Every finding on record at Avir at Pampa

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, pantry and kitchen items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses.Findings Included:During an observation of the pantry on 01/26/26 at 9:39 a.m. revealed the following:1. (1) clear container that contained what looked like rice, no lid on container, no label or date.2. (2) boxes of packets of jelly, no label or date.3. 1) container of sugar, lid not sealed.4. (1) box of potatoes, no label or date. During an observation of the freezer on 01/26/26 at 9:43 a.m. revealed the following:1. (1) box of frozen meat, no label or date.2. (1) box of what looked to be frozen bread, dated, no label.3. (1) box of what looked like tater tots, no label.During an observation of the refrigerator on 01/26/26 at 9:48 a.m. revealed the following:1. (1) box of tomatoes, no date.2. (1) box of single serve packs of sour cream - no label or date.3. (1) pitcher, 1/4 full of red liquid, no label or date. 4. (3) individual drinking cups filled with liquid, covered and dated, no label. 5. (1) Ziploc with dinner rolls, no label or date. 6. (1) Ziploc with what looks like cooked rice, dated, no label.7. (1) Ziploc containing deli meat, no label or date.8. (1) Ziploc containing cooked bacon, no label or date.9. (1) Ziploc with unidentified meat, no label or date.10. (2) open milk cartons, one 1/4 full, one 3/4 full, no label or date.11. (1) tray with 5 cups filled with white liquid, partially open to air, no label or date.During an observation of the kitchen preparation area on 01/26/26 at 9:53 a.m. revealed the following:1. (1) Ziploc bag of what looked like cookies on prep table, no label or date. 2. (1) clear container filled with cereal, no label or date. 3. (1) spice container of garlic powder, no label or date. During an interview on 01/26/26 at 9:56 a.m., [NAME] C stated she had worked at the facility since August 2025. She stated it was everyone's responsibility to label and date food and if this did not happen, food could get ruined, and residents could get sick. During an interview on 01/26/26 at 10:03 a.m., [NAME] B stated he had worked at the facility for three months and everyone who worked in the kitchen was responsible for labeling and dating food. He stated a possible negative outcome was residents could become sick. During an interview on 01/26/26 at 10:07 a.m., the DM stated it was everyone's responsibility to label and date food. She stated that she goes over this with new hires and trained them to label and date food as soon as it arrived. The DM stated that if this did not happen, there could be sickness related to food. Record review of facility policy, titled Food Storage dated 2023, revealed the following information in part:8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products and sugar. All containers or storage bags must be legible and accurately labeled ad dated. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. 13. Refrigerated food storage:f. All foods should be covered, labeled and dated. 14. Frozen Foods:c. All foods should be covered, labeled and dated.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 4 (Resident #6, #13, #30 and Resident #42) of 12 residents reviewed for infection control. The facility failed to develop and maintain an infection prevention and control program as attested to by: -LVN A did not don a gown or perform hand hygiene before donning gloves to administer a bolus feeding to Resident #6 via peg-tub.-LVN A did not ensure bedside table was clean before setting up supplies for Resident #6's bolus feeding via her peg-tube.-LVN A did not perform hand hygiene before donning gloves to perform a glucose check for Resident #42.-LVN A did not perform hand hygiene before donning gloves to perform a glucose check for Resident #30.-CNA E did not don a gown before performing foley catheter care for Resident #13. These failures could place residents at risk of contracting, spreading, and/or being exposed to bacterial or viral infections leading to the spread of communicable diseases.Finding Included:During an observation on 01/26/2026 at 10:37 AM LVN A did not perform hand hygiene before donning (putting on) gloves and no PPE was utilized during the administration of Resident #6's bolus feeding via her peg-tube. Observation revealed LVN A did not clean the bedside table before placing syringe and supplies on bedside table, During an observation on 01/26/2026 at 11:03 AM revealed there were no supplies in any of the drawer of the PPE cabinet outside Resident #6's room.During an observation on 01/27/2026 at 06:27 AM LVN A did not perform hand hygiene before donning gloves to clean glucometer, and no hand hygiene was performed before donning gloves to perform the glucose check for Resident #42. During an observation on 01/27/2026 at 6:42 AM LVN A did not perform hand hygiene before or after performing a glucose check for Resident #30. During an observation on 01/27/2026 at 2:26 PM CNA E did not don (put on) a gown to perform urinary catheter care for Resident #13. During an interview on 01/27/2026 at 2:37 PM CNA E stated the negative outcome for residents was that she could spread bacteria to other residents in the facility. During an interview on 01/27/2026 at 3:04 PM LVN A stated the negative outcome for not performing hand hygiene and donning a gown could lead to an issue with infection control. During an interview on 01/28/2026 at 1:22 PM ADON stated the negative outcome for not performing hand hygiene and not donning gowns was an infection control issue. During an interview on 01/28/2026 at 1:28 PM DON stated the negative outcome for not performing hand hygiene and not donning gowns could lead to the transfer of germs. During an interview on 01/28/2026 1:37 PM RNC stated that the negative outcome for not performing hand hygiene and donning gloves could lead to an increase in the spread of infection. Record review of policy titled, Enhanced Barrier Precautions, revised February 2025, revealed the following: Policy Statement Enhanced barrier precautions (EBPS) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.Policy Interpretation and Implementation.3. Examples of high-contact resident cared activities requiring the use of gown and gloves for EBP's include: .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and .5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.b. Indwelling medical devices include central lines, urinary catheters, . Record review of policy titled, Handwashing/Hand Hygiene, undated, revealed the following: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Indications for Hand HygieneHand Hygiene is indicated:Immediately before touching a resident;Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);After contact with blood, body fluids, or contaminated surfaces;After touching a resident;After touching the resident's environment; .g. immediately after glove removal. Record review of policy titled, Insulin Administration, revised September 2014, revealed the following: .Steps in the Procedure (insulin Injections via syringe)Wash hands.Check blood glucose per physician order or facility protocol.21. Wash hands.Record review of policy titled, Perineal Care, revised February 2018, revealed the following: PurposeThe purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Steps in the procedure.b. Gloves and PPE (gown, gloves, face mask as indicated).

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 (Hall 100 and Hall 200) of 2 medication carts, and 1 of 1 OTC closet. -two bottles of Calcium Supplement with expiration dates that were not legible in the OTC closet.-one loose pill was in the bottom of Medication cart #1. These failures could place residents at risk for not receiving the intended therapeutic action of the medication.Findings Included:During an observation on 01/26/2026 at 9:59 AM one loose pill (unidentified) was discovered in the bottom of medication cart #1's drawer. During an interview on 01/26/2026 at 10:03 AM LVN F stated the negative outcome for having loose pills in the medication cart was that the medication could fall out of the cart and a resident could pick it up and take it. During an observation on 01/26/2026 10:08 PM OTC closet revealed two bottles of Calcium Supplement with expiration dates that were not legible. During an interview on 01/26/2026 at 10:11 AM ADON stated the negative outcome for having loose pills in the medication cart could lead to a resident missing a dose. ADON also stated the negative outcome of having expired medications was the medications would not have the efficacy that was needed for a therapeutic level for the resident. During an interview on 01/26/2026 at 10:17 AM LVN F stated the negative outcome for having expired medications was the medications would not be effective for the residents.During an interview on 01/28/2026 at 1:28 PM DON stated there was no negative outcome to the residents for having loose pills in the bottom of medication cart drawers. During an interview on 01/28/2026 at 1:37 PM RNC stated a possible negative outcome of a loose pill was a nurse might pick it up thinking it was dropped and give it to a resident. RNC stated the negative outcome for having expired medications was the medication would have lost its efficacy. Record review of policy titled, Medication Labeling and Storage, undated, revealed the following: .Medication Storage.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.Medication Labeling.2. The medication label includes, at a minimum: .d. expiration date, when applicable; .4. For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains: .f. expiration date.Record review of policy titled, Administering Medication, revised April 2019, revealed the following: .12. The expiration/beyond use date on the medication label is checked before administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized medical records for 1 (Resident #11) of 12 residents reviewed for medical records. The facility failed to ensure accurate and complete medical records in that:-PICC line dressing was dated 01/19/2026 with no Haloguard in place over insertion site.-Resident #11's TAR revealed that there was no documented dressing change on 01/19/2026.-Resident #11's TAR indicated that a dressing change took place on 01/25/2026. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.Findings Included:Record review of Resident #11's face sheet dated 01/28/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute and subacute infective endocarditis (inflammation of the inner lining of the heart's chambers and valves), bacteremia (presence of bacteria in the blood stream), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), heart disease (a range of conditions that affect the heart), occlusion and stenosis of bilateral carotid arteries (plaque blocks the normal flow of blood in the carotid artery), aneurysm of iliac artery (a ballooning or weakening area of an artery), peripheral vascular disease (blood circulation disorder). Record review of Resident #11's MDS, dated [DATE], revealed Resident #11 had a BIMS of 12 which indicated moderate cognitive impairment. Resident #11 required total dependency on staff for showering only, all other care areas Resident #11 was independent. Record review of Resident #11's Order Summary Report printed 01/26/2026 included the following orders: Dressing change to PICC site every 7 Days and PRN as needed for soiling or displacement related to ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS. Start date 11/16/2025, no end date noted. Haloguard Patch; 1 in 4mm dressing; Amount to administer: 1; transdermal once a day on Monday inthe morning related to BACTEREMIA. Start date: 11/12/2025, no end date noted. Record review of Resident #11's care plan dated 11/14/2025, included the following:Focus: I require enhanced barrier precautions due to the following: I am at increased riskof a MDRO acquisition due to have an indwelling medical device. Date Initiated: 11/06/2025 Revision on: 11/14/2025Goal: I will have no signs or symptoms related to a MDRO infection Date Initiated: 11/06/2025Target Date: 02/03/2026Interventions- Discard PPE inside my room in the appropriate receptacle prior to leaving my room. Date Initiated: 11/06/2025 Revision on: 11/06/2025 Notify my physician and resident representative of any issues related to MDRO.Date Initiated: 11/06/2025 Revision on: 11/06/2025 Post a sign on my door that says 'please check with nurse before entering roomDate Initiated: 11/06/2025 Staff will wear PPE during high-contact activities such as dressing,bathing/showering, transferring, providing hygiene, changing linens, incontinent care,wound care of any type requiring a dressing, device care or use (central line).Date Initiated: 11/06/2025 There were no other care plans for PICC line dressing care. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she did not receive a dressing change on 01/04/2026. Resident #11 received her central line dressing change on 01/11/2026 by LVN D, 01/18/2026 by LVN A, and 01/25/2026 by LVN D. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she did not receive a Haloguard change on 01/04/2026. Haloguard was not placed on 01/11/2026 by LVN D. Haloguard was placed by ADON on 01/25/2026. During an observation and record review on 01/27/2026 at 9:41 AM revealed dressing to PICC line for Resident #11 had not been changed since 01/19/2026, record review revealed that the nurse that changed the dressing on 01/25/2026. There was no Haloguard in place at the time of this observation. During an observation on 01/28/2026 at 9:52 AM PICC line dressing for Resident #11 had been changed and dated01/27/2026, but no Haloguard was present under the transparent dressing. During an interview on 01/28/2026 at 1:22 PM ADON stated the negative outcome for documenting falsely was an increased risk of infection. During an interview on 01/28/2026 at 1:28 PM DON stated the negative outcome for false documentation was he doesn't have that added protection there. During an interview on 01/28/2026 at 1:37 PM RNC stated that the negative outcome for false documentation was it could increase the risk of infection for our residents. During an attempted interview on 01/28/2026 at 1:48 PM The investigator called LVN D to ask about the dressing and documentation. There was no answer, and the investigator provided contact information to call back. During a phone interview on 01/28/2026 at 2:05 PM LVN A stated she does not remember charting that she placed the Haloguard on the resident. Record review of a facility policy titled Charting and Documentation, dated July 2017, revealed the following: .Policy Interpretation and Implementation.2. The following information is to be documented in the resident medical record: .c. Treatments or services performed; .7. documentation of procedures and treatments will include care-specific details, including:a. the date and time the procedure/treatment was provided.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were to be administered consistent with professional standards of practice and physicians orders for 1 of 12 residents (Resident #11) reviewed for physician orders. The facility failed to follow physician orders for completing central line care for resident #11. This failure could place residents at risk for not receiving needed care to maintain optimum health and injury and/or deterioration in their condition.Findings Included: Record review of Resident #11's face sheet dated 01/28/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute and subacute infective endocarditis (inflammation of the inner lining of the heart's chambers and valves), bacteremia (presence of bacteria in the blood stream), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), heart disease (a range of conditions that affect the heart), occlusion and stenosis of bilateral carotid arteries (plaque blocks the normal flow of blood in the carotid artery), aneurysm of iliac artery (a ballooning or weakening area of an artery), peripheral vascular disease (blood circulation disorder). Record review of Resident #11's MDS, dated [DATE], revealed Resident #11 had a BIMS of 12 which indicated moderate cognitive impairment. Resident #11 required total dependency on staff for showering only, all other care areas Resident #11 was independent. Record review of Resident #11's Order Summary Report dated 01/26/2026 revealed the following orders: Dressing change to PICC site every 7 Days and PRN as needed for soiling or displacement related to ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS. Start date 11/16/2025, no end date noted. Haloguard Patch (antimicrobial IV disk designed to reduce catheter related blood stream infections); 1 in 4mm dressing; Amount to administer: 1; transdermal once a day on Monday in the morning related to BACTEREMIA. Start date: 11/12/2025, no end date noted. Record review of Resident #11's care plan dated 11/14/2025, included the following:Focus: I require enhanced barrier precautions due to the following: I am at increased riskof a MDRO acquisition due to have an indwelling medical device. Date Initiated: 11/06/2025 Revision on: 11/14/2025Goal: I will have no signs or symptoms related to a MDRO infection Date Initiated: 11/06/2025Target Date: 02/03/2026Interventions- Discard PPE inside my room in the appropriate receptacle prior to leaving my room. Date Initiated: 11/06/2025 Revision on: 11/06/2025 Notify my physician and resident representative of any issues related to MDRO.Date Initiated: 11/06/2025 Revision on: 11/06/2025 Post a sign on my door that says please check with nurse before entering roomDate Initiated: 11/06/2025 Staff will wear PPE during high-contact activities such as dressing,bathing/showering, transferring, providing hygiene, changing linens, incontinent care,wound care of any type requiring a dressing, device care or use (central line).Date Initiated: 11/06/2025 There were no other care plans for PICC line dressing care. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she received her central line dressing change on 01/11/2026 by LVN D, 01/18/2026 by LVN A, and 01/25/2026 by LVN D. There were no signatures or initials for 01/04/2026 dressing change. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she did not receive a Haloguard change on 01/04/2026. Haloguard was not placed on 01/11/2026 by LVN D. Haloguard was placed by ADON on 01/25/2026. During an observation and record review on 01/27/2026 at 9:41 AM revealed the dressing to the PICC line for Resident #11 was not changed since 01/19/2026, record review revealed that the nurse changed the dressing on 01/25/2026. There was no Haloguard in place at the time of this observation. During an observation on 01/28/2026 at 9:52 AM PICC line dressing for Resident #11 had been changed and dated 01/27/2026, but no Haloguard was present under transparent dressing. During an interview on 01/28/2026 at 1:22 PM ADON stated the negative outcome for not having a Haloguard over the insertion site for Resident #11's PICC line could lead to an increased risk for the resident, and the dressing would need to be changed more often. ADON stated the negative outcome for not following doctors' orders was it could lead to infection for the resident. During an interview on 01/28/2026 at 1:28 PM DON stated the negative outcome for not having a Haloguard over the insertion site for Resident #11's PICC line was increased infection risk. DON stated, It (Haloguard) is an added barrier to prevent infection. During an interview on 01/28/2026 at 1:37 PM RNC stated the negative outcome for not having a Haloguard over the insertion site for Resident #11's PICC line was, The resident is already on antibiotics for endocarditis (inflammation of inner lining of heart's chambers and valves) it (Haloguard) is an added barrier to prevent infection. During an attempted interview on 01/28/2026 at 1:48 PM the investigator called LVN D to ask about the dressing and documentation. There was no answer, and the investigator provided contact information to call back. During a phone interview on 01/28/2026 at 2:05 PM LVN A stated there was no reason that she did not place the Haloguard. LVN A stated the negative outcome for not placing one was the resident could pull out the PICC line. LVN A stated she did not remember charting that she placed the Haloguard on the resident. Record review of facility provided policy titled Peripheral and Midline IV dressing Changes dated 12/31/2025, revealed the following: PurposeThe purpose of this procedure is to prevent complication associated with intravenous therapy, including catheter-related infections.General GuidelinesPerform site care and dressing change at established intervals, or immediately if the integrity of the dressing is compromised. 4. Change the dressing if it becomes damp, loosened or visibly soiled and:At least every 7 days for TSM dressing; . 6. b. check expiration dates of infusion, dressing and administration set; . Record review of facility provided policy titled Medication Administration-Intravenous Therapy dated 11/01/2025, revealed the following: PurposeTo ensure safe, effective and standardized intravenous (IV) therapy and medication administration via Peripheral IVs, Midline Catheters and PICC Lines in accordance with facility standards and regulatory requirements.PICC Line .Follow central-line infection prevention practices .

Based on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident #2) of 5 residents reviewed for unnecessary drugs.The facility failed to ensure a gradual dose reduction of one of Resident #2's psychotropic medications was attempted or contraindicated from April 2025 to January 2026.This failure could place residents at risk of being overmedicated.Findings Included:Record review of Resident #2's admission record dated 01/28/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease with early onset and anxiety disorder.Record review of Resident #2's quarterly MDS completed on 12/16/25 revealed a BIMS score of 4 which indicated severely impaired cognition. Section N Medications revealed Resident #2 was receiving antidepressant medication.Record review of Resident #2's care plan completed on 12/04/25 revealed the following: I receive antidepressant medication R/T depression and insomnia. I will be prescribed the lowest effective dose of medication .Record review of facility's MRR book dated April 2025 to January 2026 revealed no mention of a GDR for Resident #2's antidepressant medication.Record review of Resident #2's active orders dated 01/28/26 revealed the following order: traZODone HCI Oral Tablet 50 MG (Trazodone HCI) Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED .Record review of Resident #2's Consent for Use of Psychotropic Medication dated 04/21/25 revealed Trazodone 50mg HS was ordered on 04/21/25.During an observation and interview on 01/26/26 at 11:31 AM Resident #2 was reclined in a geri chair under a blanket. She answered several questions while making eye contact with this surveyor. When asked if she had trouble with anxiety or depression she turned her head away, rubbed her eyes with her hand, and did not respond.During an interview on 01/27/26 at 09:02 AM Resident #2's family member stated Resident #2 had issues with anxiety and depression. She stated, But the facility has been working on addressing those (issues with anxiety and depression).During an interview on 01/28/26 at 10:07 AM DON stated she did not remember a GDR being addressed for Resident #2 regarding Trazodone. She stated she would call hospice and see if they had documentation.During an interview on 01/28/26 at 10:25 PM DON stated hospice told her they started Trazodone at 50 MG at bedtime for Resident #2 in October of 2024. She stated if there was a recommendation for a GDR since Resident #2 admitted to the facility it would be in the MRR book.During an interview on 01/28/26 at 10:43 AM ADM stated the facility's medical director was responsible for ensuring GDRs for residents on psychotropic drugs were addressed timely. He stated he could not say if a resident could be negatively impacted by not having a GDR addressed timely.During an interview on 01/28/26 at 10:45 AM ADON stated the pharmacy consultant was responsible for ensuring GDRs for psychotropic medications were addressed timely. She stated the pharmacy consultant would recommend a GDR, the DON would follow up, and she (ADON) would get the paperwork in order. She stated a resident could be negatively affected if a GDR was not considered for a psychotropic medication because they can get to where (the medication) is not effective.During an interview on 01/28/26 at 10:49 AM RNC stated, We rely on pharmacist consultant that comes in to review the charts to recommend GDRs. She stated a resident could be negatively affected by not receiving a GDR timely because we try to maintain medication at the lowest dose effective.During an interview on 01/28/26 at 10:52 AM DON stated the facility's pharmacy consultant was responsible for recommending GDRs for psychotropic medications. She stated she did not think a resident would not be negatively affected if a GDR was not addressed timely.Record review of facility policy titled, Tapering Medications and Gradual Dose Reduction and dated July 2022 revealed the following: . 1. After medications are ordered for a resident, the staf and practitioner shall see an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. 2. All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions. 3. Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 1. Periodically, the staff and practitioner will review the continued relevance of each resident's medications. 10. Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. 11. Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts) unless clinically contraindicated. 15. Attempted tapering of psychotropic medications other than antipsychotics or sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. Tapering shall be done consistent with the following: a. During the first year in which a resident is admitted on a psychotropic medication . or after the facility has initiated such medication, the facility will attempt to taper the medication during at least two separate quarters (with at least one month between attempts), unless clinically contraindicated.Record review of facility policy titled Psychotropic Medication Use and dated July 2022 revealed the following: . 2. Drugs in the following categories are considered psychotropic medications . b. Anti-depressants . 11. Residents on psychotropic mediations receive gradual does reductions . unless clinically contraindicated, in an effort to discontinue these medications.

Based on interview and record review, the facility failed to report the results of an investigation in accordance with State Law within 5 working days of the incident for 1 of 5 incidents (Resident #1) reviewed for reporting. -The Administrator failed to report the results of an investigation within 5 days to the State Survey Agency. This failure could affect residents if alleged violations are verified, and appropriate corrective actions are not taken. Findings include: Record review completed on 06/03/25 at 08:32 AM of the TULIP (Texas Unified Licensure Information Portal) system revealed that no Provider Investigation Report (Form 3613-A) had been filed in the system. The facility had filed the Facility Reported Incident and CII Self-Report Template on 5/11/2025. During an interview on 06/03/25 at 11:14 AM, the Administrator reported that he did not remember doing a 5-day report, that they did an original report where they separated, assessed, and documented what they did for the two residents but he did not remember anything about a 5-day report. The Administrator stated, you are talking about the 3613 right. I think I just forgot to do it. I had a lot of things going on in the building and I just forgot to do it. The Administrator reported that not completing the 3613 or the 5-day results of an investigation could have the potential to affect other residents care because the process was not completed. Record review of the Provider Investigation Report (form 3613-A) for the incident that occurred on 5/11/25 revealed that it was completed on 6/3/2025. The Provider Investigaiton Report revealed that a thorough investigation of the incident was completed. Record review of the facility provided policy titled Reporting and Protection Program Policy revised 10/2023, revealed the following: Reporting/Response: B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observations, interviews, and record reviews 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 3 of 8 employees (CNA A, LVN B and RNRS C) reviewed for infection control. The facility failed to ensure CNA A, LVN B, and RNRS C practiced proper hand hygiene while serving and assisting residents during the lunch meal on 2/5/25. This failure could place residents at risk of the spread of communicable diseases and infections and a diminished quality of life. Findings included: An observation of the lunch meal on 02/05/2025 between 12:00PM and 12:30PM revealed CNA A, LVN B and RNRS C assisted in the dining room. CNA A was observed using ABHR while standing in the service line. CNA A placed her hands in her pockets immediately after the use of ABHR and they remained in her pockets until she received a resident tray from the kitchen. CNA A left the service line with the resident's tray. While on her way to deliver the tray, CNA A dropped a single-serving butter pat on the floor. CNA A was then observed to pick up the butter pat from the floor and place it back on the resident's tray. She delivered the tray to the resident and returned to the service line, without sanitizing her hands. CNA A was observed several times during the luncheon service, using ABHR and then placing her hands in her pockets or on her hips while waiting. LVN B was observed using ABHR upon entry to the dining room, but then placed her hands on her hips, touching her clothing. LVN B's hands remained on her hips while she was waiting for a tray from the service line. LVN B received a tray from the kitchen and served it to a resident without re-sanitizing her hands. RNRS C was observed leaning against the ice machine, with her right hand resting on top of the machine. The RNRS then received a tray from the kitchen and proceeded to help a resident who needed set-up and minimal feeding assistance with his meal. An interview with RNRS C on 02/05/2025 at 1:47PM reflected she was aware of the lapse in hand hygiene and would take steps to do things better next time. RNRS C stated the negative outcome of not sanitizing her hands between resident trays was the possibility of cross-contamination or spreading of germs which might be infectious. An interview with LVN B on 02/05/2025 at 1:51PM reflected she denied the lapse in hand-hygiene. LVN B stated the negative outcome of not sanitizing her hands between resident trays would be the potential transmission of infections. Record review of the facility's employee roster reflected LVN B was the only employee with her first and last name, working at the facility, which indicated LVN B was the only LVN in the dining room during the lunch meal. An interview with CNA A on 02/05/2025 at 2:00PM revealed she realized the lapse in hand hygiene as soon as she received the resident's tray from the kitchen. CNA A stated the negative outcome of not practicing proper hand hygiene would be the spread of germs or sicknesses. An interview with the ADON on 02/05/2025 at 3:15PM revealed LVN B did not take responsibility for her actions at times, did not like to be questioned about her abilities. The ADON stated LVN B had been coached regarding customer service and employee relations. The ADON stated an in-service was going to be done on hand hygiene, starting immediately and would be passed on to the night supervisor for training of the night staff. Record review of facility policy and procedures for hand hygiene dated 01/20/2023 revealed the following: Policy Interpretation and Implementation: 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Wash hands with soap; and water, when hands are visibly soiled and after contact with a resident with an infectious diagnosis. 4. Use an alcohol-based hand rub containing at least 60%-95% ethanol alcohol or isopropyl alcohol. Procedure: Using Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry The facility did not have a policy regarding hand hygiene while serving resident meals.

Based on interviews, and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 33 days in the months of April, May, June July and October, 2024. The facility did not have an RN in the facility for 8 consecutive hours on the following dates: April 4, 5, 6, 7, 10, 13, 14, 20, 21, 27, and 28th of 2024. May 4, 5, 11, 12, 18, 19, 25, 2 6, and 27th of 2024. June 1, 2, 8, .9. 15, 16., 22, .23, .29. and 30th of 2024. July 13 and 14 of 2024. The date of October 11, 2024 only had RN coverage for 5.63 hours. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care. Findings include: During an interview on 10/29/24 at 10: 20 pm, the DON stated she did not have RN coverage for June. She stated it just fell through the cracks. When asked about RN coverage for April and May as listed on the facility PBJ report, she had no answer. She stated she had been actively looking for an RN. She stated an RN was not hired until July. The DON stated the consequences of not having an RN in the building would be There needs to be someone here to report incidents to. There was no one to report incidents to. Record reviews of the facility's last 5 months of time sheets for RN coverage revealed that the facility did not have an RN in the facility on the following dates: April 4,5, 6, 7, 10, 13, 14, 20, 21, 27, and 28 th of 2024 May 4, 5, 11, 12, 18, 19, 25, 26, and 27th of 2024 June 1, 2, 8, .9, 15. 16., 22., 23, .29. and 30th of 2024 July 13 and 14 th, 2024 The date of October 11, 2024, only had RN coverage for 5.63 hours. Record review of the CMS PBJ Staffing Data Report dated 11/1/24 revealed the facility infraction dates listed the following dates as not having RN hours for: April 4,5, 6, 7, 10, 13, 14, 20, 21, 27, and 28, 2024. May 4, 5, 11, 12, 18, 19, 25, 26, and 27 ,2024 June 1, 2, 8. 9. 15. 16., 22, .23., 29. and 30, 2024 Record review of facility presented Time Clock Punch In Hours revealed there were no RN clock in hours prior to 7/4/24. A policy for RN coverage was requested from the DON on 10/29/24 at 1:30 pm but never received.

Based on interviews and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident care and life in the facility for 1 of 1 resident council. The facility failed to ensure feedback and concerns expressed in the resident council meetings were addressed by the facility staff for the past seven months. This deficient practice could affect the residents who attended resident council meetings for the past seven months and place them at-risk to decrease quality of life and contribute to grievances not being resolved. The findings were: Record review of Resident Council Meetings from March 2024 to September 2024 revealed there was no complete feedback or response to the concerns made at the resident council meetings. Record review of Resident Council Minutes dated 03/27/2024 revealed concerns about missing clothes and not enough snacks for all residents. Record review of Resident Council Minutes dated 04/30/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 05/29/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 06/26/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 07/03/2024 revealed concerns about missing clothes and drinks at night. Record review of Resident Council Minutes dated 08/28/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 09/25/2024 revealed concerns about missing clothes and not enough snacks. During an interview on 10/28/2024 at 10:30 AM, an anonymous resident stated they do not get snacks daily and the only reason they were getting snacks was because the state was here. The resident also said that staff do not pass out snacks they sit at the counter. During an interview on 10/28/2024 at 11:00 AM, an anonymous resident said that some residents take 3 or 4 snacks at a time so there was not enough for everyone. During an interview on 10/28/2024 at 2:00 PM with residents in group, 10 of 13 residents revealed there had been concerns with missing clothes and they felt that the staff were not listening to their concerns. The, residents stated that nothing was getting done about the missing items. The residents stated that their clothing was being sent to the laundry and they would not get their clothing back or they would get clothes that did not belong to them. One resident during the group meeting stated that he wore large boxer underwear, and, on several occasions, he would get back small or medium underwear. During the meeting the group also stated that there were not enough snacks available for all residents. The group said that these concerns were brought up in the meetings but nothing changes. The resident's stated clothes were still coming up missing and not enough snacks were being offered for the entire resident population. One resident in the group was a diabetic and she stated that the snacks that were left out were full of sugar and she was not able to eat them due to her diabetes. Another resident stated that he had gone to bed hungry before because he did not have a good meal at dinner and the snacks that were left out were gone by the time, he got to the nurse's station where the snacks were located. During an interview at 10/29/2024 at 10:35 AM, an anonymous resident said if you were in bed and can't get up, you don't get a snack because the staff will not pass the snacks out. During an interview at 10/30/2024 at 8:35 AM, an anonymous resident said she had lost several clothing items and she felt staff were not listening to her concerns related to the missing items. The resident said she had to sleep in her sweats one night because she had three pair of pajamas that were still missing. The resident said she had informed the staff during resident council but had not received any feedback about her missing items. During an interview with the AD on 10/30/2024 at 8:39 AM, the AD stated she took notes for the meeting. The AD said she did not feel that missing clothes were a big concern because the facility gets donations.; If a resident had anything missing, they can get items from the donations pile. The AD said the residents have valid concerns regarding the lack of snacks and was unsure if their concerns were being heard because some residents take more snacks than they should. The AD said she did not think there was a negative outcome for missing clothing or not enough snacks for residents because of the donations that were given to the facility and that nurses have a key to the kitchen if a resident wanted food. During an observation on 10/30/2024 at 10:05 AM the State Surveyor observed the snack cart being unattended at the nurse's station. During an interview on 10/30/2024 at 10:10 AM, LVN D stated that the snacks were left at the nurse's station for residents to get a snack and some residents take more than their share of snacks. During an interview with the LS on 10/30/2024 at 10:18 AM, the LS said that she was also filling in as the dietary supervisor until the new one starts. The LS said the donated clothing was put in with the resident's lost and found laundry. The LS said that a possible negative outcome for mixing the lost and found laundry and the donations was that a resident may see their lost item on another resident and become angry thinking their items were stolen. The LS said that no one had discussed or implemented any changes in the way laundry was handled or stored. The LS said the snacks were left at the nurse's station and not passed out to residents; it was a first come first serve type situation. The LS said it was common for residents to hoard snacks causing other residents not to get one. The LS said that she believed that snacks should be passed out to each resident, so everyone had a chance to get a snack. The LS stated that she informed Administration that leaving the snack cart unattended at the nurse's station was causing issues with residents not receiving snacks because some residents were taking more than their share, but nothing had been done. During an observation on 10/30/2024 at 10:18 AM the State Surveyor observed a stack of donated clothing and the lost and found clothing in same the area stacked together in the laundry room. During an interview with the DON on 10/30/2024 at 10:45 AM, the DON said that possible negative outcome for not listening to the residents about their concerns with the laundry or snacks could be a dignity issue as they feel they were not being heard. During an interview with the ADM on 10/30/2024 at 11:00 AM, the ADM said that he was responsible for the grievances and the AD tells him of any issues with the group meetings. The ADM said that a possible negative outcome for not listening to the residents about their concerns with laundry or snacks was they may feel that their concerns do not matter. During an interview with the DON on 10/30/2024 at 1:15 PM revealed that she acknowledged that there had been issues with the not having enough snacks. Record review of facility's policy on grievances dated 1/12/2023 revealed the following: The resident has a right to organize and participate in resident groups in the facility. The facility must consider the views of a resident or family group and act promptly upon the grievance and recommendation of such groups concerning issues of resident care and life in the facility.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure facility staff wore a hair restraint while in the kitchen. B. Ensure stored food was properly labeled, dated and covered. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 10/28/24 at 9:25 am of the walk-in cooler the following was found: 1. A pan of cooked chicken, covered with foil that was torn allowing air into the pan, no label or date 2. A plastic container of strawberries, no label or date 3. A tray of individual glasses of milk, no label or date 4. A glass of milk, no cover, label or date Observations of the freezer on 10/28/24 at 9:40 AM revealed the following: A. An opened box of beef fritters, open to air and unsecured. In an observation on 10/28/24 at 11:30 am, revealed Housekeeper E was in the kitchen without a hairnet, talking to one of the kitchen staff. When asked if she was aware she did not have a hairnet on, she stated she was not aware she needed to have a hairnet on. She stated the consequences of not wearing a hairnet would be a sanitary issue. In an interview and an observation of the kitchen prep table on 10/28/24 from 11:30 am to 11:50 am revealed a tray with individual bowls of chocolate pudding with no covering. [NAME] G stated the pudding was for the noon meal for residents who eat in the dining room. She stated the nursing staff did not want foods served in the dining room to be covered. She stated that was why the glass of milk was also uncovered. She stated not covering the puddings could cause cross contamination of the foods and residents could get sick. In an interview on 10/29/24 at 1:30 pm, the HS stated she was supervising the kitchen until another manager is hired. She stated she had worked very hard to make sure the kitchen was in order. She stated she expected the staff to wear hairnets while in the kitchen and Housekeeper E had been counseled about not wearing a hairnet in the kitchen. She stated the housekeeper should not have been in the kitchen at all. She stated all food items should be covered labeled and dated. She stated the reason the pudding and drinks were not covered were because the nursing staff did not want the foods covered if the residents were eating in the dining room. The HS stated the consequences of all the issues in the kitchen could cause cross contamination and possibly make the residents sick. Record review of the facility policy titled ' Employee Sanitation' dated 2018 documented hairnets must be worn to keep hair from food and food contact surfaces. Record review of the facility's policy titled, 'Food Storage' dated June 1, 2019, documented: Date, label and tightly seal all refrigerator foods using clean nonabsorbent covered containers that are approved for food storage. To ensure freshness , store opened items in tightly covered containers. All containers must be labeled and dated. Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3201.11 Compliance with Food Law (C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under SS 3-202.17 and 3-202.18. Pf Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) , preparation, holding, and display by: (a) Using separate EQUIPMENT for each type, P or (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented, Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES.

Based on observations, interviews, and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 2 of 16 residents (Resident # 3, #13) reviewed for accommodation of needs. Resident #3 and #13's call light were not within reach . This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #3's face sheet, dated 10/29/2024, revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, difficulty in walking, legal blindness, and hearing loss. Record review of Resident #3's annual MDS dated [DATE], revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. Resident #3 required maximal assistance with chair bed transfer and walking 50 feet. Record review of Resident #3's care plan dated 08/29/2024 revealed, in part, Resident #3 had occasional bowel and bladder incontinence with an approach to have the call light in reach. Record review of Resident #13's face sheet, dated 10/29/2024, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, parkinsonism, muscle wasting and atrophy, and need for assistance with personal care. Record review of Resident #13's quarterly MDS, dated [DATE], revealed a BIMS score of 08 out of 15 which indicated moderately impaired cognition. Resident #13 required extensive two-person staff assistance with bed mobility and dressing, and total two-person staff dependence with transferring. Record review of Resident #13's care plan, dated 08/09/2024, revealed, in part, Resident #13 was at risk for injuries from falling with an approach to make sure the call light was within reach. During an observation on 10/28/2024 at 10:00 AM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner. During an interview on 10/28/2024 at 10:05 AM, LVN C said that Resident #3 yells for help so they have her room located near the nurse's station so they can hear her when she needs them. During an observation on 10/28/2024 at 1:58 PM Resident #13 was lying in her bed asleep. The call light was located on her dresser out of reach of the resident. During an interview on 10/28/2024 at 1:50 PM, CNA A came into the Resident #13's room and said that the call light should be attached to the resident's blanket so she could call for help. CNA A said the Hospice nurses had given her a bath and must not have put the call light on her blanket. CNA A said that the resident usually pounds on the wall when she needs help. CNA A said that the call light should have been near the resident . During on observation on 10/28/2024 at 1:53 PM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner. During an interview on 10/28/2024 at 5:30 PM, Resident #3's family member stated that Resident #3 was legally blind and was unable to hear well. Resident #3 said that if a call light was near Resident #3, she would use it to call for help. During on observation on 10/29/2024 at 8:29 AM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner. During an observation on 10/29/24 at 8:39 AM, Resident #13 was lying in her bed sleeping. The call light was out of reach of the resident located on her side dresser. The State Surveyor observed CNA B to be walking down the hall. The State Surveyor pounded on the wall but observed CNA B to walk by without acknowledging the noise. During an interview and observation on 10/29/2024 at 8:41 AM, CNA B stated she did not hear the pounding on the wall by the state surveyor. CNA B was observed putting the call light on Resident #13's blanket. CNA B said that she had observed Resident #13 using the call light and that it should have been on her blanket so she could call for help if needed. CNA B said that all staff were responsible for making sure call lights were near residents and a possible negative outcome for not having the call light in reach would be that the resident could fall out of bed. During an interview on 10/30/2024 at 9:14 AM the ADM said that a possible negative outcome for not having a call light near a resident would be that a resident would not be able to call for help. The ADM stated that nurses were responsible for ensuring call light placement. During an interview on 10/30/2024 at 10:45 AM, the DON said that a possible negative outcome for not having a call light near a resident would be a delay in care for that resident. During an interview on 10/30/2024 at 11:05 AM, the Corporate RN said that a possible negative outcome for not having a call light near a resident would be a delay in care and it was unacceptable. The Corporate RN said that staff were responsible for ensuring call lights were near residents. Record Review of Answering the Call light policy dated March 2021 revealed the following: When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (RN F) of 13 staff reviewed for abuse policies. The facility failed to make sure that a potential employee who would be working with residents directly was free of criminal charges. This failure could place residents of the facility at risk of abuse or neglect at the hands of an employee with a documented history of these types of behaviors. Findings Included: Record review of RN F's employee file revealed a hire date of 7/4/2024 and an Employee Misconduct Registry (EMR) with a date of 7/9/2024. During an interview on 10/30/24 at 11:21AM, HRD stated that RN F was supposed to start later in the month but started on July 4, 2024. The HRD stated the negative outcome for hiring staff without running their record first would be putting residents at risk for abuse. Record review of the facilities ANE policy dated 10/2023 stated the following: 1. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 2. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.

Based on interview and record review the facility failed to provide training to their staff for abuse, neglect, and exploitation for 4 (SLP, CNA B, CNA C, and LVN D) of 13 employees evaluated for the required trainings. SLP was hired 7-11-2020 and no training had been provided on Abuse, Neglect, and Exploitation in the last 12 months. CNA B was hired 7-11-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. CNA C was hired 6-21-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. LVN D was hired 12-23-2022 and no training was provided on Abuse, Neglect, and Exploitation at hire. This failure could place residents at risk for harm from staff that have not been trained adequately to provide appropriate care and prevent injuries. This failure could result in deterioration in resident condition, injuries, and exacerbation of the disease process. Findings included: Record review completed 9-13-2023 at 02:01 PM of SLP's (Speech Language Pathologist) employee file revealed the following: SLP was hired 7-11-2020 and no training was provided on Abuse, Neglect, and Exploitation in the last 12 months. Record review completed 9-13-2023 at 10:47 AM of CNA B's employee file revealed the following: CNA B was hired on 7-11-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. Record review completed 9-13-2023 at 10:59 AM of CNA C's employee file revealed the following: CNA C was hired on 6-21-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. Record review completed 9-13-2023 at 11:08 AM of LVN D's employee file revealed the following: LVN D was hired on 12-23-2022 and no training was provided on Abuse, Neglect, and Exploitation at hire. During an interview on 9-13-2023 at 01:38 PM the BOM/HR (Business Office Manager/Human Resource Manager) reported that she had just been placed as head of the HR department and that she was aware that new employee orientation had not been completed correctly. The BOM/HR reported that she was scheduled for a training next week that should correct all current problems with employee training. The BOM/HR verified that the 4 employees were not trained upon hire and reported that the nursing department was responsible for ensuring that the trainings were completed when hired. The BOM/HR reported that if staff did not receive the required trainings then we could have staff that are not prepared to take care of residents. During an interview on 9-14-2023 at 10:12 AM the DON verified that she completed all required trainings related to nursing to include Abuse, Neglect, and Exploitation when an employee is hired. The DON reported that she felt that all employees listed above had completed the required training and that she just felt that their orientation form had been misplaced or was simply not filled out. The DON reported that if a staff member was not trained on what they need to know then they may not provide safe care. Record review of the facility provide policy titled, New Hire and Annual Training Packet revealed the following: Section-Abuse Prevention Program, revised 1-9-2023: 4, Our Center will implement and permanently maintain an effective training program for all staff . Policy Interpretation and Implementation- 2. Requires staff training/orientation programs . 47159

Based on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident noted in 1 of 3 medication areas (medication room) reviewed for medication storage. The facility medication room contained 3 prescription medications that were expired. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: During an observation on 09-12-2023 at 09:31 AM of the facility's medication room with the DON and CRN present the following medications were noted to be expired that were present in the overflow bin for room [ROOM NUMBER]A: Atorvastatin 1 bottle with expiration of 4-26-2023 and one bottle with expiration of 8-30-2023 Losartan 1 bottle with expiration of 6-21-2023 and one bottle with expiration of 8-30-2023 Gabapentin 1 bottle with expiration of 8-30-2023 During an interview on 9-12-2023 at 09:33 AM the DON and CRN they verified that the three prescription medication were expired, were part of the overflow stock, and that if the primary medication cart on the floor was out of medication, then the nurse would grab what they needed from this stock in the medication room. The DON reported that she did not feel the expired medication would be a problem because the staff are trained to check each medication for expiration prior to being administered. The DON stated, The chance an expired medication would be given would be slim. We check dates when we pass any meds. The CRN agreed. The DON reported that the expired medications were brought in when the resident in room [ROOM NUMBER]A was admitted recently and they expected him to be short term but he has since decided to stay and the medications he brought in were not discarded as they should have been. During an interview on 09-13-2023 at 08:52 AM LVN A reported that if a resident is out of a prescription medication in the medication cart, they will check the medication room for the overflow section that is located on one wall and see if the resident has that medication that has been refilled. If the medication is available, they will check if for expiration and ensure that all other valid information is present such as resident name, dose, etc. then put the medication in use. During an observation on 09-12-2023 at 09:27 AM of Medication Cart 1, the three medications currently in use listed above for room [ROOM NUMBER]A had an expiration date listed in the year 2024. Record review of the facility provided policy titled Storage of Medications revised November 2020, revealed the following: Policy Interpretation and Implementation: 4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

48321 Based on interviews and record reviews, the facility failed to develop and implement an effective discharge planning process for 1 of 15 residents (Resident #1) reviewed for care plans. The facility failed to prepare Resident #1 to effectively transition to post-discharge care and the reduction of factors leading to preventable readmissions. This failure placed the resident at risk of readmission and his needs not being met. Findings included: Record Review of Resident #'1's face sheet reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of Chronic obstructive pulmonary disease, unspecified (Primary, Admission), Changes in skin texture, Enlarged and thickend finger nails, Labored breathing, unspecified, Generalized anxiety disorder, Hypertensive heart disease with heart failure, Unspecified systolic (congestive) heart failure, Reduced circulation of blood to another part of the body other than the brain or heart, unspecified, Other chronic pain, Nausea, Other muscle spasm, Allergic rhinitis, unspecified, Lower than normal blood potassium levels, Nicotine dependence, unspecified, uncomplicated, Anxiety disorder, unspecified, Other epilepsy, intractable, with status epilepticus, Stroke, unspecified, Narrowing and blockage of right carotid artery, Essential (primary) hypertension, Constipation, unspecified, Intense itching of the skin, unspecified, Muscle wasting and atrophy, not elsewhere classified, unspecified site, Urinary tract infection, site not specified, Unsteadiness on feet, Other abnormalities of gait and mobility, Other lack of coordination, Cognitive communication deficit, Pain, unspecified, Other reduced mobility, Need for assistance with personal care, Other excessive lipids in the blood. Record Review of an MDS assessment for Resident #1 dated 9/16/23 reflected a BIMS score of 12, indicating moderate cognitive impairment Record Review of Resident #1's Care Plan dated 8/1/2023 reflected that Resident #1 had a goal of I have no planned discharge plan at this time and will reside at the facility. Record Review of Resident #1's Care Plan dated 9/16/223 reflected a significant change in health status on 6/16/23. In an interview on 9/11/2023 at 11:40AM with the SW, SW stated that Resident #1 wanted to go to the apartments that are across the street and that he was on Hospice care and will continue to receive Hospice care when there. SW stated that Resident #1 is not being kicked out by the facility and he is asking to be discharged . In an interview with the Advocate (ADVC) on 9/11/2023 at 1:00PM, ADVC stated that she had just gotten off the phone with the SW and was told that Resident #1 was being discharged that day. She stated that she was told if the apartment isn't ready that the SW told her Resident #1 would be taken to a motel. ADVC stated that Resident #1's Medicaid is pending at this time. In an interview on 9/11/2023 at 1:18PM with the SW, the SW stated that Resident #1 was given a 30-day notice but did not know the date. In an interview on 9/11/2023 at 1:23PM, Resident #1 stated that he was not aware that he was being discharged today. Resident #1 stated that he wanted to leave the facility and if he could leave today, he would. Resident #1 stated that he feels he can take care of himself. In an interview on 9/11/2023 at 1:31PM with the DON, the DON stated that she didin't think that it was her call to say if Resident #1 was able to take care of himself or not. The DON stated that she felt better that he would stay in Hospice care and that they will not not hesitate to make an APS report if needed. In an interview on 9/11/2023 at 1:34PM with the Admin, the Admin stated that Resident #1 was being discharged . The Admin stated that Resident #1 was given a 30-day notice to move out over 40 days ago due to non-payment. In an interview on 9/11/2023 at 3:38PM with the DON, the DON stated that she was fairly certain that Resident #1's physician had been notified of his discharge and that she was ok with it. The DON stated that Resident #1 would have Hospice care and it is his right to leave. In an interview on 9/12/2023 at 9:00AM with the Admin, the Admin was asked if a Discharge Plan was done with Resident #1 and the Admin stated that they had asked what Resident #1 wanted and needed and got with Hospice to make sure that they would follow him after he moved. When asked if there were any documentation of this Discharge Plan meeting the Admin stated that there was no documentation. In an interview on 9/12/2023 at 9:03AM with the DON, the DON was asked if there was a Discharge Plan done with Resident #1, and the DON stated that she talked to Hospice to make sure that everything was going to be set up when he moved. When asked if there was documentation of this the DON stated that there wasn't any that she knew of. In an interview on 9/12/2023 at 9:06AM with the SW, the SW was asked what the Post Discharge Plan policy was. The SW stated that they determine if the resident needed healthcare services once discharged , asked the family if they have support in place and made the necessary referrals. When asked if this was done for Resident #1, the SW stated that he and the DON had planned everything out together for Resident #1. When asked if there is a copy of the Post Discharge Plan, the SW stated that he hadn't seen one for Resident #1. When asked what the negative outcome would be of discharging Resident #1 today without a Post Discharge Plan, the SW stated that he could miss a medication or get sick, or he might have to move back into the facility. In an interview on 9/12/2023 at 9:51AM with an HHSC Medicaid Specialist, HHSC Medicaid Specialist stated that Resident #1 did not have an application submitted at this time and he did not have Medicaid. In an interview on 9/12/2023 at 1:47PM with the Admin, the Admin stated that they don't have the documentation that shows the IDT meeting happened and there was no discharge plan done. The Admin stated that there was no sit-down meeting with the IDT team and Resident #1 to develop a discharge plan. When asked why the facility was not following their own discharge policy, the Admin stated that it just wasn't done. Record review of the facility discharge summary plan dated 2016 states when the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The policy also stated The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include: where the resident planned to reside, arrangements that were made for follow-up care and services, a description of the resident's stated discharge goals, the degree of caregiver/support person availability, capacity and capability to perform required care, how the IDT will support the resident or representative in the transition to post-discharge care, what factors make the resident vulnerable to preventable readmission and how those factors would be addressed.

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerated foods were properly labeled and dated. 2. The facility failed to ensure pantry foods were properly labeled and dated. 3. The facility failed to ensure expired foods were not in the pantry and refrigerator. 4. The facility failed to ensure food service workers wore gloves. These failures could place residents at risk for food-borne illness. Findings include: Observation of the kitchen staff on [DATE] at 9:18 AM revealed the following: Two dietary service workers were not wearing gloves while preparing resident food. Observation of the refrigerator on [DATE] at 9:22 AM revealed the following: -Five gallons of milk with best by date [DATE]. -75 4-ounce cartons of chocolate milk had no date. -Two heads of lettuce had no date. -4 large food service bags of cole slaw mix, had no date. -1 food service box of fresh tomatoes had no date. -3 gallons of maple syrup were open, with no date. -1 gallon of fruit punch had no date. -1 gallon of lemonade had no date. -19 ,d+[DATE] dozen fresh eggs, had no date. -4, 5-pound containers of cottage cheese with best by date [DATE]. -10 individual glasses of apple juice, covered, with no date. -10 individual glasses of tomato juice, covered, with no date. -5, 1-gallon food service containers of mayonnaise had no date. -1 gallon of Worcestershire sauce, was opened with an expiration date of [DATE]. Observation of the walk-in pantry on [DATE] at 9:51 AM revealed the following: -1 Food Service box of dry pasta, was opened to the air, with an expiration date of ,d+[DATE]. -6 boxes of wild rice pilaf, had no date. -1 open bag of Fritos corn chips had no date and was closed with a paper clip. -1 open bag of dry mashed potato flakes had no date and was closed with a paper clip. -10 Food Service canisters of oatmeal, had no date. -1 Food Service bag of bread pudding mix, had no date. -2 Food Service loaves of white bread, had no date. -15 Food Service bags of hot dog buns, had no date. -4 Food Service bags of hamburger buns, had no date -2 Food Service bags of turkey gravy mix, had no date. -2 Food Service bags of peppered gravy mix, had no date. -1 Food Service container of chicken base mix, had no date. Observation of residents who were in the dining room at the time of the noon dining service revealed 2 residents were witnessed dipping their personal cups into the facility's ice maker, without using the ice scoop . There were no interventions by staff to keep residents from doing this. In an interview with the facility Administrator on [DATE] at 10:28 AM after State Surveyor intervention, revealed the Administrator immediately reprimanded residents for using the ice machine on their own, posted a sign on the machine which indicated residents were not to use the machine without assistance and the ordering of an ice machine which dispenses ice versus having to use a scoop to put ice into a glass . In an interview on [DATE] at 11:01 AM, the Dietary Manager stated she started in the position about a month ago and she had been trying to train staff on food storage and the need to rotate things that were outdated. She stated residents could become sick if they were served foods that were expired or undated. The Dietary Manager stated residents could become sick if a food service worker did not properly sanitize their hands and don gloves before contact with resident foods . Record review of the Food and Nutrition Services and Kitchen Sanitation to Prevent the Spread of Viral Illnesses policies and procedures, dated [DATE], revealed gloves are to be worn at all times, by kitchen staff and are to be changed: 1. Between each food preparation task. 2. After touching items, utensils or equipment not related to task. 3. After touching hair, face, or another source of contamination. 4. When leaving food preparation area for any reason. 5. When damaged, soiled or when interrupted. 6. Every hour for all tasks taking longer than one hour. Record review of the Food Storage policy and procedures, dated 2018, revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation when they failed to: A. Ensure stored food was properly labeled, dated, and sealed. B. Ensure general cleanliness was maintained in the kitchen area C. Ensure kitchen staff had access to proper handwashing facilities D. Ensure frozen food was thawed correctly E. Ensure the sanitizer dispenser for the 3-compartment sink was functional These failures placed residents at risk of cross contamination and food-borne illness. Findings included: During an observation on [DATE] at 9:41 AM the handwashing sink had a gallon bottle of cleaning liquid sitting in the sink basin. The sink was grimy and stained with brown and orange splatter stains. The soap dispenser to the right of the sink was empty or not functional. The paper towel dispenser was dirty and grimy and it was necessary to touch the dispenser to get the paper towels to come out because the towels were not hanging out the bottom of the dispenser. The paper towels seemed to be loaded into the dispenser incorrectly or the dispenser was malfunctioning. There was a white, lidded, step-to-open trash can beneath the handwashing sink. The trash can was stained brown and dirty. It was turned backwards so the step for opening the trash can was inaccessible. During an observation on [DATE] at 9:42 AM the 3-compartment sink with sanitizer solution was empty except for a mop bucket DA was filling with water. The sink and the walls around the sink were dirty. The sanitizer dispenser looked corroded with a crusty build up on the tops of the tubes where they connected to the dispenser. An observation on [DATE] beginning at 9:43 AM of dishes drying on the drying rack revealed: One plastic tray of 15 small clear glasses with the glasses upside down resting directly on the tray had condensation trapped inside 13 of the 15 glasses. One plastic tray of 13 coffee cups with the cups upside down resting directly on the tray had condensation trapped inside 13 of the 13 coffee cups. One plastic tray of 3 red glasses upside down resting directly on the tray had condensation trapped in 3 of the 3 glasses and water puddled on the tray. One plastic tray of 11 red bowls with the bowls upside down and 9 of the 11 resting directly on the tray with 2 of the 11 stacked on top of the other 9 had condensation trapped in 11 of the 11 bowls. In addition, one of the bowls had globs of a whitish substance stuck to the inside of the bowl near the edge in two places and another had streaks of white down the outside of the bowl. One plastic tray of 27 blue, clear, and green glasses with the glasses upside down resting directly on the tray had brown spots of a sticky substance splattered on the tray. In addition, two of the blue glasses had brown puddled liquid on the bottoms (glasses were upside down so bottoms formed a shallow bowl) and one of the clear glasses had spots of brown dried liquid inside the glass. Sixteen insulated water cups were upside down on the top shelf of the drying rack. Two of the 16 were brown and grimy on the inside. During an interview and observation on [DATE] at 9:50 AM DA was asked if the dishes on the drying rack were clean and she said yes. When she was shown the dirty tray of blue, clear, and green glasses, she said, He (Cook C) was here yesterday, and he did not do his job. These ones I did today (gestured to the trays of clear glasses, bowls, red glasses, and coffee cups.) During an observation on [DATE] at 9:47 AM the small sink and connecting table to the dishwasher were dirty. The walls around the dishwasher were dirty and stained with brown and orange splatter. The floor under the sink and dishwasher was grimy and dirty. During an observation on [DATE] at 9:49 AM a small white chest freezer sitting next to drying rack was empty and had two 3 pieces of what appeared to be ground meat patty or waffle resting in the bottom of the freezer. During an observation on [DATE] at 9:49 AM a plastic grocery sack of small cans of soup was noted spilling out next to the red sanitizing tubs on the bottom shelf of a metal table between the dishwasher and the 3-compartment sink. During an observation on [DATE] at 9:50 AM no red sanitizing tubs were noted in use in the kitchen. An observation on [DATE] beginning at 9:51 AM of the pantry revealed: Two plastic containers of dried mashed potatoes were on the top shelf covered loosely with foil and open to air. A large package of spaghetti pasta was wrapped loosely in a piece of plastic wrap stained orange with a crusty substance. One packet of mustard, one jelly packet, small paper trash, and crumbs were on the floor of the pantry. A large, white, plastic bucket of rice in a blue bag had the blue bag folded over the edges of the bucket with no lid. The rice was not covered and open to air. A large, plastic, rectangular tub with the date ,d+[DATE] was on a shelf in the pantry with no cover and contained individually wrapped snacks jumbled together. Individual round cookies were in unmarked, unsealed plastic bags. Snack bars were in wrappers from the manufacturer. Two sealed storage bags of biscuits were on the bread shelves. One of the bags had a biscuit with a small greenish blue circle on the bottom. When the greenish-blue circle was shown to Cook B she said it was mold and took both bags of biscuits and threw them in the trash. Two undated loaves of bread were noted on the bread shelves. Cook B used a black marker to date them and said the new girl had put them up yesterday and did not know to date them. Twelve small boxes of lasagna noodles noted with a stamped expiration date of [DATE]. An observation on [DATE] beginning at 9:57 AM of the walk-in refrigerator revealed: The door to the walk-in refrigerator was not latched and was therefore open approximately 2 inches. A small, styrofoam bowl of circular, colorful cereal was uncovered and open to air on the top shelf of the walk-in. A plastic tray of 18 small, clear glasses filled with clear liquid were uncovered and open to air. A plastic opaque white tub with a green lid that had been melted use by ,d+[DATE]. It was not labeled with the name of the food inside and was open to air due to the melted lid. A plastic opaque white tub with a green lid that had been melted even more drastically than the first was dated use by ,d+[DATE]. It was not labeled with the name of the food inside and was open to air due to the melted lid. A big bag of shredded cheddar cheese was open to air. In an observation on [DATE] at 10:03 AM the floor around the oven and prep table was dirty with crumbs, paper, and splatter marks. The bottom shelf of the prep table against the wall across from the oven had crumbs on it. In an observation on [DATE] at 10:04 AM The lid and sides of the ice machine, located in the dining room, were dirty and grimy. During an observation on [DATE] at 7:13 AM the jelly packet, mustard packet, crumbs, and trash were still on the floor of the pantry. During an observation on [DATE] at 7:25 AM Cook C was observed taking temps of breakfast items on the steam table. At one point Cook C changed a glove due to picking papers up off the floor. He did not wash his hands before applying the new glove. In an interview on [DATE] at 7:35 AM DM said he did not have a certificate. He stated, I don't have one. I have the classes to take next month, but I don't have one right now. He said he has worked for SLP for 3 years and been a DM for 1 month. In an observation on [DATE] at 9:11 AM a leak was noted under the sink next to the dishwasher. The leak dripped from the U joint into a white plastic tub sitting on the floor. In an observation and interview on [DATE] at 9:12 AM Cook C attempted to test the sanitizing solution in the 3-compartment sink. He used a red sanitizing bucket and attempted to fill it in the center sink using water and the rubber tubing from the sanitizing solution dispenser hanging on the wall. He said, My chemicals aren't coming out. That's just water. I'll have to talk to my maintenance man. All three compartments of the sink were stained and dirty with crusted deposits around the drains. In an observation on [DATE] at 9:13 AM a large, sealed bag of frozen chicken or pork was thawing in a steam table pan sitting on top of the small, white chest freezer next to the drying racks in the kitchen. In an interview on [DATE] at 9:31 AM ADM provided a copy of the kitchen audit performed by the facility's contracted food service consulting company on [DATE]. In an interview on [DATE] at 10:00 AM DM stated the kitchen staff label leftovers with date made, what it is, and when it leaves. He said the kitchen had cleaning logs but we try to work together to keep it as clean as possible. It can get real dirty fast. When asked about snacks the DM said the snacks have to be individually wrapped and sealed. He said the dry snacks in the pantry can last 3 weeks if they are individually wrapped and sealed. He added, So no bugs or anything. When the DM was asked how they thaw food he said two ways, the first is to take it out of the freezer, put it in a pan, cover and date it, and leave it in the walk-in. It can stay in the walk-in for 24 hours but then it must be used. He said the second way is to take it out the day it is to be cooked, put it in a pan, and thaw it under cool running water. When DM was asked about the missing soap at the handwashing sink, he said, That's housekeeping. I did not know about that, but I know there are shortages. But there is soap in the bathroom, and I always tell my staff to wash their hands before they come in and start working. During an observation on [DATE] at 10:16 AM the expired lasagna pasta was still in the pantry. The jelly and mustard packet were still on the floor of the pantry. During an observation on [DATE] at 10:17 AM of the walk-in refrigerator there were 3 trays of 12 styrofoam bowls each plus 4 more bowls (40 total bowls) with cubes of pinkish fruit topped with dollops of white whipped topping uncovered and open to air. During an observation on [DATE] at 10:18 AM an opaque white trash bag of food garbage (approximately ,d+[DATE] full) was tied over the top of a plastic wheely cart. The trash bag was hanging open and sitting on the floor next to the drying rack. Another tall trash can of garbage with no lid was ,d+[DATE] full sitting next to the dishwasher. Three pieces of wadded up plastic wrap, three sugar packet wrappers, one straw wrapper, and two packets of some type of sauce were on the floor around the base of the trash can. During an observation on [DATE] at 10:19 AM on the drying rack there was one plastic tray of 9 coffee cups sitting upside down, directly on tray with condensation inside 9 of 9 cups. Water was in puddle rings on the tray under the cups. During an observation on [DATE] at 10:20 AM a plastic tray of 19 bowls. Three of the bowls were stacked on top of 16 stacked upside down and sitting directly on the plastic tray. 19 of 19 bowls had condensation inside. One bowl had food inside. The plastic tray had water standing in puddle rings around the bowls. During an observation on [DATE] at 10:20 AM a food cart for sliding trays in and taking them down the halls was stained with brown substance on 13 of the 20 sliding shelves. The walls around the dishwasher were dirty and stained with various colors. During an observation on [DATE] at 10:21 AM the walls around the 3 sanitizing sinks were dirty and stained. The step trash can for the handwashing sink was dirty and stained. The handwashing sink was dirty and stained with spots of reddish-brown and tan. There was no soap in the dispenser near the handwashing sink. During an observation on [DATE] at 10:22 AM the pork or chicken was still thawing in the pan on top of the white chest freezer. During an interview on [DATE] at 10:24 AM when Cook C was asked where he washed his hands, he replied, Honestly, I wash my hands in the bathroom all the time cuz it's got soap in there. During an interview on [DATE] at 12:27 PM HS said housekeeping does not go into the kitchen unless the kitchen staff request soap refills for the handwashing sink or the bathroom. She said they usually ask every two weeks and they have not asked in the last week. During an interview on [DATE] at 4:38 PM Cook C said MS is supposed to come fix the sanitizer dispenser for the 3-compartment sink, the leak under the dishwasher, and a plug for the dishwasher today. During an interview on [DATE] at 9:11 AM Cook B was asked where she washed her hands. She stated, We wash 'em in that sink (nodded head toward handwashing sink) but they ain't no soap so I wash [NAME] in the bathroom. During an interview on [DATE] 9:20 AM MS was asked if he knew about the sanitizer dispenser in the kitchen sink being broken. He stated, The sink in the kitchen, yes they told me yesterday. I didn't know about the sanitizer. The sink is on my list for today. During an interview on [DATE] at 9:21 AM Dietician D said We (contracted food service consulting company) come once a month and do an QA in the kitchen on sanitation. She said she will be following up on the recommendations from the kitchen audit done on [DATE] by her company. During an observation on [DATE] at 9:58 AM the staff bathroom in the kitchen was filthy. The corners of the floor were dark brown and grimy. The walls were dirty and stained. The toilet was full of toilet paper and yellowish water. During an observation on [DATE] at 10:00 AM the mop closet was dark brown and grimy in the corners and the tile floor was chipping up. During an observation on [DATE] at 10:01 AM the snack bucket in the pantry had individual cookies in unsealed bags, open to air. During an interview on [DATE] at 10:04 AM Cook B stated hair nets are required when in the kitchen. During an observation on [DATE] at 10:05 AM 5 styrofoam bowls of chopped pink fruit with a dollop of white whipped topping were on a tray in the walk-in refrigerator uncovered and open to air. During an observation on [DATE] at 10:05 AM a small square opaque plastic tub was covered with a green lid melted in such a way that the food in the tub (meat according to the label) was not sealed and open to air. During an interview on [DATE] at 10:08 AM DM was asked who is responsible for reporting outage of soap in the soap dispenser near the handwashing sink? He stated, All the staff tell me and I let maintenance know. Like yesterday I told him we needed some and it was very important. During an interview on [DATE] at 10:09 AM DM was asked how pans are being washed since the sanitizer dispensers for the 3-compartment sink was not functioning? He stated, Oh, they scrub them over there (pointed to the single sink in front of the dishwasher) and run them through the dishwasher. I have a call in to (name of manufacturer of the sanitizer dispenser) to get that fixed. He stated he made the call let's see, two days ago. During an interview on [DATE] at 10:10 AM DM was asked who cleans the kitchen sinks. He replied, Usually dietary aides clean the sinks and bathroom and sweep and mop the floors and take out the trash every evening. They have been slacking a little bit. During an interview on [DATE] at 10:10 AM DM was shown the melted green lids to food storage tubs. His boss, DCorp, was standing with him and said she would buy some new storage tubs. DM was asked for an example of a negative outcome of food being exposed to air? He stated, Oh, you will get microorganisms, germs and stuff in there. During an interview on [DATE] at 10:11 AM DM was asked what could go wrong when drying dishes directly on plastic trays? His boss, DCorp, picked up a glass and said, because water can get trapped underneath. She said she will buy some more of the plastic sheeting that allows air to flow underneath the dishes. During an interview on [DATE] at 10:12 AM DM was asked if they have trainings on cleaning the kitchen? He stated, We haven't but we need to. During an interview on [DATE] at 10:12 AM DM was asked if he did trainings on handwashing? I usually do that when we hire new ones, 30 seconds (making motion of washing hands) happy birthday song then turn water off with napkin. During an interview on [DATE] at 10:13 AM DM was asked when hair nets should be in use. He replied, All the time, as soon as you walk in (to the kitchen) you put it on. He was asked if he had done any trainings on hairnets. He replied, in the beginning when hired but we need to go over that again. Record review of the kitchen audit from the contracted food service consulting company written by Dietician E, dated [DATE], and titled, Quality Assurance Monitor I Kitchen/Food Service Observation revealed the following: The kitchen received an overall score of 63% out of 100%. Areas noted to need improvement were: No posted schedules of cleaning of the kitchen, No sanitizer buckets in use with PPM recorded on logs and rags stored in the buckets, The general appearance of the kitchen was not clean, Floors, walls, and tiles were not in good repair, Pipes were not free of leaks, The 3-compartment sink logs were not complete (sanitizing solution and PPM recorded on logs), Pot washing procedure was not posted and 3-compartment sink was not used properly and consistently (wash-rinse-sanitize), The area around the pot sink was not clean. Sanitizer was not in use for both the 3-compartment sink and the dishwasher Food was not thawed under proper conditions Record review of undated facility provided policy titled, Handwashing revealed the following: Policy Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures (and surrogate prosthetic devices washing procedures as appropriate). Hand washing facilities should be readily accessible and equipped with hot and cold running water, paper towels, soap, trash cans and signage notifying employees to wash hands. When to Wash Hands: . Before donning gloves for working with food. Record review of undated facility provided policy titled, Food Receiving and Storage revealed the following: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Culinary Services or other designated staff, will maintain clean food storage areas at all times. 4. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is . kept clean. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). Such foods will be rotated using a 'first in-first out' system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). Record review of undated facility provided policy titled, Food Preparation and Service revealed the following: Policy Statement Culinary Services employees shall prepare and serve food in a manner that complies with safe food handling practices. Thawing Frozen Food 1. Foods will not be thawed at room temperature. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container; b. Submerging the item in cold running water (70 F or below) c. Thawing in a microwave oven and then cooking and serving immediately; or d. Thawing as part of a continuous cooking process. Culinary Services/Distribution 25. Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food Record review of undated, facility provided policy, titled, Leftovers revealed the following: Policy: . Leftovers will be properly handled and used or discarded as appropriate. Leftovers will be covered, labeled, and dated; then stored appropriately . Leftovers can be used if used within 72 hours . Use leftovers within 3 days or discard.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 25 residents (Resident #8, Resident #9 and Resident #25) reviewed for ADL assistance. The facility failed to: Ensure Resident #8 and Resident #9 received baths/showers according to their preferred bathing schedule Ensure Resident #25 received assistance with her ADLs according to her plan of care. These failures could place residents that require assistance with ADLs at risk of depression, skin breakdown, and a decline in their quality of life. Findings include: Record review of Resident #8's face sheet, dated 07/21/22, revealed an [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's annual MDS, dated [DATE], revealed a BIMS score of 11 out of 15 which indicated his cognition was moderately impaired. He required one-person assistance with bed mobility, dressing and toilet use. He required a wheelchair for mobility. Record review of Resident #8's care plan dated 6/8/2022, revealed ADL (assisted daily living) function/rehab potential, Bathing/hygiene amount of assist: Supervision x1 Staff; The following Tasks will be documented in POC CareAssist, The Resident will perform the following tasks at their highest practicable level. I prefer to take my Bath/Shower on Tuesday, Thursday, Saturday. My preferred time to Bath/Shower Shift 2. Once A Day on Tue, Thu, Sat; 06:00 PM- 06:00 AM. Record review of Resident #8's Point of Care History dated 7/1/2022-8/8/2022, revealed 7/12/22 shower; 7/23/22 shower; 7/24/22 shower; 8/02/22 shower. During an interview on 8/7/22 at 10:24 AM with Resident #8, he stated residents did not receive showers the way it was supposed to be. Resident # 8 stated he sometimes received one shower a week because the facility did not have enough staff. Record review of Resident #9's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's annual MDS, dated [DATE], revealed a BIMS score of 8 out of 15 which indicated his cognition was moderately impaired. The resident did not have any behaviors and required a wheelchair for mobility. Record review of Resident #9's care plan dated 6/1/2022, revealed The following Tasks will be documented in POC CareAssist, The Resident will perform the following tasks at their highest practicable level. I prefer to take my Bath/Shower on M-W-F. My preferred time to Bath/Shower Shift 2. Once A Day on Mon, Tues, Fri; 06:00 PM- 06:00 AM. Record review of Resident #9's Point of Care History dated 7/1/2022-8/8/2022, revealed 7/1/22 (shower) done; 7/6/22 (shower) done; 7/8/22 (shower) done; 7/13/22 (shower) done. During an interview on 8/8/22 at 10:34 AM, Resident # 9 stated he was frustrated with not getting a shower. Resident # 9 stated it took weeks to get a shower. Resident # 9 also stated he had brought it up to the staff and they tell him it was because they were short staffed. Record review of Resident # 25's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #25's annual MDS, dated [DATE], revealed a BIMS score of 7 out of 15 which indicated her cognition was severely impaired. She required extensive assistance with bed mobility and transfer and total dependance for toilet use and bathing. The resident required a wheelchair for mobility. Record review of Resident #25's care plan dated 1/13/2022, revealed ADL (assisted daily living) function/rehab potential, The Resident will achieve maximum functional mobility. Ambulation/Transfers amount of assist: Extensive x2 Staff; Bathing/hygiene amount of assist: Extensive x1 Staff, Dressing/Grooming amount of assist: Extensive x1 Staff. During an observation and interview on 8/07/22 at 10:25 AM, Resident # 25 stated It's just there's a shortage of hands and I'm waiting to get back into bed, we're waiting for a lady to get back. Surveyor asked if she knew where the lady was, she said she did not know. She said she has been waiting 20 minutes or more to get back in bed. During an observation and interview on 08/07/22 at 10:29 AM, CNA A went into Resident # 25's room and stated, I'm waiting on her [CNA was waiting on the other CNA to get back from break]. During an interview on 08/07/22 at 10:31 AM, CNA A stated she was Running. We only have two (CNAs) and sometimes only one! It's a lot of work. During an observation on 08/07/22 at 10:42 AM, Resident # 25 was still in the wheelchair waiting to get back into bed. During an observation and interview on 08/07/22 at 11:14 AM, Resident # 25 was in the wheelchair waiting for staff to assist her to get back in bed. Surveyor asked her if she was still waiting and she said, Yes. During an observation on 08/07/22 at 11:25 AM, CNA A and CNA G entered Resident # 25's room. Resident # 25 was heard saying I want to get in bed. One of the CNAs responded, Well it's lunch time now. Resident # 25 stated, I've been waiting all morning. During an observation on 08/07/22 at 12:44 PM Resident # 25 was lying in bed asleep. During an interview on 08/08/22 at 3:52 PM with LVN F, she stated that CNAs did the bathing. LVN F stated she had not received any complaints regarding bathing. LVN F stated the CNAs filled out shower sheets and documented them on the matrix. LVN F stated if residents did not get their baths, they could have gotten skin breakdown, fungal infections, and other skin issues. LVN F stated CNAs train the CNAs regarding baths and showers. During an interview on 08/08/22 at 4:04 PM with CNA G, she stated ADLS were documented on the matrix and shower sheets got filled out after every shower/bath. CNA G stated nurse aides did the bathing. CNA G stated if residents did not get their baths, they have gotten skin issues. She also stated, There's been a few times residents did not receive their baths due to lack of time. CNA G stated the aides came in on days off to give them a bath or stay over shift. She stated sometimes residents had complaints of not getting baths. CNA G stated the residents had bath schedules according to resident's preferences. CNA G stated nurse aides train new nurse aides. During an interview on 08/08/22 at 4:12 PM with CNA A, she stated she and other nurse aides oversaw showers. She stated the DON created a shower list and the CNAs split the residents. CNA A stated if residents did not get baths, they started smelling and were prone to skin breakdown. CNA A stated it has been a while since they have done in-services regarding bathing. CNA A stated CNAs train the new CNAs. During an interview on 08/08/22 at 4:32 PM with the DON, she stated CNAs were in charge of showers. The DON stated if residents did not receive their bath, they could have gotten possible skin issues and infection. The DON stated the CNAs documented showers in the matrix and on the shower sheets located at the nurse's station. The DON stated an LVN or RN signed off on CNAs competencies. The DON stated her expectations were for residents to be showered on their shower day. The DON stated she or the ADON oversaw training of the CNAs. Record review of Facility Policy, Bath, Shower/ Tub documented, Documentation 1. The date and time the shower/tub bath was performed. 5. If the resident refused the shower/tub bath, the reason (s) why and the intervention taken. Record review of Facility Policy, Facility Assessment Tool documented, Purpose: To determine what resources are necessary to care for residents competently during regular 24/7/365 operations and during emergencies to ensure that each resident maintains or attains their highest practicable physical, mental, and psychosocial well-being. Part 2: Services and Care We Offer Based on our Residents' Needs Activities of daily living- Bathing, showers Mobility and fall/ fall with injury prevention- transfers, ambulation

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 3 residents (Resident #86) reviewed for baseline care plans. Resident #86 was admitted on [DATE] but his baseline care plan was not initiated until 08/07/22. This failure could result in newly admitted residents not receiving person-centered care in a timely manner. Findings include: Record review of Resident #86's face sheet, dated 08/09/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #86's MDS, dated [DATE], revealed it was still in process. Record review of Resident #86's care plan revealed a created date of 08/07/22. During an observation and interview on 08/07/22 at 3:45 PM, Resident #86 was lying in bed in the COVID-19 positive unit. He was not wearing a gown or brief and covered only with a blanket. He did not respond to any questions but stated, where are my teeth? when his teeth were in his mouth. During an interview on 08/09/22 at 11:45 AM, DON stated baseline care plans should have been completed within 48 hours of a resident's admission. DON stated she was responsible for resident's care plans, and she was gone from the facility when Resident #86 was admitted . When asked who was responsible for completing care plans when she was gone, she stated, probably no one. When asked what a negative resident outcome could have been if not having baseline care plans completed in a timely manner, DON stated a resident might not have gotten the care they needed. Record review of a facility provided policy titled Care Plans - Baseline, dated December 2016, revealed, in part, Policy Statement .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .Policy Interpretation and Implementation .1. To assure that resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.

Based on interviews and record review, it was determined the facility failed to ensure 1 of 4 sampled residents (Resident #1) who entered the facility without a pressure sore did not develop a pressure sore or have a worsening of a pressure sore. Resident #1 was admitted to the facility on [DATE]. A skin assessment was conducted and documentation showed no pressure ulcers at this time. There was no documentation of pressure ulcers until 3/4/13, when Resident #1 was identified as having a stage II pressure ulcer on right heel. On 3/5/13, Resident #1 was identified as having a Stage II pressure ulcer on left buttock and an unstageable pressure ulcer on his left heel. The facilities failure to provide necessary treatments and services to prevent the development of pressure ulcers for Resident #1 from 2/18/13 until 3/4/13 placed the remaining 3 resident who were identified as having a pressure ulcer at risk of having new ulcers develop or possible infections to their current pressure ulcers. The evidence is as follows: Prior to entering the facility, it was known that Resident #1 was no longer in the facility, but in the hospital. Review of Resident #1's clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. Review of a Braden Scale for Predicting Pressure Sore Risk documented the following: (Total score of 12 or less represents High Risk for pressure sores. A score of 15 - 18 represents a mild risk, while 19 is not on the chart.) 2/18/13 - scored a 17 - mild risk 2/19/13 - scored a 15 - mild risk 2/27/13 - scored a 19 3/5/13 - scored a 19 -An Admission MDS resident assessment, dated 2/25/13, documented the following: Scored 11 or 15 on mini mental exam, totally dependent on two staff for bed mobility, transfers, toileting and bathing, extensive assistance with one staff for dressing and personal hygiene, no pressure ulcers. -A 60 day scheduled MDS resident assessment, dated 4/18/13, documented the following: scored 7 of 15 on mini mental exam, rejected care 1 to 3 days in the look back period, limited assistance by one staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing, used a wheelchair for locomotion, indwelling catheter, continent of bowel, 67 inches tall, 264 pounds, has two unstageable pressure ulcers which were not present on admission to the facility, the pressure ulcer with the largest surface area measurements are 5.5.centimeters in length, 6.3 centimeters in width with the depth unknown, necrotic tissue (eschar), black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin., were not present on prior assessment, pressure reducing device for bed, ulcer care, application of nonsurgical dressings and application of dressings to feet. -An Admission Assessment, dated 2/18/13, documented under skin condition, Resident #1 had dry skin, with swelling and bruises. The body diagram had marks on the resident ' s upper and lower back, left pinky, and both feet circled, with the word pain had written above the drawing of the feet. Nurse ' s notes on the Admission Assessment documented bruising in multiple areas throughout with complaints of pain with movement. Review of Weekly Pressure Ulcer Sheets for right heel by wound care nurse, starting on 3/4/13, documented the following: (Facility uses a Pressure Ulcer Scale for Healing), (PUSH). Total PUSH Score is then graphed on a Pressure Ulcer Healing Graph from 0 (which is healed) to a 17 (which is the worst). - 3/4/13 - Resident #1's right heel ulcer measured a length and width greater than 24 centimeters squared. Tissue type was a 2 (Granulation tissue), and exudate a 2 (moderate) with a total score on Pressure Ulcer Healing Graph was 14. - 3/5/13 - Resident #1's left heel ulcer measured a length and width greater than 24 centimeters squared. Tissue type was a 4 (necrotic tissue) and exudate a 0 (closed/resurfaced), with a total score on Pressure Ulcer Healing Graph was 14. - 3/5/13 - Resident #1's left buttock ulcer measured a length and width of 8.1 to 12 centimeters squared, tissue type was 2 (granulation tissue), and Exudate was a 1 (Light). Total score on Pressure Ulcer Healing Graph was 10. There was no documentation of any pressure ulcers from 2/18/13 until 3/4/13 when the right heel was discovered to have a pressure ulcer (13 days after admission). Review of Physician Telephone Orders documented the following: - 3/4/13 - Stage II right heel - cleanse with wound cleanser or normal saline, pat dry with gauze, apply [MEDICATION NAME], cover with foam dressing, secure with roll gauze or coban daily/PRN if becomes loose or soiled. -3/5/13 - Stage II left buttock - cleanse with wound cleanser or normal saline, pat dry with gauze, apply ca alginate ag, cover with foam dressing daily/PRN if becomes loose or soiled. -3/5/13 - unstageable - purple fluid filled blister to left heel - apply [MEDICATION NAME] daily -3/6/13 - float heels while in bed (2 days after first pressure ulcer was found). During an interview on 5-3-13 at 11:21 a.m., LVN A (Wound Care Nurse), said Resident #1 did not have any skin breakdown on admission, but his heels were soft. LVN A stated she completed skin assessments weekly on all residents. LVN A said she knew Resident #1 was compromised upon admission and was checking his heels daily but did not have any documentation the daily skin assessments were being completed. During an interview on 5/3/13 at 2:03 p.m., DON said she felt the staff did everything they could possibly do to care for Resident #1 and the heel ulcers developed after only a few days after the resident was admitted to the facility. During an interview on 5/3/13 at 2:21 p.m., LVN C said she completed Resident #1's admission assessment and at that time, he had mushy purple heels and was complaining of pain in his legs. LVN C said most of the bruising was on the heels of his feet but she did not report the bruising to the wound care nurse. During an interview on 5/3/13 at 2:53 p.m., Resident #1's PA stated he was not aware of any skin breakdown to his feet until 3/4/13. He stated if Resident #1 had skin issues on admission, staff should have alerted him. He stated the delay in treatment for [REDACTED]. The facility submitted Resident Roster, received on 5/3/13, documented a census of 55, with 3 residents with pressure ulcers.