WHARTON NURSING AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 of 1 (CNA A) employees reviewed for abuse and neglect.The facility did not follow their policy on abuse when they screened CNA A for hire. CNA A had worked in the facility from 2/25/2025 through 6/27/2025. This failure could place residents at risk for possible abuse, neglect or exploitation. Findings included: Record review of an undated personnel file for CNA A indicated a hire date of 2/24/2025.Further review revealed a national background check had been conducted on 2/24/2025. It revealed CNA A had an offense date of 11/29/2023 and disposition date of 1/8/2025 charged with assault causing bodily injury statute: 22.01 (A) (1) - misdemeanor sentenced to 12-month probation; a $200 fine and $297.00 court costs. Record review of CNA A's time sheets revealed she worked 14 out of 30 days in June 2025. An interview on 7/1/2025 at 2:27pm CNA A she said had been employed at the facility since February 2025. She worked the 6a-6pm shift in the memory care unit. She said she had a deferred adjudication assault case that happened in 2023. But she received probation in January 2025. She said she preferred not to discuss the details of her case. She said she received a call on Friday (7/27/25) and HR terminated her. She said it was an unknown person from their corporate office and HRC called her around 3:54pm due to her having a background that prevented them from keeping her employed at the facility. She said the previous HRC was supposed to get a letter from her probation supervisor about her case and this was why she was allowed to be hired. An interview with HRC on 7/1/2025 at 2:58pm, revealed he was employed on 6/17/2025. He said he was responsible for new hire requests for background through a third-party company. He stated he realized that CNA A's background was not clear after Investigator requested her personnel record on last Friday (6/27/2025). He stated he called his corporate office, notified the Administrator and corporate member (last name unknown) told him that they would be terminating CNA A due to her having an assault in her background. He stated they called CNA A on Friday evening and informed her of the termination. He said since he had only been employed less than two weeks, he had not done an audit of the personnel records. He stated his audit of personnel records began on Friday (6/27/2025). He said he did not find any other employees that were unemployable. An interview with the Interim Administrator on 7/1/2025 at 3:15pm revealed he was told by the HRC that CNA A had an assault in her background, and he did not think that the previous HRC was supposed to hire her. He said the HRC immediately called corporate, and they terminated her. He said someone with an assault background could have abused the residents.Record review of Form 672 revealed census of 19 residents on the Memory Care unit where CNA A worked.Record review of the State of Texas, Health and Safety Code, Chapter 250, Section 250.006 Convictions Barring Employment revealed (Revision 24-1, Effective [DATE]): A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of: an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony.Record review of the facility's abuse policy revealed: It was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriations of resident property.The components of the facility abuse prohibition plan are discussed herein: 1. Screening -(A) Potential employees will be screened for a history of abuse, neglect exploitation and misappropriation of property.(B) Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision:<BR/>The facility failed to supervise Resident #1 who eloped from the facility on 12/5/2024.<BR/>An Immediate Jeopardy (IJ) was identified as past non-compliance on 03/05/25. The non-compliance began on 12/05/24 and ended on 12/06/24. The facility had corrected the non-compliance before the investigation began on 03/04/25.<BR/>This deficient practice could place at-risk for elopement residents at-risk of harm, serious injury, or death. <BR/>The findings included:<BR/>Record review of Resident #1's admission record, dated 11/05/24, reflected a [AGE] year-old resident with an admission date of 11/05/24, and diagnoses which included Alzheimer's disease, delusions, major depressive disorder with psychotic features, and encephalopathy (a disturbance of brain function which can cause confusion and memory loss).<BR/>Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS of 00 indicating severe cognitive impairment and had exhibited behaviors of wandering.<BR/>Record review of Resident #1's Wandering Evaluation, dated 11/06/24, reflected him to be independent with ambulation, with a history of wandering.<BR/>Record review of Resident #1's Comprehensive Person-Centered Care Plan, dated 11/06/24, reflected resident is elopement risk/wanderer. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes.<BR/>Record review on 3/5/25 at 8:31 AM of the Facility Provider Investigation Report, dated 12/6/24, reflected that on 12/5/24 around 6:15 AM, Resident #1 walked to a drycleaner approximately a 5-minute walk from the facility where he was found by the dietary manager.<BR/>In an interview with CNA A on 3/4/25 at 6:50 PM, CNA A stated on the night of the elopement on 12/5/24, the alarm sounded at approximately 3:30 or 4:00 AM. CNA A stated she performed a head count of the residents, and all residents were present, including Resident #1.<BR/>In an interview with LVN A on 3/4/25 at 7:45 PM, LVN A stated the alarm sounded around 5:00 AM to 5:15 AM. LVN A stated she looked out the window of the door to the courtyard, and it was misty outside. LVN A stated they did a head count and discovered Resident #1 was missing. LVN A stated she went back to the window of the courtyard door and saw a chair by the fence. LVN A stated the gazebo had a sofa and two chairs and one of the chairs was by the fence. LVN A stated Resident #1 could ambulate and was fit, and assumed he climbed over the fence. LVN A stated she thought Resident #1 had basic safety awareness, but with the fog and low light and his cognitive deficits, noting it was still dark outside when he left, Resident #1 could have injured himself climbing over the fence and walking through the field to get to where he was found. <BR/>In an interview with the Dietary Manager on 3/5/25 at 11:19 AM, the dietary manager stated he found Resident #1 at a drycleaner across from the facility around 6:15 AM during his search for the resident which began shortly after he arrived for his shift at the facility around 5:30 AM. Resident #1 was fully dressed and had a blanket and had a bag of his belongings. The dietary manager stated that the temperature at the time was cool, not cold, and Resident #1 appeared to be in no distress, although Resident #1 did become agitated and verbally and physically aggressive when he thought the dietary manager was going to take him back to the facility.<BR/>During an interview with the Acting Administrator on 3/5/25 at 3:56 PM, the Acting Administrator stated they found Resident #1 a more appropriate place that would accept him for admission. The Acting Administrator stated they did abuse, neglect and exploitation training, elopement training, elopement drills, and education on resident exit-seeking behaviors. The Acting Administrator stated there have been no elopements since Resident #1 eloped, and that he had never attempted to exit the facility before the incident.<BR/>During an interview with LVN A on 3/4/25 at 7:45 PM, LVN A stated Resident #1 was discharged to the hospital on [DATE] in order to find more appropriate placement.<BR/>During an interview with CNA B on 3/5/25 at 12:06 PM, CNA B stated she was called in to work to provide one on one with Resident #1 until he was discharged . <BR/>Record review of the Facility Provider Investigation Report on 3/5/25 at 8:31 AM revealed the medical director and responsible party were notified of the elopement on 12/5/24. The report further revealed 83 of 83 staff were in-serviced on the elopement policy and protocol from 12/5/24 to 12/6/24 and confirmed by the Administrator on 12/6/24.<BR/>Staff from the day and night shifts were interviewed regarding the incident including 2 CNAs (A and C) and 1 LVN from the night shift (LVN A), 2 CNAs (B and D) and 2 LVNs (B and C) and from the day shift, 1 Dietary Manager, 1 Maintenance Director, 1 facility receptionist, and 1 laundry aide on the day shift. The staff were able to confirm they had received the in-service training. The staff were able to verbalize what to do in the event of an elopement, who to notify, recognizing exit seeking behaviors, and the purpose of the elopement protocol. <BR/>The Acting Administrator was notified on 3/6/25 at 4:18 p.m., that a past non-compliance IJ situation had been identified due to the above failure.<BR/>It was determined the failure placed Resident #1 in an IJ situation on 12/5/24.<BR/>The facility implemented the following interventions:<BR/>In an interview with the Maintenance Director on 3/4/25 at 4:27 PM, the director stated he tested each door and alarm in the facility after the elopement on 12/5/24. On conclusion of the interview, an observation of the doors and alarms was made with the Maintenance Director. All doors and alarms were working properly during the tour and the courtyard was observed to have a couch only with no chairs.<BR/>In an interview with LVN A on 3/4/25 at 7:45 PM, LVN A stated an elopement protocol binder was created and stored at the nurse's station along with descriptive information for each resident and was observed by the state surveyors during the interview. <BR/>In an interview with the receptionist on 03/05/2025 at 2:50 PM, the receptionist stated there was a binder at the front desk indicating which residents can go outside the facility and was observed by the state surveyor during the interview. <BR/>In an interview with the Maintenance Director on 3/4/25 at 4:27 PM, the maintenance director stated facility alarms and doors were tested on [DATE] after the elopement. Upon completion of the interview, an observation of the doors and alarms was made with the maintenance director. All doors and alarms were observed to be functioning properly. All chairs in the courtyard were observed to have been removed.<BR/>During interviews on 3/4/25 from 6:50 PM to 7:45 PM two staff members, (CNA A and LVN A) stated they had received the facility in-service on elopement conducted from 12/5/24 to 12/6/24 which included information on elopement protocol, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility. <BR/>During interviews on 3/5/25 from 9:57 AM to 2:50 PM 3 CNAs (B, C, D), 2 LVNs (B, C), the Dietary Manager, 1 laundry aide and the facility receptionist stated they had received the facility in-service on elopement conducted from 12/5/24 to 12/6/24 which included information on elopement protocol, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility.<BR/>Record review of the facility's policy titled, Elopements and Wandering Residents, dated 11/21/22, revealed the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.<BR/>An Immediate Jeopardy (IJ) was identified as past non-compliance on 03/05/25. The non-compliance began on 12/05/24 and ended on 12/06/24. The facility had corrected the non-compliance before the investigation began on 03/04/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide routine and emergency drugs and biologicals to residents for 1 of 6 residents (Resident #2) reviewed for pharmacy services. <BR/>The facility failed to administer Resident #2's dementia medication, Memantine 10mg twice daily (a cognitive enhancer also known as Namenda) as prescribed, as the medication was never added to her MAR until the day she was discharged . As a result of this failure, Resident #2 missed all doses of her Memantine 10mg twice daily for 47 days between 07/12/2024 through 08/27/2024.<BR/>This failure could place residents at risk of not achieving the therapeutic effects intended by the physician. <BR/>Findings included:<BR/>Record review of Resident #2's Face Sheet dated 04/04/2025 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Metabolic Encephalopathy (condition where brain function is impaired due to underlying metabolic disturbance) and Alzheimer's Disease (also known as senile dementia, a progressive disease that destroys memory and other mental functions). <BR/>Record review of Resident #2's Discharge Transfer Report revealed she was discharged from the facility on 08/27/2024.<BR/>Record review of resident #2's admission MDS, dated [DATE], revealed a BIMS score of 3 indicating severe cognitive impairment.<BR/>Record review of Resident #2's care plan initiated 07/10/2024, revealed she had a focus area for impaired cognitive function/dementia or impaired thought processes, with interventions which included Administer medications as ordered.<BR/>Record Review of Resident #2's Physician Progress note dated 07/12/2024 revealed under Section Assessment & Plan. Alzheimer's dementia - chronic illness with progression-continue memantine; and under Medication List: Memantine 10mg twice daily.<BR/>Record review Resident #2's Order Summary as of 08/31/2024 revealed an order for Namenda Oral Tablet 10 mg (Memantine HCL) Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE, UNSPECIFIED (G30.9) with order and start date of 08/27/2024.<BR/>Record review of Resident's #2's MARs from July 2024 through August 2024, revealed Memantine 10 mg twice daily was not listed on her MAR until 08/27/2024 effective 1700, the day she was discharged and was added after she was already gone from the facility, reflecting she did not receive her Memantine the entire time she was at the facility.<BR/>During a telephone interview with a family member on 03/04/2025 at 12:25 p.m. the family member stated that when she was reviewing Resident #2's discharge medications with the discharge Nurse on 08/27/2024, she realized that Resident #2's dementia medication (Namenda) was not on the discharge medication list. When she asked about it, she discovered that the Namenda had never been started, even though it had been listed on the discharge medication list from the hospital when she was first admitted to the facility, and her physician had told them the medication would be continued at the facility. The family member stated that the discharge Nurse checked the admission note from the physician and told her that Resident #2's Namenda should have been continued while at the facility. The Nurse added the Namenda to Resident #2's medication list that day, as she was being discharged . The family member stated she visited Resident #2 frequently while she was at the facility and had noted that Resident #2 seemed to have worsening confusion. She had been receiving reports from the Nursing staff that Resident #2 was getting up at night and was out of it and she felt that some of that increased confusion may have been because Resident #2 did not receive her Namenda while at the facility.<BR/>During an interview with the ADON on 03/06/2025 at 1:08 p.m., the ADON reviewed the Physician Progress Note dated 07/12/2024 and the July and August 2024 MAR's for Resident #2, and confirmed that the Nurse Practioner did order that the Memantine be continued for Resident #2. She stated it should have been added to her MAR at that time, but was not added until 08/27/2024, the day of her discharge. The ADON stated she did not know why the Memantine was not added to Resident #2's MAR, and believes it was just missed. The ADON stated that not receiving her Memantine could result in Resident #2 having worsening dementia.<BR/>Interview with the Interim DON on 03/07/2025 at 2:10 p.m. revealed she has only been at the facility for about one week, but upon review of the Physician Progress Note dated 07/12/2024, and the July and August 2024 MAR's, confirmed that Resident #2 should have continued to receive her Memantine after she was admitted to the facility in July2024. She stated that not receiving medication as ordered could result in worsening of the resident's dementia. <BR/>Record review of the facility policy titled Medication Reconciliation dated 4/10/2023 revealed This facility reconciles medication frequently throughout a resident's stay to ensure that the resident ifs free of any significant medication errors, and the facility's medication error rate is less than 5 percent. Further review revealed Medication Reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians and pharmacy staff. Under section titled Pre-admission Processes: a. Obtain current medication list from referral source (hospital, home health, hospice or primary care provider); and under section titled admission Processes: Compare orders to hospital records, etc. Obtain clarification orders as needed. Transcribe orders in accordance with procedures for admission orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at &sect;483.10(c)(2) and &sect;483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #81) whose comprehensive person-centered care plans were reviewed.<BR/>The facility failed to ensure that Resident #81's diagnosis of depression was a focus area in the resident's comprehensive care plan.<BR/>This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions.<BR/>The findings included: <BR/>Record review of Resident #81's face sheet dated 08/21/2024 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels) and hyperlipidemia (a condition characterized by high levels of fats in the blood).<BR/>Record review of Resident #81's admission MDS dated [DATE] revealed a BIMS of 04, indicating severely impaired cognition. Further review of this MDS revealed Depression (other than bipolar) was checked in Section I - Active Diagnoses.<BR/>Record review of Resident #81's comprehensive care plan, updated 02/11/2025, revealed the diagnosis of depression as was not listed as a focus area.<BR/>During an interview on 03/27/2025 at 2:47 PM, MDS RN B stated a focus area of Depression was missing from Resident #81's comprehensive care plan, and this diagnosis should have been noted as a focus area. The resident recently discontinued use of all psychotropic medications, and when the focus area listing the medications was removed from the care plan, the diagnosis of depression was inadvertently removed as well. RN B usually did not list the diagnosis and medications together in one focus area and she did not know why she had done so this time. RN B was responsible for updating care plans, and they were updated quarterly or when there was a significant change requiring an update. It was important the diagnosis of depression was a focus area to ensure the resident was monitored for signs and symptoms of the depression and received appropriate treatment and care. The MDS RN received yearly training on the latest updates to MDS and care plans.<BR/>During an interview on 03/27/2025 at 3:30 PM the Regional Nurse Consultant stated Resident #81's diagnosis of depression needed to be a focus area in the resident's care plan even if the resident was not taking medication to ensure all her needs are addressed.<BR/>Record review of the facility's policy Comprehensive Care Plans implemented 10/24/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that:<BR/>-The facility stored unlabeled and unsealed foods in the freezer. <BR/>This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status.<BR/>Findings Included:<BR/>Interview and observations on 01/17/2024 at 8:22 AM with the Dietary Manager. In freezer #1 there were unlabeled bags of what the Dietary Manager identified as diced ham, chicken fried steak, and taquitos. The Dietary Manager said the bags should be labeled. <BR/>Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said he was responsible for ensuring residents are served what they needed and what they were supposed to have. He said he was responsible for the day-to-day things like inventory, ordering, training, and interviewing patients on their preferences He said the food items must be dated with the pick sticker. The pick stick contains ithe information of the date delivered, and the date it was received which he said he physically wrote on the sticker. He said the reason for the failure was the items that were unlabeled were uncooked, they were not labeled and placed in freezer #1. He said the taquitos had not been served since he had been at the facility. He said he discarded the unlabeled foods yesterday (1/17/24). He said he had not been in-serviced on food storage. He said he was responsible for ensuring policy was followed. He said the risk to residents if policy was not followed was a health risk to the residents. He said death was the worst thing to happen if policy was not followed. He said he did not know why the failure occurred, just that those foods had not been served since he had been there. <BR/>Interview on 01/18/2024 at 11:01 AM with the Administrator. She said she had worked at the facility for five months. She said she oversaw all departments, was abuse coordinator, problem solver and ensured residents were taken care of. She said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. She said the shelf life of items in the fridge was three days. She said she did not know why the items were not dated and that staff did not follow up. She said she last had training on food storage about two months ago. She said the risk to residents if policy were not followed was, they could get sick from food borne illnesses. She said the worst thing that could happen was residents got sick and ended up in the hospital or worse. She said she thought the failure occurred because staff may have been in a rush and did not follow policy.<BR/>Record review of the Food Storage policy dated October 01, 2018, reflected in part . 2. Refrigerators: D: Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers: E: Store frozen foods in moisture-proof wrap or containers that are labeled and dated .<BR/>Review of Texas food Establishment Rules accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer ' s information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, as well as to help prevent the development of communicable diseases and infections, for 1 of 3 residents (Resident #47) reviewed for infection control.<BR/>The facility did not ensure that LVN (A) followed proper infection control practices, including hand hygiene /glove changes, while checking Resident #47's blood sugar.<BR/>This failure could place residents at risk of contracting disease and infection. <BR/>The findings included:<BR/>Record review of Resident # 47's Face sheet, dated 3/27/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes (a disorder when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (excess of lipids or fats in your blood) and Hypertension (a common condition that affects the body's arteries). <BR/>Record review of Resident # 47's quarterly MDS, dated [DATE], revealed a BIMS score of 6, which indicated the resident had severely impaired cognition for daily decision making. <BR/>Record review of Resident # 47's care plan, dated 10/17/24, revealed that Resident #47 has a need for enhanced barrier precautions with interventions to wear gloves. <BR/>Record review of Resident #47's order summary, dated 3/27/25, revealed an order for enhanced barrier precautions: PPE required for high resident contact care activities. <BR/>During an observation on 3/27/25 at 8:35 AM, LVN (A )administered all morning scheduled GT medications to Resident #47 while wearing gloves and then proceeded to check the resident's blood sugar and did not change gloves. <BR/>During an Interview with LVN (A) on 3/27/25 at 8:50 AM, she stated she should have changed gloves after completing GT medications for Resident # 47 and then proceeded to check his blood sugar without changing gloves. LVN (A)stated she cross-contaminated while providing care to resident #47, therefore increasing his risk for infection and added that this error in deficent practice occurred as she was nervous because she is not used to being observed by a state surveyor. <BR/>During an interview on 3/27/25 at 11:23 a.m., the ADON stated that LVN (A) should have sanitized or washed her hands between glove changes to disinfect her hands and to get rid of organisms. The ADON stated she had trained all staff a few months ago on infection control practices; however, LVN (A) was recently hired and had not been checked off on infection control practices. The ADON further stated that not practicing proper hand hygiene was a potential for spreading germs and a risk of infection to resident # 47. <BR/>During an interview on 3/27/2025 at 3:18 PM, the Administrator expressed agreement with the Assistant Director of Nursing's expectations for infection control and prevention. She noted that the building is currently undergoing a transition in leadership, which will help ensure that these issues do not occur again.<BR/>Record review of the facility's policy titled Infection Prevention and Control Program revealed that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to immediately consult with the residents' Physician; and notify her authority, the resident' representative when there was need to alter treatment for 1 of 1 resident (Resident # 1)reviewed for notification . <BR/>The facility failed to notify Resident #1's physician and Relative # 1 when Resident # 1 experienced a change of condition including low blood sugar on 6/23/2024. <BR/>This failure placed residents experiencing a delay in medical treatment and worsening of condition symptoms.<BR/>Findings include: <BR/>Record review of Resident # 1's face sheet, dated 12/7/2021, revealed she was [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with End Stage Renal Disease (a medical condition in which kidneys cease functioning on a permanent basis), Essential (Primary) Hypertension (high blood pressure), Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar levels), Dependence on Renal Dialysis ( someone's kidneys are no longer working properly and they need regular dialysis to survive), Hyperglyceridemia ( too much cholesterol), Shortness of Breath (difficult breathing), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). <BR/>Record review of Resident # 1's MDS, dated [DATE], revealed she a BIMS score of 5 ( severe cognitive Impairment); Resident # 1 had difficulty focusing attention and altered level of consciousness. Resident # 1 required limited assistance from at least one staff for transfers and bed mobility. Insulin injections were received during the last 7 days. <BR/>Record review of Resident # 1's care plan, revised 11/30/2023 revealed the following care areas: <BR/>o <BR/>Resident # 1 has Diabetes Mellitus and was at risk for unstable blood glucose levels. Goals include resident will be free from any s/sx of hyperglycemia. Resident # 1 will have no complications related to diabetes. Resident # 1 will be from any s/sx hypoglycemia. Intervention include administer medication as ordered per MD, monitor/document /report PRN any s/sx of hypoglycemia (low blood sugar), Sweating, Tremor, Increased heart rate (Tachycardia) Pallor ( loss of skin color) , Nervousness, Confusion, slurred speech, lack of coordination, staggering gait( unsteady walking pattern).<BR/>o <BR/>Resident # 1 was on hemodialysis related to end stage renal disease on Monday, Wednesday and Friday at 11:30 am. Days may vary based on holidays and dialysis center schedule. Goals include intervention should any s/sx of complication from dialysis occurs. Interventions incudes monitor vital signs and notify MD of significant. <BR/>Record review of Resident #1's progress note dated 6/23/2023 at 12:10 pm, LVN A wrote Resident with BGS of 47, this nurse provided snack and drink to resident and stayed at bedside. Rechecked BGS approximately 10 minutes later and sugar was 157. No hypoglycemic symptoms displayed during this episode. <BR/>Record review of Resident # 1's Blood Sugar Summary for June 2024 revealed: <BR/>o <BR/>6/23/2024 at 7:53 am blood sugar was 167 mg/dl<BR/>o <BR/>6/23/2024 at 11:47 am blood sugar was 47 mg/dl<BR/>o <BR/>6/23/2024 at 6:28 pm blood sugar was 226 mg/dl<BR/>o <BR/>6/23/2024 at 10:01 pm blood sugar was 122 mg/dl<BR/>Record review of Resident # 1's reviewed on 5/28/2024 revealed: <BR/>o <BR/>Novolog injection solution 100 unit/ml-insulin aspart (an insulin analog indicated to improve glycemic control in patients with diabetes mellitus). Directions: inject 10 unit subcutaneous; start date 6/3/2024. End date: open ended<BR/>o <BR/>Give a peanut butter and jelly sandwich. Directions: at bedtime for Diabetes Mellitus; start date 5/1/2024. End date: open ended<BR/>o <BR/>Ozempic (0.25 or 0.5 mg/dose) Subcutaneous solution pen injector 2mg/3/ml (Semaglutide). Direction: Inject 0.5 mg subcutaneous; start date 4/29/2024. End date: open ended<BR/>o <BR/>Novolog Injection Solution 100 unit/ml (insulin aspart). Directions: Inject as per sliding scale; start date 3/27/2024. End date: open ended<BR/>o <BR/>ACCUCHECKS before meals and at bedtime. Directions: before meals and at bedtime; start date 6/22/2023. End date: open ended<BR/>o <BR/>Glucan emergency injection kit 1 mg (Glucagon rDNA). Directions: Inject 1 dose intramuscular; start date 6/21/2023. End date: open ended<BR/>In an interview with Relative # 1 on 6/27/2024 at 10:30 am she stated that Resident # 1 was a diabetic. She stated that on 6/23/2024 Resident # 1's sugar was 47. She stated that no one from the facility contact her about Resident # 1's change of condition. She stated that on 6/24/2024 LVN A told informed her that Resident # 1's sugar was low on 6/23/2024. She stated that LVN A stated that Resident # 1's sugar was 47 and she gave Resident# 1 cookie and juice. She stated that LVN A rechecked Resident # 1's sugar and Resident # 1's sugar was 150. She stated that LVN A did not contact Resident # 1's doctor or Relative # 1 because Resident # 1 did not have any signs of distress and Resident # 1 was talking to her and stated she was okay. She stated LVN A stated that she stayed by Resident # 1's side and she made certain Resident # 1 was not in distress and not having signs of Hypoglycemia. Relative # 1 stated that she spoke with the Administrator about Resident # 1's sugar levels. She stated that the Administrator stated that she did not know that Resident # 1's sugar dropped as LVN did not notify her, Resident # 1's doctor or the DON.<BR/>Observation of Resident # 1 on 6/27/2024 at 2:20 pm. Resident # 1 was in a wheelchair and Relative # 1 was taking her out for fresh air. Resident # 1 was non-interview able as she had limited verbal skills. <BR/>In an interview with LVNA on 6/27/2024 at 4:40 pm she stated she checked Resident #1's sugar on 6/23/2024 at 11:30 am and Resident # 1's sugar was 47. She stated that Resident # 1 had a can of sprite and cookies by her bed. She stated that she gave Resident # 1 sprite and cookies. She stated that Resident # 1 was talking to her and did not have any sign of distress. She stated that 10 minutes later she rechecked Resident # 1's sugar and it was 152. She stated she did not consider this a change of condition because Resident # 1 talking and was not altered. She stated Resident # 1's sugar was out of range. LVN A stated that she apologized to Resident # 1's family. LVN A stated that if a resident's sugar was at 47 the resident could go into a coma and lose consciousness. LVN stated that she did not contract Resident # 1's doctor or representative. LVN A stated that she did not contact the DON. LVN A stated that she in-serviced on change of conditions. <BR/>In an interview on 6/27/2024 at 4:00 pm with the DON she stated she found out about Resident # 1's low blood sugar on 6/26/2024. She stated LVN A told her Resident # 1's blood sugar was 47 and Resident # 1 did not display hypoglycemia. The DON stated LVN A gave Resident # 1 snacks and rechecked Resident # 1's blood sugar and it was 157. She stated she told LVN A that since Resident # 1's blood sugar was below 60 she should have notified the NP and family. She stated that LVN A did not notify the NP and family because when LVN A rechecked Resident # 1's blood sugar it was within normal range. The DON stated that if a resident's blood sugar is low the resident may experience sweating, confusion, and tremors. She stated that LVN A has been in-serviced on change of condition. <BR/>In an interview on 7/2/2024 at 8:20 pm with the ADON she stated that LVN A reported Resident # 1's low blood sugar after the fact. She stated that when she read the 24 hours report she noticed that Resident # 1's blood sugar was low. She stated LVN A checked Resident # 1's blood sugar and it was low. She stated LVN A gave Resident # 1 snack and later rechecked Resident # 1's blood sugar and it was within normal range. The ADON stated that she could not remember the sugar levels for Resident # 1. The ADON stated she expected the nurses to contact the residents Doctor/NP, family and DON. She stated that LVN A should have contacted the resident's doctor and received orders from the doctor. She stated that staff was in-serviced on change of condition on 6/27/2024. <BR/>Record review of Notification of Changes policy, dated 10/24/2024, revealed: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician: and notifies consistent with his or her authority, the representative when there is a change requiring notification. Circumstances requiring notification include: 2) Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a) Life-threatening conditions or <BR/>b) Clinical complications<BR/>Record review of In-service training report: Notification of Change, dated 4/6/2024, revealed For all changes of conditions, please call DON and/or Administrator. Texting is not acceptable. Signed by LVN A on 4/8/2024.<BR/>Record review of In-Service training report: Notification of Change, dated 6/27/2024, revealed When a resident has any change of condition, the physician, or NP, RP, and DON must be notified. This should be documented in PCC on Change of Condition form and a progress note should be completed with any additional information. Signed by LVN A on 6/27/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 (Resident #1) of 5 residents reviewed for dignity.<BR/>The facility failed to provide dignity and respect for Resident #1 by leaving the residents privacy bag off his foley bag exposing the full urinary bag to open doorway.<BR/>This failure placed resident and could place other residents at risk for embarrassment and low self esteem.<BR/>Findings:<BR/>Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles).<BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing and toileting with 2-person assistance. Section H noted indwelling catheter.<BR/>Record review of Resident #1's Care Plan dated 12/15/2022 revealed . has a Foley Catheter related to BPH with retention, stage IV pressure ulcer to sacrum .Goal .The resident will show no s/sx of urinary infection through review date .Interventions . change catheter every Wednesday and PRN .Change Foley Cath each month on the 15th .Change foley Cath bag the 1st and the 15th of each month .<BR/>Record review of Resident #1's Physician Orders dated 4/26/2023 revealed . Change Foley Catheter once monthly one time a day starting on the 15th and ending on the 15th every month related to Pressure Ulcer of Sacral Region, Stage 4, Obstructive and Reflux Uropathy, Unspecified .<BR/>On 8/16/2023 at 10:10am Surveyor observed Resident #1's foley catheter bag without privacy bag on. Catheter bag was observed full of urine, hanging at the end of the bed, face out to doorway. <BR/>In an interview on 8/16/2023 at 11:27am with the Wound Care Nurse she said she had worked at the facility for two weeks. She said the importance of covering the foley bag was for privacy and dignity with residents. She said she had not been in serviced on privacy and dignity since coming to work at the facility. She said she had not been in serviced on foley catheters since coming to work at the facility.<BR/>In an interview on 8/16/2023 at 11:35am with CNA A she said she had worked at the facility since June 2023. She said the privacy bag for foley catheters was to prevent others from seeing urine in the bag. She said it was embarrassing to some residents when others could see urine in their foley bag. She said she had not been in serviced on foley care since working at the facility. <BR/>In an interview on 8/16/2023 at 12:50pm with ADON A she said she had worked at the facility since April 24, 2023. She said she had been a nurse for almost 18 years. She said her duties were to check orders, check CNAs, help nurses, call doctors, help where needed, do in services, and training. She said the privacy bags on the foleys were for dignity issues for the residents, so they had privacy. She said the residents could get upset and embarrassed when others saw urine in the foley bag. <BR/>In an interview with the DON, she said she had been working at the facility for seven days. She said the reason for privacy bags was to protect resident rights and dignity. She said when privacy bags are not used, residents were embarrassed. She said she did not know when the last in service on foley care was conducted. <BR/>In an interview on 8/16/2023 at 1:36pm with ADON B she said she had been the ADON at the facility for almost three months. She said she had been a nurse for three years. She said her duties were to oversee nurses for halls three and four. She said they were last in serviced on Foleys yesterday, but she was not at work. She said the importance of having a privacy bag over a Foley was it gave resident dignity, she said staff should have had to cover the bag as it looked gross from the resident's perspective. She said the residents could have become insecure from having their urine exposed. <BR/>Record review of facilities policy titled, Promoting/Maintaining Resident Dignity read in part . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Maintain resident privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to ensure catheter changing procedures were followed by staff in the direct care for 2 (Resident #1 and Resident #2) of 5 residents reviewed for catheter care.<BR/>The facility failed to change Resident #1 and Resident #2's foley catheters when ordered.<BR/>These failures could place residents at risk for infection and blocked urinary catheters.<BR/>Findings:<BR/>Resident #1<BR/>Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles).<BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing and toileting with 2 persons. Section H noted indwelling catheter.<BR/>Record review of Resident #1's Care Plan dated 12/15/2022 revealed . a Foley Catheter related to BPH with retention, stage IV pressure ulcer to sacrum .Goal .The resident will show no s/sx of urinary infection through review date .Interventions . change catheter every Wednesday and PRN .Change Foley Cath each month on the 15th .Change foley cath bag the 1st and the 15th of each month .<BR/>Record review of Resident #1's Physician Orders dated 4/26/2023 revealed . Change Foley Catheter once monthly one time a day starting on the 15th and ending on the 15th every month related to Pressure Ulcer of Sacral Region, Stage 4, Obstructive and Reflux Uropathy, Unspecified .<BR/>Observation on 8/16/2023 at 10:10am Resident #1's Foley bag was dated 6/16/2023 written in black ink.<BR/>Resident #2 <BR/>Record review of Resident #2's Face Sheet revealed a [AGE] year-old male with a history of Unspecified Dementia, Moderate with Other Behavioral Disturbance (Memory Loss), Cerebral Infarction (Disrupted Blood Flow to the Brain), Muscle Wasting and Atrophy (Muscle Loss), Atherosclerotic Heart Disease of Native Coronary Artery (Heart Disease).<BR/>Record Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #2 required limited assistance with bed mobility, dressing and toileting. Resident #2 required extensive assistance with transfers and required the assistance of one person. Section H noted indwelling catheter. <BR/>Record review of Resident #2's Physician Orders dated 6/27/2023 revealed . Foley Catheter: Change 16F with 10ml bulb every night shift starting on the 27th and ending on the 28th every month . Neuromuscular Dysfunction of Bladder.<BR/>Observation on 8/16/2023 at 10:30am Resident #2's Foley bag was dated 6/27/23 written in black ink. <BR/>In an interview on 8/16/2023 at 11:05am with the Wound Care Nurse she said she had worked at the facility for 2 weeks. She said the importance of changing the foley catheter bag out every 30 days was to prevent bacteria from growing in the catheter and to prevent infections. She said she had not been in serviced on foley catheter care since working at the facility.<BR/>In an interview on 8/16/2023 at 11:35am with CNA A she said she had worked at the facility since June of 2023. She said she had been a CNAs for 5 years. She said her duties were to clean, feed, change and reposition residents. She said she transferred residents, showered, and groomed them. She said the reason for changing the foley out was to prevent infection. She said she had last been in serviced on foley care 1 or 2 weeks ago.<BR/>In an interview on 8/16/2023 at 12:50pm ADON A said she had worked at the facility since April 24,2023 and had been a nurse for almost 18 years. She said her duties were to check orders, check CNAs, help nurses, call physicians, and help where needed. She said she conducted in services and trainings. She said the last in service on foley care was not long ago and was not sure when. She said it was important to change a foley catheter out every 30 days because residents developed residue inside of the foleys and to prevent infection. She said foley catheters can get clogged and urine may not drain from the bladder due to not being changed out. <BR/>In an interview on 8/16/2023 at 1:25pm with the DON who said she had worked at the facility for 7 days. She said she oversaw nursing care at the facility. She said she transferred from another facility to improve care. She said changing a foley catheter as ordered was for infection prevention. She said if foleys were not changed as ordered there was potential for backflow of urine. She said she did not know when the last in service on foley care was conducted.<BR/>In an interview on 8/16/2023 at 1:36pm ADON B said she had been ADON at the facility for almost 3 months. She said she had been a nurse for almost 3 years. She said her duties were to oversee halls three and four. She said the importance of changing a foley bag out once a month was to prevent an infection of the urinary tract. <BR/>On 8/16/2023 at 1:40pm surveyor requested policy on catheter care from the DON and did not receive one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, as well as to help prevent the development of communicable diseases and infections, for 1 of 3 residents (Resident #47) reviewed for infection control.<BR/>The facility did not ensure that LVN (A) followed proper infection control practices, including hand hygiene /glove changes, while checking Resident #47's blood sugar.<BR/>This failure could place residents at risk of contracting disease and infection. <BR/>The findings included:<BR/>Record review of Resident # 47's Face sheet, dated 3/27/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes (a disorder when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (excess of lipids or fats in your blood) and Hypertension (a common condition that affects the body's arteries). <BR/>Record review of Resident # 47's quarterly MDS, dated [DATE], revealed a BIMS score of 6, which indicated the resident had severely impaired cognition for daily decision making. <BR/>Record review of Resident # 47's care plan, dated 10/17/24, revealed that Resident #47 has a need for enhanced barrier precautions with interventions to wear gloves. <BR/>Record review of Resident #47's order summary, dated 3/27/25, revealed an order for enhanced barrier precautions: PPE required for high resident contact care activities. <BR/>During an observation on 3/27/25 at 8:35 AM, LVN (A )administered all morning scheduled GT medications to Resident #47 while wearing gloves and then proceeded to check the resident's blood sugar and did not change gloves. <BR/>During an Interview with LVN (A) on 3/27/25 at 8:50 AM, she stated she should have changed gloves after completing GT medications for Resident # 47 and then proceeded to check his blood sugar without changing gloves. LVN (A)stated she cross-contaminated while providing care to resident #47, therefore increasing his risk for infection and added that this error in deficent practice occurred as she was nervous because she is not used to being observed by a state surveyor. <BR/>During an interview on 3/27/25 at 11:23 a.m., the ADON stated that LVN (A) should have sanitized or washed her hands between glove changes to disinfect her hands and to get rid of organisms. The ADON stated she had trained all staff a few months ago on infection control practices; however, LVN (A) was recently hired and had not been checked off on infection control practices. The ADON further stated that not practicing proper hand hygiene was a potential for spreading germs and a risk of infection to resident # 47. <BR/>During an interview on 3/27/2025 at 3:18 PM, the Administrator expressed agreement with the Assistant Director of Nursing's expectations for infection control and prevention. She noted that the building is currently undergoing a transition in leadership, which will help ensure that these issues do not occur again.<BR/>Record review of the facility's policy titled Infection Prevention and Control Program revealed that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, as well as to help prevent the development of communicable diseases and infections, for 1 of 3 residents (Resident #47) reviewed for infection control.<BR/>The facility did not ensure that LVN (A) followed proper infection control practices, including hand hygiene /glove changes, while checking Resident #47's blood sugar.<BR/>This failure could place residents at risk of contracting disease and infection. <BR/>The findings included:<BR/>Record review of Resident # 47's Face sheet, dated 3/27/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes (a disorder when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (excess of lipids or fats in your blood) and Hypertension (a common condition that affects the body's arteries). <BR/>Record review of Resident # 47's quarterly MDS, dated [DATE], revealed a BIMS score of 6, which indicated the resident had severely impaired cognition for daily decision making. <BR/>Record review of Resident # 47's care plan, dated 10/17/24, revealed that Resident #47 has a need for enhanced barrier precautions with interventions to wear gloves. <BR/>Record review of Resident #47's order summary, dated 3/27/25, revealed an order for enhanced barrier precautions: PPE required for high resident contact care activities. <BR/>During an observation on 3/27/25 at 8:35 AM, LVN (A )administered all morning scheduled GT medications to Resident #47 while wearing gloves and then proceeded to check the resident's blood sugar and did not change gloves. <BR/>During an Interview with LVN (A) on 3/27/25 at 8:50 AM, she stated she should have changed gloves after completing GT medications for Resident # 47 and then proceeded to check his blood sugar without changing gloves. LVN (A)stated she cross-contaminated while providing care to resident #47, therefore increasing his risk for infection and added that this error in deficent practice occurred as she was nervous because she is not used to being observed by a state surveyor. <BR/>During an interview on 3/27/25 at 11:23 a.m., the ADON stated that LVN (A) should have sanitized or washed her hands between glove changes to disinfect her hands and to get rid of organisms. The ADON stated she had trained all staff a few months ago on infection control practices; however, LVN (A) was recently hired and had not been checked off on infection control practices. The ADON further stated that not practicing proper hand hygiene was a potential for spreading germs and a risk of infection to resident # 47. <BR/>During an interview on 3/27/2025 at 3:18 PM, the Administrator expressed agreement with the Assistant Director of Nursing's expectations for infection control and prevention. She noted that the building is currently undergoing a transition in leadership, which will help ensure that these issues do not occur again.<BR/>Record review of the facility's policy titled Infection Prevention and Control Program revealed that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, as well as to help prevent the development of communicable diseases and infections, for 1 of 3 residents (Resident #47) reviewed for infection control.<BR/>The facility did not ensure that LVN (A) followed proper infection control practices, including hand hygiene /glove changes, while checking Resident #47's blood sugar.<BR/>This failure could place residents at risk of contracting disease and infection. <BR/>The findings included:<BR/>Record review of Resident # 47's Face sheet, dated 3/27/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes (a disorder when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (excess of lipids or fats in your blood) and Hypertension (a common condition that affects the body's arteries). <BR/>Record review of Resident # 47's quarterly MDS, dated [DATE], revealed a BIMS score of 6, which indicated the resident had severely impaired cognition for daily decision making. <BR/>Record review of Resident # 47's care plan, dated 10/17/24, revealed that Resident #47 has a need for enhanced barrier precautions with interventions to wear gloves. <BR/>Record review of Resident #47's order summary, dated 3/27/25, revealed an order for enhanced barrier precautions: PPE required for high resident contact care activities. <BR/>During an observation on 3/27/25 at 8:35 AM, LVN (A )administered all morning scheduled GT medications to Resident #47 while wearing gloves and then proceeded to check the resident's blood sugar and did not change gloves. <BR/>During an Interview with LVN (A) on 3/27/25 at 8:50 AM, she stated she should have changed gloves after completing GT medications for Resident # 47 and then proceeded to check his blood sugar without changing gloves. LVN (A)stated she cross-contaminated while providing care to resident #47, therefore increasing his risk for infection and added that this error in deficent practice occurred as she was nervous because she is not used to being observed by a state surveyor. <BR/>During an interview on 3/27/25 at 11:23 a.m., the ADON stated that LVN (A) should have sanitized or washed her hands between glove changes to disinfect her hands and to get rid of organisms. The ADON stated she had trained all staff a few months ago on infection control practices; however, LVN (A) was recently hired and had not been checked off on infection control practices. The ADON further stated that not practicing proper hand hygiene was a potential for spreading germs and a risk of infection to resident # 47. <BR/>During an interview on 3/27/2025 at 3:18 PM, the Administrator expressed agreement with the Assistant Director of Nursing's expectations for infection control and prevention. She noted that the building is currently undergoing a transition in leadership, which will help ensure that these issues do not occur again.<BR/>Record review of the facility's policy titled Infection Prevention and Control Program revealed that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that:<BR/>-The facility stored unlabeled and unsealed foods in the freezer. <BR/>This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status.<BR/>Findings Included:<BR/>Interview and observations on 01/17/2024 at 8:22 AM with the Dietary Manager. In freezer #1 there were unlabeled bags of what the Dietary Manager identified as diced ham, chicken fried steak, and taquitos. The Dietary Manager said the bags should be labeled. <BR/>Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said he was responsible for ensuring residents are served what they needed and what they were supposed to have. He said he was responsible for the day-to-day things like inventory, ordering, training, and interviewing patients on their preferences He said the food items must be dated with the pick sticker. The pick stick contains ithe information of the date delivered, and the date it was received which he said he physically wrote on the sticker. He said the reason for the failure was the items that were unlabeled were uncooked, they were not labeled and placed in freezer #1. He said the taquitos had not been served since he had been at the facility. He said he discarded the unlabeled foods yesterday (1/17/24). He said he had not been in-serviced on food storage. He said he was responsible for ensuring policy was followed. He said the risk to residents if policy was not followed was a health risk to the residents. He said death was the worst thing to happen if policy was not followed. He said he did not know why the failure occurred, just that those foods had not been served since he had been there. <BR/>Interview on 01/18/2024 at 11:01 AM with the Administrator. She said she had worked at the facility for five months. She said she oversaw all departments, was abuse coordinator, problem solver and ensured residents were taken care of. She said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. She said the shelf life of items in the fridge was three days. She said she did not know why the items were not dated and that staff did not follow up. She said she last had training on food storage about two months ago. She said the risk to residents if policy were not followed was, they could get sick from food borne illnesses. She said the worst thing that could happen was residents got sick and ended up in the hospital or worse. She said she thought the failure occurred because staff may have been in a rush and did not follow policy.<BR/>Record review of the Food Storage policy dated October 01, 2018, reflected in part . 2. Refrigerators: D: Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers: E: Store frozen foods in moisture-proof wrap or containers that are labeled and dated .<BR/>Review of Texas food Establishment Rules accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer ' s information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one waste receptacle reviewed for garbage disposal.<BR/>-The waste receptacle had its top left lid opened when no one was disposing of trash.<BR/>These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.<BR/>Findings include: <BR/>Observation 01/17/2024 at 8:42 AM. The left lid on the outside dumpster was observed to be open.<BR/>Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said the policy on the dumpster was the lids should have been closed. He said it was difficult to close the lids and he said he would talk to the Maintenance director for something to help close the lids. He said the wind may have helped close or open the lid to the dumpster. He said he did not know who was responsible for ensuring the dumpster lid was closed. He said the risk to residents if policy were not followed was it could draw in rodents and pests, and they could then get into the building.<BR/>Interview on 01/18/2024 at 11:01 AM with the Administrator. She said the policy on the dumpster was the lid should always be closed. She said risk to residents if policy were not followed was residents could be harmed by animals and pests getting in the dumpster. She said she thought the failure occurred because staff were careless. <BR/>Record review of the Garbage Receptacles dated October 01, 2018, read in part . Outdoor receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle .