Every finding on record at Allegiant Wellness and Rehab

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #14, #21, and #38) reviewed for infection control. 1.The facility failed to ensure CNA B and CNA C performed hand hygiene and wore gowns during Resident #14's incontinent care, ADL care, and repositioning who had a g-tube (gastrostomy tube: a tube that is surgically inserted through the skin of the belly and into the stomach), on 09/09/2026.2.The facility failed to ensure CNA B and CNA C performed hand hygiene and that CNA B did not reuse the wipes used to clean the sides of the perineal area (area between the legs) to clean the head of Resident #21's penis on 09/09/2026.3.The facility failed to ensure LVN A performed hand hygiene and did not re-use the gauze used to clean the surrounding skin of Resident #38's pressure ulcer to clean the inside of the wound on 09/10/2026.These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1.Record review of Resident #14's Face Sheet, dated 09/10/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #14's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 07/15/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 05. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach) and was incontinent (unable to control) for bladder and bowel. Record review of Resident #14's Comprehensive Care Plan, dated 07/26/2026, reflected the resident required tube feeding (delivery of nutrition through a tube inserted in the stomach) and was incontinent for bowel and bladder and the intervention for both was to monitor for signs and symptoms of infection. The care plan indicated the resident required EBP and one of the interventions was to wear gloves and gowns during high contact activities.During an observation and interview on 09/09/2026 at 9:26 a.m., CNA B was fastening Resident #14's brief. She said she was done with the resident's incontinent care and was just fixing the resident's brief. She said after she fixed the resident's brief, she would clean the resident's face and would apply some cream on it. She fixed the brief, took off her gloves, went outside the resident's room, pulled a pair of gloves from a glove box attached on the wall, and put it on. She went inside the room, cleaned the resident's face with a face towel, and applied some cream on it. She was not wearing a gown while she was fixing the resident's brief, when she cleaned the resident's face, and when she applied cream on the resident's face. The resident had a g-tube and there was a PPE (refers to protective devices, garments, or coverings worn to minimize exposure to hazards) cart and an EBP (enhanced barrier precaution: infection control intervention designed to reduce transmission of multidrug-resistant organisms) sign outside the resident's door. The sign indicated to use gown and gloves when changing briefs and when providing hygiene.During an interview on 09/09/2026 at 9:34 a.m., Resident #14 said she only had her g-tube for four to three months due to a complication. She said she already got used to it. She said some staff would wear gowns but some staff would not. During an observation on 09/09/2026 at 1:20 p.m., CNA B was about to do Resident #14's incontinent care, who had a g-tube. She did not perform hand hygiene before putting on a pair of gloves. She took a brief from the cabinet and placed it on the resident's overbed table. She unfastened the soiled brief, tucked it between the resident's legs, and cleaned the resident's perineal area using the front to back technique. After cleaning the resident's perineal area, she rolled the resident to her side, cleaned the resident's bottom, pulled the soiled brief, and threw it in the trash can. She then changed her gloves but did not sanitize her hands before putting on a new pair of gloves. She took brief from the resident's overbed table, placed it under the resident, and fixed it. It was observed that during the process of incontinent care, CNA B did not have a gown and was leaning on the resident's bed. After she was done with incontinent care, she took off her gloves and told the resident that she would call another staff to help her reposition the resident. There was a sign outside the resident's room that stated the resident was on EBP, and a gown was required when changing the brief. The sign also indicated to clean the hands before entering. At 1:34 p.m., CNA B called on CNA C to help her reposition Resident #14. CNA C took a pair of gloves from the glove box attached to the wall outside the resident's room and put it on. He did not do hand hygiene before putting on a pair of gloves. It was observed that a sanitizer dispenser was beside the box of gloves. He also did not put on a gown before helping reposition the resident. It was observed that during the process of repositioning, their scrub suits were both touching the bed of the resident.2.Record review of Resident #21's Face Sheet, dated 09/10/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and cerebral infarction (insufficient oxygen in the brain causing stroke). Record review of Resident #21's Comprehensive MDS Assessment, dated 08/19/2026, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #21's Comprehensive Care Plan, dated 09/09/2026, reflected the resident had potential impairment to skin related to incontinence and one of the interventions was perform incontinent care with each episode.During an observation and interview on 09/09/2026 at 9:53 a.m., Resident #21 was in his bed, awake. He said he needed to be changed. He pushed the call light and CNA B entered the resident's room and asked him what he needed. The resident told her that he needed to be changed. She took a new brief and placed it on the resident's side table beside the wipes. She pulled some gloves from the glove box affixed on the wall outside the resident's room, put them on but did not do hand hygiene before putting on the pair of gloves. It was observed that a sanitizer dispenser was beside the glove box. She unfastened the brief but before she tucked it between the legs of the resident, she told the resident that she would call another staff member to assist her with turning the resident. She removed her gloves and went outside the resident's room. When she returned, she pulled a pair of gloves from the glove box affixed on the wall outside the resident's room, put them on, but did not do hand hygiene before putting the gloves on. After a few minutes, CNA C came, pulled some gloves, put them on, and assisted CNA B. He did not do hand hygiene before putting on the pair of gloves. CNA B tucked the unfastened brief between the legs of the resident. She then cleaned the sides of the resident's perineal area and then went to clean the resident's penis, using the same wipes used to clean the sides of the perineal area, from the shaft towards the head of the penis. Both CNAs then assisted the resident to turn to his left side and CNA B cleaned the resident's bottom. After cleaning the resident's bottom, she changed her gloves but did not do hand hygiene. After incontinent care, CNA B changed her gloves but did not do hand hygiene. Bothe CNAs then repositioned the resident. After repositioning the resident, CNA C removed his gloves and left the room. He did not do hand hygiene after removing his gloves.During an observation and interview on 09/09/2026 at 1:40 p.m., CNA B said Resident #14 did not require PPE and the PPE cart outside the resident's room was for the next room. She then saw the signage on the resident's door that indicated gowns were required for resident's with feeding tube during incontinent care. She then said she forgot that the resident was on EBP and staff needed to wear gowns to prevent cross contamination. She said she had an in-service about infection control but was not able to apply it. She said she should have pulled new wipes to clean the penis of Resident #21 and cleaned it from the head to the shaft to prevent infection. She also said hands should be sanitized in between changing of gloves to make sure her hands were clean before touching the new gloves.During an interview on 09/09/2026 at 1:49 p.m., CNA C said he should have done hand hygiene before putting on a pair of gloves to assist CNA B in incontinent care and repositioning Resident #14 and Resident #21. He said the purpose of hand hygiene was to prevent transfer of microorganism from a resident to another resident. He said he also needed to do hand hygiene after removing his gloves to make sure his hands were clean. He said, since Resident #14 had a g-tube, then gowns should be worn when repositioning the resident, also to prevent cross contamination. He said there was sign outside Resident #14 to remind the staff that Resident #14 was on EBP. He said he did not know why he forgot to wear a gown. He said they do have an in-service for infection control.During an interview on 09/10/2026 at 8:42 a.m., the DON said hand hygiene should always be done before and after doing any care and when the staff were changing their gloves to prevent the risk of touching the new gloves with soiled hands. She said there would be hand sanitizer dispensers in the hallways so the staff could easily do hand hygiene before putting on their new gloves. She said if a resident had a g-tube, the staff should wear a gown during incontinent care and repositioning because of MDROs (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) that could attached to the clothes of the staff and eventually transfer them to another resident. She said the penis should be cleaned from the head of the penis downward to the shaft to avoid introducing microorganisms to the opening at the top of the penis that could result to probable infection. She said the expectations were for the staff to perform hand hygiene before and after every care, to perform hand hygiene when they were changing their gloves, and to wear gowns if when required. She said she would start an in-service to fix the infection control issues immediately.3.Record review of Resident #38's Face Sheet, dated 09/10/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with fracture (broken bone) of T11 - T12 (11th and 12th bones at the back) vertebra (small bones forming the backbone).Record review of Resident #38's Comprehensive MDS Assessment, dated 06/23/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident was at risk for developing pressure ulcers (injuries to the skin caused by prolonged pressure on the skin). Record review of Resident #38's Comprehensive Care Plan, dated 08/09/2026, reflected the resident had ulcer to the sacrum (bone at the base of the spine) and one of the interventions was to monitor for signs and symptoms of infection.Record review of Resident #38's Physician Order, dated 09/07/2026, reflected Cleanse sacral wound with vashe (wound cleanser), pat dry, apply anasept gel (used to inhibit the growth of microorganisms), collagen powder (powder that promotes wound healing) and calcium alginate (dressing that absorbs heavy drainage). cover with foam dressing (dressing designed to manage moisture) daily and PRN if soiled or dislodged one time a day for skin impairment.During an observation on 09/10/2026 at 8:54 a.m., LVN A was about to do Resident #38's wound care. She sanitized her hands and prepared the things needed for wound care such as anasept gel in a cup, collagen powder, collagen alginate, foam dressing, some gloves, and some gauzes in a cup soaked in vashe wound solution. She put on her gown, went inside the resident's room bringing with her the things needed for wound care, and placed them on the resident's overbed table. She unfastened the resident's brief and turned the resident to her side. She changed her gloves but did not do hand hygiene before putting on a new pair of gloves. She took the soaked gauzes and started to clean the surrounding skin of the wound. She cleaned around the surrounding skin twice. After cleaning the skin around the wound, she then cleaned the inside of the wound twice using the gauzes used to clean the skin surrounding the wound. After cleaning the wound, she changed her gloves but did not do hand hygiene before putting on the new pair of gloves. She then applied the anasept gel, collagen powder, and collagen alginate, and covered it with the foam dressing.During an interview on 09/10/2026 at 9:14 a.m., LVN A said hands should be sanitized everytime the gloves were changed for possible transfer of something dirty that could lead to possible infection. She said she should have discarded the gauzes that she used to clean the surrounding skin of the wound and took new gauzes to clean the inside of the wound because microorganisms, if any, from the surrounding could be introduced to the wound that could possibly cause the wound to be worse.During an interview on 09/10/2026 at 10:17 a.m., the DON said LVN A already made her aware about the infection control issue during wound care. She said she already had a one-on-one in-service with LVN A regarding hand hygiene. She said she also told LVN A that when cleaning the wound, the best practice was not to use the soiled gauze to clean the inside of the wound to prevent infection. She said it should be one stroke, discard, one stroke, discard and so on and so forth. She said she already started the in-service about infection control after the first interview.During an interview on 09/10/2026 at 10:32 a.m., the Administrator said the expectation was for the staff to perform hand hygiene before and after doing care and when they were changing their gloves to prevent probable infection. He if a resident was on EBP then the staff should wear gowns when attending to them. He said he would let the DON take the lead on the infection control issue during incontinent care and would care. He said the DON already started in-serving the staff.Record review of the facility's policy, Handwashing/Hand Hygiene 2001 MED-PASS, Inc., revised August 2015, reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub . b. Before and after direct contact with residents . g. Before handling clean or soiled dressings, gauze pads, etc. h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment . Procedure . Applying and Removing Gloves . 1. Perform hand hygiene before applying non-sterile gloves . 4. Hold the removed gloves . 5. Perform hand hygiene.Record review of the facility's policy Enhanced barrier Precaution undated, reflected Use EBP when performing high-contact resident care activities and for residents who meet criteria for the use of EBP . Includes the use of gown and gloves . Residents with any of the following . Indwelling medical devices . feeding tube . Everyone must . clean their hands, including before entering and when leaving the room . providers and staff must also . wear gloves and gown for the following high-contact resident care activities . transferring . providing hygiene . changing brief.Record review of the facility's policy Perineal Care 2001 MED-PASS, Inc., revised October 2010, reflected Purpose: The purposes of this procedure are . to prevent infections . Steps in the Procedure . 10. For a male resident . b. Wash perineal area starting with urethra . (3) Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same washcloth or water to clean the urethra.Record review of the facility's policy Wound Care 2001 MED-PASS, Inc., revised October 2010, reflected Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Steps in the Procedure . 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly . 6. Put on gloves . 16. Discard disposable items into the designated container . Wash and dry your hands thoroughly.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of eight (CNA A, LVN B, LVN C, and MA ) staff members and ten of ten residents (Resident #3, #4, #11, #16, #25, #37, #39, #57, #63 & #64) reviewed for infection control procedures. 1) LVN C failed to disinfect the blood pressure machine in between vital sign checks for Residents #63, #57, and #25. 2) MA D failed to cleanse the key used to open Lidocaine packages before and after usage when administering lidocaine patches to Resident #25 and #3. 3) CNA A failed to perform hand hygiene after direct contact with residents #4, #16, and #39 while serving meals trays in the common dining area. CNA A failed to perform hand hygiene after direct contact with residents #11, #7, and #65 while serving trays on Hall 100. 4) LVN B failed to cleanse the scissors before and after usage when performing wound care on Resident #3. LVN B removed the scissors from the treatment cart drawer and used them to open treatment packages and then placed them back into the drawer of the treatment cart. LVN B failed to change gloves and disinfect hands while providing wound care for Resident #3. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #63's 5-day admission MDS assessment, dated 07/23/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #63 had diagnoses which included: hypertension (high blood pressure), coronary artery disease (clogged arteries) and heart failure (heart does not pump blood like it should). Resident #63 was severely cognitively impaired and unable to make decisions and required assistance of two staff for activities of daily living. Record review of Resident #57's in progress 5-day admission MDS Assessment, dated 07/22/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: heart failure (inability for the heart to work properly), and hypertension (high blood pressure), and dementia (forgetfulness and confusion). Resident #57's was severely cognitively impaired and unable to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #25's quarterly MDS Assessment, dated 07/11/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included: hypertension (high blood pressure), renal insufficiency (kidneys not working well) and spinal stenosis (compressing the spine). Resident #15 was cognitive and able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #3's admission MDS Assessment, dated 06/30/2024, revealed an [AGE] year-old male who admitted to the facility on [DATE]. Resident #3 had diagnoses which included: coronary artery disease (clogged arteries), chronic obstructive pulmonary disease (short of breath), and non-pressure chronic ulcer of skin (wounds to toes and ankle). Resident #3 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #4's 5-day admission MDS Assessment, dated 06/27/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #4 had diagnoses which included: diabetes (high blood sugar), cerebral vascular accident (stroke), and hypertension (high blood pressure). Resident #4 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #16's 5-day MDS Assessment, dated 07/17/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #16 had diagnoses which included: seizure disorder (convulsions), hypertension (high blood pressure), and mild protein calorie malnutrition (skinny). Resident #16 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #39's annual MDS Assessment, dated 07/15/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #39 had diagnoses which included: diabetes (high blood sugar), hypertension (high blood pressure), and dementia (thyroid slow to function). Resident #39 was severely cognitively impaired unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #11's 5-day MDS Assessment, dated 07/21/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #11 had diagnoses which included: acute respiratory failure (stopped breathing), hypertension (high blood pressure), and diabetes (high blood sugar). Resident #11 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #37's 5-day MDS Assessment, dated 07/02/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #37 had diagnoses which included: cerebral vascular accident (stroke), hypertension (high blood pressure), and diabetes (high blood sugar). Resident #37 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #64's [SP1] 5-day MDS Assessment, dated 07/27/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #65 had diagnoses which included: atrial fib (irregular heartbeat), heart failure (weak heart), and left hip fracture (broken left hip). Resident #65 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Observation on 07/22/2025 at 9:10 am revealed LVN C taking the blood pressure machine into Residents #63 and Resident #57's room. LVN C did not disinfect the blood pressure machine prior to taking it in the room. LVN C performed vital sign checks on both residents without disinfecting the blood pressure machine between each usage. LVN C came out of the room and proceed into Resident # 25's room, checking the resident's vital signs without disinfecting prior of after usage. LVN C walked down the hallway, plugging the blood pressure machine in, not disinfecting the machine. In an interview on 07/22/2025 at 11:00 a.m., LVN C stated she did not clean the blood pressure machine, but she used hand sanitizer following each usage[SP2] , (this had not been observed by the surveyor) The LVN stated had attended in-services concerning infection control, but she did not recall anything mentioned about cleaning equipment. LVN C stated she guessed this could cause the spread of infections. Observation on 07/22/2025 at 9:15 a.m., revealed MA D during medication pass went to the medication cart and started preparing to perform medication administration for Resident #3. MA D took the Lidocaine Patch from the medication cart, looked for the scissors on the cart, finding no scissors. MA D took key out of her pocket and slashed through the Lidocaine Patch packet. MA D did not clean the key before or after usage, placing the key back in her pocket. MA D gathered the patch and entered Resident #3's room. MA D placed the patch on Resident #3's back. MA D left the room went back to the medication cart removed her gloves, used hand sanitizer, documented on the resident's clinical record and began to prepare for the next medication pass. Observation and interview on 07/22/2025 at 9:30 a.m., revealed MA D during medication pass went to the medication cart and started preparing to perform medication administration for Resident #25. [SP3] MA D took the Lidocaine Patch from the medication cart, looked for the scissors on the cart, finding no scissors. MA D took key out of her pocket and slashed through the Lidocaine Patch packet. MA D did not clean the key before or after usage, placing the key back in her pocket. MA D gathered the patch and entered Resident #25's room. MA D placed the patch on Resident #25's back. MA D left the room went back to the medication cart removed her gloves, used hand sanitizer, documented on the resident's clinical record and began to prepare for the next medication pass. MA D stated she had lost her scissors, and this was the fastest way she could think to open the package. MA D apologized and stated it was wrong to open the package that way, but she was trying to be efficient. MA D stated she had attended in-services on infection control, and she did not think about cleaning the key before or after usage and realized this would be a problem. Not cleaning the key, before and after usage between residents could spread germs to the residents. Observation on 07/22/2025 beginning at 12:20 p.m., revealed CNA A in the main dining room serving lunch trays. CNA A did not use hand sanitizer, available in the dining room and served a tray to Resident #16. CNA A assisted Resident #16, cutting up her meat, opening the butter, buttered the bread (using Resident #16 knife), took the top off the desert, and set the utensil so the resident could use them. CNA A then returned to the service line, not utilizing hand sanitizer. CNA A served a tray to Resident #39 at the same table. CNA removed the utensils using the knife and fork to cut up the meat. The CNA opened up the butter, butter the bread (using the resident's knife), and opened up the dessert. CNA A returned to the service line, not using hand sanitizer. CNA A served a tray to Resident # 4. CNA A opened up the butter for him and took the top of the dessert. The CNA did not use hand sanitizer, leaving the dining room, to assist with hall service. Observation on 07/22/2025 beginning at 12:45 p.m., revealed CNA A walked down Hall 100 did not use hand sanitizer, that was available in the hallway, and served a tray to Resident #7. [SP4] CNA A touched and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #37 and prepared the meal tray for the resident to eat lunch. CNA A did not have on gloves. CNA A was observed not to wash her hands or use hand sanitizer. Observation on 07/22/2025 beginning at 12:47 p.m., revealed CNA A was observed to enter Resident's #11, and #65 rooms setting up the resident's lunch trays, adjusting the overbed table, unwrapped the utensils, and removed tops off of the drinks for each resident. She did not complete hand hygiene before going to the next resident. An interview on 07/22/2025 at 1:10 p.m. with CNA A revealed she did not complete hand hygiene after direct contact with residents. CNA A stated she was supposed to use hand sanitizer in between serving each tray. CNA stated she had received in-service on hand hygiene and infection control. CNA said that she was aware it could spread germs and she was just trying to get the trays served timely. Observation on 07/23/2025 at 9:30 a.m., revealed LVN B the wound treatment nurse went to the treatment cart and started preparing to perform treatment to Resident #3's right lateral ankle. LVN B removed the supplies she needed for the treatment placing them on top of the treatment cart. LVN B then took the scissors out of the cart drawer and used the scissors to open packages and cut the treatment to fit the wound. LVN B did not clean the scissors before or after usage placing them back inside the treatment cart. LVN B donned her gloves and gown, entered Resident # 3's room and began her treatment. LVN B removed the old bandages from the ankle of Resident #3 checking drainage on the pad of the old dressing. LVN B cleaned the right ankle wound and applied the treatment and then applied the occlusive dressing to the wound. LVN B did not change her gloves from the time she started until the end of the treatment. She then removed her gloves and washed her hands, gathered the supplies, exiting the room. In an interview on 07/23/2025 at 10:00 a.m., LVN B stated she did not think about changing her gloves, the wound was so small and [NAME] well. LVN B stated that was part of the treatment process to change gloves from dirty to clean. LVN B stated you could spread infection if you did not follow the protocol, but this resident had no infection. In an interview on 07/24/2025 at 10:00 a.m., with the DON revealed she expected her staff to use hand sanitizer or wash their hands in between each contact with each resident. The DON stated if serving trays in the dining room, or on the hallways the staff should use the available hand sanitizer. The DON stated she had completed multiple infection control in-services in the past fourteen months, concerning hand washing/hand sanitizing and infection control. The DON stated when taking vital signs, the staff should place on a gown and gloves, if the resident is in contact isolation, prior to entering the room and always clean the equipment when completed. If the resident was not in contact the staff should clean all equipment between each usage. The DON stated she expected the nursing staff when conducting treatments to use appropriate dirty to clean techniques with gloves: dirty (removing bandages to cleaning hands and placing on a new pair of gloves for the new treatment, placing on treatment and new bandage). The DON stated if they were not following appropriate infection control practices, then the staff can spread germs to themselves and to the other residents. Record review of an in-service dated June 2025 log revealed CNA A, LVN C, and MA D received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted in June 2025 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands before starting meal service and use hand sanitizer between each tray served. Further review of the LVN B's employee file reflected she had only been employed for two weeks and had infection control training during her orientation. Record review of the Facility's Policy titled Handwashing/Hand Hygiene revised August 2015 reflected: This facility considers hand hygiene the primary means to prevent the spread of infections . 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .2. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors . 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. before and after direct contact with residents; . p. before and after assisting a resident with meals Record review of the Facility's Policy titled Infection Prevention and Control Program revised August 2016 reflected: . 1. The infection and control program is a facility-wide effort involving all disciplines and individual and is an integral part of the quality assurance and performance improvement program .7. prevention of infection. (3) educating staff and ensuring that they adhere to proper techniques and procedures. [SP1]

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for food safety1. The facility failed to correctly label and date 6 storage bags of pudding mix, 1 bag of scalloped potatoes, 4 packages of biscuit mix and 1 bag of strawberry gelatin. 2. The facility failed to correctly label a cart of water and juice stored in the reach-in refrigerator.3. The facility failed to discard a salad with a creation date of 07/17/2025 and was labeled discard by 2nd shift. 4. The facility failed to securely store a box of frozen green peas/mixed vegetables leaving it exposed to air. These failures could place residents at risk for food-borne illness and cross contamination.Findings included:Observation of the kitchen on 07/22/2025 at 9:15 a.m., revealed in the dry storage area, 6 storage bags containing pudding mix were observed with a date of 7/15 marked on the bag with no use by date, and no information describing the contents. There were bags of scalloped potatoes, strawberry gelatin mix, 4 bags of biscuit mix with only a singular date marked on the package. Observation of the reach-in refrigerator on 07/22/2025 at 9:30 am., revealed a tray with prepared beverages including water and juice with no date or description of the items on the tray. Observation of the walk-in freezer on 07/22/2025 at 9:32 am., revealed a large box with frozen green peas was observed in the freezer. The box was partially open and the bag inside containing the green peas/mixed vegetables was open to the air. Observation of the walk-in cooler on 07/22/2025 at 9:36 am a bag with a premade salad was observed with a 07/17/2025 date and discard by 2nd shift written on the package. A bag containing yellow cheese was observed with no use by date on the bag. In an interview with the Dietary Manager on 07/23/2025 at 11:55 a.m., revealed that he recently started the position in the past few weeks and he has not had the opportunity to go through all of products. He stated that they just received a truck before the initial kitchen observation. Surveyor explained those items would not be included as the boxes were sealed and stacked. He revealed that he noticed some things but had not caught the dates on the storage bags. He stated that he has a small staff but was in the process of training them. The dietary manager stated the facility does have a food storage policy and he will retrieve the policy. Note (Policy not provided before exit from the facility.) Interview with the Cook, on 07/23/2025 at 11:50 a.m., revealed he just started and was primarily cooking food and has not reviewed the storage policy of the facility. Interview with administrator on 07/23/2025 at 1:25 pm reveal the facility policy is the Texas Food Establishment Rules, and he does not provide a copy. Record review of the Texas Food Handler's guide taken from the DSHS webpage. 1. What are the regulations and guidelines for storing food in a commercial kitchen in Texas?In Texas, the regulations and guidelines for storing food in a commercial kitchen are primarily outlined by the Texas Department of State Health Services (DSHS) and the Texas Food Establishment Rules (TFER). Here are key regulations and guidelines that food handlers and operators in Texas must adhere to when storing food in a commercial kitchen: 3. Labeling and Dating: All food items should be properly labeled and dated to ensure proper rotation and prevent spoilage. Labels should include the name of the product, the date it was prepared or received, and the use-by or expiration date. 2. How should perishable foods be stored in a refrigerator to prevent spoilage? 3. Packaging: Store perishable foods in airtight containers or sealed bags to prevent cross-contamination and to maintain freshness.Findings included:Observation of the kitchen on 07/22/2025 at 9:15 a.m., revealed in the dry storage area, 6 storage bags containing pudding mix were observed with a date of 7/15 marked on the bag with no use by date, and no information describing the contents. There were bags of scalloped potatoes, strawberry gelatin mix, 4 bags of biscuit mix with only a singular date marked on the package. Observation of the reach-in refrigerator on 07/22/2025 at 9:30 am., revealed a tray with prepared beverages including water and juice with no date or description of the items on the tray.Observation of the walk-in freezer on 07/22/2025 at 9:32 am., revealed a large box with frozen green peas was observed in the freezer. The box was partially open and the bag inside containing the green peas/mixed vegetables was open to the air. Observation of the walk-in cooler on 07/22/2025 at 9:36 am a bag with a premade salad was observed with a 07/17/2025 date and discard by 2nd shift written on the package. A bag containing yellow cheese was observed with no use by date on the bag. In an interview with the Dietary Manager on 07/23/2025 at 11:55 a.m., revealed that he recently started the position in the past few weeks and he has not had the opportunity to go through all of products. He stated that they just received a truck before the initial kitchen observation. Surveyor explained those items would not be included as the boxes were sealed and stacked. He revealed that he noticed some things but had not caught the dates on the storage bags. He stated that he has a small staff but was in the process of training them. The dietary manager stated the facility does have a food storage policy and he will retrieve the policy. Note (Policy not provided before exit from the facility.)Interview with the Cook, on 07/23/2025 at 11:50 a.m., revealed he just started and was primarily cooking food and has not reviewed the storage policy of the facility. Interview with administrator on 07/23/2025 at 1:25 pm reveal the facility policy is the Texas Food Establishment Rules, and he does not provide a copy. Record review of the Texas Food Handler's guide taken from the DSHS webpage. 1. What are the regulations and guidelines for storing food in a commercial kitchen in Texas?In Texas, the regulations and guidelines for storing food in a commercial kitchen are primarily outlined by the Texas Department of State Health Services (DSHS) and the Texas Food Establishment Rules (TFER). Here are key regulations and guidelines that food handlers and operators in Texas must adhere to when storing food in a commercial kitchen: 3. Labeling and Dating: All food items should be properly labeled and dated to ensure proper rotation and prevent spoilage. Labels should include the name of the product, the date it was prepared or received, and the use-by or expiration date. 2. How should perishable foods be stored in a refrigerator to prevent spoilage? 3. Packaging: Store perishable foods in airtight containers or sealed bags to prevent cross-contamination and to maintain freshness.

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for 2 of 30 opportunities during medication pass resulting in an 6 percent (6%) error rate for 2 (Residents #25, and #63) of 4 residents observed for medication pass. 1. MA D failed to administer Resident #25's Biofreeze Cool the pain external gel 4% (gel for pain) her lower back.2. MA D failed to administer Resident #63's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a decreased health status. Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for 2 of 30 opportunities during medication pass resulting in a 6 percent (6%) error rate for 2 (Residents #25, and #63) of 4 residents observed for medication pass. 1. MA D failed to administer Resident #25's Biofreeze Cool the pain external gel 4% (gel for pain) her lower back.2. MA D failed to administer Resident #63's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a decreased health status. Findings included: Observation on 07/22/2025 at 9:15 a.m., revealed MA D did not administered the following medication to Resident #25: Biofreeze Cool the pain external gel 4% was administered by MA D to Resident #25's knees but not to her back. Review of Resident #25's Physician's Order dated 02/22/2025 reflected, Biofreeze Cool Gel 4% apply to knees and lower back three times a day for pain at 9:00 am, 3:00 p.m., and 9:00 p.m. Observation on 07/22/2025 at 10:00 a.m., revealed MA D administered the following medication to Resident #63: MiraLAX 17 gm. was administered to Resident #63 by MA D without the appropriate amount of fluid. Review of Resident #63's physician's order dated 07/21/2025 reflected MiraLAX Oral Powder 17 gm/scoop give one scoop one time a day with four to eight ounces of fluid at 8:00 a.m. In an interview at 05/28/24 at 11:15 a.m., MA D revealed she knew she had to apply the pain gel to both knees of Resident #25 but did not know about the back. She said she signs off on the medication administration record without looking thoroughly. MA D stated she knew better. MA D stated that the cups she thought offered 4 ounces of fluid, but was not sure, she had never measured the fluid, she just fills the cup up and gives it to Resident #63 and he has been drinking it. MA D stated she would have to slow down and be more thorough and read the orders completely. In an interview on 07/24/2025 at 10:00 a.m., the DON revealed the staff should be reading the medication administration record prior to and after giving the medication to be assured they were giving the correct medicines and at the right time. The DON stated the medication administration record gives the staff all the information for type of medication, how much, to give, and if it was by mouth, topical, or eye drops or nose spray. The MiraLAX was to be given with 4 to 6 ounces of a fluid and if the cups are not marked they should be measuring the amount the cup will hold to make sure the resident is getting the correct amount of fluid. Review of the facility policy and procedure Medication Administration dated revised December 2012 reflected, Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications should be administered in accordance with the orders. 7. The individual administering the medications must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 3 days reviewed (07/22/2025 and 07/23/2025) for nurse staffing posting.The facility failed to post the daily staffing information in a prominent place on 07/22/2025 and 07/23/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.During an observation on 07/22/2025 at 9:00 AM, there was no daily staff posting in or around the front entrance or at the nurse's station.During an observation and interview on 07/23/2025 at 11:11 a.m., information regarding the current nurse staffing and census information was not available in a public posting. The DON revealed she could not locate the daily census and nurse staffing posting. She revealed the posting was the responsibility of Human Resources. She revealed she was unable to provide a timeline of how long the daily census and nurse staffing posting was missing. The DON stated the purpose of posting the daily census and nurse staffing was to inform the residents and facility guests to know how many staff members were working. The DON stated she was unsure if the lack of posting the daily census and nurse staffing would impact residents and facility guests because family members would ask how many staff were assigned to provide care to their loved one.During an interview on 07/23/2025 at 11:45 a.m., the HR revealed that the posting was kept at the receptionist desk daily. She also could not locate the daily census and nurse staffing posting. She revealed she did not know how long the daily nurse staffing information and census had not been posted. She stated she had not had any residents or family members ask about the posting and because staffing was primarily consistent, she did not believe the lack of the posting would have impacted them. Record review of the facility's policy titled, Staffing, Sufficient and Competent Nursing, revised August 2022, indicated, 6. Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift.

Based on observation, interviews and record review, the facility failed to develop a comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans.Resident #1's care plan did not address the resident's wound care needs provided by the facility with goals and interventions.This deficient practice could result in a loss of quality of life due to residents receiving improper care.Findings included:Review of Resident#1's face sheet, dated 7/8/2025, revealed the resident was a [AGE] year-old admitted on [DATE] with diagnoses of dehiscence of surgical wound (opening of wound), injury of right knee tendon, and anemia. Review of Resident #1's hospital record, dated 6/13/2025, revealed Resident#1 was admitted for evaluation of an open wound from knee surgery performed on 5/18/2025Observation of Resident #1 on 7/8/2025 at 9:10am, revealed Resident#1 had a surgical wound on right knee, covered with dressing and the wound was being suctioned using a wound vacuum (a machine used to suction wound fluid).Review of Resident #1's physician order [surgical center name], dated 6/24/2025, revealed there was an order for Negative Pressure Wound Therapy (NPWT) three times per week, with care instructions provided in the order.Review of Resident#1's comprehensive care plan, dated 7/8/2025, reflected no care plan for the wound was developed.Interview with the treatment nurse on 7/8/2025 at 3:45pm revealed that the treatment nurse was responsible to develop a wound care plan for residents with wounds. She confirmed that there was no care plan developed for Resident #1's knee wound. She stated that the risk of not having care plans updated was the resident could receive improper care or lack of care quality. Interview with the DON on 7/8/2025 at 4:00pm revealed that the interdisciplinary team met weekly to develop and/or update residents' care plans. She stated that wound care should be included in the care plan. She stated that she was not aware Resident #1's care plan did not include wound care. Review of facility's Care plans, Comprehensive Person-centered policy, dated 12/2016, revealed that the interdisciplinary team must review and update the care plan when. there has been a significant change in the resident's condition. The policy also stated that assessments of residents are ongoing and care plans are revised as information about. the resident's condition change. The comprehensive care plan will. describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents and/or injury for 1 of 3 residents (Resident #1) reviewed for accidents and supervision. CNA A and RN B failed to ensure that Resident #1 did not receive a solid food tray, as Resident #1 was an NPO (no food by mouth) resident, with a G-Tube. As a result, Resident #1 consumed approximately 50% of the tray food given to her by CNA A. This failure could place residents at risk of aspiration (the accidental inhalation of food, liquid, saliva, or stomach contents into the airway and lungs, potentially leading to complications like pneumonia) causing serious injury or death. Findings included: Record review of Resident #1's Face Sheet dated 3-11-2025, conveyed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Metabolic Encephalopathy (a brain dysfunction caused by underlying systemic illnesses or metabolic imbalances, resulting in altered mental status or consciousness, ranging from confusion to coma) and secondary diagnoses of Type 2 diabetes with neuropathy (a condition where the body's inability to use insulin correctly leads to high blood sugar, causing nerve damage (neuropathy) without a specific type of neuropathy being identified), Morbid Obesity (a severe form of obesity characterized by a high body mass index (BMI) and significant health risks), and Acute Respiratory Failure with Hypoxia (a condition where the lungs fail to adequately deliver oxygen to the blood, leading to dangerously low oxygen levels). Record review of Resident #1's transfer orders from the hospital dated 2-6-2025 revealed Resident #1 was assessed as being a NPO patient. Record review of Resident #1's Care Plan dated 2-9-2025 revealed she required tube feeding related to Dysphagia (having difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage) with interventions to monitor Resident #1 for Aspiration. Record review of Resident #1's Nursing Home PPS (Prospective Payment System) (NP - Nurse Practitioner) MDS (Minimum Data Set) dated 2-13-2025 revealed Resident #1 had a BIMS score of 1, indicating severe cognitive impairment. The MDS indicated in the Swallowing/Nutritional Status section that Resident #1 had a swallowing disorder of Coughing or choking during meals or when swallowing medications, Holding food in mouth/cheeks or residual food in mouth after meals, and Complaints of difficulty or pain with swallowing. Record review of Resident #1's Order Summary dated 2-13-2025 indicated the facility's dietician listed Resident #1 as an NPO. Record review of Resident #1's doctor orders dated 2-13-2025 indicated Resident #1 was on an NPO Diet. Record review of Resident #1's Progress Notes by RN B, dated 2-26-2025, stated This nurse entered patient room noted tray present with food eaten. Sign above bed that says NPO. Feeding pump present in room. This nurse asked CNA if she gave patient a tray she stated, yes. CNA educated that she is supposed to ask a nurse about patient diet. Never assume. Kitchen did not send patient a tray for a reason. Patient is sitting up in wheelchair no coughing or respiratory distress noted. Dr. A notified waiting for response, DON notified. Resident #1's Progress Note dated 2-26-2025 at 3:09 PM stated RN B contacted Resident #1's [family member] saying . informed her that CNA did give [Resident #1] a [food] tray and she did eat some of the food .informed Resident [family member] that Resident #1 was a .nothing by mouth [and] we are concerned about aspiration of food going into the lungs, so we are going to get a chest x-ray. Record review of the facility's in-services on the topic of NPO residents and food trays revealed they were conducted on 2-26-2025. The in-services included NPO training for CNA A with a one-on-one session with the DON, all the kitchen staff, and facility wide for staff members indicating that NPO residents do not get a food tray. Record review of Resident #1's Radiology Note dated 3-1-2025 at 6:42 PM, indicated a chest x-ray was completed showing Resident #1's lungs were clear showing no signs of aspiration. Record review of Resident #1's Progress Note dated 3-4-2025 at 5:00 AM revealed Resident #1 had a change in condition due to vomiting and shortness of breath. Resident #1 was sent out to the hospital via ambulance on 3-4-2025 at 7:00 AM. In an interview on 3-11-2025 at 12:50 PM, it was revealed RN B worked at the facility on 2-26-2025, entered Resident #1's room after lunch was served, saw a food tray next to Resident #1's bed, and saw food had been eaten. RN B conveyed she asked CNA A why Resident #1 had a food tray in her room and CNA A stated that the kitchen did not make a meal ticket for Resident #1, so she retrieved one and gave it to Resident #1. RN B stated she informed CNA A that Resident #1 does not get food trays because Resident #1 was a tube fed patient with a NPO sign above her bed. RN B said CNA A was surprised to learn Resident #1 was a NPO. RN B said CNA A should know this. RN B said a nurse should be responsible to make sure a CNA knows a patient is an NPO. RN B said the risk to Resident #1 eating food from a food tray was aspiration into the lungs and could be very dangerous to the patient. RN B said the facility did in-services on NPO and tube feeding after this incident on 2-26-2025. In an interview with the Director of Therapy (DOT) on 3-11-2025 at 5:00 PM it was revealed she was also the facility's speech therapist and had worked at the facility since 2018. The DOT stated she screens for swallowing issues on every resident who admits into the facility. The DOT stated when Resident #1 admitted into the facility Resident #1 had a swallow test performed at the hospital prior to admission. The DOT said Resident #1 was a NPO from the beginning of her admittance into the facility and Resident #1 was not supposed to have received a food tray on 2-26-2025. The DOT said the risk to Resident #1 receiving a food tray and consuming food was that Resident #1 could aspirate and cause her to be hospitalized . In an interview with CNA A on 3-11-2025 at 3:00 PM, it was revealed CNA A has been a CNA for over 7 years, has worked at the facility since 12-2023, and usually works the 2:00 PM-10:00 PM shift. CNA A said she was working at the facility on 2-26-2025 in the hallway where Resident #1 was residing. CNA A said she did not usually work the hallway where Resident #1 was residing and was not familiar with Resident #1. CNA A said she did not see the NPO sign above Resident #1's bed but noticed she did not have a food tray. CNA A said she retrieved a food tray for Resident #1 and brought it to her in her room to eat. CNA A said she made a mistake. CNA A stated she was in-serviced by the facility on NPO residents and food trays after the incident with the DON. CNA A said the facility went over NPO training when she was orientated back in 12-2023. In an interview on 3-12-2025 at 4:28 PM, it was revealed that the Facility's Dietitian stated Resident #1 was the facility's only G-Tube patient and the only NPO patient. The Facility's Dietician said Resident #1 was not supposed to receive a food tray on 2-26-2025 as Resident #1 was not supposed to receive any food by mouth. The Facility's Dietician said her expectation was for the facility staff to not give Resident #1 a food tray as eating tray food could cause Resident #1 aspirate. In an interview on 3-14-2025 at 12:30 PM it was revealed from RN B that Resident #1 ate approximately 50% of the tray food that was given to her on 2-26-2025. Record review of Resident #1's current hospital record dated 3-6-2025 revealed Resident #1's reason for admission was a Bilateral acute on chronic Subdural Hematoma and did not have aspiration (a condition where a new bleeding episode (acute) occurs on top of a pre-existing, older hematoma (chronic) in the subdural space, affecting both sides of the brain) and not aspiration. Record review of the facility's policy called Enteral Nutrition dated 2001 and revised on 1-2014 stated: .11. The Nurse will confirm that there are appropriate orders for oral (PO) intake or restrictions for nothing by mouth (NPO), as appropriate. .13. Staff caring for residents with feeding tubes will be trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as: a. Aspiration . 15. Risk of aspiration will be assessed by the Nurse and Physician and addressed in the individual care plan .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for: 1. The facility failed to ensure food items, placed in the refrigerator were properly sealed, dated, and labeled. 2. The facility failed to ensure food items, placed in the dry storage area, were sealed and kept off of the floor. This failure could affect residents by placing them at risk for food-borne illness. Findings included: 1. In an observation on [DATE], at 8:50 AM, of the facility's only walk-in refrigerator, revealed an unsealed bag of sliced cheese exposed to air. In an observation on [DATE], at 8:53 AM, of the facility's only free-standing refrigerator, revealed 2 glasses of milk and 3 glasses of juice, undated and unlabeled. 2. In an observation on [DATE], at 8:57 AM, of the facility's only kitchen pantry area, revealed used seasoning containers of onion, lemon, and garlic powder on the floor, an unsealed bag of potato chips, an unsealed container of breadcrumbs, and an unsealed box of tea bags. In an interview with Dietary Aide A on [DATE], at 9:00 AM, it was conveyed that the Dietary Manager was on vacation and would return to the facility the next day. Dietary Aide A stated the risk to residents having food not sealed in refrigerators, not having dates and/or labels in refrigerators, foods not being kept off floors, and foods, in the dry storage area, not being sealed, was the food could get stale and insects could get into the food. In an interview with [NAME] B on [DATE] at 9:15 AM, [NAME] B said the concern to residents for not keeping food or drinks dated and labeled was no one would know how long the food had been in a refrigerator and someone could have gotten sick. In an interview with the Dietary Manager on [DATE], at 10:25 AM, it was stated everyone who worked in the kitchen was responsible for ensuring food was kept off the floor, food packages were kept sealed, and food and drinks, in the refrigerator, were dated and labeled. The Dietary Manager stated her expectations were for these things to be done daily. The Dietary Manager stated the concern for these areas was that food could have expired, bugs could get into foods, and residents could have gotten sick. In an interview with the Dietician on [DATE] at 10:41 AM, it was revealed that the Administrator was on vacation. The Dietician said food and drinks should be dated, labeled, and food storage containers should be closed. The Dietician stated the dry storage bins should be sealed to prevent pest from getting in the food and to maintain freshness. The dating of foods was important to protect freshness, prevent spoilage, and to make sure the foods are used within the correct timeframe. The Dietician stated it was her expectation for these things to be done in the kitchen and the facility used the Texas Food Establishment Rules as their policy for food storage. Record review of the facility's food storage policy entitled; Texas Food Establishment Rules dated [DATE] stated: S229.164 (c)(5) Package integrity. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. S229.164 (h)(1) Food Storage. (A) Except as specified in subparagraphs (B) and (C) of this paragraph, food shall be protected from contamination by storing the food: (i) in a clean, dry location; (ii) where it is not exposed to splash, dust, or other contamination; and (iii) at least 15 cm (6 inches) above the floor. S229.164 (o)(B) When placed in cooling or cold holding equipment, food containers in which food is being cooled shall be: . (7) Ready-to-eat, potentially hazardous food, date marking. (A) Except as specified in subparagraphs (D)-(F) of this paragraph refrigerated, ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked using calendar dates, days of the week, color coded marks, or other effective means to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified below. The day of preparation shall be counted as Day 1. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request .

Based on observation, interview, and record review, the facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards for 1 of 1 kitchen for kitchen sanitation and failed to ensure the facility's only garbage storage dumpster was maintained in a sanitary condition to prevent the harborage and feeding of pest. 1. The facility failed to ensure trash receptacles in the kitchen were closed with a lid. 2. The failed to ensure the trash dumpster's door outside of the kitchen was closed and failed to ensure trash was not left outside of the dumpster. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: 1. During an observation on 6-18-2024 at 8:55 AM, a large trash receptacle had trash contents inside, without a lid, in the facility's only kitchen. The trash can was observed to not be in use. 2. During an observation on 6-18-2024 at 9:03 AM, the facility's only trash dumpster was observed to have its door open, with a trash bag full of trash, hanging out the door. In an interview on 6-18-2024 at 9:05 AM, Dietary Aide A stated trash can lids should be covering trash cans in the kitchen unless they were in use. Dietary Aide A said the concern for the trash cans not being covered was that it could attract flies. In an interview on 6-18-2024 at 9:15 with [NAME] B, it was stated the trash dumpster door should remain closed and trash should not be hanging out of the door because it could attract pest to the area. [NAME] B stated staff were in-serviced on this issue. [NAME] B said the trash cans, in the kitchen, should have lids on them when not in use. [NAME] B stated the trash cans could attract bugs if not covered. In an interview on 6-19-2024 at 10:25 AM, the Dietary Manager stated the doors to the trash cans in the kitchen should be sealed with a lid unless being used. It was everyone's responsibility, in the kitchen, to ensure that happens. The Dietary Manager stated it is her responsibility to ensure the trash dumpster doors stay closed and trash wasn't hanging outside the doors. The Dietary Manager stated the concern for the trash dumpster not staying closed and having a trash bag hanging out of the door, is that it can attract pests' odors and rodents. In an interview on 6-20-2024 at 10:41 AM, the Dietitian stated, it was revealed that the Administrator was on vacation. She stated when she was at the facility, she ensured the trash cans in the kitchen area were closed with lids, and the dumpster outside stayed closed with its doors. The Dietician's expectation was for trash cans in the kitchen area, unless they were being used, to have a lid on them and for the trash dumpster, outside the kitchen, to stay closed unless being used. Record review of the facility's Garbage Containment and Disposal Policy entitled; Texas Food Establishment Rules dated 3-16-2006 stated: S229.166(k) (l) Storage facilities on the premises. (1) Indoor storage area. If located within the food establishment, a storage area for refuse, recyclables, and returnables shall meet the requirements specified under S229.167(a), (c)(1) - (8), (d)(5) and (6) of this title (relating to Physical Facilities). (4) Receptacles. (A) Except as specified in subparagraph (B) of this paragraph, receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect and rodent-resistant, leakproof, and nonabsorbent. (6) Outside receptacles. (A) Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. S229.166(l) (A) An inside storage room and area and outside storage area and enclosure, and receptacles shall be of sufficient capacity to hold refuse, recyclables, and returnables that accumulate. (B) A receptacle shall be provided in each area of the food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed . (11) Storing refuse, recyclables, and returnables. Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . (14) Covering receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) inside the food establishment if the receptacles and units: (i) contain food residue and are not in continuous use; or (ii) after they are filled; and (B) with tight-fitting lids or doors if kept outside the food establishment.

Based on observation, 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 timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 3 of 9 residents (Residents #1, #2 and #3) reviewed for care plans in that: Resident #1, Resident #2 and Resident#3's comprehensive care plan did not reflect they used continuous oxygen. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Record review of Resident #1's admission MDS assessment (dated 05/02/24) revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses of unspecified Dementia (loss of cognitive functioning- thinking, remembering, and reasoning, to such an extent that it interfered with a person's daily life and activities), fracture of unspecified part of neck of left femur, anemia (blood produces a lower-than-normal amount of healthy red blood cells), and hypokalemia (low blood potassium levels). No oxygen therapy documented on admission MDS. Record review of Resident#1's orders revealed Resident#1 had an new order (dated 4/26/24) for Oxygen 02 at 2LPM from NC continuously every shift for Hypoxia (low levels of oxygen in body tissues). Record review of Resident#1's care plan (dated 05/02/24) revealed no oxygen therapy documented on admission and was not added to care plan. Record review of Resident #2's admission MDS (dated 05/30/24) revealed, Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses of unspecified Asthma with (acute) exacerbation (episodes of worsening asthma symptoms and lung functions) and chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). No oxygen therapy documented on admission MDS. Record review of Resident#2's orders revealed, Resident#2 had an new order (dated 5/24/24) for Oxygen 02 at 2LPM from NC continuously every shift for Hypoxia(low levels of oxygen in body tissues). Record review of Resident#2's care plan (dated 05/06/24) revealed no oxygen therapy documented on admission and was not added to care plan. Record review of Resident #3's quarterly MDS (dated 07/20/24) revealed Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses of unspecified Dementia (loss of cognitive functioning- thinking, remembering, and reasoning, to such an extent that it interfered with a person's daily life and activities), anxiety disorder (persistent and excessive worry that interferes with daily activities), and Cyclothymic disorder (rare mood disorder). No oxygen therapy documented on quarterly MDS. Record review of Resident#3's orders revealed Resident #3 had an new order (dated 05/24/24) for Oxygen 02 at 2 to 3LPM from NC continuously every shift for Hypoxia (low levels of oxygen in body tissues). Record review of Resident#3's care plan (dated 04/21/24) revealed no revision for oxygen therapy documented. An observation on 05/24/24 at 6:40 AM revealed Resident #2 was hooked up to her oxygen machine and lying in bed. An observation on 05/24/24 at 6:43 AM revealed Resident #3 was hooked up to her oxygen machine and was lying in bed. An observation on 05/24/24 at 6:45 AM revealed Resident #1 did not have her oxygen machine plugged up. An observation on 05/24/24 at 2:15 PM revealed Resident #1 was in her bed with her oxygen machine connected and on. In an interview on 05/24/24 at 7:03 AM with LVN A, revealed Resident #1 would take her oxygen off. LVN A revealed Resident#2 and Resident#3 keep their oxygen on all the time. In an interview on 05/24/24 at 8:04 AM Residen t#1 was not able to answer questions about her oxygen machine. An interview on 05/24/24 at 8:06AM revealed Resident #3 was not able to answer questions about her oxygen machine. In an interview on 05/24/24 at 10:14 AM revealed Resident #2 had to use her oxygen machine all the time or she would have shortness of breath. An interview on 05/24/24 at 2:42 PM with CNA B revealed Resident#1 wore her oxygen in bed when she was in bed. An interview on 05/24/24 at 3:00 PM with MD revealed Resident #1 had not had any adverse reactions at the time from not wearing her oxygen continuous. MD stated that she was not changing her order and she needed to use her oxygen continuously. The MD stated Resident #2 was on continuous oxygen and no reported issues of Resident #2 not wearing oxygen. The MD stated Resident #3 was on continuous oxygen and no reports of her taking off her oxygen. An interview on 05/28/24 at 3:50 PM with the Case Manager revealed, care plans were completed within the first 7 days of a resident being admitted to the facility. The Case Manager revealed that she worked on the care plan with family. The Case Manager revealed she would update the resident's nurse or DON when reporting a change in condition. An interview on 05/28/24 at 4:10 PM with the DON revealed she had been in the facility for 5 days. The DON stated the care plans were completed at admission and at the care plan meetings. The DON stated the residents were not at any risk because the residents received their oxygen treatments. An interview on 05/28/24 at 4:28 PM with the MDS nurse revealed that she was responsible for updating the care plan. The MDS nurse stated she made updates to the care plan when the DON let her know there had been a change in condition. The MDS nurse stated the residents were not at any risk because the orders were still being followed by nursing staff. An interview on 05/28/24 at 4:38 PM with the Administrator revealed the initial care plan should be completed at admission. The Administrator stated acute changes in the residents should be updated on the care plan when the change occurred. The Administrator stated there was no physical risk to the resident if the change of condition was not listed on the care plan. Record review of facility policy titled Change in a Resident's Condition or Status (revised December 2016) revealed, . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interviews and record reviews the facility failed to maintain medical records that were complete and accurately documented for 1 (Resident #4) of 4 residents reviewed for resident records. The facility failed to accurately document Resident #4's skin tear on the elbow that occurred on 05/24/24. This failure could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care. This failure could place residents at risk for skin tears injuries. The findings were: Record review of Resident #4's initial MDS assessment (dated 05/26/24) reflected Resident #4 was admitted to the facility on [DATE] and had diagnoses of Lobar Pneumonia (affects an entire lobe of the lung), unspecified Glaucoma (eye's optic nerve, which provides information to the brain is damaged), type 2 Diabetes Mellitus (a condition results from insufficient production of insulin, causing high blood sugar) with Diabetic Neuropathy (nerve damage caused by diabetes), unspecified atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), and combined systolic and Diastolic (Congestive) heart failure. Resident#4 had a BIMS of 14 which indicated cognition was intact. Record review of progress notes from 5/14/24 to 5/24/24 for Resident #4 revealed no documentation of skin tear. Record review of incident reports from 5/14/24 to 5/24/24 for Resident #4 revealed no documentation of skin tear. Record review of skin assessments from 5/14/24 to 5/24/24 for Resident #4 revealed no documentation of skin tears . An observation on 05/24/24 at 7:58 AM revealed four quarter sized spots of blood were noticed on Resident#4's fitted sheet and top sheet that appeared fresh. Resident #4's elbow was observed to still be bleeding. An interview on 05/24/24 at 8:00 AM with Resident #4 revealed Resident #4 had stumbled and scraped his elbow on his bed. Resident #4 stated he told the nurse around 3:00 AM and she put a Band-Aid on his elbow and it came off. Resident #4 could not recall the name of the nurse who assisted him. Resident #4 stated he had not reported to staff that the band-aid had came off. An interview on 05/24/24 at 12:36 PM with the ADON revealed no incident report or progress note were documented about the skin tear. The ADON revealed Resident #4 did not need stitches, and she provided treatment to the skin tear with wound cleaner and applied sterile strips. The ADON revealed she completed a skin assessment and documented in the progress note. The ADON stated Resident #4's family member and the MD were notified. An interview on 05/28/24 at 4:10 PM with the DON revealed the skin tear should have been documented in a progress note and incident report. The DON stated Resident #4's elbow was treated for the skin tear and his family and the doctor had been notified. The DON revealed the overnight staff who initially treated Resident #4's skin tear were not identified. An interview on 05/28/24 at 4:38 PM with the Administrator revealed nurse staff should have followed the skin tear policy and procedures. The Administrator stated nurse staff should have notified the ADON or DON for further assistance with the wound care. The Administrator stated the incident should have been captured so that a risk assessment on Resident #4 could have been completed. Record review of facility policy (Revised September 2013) titled Skin Tears- Abrasions and Minor Breaks Care of reflected Documentation 1.) Completes in-house investigation of causation. 2) Generate non-pressure form 9)When a skin tear is discovered, complete a Report of Incident/Accident

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 1 treatment carts reviewed. The facility failed to ensure one facility treatment cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: An observation on 05/24/24 at 6:15 AM revealed the facility's treatment cart was unlocked and unattended. The treatment cart was positioned at the far end of hall 100 in front of room [ROOM NUMBER]. The treatment cart top drawer was opened and the drawers were faced outward toward the hallway. All drawers of the treatment cart could be opened, and supplies were easily accessible. No staff were observed within eyesight of the treatment cart. An observation on 05/24/24 at 11:20 AM revealed the facility's treatment cart was unlocked and unattended. The treatment cart was positioned in the middle of the hallway against the wall between 100 and 200 halls. The treatment cart drawers faced outward toward the hallway All drawers of the treatment cart could be opened, and supplies were easily accessible. No staff were observed within eyesight of the treatment cart. An observation on 05/24/24 at 3:30 PM revealed the facility's treatment cart was unlocked and unattended. The treatment cart was positioned at the end of 200 hall. The treatment cart drawer faced outward toward the hallway All drawers of the treatment cart could be opened, and supplies were easily accessible. No staff were observed within eyesight of the treatment cart. An observation on 05/24/24 at 3:32 PM of the treatment cart revealed the following contents: *Diclofenac sodium gel (Temporarily relieves minor to moderate aches and pains caused by arthritis) *Nystatin topical powder (Used to treat fungal (or yeast) infections that affect the skin, mouth, and intestinal tract) *Nystatin topical ointment (Used to treat fungal (or yeast) infections that affect the skin, mouth, and intestinal tract) Gentamicin sulfate ointment 0.1% (Used to treat minor skin infection) *Bacitracin ointment (Used to prevent minor skin infections caused by small cuts, scrapes or burns) *Hydrocortisone cream (A mild corticosteroid that treats various skin conditions such as itching.) *Calamine clear lotion (Used to relieve itchiness) *Mupirocin ointment 2% (Antibiotic ointment used to trat certain skin infections) *Ammonium Lactate lotion (Used to treat dry, scaly skin conditions. *Triamcinolone acetonide cream (Used to treat a variety of skin conditions such as eczema, dermatitis, allergies, rash). *Hibiclens (Antibacterial anti microbial skin cleanser) *Povidone iodine 10%Solution (Topical antiseptic to aid in the prevention of infection) An interview on 05/24/24 at 6:30 AM with LVN S revealed the treatment cart should be locked and secured. LVN S revealed stated residents could get into the cart and take something. An interview on 05/24/24 at 7:00 AM with LVN A revealed the treatment carts should be locked. LVN A stated he was not sure of any risk to the resident. An interview on 05/24/24 at 12:36 PM with the ADON revealed the wound care doctor treated residents on 05/24/24. The ADON stated the treatment cart should be locked when it was not in use. The ADON stated the items in the treatment cart would not be harmful to the residents. An interview on 05/28/24 at 4:10 PM with the DON revealed the treatment cart should be locked. The DON stated the residents were not at any risk of being harmed. An interview on 05/28/24 at 4:38 PM with the Administrator revealed nurse staff should have followed the medication/treatment drug storage policy. The Administrator stated the carts should be locked when not in use. The Administrator stated residents could get into the cart. A record review of the policy titled Security of Medication Cart (dated revised on April 2007) revealed, 3 .the cart should be parked in the hallway against the wall with doors and drawers facing the wall 4. Medication cart must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable disease and infection, for 1 of 2 residents (Resident #1) reviewed for infection control, in that: CNA A was not wearing eye protection when entering the room of Resident #1, in the hot zone. This failure could place the residents at risk for spread of infection. Findings included: Record review of Resident #1's face sheet dated 07/14/2022 revealed he was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admission Minimum Data Set was not yet completed. Record review of Resident #1's Brief Interview for Mental Status, dated 07/9/2022, revealed a score of 9, indicating moderate cognitive impairment. Record review of Resident #1's nursing progress notes, dated 07/14/2022 at 1:39 PM, revealed Patient tested positive for Covid. tested twice per [family member] request. Assessment done has cough. MD notified. Record review of Resident #1's nursing progress notes, dated 07/14/2022 at 4:20 PM, revealed patient continue on contact droplet precautions will continue to monitor. Record review of Resident #1's TAR, dated 07/14/2022, revealed Strict isolation with Contact and Droplet precautions for COVID 19. Resident to be in a private room. All services including but not limited to, activities, dietary, therapy, and nursing are to be provided in residents private room until cleared by physician. Every shift for Isolation COVID start date 07/14/2022. Record review of Resident #1's EHR had an undated entry that revealed patient's [family member] stated the patient is not fully vaccinated. An observation on 07/14/22 at 10:32 AM revealed orange signs that read Full PPE gown, mask, gloves, face shield on the following rooms: 104, 109, 110, 111, 113, and 114. An observation on 07/14/22 at 2:37 PM revealed on orange sign that read Full PPE, gown, mask, gloves, face shield on Resident #1's door . CNA A was observed outside Resident #'1 room wearing a mask and then donned a gown and gloves. CNA A was not observed to put on goggles or a face shield and then went into Resident #1's room. In an interview on 07/14/22 at 2:55 PM, CNA A stated full PPE included gown, gloves, face shield or goggles, and mask. CNA A stated there was no face shield in the PPE bin outside of Resident #'1 room. CNA A stated she knew when a resident was on isolation because the nurse will inform her or there are orange signs on the door. In an interview on 07/14/22 at 4:16 PM, the Regional RN said that Resident #1 had tested positive for COVID that morning. She stated the CNA should have had a face shield on before going into Resident #1's room. She stated the risk of staff not wearing a face shield was transmission to others or themselves. She stated when they have new cases of COVID they Inservice staff by providing written material, explanation, demonstration if needed, and why they should don PPE. In an interview on 07/14/22 at 4:40 PM, CNA A stated if she does not have a face shield, she will go to the nurse to get what she needs. She stated the nurse said she forgot to give her a face shield when she came in. CNA A stated by not wearing eye protection, she could get COVID, could spread it or take it home. In an interview on 07/14/22 at 7:00 PM, the Administrator stated the expectation for staff was to wear full PPE when going into an isolation room. He stated the risk of staff not wearing eye protection was becoming positive or spreading it around. He stated they have done in services for staff on donning and doffing PPE, to put on PPE before walking in and doff as they leave the room. He stated they should have a face shield on and should doff before leaving the room because there was a potential for it to spread. Record review of Infection Control Basics & PPE for Essential Caregivers, undated, provided by the facility, revealed Personal Protective Equipment (PPE). Personal Protective equipment, or PPE, is used to protect yourself whenever you are in a situation whey you might be exposed to infectious material. Personal protective equipment most often includes Gloves Gowns Face masks Eye protection. Page 7 revealed Donning and Doffing PPE. Putting on and taking of PPE (also known as donning and doffing) is critical in preventing the spread of infectious disease. Knowing, and properly following, the steps to putting on and taking off PPE will help to protect you and the resident you care about. These steps include: 1. Putting on a mask or respirator 2. Putting on a gown 3. Putting on a face shield or goggles 4. Putting on gloves. Record review of the facility's COVID-19 response plan, revised 12/28/2021, revealed Admissions .operations will be based on the following: Infection Control Protocols for PPE based on CDC/Building configuration - PPE always required - Mask, Full PPE while working with residents on IC Precautions and Quarantined (face mask, shield or goggles, gown) COVID Positive Patients. Residents testing positive will quarantine in their rooms with full isolation precautions .

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete in accordance with accepted professional standards and practices for 1 (Resident #1) of 4 residents whose clinical records were reviewed. The facility failed to ensure Resident #1's progress notes were complete and accurately documented when the resident reported left knee pain and an x-ray was obtained on 06/01/22. This failure could place residents, who received care at the facility, at risk for inaccurate or incomplete clinical records. Findings included: Record Review of Resident #1's Admission Record dated 06/13/22 indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was his own responsible party. Record Review of Resident #1's Admission MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). He required extensive assistance of one staff for most of his activities of daily living. He was dependent on two staff for transfers and bathing. He was not ambulatory. Record Review of Resident #1's Incident Report dated 05/31/22 at 11:15 AM indicated the resident slid out of his wheelchair in the therapy gym. He was assessed for injury and no injuries were observed at the time of the incident. His pain level was documented as a 2 out of 10. He was alert and oriented to person, place, time, and situation. Record Review of Resident #1's Progress Note dated 5/31/2022 at 11:55 AM, indicated therapy reported the resident slid out of his wheelchair in the therapy gym. The resident was assessed for injury. A skin assessment indicated no bruising, redness or open areas were noted. The resident was at his baseline and the physician was notified. Record Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #1's Progress Notes and Daily Skilled Notes from 06/01/22 - 06/13/22 did not indicate an assessment of the resident or that the order was obtained from the physician for the x-ray. Record Review of Resident #1's Radiology Interpretation report dated 06/01/22 indicated the x- ray revealed no acute fracture or dislocation of the left knee. In an interview on 06/13/22 at 3:44 PM, the Corporate Nurse said she reviewed Resident #1's clinical record and could not find any documentation the resident was assessed, and an x-ray was ordered on 06/01/22. She said LVN B obtained the order for the x-ray on 06/01/22 at 9:33 AM. She said LVN B should have documented an assessment of the resident and the order for the x-ray in the progress notes or daily skilled nursing notes. In an interview on 06/13/22 at 3:49 PM, Resident #1 said he thought he was fine after the incident in therapy on 05/31/22 but on 06/01/22 he experienced pain in his left knee. He said LVN B assessed him and contacted his physician. He said LVN B informed him an x-ray of his left knee was ordered and an analgesic cream. In a telephone interview on 06/13/22 at 4:03 PM, LVN B said on 06/01/22 Resident #1 reported left knee pain. She said she assessed the resident, contacted his physician, obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said it was important to document her assessment and provide information as to why the x-ray was ordered. In an interview on 06/13/22 at 6:23 PM, the DON said LVN B should have documented in the progress notes her assessment and contact with the physician. She said it was important to document to take credit for the care provided to the resident and for continuity of care. She said she was responsible to ensure the documentation was completed and she needed to review the documentation to see if it was accurate and complete. Record Review of the facility's, Charting and Documentation policy dated July 2017 indicated all changes in the resident's medical and physical function shall be documented in the resident's medical record. The documentation required included changes in the resident's condition and treatments and services performed.

Based on interview and record review the facility failed to ensure residents had the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for 1 (Resident #1) of 4 residents reviewed for residents' rights. The facility failed to ensure Resident #1 was informed of his x-ray results on 06/01/22. The failure could place the residents, who received care at the facility, at risk of not being informed of their health status, in order, to make informed decisions regarding their care. Findings included: Record Review of Resident #1's Admission Record dated 06/13/22 indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was his own responsible party. Record Review of Resident #1's Admission MDS assessment dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). He required extensive assistance of one staff for most of his activities of daily living. He was dependent on two staff for transfers and bathing. He was not ambulatory. Record Review of Resident #1's Incident Report dated 05/31/22 at 11:15 AM indicated the resident slid out of his wheelchair in the therapy gym. He was assessed for injury and no injuries were observed at the time of the incident. His pain level was documented as a 2 out of 10. He was alert and oriented to person, place, time, and situation. Record Review of Resident #1's Progress Note dated 05/31/2022 at 11:55 AM, indicated therapy reported the resident slid out of his wheelchair in the therapy gym. The resident was assessed for injury. A skin assessment indicated no bruising, redness or open areas were noted. The resident was at his baseline and the physician was notified. Record Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #1's Radiology Interpretation report dated 06/01/22 indicated the x- ray revealed no acute fracture or dislocation of the left knee. Record Review of Resident #1's Progress Notes and Daily Skilled Notes from 06/01/22 - 06/13/22 did not indicate the results of the x-ray report or that the resident was informed of the results. In an interview on 06/13/22 at 3:44 PM, the Corporate Nurse said she reviewed Resident #1's clinical record and could not find any documentation the resident was informed about the x-ray results. She said LVN B obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said LVN A received the results on 06/01/22 at 11:11 PM. She said LVN A should have documented in the progress notes or daily skilled nursing notes she received the results and informed the resident of the results. In an interview on 06/13/22 at 3:49 PM, Resident #1 said he thought he was fine after the incident in therapy on 05/31/22 but on 06/01/22 he experienced pain in his left knee. He said LVN B assessed him and contacted his physician. He said LVN B informed him an x-ray of his left knee was ordered and an analgesic cream. He said the x-ray was done on 06/01/22, but no one told him the results of the x-ray and his knee still felt sore. In an interview on 06/13/22 at 5:54 PM, LVN A said she did notify Resident #1 of his x-ray results on 06/01/22, but she could not remember the time she received the results or the time she notified the resident of the results. She said she informed the resident his x-ray result was negative, and he said he was glad it was negative, and nothing was wrong. She said she was supposed to document the results and resident notification in the progress notes, but she did not. She said she did not know why she failed to do so. She said it was important to document so anyone could look at the results and knew the resident was informed of the results. In an interview on 06/13/22 at 6:23 PM, the DON said LVN A should have documented the x-ray results and notification of the resident in the progress notes. She said it was important to inform the resident to provide continuity of care. She said she was responsible to ensure the nurses followed the policies and procedures by reviewing the documentation. Record Review of the facility's Resident Rights policy dated December 2016 indicated the resident had the right to be notified of his or her medical condition and of any changes in his or her condition.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) and refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for one (Resident #5) of two residents reviewed for PASRR Screenings. The facility failed to reassess Resident #5 who had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: Review of Resident #5's Face Sheet dated, 04/14/22, revealed, a 92- year-old female admitted to the facility on [DATE]. The Face Sheet revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet revealed that on 08/08/19 the following three diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's PASRR Level 1 screen dated 12/26/18 revealed, Referring Entity: Hospital . C. 100 Mental Illness: NO . This was Resident #5's only PASRR Level 1 Screen uploaded to facility Electronic Medical Record. Review of Resident #5's MDS dated [DATE], and her Annual MDS, dated [DATE], both reflected for the question: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? the question was marked No. The MDS further reflected she had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #5 on 04/13/22 at 10:29 AM revealed she was seated in the dining room with oxygen via nasal canula, participating in Activities, singing along with the facilitator. In an interview on 04/13/22 at 10:30 AM, Resident #5 revealed she enjoyed participating in activities, she felt safe at the facility, the staff were nice and came when she used her call light. Resident #5 stated she had a urinary tract infection and was receiving antibiotics via a midline in her left arm to which she pointed. In an Interview with MDS A, who was responsible for PASRR at the facility, on 04/14/22 at 1:33 PM, she revealed she understood Resident #5's [CONDITION(S)] was a side effect of the [CONDITION(S)] and would therefore deem her ineligible for PASARR services. MDS A revealed she was unaware there was a form that existed to inform the LIDDA about a new diagnosis. MDS A stated she worked at the facility since 2018 and had not received any PASARR training since then. MDS A stated the benefit of having residents evaluated by the LIDDA was that they could get extra services that would be very beneficial to the residents. The facility's undated PASRR Policy and Procedure, revealed, All residents will be screened with PL1 prior to admission at [Facility name]. The MDS Coordinator is responsible to input all resident data in TMP. When a resident is PASRR positive, prior to admission, PASSAR services will be contacted to perform a level 2 prior to admission if the resident stay will be more than 30 days. PASRR are uploaded into PCC under the documentation tab. The policy did not mention specifically about new diagnoses.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control. CNA A failed to change her gloves while providing Resident #1 with incontinence care. This failure placed residents at risk for cross contamination and infection. Findings included: Review of Resident #1's Face Sheet revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 07/15/20, revealed Resident #1 had severe cognitive impairment but could sometimes make herself understood and understand others. The MDS further reflected she was always incontinent of bowel and bladder and required extensive assistance with all ADLs. Review of Resident #1's comprehensive care plan, dated 07/20/20, revealed Resident #1 was incontinent of bowel and bladder and staff should clean the peri-area after every incontinence episode. Observation on 09/15/20 at 10:00 AM revealed CNA A removed Resident #1's brief. CNA A then applied barrier cream to Resident #1's anal area. Without removing her gloves or performing hand hygiene, CNA A turned the resident and applied the remaining cream which was on the glove to the resident's vaginal area. In an interview on 09/15/20 at 3:00 PM, CNA A stated she should have changed her gloves and should have started with the vaginal area first. CNA A stated she was nervous being observed and forgot to do this. In an interview on 09/15/20 at 3:58 PM, the DON stated a seasoned aide should have not made the mistakes that were made during the incontinence care provided by CNA A. She stated the expectation was that gloves were to be changed when they were contaminated and residents should be cleaned front to back. Review of the facility's undated Perineal Skill Competency list revealed the following: .7. female patient a). wash perineal area front to back with cloth, soap & and water or skin cleansing agent Review of Mosby's Textbook for Nursing Assistants, Ninth Edition, copyright 2017, page 360 revealed the following: Giving Female Perineal Care .20 .Remove any wet or soiled incontinence products. 21 Remove and discard gloves. Practice hand hygiene. Put on clean gloves. .24 Clean the perineum d Clean the vaginal area. Clean downward from front to back (top to bottom) with 1 stroke . .30 Clean and rinse the rectal area. .33 Remove and discard the gloves. Practice hand hygiene. Put on clean gloves.