the RP, ADM, DON, and RD. She said the RP told her she did not want Resident #1 to be on psychotropics because they would make her too sleepy. The SW said the RP told her she was going to see if the other nursing home in town would take her. The SW said the RP was able to get a referral yesterday (05/13/25) to transfer Resident #1 to the other nursing home in town. The SW said the Ombudsman would meet with the SW, RP, ADM, and DON on Friday, 05/16/25. <BR/>Interview with LVN B on 05/14/25 at 1:43 pm, she said Resident #1's RP had not wanted her to be on any medications, and the facility was just recently able to try the medications (last 5 days ago). LVN B said she explained to the RP that it would take several days or even weeks for the medications to take effect. LVN B said the RP did not want Resident #1 to go to the local psychiatric hospital for evaluation and stabilization. LVN B said the facility told the RP if she did not allow them to try psyche or meds on Resident #1, they would have to transfer her due to not being able to meet her needs. She said the RP agreed this time. LVN B said the facility called the local psychiatric hospital back and they refused Resident #1 due to the way she treated them on the phone. She said she called the doctor and had to get consent for the medication Resident #1 needed. She said she called the RP to inform her and she gave consent. LVN B said Resident #1 was only on the Depakote for 3 days before Resident #1 slapped the arm of Resident #3. She said they were standing near each other when Resident #1 picked up Resident #3 ' s arm and said, I. Told. You. So., slapping lightly with each word as if she was reprimanding a child and was placed back on 1:1. She said she informed the RP and the RP told her she was scared Resident #1 would be thrown out (of the facility). LVN B said she called the doctor again and was placed on Zoloft and Trazodone. LVN B said Resident #1 remained on 1:1 until she was cleared by psyche. LVN B said the doctor saw Resident #1 in the facility on Sunday, 05/11/25 when he changed her meds. She said the RP came 2-3 times a week at lunch. She said staff in the memory unit got special training including the virtual dementia course. She said she told the RP about the course so she could try to better understand what Resident #1 was going through. She said Resident #3 did not seem to be effected or fearful and she did not recall the altercation at all. <BR/>In an interview with the SW on 05/15/25 at 8:45 am, she said she reached out to a behavioral health hospital in the valley yesterday and they requested lab results for Resident #1, and she was still waiting for a call back at this time. <BR/>In an interview with the DON on 05/15/25 at 1:00 pm, she said all staff received dementia training on computer based training and Virtual Dementia training. She said the families and community were also offered the virtual opportunity. She said the last virtual training was in November and done annually and as needed. She said Resident #1's RP had not done any of the dementia training that she knew of. The DON said everyone was invited to the dementia classes and courses via flyers, social media, and through their mass messaging for families. She said Resident #1 had a history of aggression. She said from Dec. 31, 2022, physical aggression was initiated by risk management (incidents & accidents). She said the facility was protecting other residents because they had Resident #1 on 1:1, doing/saying/watching to try to find a root cause, labs with urinalysis (UA), medication changes, and was currently trying to get her into a facility like a behavioral hospital to see if they could make medication changes or be able to help her with whatever therapy modalities they had such as group therapy. She said the facility may have found a place in the valley-they were waiting for a call back today. She said Resident #1 had been on 1:1 continuously since 05/05/25. The DON said the facility had Resident #1set up to transfer to the local behavioral hospital but they declined because her RP was hostile toward them. She said the RP came to the facility and met with the ADM, DON, SW and the RP 's SIL. She said during the meeting, the RP was reluctant and unsure and not understanding so she wanted to call the local behavioral hospital again, so they did and that was when the local behavioral hospital said they did not have a bed for Resident #1. The DON said the RP was upset at the news then agreed to let Resident #1 go somewhere and the meeting finished. She said encounters/incidents with Resident #1 started 10/2023 when she was yelling at another resident. She said the next encounters/incidents involving Resident #1's aggression was 12/3/0/24, 05/05/25 at 1:54 pm with Resident #2, and 05/10/25 with Resident #3. She said Residents #2 and #3 did not seem to be effected or fearful and neither recalled the altercations at all. <BR/>In an interview with the ADM on 05/15/25 at 2:00 pm, he said he started working at the facility on 12/29/24. He said he first learned of Resident #1's aggression when she slapped Resident #2 in the face earlier this month. He said the 1:1 and in-services were immediate. He said the RP blocked the transfer to the local behavioral hospital because of her hostility towards them. He said he spoke to the RP and explained why the facility needed to get the help her mother needed that could not be attained at the facility. He mentioned the RP said I don ' t have time; I have a life when the facility asked if she or someone else could sit with Resident #1. He said the physician came in on Sunday 05/11/25 and met with him. He said the physician prescribed medication for insomnia and anxiety for Resident #1. He said he spoke with the RP Tuesday 05/13/25 and informed her of the 1:1 and she was upset and demanding to know how long she was going to be on the 1:1. The RP also told the other nursing home in town Resident #1 was on a 1:1 so they did not want to accept her and told the ADM he could lift the 1:1. He explained he could not for the safety of others. He said the facility was providing 1:1's and more education specific to the aggressors to keep others safe. He said he was interviewing the staff in the memory unit to make sure they knew who the abuse coordinator was, reporting immediately, and approved paid in-services utilizing videos on the company you tube page. He said he also discusses incidents in their daily morning meetings with the department heads. <BR/>In an interview with the SW on 05/15/25 at 2:25 pm, she said the valley behavioral hospital was waiting for their clinical intake person to review the lab results for Resident #1 she sent this morning. She said she had not started a NOMOC because Resident #1 was LTC and she would be considered a transfer. She said if Resident #1 was denied at the valley behavioral hospital, the next behavioral hospital was near, and she would keep trying until she found a suitable fit for Resident #1. She said the RP told the other nursing home in town Resident #1 was a 1:1 and they declined. She said the RP wanted to speak with the Ombudsman face to face, and a meeting was set for 05/16/25 at 1:15 pm. <BR/>In an interview with CNA C, LVN B, CNA D, and RN E on 05/15/25 at 2:45 pm, they all stated the Abuse Coordinator was the ADM. CNA C said she worked only in the memory unit and worked at the facility for 26 years. She said staff received in-services and seminars for training. She said they got the Virtual Dementia Training Annually. She said they also had courses on the electronic education courses such as abuse, transfers, infection control and more. She said some of the symptoms they were taught to look for if a resident was starting to become aggressive were pain, agitation, pacing. LVN B said if a staff member did not have dementia training, they had to take the all-day course. CNA D said staff they had to take the dementia course and testing for it. RN E said she was the instructor for the CNA ' s and hospitality aides at the facility. She said the courses included dementia, behavior managing, communication, falls, safety risks, sensory impairment, agitation, and being hypervigilant. They all said Residents #2 and #3 did not seem to be effected or fearful and neither did not recall the altercations at all. <BR/>The RP was not available for interview after 3 good faith attempts to contact her.<BR/>Record review of all staff in-service/training dated Record review of in-services: dated 05/05/25 All staff Abuse resident to resident. <BR/>Record review of psychiatric physician note dated 05/08/25 revealed Resident #1 was released from 1:1 status. <BR/>Record review of 15-minute monitoring of Resident #1 beginning 05/09/35 at 6:00 am through 05/11/25 at 12:00 pm. <BR/>Record review of PIR (provider investigation report) dated 05/09/25 revealed Resident #2 was sitting in her wheelchair holding a napkin. Resident #1 attempted to grab the napkin to no avail resulting in Resident #1 slapping Resident #2. Head to toe assessments conducted on both residents. No physical or emotional distress noted to either resident. Residents were immediately separated to make sure residents were protected including if Resident #2 felt safe, increased supervision for Resident #1 by placing her on 1:1, immediate notification to physician and RP ' s and removal of alleged perpetrator. Family conference was held with Resident #1 ' s RP. In-service for Abuse and Neglect initiated for all staff. No malicious intent was determined by Resident #1. Residents did not recall the interaction. A referral was made to the local behavioral health hospital for Resident #1. He said because of the communication between the local behavioral health hospital and RP, they failed to secure a bed. He said Resident #1 ' s RP expressed she did not want Resident #1 on medications because she would fall. The facility suggested the RP come in and sit with her mom and she said, I have a life and I don't have time to sit 1:1. The ADM said another family member was also present during the conference and expressed the same concerns. He said when the doctor was on site, he gave new orders for Resident #1's anxiety and insomnia. The ADM said the RP finally gave verbal consent for med adjustment. He said Resident #1 would stay on 1:1 supervision. The ADM said, However, another altercation occurred with Resident #3 on 05/10/25. No injuries noted to either resident. He said the SW, himself, and the DON were still working with family for further review on what to do next about Resident #1' s aggressions. <BR/>Record review of progress note by LVN B dated 05/10/25 at 7:03 pm: COMMUNICATION - with Physician, Situation: Resident #1 was in the activity room and was standing next to Resident #2. Resident #1 grabbed Resident #3 by the left arm and hit her three times and said I told you so in Spanish. LVN B assessed the resident, removed her from other residents, ensured her safety and notified RP, DON, ADMN, MD. New order has been obtained for on-on-one monitoring and has been initiated. Doctor has been contacted and gave a new order for Depakote 125mg BID for mood stabilizer. UA culture was also ordered to rule out UTI. Consent was obtained from RP. <BR/>Record review of the facility policy titled, In-Service Training, Nurse Aid reviewed 12/09/24 4. Annual in-services: d. address the special needs of the residents, as determined by the facility assessment. e. include training that addresses the care of residents with cognitive impairment; and f. include training in dementia management and resident abuse prevention. 9. Required training topics for all staff (including nurse aides) include: c. abuse, neglect, and exploitation of residents; g. behavioral health. <BR/>Record review of the facility policy titled, Abuse, Neglect, and Exploitation dated 08/15/22 defined abuse as the willful infliction of injury or intimidation. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. <BR/>

Based on observations, interviews, and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41% based on 2 errors out of 27 opportunities, which involved 2 of 4 residents (Resident #45 and Resident #133) reviewed for medication errors. <BR/>- LVN C failed to administer medication as ordered to Resident #45 by administering only one 400 mcg tablet of folic acid (Vitamin B-9, important in red blood cell formation and cell growth) instead of 800 mcg as ordered.<BR/>- LVN C failed to administer medication as ordered to Resident #133 by holding one 12.5 mg tablet of hydrochlorothiazide (diuretic that lowers blood pressure as well as treat fluid retention) despite an active order to administer it.<BR/>These failures could place residents receiving medication at risk of inadequate therapeutic outcomes.<BR/>The findings included: <BR/>1. During an observation on 06/18/25 at 8:25 AM, LVN C prepared medications for Resident #45 during medication pass. LVN C only gathered one 400 mcg tablet of folic acid from the medication bottle. LVN C only administered one 400 mcg tablet of folic acid to Resident #45. This state surveyor asked LVN C if she was finished administering medications to Resident #45 and she stated she was finished. <BR/>Record review of Resident #45's order summary revealed an active order dated 05/28/25 for Folic Acid Oral Capsule 0.8 MG (Folic Acid). Give 1 capsule via G tube one time a day for SUPPLEMENT related to ANEMIA, UNSPECIFIED.<BR/>2. During an observation on 06/18/25 at 8:34 AM, LVN C prepared medications for Resident #133 during medication pass. LVN C did not pop any hydrochlorothiazide tablets out of the blister pack to administer to Resident #133. LVN C did not administer any tablets of hydrochlorothiazide to Resident #133. This state surveyor asked LVN C if she finished administering medications to Resident #133 and she stated she was finished. <BR/>Record review of Resident #133's order summary revealed an active order dated 06/10/25 for hydrochlorothiazide Oral Tablet 12.5 MG (Hydrochlorothiazide). Give 12.5 mg by mouth one time a day for hypertension [elevated blood pressure] related to ESSENTIAL (Primary) HYPERTENSION.<BR/>In an interview with LVN C on 06/18/25 at 11:02 AM, LVN C stated Resident #45 had an active order for 800 mcg of folic acid 1 time per day. LVN C stated she administered 0.4 mg of folic acid to Resident #45 earlier that day. LVN C stated there were no 0.8 mg tablets in the nurse's cart. LVN C stated she made an error in only administering 1 400 mcg folic acid tablet to Resident #45. LVN C stated she chose to hold the hydrochlorothiazide for Resident #133 because her blood pressure was low. LVN C stated Resident #133 had three other blood pressure medications that were all held as well because Resident #133's blood pressure was below the threshold for administering them. LVN C stated the order for hydrochlorothiazide stated it was used to treat hypertension, so it should have had the same parameters on it as the other blood pressure medications. LVN C stated it was important for residents to receive medications as ordered so their symptoms and conditions did not worsen and harm the resident. <BR/>In an interview with ADON 1 on 06/19/25 at 1:28 PM, ADON 1 stated before administering medication, nurses and med aides should compare what was written in the MAR to what was written on the blister pack to ensure there were no inconsistencies. ADON 1 stated LVN C should have given 800 mcg of folic acid to Resident #45 during medication pass. ADON 1 stated LVN C should have administered the hydrochlorothiazide to Resident #133 because the order was correct as written. ADON 1 stated the order did not have hold parameters because it was being used primarily to treat edema (excess fluid in the body tissues). ADON 1 stated the administration of incorrect doses of medications or holding medications inappropriately could lead to unnecessary changes in the treatment plans of residents leading to harm. <BR/>In an interview with the CCS on 06/19/25 at 2:02 PM, the CCS stated if LVN C had questions about whether to administer the hydrochlorothiazide to Resident #133, she should have called the doctor to confirm the order. The CCS stated the order did not have hold parameters because it was being used primarily to treat edema. The CCS stated holding medications when they were supposed to be administered could harm the residents because it was not what the doctor ordered. The CCS stated errors in medication administration could lead to unnecessary changes to the treatment plan of residents. <BR/>Record review revealed the facility policy titled Medication Administration last reviewed 07/08/24 stated the following:<BR/> .4. Medications are administered in accordance with prescriber orders, including any required time frame . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 3 med room nutrition refrigerators in that:<BR/>The steam table was not clean <BR/>The shelf on the steam table was not clean <BR/>The juice gun and rest tray were not clean <BR/>The ice machine was not clean<BR/>The refrigerator temperatures were above the required minimum<BR/>The dishwasher temperatures were below the required minimum<BR/>There were unlabeled foods in the med room nutrition refrigerator<BR/>These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness.<BR/>Findings were:<BR/>Observations of the kitchen during the initial tour on 02/21/23 at 10:15 AM revealed: The juice gun & rest tray was covered with a thick, sticky-looking substance. The steam table wells had thick, flaking, crusty yellowish, and brown substances in each of the 4 compartments. The shelf above the steam table had a brown substance the entire width of the underside of the shelf, above the food compartments. The underside of the shelf above the steam table had pieces of brown substance hanging down from it, above the food compartments. The ice machine had dots of a black fuzzy substance inside all over the ice chute and a white fuzzy substance around the rim of the inside of the door. The can opener had debris on it. <BR/>Observation of the med room nutrition refrigerator in the 200 hallway on 02/21/23 at 12:15 PM revealed a package of grapes and a container of food that were both unlabeled and had no resident name on them. <BR/>Observation and interview with the MS on 02/21/23 at 01:50 PM regarding the ice machine, the MS stated the last time the ice machine was cleaned was about a month ago. The MS demonstrated what parts of the machine he cleaned and stated the black dots on the ice chute were always there and he tried scrubbing it before. Some of the black dots came off when he rubbed his finger on them. The MS stated that very hard water in the facility caused the substances. The MS stated the white substance around the inside of the door was dust. The MS stated he was responsible for ceaning the ice machine. The MS stated he cleaned the ice machine monthly. The ice machine remained as described throughout the survey.<BR/>Observations and interview with the DM on 02/22/23 beginning at 09:10 AM: the DM stated the steam table was basically cleaned every two days on a rotating schedule by the cooks. The DM stated, the steam table wells had looked that way (thick, flaking, crusty yellowish, and brown substances in all compartments) for 5 years since she was first employed at this facility. The DM stated, we wash the wells and scrub them but it doesn't come off. The DM stated she had not reported it because they had always been that way and she did not know it was wrong. The DM stated she was unaware of the condition of the underside of the shelf above the steam table. The DM stated the brown substance looked like rust. The DM stated it was important to keep equipment clean because the residents were at risk of getting sick if something dropped into the food on the steam table from the bottom of the shelf. The DM stated it was likely the brown stuff had fallen into the food on the steam table. The DM stated the wells in the steam table could harbor germs. The DM stated the cooks were responsible for cleaning the steam table. The DM stated the shelf above the steam table was part of the steam table, but the staff did not clean it. The DM stated the stuff on the shelf above the steam table could fall into the food or attract gnats. The DM stated it was important so they wouldn't have contaminations, gnats and things falling into food. The DM stated, the residents could get sick-pretty badly. <BR/>Observation of the dishwasher temperature/chemical logs documented the temperature to be below the minimum 120F for 15 of 31 days in January 2023, 8 of 22 days in February, and 3 days in February were not logged at all. The DM stated she was not sure what the temperature should be, only that she was taught the temperature gauge had to be in the green zone on the temperature gauge. [The green zone on the temperature gauge showed 135F-145F] <BR/>The DM stated the chemical testing strips (used to determine correct sanitation levels) were not reading since the beginning of the month (February), but she noticed values had been logged. The DM stated she asked her staff how they were determining those values and none of them would say. The DM stated the logs had been falsified. <BR/>The DM stated she obtained new testing strips from the vendor on 02/21/23. The DM stated the vendor showed her the expiration date on the vial she had been using, and the test strips were outdated. The DM stated she was unaware of the expiration dates on the vials, or that the vials had expiration dates. <BR/>The DM stated she had informed the MS about the refrigerator temperatures being above the required 41F in January 2023, but nothing had been done to fix it. The DM stated the process for reporting malfunctioning or broken equipment was to let the MS know. The kinds of food not stored at the appropriate temperature were butter, milk, cheeses, mayonnaise, dressing, eggs, opened pickles and relish [the labels read refrigerate after opening], various vegetables, pre-made sandwiches, breads, and left-over foods; bagged scrambled eggs, chopped sausage and pork. <BR/>[The current refrigerator temperature was 40F]<BR/>During an interview with LVN A on 02/21/23 at 12:17 PM, LVN A stated all food and drinks that belong to the residents should have their name, date, and contents labeled. LVN A stated since there was only 1 resident who kept food in there, they knew it was his. When asked if someone else put something in the refirgerator belonging to another resident, how would anyone one know what belonged to whom? LVN A stated she would label the items, and it was the nurses responsibility to label residents items in the refrigerators.<BR/>Interviews with COOK A and COOK B on 02/22/23 at 09:30 AM: COOK A stated she was new and had not cleaned the steam table. COOK B stated when it was his turn, he washed out the steam table wells and scrubbed them as best he could. COOK B stated the wells had always been that way.<BR/>During an interview with the MS on 02/22/23 at 04:36 PM regarding the refrigerator temperatures: the MS stated the thermostat had been getting stuck in the open position and that would cause the temperatures to be off. The MS stated he knew nothing of the logbook from January 2023 to now, documenting higher than the required minimum of 41F. The MS stated the thermostat had been replaced a couple of hours ago. The MS stated the process for reporting malfunctioning equipment was to let him know and he would either attempt to fix it himself or call the vendor for repairs. The MS denied having been informed about the temperatures in January 2023. The MS stated every morning, the first thing he did was to check all the doors, then look at the temperature gauges on the refrigerators and freezer in the kitchen. The MS stated he never looked at the logbooks.<BR/>During an interview with the ADM on 02/23/23 at 01:00 PM, she stated the process of reporting malfunctioning equipment was for anyone to place the request in the facility's electronic maintenance log, to inform a supervisor or the ADM. The ADM stated she checked the electronic maintenance log this morning and there were no requests from the kitchen. The ADM stated she was conducting weekly rounds in the kitchen that did not include reviewing the logbooks. The ADM stated the DM was responsible for training new kitchen staff but was obviously not teaching them the right way if she herself did not know. The ADM stated she was ultimately responsible for the kitchen. <BR/>Record review of the refrigerator temperature logs, 20 days of 31 in January 2023 were above the minimum safe temperature of 41F, and 3 days were not logged at all. The high temperatures in January ranged from 41F to 58F. For 12 of 22 days in February 2023 were above the minimum safe temperature of 41F, with 2 days not logged at all. <BR/>The high temperatures in February ranged from 41F to 50F.<BR/>Record review of the facility's policy titled Refrigerator and Freezers dated 10/2022 stated: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .1) Acceptable temperature ranges are 35F to 40F for refrigerators .3) Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. [There was no column for action taken on the tracking sheets.] 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted.<BR/>Record review of the facility policy titled Sanitization dated 10/2022 stated: The food service area shall be maintained in a clean and sanitary manner. 2) All utensils, counters, shelves, and equipment shall be kept clean, and maintained in good repair and shall be free from breaks, corrosions, open cracks, and chipped areas that may affect their use or proper cleaning .8) Low-temperature dishwasher a) Wash temperature (120F) 12) Ice machines .will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 17) The food service manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas .

**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, consistent with professional standards of practice, for 3 Residents (Resident #21, Resident #23, and Resident #170) of 6 residents reviewed for respiratory care and services, in that:<BR/>The facility failed to ensure Resident #21, Resident #23, and Resident #170's oxygen tubing was not dated according to physician's order.<BR/>This deficient practice could place residents who required oxygen therapy at risk of receiving inadequate respiratory treatments and could result in decline in health. <BR/>The findings included:<BR/>1.) Record review of Resident # 21 face sheet dated 4/25/2024 reflected a [AGE] year-old-female with an original admission date of 2/22/2020. Diagnosis included heart failure, type two diabetes (insufficient production of insulin in the body), and chronic obstructive pulmonary disease (chronic obstructed airflow from the lungs). <BR/>Record review of Resident #21's MDS dated [DATE] reflected a BIM score of 15 (Cognitively Intact) and on continuous oxygen therapy.<BR/>Record review of Resident #21's physician orders dated 1/28/2024 stated to Change, label, date O2 (oxygen) tubing and clean filter weekly. <BR/>Record review of Resident #21's care plan dated 10/3/2023 reflected Resident #21 is on oxygen therapy to keep oxygen saturation levels at 90% or above. <BR/>Observation on 04/24/24 at 02:44 PM of Resident # 21's oxygen tubing was in use and not dated. <BR/>Observation on 04/25/24 at 11:11 AM of Resident #21's oxygen tubing was in use and not dated.<BR/>In an interview on 04/25/24 at 11:11 AM, Resident #21 stated staff does change the oxygen tubing every Sunday.<BR/>2.) Record review of Resident #23's face sheet dated 4/25/2024 reflected a [AGE] year-old male with an original admission date of 3/6/2015 and a readmission date of 4/4 2022. Diagnoses included heat failure, atrial fibrillation (irregular and often very rapid heart rhythm), and cerebral infarction due to thrombosis (disrupted blood supply and restricted oxygen of the major vessels to the brain). <BR/>Record review of Resident #23's MDS dated [DATE] reflected continuous oxygen therapy. No BIM score was provided. Resident #23 was not able to answer questions appropriately when questioned. <BR/>Record review of #23's physician orders dated 1/28/2024 stated change, label, and date oxygen tubing and clean filter weekly. <BR/>Record review of #23's care plan dated 08/5/2023 reflected Resident #23 had congestive heart failure and oxygen at 2 litters per minute continuously. <BR/>Observation on 04/23/24 at 03:09 PM of Resident #23's oxygen tubing was in use and not dated.<BR/>Observation on 04/25/24 at 11:25 AM of Resident #23's oxygen tubing was in use and not dated. <BR/>3.) Record review of Resident # 170's face sheet dated 4/25/2024 reflected a [AGE] year-old female with an admission date of 3/21/2024. Diagnoses included chronic obstructive pulmonary disease (chronic obstructed airflow from the lungs), type two diabetes (insufficient production of insulin in the body), and heart disease. <BR/>Record review of Resident #170's MDS dated [DATE] reflected a BIMS of 14 (cognitively intact) oxygen therapy. <BR/>Record review of Resident #170's physician orders dated 4/21/2024 stated change, label, date oxygen tubing weekly. <BR/>Record review of Resident #170's care plan dated 4/3/2024 reflected Resident has oxygen therapy related to infective gas exchange from COPD due to smoking in the past. <BR/>Observation on 04/24/24 at 02:03 PM of Resident #170's oxygen tubing was in use and not dated. <BR/>Observation on 04/25/24 at 11:10 of Resident #170's oxygen tubing was in use and not dated.<BR/>In an interview on 04/25/24 at 11:20 AM Resident #170 stated she believes her oxygen tubing is changed out every Sunday night.<BR/>In an interview on 04/25/24 at 11:26 AM LVN B stated resident's oxygen tubing should be dated to ensure patency and cleanliness. LVN B stated oxygen tubing is changed every week on Sundays during night shift and it is the responsibility of the nurse changing out the oxygen tubing to ensure it is dated at the time of change as well as all charge nurses. <BR/>In an interview on 04/25/24 at 11:29 AM, the DON stated resident's oxygen tubing should be dated to make sure that they are being changed weekly so staff would be aware of the date when the oxygen tubing was changed. The DON stated the charge nurses are responsible for making sure oxygen tubing was dated as it could lead to not knowing when the oxygen tubing needed to be replaced for being used longer than it should be. The DON stated she was could not recall when the last in-service on oxygen tubing was conducted but would conduct an in-service immediately. <BR/>Record review of the Oxygen Administration policy dated 2/2023 stated:<BR/>Purpose<BR/>The purpose of this procedure is to provide guidelines for safe oxygen administration.'<BR/>Preparation<BR/>1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.<BR/>2. Review resident's care plan to assess for any special needs of the resident.<BR/>3. Assemble the equipment and supplies as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 3 med room nutrition refrigerators in that:<BR/>The steam table was not clean <BR/>The shelf on the steam table was not clean <BR/>The juice gun and rest tray were not clean <BR/>The ice machine was not clean<BR/>The refrigerator temperatures were above the required minimum<BR/>The dishwasher temperatures were below the required minimum<BR/>There were unlabeled foods in the med room nutrition refrigerator<BR/>These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness.<BR/>Findings were:<BR/>Observations of the kitchen during the initial tour on 02/21/23 at 10:15 AM revealed: The juice gun & rest tray was covered with a thick, sticky-looking substance. The steam table wells had thick, flaking, crusty yellowish, and brown substances in each of the 4 compartments. The shelf above the steam table had a brown substance the entire width of the underside of the shelf, above the food compartments. The underside of the shelf above the steam table had pieces of brown substance hanging down from it, above the food compartments. The ice machine had dots of a black fuzzy substance inside all over the ice chute and a white fuzzy substance around the rim of the inside of the door. The can opener had debris on it. <BR/>Observation of the med room nutrition refrigerator in the 200 hallway on 02/21/23 at 12:15 PM revealed a package of grapes and a container of food that were both unlabeled and had no resident name on them. <BR/>Observation and interview with the MS on 02/21/23 at 01:50 PM regarding the ice machine, the MS stated the last time the ice machine was cleaned was about a month ago. The MS demonstrated what parts of the machine he cleaned and stated the black dots on the ice chute were always there and he tried scrubbing it before. Some of the black dots came off when he rubbed his finger on them. The MS stated that very hard water in the facility caused the substances. The MS stated the white substance around the inside of the door was dust. The MS stated he was responsible for ceaning the ice machine. The MS stated he cleaned the ice machine monthly. The ice machine remained as described throughout the survey.<BR/>Observations and interview with the DM on 02/22/23 beginning at 09:10 AM: the DM stated the steam table was basically cleaned every two days on a rotating schedule by the cooks. The DM stated, the steam table wells had looked that way (thick, flaking, crusty yellowish, and brown substances in all compartments) for 5 years since she was first employed at this facility. The DM stated, we wash the wells and scrub them but it doesn't come off. The DM stated she had not reported it because they had always been that way and she did not know it was wrong. The DM stated she was unaware of the condition of the underside of the shelf above the steam table. The DM stated the brown substance looked like rust. The DM stated it was important to keep equipment clean because the residents were at risk of getting sick if something dropped into the food on the steam table from the bottom of the shelf. The DM stated it was likely the brown stuff had fallen into the food on the steam table. The DM stated the wells in the steam table could harbor germs. The DM stated the cooks were responsible for cleaning the steam table. The DM stated the shelf above the steam table was part of the steam table, but the staff did not clean it. The DM stated the stuff on the shelf above the steam table could fall into the food or attract gnats. The DM stated it was important so they wouldn't have contaminations, gnats and things falling into food. The DM stated, the residents could get sick-pretty badly. <BR/>Observation of the dishwasher temperature/chemical logs documented the temperature to be below the minimum 120F for 15 of 31 days in January 2023, 8 of 22 days in February, and 3 days in February were not logged at all. The DM stated she was not sure what the temperature should be, only that she was taught the temperature gauge had to be in the green zone on the temperature gauge. [The green zone on the temperature gauge showed 135F-145F] <BR/>The DM stated the chemical testing strips (used to determine correct sanitation levels) were not reading since the beginning of the month (February), but she noticed values had been logged. The DM stated she asked her staff how they were determining those values and none of them would say. The DM stated the logs had been falsified. <BR/>The DM stated she obtained new testing strips from the vendor on 02/21/23. The DM stated the vendor showed her the expiration date on the vial she had been using, and the test strips were outdated. The DM stated she was unaware of the expiration dates on the vials, or that the vials had expiration dates. <BR/>The DM stated she had informed the MS about the refrigerator temperatures being above the required 41F in January 2023, but nothing had been done to fix it. The DM stated the process for reporting malfunctioning or broken equipment was to let the MS know. The kinds of food not stored at the appropriate temperature were butter, milk, cheeses, mayonnaise, dressing, eggs, opened pickles and relish [the labels read refrigerate after opening], various vegetables, pre-made sandwiches, breads, and left-over foods; bagged scrambled eggs, chopped sausage and pork. <BR/>[The current refrigerator temperature was 40F]<BR/>During an interview with LVN A on 02/21/23 at 12:17 PM, LVN A stated all food and drinks that belong to the residents should have their name, date, and contents labeled. LVN A stated since there was only 1 resident who kept food in there, they knew it was his. When asked if someone else put something in the refirgerator belonging to another resident, how would anyone one know what belonged to whom? LVN A stated she would label the items, and it was the nurses responsibility to label residents items in the refrigerators.<BR/>Interviews with COOK A and COOK B on 02/22/23 at 09:30 AM: COOK A stated she was new and had not cleaned the steam table. COOK B stated when it was his turn, he washed out the steam table wells and scrubbed them as best he could. COOK B stated the wells had always been that way.<BR/>During an interview with the MS on 02/22/23 at 04:36 PM regarding the refrigerator temperatures: the MS stated the thermostat had been getting stuck in the open position and that would cause the temperatures to be off. The MS stated he knew nothing of the logbook from January 2023 to now, documenting higher than the required minimum of 41F. The MS stated the thermostat had been replaced a couple of hours ago. The MS stated the process for reporting malfunctioning equipment was to let him know and he would either attempt to fix it himself or call the vendor for repairs. The MS denied having been informed about the temperatures in January 2023. The MS stated every morning, the first thing he did was to check all the doors, then look at the temperature gauges on the refrigerators and freezer in the kitchen. The MS stated he never looked at the logbooks.<BR/>During an interview with the ADM on 02/23/23 at 01:00 PM, she stated the process of reporting malfunctioning equipment was for anyone to place the request in the facility's electronic maintenance log, to inform a supervisor or the ADM. The ADM stated she checked the electronic maintenance log this morning and there were no requests from the kitchen. The ADM stated she was conducting weekly rounds in the kitchen that did not include reviewing the logbooks. The ADM stated the DM was responsible for training new kitchen staff but was obviously not teaching them the right way if she herself did not know. The ADM stated she was ultimately responsible for the kitchen. <BR/>Record review of the refrigerator temperature logs, 20 days of 31 in January 2023 were above the minimum safe temperature of 41F, and 3 days were not logged at all. The high temperatures in January ranged from 41F to 58F. For 12 of 22 days in February 2023 were above the minimum safe temperature of 41F, with 2 days not logged at all. <BR/>The high temperatures in February ranged from 41F to 50F.<BR/>Record review of the facility's policy titled Refrigerator and Freezers dated 10/2022 stated: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .1) Acceptable temperature ranges are 35F to 40F for refrigerators .3) Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. [There was no column for action taken on the tracking sheets.] 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted.<BR/>Record review of the facility policy titled Sanitization dated 10/2022 stated: The food service area shall be maintained in a clean and sanitary manner. 2) All utensils, counters, shelves, and equipment shall be kept clean, and maintained in good repair and shall be free from breaks, corrosions, open cracks, and chipped areas that may affect their use or proper cleaning .8) Low-temperature dishwasher a) Wash temperature (120F) 12) Ice machines .will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 17) The food service manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 (Resident #2 and Resident # 122) of 5 residents and 4 of ( CNA C, CNA D, CNA E, and HA F) staff that were reviewed for infection control in that:<BR/>1. CNA C and CNA D did not perform hand hygiene for 20 seconds or longer and did not remove contaminated gloves during peri care after changing Resident # 2's brief and prior to putting on a new brief. <BR/>2. CNA E and Hospitality Aide F did not perform hand hygiene prior to peri care and did not perform hand hygiene for 20 seconds or longer after peri care. CNA E and Hospitality Aide E did not remove contaminated gloves during peri care after changing Resident #122's brief and prior to putting on a new brief. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings include:<BR/>1. Record review of Resident # 2's face sheet dated 4/25/2024 reflected a [AGE] year-old female with an admission date of 1/19/2024. Diagnoses included chronic obstructive pulmonary disease (chronic obstructed airflow from the lungs), type two diabetes (insufficient production of insulin in the body), and heart failure.<BR/>Record review of Resident #2's MDS dated [DATE] reflected a BIMS of 99 (Severe cognitive impairment) and was always incontinent and required total dependence.<BR/>During an observation of peri care for Resident #2 on 04/23/2024 at 02:33 PM CNA C and CNA D did not change gloves after removing Resident #2's soiled brief and began to place a clean brief on using contaminated gloves. After peri care was performed, CNA C and CNA D performed hand hygiene for approximately 15 seconds.<BR/>In an interview on 4/23/2024 at 02:50 PM, CNA C stated Resident #2's brief was wet but did not change her gloves after she removed the soiled brief because it was not a BM (bowel movement), and she did not see anything that was dirty on her gloves and did not think she had to change them. CNA C stated she did not count while she washed her hands and did not know how long she washed her hands for. CNA C stated hand washing should be around 30 seconds to prevent the spread of germs to residents and others. CNA C could not recall when the last in-service or training was.<BR/>In an interview on 4/23/2024 at 02:52 PM CNA D stated gloves should be changed between a dirty and a clean procedure if there was feces or if gloves were visibly soiled. CNA D stated hand hygiene should be for about 20 to 30 seconds to prevent the spread of germs to residents. CNA D could not recall when the last in-service on hand washing, or infection control was.<BR/>2. Record review of Resident #122's face sheet dated 4/25/2024 reflected an [AGE] year-old-female with an original admission date of 12/22/2014. Diagnoses included cerebrovascular disease (disease that affects the blood vessels in your brain), cognitive communication deficit, and hypertension (high blood pressure). <BR/>Record review of Resident #122's MDS dated [DATE] reflected a BIM score of 7 (severe cognitive impairment) and was always incontinent with partial to moderate assistance required.<BR/>During an observation of peri care for Resident #122 on 04/25/24 at 02:11 PM, CNA E and Hospitality Aide F did not perform hand hygiene prior to putting on gloves and began to perform peri care. After peri care was performed and soiled brief was removed, CNA E and Hospitality Aide F did not remove contaminated gloves. Hospitality Aide F then began to open Resident #122's drawers with contaminated gloves looking for barrier cream. Hospitality Aide F then removed gloves, left Resident #122's room to get barrier cream and returned. Hospitality Aide F did not perform hand Hygiene before proceeding with care and put on new gloves. CNA E removed only one glove and did not perform hand hygiene and placed on one new glove prior to placing a clean brief on Resident #122. After peri care was performed, CNA E removed gloves and performed hand hygiene for approximately 5 seconds. <BR/>In an Interview on 04/25/24 at 02:25 PM, both CNA E and Hospitality Aide F stated they were nervous and did not realize they had missed steps. CNA E stated it was important to wash hands for about 20 seconds or longer to stop the spread of germs and diseases to residents. Both CNA E and Hospitality Aide F stated they did not think they had to change their gloves after cleaning Resident #122 because her brief was not visibly soiled. Both CNA E and Hospitality Aide F stated the last infection control and hand hygiene in-service was done within the past month. <BR/>In an interview on 04/25/24 at 02:32 AM, the DON stated hand washing should be 20 seconds or greater to prevent the spread of bacteria to residents and other surfaces. The DON stated all gloves should be changed between brief changes from a dirty to clean procedure to ensure effective infection control practices and stop the spread of germs to staff, residents, and other surfaces. The DON stated last hand hygiene/ infection control in-service was done within the last month and is also conducted on an as needed basis.<BR/>In an interview on 04/25/24 at 02:46 PM, the ADON stated effective hand washing of 20 seconds or greater is important to prevent the spread of infection to residents, staff, and visitors. ADON stated hands should be washed prior to performing care and gloves should be changed after performing peri care to reduce the risk of cross contamination from a clean to dirty surface. ADON stated once a month in-service on infection control and hand washing is conducted with staff. <BR/>Record review of Handwashing/Hand Hygiene policy dated 3/1/2020 stated:<BR/>Policy Statement<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>b. Before and after direct contact with residents;<BR/>d. Before performing any non-surgical invasive procedures;<BR/>i. After contact with a resident's intact skin;<BR/>m. After removing gloves;<BR/>9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine. <BR/>Record review of Infection Prevention and Control Program revised on 10/2022 and reviewed on 1/2023 stated:<BR/>An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to take appropriate actions during an investigation of an unwitnessed accident in that facility policy required investigations to be prompt, comprehensive and responsive to the situation and contain founded conclusions for 1 of 1 (Resident #1) residents reviewed for incidents/accidents. <BR/>Resident #1 experienced a fractured right humerus. During the investigation no conclusion was drawn as to how the injury occurred. This incident was reported to the state on 6/17/2023. <BR/>This failure could affect residents by having unnecessary or inappropriate remedies implemented, or having no appropriate remedies implemented to ensure resident safety. <BR/>Findings include:<BR/>Record review of Resident #1's clinical record's face sheet revealed an [AGE] year-old female with the diagnoses of other specified disorders of bone density and structure (unspecified site), Alzheimer's disease, dementia, abnormal gait, humerus fracture. <BR/>Record review of Resident #1's Care Plan, accessed on 7/20/2023 at 3:30 PM, indicated Resident #1 had limited physical mobility r/t muscle weakness. Interventions revealed Resident #1 was WEIGHT-BEARING with transfers. She required the assistance of one staff. <BR/>Record review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #1 experienced a significant change. Resident #1 had a documented BIMS score of 03 out of 15, indicating severe cognitive impairment. <BR/>A review of Resident #1's medical notes dated 6/17/23 at 5:50 AM and written by LVN B indicated CNA C notified charge nurse that resident was complaining of right arm pain, charge nurse assessed arm and noted three discolorations to right arm on forearm 3.5cm x3.5cm, above elbow 8cm x2cm and on elbow2.5cm x1.5cm, PRN pain medication administered, communication note sent to physician, VS- 96%, 67-P, 106/61, 18-RR, will ask morning nurse to contact RP due to early morning hours. <BR/>During an interview with CNA C on 8/7/2023 at 3:33 PM she indicated she went to change Resident #1 on 6/17/2023 around 1 PM and barely touched her arm and Resident #1 said her arm hurt. CNA C said she moved her sleeve and saw a bruise. <BR/>Record review of Resident #1's medical notes dated 6/17/2023 at 1:26 AM, written by LVN B, indicated LVN B texted PCP with request for X-ray. <BR/>Record review of Resident #1's medical notes dated 6/17/2023 at 12:35 PM, written by LVN B, indicated RP was notified. <BR/>Record review of Resident #1's medical notes dated 6/17/2023 at 4:00 PM, written by LVN B, indicated X-ray was performed. <BR/>A review of Resident #1's medical notes dated 6/17/2023 at 7:14 PM, written by LVN B, indicated RP was not available to be informed of positive x-ray results. The facility medical director ordered Resident #1 to the ER for a second opinion of x-ray interpretation. <BR/>A review of Resident #1's medical notes dated 6/17/2023 at 7:36 PM, written by LVN B, indicated EMS was notified to pick Resident #1 up from facility and transport to ER. <BR/>A review of Resident #1's medical notes dated 6/17/2023 at 10:24 PM and written by MDS coordinator indicated: Received report from RN at Local Hospital ER that the resident (Resident #1) had a mild displacement with fracture to right humeral neck and is to keep sling in place until follow up with ortho of PCP choice. Floor nurse and DON made were made aware. <BR/>During an interview and observation of Resident #1 on 7/20/2023 at 3:45 PM, she expressed no pain. Resident #1 was able to follow simple requests. Resident #1 was wearing socks on her feet and could not display a full range of motion when requested to move her feet. Resident #1 was unable to describe her injury, or how her injury occurred. Resident #1 was in no obvious distress. <BR/>During an interview with Resident #1's daughter on 8/8/2023 at 10:40 AM she said the facility DON told her they did not know how her mother broke her arm and that her mother did not fall. <BR/>During an interview with the DON on 7/21/2023 at 11:20 AM, she stated she did not want to assume anything and therefore did not reach a conclusion as to what probably happened with the resident. When asked why the bruise looked elongated, as if Resident #1 had banged her arm on a table or bar, she said she did not know. No conclusion as to what happened or what probably happened was forthcoming. <BR/>During an interview with CNA E on 8/8/2023 at 3:40 PM she said she worked from 2 to 10 on 6/16/2023. She said Resident #1 usually takes a nap after dinner and does not get out of bed again until breakfast. CNA E said she did not remember changing Resident #1, but probably changed her before 10 PM. CNA E said they always do a last round before leaving. CNA C said there was nothing out of the ordinary. <BR/>During an interview with hospitality aid D on 8/8/2023 at 4:05 PM she said she probably interacted with Resident #1 but does not remember. Hospitality aid D said the next time she came to work, Resident #1 was a Hoyer lift. <BR/>Record review of the facility's Provider Investigation Report #431171 included:<BR/>Resident chart notes 6/16/2023 - 6/17/2023<BR/>in-service: abuse and neglect dated 6/17/2023 <BR/>in-service: gait belt transfers dated 6/17/2023 <BR/>Attestation form of gait belt requirement (all direct care staff) <BR/>Grievance log July, June, May, April, March: no trends <BR/>Record review of Abuse Policy (5/01/01 Revised 5/28/2021) indicated:<BR/>The facility will thoroughly investigate all alleged violations and take appropriate actions. <BR/>Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 1 resident (R #2) reviewed for abuse/neglect.<BR/>The facility failed to report allegations of resident neglect for R #2 for incidents on 08/13/23 and 08/17/23 to the State Survey Agency within the allotted time frame (incident on 08/17/23 was at around 12:05 PM and it was reported until 08/18/23 at 8:55 AM). <BR/>This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect.<BR/>The findings included:<BR/>Record review of Provider Investigation dated 08/28/23 reflected <BR/>date and time reported to HHSC on 08/18/23 at 8:55 AM. <BR/>Incident category: other, fall with injury. <BR/>Incident date and time on 08/17/23 at 12:05 PM.<BR/>Record review of R #2 's file reflected a [AGE] year-old female, with an original admission date of 08/11/23. Her diagnoses included: unspecified fracture of upper end of left humerus (upper arm bone), muscle wasting and atrophy, other lack of coordination, cognitive communication deficit (difficulties with thinking and how someone uses language), dysphagia (swallowing difficulties), cerebral infarction (stroke), anxiety disorder, and other specified depressive episodes.<BR/>Record review of R #2's MDS assessment dated [DATE] reflected R#2 had a BIMS score of 12 (moderate cognitive impairment) and required extensive assistance for bed mobility, transfer, locomotion on/off unit (how resident moves between locations), dressing, eating, toilet use, and personal hygiene. MDS reflected R #2 uses a mobility device: wheelchair. <BR/>Record review of R #2's Care Plan dated 08/22/23 reflected <BR/>Focus: R #2 has limited physical mobility due to weakness and left humerus fracture. <BR/>Date initiated: 08/22/23<BR/>Interventions included: <BR/>Physical therapy and occupational therapy referrals as ordered, pro re nata (PRN) (as needed).<BR/>Focus: The resident has had an actual fall with serious injury due to poor balance, psychoactive drug use, and unsteady gait. <BR/>Date Initiated: 08/22/23<BR/>Interventions included:<BR/>On 08/16/23: floor mattress next to bed while in bed for safety<BR/>On 08/17/23: R #2 will be taken to bed after meals and shower, not left alone in wheelchair, bed in lowest position, call light within reach, fall mats beside bed, sent to emergency room for evaluation and treatment. <BR/>- Continue interventions on the at-risk plan.<BR/>- Monitor/document /report PRN for 72 hours to doctor for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, and agitation.<BR/>- Pharmacy consult to evaluate medications.<BR/>- Physical therapy consult for strength and mobility.<BR/>Focus: The resident is high risk for falls due to confusion, gait/balance problems, incontinence, psychoactive drug use, and unaware of safety needs. <BR/>Date Initiated: 08/22/23<BR/>Interventions included:<BR/>- Follow facility fall protocol.<BR/>- Physical therapy evaluate and treat as ordered or PRN.<BR/>Record review of Hospital records dated 08/13/23 at 3:20 PM reflected right arm x-ray with no fracture noted. Record reflected a head CT scan was done with a right frontal scalp hematoma noted. Record reflected CT of facial bones with no fracture. Record reflected a CT of the cervical spine with no fracture. <BR/>Record review of X-Ray from mobile x-ray imaging date of exam: 08/17/23 reflected left shoulder, left humerus, left elbow, left forearm, left wrist, and left-hand x-rays complete. Findings: There is an acute displaced left humeral neck fracture with angulation. No dislocation is identified. Mild degenerative changes are present. Impression: Acute displaced left humeral neck fracture. Electronically signed on: 08/17/23 at 11:01 PM. <BR/>Record review of Hospital records dated 08/17/23. Patient visit information: altered mental status and shoulder fracture (left). Shoulder fracture received on 08/18/23 at 1:14 AM. Left shoulder fracture requires immobilization with arm sling, and orthopedic referral. 95 % of the case was treated non-surgically. The patient can follow up with orthopedic referral as an outpatient. The treatment is shoulder immobilization and analgesics. Education was provided for shoulder fracture.<BR/>In an interview with CNA B on 09/07/23 at 2:30 PM. CNA B said on 08/17/23, R #2 fell during CNA B's shift. CNA B said she did not see R #2 fall. CNA B said she did not remember at what time R #2 fell. <BR/>In an interview with LVN A on 09/07/23 at 3:40 PM. LVN A said she worked on 08/13/23 when R #2 fell off her wheelchair at around 2 PM. LVN A said R #2 had a hematoma (bump) to the right side of her forehead. LVN A said R #2 could not tell LVN A what happened. LVN A said she notified the doctor and the doctor ordered x-rays to make sure there was nothing broken and because she had the hematoma. LVN A said the ambulance arrived sometime after and transported R #2 to the hospital. <BR/>In an interview with Laundry Staff (LS) on 09/07/23 at 4:00 PM. LS said she did not see R #2 fall on 08/17/23. LS said when LS saw R #2 at around 12:30 PM, R #2 was already on the floor, and nobody had witnessed R #2 fall because nobody was assisting R #2 yet. <BR/>In an interview with Housekeeper on 09/07/23 at 4:20 PM. Housekeeper said she recalls working when R #2 had a fall in the tv room on 08/13/23 at around 2 PM. Housekeeper said she was talking to RN A down the hallway. Housekeeper said they heard a thump, so she and RN A went down the hallway to the tv room. Housekeeper said R #2 was on the floor. Housekeeper said R #2 fell face forward off the chair. Housekeeper said she does not know if R #2 was trying to get up to walk or how she fell as Housekeeper did not witness the fall. Housekeeper said R #2 did not say anything and did not mention what happened. <BR/>In an interview with DON on 09/07/23 at 5:00 PM. DON said regarding reporting, once the facility finds out about a major injury such as a fracture, the abuse coordinator, the Administrator, will report it. DON said for major injury, DON believes it is 2 hours to report it to the state. DON said once they get the x-ray results and the confirmation of the fracture, DON said she was not sure if it was 2 or 24 hours to report it. DON said the hospital x-ray is considered a confirmed fracture. DON said they knew R #2 fell and R #2 complained of pain on 08/17/23. DON said it was not from an unknown source, as they knew R #2 fell, so it would have been 24 hours to report it. <BR/>In an interview with AD on 09/08/23 at 11:30 AM. AD said she recalls working when R #2 fell on [DATE] around lunch time. AD said she did not see R #2 fall. AD said she asked R #2 what happened, and R #2 said she was trying to scoot up out of the chair and fell off the chair. <BR/>In an interview with LVN B on 09/08/23 at 11:45 AM. LVN B said she recalls working on 08/17/23 when R #2 fell. LVN B said LVN B did not remember what time it was at. LVN B said R #2 had told LVN B that R #2 was not in pain and that R #2 had not hit her head. LVN B said R #2 did not tell her what happened or how she ended up on the floor. LVN B said R #2 will be in and out of reality at times. LVN B said R #2 said yes that she was in pain. LVN B said she informed the doctor and the doctor ordered x-ray. LVN B said the mobile x-ray company arrived and did the x-rays. LVN B said R #2 did have a fracture to her left shoulder. LVN B said the doctor ordered for R #2 to be sent out to the hospital to confirm the fracture. LVN B said when there is a fall, the nurse notifies the DON and the Administrator, and they are made aware of the fracture or injury. <BR/>In an interview with RN A on 09/18/23 at 10:50 AM. RN A said she recalls working on 08/13/23 when R #2 fell off the wheelchair at around 2 PM. RN A said R #2 did mention something that she was trying to get something, but R #2 did not say what. RN A said R #8 told RN A that R #2 was trying to get up, but R #8 is also confused at times. <BR/>In an interview with R #8 on 09/18/23 at 11:20 AM. R #8 said she does not know who R #2 is. R #8 said she has not seen any resident fall. R #8 said she does not remember.<BR/>In an interview with the Administrator on 09/18/23 at 1:45 PM. Administrator said on 08/13/23, R #2 had a fall off R #2's wheelchair. Administrator said it was considered witnessed because it was witnessed by the Housekeeper and R #8. Administrator said R #2 had a hematoma to the right of R #2's forehead. Administrator said the fall on 08/13/23 was not reported to the state because it was witnessed. Administrator said the Housekeeper and R #8 saw how R #2 fell. Administrator said she does not report every fall with injury but does report falls with major injury (fractures, etc.). Administrator said R #2 was taken to the hospital for the fall on 08/13/23, but Administrator is not sure why. Administrator said if the doctor orders for the resident to be sent out to the hospital, that is not a reason for the fall or incident to be reported to the state. Administrator said the Housekeeper did witness R #2's fall. Administrator said a resident also saw R #2's fall. Administrator said R #8 is coherent and knows what she is saying. Administrator said it was witnessed and there was nothing neglectful happening (wearing socks, no liquids found). Administrator said if the Housekeeper had not witnessed then they would not report it, because it would not be a major injury. Administrator said the hematoma would not be considered a major injury so it would not be something to report. Administrator said being sent out to the hospital would not be a reason to report it to the state. Administrator said on 08/17/23, R #2 had a fall. Administrator said R #2 told the staff that R #2 tried to get up and walk and R #2 fell. Administrator said R #2 sustained a fracture to R #2's left shoulder. Administrator said there was an in-house x-ray on wheels that determined the fracture at 11:45 PM. Administrator said R #2 was then sent out to the hospital to confirm the fracture. Administrator said this fall was reported to the state when they got the x-rays results from the hospital. Administrator said she got the call around 7:30 AM on 08/18/23 from the nurse saying that the hospital gave them report and indicated the x-ray showed the fracture. Administrator said she waited for the confirmation of the fracture from the hospital because their equipment is more accurate. Administrator said this fall was unwitnessed, but R #2 told them how R #2 fell. Administrator said it would be a fall with injury so they would have had 24 hours to report it. Administrator said it would be 24-hour mark because it was not an injury of unknown origin since it was from a fall, and they knew what happened. Administrator said they would report an injury of unknown origin within 2 hours. Administrator said it was not considered an injury of unknown origin because they knew it came from the fall. Administrator said the Housekeeper did not witness R #2 fall but heard R #8 yelling out that R #2 fell. Administrator said R #8 witnessed the fall. <BR/>Abuse Prohibition Policy (revised 10/2022)<BR/>Reporting/Response:<BR/>The facility will report all allegations and substantiated occurrences of abuse, neglect, misappropriation of resident property to the state agency and to all other agencies are required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were investigated for 1 of 1 resident (R #2) reviewed for abuse/neglect.<BR/>The facility failed to thoroughly investigate alleged violations of neglect after R #2 fell on [DATE] and 08/17/23.<BR/>This failure could place all residents at increased risk for potential abuse due to uninvestigated allegations of abuse and neglect.<BR/>The findings included:<BR/>Record review of R #2 's file reflected a [AGE] year-old female, with an original admission date of 08/11/23. Her diagnoses included: unspecified fracture of upper end of left humerus (upper arm bone), muscle wasting and atrophy, other lack of coordination, cognitive communication deficit (difficulties with thinking and how someone uses language), dysphagia (swallowing difficulties), cerebral infarction (stroke), anxiety disorder, and other specified depressive episodes.<BR/>Record review of R #2's MDS assessment dated [DATE] reflected R#2 had a BIMS score of 12 (moderate cognitive impairment) and required extensive assistance for bed mobility, transfer, locomotion on/off unit (how resident moves between locations), dressing, eating, toilet use, and personal hygiene. MDS reflected R #2 uses a mobility device: wheelchair. <BR/>Record review of R #2's Care Plan dated 08/22/23 reflected <BR/>Focus: R #2 has limited physical mobility due to weakness and left humerus fracture. <BR/>Date initiated: 08/22/23<BR/>Interventions included: <BR/>Physical therapy and occupational therapy referrals as ordered, pro re nata (PRN) (as needed).<BR/>Focus: The resident has had an actual fall with serious injury due to poor balance, psychoactive drug use, and unsteady gait. <BR/>Date Initiated: 08/22/23<BR/>Interventions included:<BR/>On 08/16/23: floor mattress next to bed while in bed for safety<BR/>On 08/17/23: R #2 will be taken to bed after meals and shower, not left alone in wheelchair, bed in lowest position, call light within reach, fall mats beside bed, sent to emergency room for evaluation and treatment. <BR/>- Continue interventions on the at-risk plan.<BR/>- Monitor/document /report PRN for 72 hours to doctor for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, and agitation.<BR/>- Pharmacy consult to evaluate medications.<BR/>- Physical therapy consult for strength and mobility.<BR/>Focus: The resident is high risk for falls due to confusion, gait/balance problems, incontinence, psychoactive drug use, and unaware of safety needs. <BR/>Date Initiated: 08/22/23<BR/>Interventions included:<BR/>- Follow facility fall protocol.<BR/>- Physical therapy evaluate and treat as ordered or PRN.<BR/>Record review of Hospital records dated 08/13/23 at 3:20 PM reflected right arm x-ray with no fracture noted. Record reflected a head CT scan was done with a right frontal scalp hematoma noted. Record reflected CT of facial bones with no fracture. Record reflected a CT of the cervical spine with no fracture. <BR/>Record review of X-Ray from mobile x-ray imaging date of exam: 08/17/23 reflected left shoulder, left humerus, left elbow, left forearm, left wrist, and left-hand x-rays complete. Findings: There is an acute displaced left humeral neck fracture with angulation. No dislocation is identified. Mild degenerative changes are present. Impression: Acute displaced left <BR/>humeral neck fracture. Electronically signed on: 08/17/23 at 11:01 PM. <BR/>Record review of Hospital records dated 08/17/23. Patient visit information: altered mental status and shoulder fracture (left). Shoulder fracture received on 08/18/23 at 1:14 AM. Left shoulder fracture requires immobilization with arm sling, and orthopedic referral. 95 % of the case was treated non-surgically. The patient can follow up with orthopedic referral as an outpatient. The treatment is shoulder immobilization and analgesics. Education was provided for shoulder fracture.<BR/>In an interview with CNA B on 09/07/23 at 2:30 PM. CNA B said on 08/17/23, R #2 fell during CNA B's shift. CNA B said she did not see R #2 fall. CNA B said she did not remember at what time R #2 fell. <BR/>In an interview with LVN A on 09/07/23 at 3:40 PM. LVN A said she worked on 08/13/23 when R #2 fell off her wheelchair at around 2 PM. LVN A said R #2 had a hematoma (bump) to the right side of her forehead. LVN A said R #2 could not tell LVN A what happened. <BR/>In an interview with Laundry Staff (LS) on 09/07/23 at 4:00 PM. LS said she did not see R #2 fall on 08/17/23. LS said when LS saw R #2 at around 12:30 PM, R #2 was already on the floor, and nobody had witnessed R #2 fall because nobody was assisting R #2 yet. <BR/>In an interview with Housekeeper on 09/07/23 at 4:20 PM. Housekeeper said she recalls working when R #2 had a fall in the tv room on 08/13/23 at around 2 PM. Housekeeper said she was talking to RN A down the hallway. Housekeeper said they heard a thump, so she and RN A went down the hallway to the tv room. Housekeeper said R #2 was on the floor. Housekeeper said R #2 fell face forward off the chair. Housekeeper said she does not know if R #2 was trying to get up to walk or how she fell as Housekeeper did not witness the fall. Housekeeper said R #2 did not say anything and did not mention what happened. <BR/>In an interview with AD on 09/08/23 at 11:30 AM. AD said she recalls working when R #2 fell on [DATE] around lunch time. AD said she did not see R #2 fall. AD said she asked R #2 what happened, and R #2 said she was trying to scoot up out of the chair and fell off the chair. <BR/>In an interview with LVN B on 09/08/23 at 11:45 AM. LVN B said she recalls working on 08/17/23 when R #2 fell. LVN B said LVN B did not remember what time it was at. LVN B said R #2 had told LVN B that R #2 was not in pain and that R #2 had not hit her head. LVN B said R #2 did not tell her what happened or how she ended up on the floor. LVN B said R #2 will be in and out of reality at times. LVN B said when there is a fall, the nurse notifies the DON and the Administrator, and they are made aware of the fracture or injury. <BR/>In an interview with RN A on 09/18/23 at 10:50 AM. RN A said she recalls working on 08/13/23 when R #2 fell off the wheelchair at around 2 PM. RN A said R #2 did mention something that she was trying to get something, but R #2 did not say what. RN A said R #8 told RN A that R #2 was trying to get up, but R #8 is also confused at times. <BR/>In an interview with R #8 on 09/18/23 at 11:20 AM. R #8 said she does not know who R #2 is. R #8 said she has not seen any resident fall. R #8 said she does not remember.<BR/>In an interview with DON on 09/18/23 at 1:00 PM. DON said DON completed the investigation with staff regarding the 08/13/23 fall, and there were no concerns of abuse or neglect. DON said the investigation is what is documented in the investigation report, and it would not be documented anywhere else. DON said she does not recall exactly who she spoke to.<BR/>In an interview with the Administrator on 09/18/23 at 1:45 PM. Administrator said on 08/13/23, R #2 had a fall off R #2's wheelchair. Administrator said it was considered witnessed because it was witnessed by the Housekeeper and R #8. Administrator said R #2 had a hematoma to the right of R #2's forehead. Administrator said the Housekeeper and R #8 saw how R #2 fell. Administrator said the Housekeeper did witness R #2's fall. Administrator said a resident also saw R #2's fall. Administrator said they took witness statements from the Housekeeper and R #8. Administrator said R #8 is coherent and knows what she is saying. Administrator said it was witnessed and there was nothing neglectful happening (wearing socks, no liquids found). Administrator said they make sure the report is complete and shows a complete picture of what it looked like when they do the fall investigation to ensure there was nothing else happening that could have caused the fall or caused them to fall off the wheelchair. Administrator said on 08/17/23, R #2 had a fall. Administrator said R #2 told the staff that R #2 tried to get up and walk and R #2 fell. Administrator said R #2 sustained a fracture to R #2's left shoulder. Administrator said this fall was unwitnessed, but R #2 told them how R #2 fell. Administrator said it was not considered an injury of unknown origin because we knew it came from the fall. Administrator provided witness statements. Administrator said the Housekeeper did not witness R #2 fall but heard R #8 yelling out that R #2 fell. Administrator said R #8 witnessed the fall. <BR/>Record review of the Facility Investigation Report dated 08/13/23 reflected a fall with injury. Incident location: hallway. Person preparing report: LVN A. Nursing description: Housekeeper notified nurse that R #2 was on the floor in the hallway. Upon assessment, R #2 was lying on the right side, with her arm tucked under. R #2 was wearing socks, floor was dry, and clutter free. R #2 unable to give description. Immediate action taken: Head-to-toe assessment was done. Neuro checks in place. R #2 was assessed for pain. R #2 was alert and oriented X3. Hematoma to the head noted on R #2's right temporal. NP and RP notified. DON notified. EMS notified for transportation. RN from hospital notified on R #2's situation. R #2 was taken to the hospital. Injuries observed: hematoma to top of scalp. Level of pain: 6. Mental status: oriented to person, situation, and place. No injuries observed post incident. Predisposing situation factors: admitted within last 72 hours. Witnesses listed as Housekeeper and R #8. DON, FM, and MD notified. Notes: R #2 anxious and RP revealed R #2 was on medication for anxiety and hallucinations. NP to be in on 08/15/23 to evaluate and adjust medications as needed. R #2 to be put in bed after each meal within a timely manner. Fall mat to be placed at bedside when R #2 is in bed. Call light within reach. RP and MD aware. Full body assessment completed. Neuros in place. Incident witness: R #8. Dated 08/13/23. Statement: R #8 stated that she saw R #2 trying to get out of wheelchair and then fell on the ground. Incident witness: Housekeeper. Dated on 08/13/23. Who took statement: LVN A. Statement: Housekeeper was in hallway cleaning when she heard R #8 say someone fell, then notified nurse. Staff interviews and investigation process were not noted in this report regarding 08/13/23 fall. <BR/>Record review of Provider Investigation dated 08/28/23 reflected <BR/>date and time reported to HHSC on 08/18/23 at 8:55 AM. <BR/>Incident category: other, fall with injury. <BR/>Incident date and time on 08/17/23 at 12:05 PM. <BR/>R #2 required no special supervision, was not able to ambulate independently, was not interviewable, and did not have the capacity to make informed decisions. <BR/>Provider response: Head-to-toe assessment, MD notified, RP notified, orders obtained for x-ray to left shoulder, R #2 sent to the hospital to confirm fracture.<BR/>Investigation Summary: R #2 had an unwitnessed fall in the hallway in front of the shower room at approximately 12:05 PM. R #2 was found by the CNA sitting on her bottom. R #2 stated she was trying to walk. The hallway was free from clutter and of spills leading to the fall. The nurse was notified, and a head-to-toe assessment completed. R #2 was noted with bruising and a skin tear to her left elbow with complaints of pain to her left shoulder. RP notified, MD notified, and orders obtained for an x-ray. At approximately 10:35 PM, X-ray company arrived at the facility and performed x-rays to left shoulder, humerus, elbow, forearm, wrist, and hand. At approximately 1:45 AM results showed an acute displaced left humeral neck fracture. R #2 sent to ER for confirmation and returned to the facility on [DATE] at 2:25 AM with confirmation of left humeral neck fracture. Orders to follow up with ortho. Peer to peer surveys with 15 employees show no signs of neglect. Life satisfaction rounds with 9 random residents show no signs or trends of neglect. Facility concluded the resident's fall was not due to neglect or abuse and fracture was a result of the fall. Neglect/Abuse unsubstantiated. Investigation findings: Unconfirmed. <BR/>Record review of the Policy:<BR/>Resident Incident and Visitor Accident Report Policy (revised 07/23/18)<BR/>Policy:<BR/>- The facility will conduct an investigation of all incidents involving residents of the facility. <BR/>- The investigation will be conducted by designated personnel and reported to the Administrator/designee.<BR/>B. Resident Incidents/Accidents:<BR/>6. Conclusion: <BR/>a. The witness form (s), incident report, and investigation report are submitted to the DON/designee upon their completion.<BR/>b. The DON/designee then completes the investigation follow up on the investigation report form to come to a reasonable conclusion regarding the causative factors surrounding the incident and the actions necessary to prevent further incidents/accidents.<BR/>Abuse Prohibition Policy (revised 10/2022)<BR/>Policy:<BR/>- The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations.<BR/>Investigation: <BR/>1. <BR/>The facility will thoroughly investigate all alleged violations and take appropriate actions.<BR/>5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R#2) reviewed for accidents. <BR/>The facility failed to provide R #2 with adequate supervision, resulting in falls on 08/13/23 and 08/17/23. <BR/>This failure could lead to the injury of residents that are at risk of falls.<BR/>The findings included:<BR/>Record review of R #2 's file reflected a [AGE] year-old female, with an original admission date of 08/11/23. Her diagnoses included: unspecified fracture of upper end of left humerus (upper arm bone), muscle wasting and atrophy, other lack of coordination, cognitive communication deficit (difficulties with thinking and how someone uses language), dysphagia (swallowing difficulties), cerebral infarction (stroke), anxiety disorder, and other specified depressive episodes.<BR/>Record review of R #2's MDS assessment dated [DATE] reflected R#2 had a BIMS score of 12 (moderate cognitive impairment) and required extensive assistance for bed mobility, transfer, locomotion on/off unit (how resident moves between locations), dressing, eating, toilet use, and personal hygiene. MDS reflected R #2 uses a mobility device: wheelchair. <BR/>Record review of R #2's Care Plan dated 08/22/23 reflected <BR/>Focus: R #2 has limited physical mobility due to weakness and left humerus fracture. <BR/>Date initiated: 08/22/23<BR/>Interventions included: <BR/>Physical therapy and occupational therapy referrals as ordered, pro re nata (PRN) (as needed).<BR/>Focus: The resident has had an actual fall with serious injury due to poor balance, psychoactive drug use, and unsteady gait. <BR/>Date Initiated: 08/22/23<BR/>Interventions included:<BR/>On 08/16/23: floor mattress next to bed while in bed for safety<BR/>On 08/17/23: R #2 will be taken to bed after meals and shower, not left alone in wheelchair, bed in lowest position, call light within reach, fall mats beside bed, sent to emergency room for evaluation and treatment. <BR/>- Continue interventions on the at-risk plan.<BR/>- Monitor/document /report PRN for 72 hours to doctor for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, and agitation.<BR/>- Pharmacy consult to evaluate medications.<BR/>- Physical therapy consult for strength and mobility.<BR/>Focus: The resident is high risk for falls due to confusion, gait/balance problems, incontinence, psychoactive drug use, and unaware of safety needs. <BR/>Date Initiated: 08/22/23<BR/>Interventions included:<BR/>- Follow facility fall protocol.<BR/>- Physical therapy evaluate and treat as ordered or PRN.<BR/>Record review of Hospital records dated 08/13/23 at 3:20 PM reflected right arm x-ray with no fracture noted. Record reflected a head computer tomography (CT) (medical imaging technique used to obtain detailed internal images of the body) scan was done with a right frontal scalp hematoma noted. Record reflected CT of facial bones with no fracture. <BR/>Record reflected a CT of the cervical spine with no fracture. <BR/>Record review of X-Ray from mobile x-ray imaging date of exam: 08/17/23 reflected left shoulder, left humerus, left elbow, left forearm, left wrist, and left-hand x-rays complete. Findings: There is an acute displaced left humeral neck fracture with angulation (normal axis of the bone has been altered). No dislocation is identified. Mild degenerative changes are present. Impression: Acute displaced left humeral neck fracture. Electronically signed on: 08/17/23 at 11:01 PM. <BR/>Record review of Hospital records dated 08/17/23. Patient visit information: altered mental status and shoulder fracture (left). Shoulder fracture received on 08/18/23 at 1:14 AM. Left shoulder fracture requires immobilization with arm sling, and orthopedic referral. 95 % of the case was treated non-surgically. The patient can follow up with orthopedic referral as an outpatient. The treatment is shoulder immobilization and analgesics. Education was provided for shoulder fracture.<BR/>Record review of R #2's file reflected progress notes:<BR/>On 08/11/23 at 11:08 PM, written by: LVN A. Resident arrived at facility via facility transportation van, resident was transferred from another facility to this at 3:00 PM. Resident is at facility for long term care. Resident was in good spirits; resident was noted with discoloration on left hand and bruising on bilateral upper extremities. Resident denied any pain to the area. Resident is incontinent of both bowel/bladder, full code, 1-person physical assist, alert and oriented X 3. Resident has a diet of NAS (low sodium diet), Pureed texture, Nectar thickened, and needs assistance with feedings. Resident's family was present during resident's admission and had no verbal concerns. Notified NP on resident's arrival and to verify medications, there were no verbal concerns made.<BR/>On 08/13/23 at 3:36 PM, written by: LVN A. Housekeeper notified nurse that resident was on the floor in the hallway. Upon assessment resident was laying on the right side, with her right arm tucked under. Resident was wearing socks, floor was dry, and clutter free. Head-To-Toe Assessment was done. Neuro checks in place. Resident was assessed for pain. Resident is alert and oriented to person, place, and time. Hematoma (bump) to the head noted on resident's right temporal, PERRLA (pupils equal, round, reactive to light and accommodation) noted. NP notified, emergency contact notified, DON notified, EMS notified for transportation, RN from Hospital was notified on resident's situation and transportation.<BR/>On 08/13/23 at 5:51 PM, written by: LVN A. RN from Hospital called to give report regarding to resident. Resident has negative CT scans with a hematoma on the scalp and negative x-ray on the right upper extremity. RN stated there were no new orders and resident is going to be transferred back to facility. At 5:40 PM resident arrived at facility via stretcher, resident is in good spirits and denies any pain. PERRLA noted. Notified emergency contact about resident's arrival, no verbal concerns were made. Notified NP, no verbal concerns were made.<BR/>On 08/14/23 at 10:31 AM, written by: Social Worker (SW). Care plan meeting was held, in attendance was SW, Business office manager (BOM), activities director, responsible party (RP), and RP's family member. BOM discussed insurance authorization that is going on. BOM explained how the insurance covers therapy. DON discussed the possibility of needing psych services. RP wants resident going to dining room and will need help feeding. Director of Rehab (DOR) explained the therapy services. RP stated plan is to stay long term. DON explained that resident will stay full code (intercede if a resident's heart stops beating or if the resident stops breathing) until power of attorney (POA) is filled out and do not resuscitate (DNR) order can be signed.<BR/>On 08/16/23 at 11:58 AM, written by: MDS Coordinator. late entry: Resident stated that she wanted to get up from bed and go to the bathroom, let resident know that she cannot get up on her own. Resident attempted to stand up on her own and fell on her knees on the side mat that is next to her bed that is in the lowest position. The room was clutter free. Notified CNA to help assist resident back to bed. Performed head-to-toe assessment, no bruising or active bleeding was noted. Resident denied any pain. Neuros have been placed. Notified ADON, NP, and Emergency contact.<BR/>On 08/17/23 at 12:39 PM, written by: LVN B. Communication with physician: Resident had a fall in the hallway in front of the shower room. Resident was sitting down on her bottom. Resident denied hitting her head. Resident stated that she had pain to her left shoulder area. No distress noted. Resident noted with bruising and skin tear to left elbow. Bruising with skin tear measuring at 3 x 1.5 centimeters. Head to toe and skin assessment done. Encouraged resident to not try and stand or walk alone. Skin tear cleansed with saline, pat dried with gauze, applied marathon (liquid skin protectant) to stop bleeding and secured with dressing. <BR/>On 08/17/23 at 1:34 PM, written by: LVN B. Resident had a fall and landed on her left elbow area. Resident noted with bruising and skin tear to left elbow. Resident reported pain and was given PRN medication for pain. PCP contacted and received orders for x-ray on left shoulder, elbow, and wrist. X-ray company called for x-rays and will call back with estimated time for arrival. RP aware of situation.<BR/>On 08/17/23 at 10:35 PM, written by: LVN B. X-ray company here to perform x-rays. Pending results.<BR/>On 08/17/23 at 11:45 PM, written by: LVN C. NP updated with x-ray results. Order send resident to ER for evaluation/treatment. EMS transported resident to ER. RPs updated. Questions answered. DON informed. Report called to staff at ER.<BR/>On 08/18/23 at 2:25 PM, written by: LVN A. Resident arrived from ER from Hospital at 2:00 PM, resident arrived via stretcher. Resident is alert and oriented X 3. Notified NP and RP. Faxed over discharged papers to NP. No verbal concerns were made.<BR/>Record review of the Facility Investigation Report dated 08/13/23 reflected a fall with injury. Incident location: hallway. Person preparing report: LVN A. Nursing description: Housekeeper notified nurse that R #2 was on the floor in the hallway. Upon assessment, R #2 was lying on the right side, with her arm tucked under. R #2 was wearing socks, floor was dry, and clutter free. R #2 unable to give description. Immediate action taken: Head-to-toe assessment was done. Neuro checks in place. R #2 was assessed for pain. R #2 was alert and oriented X3. Hematoma to the head noted on R #2's right temporal. NP and RP notified. DON notified. EMS notified for transportation. RN from hospital notified on R #2's situation. R #2 was taken to the hospital. Injuries observed: hematoma to top of scalp. Level of pain: 6. Mental status: oriented to person, situation, and place. No injuries observed post incident. Predisposing situation factors: admitted within last 72 hours. Witnesses listed as Housekeeper and R #8. DON, FM, and MD notified. Notes: R #2 anxious and RP revealed R #2 was on medication for anxiety and hallucinations. NP to be in on 08/15/23 to evaluate and adjust medications as needed. R #2 to be put in bed after each meal within a timely manner. Fall mat to be placed at bedside when R #2 is in bed. Call light within reach. RP and MD aware. Full body assessment completed. Neuros in place. Incident witness: R #8. Dated 08/13/23. Statement: R #8 stated that she saw R #2 trying to get out of wheelchair and then fell on the ground. Incident witness: Housekeeper. Dated on 08/13/23. Who took statement: LVN A. Statement: Housekeeper was in hallway cleaning when she heard R #8 say someone fell, then notified nurse.<BR/>Record review of Provider Investigation dated 08/28/23 reflected <BR/>date and time reported to HHSC on 08/18/23 at 8:55 AM. <BR/>Incident category: other, fall with injury. <BR/>Incident date and time on 08/17/23 at 12:05 PM. <BR/>R #2 required no special supervision, was not able to ambulate independently, was not interviewable, and did not have the capacity to make informed decisions. <BR/>Provider response: Head-to-toe assessment, MD notified, RP notified, orders obtained for x-ray to left shoulder, R #2 sent to the hospital to confirm fracture.<BR/>Investigation Summary: R #2 had an unwitnessed fall in the hallway in front of the shower room at approximately 12:05 PM. R #2 was found by the CNA sitting on her bottom. R #2 stated she was trying to walk. The hallway was free from clutter and of spills leading to the fall. The nurse was notified, and a head-to-toe assessment completed. R #2 was noted with bruising and a skin tear to her left elbow with complaints of pain to her left shoulder. RP notified, MD notified, and orders obtained for an x-ray. At approximately 10:35 PM, X-ray on Wheels arrived at the facility and performed x-rays to left shoulder, humerus, elbow, forearm, wrist, and hand. At approximately 1:45 AM results showed an acute displaced left humeral neck fracture. R #2 sent to ER for confirmation and returned to the facility on [DATE] at 2:25 AM with confirmation of left humeral neck fracture. Orders to follow up with ortho. Peer to peer surveys with 15 employees show no signs of neglect. Life satisfaction rounds with 9 random residents show no signs or trends of neglect. Facility concluded the resident's fall was not due to neglect or abuse and fracture was a result of the fall. Neglect/Abuse unsubstantiated. Investigation findings: Unconfirmed. <BR/>Provider action taken post-investigation: In-services on fall prevention with 18 staff. R #2 pending referral from insurance for an ortho follow up. Facility to continue all previous fall interventions. Interventions: bed in lowest position, fall mats, R #2 to be placed in bed after meals and showers. Therapy to evaluate and treat. Psych evaluation for anxiety concerns. <BR/>Witness statement dated 08/18/23 reflected LS was walking through the dining hall. LS saw R #2 on the floor and reported it to the cafeteria aide. She reported it to AD. LS saw a CNA and she attended to R #2. A nurse went to R #2. Signed. <BR/>Record review of the in-service record dated 08/18/23 for Topics: abuse and neglect, fall prevention, and plan of care (POC). <BR/>Record review of the Policy:<BR/>Resident Incident and Visitor Accident Report Policy (revised 07/23/18)<BR/>Resident Incidents/Accidents:<BR/>-If staff witness an incident/accident, staff must: immediately summon help, do not move the resident until he/she has been assessed by a licensed nurse, and do not leave the resident unattended.<BR/>-Licensed nurse must: examine the resident and obtain vital signs, if the resident hit his/her head or if the incident is unwitnessed initiate neurological checks, conduct further assessment as warranted, render appropriate treatment, notify the physician, family, legal representative, and notify the administrator/designee and/or DON/designee.<BR/>In an interview with R #2 on 09/07/2023 at 11:30 AM. R #2 said her arm is in a sling because it is broken. R #2 said she cannot be walking because she loses her balance. R #2 said she has fallen several times. R #2 said when she falls, the staff always respond. R #2 said the staff help her up. R #2 said she does not remember how many times she has fallen. R #2 said it seems like a lot. R #2 said she does not remember when R #2 fell. R #2 said she does not know until when she needs to wear the sling. R #2 said she fell out of bed. R #2 said she fell out of her wheelchair. R #2 said she was in the hallway. R #2 said she fell out of bed. R #2 said she is pretty sure the nurse checked her. R #2 started mumbling random words and was speaking nonsensically. R #2 said she can eat. R #2 said somebody feeds her. R #2 said the staff feed her. R #2 said somebody stays with her to eat. R #2 said her son said she can stay here. R #2 said random words. R #2 said they wrote the sign for her. R #2 said her purse was in the restroom. R #2 was confused. R #2 said she can have things like she wants. R #2 said she does not know if she has lost weight. R #2 said she gets hungry and receives enough food here. R #2 said she did have bruising to her face. R #2 said the bruising was from a fall before she came here to this facility. R #2 said she does not remember where she fell but it was not here. R #2 said the nurses give her medications with thick water. R #2 said she needs that kind of water. R #2 said she does not know why. R #2 said she takes pain medication and other medications, but she does not know the names of the medications. R #2 started mumbling random words again. R #2 was speaking nonsensically. This investigator attempted to redirect R #2 to answer questions. R #2 continue to speak about random topics.<BR/>Observation on 09/07/23 at 11:45 AM. R #2 was lying in with the bed in lowest position. R #2 had a thick mattress next to her bed. The call light was within reach and the room had a homelike environment with personal photos and decor. R #2 was observed with purplish bruising, mainly to the right side of R #2's face and arms. R #2 was observed to be wearing a sling on her left shoulder. R #2 was observed moving her right arm. The room was clean and free of odors. R #2 had good personal hygiene and was not in distress.<BR/>In an interview with CNA B on 09/07/23 at 2:30 PM. CNA B said on 08/17/23, R #2 fell during CNA B's shift. CNA B said she did not see R #2 fall. CNA B said somebody said R #2 was on the ground. CNA B said she does not remember who said R #2 was on the ground. CNA B said she went to tell the nurse. CNA B said she went to tell the morning nurse, but she does not remember which nurse it was. CNA B said the nurse went to check on R #2. CNA B said she does not remember if R #2 said what happened. CNA B said R #2 was on the ground in front of the shower area. CNA B said the nurse went to assess R #2, but CNA B did not stay there. CNA B said R #2 was sitting in her wheelchair, she assumes because she was up to go to dining. CNA B said she did not put R #2 in her wheelchair that day. CNA B said she did not know who put her in the wheelchair. CNA B said R #2 did not require any special supervision. CNA B said she does not remember if R #2 was sent to the hospital. CNA B said she was informed about the fracture the next day. CNA B said R #2 had a sling on her left shoulder. CNA B said she thinks R #2 already had the bruising to her face before her fall on 08/17/23. CNA B said R #2 had fallen on her face. CNA B said she was informed that R #2 had fallen. CNA B said after those two times, R #2 never fell off the wheelchair again because they were instructed to not get her up that frequently. CNA B said they get her up into her wheelchair for meals and they cannot leave her alone in the wheelchair. CNA B said R #2 also has a mattress next to her bed now. CNA B said they try to explain to R #2 that she cannot get up, but she does not understand sometimes and will still try.<BR/>In an interview with LVN A on 09/07/23 at 3:40 PM. LVN A said she worked on 08/13/23 when R #2 fell off her wheelchair. LVN A said when she was notified by the housekeeper that R #2 had fallen. LVN A said when she arrived to the tv room, R #2 was on the floor. LVN A said she saw R #2 had a hematoma (bump) to the right side of her forehead. LVN A said R #2 had fallen on R #2's right side. LVN A said she assumed this because of the bump, not because anyone told her this. LVN A said it was at around 2 PM because it was almost time for shift report. LVN A said R #2 could not tell LVN A what happened. LVN A said she notified the doctor and the doctor ordered x-rays to make sure there was nothing broken and because she had the hematoma. LVN A said she notified the family, and they had no concerns. LVN A said the ambulance arrived sometime after and transported R #2 to the hospital. LVN A said R #2 came back to the facility. LVN A said R #2 did not have any other injuries besides the hematoma. LVN A said R #2 did have bruising around the hematoma. LVN A said she had bruising on the right side of her face, but nothing else, no fractures. LVN A said the bruising was a result of this fall. LVN A said she had not seen bruising to R #2's face before this fall. LVN A said when R #2 was first admitted she was very anxious. LVN A said R #2's medications were reviewed and adjusted. LVN A said she is not sure exactly when the medications were adjusted. LVN A said R #2 is doing much better now. LVN A said R #2 also has the fall mattress next to her bed and she has not fallen off her wheelchair anymore because she cannot be left alone in the wheelchair after the fall on 08/17/23 when R #2 sustained the fracture.<BR/>In an interview with Laundry Staff (LS) on 09/07/23 at 4:00 PM. LS said she clocked out to go to lunch at around 12:30 PM, and on the way to the break room, LS turned towards the nurse's station. LS said she saw R #2 on the floor in the hallway in front of the shower area. LS said she turned and called the other staff, AD, that was coming from the other hall. LS said LS walked towards R #2. LS said R #2 was not yelling or calling out for help. LS said R #2 was not saying anything. LS said LS told CNA B. LS said CNA B went to call LVN B. LS said once CNA B came back and stayed with R #2, LS went to the break room. LS said nobody else had seen R #2 on the floor before LS saw her. LS said when LS saw R #2, nobody had witnessed R #2 fall because nobody was assisting R #2 yet. LS said R #2 was not bleeding and she did not see any injuries on R #2. LS said she assumed R #2 fell. LS said she did not see R #2 fall. LS said nobody had witnessed R #2 fall. LS said she did not see any scratches or other injuries to R #2, but she did not move R #2. LS said she was not sure on which side R #2 was on. LS said she thinks R #2 was sent to the hospital to get checked. <BR/>In an interview with Housekeeper on 09/07/23 at 4:20 PM. Housekeeper said she recalls working when R #2 had a fall in the tv room on 08/13/23. Housekeeper said she was talking to RN A down the hallway. Housekeeper said they heard a thump, so she and RN A went down the hallway to the tv room. Housekeeper said R #2 was on the floor. Housekeeper said R #2 fell face forward off the chair. Housekeeper said she does not know if R #2 was trying to get up to walk or how she fell as Housekeeper did not witness the fall. Housekeeper said when she saw R #2 in the tv room a little while before the fall, R #2 was just sitting there in the tv room and R #2 was fine. Housekeeper said R #2 did not say anything and did not mention what happened. Housekeeper said RN A called out for the nurse who was working on R #2's hall that day. Housekeeper said she did not recall who that other nurse was. Housekeeper said the nurses assessed and took care of R #2, so Housekeeper continued with her tasks. Housekeeper said she was not sure if R #2 was sent to the hospital or what happened after that. <BR/>In an interview with DON on 09/07/23 at 5:00 PM. DON said R #2 fell on [DATE] and then on 08/17/23. DON said both times were off the wheelchair. DON said it took them some time to realize that R #2 was at risk for falls. DON said the team was told by the family that R #2 would be fine in a wheelchair and did not mention R #2 would fall off the wheelchair. DON said after the falls, the team realized R #2 was at risk for falls. DON said if they knew R #2 was at risk for falls, then they would have implemented something sooner. DON said the family told the team that if R #2 was in her wheelchair, that R #2 would not fall. DON said when she was first admitted , R #2 was very erratic and high anxiety. DON said R #2 needed the medications for her anxiety. DON said after the first fall, the bedside fall mats were put in place, and they also put R #2's bed in the lowest position, even though the first fall was not in R #2's room. DON said R #2 was referred to psych services and had R #2's medications reviewed. DON said R #2 was put back on some of the medication that the hospital had discontinued. DON said after the second fall they implemented the mattress which is what R #2 has now, which is a mattress that is at the same level as R #2's bed. DON said the second fall off the wheelchair was in the hallway. DON said R #2 moves around a lot. DON said after the second fall, R #2 wears a sling since R #2's left shoulder is fractured. DON said R #2 takes off the sling. DON said now they do not get R #2 up as often as per the family's request, to prevent falls. DON said R #2 rolls around in bed but since she has that mattress, R #2 does not fall. DON said R #2 had a bump on her head resulting from the fall on 08/13/23. DON said R #2 was admitted with bruising to her face. DON said the bruising had healed a little, but then R #2 fell on [DATE] and the bruising got worse. DON said R #2 still has some bruising, mainly on the right side. DON said R #2 had bruising on her body too. DON said R #2 had the bedside fall mats and R #2 was falling on those too. DON said they decided to put the mattress, which is still considered a fall mat, but it is higher. DON said R #2 can move around more especially when R #2 gets anxious, R #2 will be moving around a lot. <BR/>In an interview with AD on 09/08/23 at 11:30 AM. AD said she recalls working when R #2 fell on [DATE]. AD said one of the laundry workers made her aware that R #2 was on the floor. AD said she did not see R #2 fall. AD said she asked R #2 what happened, and R #2 said she was trying to scoot up out of the chair and fell off the chair. AD said after the nurse arrived, AD left the area. AD said R #2 was admitted into the facility with bruising to her face and body, so R #2 already had bruising before this fall. AD said the nursing staff did inform everybody that R #2 had a fracture to her left shoulder. AD said R #2 tends to try to do things by herself even though she is not able to anymore. AD said R #2 does not understand that she cannot get up and walk.<BR/>In an interview with FM on 09/08/23 at 11:42 AM. FM said he was concerned about R #2 falling at the facility. FM said on 08/13/23, R #2 fell and hurt her head. FM said on 08/17/23, R #2 fell again and fractured her left shoulder. FM said for the first fall, R #2 wanted to get up and walk, and R #2 fell on her face. FM said the second fall, R #2 fell off the wheelchair. FM said R #2 was in the hallway and again she tried to get up to walk and fell. FM said after the first fall, he does not think much was done to prevent another fall. FM said the family wanted more interventions in place. FM said after the fall on 08/17/23, the family asked that R #2 is not put in the wheelchair as much because R #2 fell off the wheelchair on 08/17/23.<BR/>In an interview with LVN B on 09/08/23 at 11:45 AM. LVN B said she recalls working on 08/17/23 when R #2 fell. LVN B said she does not remember who, but one of the CNAs or staff informed her that R #2 was on the floor in the hallway. LVN B said R #2 was lying on her side. LVN B said R #2 had told LVN B that R #2 was not in pain and that R #2 had not hit her head. LVN B said R #2 did not tell her what happened or how she ended up on the floor. LVN B said when she asked R #2 what happened, R #2 said the little girl. LVN B said R #2 will be in and out of reality at times. LVN B said the doctor said to monitor R #2 for any changes. LVN B said she and another staff assisted R #2 up into the wheelchair. LVN B said she kept R #2 sitting in the wheelchair, but she put her right next to LVN B in the nurse's station, so she could monitor her. LVN B said R #2 kept tugging at R #2's arm. LVN B said she asked R #2 if she was in pain, but R #2 continued to say no. LVN B said about an hour later, R #2 said yes that she was in pain. LVN B said she informed the doctor and the doctor ordered x-ray. LVN B said the mobile x-ray company arrived and did the x-rays. LVN B said R #2 did have a fracture to her left shoulder. LVN B said the doctor ordered for R #2 to be sent out to the hospital to confirm the fracture. LVN B said her shift ended and the next shift sent her out to the hospital. LVN B said the next day she came into work and was informed during report that R #2 did have a fracture to her left shoulder. LVN B said R #2 was wearing a sling on her left shoulder. LVN B said when there is a fall, the nurse notifies the DON and the Administrator, and they are made aware of the fracture or injury. LVN B said after the fall on 08/17/23, the staff were told to not leave R #2 alone in the wheelchair. LVN B said R #2 is also fed in her room to lessen the falls. LVN B said the interventions have been working as R #2 has not had any more falls off the wheelchair. <BR/>In an interview with Administrator on 09/08/23 at 1:45 PM. Administrator said R #2 has had several falls since her admission. Administrator said she was not sure exactly how many falls R #2 has had. Administrator said after the first fall, they put fall mats into place in R #2's room. Administrator said R #2 was referred to therapy services but the facility was having an issue with the insurance authorization. Administrator said R #2 was referred to psych services because R #2 was very anxious which is why R #2 was trying to get out of the wheelchair. Administrator said the NP did a medication review and adjustment to control R #2's anxiety and because R #2 was hallucinating. Administrator said she does not think R #2 had injuries from the first fall. Administrator said R #2 had come to the facility bruised up from previous falls at the other facility. Administrator said R #2 already had that bruising to her face. Administrator said after the fall on 08/17/23, R #2 had the fracture to her left shoulder. Administrator said she does not really know what happened. Administrator said when she spoke to R #2 after the second fall, R #2 was just rambling and saying random sentences. Administrator said R #2 said her arm hurt. Administrator said R #2 did not tell Administrator that R #2 fell off the wheelchair. Administrator said staff followed the proper protocol for the falls/incidents. Administrator said the staff notified the nurse, the nurse assessed R #2, and the nurse notified the doctor and family. Administrator said upon admission, R #2 was already at fall risk from report from the other facility. Administrator said that is why R #2's bed was lowered to the lowest position since admission. <BR/>In an interview with FM on 09/18/23 at 9:00 AM. FM said things have been going much better. FM said R #2 has not had any more falls. FM said R #2 has not been injured anymore which was their biggest concern.<BR/>In an interview with R #2 on 09/18/23 at 10:00 AM. R #2 said she was doing well. R #2 said she had eaten breakfast. R #2 said it was good. R #2 said everything was fine. R #2 was asked other questions however R #2 continued to say everything was fine.<BR/>Observation on 09/18/23 at 10:10 AM. R #2 was lying in with the bed in lowest position. R #2 had a thick mattress next to her bed. The call light was within reach and the room had a homelike environment with personal photos and decor. R #2 was observed to be wearing a sling on her left shoulder. R #2's bruising on face was almost gone. The room was clean and free of odors. R #2 had good personal hygiene and was not in distress.<BR/>In an interview with MDS Coordinator (MDSC) on 09/18/23 at 11:40 AM. MDSC said R #2 thinks she can still walk but she cannot. MDSC said R #2 cannot ambulate because of R #2's cognition. MDSC said R #2 did use the wheelchair and R #2 could self-propel the wheelchair with her feet and grab the hallway rail and pull herself. MDSC said R #2 was still using the wheelchair after 8/13/23 and still uses the wheelchair now. MDSC said they did not put any assistive devices on R #2's wheelchair because the issue was not R #2's wheelchair. MDSC said the issue was that R #2 did not understand that R #2 cannot get up to walk. MDSC said between R #2's psychosis, dementia, and stroke, R #2 just does not comprehend. MDSC said R #2's medications were adjusted. MDSC said on 08/16/23 they implemented the floor mattress next to the bed after the 08/13/23 fall. MDSC said that is when R #2's medications were also referred to be reviewed. MDSC said on 08/17/23 they implemented for R #2 to be taken to bed after meals and shower, bed in lowest position, floor bed mats at bedside, and emergency room (ER) for evaluation. MDSC said 08/13/23 was a weekend so once they were back, the team evaluated and implemented interventions. MDSC said the dates on the care plan would be the dates those interventions were implemented. MDSC said the team put an intervention in place that R #2 cannot be left alone in her wheelchair anymore. MDSC said that was after the second fall off her wheelchair on 08/17/23. MDSC said on 8/16/23, R #2 had a fall in her room where R #2 fell to her knees on the bedside mat. MDSC said the floor mattress was implemented after that as the care plan notes on 08/16/23. MDSC said the floor mattress was for the 08/16/23 fall, not for the one on 08/13/23. MDSC said on 08/13/23, R #2 was sent to the ER. MDSC said R #2 returned from the hospital on [DATE]. MDSC said on 08/15/23, the NP did a medication review to address the 08/13/23 fall.<BR/>In an interview with DON on 09/18/23 at 1:00 PM. DON said on

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to take appropriate actions during an investigation of an unwitnessed accident in that facility policy required investigations to be prompt, comprehensive and responsive to the situation and contain founded conclusions for 1 of 1 (Resident #1) residents reviewed for incidents/accidents. <BR/>Resident #1 experienced a fractured right humerus. During the investigation no conclusion was drawn as to how the injury occurred. This incident was reported to the state on 6/17/2023. <BR/>This failure could affect residents by having unnecessary or inappropriate remedies implemented, or having no appropriate remedies implemented to ensure resident safety. <BR/>Findings include:<BR/>Record review of Resident #1's clinical record's face sheet revealed an [AGE] year-old female with the diagnoses of other specified disorders of bone density and structure (unspecified site), Alzheimer's disease, dementia, abnormal gait, humerus fracture. <BR/>Record review of Resident #1's Care Plan, accessed on 7/20/2023 at 3:30 PM, indicated Resident #1 had limited physical mobility r/t muscle weakness. Interventions revealed Resident #1 was WEIGHT-BEARING with transfers. She required the assistance of one staff. <BR/>Record review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #1 experienced a significant change. Resident #1 had a documented BIMS score of 03 out of 15, indicating severe cognitive impairment. <BR/>A review of Resident #1's medical notes dated 6/17/23 at 5:50 AM and written by LVN B indicated CNA C notified charge nurse that resident was complaining of right arm pain, charge nurse assessed arm and noted three discolorations to right arm on forearm 3.5cm x3.5cm, above elbow 8cm x2cm and on elbow2.5cm x1.5cm, PRN pain medication administered, communication note sent to physician, VS- 96%, 67-P, 106/61, 18-RR, will ask morning nurse to contact RP due to early morning hours. <BR/>During an interview with CNA C on 8/7/2023 at 3:33 PM she indicated she went to change Resident #1 on 6/17/2023 around 1 PM and barely touched her arm and Resident #1 said her arm hurt. CNA C said she moved her sleeve and saw a bruise. <BR/>Record review of Resident #1's medical notes dated 6/17/2023 at 1:26 AM, written by LVN B, indicated LVN B texted PCP with request for X-ray. <BR/>Record review of Resident #1's medical notes dated 6/17/2023 at 12:35 PM, written by LVN B, indicated RP was notified. <BR/>Record review of Resident #1's medical notes dated 6/17/2023 at 4:00 PM, written by LVN B, indicated X-ray was performed. <BR/>A review of Resident #1's medical notes dated 6/17/2023 at 7:14 PM, written by LVN B, indicated RP was not available to be informed of positive x-ray results. The facility medical director ordered Resident #1 to the ER for a second opinion of x-ray interpretation. <BR/>A review of Resident #1's medical notes dated 6/17/2023 at 7:36 PM, written by LVN B, indicated EMS was notified to pick Resident #1 up from facility and transport to ER. <BR/>A review of Resident #1's medical notes dated 6/17/2023 at 10:24 PM and written by MDS coordinator indicated: Received report from RN at Local Hospital ER that the resident (Resident #1) had a mild displacement with fracture to right humeral neck and is to keep sling in place until follow up with ortho of PCP choice. Floor nurse and DON made were made aware. <BR/>During an interview and observation of Resident #1 on 7/20/2023 at 3:45 PM, she expressed no pain. Resident #1 was able to follow simple requests. Resident #1 was wearing socks on her feet and could not display a full range of motion when requested to move her feet. Resident #1 was unable to describe her injury, or how her injury occurred. Resident #1 was in no obvious distress. <BR/>During an interview with Resident #1's daughter on 8/8/2023 at 10:40 AM she said the facility DON told her they did not know how her mother broke her arm and that her mother did not fall. <BR/>During an interview with the DON on 7/21/2023 at 11:20 AM, she stated she did not want to assume anything and therefore did not reach a conclusion as to what probably happened with the resident. When asked why the bruise looked elongated, as if Resident #1 had banged her arm on a table or bar, she said she did not know. No conclusion as to what happened or what probably happened was forthcoming. <BR/>During an interview with CNA E on 8/8/2023 at 3:40 PM she said she worked from 2 to 10 on 6/16/2023. She said Resident #1 usually takes a nap after dinner and does not get out of bed again until breakfast. CNA E said she did not remember changing Resident #1, but probably changed her before 10 PM. CNA E said they always do a last round before leaving. CNA C said there was nothing out of the ordinary. <BR/>During an interview with hospitality aid D on 8/8/2023 at 4:05 PM she said she probably interacted with Resident #1 but does not remember. Hospitality aid D said the next time she came to work, Resident #1 was a Hoyer lift. <BR/>Record review of the facility's Provider Investigation Report #431171 included:<BR/>Resident chart notes 6/16/2023 - 6/17/2023<BR/>in-service: abuse and neglect dated 6/17/2023 <BR/>in-service: gait belt transfers dated 6/17/2023 <BR/>Attestation form of gait belt requirement (all direct care staff) <BR/>Grievance log July, June, May, April, March: no trends <BR/>Record review of Abuse Policy (5/01/01 Revised 5/28/2021) indicated:<BR/>The facility will thoroughly investigate all alleged violations and take appropriate actions. <BR/>Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that include measurable objectives and time frames to meet residents' physical needs for 1 of 1 (Resident #1) residents reviewed for care plans.<BR/>The facility failed to develop a care plan to address Resident #1's fractured Humerous, which is the largest bone in the upper arm. <BR/>This failure could affect residents by placing them at risk of not having their needs met.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet revealed an 85 y/o female with diagnoses of other specified disorders of bone density and structure (unspecified site), Alzheimer's disease, dementia , abnormal gait, and a Humerus fracture. <BR/>Record review of Resident #1's Care Plan, accessed on 7/20/2023 at 3:30 PM indicated Resident #1 had limited physical mobility r/t muscle weakness. Interventions revealed Resident #1 was WEIGHT-BEARING with transfers. She required the assistance of one staff. <BR/>Record review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 experienced a significant change. Resident #1 had a documented BIMS score of 03 out of 15, indicating severe cognitive impairment. <BR/>A review of Resident #1's medical notes dated 6/17/23 at 5:50 AM indicated: CNA C notified charge nurse that resident was complaining of right arm pain, charge nurse assessed arm and noted three discolorations to right arm on forearm 3.5cm x3.5cm, above elbow 8cm x2cm and on elbow2.5cm x1.5cm, PRN pain medication administered, communication note sent to physician, VS- 96%, 67-P, 106/61, 18-RR, will ask morning nurse to contact RP due to early morning hours.<BR/>A review of Resident #1s medical notes from 6/17/2023 at 2200 (10:00 PM) indicated: Received report from RN at Local Hospital ER that the resident has a mild displacement with fracture to right humeral neck and is to keep sling in place until follow up with ortho of PCP choice. Floor nurse and DON made aware. <BR/>During an interview and observation of Resident #1 on 7/20/2023 at 3:45 PM, she expressed no pain. Resident #1 was able to follow simple requests. Resident #1 was wearing socks on her feet and could not display a full range of motion when requested to move her feet. Resident #1 was unable to describe her injury, or how her injury occurred. Resident #1 was in no obvious distress. <BR/>During an observation on 7/20/2023 at 3:45 PM all staff on hall had gait belts available. <BR/>During an interview and observation of Resident #1 on 7/20/2023 at 3:45 PM with CNA E she said Resident #1 could not walk and used a Hoyer Lift to get from her bed to her wheelchair. <BR/>During an interview with DON on 7/20/2023 at 3:50 PM, she said she thought there should be a care plan for that (using a Hoyer Lift). The DON said they could possibly be providing incorrect care. <BR/>During an interview with the MDS coordinator on 7/20/2023 at 4:00 PM, she said they just changed Resident #1's transfer requirements to a Hoyer lift, and she just updated her care plan. <BR/>During an interview with the DON on 7/21/2023 at 9:00 AM, she said she thought they had 5 days once the incident investigation was done to do the care plan. The DON said the MDS coordinator had been on vacation and that is why the care plan was late.<BR/>During an interview with CNA E and CNA B on 7/21/2023 at 4:25 PM, they said they received a turnover report and were told then Resident #1 was a Hoyer lift now because of her arm. <BR/>Record review of Care Plan Policy (Nexion 10-2022; Reviewed [DATE]) indicated the comprehensive, person-centered care plan is developed within (7) days of the completion of the required comprehensive assessment (MDS).<BR/>Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 (Resident #2 and Resident # 122) of 5 residents and 4 of ( CNA C, CNA D, CNA E, and HA F) staff that were reviewed for infection control in that:<BR/>1. CNA C and CNA D did not perform hand hygiene for 20 seconds or longer and did not remove contaminated gloves during peri care after changing Resident # 2's brief and prior to putting on a new brief. <BR/>2. CNA E and Hospitality Aide F did not perform hand hygiene prior to peri care and did not perform hand hygiene for 20 seconds or longer after peri care. CNA E and Hospitality Aide E did not remove contaminated gloves during peri care after changing Resident #122's brief and prior to putting on a new brief. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings include:<BR/>1. Record review of Resident # 2's face sheet dated 4/25/2024 reflected a [AGE] year-old female with an admission date of 1/19/2024. Diagnoses included chronic obstructive pulmonary disease (chronic obstructed airflow from the lungs), type two diabetes (insufficient production of insulin in the body), and heart failure.<BR/>Record review of Resident #2's MDS dated [DATE] reflected a BIMS of 99 (Severe cognitive impairment) and was always incontinent and required total dependence.<BR/>During an observation of peri care for Resident #2 on 04/23/2024 at 02:33 PM CNA C and CNA D did not change gloves after removing Resident #2's soiled brief and began to place a clean brief on using contaminated gloves. After peri care was performed, CNA C and CNA D performed hand hygiene for approximately 15 seconds.<BR/>In an interview on 4/23/2024 at 02:50 PM, CNA C stated Resident #2's brief was wet but did not change her gloves after she removed the soiled brief because it was not a BM (bowel movement), and she did not see anything that was dirty on her gloves and did not think she had to change them. CNA C stated she did not count while she washed her hands and did not know how long she washed her hands for. CNA C stated hand washing should be around 30 seconds to prevent the spread of germs to residents and others. CNA C could not recall when the last in-service or training was.<BR/>In an interview on 4/23/2024 at 02:52 PM CNA D stated gloves should be changed between a dirty and a clean procedure if there was feces or if gloves were visibly soiled. CNA D stated hand hygiene should be for about 20 to 30 seconds to prevent the spread of germs to residents. CNA D could not recall when the last in-service on hand washing, or infection control was.<BR/>2. Record review of Resident #122's face sheet dated 4/25/2024 reflected an [AGE] year-old-female with an original admission date of 12/22/2014. Diagnoses included cerebrovascular disease (disease that affects the blood vessels in your brain), cognitive communication deficit, and hypertension (high blood pressure). <BR/>Record review of Resident #122's MDS dated [DATE] reflected a BIM score of 7 (severe cognitive impairment) and was always incontinent with partial to moderate assistance required.<BR/>During an observation of peri care for Resident #122 on 04/25/24 at 02:11 PM, CNA E and Hospitality Aide F did not perform hand hygiene prior to putting on gloves and began to perform peri care. After peri care was performed and soiled brief was removed, CNA E and Hospitality Aide F did not remove contaminated gloves. Hospitality Aide F then began to open Resident #122's drawers with contaminated gloves looking for barrier cream. Hospitality Aide F then removed gloves, left Resident #122's room to get barrier cream and returned. Hospitality Aide F did not perform hand Hygiene before proceeding with care and put on new gloves. CNA E removed only one glove and did not perform hand hygiene and placed on one new glove prior to placing a clean brief on Resident #122. After peri care was performed, CNA E removed gloves and performed hand hygiene for approximately 5 seconds. <BR/>In an Interview on 04/25/24 at 02:25 PM, both CNA E and Hospitality Aide F stated they were nervous and did not realize they had missed steps. CNA E stated it was important to wash hands for about 20 seconds or longer to stop the spread of germs and diseases to residents. Both CNA E and Hospitality Aide F stated they did not think they had to change their gloves after cleaning Resident #122 because her brief was not visibly soiled. Both CNA E and Hospitality Aide F stated the last infection control and hand hygiene in-service was done within the past month. <BR/>In an interview on 04/25/24 at 02:32 AM, the DON stated hand washing should be 20 seconds or greater to prevent the spread of bacteria to residents and other surfaces. The DON stated all gloves should be changed between brief changes from a dirty to clean procedure to ensure effective infection control practices and stop the spread of germs to staff, residents, and other surfaces. The DON stated last hand hygiene/ infection control in-service was done within the last month and is also conducted on an as needed basis.<BR/>In an interview on 04/25/24 at 02:46 PM, the ADON stated effective hand washing of 20 seconds or greater is important to prevent the spread of infection to residents, staff, and visitors. ADON stated hands should be washed prior to performing care and gloves should be changed after performing peri care to reduce the risk of cross contamination from a clean to dirty surface. ADON stated once a month in-service on infection control and hand washing is conducted with staff. <BR/>Record review of Handwashing/Hand Hygiene policy dated 3/1/2020 stated:<BR/>Policy Statement<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>b. Before and after direct contact with residents;<BR/>d. Before performing any non-surgical invasive procedures;<BR/>i. After contact with a resident's intact skin;<BR/>m. After removing gloves;<BR/>9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine. <BR/>Record review of Infection Prevention and Control Program revised on 10/2022 and reviewed on 1/2023 stated:<BR/>An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 3 med room nutrition refrigerators in that:<BR/>The steam table was not clean <BR/>The shelf on the steam table was not clean <BR/>The juice gun and rest tray were not clean <BR/>The ice machine was not clean<BR/>The refrigerator temperatures were above the required minimum<BR/>The dishwasher temperatures were below the required minimum<BR/>There were unlabeled foods in the med room nutrition refrigerator<BR/>These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness.<BR/>Findings were:<BR/>Observations of the kitchen during the initial tour on 02/21/23 at 10:15 AM revealed: The juice gun & rest tray was covered with a thick, sticky-looking substance. The steam table wells had thick, flaking, crusty yellowish, and brown substances in each of the 4 compartments. The shelf above the steam table had a brown substance the entire width of the underside of the shelf, above the food compartments. The underside of the shelf above the steam table had pieces of brown substance hanging down from it, above the food compartments. The ice machine had dots of a black fuzzy substance inside all over the ice chute and a white fuzzy substance around the rim of the inside of the door. The can opener had debris on it. <BR/>Observation of the med room nutrition refrigerator in the 200 hallway on 02/21/23 at 12:15 PM revealed a package of grapes and a container of food that were both unlabeled and had no resident name on them. <BR/>Observation and interview with the MS on 02/21/23 at 01:50 PM regarding the ice machine, the MS stated the last time the ice machine was cleaned was about a month ago. The MS demonstrated what parts of the machine he cleaned and stated the black dots on the ice chute were always there and he tried scrubbing it before. Some of the black dots came off when he rubbed his finger on them. The MS stated that very hard water in the facility caused the substances. The MS stated the white substance around the inside of the door was dust. The MS stated he was responsible for ceaning the ice machine. The MS stated he cleaned the ice machine monthly. The ice machine remained as described throughout the survey.<BR/>Observations and interview with the DM on 02/22/23 beginning at 09:10 AM: the DM stated the steam table was basically cleaned every two days on a rotating schedule by the cooks. The DM stated, the steam table wells had looked that way (thick, flaking, crusty yellowish, and brown substances in all compartments) for 5 years since she was first employed at this facility. The DM stated, we wash the wells and scrub them but it doesn't come off. The DM stated she had not reported it because they had always been that way and she did not know it was wrong. The DM stated she was unaware of the condition of the underside of the shelf above the steam table. The DM stated the brown substance looked like rust. The DM stated it was important to keep equipment clean because the residents were at risk of getting sick if something dropped into the food on the steam table from the bottom of the shelf. The DM stated it was likely the brown stuff had fallen into the food on the steam table. The DM stated the wells in the steam table could harbor germs. The DM stated the cooks were responsible for cleaning the steam table. The DM stated the shelf above the steam table was part of the steam table, but the staff did not clean it. The DM stated the stuff on the shelf above the steam table could fall into the food or attract gnats. The DM stated it was important so they wouldn't have contaminations, gnats and things falling into food. The DM stated, the residents could get sick-pretty badly. <BR/>Observation of the dishwasher temperature/chemical logs documented the temperature to be below the minimum 120F for 15 of 31 days in January 2023, 8 of 22 days in February, and 3 days in February were not logged at all. The DM stated she was not sure what the temperature should be, only that she was taught the temperature gauge had to be in the green zone on the temperature gauge. [The green zone on the temperature gauge showed 135F-145F] <BR/>The DM stated the chemical testing strips (used to determine correct sanitation levels) were not reading since the beginning of the month (February), but she noticed values had been logged. The DM stated she asked her staff how they were determining those values and none of them would say. The DM stated the logs had been falsified. <BR/>The DM stated she obtained new testing strips from the vendor on 02/21/23. The DM stated the vendor showed her the expiration date on the vial she had been using, and the test strips were outdated. The DM stated she was unaware of the expiration dates on the vials, or that the vials had expiration dates. <BR/>The DM stated she had informed the MS about the refrigerator temperatures being above the required 41F in January 2023, but nothing had been done to fix it. The DM stated the process for reporting malfunctioning or broken equipment was to let the MS know. The kinds of food not stored at the appropriate temperature were butter, milk, cheeses, mayonnaise, dressing, eggs, opened pickles and relish [the labels read refrigerate after opening], various vegetables, pre-made sandwiches, breads, and left-over foods; bagged scrambled eggs, chopped sausage and pork. <BR/>[The current refrigerator temperature was 40F]<BR/>During an interview with LVN A on 02/21/23 at 12:17 PM, LVN A stated all food and drinks that belong to the residents should have their name, date, and contents labeled. LVN A stated since there was only 1 resident who kept food in there, they knew it was his. When asked if someone else put something in the refirgerator belonging to another resident, how would anyone one know what belonged to whom? LVN A stated she would label the items, and it was the nurses responsibility to label residents items in the refrigerators.<BR/>Interviews with COOK A and COOK B on 02/22/23 at 09:30 AM: COOK A stated she was new and had not cleaned the steam table. COOK B stated when it was his turn, he washed out the steam table wells and scrubbed them as best he could. COOK B stated the wells had always been that way.<BR/>During an interview with the MS on 02/22/23 at 04:36 PM regarding the refrigerator temperatures: the MS stated the thermostat had been getting stuck in the open position and that would cause the temperatures to be off. The MS stated he knew nothing of the logbook from January 2023 to now, documenting higher than the required minimum of 41F. The MS stated the thermostat had been replaced a couple of hours ago. The MS stated the process for reporting malfunctioning equipment was to let him know and he would either attempt to fix it himself or call the vendor for repairs. The MS denied having been informed about the temperatures in January 2023. The MS stated every morning, the first thing he did was to check all the doors, then look at the temperature gauges on the refrigerators and freezer in the kitchen. The MS stated he never looked at the logbooks.<BR/>During an interview with the ADM on 02/23/23 at 01:00 PM, she stated the process of reporting malfunctioning equipment was for anyone to place the request in the facility's electronic maintenance log, to inform a supervisor or the ADM. The ADM stated she checked the electronic maintenance log this morning and there were no requests from the kitchen. The ADM stated she was conducting weekly rounds in the kitchen that did not include reviewing the logbooks. The ADM stated the DM was responsible for training new kitchen staff but was obviously not teaching them the right way if she herself did not know. The ADM stated she was ultimately responsible for the kitchen. <BR/>Record review of the refrigerator temperature logs, 20 days of 31 in January 2023 were above the minimum safe temperature of 41F, and 3 days were not logged at all. The high temperatures in January ranged from 41F to 58F. For 12 of 22 days in February 2023 were above the minimum safe temperature of 41F, with 2 days not logged at all. <BR/>The high temperatures in February ranged from 41F to 50F.<BR/>Record review of the facility's policy titled Refrigerator and Freezers dated 10/2022 stated: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .1) Acceptable temperature ranges are 35F to 40F for refrigerators .3) Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. [There was no column for action taken on the tracking sheets.] 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted.<BR/>Record review of the facility policy titled Sanitization dated 10/2022 stated: The food service area shall be maintained in a clean and sanitary manner. 2) All utensils, counters, shelves, and equipment shall be kept clean, and maintained in good repair and shall be free from breaks, corrosions, open cracks, and chipped areas that may affect their use or proper cleaning .8) Low-temperature dishwasher a) Wash temperature (120F) 12) Ice machines .will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 17) The food service manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas .

Based on interviews, and record review, the facility failed to designate a person to serve as director of food and nutrition services who is a qualified dietary manager 1 of 1 facility in that:<BR/>The facility has been without a certified dietary manager since 10/01/2018.<BR/>This failure could result in the dietary needs of all residents served by the kitchen not being met. <BR/>Findings included:<BR/>Record review of the DM's Personnel file on 02/21/23 revealed that the facility's current Dietary Manager was hired on 10/01/18. The file contained documentation that the Dietary Manager had completed a precertification course on 06/20/20, but contained no other qualifications.<BR/> An interview with the DM on 02/21/23 at 2:30 PM revealed that she completed her coursework in June 2020. The DM stated she applied for testing for her DM certification in January 2022. The DM stated something happened at the testing center and the program locked up and kicked her out. The DM stated she attempted the test again in August 2022 and failed. The DM provided proof to re-test on 03/15/23. The DM did not respond as to why testing had still not been completed. The DM stated there had been no interim DM assigned. <BR/>During an interview on 02/23/23 at 1:00 PM, the ADM confirmed the system failure at the testing center in January 2022. The ADM also stated the DM attempted testing again in August 2022 but failed. The ADM was unable to provide any documentation/transcripts as proof of attendance. The ADM stated she had not been following up weekly with DM to assure compliance with the certification exam was complete. The ADM did not answer the question as to why a corporate (or other) interim DM had not been assigned since the December 2021 survey. The ADM stated there was an RD, but the RD was not full-time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide separately locked and permanently affixed compartments for Schedule II-V medications and/or other medications subject to abuse in two (B and C wing) of two medication rooms that contained emergency use narcotics boxes.<BR/>The facility failed to ensure the emergency use narcotic boxes in B and C wing medication rooms were permanently affixed.<BR/>These failures could place residents at risk for misappropriation and/or diversion of medication.<BR/>Findings included:<BR/>Observation on [DATE] at 10:20 AM, the medication storage room on the secured memory unit C wing revealed a key locked door into the medication room. LPN A had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. <BR/>Observation on [DATE] at 11:32 AM, the medication storage room in B wing revealed a locked door into the room. The ADON had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. <BR/>In an interview on [DATE] at 11:35 AM, the ADON stated the rules for storing narcotics were that the narcotics had to be double locked, logged, and expiration dates checked. The ADON stated narcotics stored in the refrigerator had to be at the correct temperature and in a separate locked, unmovable box. The ADON stated the red boxes came from the pharmacy and if something was expired or a medication was used, the pharmacy would take the whole box and replace it with another. The ADON stated she would call the pharmacy to see what they could do about a permanently affixed box.<BR/>In an interview on [DATE] at 01:08 PM, the DON stated narcotics are to be double locked and secured. The DON stated the pharmacy brought the red boxes to the facility. The DON stated the pharmacist who checked the boxes never told the facility the boxes had to be permanently affixed and just made them double lock them. The DON stated the red boxes had been that way for years and no one had said anything about it.<BR/>Record review of the facility's Medication Labeling and Storage Policy dated 2001 and revised February 2023 stated in part:<BR/>7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide separately locked and permanently affixed compartments for Schedule II-V medications and/or other medications subject to abuse in two (B and C wing) of two medication rooms that contained emergency use narcotics boxes.<BR/>The facility failed to ensure the emergency use narcotic boxes in B and C wing medication rooms were permanently affixed.<BR/>These failures could place residents at risk for misappropriation and/or diversion of medication.<BR/>Findings included:<BR/>Observation on [DATE] at 10:20 AM, the medication storage room on the secured memory unit C wing revealed a key locked door into the medication room. LPN A had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. <BR/>Observation on [DATE] at 11:32 AM, the medication storage room in B wing revealed a locked door into the room. The ADON had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. <BR/>In an interview on [DATE] at 11:35 AM, the ADON stated the rules for storing narcotics were that the narcotics had to be double locked, logged, and expiration dates checked. The ADON stated narcotics stored in the refrigerator had to be at the correct temperature and in a separate locked, unmovable box. The ADON stated the red boxes came from the pharmacy and if something was expired or a medication was used, the pharmacy would take the whole box and replace it with another. The ADON stated she would call the pharmacy to see what they could do about a permanently affixed box.<BR/>In an interview on [DATE] at 01:08 PM, the DON stated narcotics are to be double locked and secured. The DON stated the pharmacy brought the red boxes to the facility. The DON stated the pharmacist who checked the boxes never told the facility the boxes had to be permanently affixed and just made them double lock them. The DON stated the red boxes had been that way for years and no one had said anything about it.<BR/>Record review of the facility's Medication Labeling and Storage Policy dated 2001 and revised February 2023 stated in part:<BR/>7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide separately locked and permanently affixed compartments for Schedule II-V medications and/or other medications subject to abuse in two (B and C wing) of two medication rooms that contained emergency use narcotics boxes.<BR/>The facility failed to ensure the emergency use narcotic boxes in B and C wing medication rooms were permanently affixed.<BR/>These failures could place residents at risk for misappropriation and/or diversion of medication.<BR/>Findings included:<BR/>Observation on [DATE] at 10:20 AM, the medication storage room on the secured memory unit C wing revealed a key locked door into the medication room. LPN A had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. <BR/>Observation on [DATE] at 11:32 AM, the medication storage room in B wing revealed a locked door into the room. The ADON had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. <BR/>In an interview on [DATE] at 11:35 AM, the ADON stated the rules for storing narcotics were that the narcotics had to be double locked, logged, and expiration dates checked. The ADON stated narcotics stored in the refrigerator had to be at the correct temperature and in a separate locked, unmovable box. The ADON stated the red boxes came from the pharmacy and if something was expired or a medication was used, the pharmacy would take the whole box and replace it with another. The ADON stated she would call the pharmacy to see what they could do about a permanently affixed box.<BR/>In an interview on [DATE] at 01:08 PM, the DON stated narcotics are to be double locked and secured. The DON stated the pharmacy brought the red boxes to the facility. The DON stated the pharmacist who checked the boxes never told the facility the boxes had to be permanently affixed and just made them double lock them. The DON stated the red boxes had been that way for years and no one had said anything about it.<BR/>Record review of the facility's Medication Labeling and Storage Policy dated 2001 and revised February 2023 stated in part:<BR/>7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.