BROWNWOOD NURSING AND REHABILITATION

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 3 medication carts reviewed for storage in that:<BR/>The facility failed to ensure medication cart #1 was locked and secured while unattended.<BR/>This failure could result in a drug diversion. <BR/>The findings include:<BR/>During an observation and interview on 02/13/2025 at 1:55 PM, the medication cart was unattended at the nursing station with the drawers facing out, the button that locks the cart was not pushed in and the drawers opened when they were pulled. There was a resident standing within arm's reach of the medication cart. RN A was seen coming down the hall at 2:00 pm. RN A stated she had gotten distracted because therapy had asked her to do something.<BR/>During an interview on 02/13/2025 at 02:15 PM, RN A stated the medication cart should not be left unlocked and unattended at any time. RN A stated she got called away to give a resident in physical therapy a medication and just forgot to lock medication cart. RN A stated the harm could be if a resident opened the medication cart and took a medication that was not prescribed for them, if could cause an adverse reaction to medication. RN A stated the types of medications stored on this cart are Insulin, are , creams, inhalers, nebulizers, glucometer and lancets, needles, alcohol wipe pads and over the counter pain relievers, vitamins, stool softeners. RN A stated she had been trained on use of medication carts and to keep the cart locked when not in use.<BR/>During an interview on 02/13/2025 at 02:20 PM, the DON stated medication carts should always be locked when not in use. The DON stated the harm could be a resident or visitor accessed the medication cart and took a medication not for them. The resident or visitor could have allergic reaction, overdose for even cause death. DON stated her expectations were that all medication carts be always locked when not in use. DON stated and she and the ADON monitor medication carts throughout the day to ensure they are kept locked and secured for resident safety. DON failure likely occurred because nurse was in a hurry to get medication to resident and forgot to lock medication cart. DON stated all nurses and CMAs (certified medication aide) were trained on use of medication carts and when and how to lock them. <BR/>Review of facility's policy titled:<BR/>Medication Carts (ND)<BR/>1. <BR/> The medication carts shall be maintained by the facility.<BR/>2. <BR/>The carts are to be locked when not in use or under the direct supervision of the designated nurse.<BR/>3. <BR/>Carts not in use are to be stored in a designated area not blocking egress in the building.<BR/>4. <BR/>Carts must be secured.<BR/>5. <BR/>Cart should be clean

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.<BR/>The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage.<BR/>The facility failed to ensure all food was not past expiration date.<BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>The findings included:<BR/>During an observation on 01/23/2024 between 9:55 AM and 10:25 AM of the kitchen revealed: <BR/>Refrigerator #1<BR/>1. <BR/>One open container of cottage cheese with an use by date of 01/06/2024.<BR/>2. <BR/>One unopened container of cottage cheese with an use by date of 01/06/2024.<BR/>3. <BR/>One plastic container with a seal contained canned mushrooms and was not labeled with a food item description or an use by date. <BR/>4. <BR/>One plastic container with a seal contained canned black olives and was not labeled with a food item description or an use by date. <BR/>Dry Storage<BR/>1. <BR/>Ten packages of flour tortillas out of the original box not labeled with a food item description or date. <BR/>2. <BR/>One package of green tortillas out of the original box was not labeled with a food item description or date. <BR/>During an interview on 01/23/2024 at 10:30 AM, the DM stated items that were passed their use by date should have been discarded. The DM stated food items should have label of item and dated. The DM stated residents could have been affected by getting food that was not flavorful. The DM stated the cooks and herself were responsible to ensure items were discarded and labeled correctly. The DM did not have a reason for the failure. <BR/>During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that food should have been labeled with a use by 'date and food item description. The ADO stated food should have been thrown out when past the use by date. The ADO stated the DM was responsible to monitor. The ADO stated what led to failure was the DM just missed them. <BR/>Record review of facility policy title, Food Storage and Supplies dated 2012 revealed: Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.<BR/>Record review of facility policy title, Storage Refrigerators dated 2012 revealed: Food must be covered when stored, with a date label identifying what is in the container.<BR/>Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/25/2024 revealed: <BR/>3-602.11 Food Labels.<BR/>(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.<BR/>(B) Label information shall include:<BR/>(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement.<BR/>(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD.<BR/>(3) An accurate declaration of the net quantity of contents.<BR/>(4) The name and place of business of the manufacturer, [NAME], or distributor; and<BR/>(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf<BR/>(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act &sect; 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.<BR/>(7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.<BR/>Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs for 6 (Resident # 1, Resident #33, Resident #37, Resident #44, Resident #46, and Resident #51) of 6 residents reviewed for care plans. <BR/>The facility failed to specify measurable objectives that could be evaluated or quantified for Resident #1, Resident #33, Resident #37, Resident #44, Resident #46, and Resident #51.<BR/>The facility failed to specify measurable objectives that could be evaluated or quantified with a timeframe to achieve for Resident #1, Resident #44, and Resident #46.<BR/>These failures could place residents at risk for not receiving timely interventions or interventions not individualized to meet their specific physical, mental, and/or emotional needs.<BR/>Findings included:<BR/>Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of respiratory failure, low red blood cell count, heart disease, back pain, Type 2 diabetes, kidney disease, and mental illness.<BR/>Resident #1's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Record review of Resident #1's Comprehensive Care Plan reviewed and revised 12/29/2023 revealed objectives lacking ability to be evaluated or quantified were: the resident will be free from discomfort or adverse reactions related to anticoagulant [drug that thins the blood] use ., the resident will have reduced episodes of diarrhea ., the resident will display optimal breathing pattern daily . , the resident will have no s/sx of poor oxygen absorption . , the resident will have complication related to medications kept to a minimum . , the resident will have complications related to diabetes kept to a minimum . , the resident will have discomfort or adverse reactions related to antidepressant therapy kept to a minimum . , the resident will maintain optimal quality of life within limitation imposed by visual function ., the resident will not have discomfort related to side effects of analgesia [drug used to treat pain] and will report adequate pain relief after intervention ., the resident will not have any complications r/t bowel incontinence . ,the resident's will Skin tear of the right for-arm will be healed . , and The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score .<BR/>The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were the resident will maintain or improve their independence with ADLs and will not be injured related to bed rail use, and resident will have the specialized services recommended by local authority per PASRR Specialized Services program as needed.<BR/>Record review of Resident #33's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of obesity, heart failure, arthritis, respiratory failure, high blood pressure, difficulty sleeping, and depression.<BR/>Resident #33's MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Record review of Resident #33's Comprehensive Care Plan reviewed and revised 12/29/2023 revealed objectives lacking ability to be evaluated or quantified were: The Resident will display optimal breathing pattern daily . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use . , The Resident will cooperate with care . , The resident will not have any complications r/t bowel incontinence . , and The Resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score .<BR/>Record review of Resident #37's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of broken left arm, Type 2 diabetes, heart disease, high blood pressure, weakness, heartburn, stroke, and malnutrition.<BR/>Resident #37's Significant Change in Status MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 8 out of 15 indicating moderate cognitive impairment. <BR/>Record review of Resident #37's Comprehensive Care Plan reviewed and revised 01/09/2024 revealed objectives lacking ability to be evaluated or quantified were: The resident will have complications of cardiac problems kept to a minimum . , The resident will have complication related to hypertension kept to a minimum . , The resident will have complication related to diabetes kept to a minimum . , The resident will show decreased episodes of s/sx of depression . , The resident will be able to make basic needs known verbally on a daily basis ., The resident will not have discomfort related to side effects of analgesia . , and Resident will not show a decline in psychosocial well-being or experience adverse effects . , <BR/>Record review of Resident #44's electronic face sheet revealed an [AGE] year-old male, admitted on [DATE] with medical diagnoses of dementia, kidney stones, high blood pressure, arthritis, knee pain, and anxiety.<BR/>Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 11 out of 15 indicating moderate cognitive impairment. <BR/>Record review of Resident #44's Comprehensive Care Plan reviewed and revised 12/12/2023 revealed objectives lacking ability to be evaluated or quantified were: The Resident will have complications related to Diabetes kept to a minimum . , The Resident will have no indications of acute [sudden onset] eye problems . , The Resident will not have discomfort related to side effects of analgesia ., The Resident will show decreased episodes of s/sx of Anxiety . , The Resident will have discomfort or adverse reactions related to antidepressant therapy kept to a minimum . , The Resident will be able to communicate basic needs, needs will be met and dignity will be maintained on a daily basis . , The Resident will return to prior level of function after wound healing and rehabilitation . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use . , The resident will receive daily opportunities for social contact . , and The Resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was Maintain stable weight and nutritional parameters.<BR/>Record review of Resident #46's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of broken right upper leg, Parkinson's disease (a disorder of the nervous system), heart disease, Type 2 diabetes, Alzheimer's disease (a disease that affect memory and thought processes), chronic pain, history of falling, and high blood pressure.<BR/>Resident #46's Significant Change in Status MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Record review of Resident #46's Comprehensive Care Plan reviewed and revised 01/23/2024 revealed objectives lacking ability to be evaluated or quantified were: The Resident will be offered encouraged and assisted to accept adequate hydration . , The resident will not have any complications r/t bowel incontinence . , Resident will maintain the highest level of communication for this resident . , , The Resident will be able to communicate basic needs, needs will be met and dignity will be maintained on a daily basis . , The resident will demonstrate effective coping skills . , Dignity will be maintained and the resident will be kept comfortable and pain free with in one hour of intervention . , The Resident will return to prior level of function after wound healing and rehabilitation . , The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene .<BR/>The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was The resident will not have any cardiac complications related to Antiarrhythmic [drug that regulates the heart's rhythm] use. <BR/>Record review of Resident #51's electronic face sheet revealed an [AGE] year-old male, admitted on [DATE] with medical diagnoses of dementia, weakness, heartburn, dizziness, cardiac pacemaker, high cholesterol, and hearing loss.<BR/>Resident #51's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 15 out of 15 indicating intact cognition. <BR/>Record review of Resident #51's Comprehensive Care Plan reviewed and revised 12/14/2023 revealed objectives lacking ability to be evaluated or quantified were: The resident will have discomfort or adverse reactions related to anticoagulant use kept to a minimum . , The resident will have drug related complications, including movement disorder, discomfort, hypotension [low blood pressure], gait [walking]disturbance, constipation/impaction or cognitive/behavioral impairment kept to a minimum . , The resident's safety will be maintained . , The resident will demonstrate effective coping skills . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use ., The resident will be compliant with thyroid replacement therapy . , The resident will have s/sx of complications of cardiac problems kept to a minimum . , The resident will improve current level of cognitive function . , and The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene and will be clean, dry, and free from odors with dignity maintained.<BR/>During an interview on 01/25/2024 at 2:45 PM MDS B stated that care plans should have incorporated all areas of patient care. MDS B stated minimum was not a measurable goal. MDS B stated the negative affect on residents could have affected their plan of care. MDS B stated what led to failure was new staff not knowing how to enter data into care plan and a lack of communication. <BR/>During an interview on 01/25/2024 at 3:05 PM the DON stated her expectation was that care plan would incorporate all areas of care for residents. The DON stated minimum was not a measurable goal. The DON stated MDS nurses were responsible to ensure that care plans were accurate and complete. The DON stated the residents could have been affected by residents may not have received conducive or accurate care. The DON stated the failure was caused by staff not being properly trained on initiating and entering data into care plan.<BR/>Record review of facility policy titled, Comprehensive Care Planning undated revealed, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 2 residents (Resident #44) reviewed for (DRR) Drug Regimen Review.<BR/>The facility failed to timely follow up on Resident #44's medication regimen review which had pharmacy recommendations. <BR/>This failure could place residents at risk for receiving unnecessary medications at the most effective dosage.<BR/>The findings included:<BR/>Resident #44<BR/>Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of dementia, kidney stones, high blood pressure, arthritis, knee pain, and anxiety.<BR/>Record review of Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 11 out of 15 indicating moderate cognitive impairment.<BR/>Record review of Resident #44's physician orders on 01/25/2024 revealed mirtazapine oral tablet 30mg give 1 tabled by mouth at bedtime for insomnia.<BR/>Record review of Resident #44's November 2023 MAR revealed mirtazapine was administered every day in November at 7:00 p.m.<BR/>Record review of Resident #44's December 2023 MAR revealed mirtazapine was administered every day in December at 7:00 p.m.<BR/>Record review of the Medication Regimen Review note written by consulting pharmacy with review date 11/08/2023 revealed Resident #44 had an order for Mirtazapine 30mg give 1 tablet at bedtime for Insomnia with recommendation of gradual dose reduction. Physician disagreed with recommendation and signed note on 12/01/2023 which was 24 days after recommendation. <BR/>During an interview on 01/25/2024 at 5:01 p.m., the DON stated that she was responsible for ensuring pharmacy recommendations were completed. The DON stated that the physician's office was faxed the MRR, but that facility never received the completed form. She stated that on 01/25/2024 facility sent someone to physician's office to receive MRR form with physician signature on 12/01/2023. The DON stated she did not know if the facility had a time frame in which to get MRR completed, and she asked the RCN. The DON stated that the failure occurred due to her being busy and overlooked the follow up part of the process. The DON stated that effect to patient could be detrimental depending on medication and resident. <BR/>During an interview on 01/25/2024 at 5:04 p.m., the RCN stated that it was the DON's responsibility to follow up on MRR recommendations. She stated that it was her expectation the DON would send MRR to physician within 72 hours of receiving recommendations then follow up with physician after no response in 5 days. She stated that the effect failure could have on residents was that they would be on unnecessary medication or dosage. <BR/>Record review of facility policy titled Consultant Pharmacist revised on 10/25/17 revealed: The pharmacist will provide a separate written report of irregularities to the attending physician, medical director, and director of nursing after their review .The attending physician will be notified of irregularities within 2 business days. The facility will deliver the reports either by email, fax, or hand delivery .If the facility has not received any communication from the physician regarding the irregularity within 5 business days, the facility staff will call the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed for 6 of 6 (Resident # 6, #4, #8, #42, #17 and #41) residents who received a pureed meal reviewed during the lunch meal. <BR/>The facility failed to ensure Residents recieving a puree texture diet were provided the food according to the menu, incuding potato salad and a roll. <BR/>This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss.<BR/>Findings included:<BR/>Record review of Resident #6's Quarterly MDS dated [DATE] revealed: Section A- Identification Information Resident #6 was an [AGE] year old male admitted on [DATE]; Section C- Cognitive Patterns Resident #6 had a BIMS of 12 (moderate cognitive impairment); Section K- Swallowing/Nutritional Status Resident #6 had a mechanically altered diet. <BR/>Record review of facility documents, titled, Resident Roster Diet Type dated 01/23/2024 revealed that Resident # 6, #4, #8, #42, #17 and #41 had texture type of puree for all meals. <BR/>During an observation on 01/23/2024 at 10:30 AM of the dining room revealed a posted menu on the dining room wall that stated Tuesday Lunch Menu: Barbeque Ribs, Baked Beans, Potato Salad, Honey Kissed Roll and Fried Apple pie. <BR/>During an observation and interview on 01/23/2024 starting at 11:30 AM of the kitchen, [NAME] A was observed pureeing the lunch meal. [NAME] A pureed barbeque meat and baked beans she did not puree potato salad or a roll . [NAME] A started lunch plate service and served a puree meal, that consisted of pureed barbeque meat, fortified mashed potatoes, pureed baked beans, and pureed fried pie. When questioned the DM stated the puree diets should have received potato salad and a roll not the fortified mashed potatoes. The DM asked [NAME] A if she had pureed the potato salad and roll, [NAME] A stated she had forgotten to puree the potato salad and roll. [NAME] A continued to serve the rest of the puree diets with fortified mashed potatoes and did not puree the potato salad and the roll. <BR/>During an interview on 01/23//2024 at 12:30 PM, the DM stated her expectation was residents who received pureed diets should have received the same meal as regular diets. The DM stated the effect on residents could have been not receiving the correct number of calories their meal was budgeted. The DM stated the cooks and herself were responsible for ensuring the menu was followed. The DM did not have an explanation to what led to the failure. <BR/>During an interview on 01/24/2024 at 9:11 AM, Resident #6 stated he had gotten potato salad once since he had been there and would like it more often and that he was usually served mashed potatoes. <BR/>During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that all residents were served the same menu. The ADO stated the purred meal should have received the potato salad and the roll. The ADO stated the effect on residents could have been residents might not have received the correct nutrient values their diet required. The ADO stated the DM was responsible to ensure the menu was followed. The ADO stated she was not able to provide a response to why the menu was not followed for the puree diet. <BR/>During exit conference on 1/25/204 at 6:30 PM the ADO stated they did not have any other policies to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.<BR/>The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage.<BR/>The facility failed to ensure all food was not past expiration date.<BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>The findings included:<BR/>During an observation on 01/23/2024 between 9:55 AM and 10:25 AM of the kitchen revealed: <BR/>Refrigerator #1<BR/>1. <BR/>One open container of cottage cheese with an use by date of 01/06/2024.<BR/>2. <BR/>One unopened container of cottage cheese with an use by date of 01/06/2024.<BR/>3. <BR/>One plastic container with a seal contained canned mushrooms and was not labeled with a food item description or an use by date. <BR/>4. <BR/>One plastic container with a seal contained canned black olives and was not labeled with a food item description or an use by date. <BR/>Dry Storage<BR/>1. <BR/>Ten packages of flour tortillas out of the original box not labeled with a food item description or date. <BR/>2. <BR/>One package of green tortillas out of the original box was not labeled with a food item description or date. <BR/>During an interview on 01/23/2024 at 10:30 AM, the DM stated items that were passed their use by date should have been discarded. The DM stated food items should have label of item and dated. The DM stated residents could have been affected by getting food that was not flavorful. The DM stated the cooks and herself were responsible to ensure items were discarded and labeled correctly. The DM did not have a reason for the failure. <BR/>During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that food should have been labeled with a use by 'date and food item description. The ADO stated food should have been thrown out when past the use by date. The ADO stated the DM was responsible to monitor. The ADO stated what led to failure was the DM just missed them. <BR/>Record review of facility policy title, Food Storage and Supplies dated 2012 revealed: Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.<BR/>Record review of facility policy title, Storage Refrigerators dated 2012 revealed: Food must be covered when stored, with a date label identifying what is in the container.<BR/>Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/25/2024 revealed: <BR/>3-602.11 Food Labels.<BR/>(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.<BR/>(B) Label information shall include:<BR/>(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement.<BR/>(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD.<BR/>(3) An accurate declaration of the net quantity of contents.<BR/>(4) The name and place of business of the manufacturer, [NAME], or distributor; and<BR/>(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf<BR/>(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act &sect; 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.<BR/>(7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.<BR/>Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure ulcers.<BR/>The facility failed to ensure unnecessary pressure wasn't caused by Resident #1's knee immobilizer to Resident #1's left posterior ankle/calf and left lateral leg which caused an unstageable pressure injury and left lateral leg unstageable pressure injury from a medical device.<BR/>An Immediate Jeopardy (IJ) situation was identified on 2/22/2023 at 5:21 PM. While the IJ was removed on 2/23/2023 at 4:07 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. <BR/>This failure placed residents at risk for improper wound management, the development of new pressure ulcers, deterioration, infection, pain, loss of limb, or death. <BR/>Findings include:<BR/>Record review of Resident #1's electronic face sheet, dated 12/29/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: displaced supracondylar fracture without intercondylar extension of lower end of right femur (Supracondylar femoral fracture (also called a distal fracture) is when the thigh bone, or femur, is broken at the knee), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), muscle weakness and lack of coordination. <BR/>Record review of Resident #1's Initial MDS assessment, dated 1/2/2023, revealed a BIMS score was not obtained. Section G revealed Resident #1 required extensive assistance from two persons for bed mobility and toilet use; extensive assistance from two staff for locomotion on and off the unit, dressing, personal hygiene, and bathing; Limited assistance of two staff members for transfers. Section M revealed Resident #1 was at risk for pressure ulcers/injuries but did not have any. <BR/>Record review of Resident #1's care plan, dated 12/24/2023, revealed resident has the potential for pressure ulcer development Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Date Initiated: 12/24/2022. Ensure heels are floated with the use of pillows. Resident has a surgical site observe for s/s of infection (increased redness, increased pain, drainage, etc). Report to physician if noted. <BR/>Record review of the hospital progress notes dated 12/16/2022 revealed Resident #1 was admitted to hospital on [DATE] due to a fall sustained at home which resulted in both femurs being fractured. <BR/>Record review of the hospital progress notes, dated 12/18/2022, revealed Resident #1's skin assessment which indicated no wounds on the resident. The skin was normal appearing in texture and temperature, no rash, petechiae (are pinpoint, round spots that appear on the skin because of bleeding), or lesions noted. <BR/>Record review of the hospital progress notes, dated 12/21/2022, revealed Resident #1 had Bilateral Supracondylar Fractures of the femur, operation completed, a long-leg compression bandages were applied in both lower extremities and knee immobilizers. <BR/>Record review of the hospital progress notes, dated 12/23/2022, revealed Resident #1's was transferred from the hospital to Facility A on 12/24/23. <BR/>Record Review of Resident #1 DR-C orders, dated 12/21/2023, did not indicate any removal or non-removal of knee immobilizers. Did not indicate anything with skin care. Orders were not clear. <BR/>Record review of Resident #1's initial skin assessment, dated 12/24/2023, completed by LVN-D, indicated skin color normal, skin temperature warm, bruising: no, skin tear: no, moisture associated skin damage: no, and does the resident have a pressure, venous, arterial, or diabetic ulcer: no.<BR/>During an interview on 2/16/2023 at 3:15 PM, LVN-D stated she really couldn't remember about Resident #1 knee immobilizers. She stated she couldn't remember if the residents' braces were ever taken off. She stated she couldn't remember ever taking the residents braces off personally. She stated she could not remember removing or opening immobilizers to do the initial skin assessment. She stated that any device that is on a resident when they enter the facility should be removed to do an initial skin assessment, unless doctor orders specify to not remove the device. She stated this is done to know if the resident had any skin injury before being accepted into the facility. <BR/>Record review of Resident #1's skin assessment, dated 12/31/2023, completed by RN-B, indicated skin color normal, skin temperature warm, bruising: no, skin tear: no, moisture associated skin damage: no, and does the resident have a pressure, venous, arterial, or diabetic ulcer: no.<BR/>Attempted interview with RN-B on 2/16/2023 at 4:30 PM, 2/17/2023 at 10:25 AM, 2/21/2023 at 3:15 PM and 2/22/2023 at 11:45 AM were unsuccessful. No call back was received prior to exit on 2/23/2023.<BR/>Record review of Resident #1 transfer order, dated 1/2/2023, indicated per family request resident was sent back to the hospital due to being confused and not acting like herself. <BR/>Record review of the hospital progress notes, indicated on 1/3/23, ICU-E nurse notes that bilateral knee immobilizers and pressure prevention boots removed. ACE wrap/kerlex and Inconel original dressing removed. Multiple wound/skin abnormalities/pressure injuries noted; too numerous to count. Called for unit camera for detailed admission documentation, but one was not available. Upon my assessment I see: Left lateral foot deep tissue injury left posterior ankle/calf unstageable pressure injury, left lateral leg unstageable PI, left heel DTI with blood blister, Right heel Stage 1 PI, R posterior Upper thigh intact blood blister, posterior bilateral thighs DTI's, sacral and coccyx DTI's, L hip stage 2/open blister, multiple mid-back DTI's/Bruises. All present on admission. Family reports she had surgery on 12/21/22 and was discharged on 12/23/22<BR/>Attempted interview with ICU-E on 2/21/2023 at 3:45 PM, 2/22/2023 at 10:45 AM, and 2/23/2023 at 9:45 AM was unsuccessful. No call back was received prior to exit on 2/23/2023.<BR/>Record review of the hospitals wound care notes, with pictures, dated 1/4/23, indicated 4 wounds total on left leg. Left posterior ankle/calf unstageable PI Measuring 9x2.5x0 (LxWxD in cm), Left lateral leg unstageable PI measuring 2.5x1.5x0.1, R posterior upper thigh intact blood blister, and posterior bilateral thigh DTI's.<BR/>Record review of transfer orders dated 1/9/2023 revealed Resident #1 was transferred to Facility B on 1/10/2023 due to wounds.<BR/>Record review of Resident #1 transfer order dated 1/25/2023, revealed Resident #1 was transferred back to the hospital on 1/25/2023 due to wounds.<BR/>Record review of Resident #1's wound care notes, dated 1/25/2023, indicated: Left posterior Achilles/calf, wound condition-chronic, odor-yes, Unstageable pressure injury obscured full thickness skin and tissue loss, Measurement- 23x5x0.1 (previously it was 9x2.5x0), S/S of infection-Yes Assessment Notes: Under the care of DR-C in the nursing home. Wounds originally caused from knee immobilizer, worse than last admission. <BR/>Record review of Resident #1 transfer order dated 1/27/2023 revealed Resident #1 was transferred back to Facility B on 1/27/2023 due to wounds.<BR/>Record review of Resident #1 transfer order dated 2/13/2023 revealed Resident #1 was transferred back to the hospital on 2/13/2023 due to wounds.<BR/>Record review of wound care notes, dated 2/13/2023, indicated: Left posterior Achilles/calf, <BR/>wound condition-chronic, odor-yes, Unstageable pressure injury obscured full thickness skin and tissue loss, Measurement- 30x9x0.2 (originally it was 9x2.5x0) S/S of infection-Yes, Pain-4/10, Assessment Notes: DR-C consulted and per note no further surgical intervention. Need consult for wound care doctor to see patient. <BR/>During an interview on 2/16/2023 at 11:15 AM, MR-A stated if the only wound care notes in her system were of the initial assessment on 12/19/2023 and there was nothing by the date of Resident #1's transfer on 12/24/2023 this indicated no wounds were formed/found on the resident by the time of discharge from the hospital. <BR/>During an interview on 2/15/23 at 3:30 PM, the DON stated Resident #1 was only at the facility for 8 days. She stated the only thing she remembered about the resident was the resident was in double braces for both legs due to having a double hip fracture. She stated the resident had two leg braces on. She stated she never removed the leg devices while she was at the facility, to assess the skin. She stated she remembered because the two scheduled shower days while she was at the facility, she was due for showers and the braces were not removed. She stated the braces were not removed to do the shower, Resident #1 was wrapped in plastic from the waist to the lower legs to transfer to shower and give the resident her shower. She stated facility staff should have called the physician for the directions on if the braces should be removed or not, but we did not contact the physician. <BR/>During a phone interview on 2/17/2023 at 4:45 PM, DR-C stated his expectation was Resident #1's braces should have been at least opened or removed for a skin assessment at the facility. He stated when Resident #1 left the hospital her skin was in good condition. He stated he was unaware the resident had skin wounds even when she got back to the hospital. <BR/>During an interview on 2/16/2023 at 4:15 PM, the ADON stated if any resident came into the facility with a brace around any part of the body and a skin assessment was to be done, the brace should be removed. She stated she didn't remember Resident #1 directly but, in her case, if she came into the facility with braces on around both legs, they should have been removed to access the skin for the initial skin assessment when she was transferred from the hospital to their facility. She stated the first thing that should be followed was the doctors' orders. She stated if there were no doctors' orders the facility should reach out to the physician for the orders.<BR/>Record review of the facility's policy, dated 2003, titled Immobilization Devices, Splints/Slings/Collars/Straps indicated: <BR/>Goals<BR/>1. <BR/>The resident will achieve safe and effective application of supportive immobilization devices.<BR/>2. <BR/>The resident will maintain baseline neurovascular and skin integrity status.<BR/>3. <BR/>The resident will be free from injury associated with immobilization devices.<BR/>Procedure<BR/>1. <BR/>Review physician's order. <BR/>1. <BR/>Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint.<BR/>2. <BR/>All immobilization devices, except clavicle straps, should be removed periodically. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet.<BR/>3. <BR/>Skin integrity should be assessed periodically when the device is removed.<BR/>This was determined to be an Immediate Jeopardy on 2/22/2023 at 5:21 PM. The Administrator was notified. The Administrator was provided with the IJ template on 2/22/2023 at 5:21 PM. <BR/>The following Plan of Removal was submitted by the facility was accepted on 2/23/2023 at 11:00 AM: <BR/>Identified Concern: The facility failed to prevent the development of multiple avoidable pressure sores for one resident. [Resident #1] who was ordered bilateral knee immobilizers on 12/21/2022 related to fracture's resulting from a fall. From 12/24/2022 to 1/2/2023 both knee immobilizers were never removed to assess skin. On 1/2/2023 [Resident #1] was identified with multiple wounds to an area covered by the knee immobilizer on both legs . <BR/>The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues:<BR/>Problem: Failure to prevent pressure injury <BR/>Interventions:<BR/>100% skin rounds initiated 2/22/23 by DON, ADON, Treatment Nurse LVN-D. With RCN oversight. <BR/>Assessment done for Resident #2, Resident #3 and Resident #4 (only other residents in house with braces of any kind. No immobilizers in house. <BR/>Issues founded during skin rounds will be addressed, treatment orders will be obtained, ulcer assessment will be completed, and care plans updated. Families and physicians will be notified if any skin issues are found. <BR/>Residents with immobilizers or braces have the potential to be affected by alleged deficient practice. <BR/>The following in-services were initiated by the RCN 2/22/23: Any nurse not present or in-serviced on 2/22/23, will not be allowed to assume their duties until in-serviced. Ongoing <BR/>In-service will be completed by DON/ADON/TREATMENT NURSE/OR RN Supervisor, until all staff, weekend, PRN, and agency staff in completed. <BR/>The following in-services were initiated by the RCN 2/22/23<BR/>o <BR/>Licensed Nurses: <BR/>Pressure ulcer prevention and treatment. <BR/>What to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses.<BR/>Licensed Nurses will have competency for performing skin assessments starting 2/22/23 by DON/RCN, and will continue until all staff is competent including, PRN, agency, and weekend staff is complete.<BR/>The medical director [DR-F] (acting medical director while [DR-G] is unavailable due to being out of the country) was notified of the immediate jeopardy situation on 2/22/23 at 6:23 pm.<BR/>Monitoring<BR/>The DON/designee will monitor all new residents with immobilizers/braces to ensure orders are in place for removal of immobilizer per physician orders, treatments have been ordered, ensure assessments done daily, 7 days a week X's 6 weeks, to ensure compliance using the monitoring tool. <BR/>The DON / designee will view each pressure ulcer weekly X's 6 weeks suing available monitoring tool.<BR/>The DON / designee will audit all skin assessments weekly to ensure all assessment match the resident's current condition for 6 weeks using current monitoring tool.<BR/>DON/designee will audit charting daily for accuracy of weekly skin assessments x's 6 weeks.<BR/>DON/designee will monitor all treatments being done for accuracy per orders using monitoring tools, x's 6 weeks <BR/>The QA committee will review findings at the monthly QA meeting and makes changes as needed. <BR/>Monitoring of the POR included the following:<BR/>During an interview on 2/23/2023 at 11:15 AM, RN-H (day shift) stated he did receive in-service that morning over immobilizers and devices on residents. He stated the in-service in detail was what to look for on the resident in skin assessments around a device and above and below the device if physician orders indicated to not remove the device, make sure there were physician orders in for every single device, if no there were no physician orders, do not make any assumptions about devices, make sure everything was spelled out in the doctor's orders on the details of removal or non-removal of the device, call physician if anything is no clear about the device and if it is allowed to be removed or not. <BR/>During a phone interview on 2/23/2023 at 2:00 PM, CNA-I (night shift) stated she was part of both in-services last night, dated 2/22/2023. She stated it was over how to reposition a resident, which is every 2 hours, the signs and symptoms of infection such as tenderness, redness, warm, and smell/drainage. She stated if there was anything on a resident that was observed to inform the charge nurse immediately. She stated they were to make sure from the charge nurse or DON that orders were in the system from the physician on what was allowed to be removed or not removed before taking a resident to the shower. She stated if no orders were in the system she is to wait until DON or charge nurse reaches out to the physician for exact orders. <BR/>Observation of LVN-D and the ADON revealed them completing skin assessment of Resident #2. The removable soft brace around the right knee was removed and skin was assessed by both nurses. The skin looked good, there was no breakdown, bruising or indentions within the skin where the brace was placed. Resident #2 did not complain in any way towards pain, tightness, or sensitivity. The braces were replaced back around the right knee and the resident went back to sleep.<BR/>During an interview on 2/23/2023 at 2:15 PM DON stated that she is doing all the checks that are indicated in the PoR. She stated she is going around every 2 hours to ensure residents are being repositioned and that the staff understands everything in the two in-services given on 2/22/2023 at 8:15 PM. She stated she will be working with LVN-D who is the new wound care nurse to do all assessments which she would review on ever new resident. She stated she would be the one doing all checks in the facility from this point on especially new resident with devices. She stated that care plans were being reviewed for all residents with devices. <BR/>During an interview on 2/23/2023 at 2:45 PM, CNA-J (day shift) stated she did get in-serviced the second she came into the facility. She stated it was over repositioning, skin checks, and wheelchair moving for residents. She stated she never messed with any devices unless it came to giving the resident a shower. She stated if this was a question, we go to our charge nurse or the DON for clarification on if the device needed to be removed or not before showering. She stated overall the in-service was on making sure the residents were being repositioned correct, in a timely manner. She stated that residents that need to be repositioned every 2 hours and if indicated as a 2 person assist, she should get help to do so. She stated that the in-service covered who to report if they saw anything unusual with the residents' skin, which includes tenderness, redness, heat, drainage, pain, etc.<BR/>During a phone interview on 2/23/2023 at 3:45 PM, LVN-K (night shift) stated the in-services covered skin and devices. She stated the first thing nurses needed to look at if they had a resident with a device/immobilizer was if there were physician orders in the system that specifically stated if the devices were allowed to be removed or not. She stated if there were orders, and the device was allowed to be removed then it should be removed every couple of hours to access the skin to make sure everything looked good. She stated if the physician order stated do not remove the device the skin still needed to be accessed above and below the device for any infection, swelling, or signs of wounds. She stated if anything was found during any of these assessments this was to be reported to the charge nurse or the DON immediately. She stated residents should be checked every two hours for repositioning.<BR/>Record review of in-services dated 2/22/2023 at 8:15 PM, titled what to do when resident is admitted with an immobilizer, led by the DON revealed the Topic covered: 1. When a resident is admitted to the facility with an immobilizer you must make sure that you have written orders from the physician stating whether you can remove the immobilizer. If there is no order, contact the physician to obtain orders for removal of immobilizer daily to assess skin and pulses under the immobilizer and notify the DON that a resident was admitted with an immobilizer without an order to remove for skin assessment. 2. If there was an order to leave the immobilizer in place you must assess the residents' skin around the top and bottom of the immobilizer for redness, swelling or any signs/symptoms of infection, check pulses and document it accurately. 3. If there is an order that you may remove the immobilizer, you must remove it to assess the skin and pulses under the immobilizer and document it accurately. 4. If there are any skin issues found under the immobilizer you need to notify the physician to obtain treatment orders, notify the DON, and document the finding accurately by completing an ulcer assessment. A signature page included which did have all staff that had worked the night before 2/22/2023 signatures and all employees in the building at currant time on 2/23/2023. <BR/>Record review of in-services dated 2/22/2023 at 8:15 PM, titled pressure ulcer prevention and treatment, led by DON revealed the topic covered: 1. Resident must be changed every time they had an incontinent episode or at the very least, every 2 hours, even when up out of bed. 2. Residents must be turned and repositioned at least every 2 hours. This included when they were up in their wheelchairs. 3. If you find they don't need incontinent care, they still need to be turned and repositioned a minimum of every 2 hours. 4. Residents that are difficult to turn must be repositioned and changed by 2 people. 5. Heels must be floated. 6. If a resident sits up in a chair, make sure they have a cushion in place. 7. It does not take long to develop a pressure ulcer and poor incontinent care and lack of turning and repositioning increases a resident's risk. 8. Nurses-you must do treatments as ordered. You are responsible for making sure the treatments are done when the treatment nurse is not here. If you have any concerns about a wound, report it to the treatment nurse or the DON/ADON immediately. A signature page included which did have all staff that had worked the night before 2/22/2023 signatures and all employees in the building at currant time on 2/23/2023. <BR/>The Administrator was informed that the Immediate Jeopardy was removed on 2/23/2023 at 4:07 PM. the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 24 residents (Residents #177) reviewed for baseline care plans. <BR/>The facility failed to develop baseline care plans for Insulin use, blood glucose monitoring, and self-medicating of insulin via insulin pump for Resident #177.<BR/>This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. <BR/>The findings included:<BR/>During an observation on 11/06/2022 at 2:24 PM, Resident #177 walked to the nurses' station on back hall and asked LVN A to get his Humalog insulin so he could refill his wearable insulin pump. Then Resident #177 drew up insulin, filled his insulin pump and placed pump on his left abdomen area.<BR/>Review of Resident #177's electronic face sheet revealed a [AGE] year-old male admitted [DATE] with diagnosis of Acute Osteomyelitis (infection of the bone) left ankle and foot, Type 2 Diabetes Mellitus (body does not control amount of glucose), schizoaffective disorder (psychotic and mood disorder), and non-pressure chronic ulcer of unspecified foot.<BR/>Review of the Physician orders dated 10/28/2022 for Resident #177 revealed no orders for insulin, glucose blood monitoring, or use of insulin pump.<BR/>Review of Resident # 177's baseline care plan dated 10/27/2022 revealed no mention of insulin pump. <BR/>Record review of the MDS dated [DATE] for Resident #177 revealed Section C, Cognitive Patterns BIMS score 15 (intact cognitive status). <BR/>Record review of the treatment administration record dated 10/27/2022 for Resident #177 revealed no recordings of glucose blood monitoring.<BR/>During an interview on 11/06/2022 at 02:24 PM, Resident #177 stated the insulin for his insulin pump was kept at the nurse's station. He stated he goes up to the nurses' station, request his insulin, fills his insulin pump and attaches the new pump himself. He stated he monitored his blood glucose with his monitor the on his left upper arm. <BR/>During an interview on 11/08/2022 at 10:45 AM, Resident #177 stated he did not have his insulin pump on admission to the facility. He stated his family brought the insulin pump to him about a week after being admitted to the facility. He stated before he had his insulin pump, the nurses were checking his finger stick blood sugar and administering Lantus(insulin) every day. He stated now that he had the insulin pump, the nurses asked him what his blood sugar was each day. He stated no one at the facility had monitored him on the use of insulin pump. He stated he took care of it himself.<BR/>During an interview on 11/08/2022 at 10:50 AM, LVN A stated Resident #177 did not have insulin pump on admission to the facility. LVN A was not able to find an order in resident record for Humalog insulin. She stated Resident #177 was on Lantus at time of admission. She stated Humalog the resident used in insulin pump was kept in the medication room refrigerator on back hall. She stated the resident brought Humalog from home. She stated she asked the resident what his blood glucose readings were each shift but did not record them anywhere in the resident's record.<BR/>During an interview on 11/08/2022 at 11:20 AM, the DON stated she was not sure why there were no orders for Humalog for Resident #177. She stated she was not sure when Humalog was ordered, and Lantus discontinued. She stated she did not know why there was not a self-medication evaluation for Resident #177 for his use of insulin pump. She stated all residents who wish to self-medicate should be evaluated prior to them doing so, to be sure they were safe with self-medicating. She stated Resident #177's use of insulin pump and his continuous glucose monitor should have been in his baseline care plan. She stated the admission RN or herself initiated the baseline care plan within 48 hours of admission. She stated not knowing the resident need for insulin could affect his health in a negative way, such as blood glucose being too high or too low, not receiving insulin as needed. She stated not monitoring his blood glucose could affect his health in a negative way with resident blood glucose being too low or too high and could cause resident to be hospitalized . She stated the hospital discharge orders had Humalog and insulin pump on his list. S he stated she reviewed the baseline care plans. She stated she did not know what caused the failure to occur.<BR/>During an interview on 11/08/2022 at 11:23 AM, LVN B stated she did the admission note for Resident #177. She stated the resident had his insulin pump on admission and that he showed her how it was used. She stated for new admissions, she would transcribe hospital orders to facility's Physician orders and then it was reviewed by an RN. She stated the potential for not having insulin pump on orders could be potential for missed doses, blood glucose being too high or too low and either of these could cause resident to be hospitalized .<BR/>Review of facility's policy titled Base Line Care Plans (no date)<BR/>The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- .<BR/>Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-<BR/> Initial goals based on admission orders.<BR/> Physician orders<BR/> Dietary orders <BR/>The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transcribing provider Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.<BR/>The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage.<BR/>The facility failed to ensure all food was not past expiration date.<BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>The findings included:<BR/>During an observation on 01/23/2024 between 9:55 AM and 10:25 AM of the kitchen revealed: <BR/>Refrigerator #1<BR/>1. <BR/>One open container of cottage cheese with an use by date of 01/06/2024.<BR/>2. <BR/>One unopened container of cottage cheese with an use by date of 01/06/2024.<BR/>3. <BR/>One plastic container with a seal contained canned mushrooms and was not labeled with a food item description or an use by date. <BR/>4. <BR/>One plastic container with a seal contained canned black olives and was not labeled with a food item description or an use by date. <BR/>Dry Storage<BR/>1. <BR/>Ten packages of flour tortillas out of the original box not labeled with a food item description or date. <BR/>2. <BR/>One package of green tortillas out of the original box was not labeled with a food item description or date. <BR/>During an interview on 01/23/2024 at 10:30 AM, the DM stated items that were passed their use by date should have been discarded. The DM stated food items should have label of item and dated. The DM stated residents could have been affected by getting food that was not flavorful. The DM stated the cooks and herself were responsible to ensure items were discarded and labeled correctly. The DM did not have a reason for the failure. <BR/>During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that food should have been labeled with a use by 'date and food item description. The ADO stated food should have been thrown out when past the use by date. The ADO stated the DM was responsible to monitor. The ADO stated what led to failure was the DM just missed them. <BR/>Record review of facility policy title, Food Storage and Supplies dated 2012 revealed: Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.<BR/>Record review of facility policy title, Storage Refrigerators dated 2012 revealed: Food must be covered when stored, with a date label identifying what is in the container.<BR/>Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/25/2024 revealed: <BR/>3-602.11 Food Labels.<BR/>(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.<BR/>(B) Label information shall include:<BR/>(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement.<BR/>(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD.<BR/>(3) An accurate declaration of the net quantity of contents.<BR/>(4) The name and place of business of the manufacturer, [NAME], or distributor; and<BR/>(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf<BR/>(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act &sect; 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.<BR/>(7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.<BR/>Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 3 medication carts reviewed for storage in that:<BR/>The facility failed to ensure medication cart #1 was locked and secured while unattended.<BR/>This failure could result in a drug diversion. <BR/>The findings include:<BR/>During an observation and interview on 02/13/2025 at 1:55 PM, the medication cart was unattended at the nursing station with the drawers facing out, the button that locks the cart was not pushed in and the drawers opened when they were pulled. There was a resident standing within arm's reach of the medication cart. RN A was seen coming down the hall at 2:00 pm. RN A stated she had gotten distracted because therapy had asked her to do something.<BR/>During an interview on 02/13/2025 at 02:15 PM, RN A stated the medication cart should not be left unlocked and unattended at any time. RN A stated she got called away to give a resident in physical therapy a medication and just forgot to lock medication cart. RN A stated the harm could be if a resident opened the medication cart and took a medication that was not prescribed for them, if could cause an adverse reaction to medication. RN A stated the types of medications stored on this cart are Insulin, are , creams, inhalers, nebulizers, glucometer and lancets, needles, alcohol wipe pads and over the counter pain relievers, vitamins, stool softeners. RN A stated she had been trained on use of medication carts and to keep the cart locked when not in use.<BR/>During an interview on 02/13/2025 at 02:20 PM, the DON stated medication carts should always be locked when not in use. The DON stated the harm could be a resident or visitor accessed the medication cart and took a medication not for them. The resident or visitor could have allergic reaction, overdose for even cause death. DON stated her expectations were that all medication carts be always locked when not in use. DON stated and she and the ADON monitor medication carts throughout the day to ensure they are kept locked and secured for resident safety. DON failure likely occurred because nurse was in a hurry to get medication to resident and forgot to lock medication cart. DON stated all nurses and CMAs (certified medication aide) were trained on use of medication carts and when and how to lock them. <BR/>Review of facility's policy titled:<BR/>Medication Carts (ND)<BR/>1. <BR/> The medication carts shall be maintained by the facility.<BR/>2. <BR/>The carts are to be locked when not in use or under the direct supervision of the designated nurse.<BR/>3. <BR/>Carts not in use are to be stored in a designated area not blocking egress in the building.<BR/>4. <BR/>Carts must be secured.<BR/>5. <BR/>Cart should be clean

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 25 residents (Resident #215) reviewed for oxygen administration.<BR/>The facility failed to ensure an Oxygen in Use sign was posted on the outside of Resident #215's door. <BR/>These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection.<BR/>The findings include: <BR/>Record review of Resident # 215's face sheet dated 02/13/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and shortness of breath.<BR/>Record review of Resident #215's Entry MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS score had not been completed. <BR/>Record review of Resident #215's Physician Orders revealed a start date of 02/07/2025 May use oxygen at 2-3 liters/minute via nasal canula. <BR/>During an observation on 02/13/2025 at 2:18 PM, Resident #215's door to her room did not have a sign stating Oxygen in Use or No Smoking sign posted outside the entrance of her door. <BR/>During an interview on 08/09/24 at 03:25 PM, the DON stated her expectation was that an Oxygen in Use or no smoking sign should have been placed on the outside of door of residents who used oxygen. The DON stated management staff were responsible for ensuring the signs were posted on the door. The DON stated the ADON and herself make random rounds daily throughout the facility. The DON stated the effect on residents would be that staff may not know who used oxygen during an emergency. The DON stated what led to failure was oversight. <BR/>Record review of facility policy titled Oxygen Administration dated March 21, 2023, revealed: Place NO SMOKING signs in areas when oxygen is administered and stored.