CONCHO HEALTH & REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #1) reviewed for Abuse. The facility did not report an allegation of abuse per facility policy to the State Survey Agency (HHSC) when Resident #1 alleged abuse occurred during a recent hospital visit. This deficient practice could delay assessment and care of residents who report abuse. The findings were:Record review of Resident #1 's face sheet dated 10/17/25 revealed a [AGE] year-old female originally admitted to the facility on [DATE], readmitted on [DATE] after observation stay at Hospital #1 for delirium (a state of acute mental confusion and disorientation that can cause significant changes in a person's behavior, thinking, and perception) and readmitted [DATE] after a hospital stay at Hospital #2 with the diagnosis that included: altered mental status (a significant change in a person's level of consciousness, awareness, and cognitive function. Record review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated moderate cognitive impairment. Section G revealed Resident #1 required moderate to maximum assistance with dressing and toileting. MDS indicated no behaviors present.Record review of Resident #1's progress note dated 10/8/2025 at 3:00PM written by DON revealed she was sent to Hospital #1 emergency room at 1:00PM due to physically aggressive behavior. Record review of Resident #1's hospital records Hospital #1 revealed on 10/8/25 at 1:30PM upon arrival she was administered Ativan (a benzodiazepine medication that is used for anxiety, insomnia, and seizures) 1mg for agitation and Haldol (antipsychotic medication used to treat psychotic disorders) and placed in soft restraints. Resident #1 was discharged back to the nursing facility on 10/10/2025.Record review of Resident #1's progress note dated 10/12/2025 at 11:15AM written by RN C revealed Resident #1 reported an allegation of abuse that occurred during her hospital stay on 10/8/2025. Resident #1 stated while at Hospital #1 they took her to a back room and a very big, tall man began to repeatedly hit her with his hands on her private area and was repeatedly called her name. Record review of Resident #1's progress note dated 10/10/2025 by Nurse Practitioner indicated upon returning to facility reveals no wounds and generalized bruising to bilateral upper and lower extremities.Record review of Resident #1's progress notes on 10/12/2025 at 12:15PM written by RN C revealed there was no bruising to perineal/private area and posterior buttocks/anal area. There was an elongated bruise to the left upper anterior thigh and a circular bruise to the right upper anterior thigh. Further review of the progress note revealed resident does carry her wallet inside her brief. The progress note revealed this was reported to the Administrator. The progress note revealed Resident #1 has had a history of behaviors that have escalated in the last 2 weeks which included hallucinations, delusions, verbal and physical aggression and increased falls. Observation of Resident #1 on 10/17/2025 at 1:46PM revealed she was in bed with eyes closed lying on her back. An interview with the Administrator on 10/17/25 at 1:45 P.M. revealed she did not report the allegation from Resident #1, as the allegation occurred outside the facility. She stated RNC reported Resident #1's allegation to her. She stated she did call the ADO but did not follow up because the allegation occurred outside the facility. However, upon reviewing the abuse guidelines from HHSC, she stated she should have reported the incident.An interview with the ADO on 10/17/25 at 9:20 AM revealed they did not report this allegation to the State office when it was first reported to the Administrator on 10/12/2025. It was not reported to the State office until 10/16/2025 after ADO and Regional Compliance nurse read the progress notes. They were performing an audit of Resident #1's chart prior to readmission and read the residents allegations in the progress note. ADO stated they did not have a DON at the facility at this time and the DON reviewed all progress notes. She stated the Administrator attempted to call her on 10/12/2025 but they did not speak, and no messages were left. The ADO stated she was traveling at that time and unable to answer. She stated her expectations are for the Administrator to leave a message or continue to call. The ADO stated she did not follow up because she was traveling and forgot to return the phone call. On 10/17/2025 at 10:30AM the surveyor attempted to reach the RN C with no success. The surveyor left a message but did not receive a return call. An interview with DON on 10/17/2025 at 2:30PM revealed she was not employed on the date this allegation occurred. She was the current Interim DON and started on 10/15/2025 and does not have access to electronic health records as of this time. She stated her expectation is for and abuse, neglect, or misappropriation to be reported to her or the Administrator immediately. Record review of facilities in-service records revealed a one-on-one written in-service dated 10/17/2025 with the administrator, DON, ADON, and MDS coordinator regarding reporting every allegation of abuse or neglect to HHSC per guidelines. Abuse and Neglect in-services were started on 10/16/2025 with facility policy labeled Abuse and Neglect attached. Record review of Texas Unified Licensure Information Portal (TULIP) on 10/16/25 at 4:30 P.M. revealed no self-reported incidents regarding allegations of abuse were reported for Resident # 1 . Record review of undated facility policy on 10/17/2024 titled, Abuse, Neglect revealed: 1. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants and volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 2. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/2024.a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationb. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record Review of Provider Letter 2024-14 dated 8/29/2024 revealed a nursing facility must report the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect, exploitation, death due to unusual circumstances, a missing resident, misappropriation, drug theft, suspicious injuries of unknown source, fire, emergency situations that pose a threat to resident health and safety, communicable disease situations that are an unusual or abnormal event that poses a threat to resident health and safety. Do report abuse or an incident that results in serious bodily injury immediately but not later than two hours after the incident occurs or is suspected. Do report an incident that does not result in serious bodily injury immediately but no later that 24 hours after the incident occurs or is suspected.

**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 that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #5, #20, and #32) reviewed for care plans in that:<BR/>Resident #5 did not have a care plan to address her pain. <BR/>Resident #20 did not have a care plan to address her pain. <BR/>Resident #32 did not have a care plan to address her Alzheimer's/Dementia or pain. <BR/>This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.<BR/>The findings included the following:<BR/>Review of Resident #5's admission Record dated 4/12/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included arthritis. <BR/>Record review of Resident #5's Annual MDS Assessment, dated 3/27/23, revealed:<BR/>She scored a 9 of 15 on her mental status exam (indicating moderate cognitive impairment).<BR/>She received scheduled and as-needed pain medications. She reported she frequently experienced pain at a level of 6 of 10.<BR/>She received opiate medications for 7 of 7 days prior to the assessment<BR/>Resident #5's MDS CAA documented pain as a triggered area that needed to be care planned.<BR/>Record review of Resident #5's Order Summary Report, dated 4/12/23, revealed orders:<BR/>Fentanyl Transdermal Patch 72 hours 12 mcg/hour - apply 1 patch transdermally one time a day every 72 hours (3 days) for pain and remover per schedule beginning 3/3/23 (no diagnosis)<BR/>Meloxicam Tablet 15 mg, give 1 tablet by mouth one time a day related to arthritis. beginning 7/4/22<BR/>Oxycodone-acetaminophen 7.5mg/325 mg 1 tablet by mouth every 6 hours as needed for pain beginning 1/26/23.<BR/>Tizanidine 2 mg 1 capsule every 8 hours as needed for pain and muscle spasms. beginning 2/7/23<BR/>Review of Resident #5's care plan, last updated 3/30/23, revealed no care plan for pain. <BR/>Interview on 4/12/23 at 4:23 PM the MDS Coordinator stated there was no care plan for Resident #5's pain or pain medication. The MDS Coordinator stated she did not know why pain medication interventions were getting missed. She said any time there was a medication change the DON or whoever could do a care plan. She said new orders were reviewed every morning in the morning meetings and were on the 24-hour report and in the nurse's notes which she had access too. The MDS Coordinator stated the facility did not have a stable DON or ADON in she did not know how long so the Compliance RN had been reviewing the care plans on Monday - Wednesday - Friday . She said usually medications were added when they reviewed new orders in the morning meetings. <BR/>Review of Resident #20's admission Record, dated 4/12/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and restless leg syndrome (uncontrollable, painful urge to move legs). <BR/>Review of Resident #20's Initial MDS Assessment, dated 12/13/22, revealed:<BR/>She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact).<BR/>She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. <BR/>Review of Resident #20's Quarterly MDS Assessment, dated 3/22/23, revealed:<BR/>She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact).<BR/>She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. <BR/>Her CAA Summary documented Pain was a triggered item and was addressed in the care plan .<BR/>Review of Resident #20's Order Summary Report, dated 4/12/23, revealed orders for:<BR/>Gabapentin 300 mg twice a day for Neuropathic pain dated 12/2/22.<BR/>Meloxicam 15 mg for pain dated 3/25/23<BR/>Methadone 5 mg every 8 hours as needed for pain dated 12/2/22<BR/>Morphine Sulfate 15 mg twice a day for pain dated 1/25/23<BR/>Hydrocodone-Acetaminophen every 6 hours as needed for pain dated 12/2/22<BR/>Tizanidine 4 mg every 8 hours as needed for muscle relaxant. <BR/>Review of Resident #20's Care Plan, last updated 1/18/23, revealed no care plan for pain. <BR/>In an interview on 04/12/23 at 2:40 PM the MDS nurse stated that the comprehensive plan of care was created based upon the MDS assessment and initial baseline care plan by herself (the MDS nurse). She stated the comprehensive care plan for Resident #20 was created on 12/5/22, and although pain was triggered on the MDS assessment, it was not addressed in the comprehensive care plan on 12/5/22. The MDS nurse stated, it was an oversight on my part and I should have caught this. She also stated that changes to the care plans were done upon identified issues such as when a resident started an antibiotic or had a change in condition. She stated that she was made aware of changes to resident status during the morning meetings that occurred at 9:00AM each weekday since all department heads were present (Administrator, DON, ADON, Director of Rehab, Dietary, Maintenance, Medical Records), and each party present reported issues regarding the residents related to their discipline. <BR/>Review of Resident #32's admission Record, dated 4/12/23, revealed she was an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with psychotic disturbance and anxiety, Alzheimer's Disease, and Seizures (abnormal brain activity that causes abnormalities in muscles, movement and consciousness needing specialized medication/ monitoring to control and/or other interventions to prevent injury during a seizure).<BR/>Review of Resident #32's Initial MDS Assessment, dated 3/24/23, revealed: <BR/>She scored a 2 of 15 on her mental status exam with no signs of delirium (indicating she was severely cognitively impaired).<BR/>Identified diagnoses included: Alzheimer's Disease, Dementia, and Anxiety. (Seizures were not indicated) <BR/>Review of the CAA Summary revealed Cognitive status was a triggered care area and was addressed in the care plan<BR/>Review of Resident #32's Order Summary Report, dated 4/12/23, revealed orders:<BR/>Gabapentin 300 mg three times a day for mild pain<BR/>Memantine HCL 10mg twice a day related to Alzheimer's Disease<BR/>Review of Resident #32's care plan, last updated 3/20/23 revealed no care plan for dementia/Alzheimer's disease or pain.<BR/>Interview on 4/12/23 at 3:10 PM the DON stated she went and reviewed the MDS assessments to make sure the CAA Areas were triggered. <BR/>In an interview on 04/12/23 at 3:20 PM the Administrator and the Director of Nurses, confirmed that plans of care were reviewed and or implemented by the Director of Nurses or Assistant Director of Nurses. The Administrator stated that the corporate Program Compliance nurse conducted audits on assessments and for Risk Management for the facility, ensured assessments matched orders and care plans, and then shared her findings with the Director of Nurses and Administrator as well as the Assistant Director of Operations. <BR/>Review of the facility's policy and procedure on Comprehensive Care Planning, undated, revealed: The facility will develop and implement a comprehensive care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.<BR/>The comprehensive care plan will describe the following:<BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the right to refuse treatment. <BR/>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.<BR/>Through the care planning process, facility staff will work with the resident and his/her representative, if applicable to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintain his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. <BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.<BR/>When developing the comprehensive care plan, facility staff will, at a minimum, used the Minimum Data Set to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. <BR/>There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment but may not cause a CAA to trigger. The facility will address these areas and will document the assessment of these risks, weakness or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area. If the decision to proceed to care planning is made, the interdisciplinary team, in conjunction with the resident and/or resident's representative, if applicable, will develop and implement the comprehensive care plan and describe how the facility will address the resident's goals, preferences, strengths, weaknesses, and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #5, #9 and #31) of 5 residents reviewed for infection control. <BR/>The facility failed to ensure:<BR/>CNA E did not turn off the faucet with her bare hands after washing them and before performing personal care for Resident #5. <BR/>CNA's E and F change their gloves after they became contaminated during incontinent care while assisting Resident #9. <BR/>CNA B change her gloves after they became contaminated during incontinent care while assisting Resident #31. <BR/>This failure could place resident's risk for cross contamination and the spread of infection. <BR/>Finding include:<BR/>RESIDENT #5<BR/>During an observation on 05/21/24 at beginning at 02:46 PM CNA E entered Resident #5's bathroom and rinsed her hands (no soap was used), turned off the faucet with her bare hands and then dried her hands with a paper towel. Immediately after, CNA E entered the bathroom washed her hands with soap but turned off the faucet with her bare hands. <BR/>During an interview on 05/22/24 at 4:24 p.m. CNA E stated she worked for the facility on and off for 1.5 years. CNA E confirmed she washed her hands after doing performing care for Resident #5. She said she turned on the faucet, soaped her hands, rinsed them, turned the faucet off with a paper towel and then dried her hands with a paper towel. Surveyor read the observation that she turned the faucet off with her bare hands, and CNA E said she was flustered from helping another CNA with care. <BR/>During an interview on 05/23/24 at 9:42 a.m. the DON and Regional Consultant stated the expectation for handwashing was to wet hands, use soap, wash the entire hand and nails, rinse, dry the hands with a paper towel, and then use a paper towel to turn off the faucet. When asked what the expectation about handwashing was, the DON sighed, let me guess, they turned off the faucet with their hands? The DON said staff were in-serviced on how to wash their hands. <BR/>During an interview on 05/23/24 at 10:24 a.m. the Administrator was informed of the handwashing observation. The Administrator agreed there was a chance of cross contamination and asked how the investigation was completed. <BR/>RESIDENT #9<BR/>Record review of Resident #9's admission record dated 05/23/2024 indicated she was a [AGE] year-old female that was initially admitted to facility on 04/02/2022 with medical diagnosis that include muscle weakness, age-related cognitive decline and care provider dependency. <BR/>Record review of Resident #9's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent. Bowel Continence = 3. Always incontinent.<BR/>Record review of Resident #9's care plan dated 05/15/2024 indicated in part: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use. Interventions/Task: Notify nursing if incontinent during activities. Apply barrier cream after each incontinent episode. Brief use: the resident uses disposable briefs. Change every 2 hours and prn.<BR/>During an observation of incontinent care on 05/22/24 at 02:26 PM with CNA E and CNA F for Resident #9. CNA F wiped Resident #9 perineal area from front to back with a clean wipe each time, she did not change her gloves. Resident #9 was rolled to the side to CNA E who then wiped the resident's bottom, removed the old brief, did not change gloves and placed new clean brief. CNA E then placed barrier cream, removed the one glove that had barrier cream and put on one new glove. Both CNA's adjusted the brief, both pulled resident up in bed and without changing her gloves CNA E touched the wipes, the remote, the barrier cream container and the dresser drawer. <BR/>During an interview with both CNA F and CNA E on 05/22/24 at 2:40 pm. Both CNA's stated they should have changed their gloves and hand sanitized or washed their hands before going from dirty to clean on Resident #9. CNA E stated that changing gloves and hand hygiene were used to help prevent cross contamination. <BR/>RESIDENT #31<BR/>Record review of Resident #31's admission record dated 05/23/2024 indicated she was admitted to the facility on [DATE] with diagnoses which included dementia and muscle weakness. She was [AGE] years of age.<BR/>Record review of Resident #31's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 2. Frequently incontinent. Bowel Continence = 3. Always incontinent.<BR/>Record review of Resident #31's care plan dated 06/01/22 indicated in part: Focus: The resident has bladder incontinence. The resident has bowel incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through review date. The resident will not have any complications related to bowel incontinence. Interventions: Incontinent care at least every 2 hours and apply moisture barrier after each episode. Apply barrier cream after every incontinent episode. Check resident every two hours and assist with toileting as needed. Provide pericare after each incontinent episode.<BR/>During an observation on 05/22/24 at 03:34 PM CNA B performed incontinent care for Resident #31. CNA B entered the resident's room, washed her hands and put on a pair of new gloves. CNA B then undid the resident's brief and it was noted that the brief was wet with urine. CNA B then took some wet wipes and wiped the resident's vaginal area. The CNA then rolled Resident #31 on her right side and took some more wet wipes and wiped the resident's rectal area. While CNA B performed the wiping her gloves came in contact with the resident's vaginal and rectal areas. While still wearing the same gloves CNA B then took the clean brief and fastened it to Resident #31. <BR/>During an interview on 05/22/24 at 03:46 PM CNA B said she usually changed her gloves before going from clean to dirty but this time she was in a hurry and did not do it. CNA B said not changing her gloves and touching the clean items could lead to cross contamination. <BR/>During an interview on 05/23/24 at 01:44 PM the DON said it was expected for staff to remove their gloves and wash their hands and install a pair of new gloves once they became contaminated. The DON said staff were supposed to change their gloves to prevent from contaminating other items. The DON believed the failure occurred because the staff got nervous and forgot to change their gloves once they became contaminated. <BR/>During an interview on 05/23/24 at 03:28 PM the Administrator was made aware of the incontinent observations. The Administrator said staff were supposed to change their gloves and wash their hands once they became contaminated. The Administrator said it was the DON's and ADON's job to monitor staff to make sure those steps were followed. The Administrator said the failure probably occurred because the staff got nervous and forgot to change their gloves at the appropriate time. <BR/>Record review of the facility's document titled Personal care and dated 05/11/2022 indicated in part: Start: Perform hand hygiene. DON (put on) gloves and all other PPE per standard precautions. Gently perform perineal care wiping from clean urethral area to dirty rectal area to avoid contaminating the urethral area- clean to dirty. DOFF (remove) gloves and PPE, perform hand hygiene. Provide resident comfort and safety by re-clothing (if applicable - incontinence pads and briefs), straightening bedding, adjusting the bed and/or side rails and placing call light within residents reach. Perform hand hygiene. Important points: Doffing and discarding of gloves are required if visibly soiled, always perform hand hygiene before and after glove use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents hazards/supervision/devices, in that: (Resident #42). <BR/>CNA A failed to complete an appropriate one-person gait belt transfer.<BR/>This failure could place residents at risk of inadequate supervision and preventable injuries. <BR/>Findings included:<BR/>Review of Resident #42's admission Record dated 4/11/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anorexia (lack of appetite causing abnormal weight loss), dementia with behavioral disturbance , muscle weakness, lack of coordination, and stroke. Resident #42 was on hospice services. <BR/>Review of Resident #42's Significant Change MDS, dated [DATE], revealed: <BR/>He scored a 6 of 15 on his mental status exam (indicating severe cognitive impairment)<BR/>He needed stand by assistance of two staff for transfers. <BR/>Review of Resident #42's Care Plan, updated 1/21/23, revealed a Focus: Resident has a terminal prognosis and/or is receiving hospice services. The Goal was the resident's comfort will be maintained through review. Interventions included: adjust provision of ADLs to compensate for resident's changing abilities. <BR/>Review of Resident #42's Care plan, updated 10/21/22, revealed a focus of: Resident has an ADL self- care performance Deficit. The Goal was: the resident will maintain or improve current level of function through the revies date. Identified interventions included: Transferring: requires staff x2 for assistance and the resident requires total assistance with transfers, initiated 1/21/23.<BR/>Observation on 04/10/23 at 12:55 PM revealed CNA A took Resident #42 to his room. CNA A rolled Resident #42 to his and checked his dresser for a gait belt; when she was unable to find the gait belt she left the room to find one. Resident #42 was observed to have tremors on his left said. LVN B came into the room with CNA A stating she had a gait belt. CNA A put the gait belt around Resident #42, scooted the resident to the end of the wheelchair and locked the brakes. CNA A tried to lift Resident #42. Resident #42 was not cooperative (did not participate in the process) and the gait belt slid up to his arm pits. CNA A let Resident #42 sit again and tightened the gait belt. CNA A put one hand on either side of Resident #42 and assisted him to stand, when the gait belt started sliding up his ribs, CNA A slightly pushed in to lift him with her hands on the sides. LVN B reached over the wheelchair and grabbed Resident #42 by the waistband. Resident #42 was not able to straighten his legs or bear weight. CNA A lifted Resident #42 into the bed where he laid back with his knees in the air like he was still sitting. CNA A took off the belt, straightened Resident #42's legs and covered him with a blanket. <BR/>Interview on 4/11/23 at 6:01 PM CNA stated she worked at the facility for about a month. CNA A said she worked at the facility for about a month but had received in-service on how to transfer residents. CNA A said to complete a one-person gait belt transfer the aide was to wash her hands, put on the gait belt tight enough to fit two-fingers under it, put their feet on either side of the resident, put the aide's hands on either side of the resident, lift with the knees and transfer. CNA A said the 4/10/23 transfer did not go that way because she had not worked on Resident #42's hall and did not know the residents and what they were capable of doing . CNA A said Resident #42 had a bad day and was not bearing weight on 4/10/23. She stated a mechanical lift would have been more appropriate, but she did not think to get it. <BR/>Interview on 4/12/23 at 9:45 AM the DON, ADON, and Corporate RN stated the expectation for a one-person gait belt transfer was to make sure the bed was at the same level as the wheelchair, make sure the gait belt was tight enough, explain what the person was doing with the resident, make sure the wheelchair was locked, put a hand on either side of the resident and lift with the knees. They stated if a resident was not weight-bearing they were not appropriate for a gait belt transfer and the aides did have the ability to say if a resident needed to use a mechanical lift. They said all the aides needed to do was to go to the ADON or DON and let them know . They were informed of the observation and stated the aide should have asked for help with the transfer. <BR/>Interview on 4/12/23 at 10:09 AM the Administrator was informed of the improperly completed transfer. <BR/>Review of the computerized in-services revealed CNA A was in-serviced on safely moving residents - lifting and transferring on 1/2/23. <BR/>Review of the in-service Transfer from Bed to Wheelchair using a Transfer Belt Inservice, completed 1/10/23, revealed: <BR/>Procedure guidelines for transferring from a bed to a wheelchair using a transfer belt. <BR/>Lock the bed brakes and wheelchair wheels.<BR/>Adjust the height of the bed to the level of the wheelchair seat. <BR/>Place the wheelchair facing toward the foot of the bed, midway between the head and the foot of the bed.<BR/>Position the wheelchair at a 45-degree angle to the bed on the same side of the patient's stronger side. <BR/>Secure the wheels by pushing handles forward on the locks above the wheel rims. <BR/>Place the transfer belt on the waist of the patient over the gown (clothes)<BR/>With the tag of the belt touching the patient's gown, slide the metal trimmed end of the gait belt through the teeth on the other end. Pull the metal trimmed end away from the teeth. Tighten the belt until snug on the patient's center of gravity. The belt should be tight enough for 2 fingers to slide into the belt. <BR/>Spread your feet, flex you r hips and knees and align your knees with those of the patient.<BR/>Grasp the transfer belt along the patient's sides.<BR/>Position yourself slightly in front of the patient, to guard and protect him or her throughout the transfer. <BR/>Safety points<BR/>Determine if the patient can fully assist or partially assist. Do not start the procedure until all required care givers are at the bedside. <BR/>Properly apply the transfer belt. <BR/>Review of the facility's policy and procedure on Moving a Resident, Bed to Chair /Chair to Bed, undated, revealed:<BR/>Purpose: The purpose of this procedure is to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident.<BR/>Steps in the Procedure:<BR/>Lower the height of the bed to the lowest position.<BR/>If moving a Resident from chair to bed:<BR/>Place the chair so it touches the side of the bed and faces the foot of the bed (Note: have the chair on the resident's strong side)<BR/>Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable.<BR/>If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or the edge of the bed.<BR/>If the resident can assist in the procedure, stand on the resident's weak side (Note: encourage the resident to use his or her strong side and to assist in the procedure as much as possible.)<BR/>Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident.<BR/>Instruct the resident to place his or her hands on the arms of the chair for support.<BR/>Instruct the resident to stand and turn with his or her back to the bed and sit on the edge of the bed.<BR/>Move with the resident. <BR/>Should the resident become weak, pale, begin to perspire, complain of chest pain, feel dizzy or any other symptoms of acute distress, cease the procedure and summon the charge nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #5, #9 and #31) of 5 residents reviewed for infection control. <BR/>The facility failed to ensure:<BR/>CNA E did not turn off the faucet with her bare hands after washing them and before performing personal care for Resident #5. <BR/>CNA's E and F change their gloves after they became contaminated during incontinent care while assisting Resident #9. <BR/>CNA B change her gloves after they became contaminated during incontinent care while assisting Resident #31. <BR/>This failure could place resident's risk for cross contamination and the spread of infection. <BR/>Finding include:<BR/>RESIDENT #5<BR/>During an observation on 05/21/24 at beginning at 02:46 PM CNA E entered Resident #5's bathroom and rinsed her hands (no soap was used), turned off the faucet with her bare hands and then dried her hands with a paper towel. Immediately after, CNA E entered the bathroom washed her hands with soap but turned off the faucet with her bare hands. <BR/>During an interview on 05/22/24 at 4:24 p.m. CNA E stated she worked for the facility on and off for 1.5 years. CNA E confirmed she washed her hands after doing performing care for Resident #5. She said she turned on the faucet, soaped her hands, rinsed them, turned the faucet off with a paper towel and then dried her hands with a paper towel. Surveyor read the observation that she turned the faucet off with her bare hands, and CNA E said she was flustered from helping another CNA with care. <BR/>During an interview on 05/23/24 at 9:42 a.m. the DON and Regional Consultant stated the expectation for handwashing was to wet hands, use soap, wash the entire hand and nails, rinse, dry the hands with a paper towel, and then use a paper towel to turn off the faucet. When asked what the expectation about handwashing was, the DON sighed, let me guess, they turned off the faucet with their hands? The DON said staff were in-serviced on how to wash their hands. <BR/>During an interview on 05/23/24 at 10:24 a.m. the Administrator was informed of the handwashing observation. The Administrator agreed there was a chance of cross contamination and asked how the investigation was completed. <BR/>RESIDENT #9<BR/>Record review of Resident #9's admission record dated 05/23/2024 indicated she was a [AGE] year-old female that was initially admitted to facility on 04/02/2022 with medical diagnosis that include muscle weakness, age-related cognitive decline and care provider dependency. <BR/>Record review of Resident #9's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent. Bowel Continence = 3. Always incontinent.<BR/>Record review of Resident #9's care plan dated 05/15/2024 indicated in part: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use. Interventions/Task: Notify nursing if incontinent during activities. Apply barrier cream after each incontinent episode. Brief use: the resident uses disposable briefs. Change every 2 hours and prn.<BR/>During an observation of incontinent care on 05/22/24 at 02:26 PM with CNA E and CNA F for Resident #9. CNA F wiped Resident #9 perineal area from front to back with a clean wipe each time, she did not change her gloves. Resident #9 was rolled to the side to CNA E who then wiped the resident's bottom, removed the old brief, did not change gloves and placed new clean brief. CNA E then placed barrier cream, removed the one glove that had barrier cream and put on one new glove. Both CNA's adjusted the brief, both pulled resident up in bed and without changing her gloves CNA E touched the wipes, the remote, the barrier cream container and the dresser drawer. <BR/>During an interview with both CNA F and CNA E on 05/22/24 at 2:40 pm. Both CNA's stated they should have changed their gloves and hand sanitized or washed their hands before going from dirty to clean on Resident #9. CNA E stated that changing gloves and hand hygiene were used to help prevent cross contamination. <BR/>RESIDENT #31<BR/>Record review of Resident #31's admission record dated 05/23/2024 indicated she was admitted to the facility on [DATE] with diagnoses which included dementia and muscle weakness. She was [AGE] years of age.<BR/>Record review of Resident #31's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 2. Frequently incontinent. Bowel Continence = 3. Always incontinent.<BR/>Record review of Resident #31's care plan dated 06/01/22 indicated in part: Focus: The resident has bladder incontinence. The resident has bowel incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through review date. The resident will not have any complications related to bowel incontinence. Interventions: Incontinent care at least every 2 hours and apply moisture barrier after each episode. Apply barrier cream after every incontinent episode. Check resident every two hours and assist with toileting as needed. Provide pericare after each incontinent episode.<BR/>During an observation on 05/22/24 at 03:34 PM CNA B performed incontinent care for Resident #31. CNA B entered the resident's room, washed her hands and put on a pair of new gloves. CNA B then undid the resident's brief and it was noted that the brief was wet with urine. CNA B then took some wet wipes and wiped the resident's vaginal area. The CNA then rolled Resident #31 on her right side and took some more wet wipes and wiped the resident's rectal area. While CNA B performed the wiping her gloves came in contact with the resident's vaginal and rectal areas. While still wearing the same gloves CNA B then took the clean brief and fastened it to Resident #31. <BR/>During an interview on 05/22/24 at 03:46 PM CNA B said she usually changed her gloves before going from clean to dirty but this time she was in a hurry and did not do it. CNA B said not changing her gloves and touching the clean items could lead to cross contamination. <BR/>During an interview on 05/23/24 at 01:44 PM the DON said it was expected for staff to remove their gloves and wash their hands and install a pair of new gloves once they became contaminated. The DON said staff were supposed to change their gloves to prevent from contaminating other items. The DON believed the failure occurred because the staff got nervous and forgot to change their gloves once they became contaminated. <BR/>During an interview on 05/23/24 at 03:28 PM the Administrator was made aware of the incontinent observations. The Administrator said staff were supposed to change their gloves and wash their hands once they became contaminated. The Administrator said it was the DON's and ADON's job to monitor staff to make sure those steps were followed. The Administrator said the failure probably occurred because the staff got nervous and forgot to change their gloves at the appropriate time. <BR/>Record review of the facility's document titled Personal care and dated 05/11/2022 indicated in part: Start: Perform hand hygiene. DON (put on) gloves and all other PPE per standard precautions. Gently perform perineal care wiping from clean urethral area to dirty rectal area to avoid contaminating the urethral area- clean to dirty. DOFF (remove) gloves and PPE, perform hand hygiene. Provide resident comfort and safety by re-clothing (if applicable - incontinence pads and briefs), straightening bedding, adjusting the bed and/or side rails and placing call light within residents reach. Perform hand hygiene. Important points: Doffing and discarding of gloves are required if visibly soiled, always perform hand hygiene before and after glove use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a notice of transfer or discharge required under this section was made by the facility at least 30 days before the resident was transferred for one (Resident #1) of 3 Residents reviewed for discharge requirement.<BR/>1) The facility failed and refused to readmit Resident #1 from the hospital where she was transferred for evaluation and treatment.<BR/>2) The facility did not give Resident #1 or the representative a discharge notice when she was transferred to another facility from the hospital.<BR/>3) The facility did not permit Resident #1 to remain in the facility and failed to initiate a 30-day discharge based upon the facility's ability to meet the resident's needs and welfare. <BR/>4) There was no documentation from the physician indicating that the resident had specific needs that could not be met in the facility.<BR/>5) The facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay that included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.<BR/>6) The facility failed to establish and follow a written policy on permitting resident to return to the facility after she was hospitalized .<BR/>This failure affected discharged residents and could place the residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process.<BR/>Findings Included:<BR/>Record review of the face sheet for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Paraplegic (paralysis), urinary tract infection, schizoaffective disorder (chronic mental health), cerebellar ataxia (inflamed brain), cervicalgia (neck injury), dry eye syndrome, postmenopausal atrophic vaginitis (inflamed vagina), mood disorder, restless leg syndrome and insomnia (difficulty sleeping).<BR/>Review of Resident #1's admission MDS assessment, dated 06/09/23, reflected the resident had a BIMS score of 08, which reflected the resident was moderately impaired. Section BO300 indicated highly impaired hearing. Resident #1 required extensive assistance with two persons for bed mobility, transfer, and toilet use, dressing, and locomotion on and off unit. Extensive assistance with one person for personal hygiene and eating. The resident required total assistance in bathing activity. Resident #1 had an impairment on both sides of upper and lower upper extremities (paralysis). <BR/>Review of Resident #1's care plan dated 06/06/23 reflected care area problems with potential for uncontrollable pain, use of anti-anxiety medication and hearing deficit. However, there was no care plan for behavioral issues as reflected on the interviews with staffs and administration.<BR/>During interview with SWH on 07/11/23 at 12:37pm, she said she was the Social Worker at the hospital where Resident #1 was transferred for evaluation and treatment of suicidal ideation. SWH explained Resident #1 was hard of hearing and communicated with her through a white board. SWH noted Resident#1 said she was being abuse by a staff member in the facility which made her say she didn't want to live any longer. SWH stated they treated Resident #1 and was ready to discharge the resident to the facility. She contacted ADM of the facility who said they are not taking Resident #1 back because they cannot meet her psychological needs. SWH informed the Administrator (ADM) the hospital was not a place to keep the resident and should take her back and initiate a proper discharge. She said ADM refused to take back the Resident #1. Meanwhile, Resident #1 said she did not want to go back to the facility because she did not feel safe in the facility.<BR/>During interview with SWG on 07/11/23 at 1:32p.m, he said he was the Social Worker of the facility. SWG explained he was not involved in the discharge of Resident #1. He found out in the Morning meeting after Resident #1 was discharged . He said he did not know the facility did not want Resident #1 back after her discharge from the hospital. SWG explained Resident #1 has been trying to leave the facility to move to Abilene close to his brother. He called the brother who stated no facility will take her because of behavioral issues. SWG said he made several calls to different facility and none will take the resident. He explained Resident #1 constantly calls for assistance and gets very angry if the facility did not respond fast enough. SWG noted the DON and Administrator were involved with the discharge of Resident #1. He normally calls discharge residents to ensure they were getting services at home. However, Resident #1went to another facility and he did not call her.<BR/>During interview with ADM on 07/10/2023 at 3:15p.m, she said she was the Administrator and responsible for the discharge of Resident #1. ADM explained Resident #1 was transferred to the hospital for suicidal ideation and did not return to the facility. The ADM was asked to provide information about the discharge of Resident #1. She said did not have documentation because she was not planning on discharging Resident #1 when she went to hospital. She stated she did not have the following: <BR/>1) <BR/>Resident/Representative verbal or written notice of intent to leave the facility.<BR/>2) <BR/>Comprehensive care plan that includes the resident's goals for admission and discharge<BR/>3) <BR/>Discharge planning process<BR/>4) <BR/>Discharge summary<BR/>5) <BR/>Signed physician order of discharge<BR/>6) <BR/>Notice to Adult Protective Service (APS)<BR/>7) <BR/>Meeting with Interdisciplinary Team (IDT) about discharge<BR/>8) <BR/>Required 30-day notice to Resident #1<BR/>9) <BR/>No communication with receiving facility<BR/>The ADM went on to say Resident #1 has some behavioral problems which included calling police for staff member. Resident #1 she said calls staff terrible names and was difficulty to care for. ADM explained when the hospital called to return Resident #1 to facility, she informed them she was not sure if the facility can meet the psychological needs of the resident. She told hospital she will contact corporate and let them know. <BR/>In an interview with LVNA on 07/11/23 at 3:21p.m, she said was the charge nurse responsible for Resident #1 during the evening shifts. LVNA explained she admitted Resident #1to the facility and was familiar with her care. She said she was the nurse who transferred Resident #1 for suicidal ideation. She was told Resident was not coming back. LVNA explained Resident #1 was rude and hateful. She made it hard on staffs to care for her. Resident #1 she said, throws trays and utensils on the floor for no reason. She says racial words on demand and yells on staffs. LVNA stated resident told her she wanted to die which was the reason she transferred her to the hospital for psych evaluation and treatment. She said it was not safe for the Resident #1 to be in the facility because they don't have one-on-one care which she requires.<BR/>During interview with PhyP on 07/11/23 at 3:45p.m, he said he was the medical doctor for Resident#1. PhyP explained Resident#1 was threatening to commit suicide and gave order to transfer resident to the hospital. He said Resident #1 was denied inpatient psychological care and the facility could not meet his needs. PhyP stated Resident #1 has chronic history attempting suicide and the facility don't have the needed staff to care for the resident. When informed of lack of documentation, phyP insisted the facility followed the discharge process.<BR/>Review of Resident #1 clinical records revealed there was no documentation from the PhyP indicating the specific needs of the resident, the efforts to meet those needs and specific services the receiving facility will be able to provide that was not present in the current facility. Furthermore, there was no documentation that the safety of the residents or other residents are endangered due to clinical or behavioral status of the resident.<BR/>Closed record review of Resident #1's EHRs revealed there was no documentation of the following in either resident's record: The basis for the transfer or discharge (i.e., the specific resident needs that cannot be met, the facility's attempt to meet those needs); that an appropriate notice was provided to the resident and/or legal representative; disposition of personal effects, or any documentation by a physician that the transfer or discharge was necessary for the residents' welfare or the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident or the health of individuals in the facility would otherwise be endangered.<BR/>Record review of undated facility policy Admission, Transfer and Discharge reflected The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges:<BR/>A) <BR/>The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.<BR/>B) <BR/>The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs services provided by the facility.<BR/>C) <BR/>The safety of individuals is endangered due to the clinical or behavioral status of the resident.<BR/>D) <BR/>The health of the individuals in the facility would otherwise be endangered.<BR/>E) <BR/>The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his or her stay at the facility.<BR/>F) <BR/>The facility ceases to operate.<BR/>Emergent Transfers to Acute Care<BR/>Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected. Residents who are not sent to the emergency room, will be permitted to return to the facility, unless the residents meet one of the criteria under which the facility can initiate discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 10 residents (Resident #44, Resident # 148) reviewed for resident rights .<BR/>The facility failed to obtain informed consent from Resident #44 prior to administering Bupropion, an antidepressant used to treat depression. The facility also failed to obtain informed consent from Resident #44 prior to administering Duloxetine, an antidepressant used to treat depression in adults and generalized anxiety disorders (excessive worry and tension that disrupts daily life and lasts 6 months or longer).<BR/>The facility failed to obtain informed consent for Resident #148 for Seroquel with a start date of 03/20/23. The consent on file was not signed by prescribing provider, by resident, or by resident representative prior to the facility administering Seroquel Tablet related to psychotic disorder with delusions.<BR/>This failure places residents at risk of being administered medications without consent.<BR/>Findings include:<BR/>Record review of Record review of Resident #44's face sheet revealed admission date of 1/3/23 with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus , metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), dementia a condition characterized by progressive or persistent loss of intellectual functioning), hypertension, Stage 3 kidney failure (moderate kidney damage), hypothyroidism (abnormally low activity of the thyroid gland). She was [AGE] years of age.<BR/>Record review of Resident #44's admission MDS, dated [DATE], indicated he had a BIMS score of 08, which indicated he was cognitively moderately impaired. The MDS also indicated Resident #44 was receiving antidepression medications.<BR/>Record review of Resident #44's care plan indicated, in part: Focus: resident requires antidepressant medication. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through review date. Intervention: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness.<BR/>Record review of Resident #44's medication profile dated 01/27/23 indicated in part:<BR/>Bupropion Sustained Release Tablet Extended Release, every 12 Hour, 200 MG, Give 1 tablet by mouth two times a day for Depression.<BR/>Duloxetine Hydrochloride capsule Delayed Release Particles, 60 MG, Give 1 capsule by mouth two times a day for Depression.<BR/>Record review of Resident #44's clinical records, revealed the consent on file was signed by Family Nurse Practitioner, but not signed by resident or representative prior to the facility administering Bupropion SR Tablet Extended Release for depression with a start date of 01/27/23 and Duloxetine HCl Capsule Delayed Release Particles for depression with start date of 01/27/23.<BR/>Record review of Record review of Resident #148's face sheet revealed admission date of 3/15/22 with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus, dysphagia (impairment of speech), dementia (progressive loss of intellectual functioning, memory, and abstract thinking), generalized anxiety disorder (severe ,ongoing anxiety that interferes with daily activities), psychotic disorder with delusions (unshakeable belief in something implausible). He was [AGE] years of age.<BR/>Record review of Resident #148's admission MDS, dated [DATE], indicated he had a BIMS score of 08, which indicated he was cognitively moderately impaired. The MDS also indicated Resident #148 was diagnosed with major depressive disorder, psychotic disorder with delusions.<BR/>Record review of Resident #148's care plan indicated, in part: Focus: resident requires antipsychotic and anticonvulsant medications for diagnosis of psychotic disorder with delusions due to known physiological condition. Goal: resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Discuss with MD, family regarding ongoing need for use of medication.<BR/>Record review of Resident #148's medication profile dated 03/20/23 indicated in part:<BR/>Seroquel Tablet, Give 100 mg via PEG-Tube two times a day related to psychotic disorder with delusions.<BR/>Record review of Resident #148's clinical records, revealed the consent on file was not signed by prescribing provider, by resident, or by resident representative prior to the facility administering Seroquel Tablet related to psychotic disorder with delusions with start date of 03/20/23.<BR/>Interview on 04/12/2023 at 1:00pm, the DON stated that the ADON and DON are in charge of obtaining consents for medications from residents or resident representatives. She stated that she was aware medication should not be administered without obtaining consents first. <BR/>Record review of the facility's policy revised 02/01/2007, titled Resident Rights and Consent to Receive Psychotropic Medications indicated, in part: <BR/>Consent must be obtained before the medication may be started. The attempt to receive this consent must be documented. Consent may be obtained by residents or their legal representatives giving the facility consent as indicated by signing the psychotropic consent form or, <BR/>The person who prescribes the medication or his/her designee, including facility nursing staff, obtains consent from the resident or legal representative, documents in the chart that the required information was discussed with the resident or legal representative and the circumstances under which consent was given. Telephone consent will be acceptable. The facility staff will fill out the Psychotropic Permission Form which will be kept as permanent document to be kept in chart.

**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 that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #5, #20, and #32) reviewed for care plans in that:<BR/>Resident #5 did not have a care plan to address her pain. <BR/>Resident #20 did not have a care plan to address her pain. <BR/>Resident #32 did not have a care plan to address her Alzheimer's/Dementia or pain. <BR/>This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.<BR/>The findings included the following:<BR/>Review of Resident #5's admission Record dated 4/12/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included arthritis. <BR/>Record review of Resident #5's Annual MDS Assessment, dated 3/27/23, revealed:<BR/>She scored a 9 of 15 on her mental status exam (indicating moderate cognitive impairment).<BR/>She received scheduled and as-needed pain medications. She reported she frequently experienced pain at a level of 6 of 10.<BR/>She received opiate medications for 7 of 7 days prior to the assessment<BR/>Resident #5's MDS CAA documented pain as a triggered area that needed to be care planned.<BR/>Record review of Resident #5's Order Summary Report, dated 4/12/23, revealed orders:<BR/>Fentanyl Transdermal Patch 72 hours 12 mcg/hour - apply 1 patch transdermally one time a day every 72 hours (3 days) for pain and remover per schedule beginning 3/3/23 (no diagnosis)<BR/>Meloxicam Tablet 15 mg, give 1 tablet by mouth one time a day related to arthritis. beginning 7/4/22<BR/>Oxycodone-acetaminophen 7.5mg/325 mg 1 tablet by mouth every 6 hours as needed for pain beginning 1/26/23.<BR/>Tizanidine 2 mg 1 capsule every 8 hours as needed for pain and muscle spasms. beginning 2/7/23<BR/>Review of Resident #5's care plan, last updated 3/30/23, revealed no care plan for pain. <BR/>Interview on 4/12/23 at 4:23 PM the MDS Coordinator stated there was no care plan for Resident #5's pain or pain medication. The MDS Coordinator stated she did not know why pain medication interventions were getting missed. She said any time there was a medication change the DON or whoever could do a care plan. She said new orders were reviewed every morning in the morning meetings and were on the 24-hour report and in the nurse's notes which she had access too. The MDS Coordinator stated the facility did not have a stable DON or ADON in she did not know how long so the Compliance RN had been reviewing the care plans on Monday - Wednesday - Friday . She said usually medications were added when they reviewed new orders in the morning meetings. <BR/>Review of Resident #20's admission Record, dated 4/12/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and restless leg syndrome (uncontrollable, painful urge to move legs). <BR/>Review of Resident #20's Initial MDS Assessment, dated 12/13/22, revealed:<BR/>She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact).<BR/>She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. <BR/>Review of Resident #20's Quarterly MDS Assessment, dated 3/22/23, revealed:<BR/>She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact).<BR/>She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. <BR/>Her CAA Summary documented Pain was a triggered item and was addressed in the care plan .<BR/>Review of Resident #20's Order Summary Report, dated 4/12/23, revealed orders for:<BR/>Gabapentin 300 mg twice a day for Neuropathic pain dated 12/2/22.<BR/>Meloxicam 15 mg for pain dated 3/25/23<BR/>Methadone 5 mg every 8 hours as needed for pain dated 12/2/22<BR/>Morphine Sulfate 15 mg twice a day for pain dated 1/25/23<BR/>Hydrocodone-Acetaminophen every 6 hours as needed for pain dated 12/2/22<BR/>Tizanidine 4 mg every 8 hours as needed for muscle relaxant. <BR/>Review of Resident #20's Care Plan, last updated 1/18/23, revealed no care plan for pain. <BR/>In an interview on 04/12/23 at 2:40 PM the MDS nurse stated that the comprehensive plan of care was created based upon the MDS assessment and initial baseline care plan by herself (the MDS nurse). She stated the comprehensive care plan for Resident #20 was created on 12/5/22, and although pain was triggered on the MDS assessment, it was not addressed in the comprehensive care plan on 12/5/22. The MDS nurse stated, it was an oversight on my part and I should have caught this. She also stated that changes to the care plans were done upon identified issues such as when a resident started an antibiotic or had a change in condition. She stated that she was made aware of changes to resident status during the morning meetings that occurred at 9:00AM each weekday since all department heads were present (Administrator, DON, ADON, Director of Rehab, Dietary, Maintenance, Medical Records), and each party present reported issues regarding the residents related to their discipline. <BR/>Review of Resident #32's admission Record, dated 4/12/23, revealed she was an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with psychotic disturbance and anxiety, Alzheimer's Disease, and Seizures (abnormal brain activity that causes abnormalities in muscles, movement and consciousness needing specialized medication/ monitoring to control and/or other interventions to prevent injury during a seizure).<BR/>Review of Resident #32's Initial MDS Assessment, dated 3/24/23, revealed: <BR/>She scored a 2 of 15 on her mental status exam with no signs of delirium (indicating she was severely cognitively impaired).<BR/>Identified diagnoses included: Alzheimer's Disease, Dementia, and Anxiety. (Seizures were not indicated) <BR/>Review of the CAA Summary revealed Cognitive status was a triggered care area and was addressed in the care plan<BR/>Review of Resident #32's Order Summary Report, dated 4/12/23, revealed orders:<BR/>Gabapentin 300 mg three times a day for mild pain<BR/>Memantine HCL 10mg twice a day related to Alzheimer's Disease<BR/>Review of Resident #32's care plan, last updated 3/20/23 revealed no care plan for dementia/Alzheimer's disease or pain.<BR/>Interview on 4/12/23 at 3:10 PM the DON stated she went and reviewed the MDS assessments to make sure the CAA Areas were triggered. <BR/>In an interview on 04/12/23 at 3:20 PM the Administrator and the Director of Nurses, confirmed that plans of care were reviewed and or implemented by the Director of Nurses or Assistant Director of Nurses. The Administrator stated that the corporate Program Compliance nurse conducted audits on assessments and for Risk Management for the facility, ensured assessments matched orders and care plans, and then shared her findings with the Director of Nurses and Administrator as well as the Assistant Director of Operations. <BR/>Review of the facility's policy and procedure on Comprehensive Care Planning, undated, revealed: The facility will develop and implement a comprehensive care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.<BR/>The comprehensive care plan will describe the following:<BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the right to refuse treatment. <BR/>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.<BR/>Through the care planning process, facility staff will work with the resident and his/her representative, if applicable to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintain his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. <BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.<BR/>When developing the comprehensive care plan, facility staff will, at a minimum, used the Minimum Data Set to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. <BR/>There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment but may not cause a CAA to trigger. The facility will address these areas and will document the assessment of these risks, weakness or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area. If the decision to proceed to care planning is made, the interdisciplinary team, in conjunction with the resident and/or resident's representative, if applicable, will develop and implement the comprehensive care plan and describe how the facility will address the resident's goals, preferences, strengths, weaknesses, and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents hazards/supervision/devices, in that: (Resident #42). <BR/>CNA A failed to complete an appropriate one-person gait belt transfer.<BR/>This failure could place residents at risk of inadequate supervision and preventable injuries. <BR/>Findings included:<BR/>Review of Resident #42's admission Record dated 4/11/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anorexia (lack of appetite causing abnormal weight loss), dementia with behavioral disturbance , muscle weakness, lack of coordination, and stroke. Resident #42 was on hospice services. <BR/>Review of Resident #42's Significant Change MDS, dated [DATE], revealed: <BR/>He scored a 6 of 15 on his mental status exam (indicating severe cognitive impairment)<BR/>He needed stand by assistance of two staff for transfers. <BR/>Review of Resident #42's Care Plan, updated 1/21/23, revealed a Focus: Resident has a terminal prognosis and/or is receiving hospice services. The Goal was the resident's comfort will be maintained through review. Interventions included: adjust provision of ADLs to compensate for resident's changing abilities. <BR/>Review of Resident #42's Care plan, updated 10/21/22, revealed a focus of: Resident has an ADL self- care performance Deficit. The Goal was: the resident will maintain or improve current level of function through the revies date. Identified interventions included: Transferring: requires staff x2 for assistance and the resident requires total assistance with transfers, initiated 1/21/23.<BR/>Observation on 04/10/23 at 12:55 PM revealed CNA A took Resident #42 to his room. CNA A rolled Resident #42 to his and checked his dresser for a gait belt; when she was unable to find the gait belt she left the room to find one. Resident #42 was observed to have tremors on his left said. LVN B came into the room with CNA A stating she had a gait belt. CNA A put the gait belt around Resident #42, scooted the resident to the end of the wheelchair and locked the brakes. CNA A tried to lift Resident #42. Resident #42 was not cooperative (did not participate in the process) and the gait belt slid up to his arm pits. CNA A let Resident #42 sit again and tightened the gait belt. CNA A put one hand on either side of Resident #42 and assisted him to stand, when the gait belt started sliding up his ribs, CNA A slightly pushed in to lift him with her hands on the sides. LVN B reached over the wheelchair and grabbed Resident #42 by the waistband. Resident #42 was not able to straighten his legs or bear weight. CNA A lifted Resident #42 into the bed where he laid back with his knees in the air like he was still sitting. CNA A took off the belt, straightened Resident #42's legs and covered him with a blanket. <BR/>Interview on 4/11/23 at 6:01 PM CNA stated she worked at the facility for about a month. CNA A said she worked at the facility for about a month but had received in-service on how to transfer residents. CNA A said to complete a one-person gait belt transfer the aide was to wash her hands, put on the gait belt tight enough to fit two-fingers under it, put their feet on either side of the resident, put the aide's hands on either side of the resident, lift with the knees and transfer. CNA A said the 4/10/23 transfer did not go that way because she had not worked on Resident #42's hall and did not know the residents and what they were capable of doing . CNA A said Resident #42 had a bad day and was not bearing weight on 4/10/23. She stated a mechanical lift would have been more appropriate, but she did not think to get it. <BR/>Interview on 4/12/23 at 9:45 AM the DON, ADON, and Corporate RN stated the expectation for a one-person gait belt transfer was to make sure the bed was at the same level as the wheelchair, make sure the gait belt was tight enough, explain what the person was doing with the resident, make sure the wheelchair was locked, put a hand on either side of the resident and lift with the knees. They stated if a resident was not weight-bearing they were not appropriate for a gait belt transfer and the aides did have the ability to say if a resident needed to use a mechanical lift. They said all the aides needed to do was to go to the ADON or DON and let them know . They were informed of the observation and stated the aide should have asked for help with the transfer. <BR/>Interview on 4/12/23 at 10:09 AM the Administrator was informed of the improperly completed transfer. <BR/>Review of the computerized in-services revealed CNA A was in-serviced on safely moving residents - lifting and transferring on 1/2/23. <BR/>Review of the in-service Transfer from Bed to Wheelchair using a Transfer Belt Inservice, completed 1/10/23, revealed: <BR/>Procedure guidelines for transferring from a bed to a wheelchair using a transfer belt. <BR/>Lock the bed brakes and wheelchair wheels.<BR/>Adjust the height of the bed to the level of the wheelchair seat. <BR/>Place the wheelchair facing toward the foot of the bed, midway between the head and the foot of the bed.<BR/>Position the wheelchair at a 45-degree angle to the bed on the same side of the patient's stronger side. <BR/>Secure the wheels by pushing handles forward on the locks above the wheel rims. <BR/>Place the transfer belt on the waist of the patient over the gown (clothes)<BR/>With the tag of the belt touching the patient's gown, slide the metal trimmed end of the gait belt through the teeth on the other end. Pull the metal trimmed end away from the teeth. Tighten the belt until snug on the patient's center of gravity. The belt should be tight enough for 2 fingers to slide into the belt. <BR/>Spread your feet, flex you r hips and knees and align your knees with those of the patient.<BR/>Grasp the transfer belt along the patient's sides.<BR/>Position yourself slightly in front of the patient, to guard and protect him or her throughout the transfer. <BR/>Safety points<BR/>Determine if the patient can fully assist or partially assist. Do not start the procedure until all required care givers are at the bedside. <BR/>Properly apply the transfer belt. <BR/>Review of the facility's policy and procedure on Moving a Resident, Bed to Chair /Chair to Bed, undated, revealed:<BR/>Purpose: The purpose of this procedure is to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident.<BR/>Steps in the Procedure:<BR/>Lower the height of the bed to the lowest position.<BR/>If moving a Resident from chair to bed:<BR/>Place the chair so it touches the side of the bed and faces the foot of the bed (Note: have the chair on the resident's strong side)<BR/>Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable.<BR/>If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or the edge of the bed.<BR/>If the resident can assist in the procedure, stand on the resident's weak side (Note: encourage the resident to use his or her strong side and to assist in the procedure as much as possible.)<BR/>Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident.<BR/>Instruct the resident to place his or her hands on the arms of the chair for support.<BR/>Instruct the resident to stand and turn with his or her back to the bed and sit on the edge of the bed.<BR/>Move with the resident. <BR/>Should the resident become weak, pale, begin to perspire, complain of chest pain, feel dizzy or any other symptoms of acute distress, cease the procedure and summon the charge nurse.

Based on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 10 of 41 residents (Residents #6, #10, #11, #13, #14, #17, #18, #25, #28, #32) reviewed for safe, functional equipment, in that:<BR/>Residents #6, #10, #11, #13, #14, #17, #18, #25, #28 and #32 wheelchairs, to include the brakes, were not in safe working order.<BR/>These failures could place residents at risk for skin issues, discomfort, and falls. <BR/>Findings included:<BR/>Observation, interview and record review on 4/11/23 at 3:40 PM during resident council meeting Resident #18 complained the brakes on her wheelchair were loose and that she was concerned because she knew most of the other wheelchairs in the building had similar issues. Resident #11 stated that her wheelchair brakes were also loose and had wobbly wheels but, she stated she had not reported it to anyone. On Inspection, the wheelchair brakes did not properly engage on either wheel of the wheelchair for Resident #18, #11, #10, #25 and #32. The brakes would lock but were not tight and the wheels would continue to roll even with the brake in the locked position. Resident #18 stated she had reported her brakes to a CNA but could not remember their name . No other resident had reported the brakes not working correctly to any facility staff. Record review of resident council meeting minutes book revealed no reports of any issues related to wheelchairs.<BR/>Observation on 4/11/23 at 6:00 PM revealed Resident #28's right wheelchair brake not engaged. The brake would lock, but the wheel would still roll. <BR/>Observation on 4/12/23 at 2:05 PM of residents gathered in the dayroom, revealed Resident #14's right wheelchair brake did not properly engage when in the locked position, Resident #6 and Resident #17's wheelchair brakes on both sides did not properly engage when in the locked position, and Resident #13's left wheelchair brake did not properly engage when in the locked position. All of the brakes locked, but the wheels continued to roll.<BR/>Interview on 4/12/23 at 2:15 PM the DON, ADON, and Corporate RN stated wheelchair safety monitoring included determining which wheels roll and if the brakes worked. The ADON added they checked if brakes engaged would the wheelchair actually stop. The Corporate RN stated there was no set schedule of wheelchair monitoring. The DON stated the staff would come and tell them if there were problems with a wheelchair. The DON said if it was a weekday, the aides would come and tell the management and if it was a weekend, they would text. The Corporate RN stated there was a maintenance log and there were QR codes they could scan into their phones to access the maintenance log . They all stated loose brakes would not wait because if the resident transferred the wheelchair could move out from under them. The Corporate RN stated fixing brakes on the wheelchair was usually a quick fix completed by the Maintenance Director. Once informed of the observation the ADON stated there needed to be a sweep of the building. The DON stated the aides washed wheelchair and should check then <BR/>Interview on 4/12/23 at 2:30 PM the Administrator was informed of the wheelchair brake observations. She said they don't lock?! I'll get maintenance on it right now. The Administrator stated anyone who found wheelchair brakes not working could report the issue. The Administrator said the risk to the residents was an increased risk of falls during transfers. She stated anytime there was anything wrong with equipment it should go into the maintenance book. The Administrator added if the Maintenance Director could not fix it they would order a new wheelchair. <BR/>Interview on 4/12/23 at 6:34 PM the DON and Corporate RN stated there was no policy for wheelchair maintenance or resident equipment. <BR/>Record review on 4/12/23 of maintenance Status Task List for date range 3/12/23 through 4/12/23 revealed no requests regarding wheelchair brake repairs.

Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 2 medication carts (Med Cart #1), reviewed for labeling/storage of drugs and biologicals. <BR/>The facility failed to secure controlled medication in a locked compartment.<BR/>These failures could place the facility at risk of drug diversion and access to medications.<BR/>Findings included:<BR/>Observation of the facility Med Cart #1 on 05/21/24 at 03:27 PM with LVN A revealed one sublingual morphine medication blister pack in the regular section of the chart instead of in the locked narcotic drawer.<BR/>An interview with LVN A on 05/21/24 at 03:50 PM LVN A stated she did not remember putting the morphine in the regular part of the med cart. LVN A stated she must have just grabbed all the medication packs and put them in the regular section. LVN A stated that she knows all narcotics need to be in the locked part of the medication for safety reasons. LVN A stated at the beginning and end of the shift the oncoming and off going nurse will do a narcotic check on the cart to ensure count is correct.<BR/>An interview with the DON on 05/23/24 at 03:46 PM the DON stated that all carts should be kept orderly, medication carts should be locked when unattended and all narcotics should be double locked and signed out on narcotic sheet when given. DON stated the nurses or medication aids do a Narcotic count with each shift. <BR/>A review of the facility policy titled Storage of controlled substance dated 2003, provided by the DON, reads, in part, Controlled drugs (schedule II) .will be kept in a separate, permanently affixed compartment .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for 1 of 3 medication carts and 1 of 1 surplus-stocked medication cart reviewed for medication storage. <BR/>Medication Cart #1 had seven (7) expired medications. Medication Surplus Cart had one (1) expired controlled medication of ten (10) capsules in the med storage room, available for use.<BR/>This failure could place residents at risk for not receiving the therapeutic effects of the medications ordered.<BR/>The findings included:<BR/>Observation on 04/12/23 at 08:30 AM, of surplus-stocked medication cart, revealed:<BR/>- <BR/>Temazepam 7.5mg (10 capsules) expiration date 3/11/23<BR/>Interview on 04/12/23 at 09:00 AM , the ADON stated that the Consulting Pharmacist checked the locked medication cart in the medication storage room. She stated the Consulting Pharmacist rotated a review of medication in the medication storage room followed by medication carts on the floor one month and the next month conducted a review of medication carts on the floor only. He does not review all med carts and storage area each month. The ADON said the Pharmacist reviewed the medication in the medication storage area in February 2023. The ADON said the nurses look for expiration dates on medication packages prior to administration. <BR/>Observation of medication cart #1 on 04/12/23 beginning at 09:30 AM, revealed :<BR/>- <BR/>Three foil packages of Hemorrhoidal Suppositories expiration date 3/23<BR/>- <BR/>One 16 oz bottle Isopropyl Alcohol expiration date 03/23<BR/>- <BR/>One package Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg/ml expiration date 2/10/23<BR/>- <BR/>Two Povidone Iodine Swab sticks single-use package expiration date 08/22<BR/>- <BR/>One 4 oz bottle Tincture of Benzoin Prep Spray expiration date 07/22<BR/>- <BR/>One 30 oz bottle of ProStat Sugar free expiration date 6/6/22<BR/>- <BR/>One 16 oz bottle Ultra Tuss Dextromethorphan Cough Suppressant expiration date 5/22<BR/>- <BR/>One Povidone Iodine Swab sticks single-use package expiration date 01/21 <BR/>The expired medications were stored with non-expired medications, not separated and could be inadvertently dispensed<BR/>Record review of the facility policy titled Recommended Medication Storage (PA 03-3.02h) Revised date 7/2012. There is no mention of an audit process for removal of expired medications nor a responsible party who would remove the medications.

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 in the facility's only kitchen in that:<BR/>The facility failed to ensure kitchen staff wore facial hair restraints during meal preparation. <BR/>These failures could place residents who received meals prepared in the kitchen at risk for food borne illness and cross-contamination.<BR/>Findings include:<BR/>During an observation and interview on 05/21/24 at 10:24 AM Dietary [NAME] D and Dietary Aide C were not wearing facial hair restraints as they each had a moustache and beard. Dietary [NAME] D and Dietary Aide C said they normally wore their facial hair restraints but had forgotten to put them on this morning. There was food set out such as chicken and cake which both staff members were currently preparing when seen without the restraints. <BR/>During an interview on 05/22/24 at 10:54 AM the Dietary Manager said when staff were in the kitchen, they were supposed to wear hair restraints including facial hair restraints. The DM was made aware of dietary cook and aide not wearing facial hair restraints when they were in the process of preparing food. The DM said the staff were supposed to wear their facial hair restraints when they were in the kitchen and they knew that. The DM said she was not sure why they were not wearing them. The DM said if the staff did not wear their hair restraints that could lead to hair getting on the food. The DM said she would do some training on them wearing their facial hair restraints.<BR/>During an interview on 05/23/24 at 03:24 PM the Administrator said it was expected for kitchen staff to wear their hair restraints to include facial hair restraints. The Administrator said the DM was responsible for making sure the staff wore their hair restraints. The Administrator said if the staff did not wear their hair restraints, then there was a possibility of hair landing on the food. The Administrator said she believed the failure occurred because the staff forgot to put the restraints on. <BR/>Record review of the facility's document titled dietary services policy and procedures manual 2012 indicated in part: Sanitation and food handling: All employees receive instruction in sanitation during orientation and through in-services training programs. Hair nets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair.