Every finding on record at Coldwater Manor

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 freezer, refrigerator, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses. Findings included:Observation of the freezer on 08/18/26 at 9:39 AM revealed the following:1. (1) bag of meat, not labeled, date unreadable.2. (1) bag of meat, not labeled or dated.3. (2) bags of meat, label and date were unreadable.4. (1) bag frozen vegetables, not labeled.5. (2) bags of breaded meat, not labeled.6. (3) bags of what looked like sweet potatoes, not labeled. 7. (1) box of puff pastry, open to air.8. (1) box of frozen strawberries, not dated. Observation of the pantry on 08/18/26 at 9:46 AM revealed the following:1. (1) box of pinto beans, not labeled or dated.2. (1) box of lemon pepper seasoning, not dated.Observation of the refrigerator on 08/18/26 at 9:49 AM revealed the following:1. (1) bag with a head of lettuce inside, not labeled or dated.2. (1) opened bag of onions, not labeled or dated.3. (1) bag of hot dogs, label was unreadable, open to air.4. (1) bag of bacon, not in original package, not labeled or dated.During an interview on 08/18/26 at 9:52 AM, the DM stated she had worked at the facility for 2 years and it was everyone's responsibility to label and date the food in the kitchen. She stated it was ultimately her responsibility to check that everything had been labeled and dated. The DM stated if that did not happen, residents could get sick because they would not know how long the food had been there and when it should be thrown away. The DM stated she talked with staff daily about labeling and dating food and the importance of it. During an interview on 08/18/26 at 9:54 AM, [NAME] A stated she had worked at the facility for 20 years and was trained to label and date all food in the kitchen and everyone who worked in the kitchen was responsible for doing that. [NAME] A stated that if it did not happen, they would not know how long food had been stored and it could grow bacteria making residents sick.During an interview on 08/18/26 at 9:59 AM, [NAME] B stated it was everyone's responsibility to label and date food, and she was trained to do that. She stated if food was not labeled and dated properly, it could make residents sick.Record review of facility policy titled, Food Receiving and Storage, dated November 2022, revealed the following in part:Policy Statement: Foods shall be received and stored in a manner that complies with safe handling practices. Dry Food Storage:4. Dry foods that are stored in bins are removed from original packaging, labeled and dated.Refrigerated/Frozen Storage:1. All food stored in the refrigerator or freezer are covered, labeled, and dated.

Based on observation, interview, and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (Resident #7) of 12 residents reviewed for assessment accuracy.The facility failed to ensure Resident #7's MDS accurately reflected that she did not have an indwelling catheter.This failure could place residents at risk of potentially receiving unnecessary catheter-related care or monitoring or inaccurate care planning. Findings Included:Record review of Resident #7's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life), diabetes mellitus (a chronic condition where the body cannot properly control blood sugar levels), arthritis (swelling, pain, and stiffness in the joints), vitamin D deficiency (the body does not have enough vitamin D to keep the bones, muscles, and immune system healthy), hypothyroidism (a condition where the thyroid gland does not make enough thyroid hormones), allergic rhinitis (an immune system reaction that inflames the inside of the nose), hyperlipidemia (too many fats or lipids in the blood), dysthymic disorder (a long-lasting, continuous form of depression), and acute kidney failure (the sudden loss of kidney function).Record review of Resident #7's quarterly MDS, with a completion date of 07/09/2026, revealed Section H (Bladder and Bowel) was coded to indicate Resident #7 had an indwelling catheter, including suprapubic catheter or nephrostomy tube. Section H0300 (Urinary Incontinence) was coded to indicate Resident #7 was always continent. Record review of Resident #7's care plan, completed on 07/17/2026, revealed the resident has occasional bladder incontinence. The care plan directed staff to ensure the resident had an unobstructed path to the bathroom, and for staff to monitor and document any possible causes for incontinence.Record review of Resident #7's active order summary, obtained on 08/19/2026, revealed no order for an indwelling catheter.During an observation on 08/18/2026 at 10:29 AM revealed Resident #7 sitting in her room watching television. Resident #7 was clean and well groomed. No indwelling catheter was observed to be present on Resident #7.During an observation on 08/19/2026 at 1:53 PM revealed Resident #7 attending the Resident Council meeting with survey staff. Resident #7 was clean and well groomed. No indwelling catheter observed.During an interview on 08/19/2026 at 3:33 PM, the DON stated she had worked at the facility for 3 years and did not recall Resident #7 ever having an order for an indwelling catheter. The DON stated Resident #7 had resided at the facility since 2020 and may have had an order for a catheter before the DON began working at the facility; however, to her knowledge, Resident #7 had not had a catheterDuring an interview and observation on 08/19/2026 at 5:06 PM, Resident #7stated she had resided at the facility since 2020 and did not recall having a catheter. Resident #7 stated her memory was not always great and acknowledged she may have had a catheter at some point; however, to her knowledge she had not had a catheter since residing at the facility. Observation of Resident #7 during the interview revealed no indwelling catheter.During a phone interview on 08/20/2026 at 11:24 AM, the MDS Coordinator stated she worked remotely under contract with the facility and was responsible for completing MDS assessments. The MDS Coordinator stated the process for completing MDS assessments included the DON completing an evaluation/assessment of the resident and providing the information to her for entry into the MDS. She stated she then called the facility and reviewed the information with a nurse to ensure the information entered into the MDS was accurate. The MDS Coordinator stated she was traveling at the time of the interview and was unable to access her computer to review Resident #7's information related to the indwelling catheter. The MDS Coordinator stated a negative outcome of an inaccurate MDS assessment could include an effect on funding and, depending on the care area involved, could negatively affect residents. During an interview on 08/20/2026 at 11:42 AM, the DON stated the contracted MDS Coordinator was responsible for completing the MDS assessments for the residents. The DON stated the process included the DON completing an assessment of the resident and providing the information to the MDS Coordinator. The MDS Coordinator then coordinated with the DON or another nurse by telephone to review the information before the MDS Coordinator entered it into the MDS. The DON stated facility staff did not enter information into the MDS and would notify the MDS Coordinator if staff identified an error. The DON stated she did not know why Resident #7's MDS was coded to indicate an indwelling catheter and believed the item had been accidentally marked during completion of the assessment. The DON stated she was unaware Resident #7's MDS indicated she had an indwelling catheter until survey staff brought it to the facility's attention. The DON stated a negative outcome of an inaccurate MDS assessment was that the assessment would inaccurately reflect the resident's status.During an interview on 08/20/2026 at 11:49 AM, the ADM stated the contracted MDS Coordinator worked remotely and was responsible for completing MDS assessments. The ADM stated the process included the DON assessing the resident and sending the information to the MDS Coordinator for entry into the MDS. The ADM stated a negative outcome of an inaccurate MDS assessment could include improper care if staff did not have a close relationship with and understanding of residents and their needs.Record review of the facility's policy titled MDS Assessment Coordinator and dated November 2019 revealed Policy Interpretation and Implementation 2. The resident assessment coordinator must date and sign each assessment (MDS) to certify that the assessment has been completed. 3. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by: a. dating and signing the assessment (MDS); and b. identifying each section completed. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: SECTION H: BLADDER AND BOWEL H0100: Appliances Steps for Assessment1. Examine the resident to note the presence of any urinary orbowel appliances.2. Review the medical record, including bladder and bowelrecords, for documentation of current or past use of urinaryor bowel appliances.Coding InstructionsCheck next to each appliance that was used at any time in thepast 7 days. Select none of the above if none of the appliancesA-D were used in the past 7 days. H0100A, indwelling catheter (including suprapubiccatheter and nephrostomy tube)

Based on observation, interview, and record review, the facility failed to maintain personal privacy and confidentiality of residents personal and medical records for 2 out of 2 unidentified residents.The facility failed to ensure that protected health information, personal identifiers, and clinical medical charts were adequately safeguarded against unauthorized viewing, public disclosure, or casual verbal sharing by staff members on 08/18/2026 at 11:30 AM and 11:58 AM.This failure could result in a breach of personal privacy, lead to medical identity theft, or cause emotional distress and humiliation to the residents due to the unauthorized exposure of their private medical history and diagnoses.Findings Included:During an observation on 08/18/2026 at 11:30 AM of a medication pass on medication cart A, RN E was observed walking away from the medication cart to administer medications. The cart's binder containing paper Medication Administration Record (MAR) was left active and unsecured, visibly displaying the MAR and private clinical details of a resident. At the time of this observation, the medication cart was positioned in the hallway in the front of the building next to the nurses' station and the dining room exposing the MAR record which contained residents' names, dates of birth, medical record numbers, and medications prescribed to residents to anyone passing through the corridor. During an observation on 08/18/2026 at 11:58 AM, RN E was observed walking away from medication cart A a second time to administer medications to a resident. The binder was again left fully open, publicly displaying residents' private MAR information. During an interview on 08/19/2026 at 4:50 PM, RN E stated that to ensure patient confidentiality as maintained staff should close all computer screens, the MAR book, and make sure no information was left out in the open for other residents and families to see. RN E stated that training for HIPAA as done upon hire during the onboarding process, annually on the computer through the facility's computer-based training system, and through in-service trainings conducted by the DON. RN E stated a negative outcome of not keeping resident information secured is HIPAA information can be displayed which violates a resident's confidently and that a family member or resident could see the information about them they aren't supposed to know. During an interview on 08/19/2026 at 4:57 PM, CNA D stated that confidentiality as making sure laptop computers were closed and papers were turned over. CNA D stated training was done upon hire with onboarding and monthly through computer-based training. CNA D stated that a negative outcome would be that it could show personal conditions and things that they might have diagnosis of and could cause the resident to be embarrassed. During an interview on 08/19/2026 at 4:59 PM, the ADON stated that she worked for 1 year as the ADON and worked in the in the facility since 2020. The ADON stated that staff should make sure that everything stayed confidential when they were talking about residents, log out of computers, and turn papers over. Additionally, the ADON stated that when staff made calls they should speak softly and make sure no one else was around and discuss any health issues in the resident's room. The ADON stated that training for new employees are done during orientations, monthly, and when something happens through in-services completed by DON and ADON. ADON stated that a negative outcome could be that it could affect the resident's dignity, not protecting privacy, and the resident could be ashamed or embarrassed. During an interview on 08/19/2026 at 5:04 PM, the DON stated that she worked in the facility for three and a half years. She stated that to maintain confidentiality all staff should lock their computer screens, close MARs, don't give out information, and turn the clip boards over. She stated that training was done upon hire at onboarding and on their computer-based system annually. The DON stated that a negative outcome to the residents was their protected information could be seen by people that don't need to be seeing it. During an interview on 08/19/2026 at 5:35 PM, LVN C stated that to ensure resident confidentiality was maintained the MAR book should be closed, any clip boards are turned upside down, and all computers are logged out. Additionally, LVN C stated that residents should never discuss outside of the facility. LVN C stated that training for confidentiality as completed on the facility's computer-based education system once a month and upon hire and that the DON as responsible for ensuring it was done. LVN C stated that a negative outcome for the resident could be someone could use the resident's information in a negative way and open the resident up to safety issues such as identity theft.Record review of facility's employee handbook dated November 2021 revealed the following: Due to the Health Insurance Portability and Privacy Act (HIPAA), employees will not disclose any person health or financial information of which they have knowledge regarding residents which come into their possession as a result of their employment with [NAME] Hospital District]. Every employee is expected to maintain strict confidence concerning these matters and to refrain from discussing them inside/outside of the facility except on a need-to-know basis. Record review of facility's policy entitled Statement of Resident Rights no date revealed the following, You have a right: to have the information about you maintained as confidential.

Based on observation, interview, and record review, the facility failed to give residents drinks, including water and other liquids consistent with resident needs and preferences (Resident #1). The facility failed to ensure LVN C gave Resident #1 honey thickened liquids during med pass, as ordered, on 08/19/2026 at 1:53 PM which resulted in the resident coughing.This failure could result in residents coughing, choking, aspirating (the action of drawing fluid by suction) thin fluids into her lungs, contracting aspiration pneumonia (an infection of the lungs).Findings Included:Record review of Resident #1's admission record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dementia (memory loss), psychotic disturbance (a mental state where a person loses touch with reality), mood disturbance, anxiety, chronic pulmonary disease (a condition of the lungs that affects the airway and lung tissue that causes difficulty breathing), atherosclerotic heart disease (thickening, hardening, and loss of elasticity in the walls of the arteries), asthma, bradycardia (slow heart rate), atrial fibrillation (irregular heart rhythm where the heart's upper chambers beat fast and out of sync with the lower chambers), repeated falls, dizziness, vitamin D deficiency (lower than normal vitamin D levels), hyperglyceridemia (high blood sugar), insomnia (difficulty sleeping, chronic pain, hypertension (high blood pressure), constipation, and edema (swelling).Record review of Resident #1's quarterly MDS assessment completed on 05/22/26 revealed a BIMS score of 7 out of 15 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #1 was partially/moderately dependent on staff for toileting, bathing, and dressing and required setup assistance for eating.Record review of Resident #1's care plan completed on 06/01/26 revealed she had an ADL self-care performance deficit requiring partial to moderate assistance, resident is at risk for behaviors and cognitive impairment due to dementia, and resident is at risk for falls.Record review of Resident #1's orders revealed an active order started 08/11/2026 for honey consistency thickened liquids.During an observation on 08/19/2026 at 1:53 PM during a medication pass with LVN C, after giving medications, LVN C gave Resident #1 a cup of water from the water pitcher that was on the medication cart. The water did not have any thickener in it. Resident #1 started coughing and choking on the water.During an interview on 08/19/2026 at 4:54 PM, RN E stated that following an order when a resident was on thickened liquids was important, so the resident did not choke. RN E stated that a negative outcome could be the resident could choke and aspirate and aspiration could lead to pneumonia. During an interview on 08/19/2026 at 4:57 PM, CNA D stated that if a resident was on thickened liquids and they needed water that she would get the nurse to assist in getting the correct consistency. CNA D stated that a negative outcome could be that the resident could choke on the thin liquids.During an interview on 08/19/2026 at 4:59 PM, the ADON stated that she worked for 1 year as the ADON and worked in the in the facility since 2020. The ADON stated that not giving a resident thickened liquids when it was ordered could cause aspiration and choking and that could lead to the resident getting pneumonia and the to become really ill. During an interview on 08/19/2026 at 5:07 PM, the DON stated that she worked in the facility for three and a half years. The DON stated that Resident #1 was on thickened liquids due to episodes of choking. The DON stated that a negative outcome for the resident not to receive thickened liquids as ordered could be that the resident choked which could cause aspiration and the resident to get pneumonia. The DON stated that training for staff was completed when the diet was updated. She made sure that everyone was aware and that the nurses were checking meal trays and passed on in report to the next shift.During an interview on 08/19/2026 at 5:35 PM, LVN C stated that thickened liquids were checked when on the dietary meal trays before they were sent out and that the nurses follow up with rounds to ensure the proper thickness is completed. LVN C stated that a negative outcome could be choking and aspirating which could lead to them getting pneumonia. Record review of the facility's policy entitled Therapeutic Diets dated October 2017 revealed the following: Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. On 08/20/2026 at 9:15 AM the surveyor requested a policy more related to thickened liquids. The ADON stated she would look and get back with surveyor. No additional policies were given.

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 food and nutritional services, when they failed to: A. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings include: In an observation and interview on 6/16/25 at 12:00 pm, [NAME] A was observed in the kitchen with gloved hands serving the noon meal. [NAME] A changed her gloves, touched various kitchen surfaces, picked up a plate and the serving utensils. [NAME] A plated the food then used her gloved hand and picked up a roll. [NAME] A set the plate on the counter then picked up another plate. [NAME] A did not make any attempts to change her gloves or wash her hands. [NAME] A was asked if she realized she had touched the bread without changing her gloves. [NAME] A did not speak English well and just looked at this writer. The DM explained to [NAME] A what had happened. [NAME] A nodded. In an observation and interview on 6/16/25 at 12:05 pm, [NAME] B touched various kitchen surfaces, walked to the tray cart, picked up a tray with both gloved hands, set the tray on the counter, touched the tray ticket, picked up a plate, picked up the serving utensils and plated the food. [NAME] B then used her gloved hands to pick up a roll from the muffin tin. [NAME] B picked up a knife to loosen the rolls from the pan and touched the rolls and the pan with her gloved hands. [NAME] B then went to the window and placed the tray of food in the window. [NAME] B picked up a new tray and took the tray to the serving table. [NAME] B did not make any attempts to change her gloves or wash her hands. [NAME] B stated the roll was stuck to the pan. The DM stated tongs should be used to serve bread. In an interview on 6/18/25 at 8:50 am, the DM stated she expected staff to use tongs when touching food and she expected gloves to be changed as the tasks change and she expected hands to be washed when changing tasks. The DM stated both [NAME] A and [NAME] B were not supposed to touch the food and should have used utensils and should have washed hands and changed gloves between tasks. The DM stated the consequences of not washing hands and changing gloves would be risk of food borne illness. The DM stated she trained the staff in hand washing and glove use and expected all staff to wash hands and change gloves between tasks. The DM stated there was no policy on using tongs for serving food. Record Review of the facility policy dated November 2022, titled Preventing Food Borne Illness-Employee Hygiene and Sanitary Practices documented: Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #8, #17, and #18) of 15 residents reviewed for advanced directives. Residents #8, #17, and #18 had a DNR in their records that was missing the date when the notary signed the form. The facility's failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Resident #8: Record review of Resident #8's face sheet printed [DATE] revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #8 was listed as a DNR. Record review of Resident #8's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS score of 09 indicating she was moderately cognitively impaired, and she had a functionality of being dependent on staff for most of her activities of daily living. Record review of Resident #8's care plan with admission date of [DATE] revealed the following: Focus: -Resident had a DNR in her chart. Goal: -Resident and family wishes will be honored over the next 90 days. Intervention/Tasks: -If resident found not breathing, do not perform CPR, notify nurse, physician, and family. -Revision [DATE]. Record review of the clinical record for Resident #8 revealed an Order Summary Report with active orders as of [DATE] with the following order: -DNR - Active [DATE]. Record review completed on [DATE] at 12:09 PM of the clinical record for Resident #8 revealed a DNR dated [DATE] (signed by the physician) with the following: Section - Two Witnesses - Notary in the State of Texas and County of Sherman - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form. Resident #17: Record review of Resident #17's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions). Resident #17 was listed as a DNR. Record review of Resident #17's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS that could not be evaluated due to short- and long-term memory problems, and she had a functionality of being dependent for most of her activities of daily living. Record review of Resident #17's care plan with admission date of [DATE] revealed the following: Focus: -Resident had a DNR in her chart. Goal: -Resident and family wishes will be honored over the next 90 days. Intervention/Tasks: -If resident found not breathing, do not perform CPR, notify nurse, physician, and family. -Revision [DATE]. Record review of the clinical record for Resident #17 revealed an Order Summary Report with active orders as of [DATE] with the following order: -DNR - Active [DATE]. Record review completed on [DATE] at 12:12 PM of the clinical record for Resident #17 revealed a DNR dated [DATE] (signed by the physician) with the following: Section - Two Witnesses - Notary in the State of Texas and County of Sherman - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form. Resident #18: Record review of Resident #18's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Resident #18 was listed as a DNR. Record review of Resident #18's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS of 06 indicating she was severely cognitively impaired, and she had a functionality of being dependent for most of her activities of daily living. Record review of Resident #18's care plan with admission date of [DATE] revealed the following: Focus: -Resident had a DNR in her chart. Goal: -Resident and family wishes will be honored over the next 90 days. Intervention/Tasks: -If resident found without spontaneous respirations, do not initiate CPR, notify nurse, physician, and family. -Revision [DATE]. Record review of the clinical record for Resident #18 revealed an Order Summary Report with active orders as of [DATE] with the following order: -DNR - Active [DATE]. Record review completed on [DATE] at 12:02 PM of the clinical record for Resident #18 revealed a DNR dated [DATE] (signed by the physician) with the following: Section - Two Witnesses - Notary in the State of Texas and County of Sherman - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form. During an interview on [DATE] at 12:47 PM LVN C (the nurse responsible for Resident #8, #17, and #18 this shift) and LVN D both reported if a staff member reported to them that a resident was not breathing or had no heart beat they would verify the residents condition and if they that resident was in the process of coding (no heart beat or respirations) they would review the resident chart to verify if the resident was a DNR code status. LVN C and LVN D both reported that if the resident was a DNR they would not start CPR then contact the physician, DON, and Administrator. They reviewed Resident #17's chart, found her DNR, and reported that Resident #17 was a DNR and therefor they would not start CPR. When asked to review Resident #17's DNR to see if the form was complete, both LVN C and LVN D reviewed Resident #17's DNR form and verified that the notary did not date their signature and therefore the DNR was not valid. LVN C and LVN D reported that they would get the code status corrected immediately and complete a new DNR form for Resident #17. LVN C and LVN D reviewed Resident #8 and Resident 18's DNR forms, verified both forms did not have a date of when the notary signed the form and both DNR forms were invalid also. LVN C and LVN D reported that they would have to treat all three residents as if they were a full code which would mean that the resident wishes would not be carried through. LVN C and LVN D verified that N E (who was the notary that signed for Resident #8 and #17's DNR forms) was the former Business Office Manager and no longer worked for the facility. During an interview on [DATE] at 08:45 AM the DON reported that she had been made aware of Resident #8, #17, and #18 DNR's that the notary did not date their signatures. The DON reported that she was not sure if this made the form invalid or not but if the form was invalid then staff could possibly perform CPR on a resident that may or may not have wanted it which would affect that residents care. The DON reported that she personally checked the residents DNR's at least every 3 months and that she just missed these. During an interview on [DATE] at 09:23 AM the BOM (the notary for the facility) verified that she was a notary and that she was the notary for Resident #18's DNR. The BOM reported that she did forget to date Resident #18's DNR and that if a notary forgot to date a DNR then that DNR was invalid until it was properly completed. BOM reported that if the DNR was not valid then staff would not follow the order/DNR as it should be. She verified that the notary did not date Resident #8's and Resident #17's DNR and reported that the notary for both Resident #8 and #17 no longer worked for the facility, that she (the current BOM) had taken the previous notary's place when she resigned. Record review of the facility provided policy titled Advanced Directives undated, revealed the following: Policy Statement: The resident has the right to formulate and advance directive . Advance directives are honored in accordance with state law and facility policy. Determining Existence of Advance Directives: 4. Written information includes a description of the facility's policies to implement advance directives and applicable state law. -there was no information provided in the Advanced Directives policy about ensuring the Advanced Directive was fully and properly completed. A copy of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES form was provided with the policy. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES undated, revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on interview and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service of 2 of 3 confidential residents interviewed. The facility did not deliver unopened mail for 2 of 3 resident interviewed during a confidential group interview. This failure could affect residents personal privacy and could result in decreased quality of life. Findings included: During a confidential group interview on 06/17/2025 at 2:00 PM two of three residents identified by the facility as being alert, oriented, and interview able, revealed that their mail was delivered open by the activity director. One confidential resident stated he had his mail opened twice and one confidential resident stated she had a card from her church opened once. Two of the three residents stated they would like their mail to be unopened when it was delivered. In an Iinterview on 06/17/2025 at 2:47 PM, the AD stated that she did not like carrying the big letter opener throughout the facility because of safety issues so at times she would open the mail before delivering it. The AD said a possible negative outcome for not opening mail in the presence of the resident would be if something in the mail comes up missing, she could be blamed. In an interview on 06/17/2025 at 2:54 PM, the DON stated the BOM and AD were the staff responsible for getting the mail and delivering it to the residents. The DON stated the ADM was the one responsible for ensuring the BOM and AD and all staff were responsible for ensuring privacy for residents and a negative outcome for opening mail without permission from the resident would be invasion of the resident's privacy. In an interview on 06/18/2025 at 8:55 AM, the BOM stated that she had worked at the facility for about six months, and she was responsible for picking up the mail from the post office, bringing it back to the facility, and putting it in the AD's office area. The BOM stated she had not seen the AD open the mail prior to delivering it, but the AD was the one responsible for delivering the mail to each resident. The BOM stated that a possible negative outcome for opening mail outside the presence of a resident would be a violation of privacy. The BOM stated the ADM was responsible for ensuring her staff was aware of resident rights. In an interview on 06/18/2025 at 10:39 AM , the ADM stated that she was notified of his violation and that she was working on educating the AD. The ADM stated this was a resident rights issues and an invasion of privacy. The ADM stated she was working with the AD and stated that it did not matter what cognition level the resident had, it was their right to open their own mail, and if they needed or wanted her help, then it needed to be in their presence and requested each time mail was received. Record Review of the facility's Residents' Rights Policy located in the admission Packet dated November 2021 revealed the following: Privacy and Confidentiality: You have the right to: Send and receive unopened mail and to receive help in reading or writing correspondence.

Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the medication room) of 2 medication storage areas reviewed for medication storage. The medication room refrigerator had medications that had been stored outside of the recommended storage temperatures. The facility's failure could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings included: Record review of the medication room's only refrigerator log for May 1, 2025, to June 17, 2025, revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 05/08/25 - 35 degrees Fahrenheit 05/09/25 - 32 degrees Fahrenheit 05/11/25 - 32 degrees Fahrenheit 05/16/25 - 34 degrees Fahrenheit 05/17/25 - 34 degrees Fahrenheit 05/18/25 - 32 degrees Fahrenheit 05/19/25 - 32 degrees Fahrenheit 05/20/25 - 32 degrees Fahrenheit 05/21/25 - 32 degrees Fahrenheit 05/22/25 - 34 degrees Fahrenheit 05/23/25 - 34 degrees Fahrenheit 05/24/25 - 34 degrees Fahrenheit 05/25/25 - 34 degrees Fahrenheit 05/26/25 - 32 degrees Fahrenheit 05/27/25 - 34 degrees Fahrenheit 05/28/25 - no temperature check completed. 05/29/25 - 34 degrees Fahrenheit 05/30/25 - 32 degrees Fahrenheit 05/31/25 - 30 degrees Fahrenheit 06/01/25 - 34 degrees Fahrenheit 06/02/25 - 34 degrees Fahrenheit 06/04/25 - 32 degrees Fahrenheit 06/05/25 - 32 degrees Fahrenheit 06/06/25 - 34 degrees Fahrenheit 06/08/25 - no temperature check completed. 06/09/25 - no temperature check completed. 06/10/25 - no temperature check completed. During an observation on 06/17/25 at 09:33 AM of the medication room completed with LVN C the following was noted in the medication room refrigerator: 1. 1 - Timolol eye drop solution filled 6-5-2025. Manufacturer recommended storage temperature was between 59 degrees Fahrenheit to 77 degrees Fahrenheit. 2. 1 - Novolog Insulin Vial filled 6-3-202. Manufacturer recommended storage temperature for unopened Novolog insulin vials was between 36 degrees Fahrenheit to 46 degrees Fahrenheit. 3. 2 - Lantus Insulin Pens filled 5-5-2025. Manufacturer recommended storage temperature for unopened Lantus insulin pens was between 36 degrees Fahrenheit to 46 degrees Fahrenheit. 4. 4 - Humalog Insulin Pens filled 5-8-2025. Manufacturer recommended storage temperature for unopened Humalog insulin pens was between 36 degrees Fahrenheit to 46 degrees Fahrenheit. 5. 3 - Lantus Pens filled 6-16-2025. Manufacturer recommended storage temperature for unopened Lantus insulin pens was between 36 degrees Fahrenheit to 46 degrees Fahrenheit. 6. 1 - Humalog insulin Pen filled 10-4-2024. During an interview on 06/17/25 at 09:40 AM LVN C verified each medication stored in the medication room refrigerator and the dates each medication was filled. LVN C reported that a medication stored at 32 degrees or less would be considered freezing. LVN C reviewed the temperature log for the medication room refrigerator from 5-1-2025 to 6-17-2025 and noted several temperatures documented at 32 degrees of less and several missing temperature checks. When asked if this was an issue, LVN C stated, Oh yes, definitely. It will freeze the liquid solution. LVN C reported that if a resident received a medication that was not stored properly then they could have a reaction to the medication, or the medication would not be effective for their treatment such as if they have a high blood sugar then the medication would not do anything for their condition. During an interview on 06/18/25 at 08:50 AM the DON reported that the staff had made her aware of the issue with the medications being stored improperly in the medication room refrigerator and that she did not think it was an issue because she was in and out of that refrigerator often and she had never seen any of the medications frozen. The DON reported that 32 degrees was considered a freezing temperature. The DON reported that if a medication was stored outside of recommended storage temperature ranges, then that could affect the medications efficiency and it may not have the desired effect on the resident's care. Record review of the facility provided policy titled Medication Labeling and Storage undated, revealed the following: Policy Statement: The facility stores all medications and biologicals in locked compartment under proper temperatures .

Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 16 residents (Resident #18) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #18 for the use of oxygen on her 06/04/25 quarterly MDS. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Record review of Resident #18's face sheet printed 06/16/25 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #18's last MDS was a quarterly assessment completed 06/04/25 listing her with a BIMS of 06 indicating she was severely cognitively impaired, and she had a functionality of being dependent for most of her activities of daily living. Section O - Special Treatments, Procedures, and Programs: Resident #18 was not listed for Oxygen Therapy while a resident. Record review of Resident #18's care plan with admission date of 03/03/25 revealed the following: Focus: -The resident has oxygen therapy. - Date initiated 03/25/25. Record review of the clinical record for Resident #18 revealed an Order Summary Report with active orders as of 06/17/25 with the following order: - Continuous Oxygen @ 2LPM via NC to keep sats greater than 90%, humidify PRN every day and night shift. Start Date: 03/03/25. During an observation on 06/16/25 at 10:14 AM Resident #18 was in her bed sleeping restlessly with her oxygen on set a 2L/min via NC. Resident #18 awoke to knocking. Resident #18 reported no issues with her oxygen and that staff provided all care related to her oxygen. During an interview on 06/18/25 at 08:59 AM the DON reported that she was responsible for completing all resident MDS's. The DON reviewed Resident #18's chart and verified that Resident #18 was on oxygen per her orders and care plans. The DON reviewed Resident #18's 6/04/25 quarterly MDS and reported that the MDS did not address Resident #18's use of oxygen. The DON reported that she just missed it. and it would have to be corrected. The DON reported that a MDS not accurately reflecting the resident's condition and care could result in the resident not receiving the care that they were required to have. The DON reported that the facility followed the RAI manual for all MDS related issues. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the last 14 days or since admission/entry or reentry, check Z, None of the above. o O0110C1, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes their own oxygen mask, cannula.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The facility did not have an RN in the facility on 4/5/25, in the 5 past months. 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: Record review 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 4/5/25. During an interview on 6/17/25 at 10:15 am, the ADM stated she had only been at the facility for 3 weeks and was not aware of the RN coverage until now. She stated it was one day and the DON had surgery. The ADM stated the consequences of not having RN coverage were that it was against federal guidelines and that the facility needed to have an RN on duty every day. She stated she could not see any grave consequences or impact to residents by not having RN coverage for I day. During an interview on 6/17/25 at 11:15 am, the DON stated there was probably no RN coverage that day. She stated she had been out for surgery during that time period and had not been able to monitor the schedule. She stated if she was not there to monitor the schedule, it got missed. She stated the consequences of not having RN coverage would have been possible poor care for residents. Record review of facility presented Time Clock- In and Out information revealed the facility had no RN coverage for 4/5/25. Record review of facility policy dated August 2022, titled, Departmental Supervision revealed a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure stored food was properly labelled and dated. The facility failed to discard leftover food by use by date on the label. These failures could place residents at risk of food borne illness. Findings included: An observation on [DATE] at 09:30 AM of shelving in the kitchen revealed the following: A plastic lidded tub of what appeared to be heart-shaped cereal with no label and no date. A plastic lidded container of whipped vanilla frosting with an open date of [DATE]. The lid was ballooning up as if pressure was inside the container. The manufacturer's instructions read to cover and refrigerate for up to 30 days after opening. A resealable plastic bag containing ,d+[DATE] bread-like objects in roundish asymmetrical shapes approximately ,d+[DATE] inches in diameter with no label or date. An observation on [DATE] at 09:33 AM of the walk-in refrigerator revealed the following: An open bottle of yellow electrolyte drink ,d+[DATE] full with no open date. A pitcher approximately ,d+[DATE]th full of cloudy, yellowish liquid labelled pineapple juice and dated [DATE]. 3 whole heads of lettuce no date. 1 partial head of what appeared to be lettuce wrapped in plastic wrap no date. 1 partial head of lettuce in original packaging open to air with brown slimy substance on packaging and a cut edge of lettuce. Cardboard box of tomatoes with no date. One tomato of several visible in the box had a brownish caved in area the size of a $.50 piece. Round plastic lidded container labelled as whole tomatoes half full of red liquid open to air as the lid was warped and not sealed. Round plastic lidded container labelled as cherry pie filling with the following dates [DATE] and [DATE]. Non-dairy whipped topped in original plastic bag packaging, half full. The end of the bag was not secured, open to air. Cheese slices with the following dates [DATE] and [DATE]. An observation on [DATE] at 09:48 AM of freezers revealed the following: Box of pork sausage with no date. Box of tilapia with no date. 6 pies with no date 1 bag of round cream-colored objects approximately 2 inches in diameter with no label or date. Box of individual ice cream cups no date. Bag of round white disks approximately ,d+[DATE] inch thick and ,d+[DATE] inches across with no label or date. Box of pizza with no date. Box of waffles with no date. Box of meat with no date. During an interview on [DATE] at 09:34 AM ADM stated they do not have any kitchen policies regarding food labelling, storage, and leftovers. During an interview on [DATE] at 12:36 PM DM stated she did not have food policies. She said she followed the Texas Food Establishment Rules regarding food storage. She stated she had verbal trainings with her staff almost every day but did not have any written copies of the trainings or sign in sheets for trainings. DM stated she had trouble with her staff remembering to label and date food appropriately. She stated leftover food was to be thrown away in 3 days to keep residents from getting sick. DM stated she has trained her staff to label food and date it the day it was made and the day it needed to be thrown out. She stated food in the freezers should be labelled with the date received on the case and on any individual packages taken out of the case. During an interview on [DATE] at 08:44 AM DM stated residents could get sick if food was stored without correct labels, dates, refrigeration or if food is not thrown out when scheduled. She said, They (residents) can get sick if we serve it to them and don't know when we put it in there (refrigerator). During an interview on [DATE] at 08:46 AM DS stated leftover food was to be labelled and dated with the day it was made and three days after. She stated the food should be thrown out 3 days after it was made. She stated residents could get sick if food was not labelled and dated correctly. DS stated she had been trained to label food with the date cooked and the date it needed to be taken out of the freezer or refrigerator. She stated she was trained to date cases of food on the day they were received from the truck. Record review of facility policy titled Foods Brought by Family/Visitors and dated [DATE] revealed the following: . 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Record review of facility policy titled Refrigerators and Freezers and dated [DATE] revealed the following: . 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Record review of the undated pages of the Texas Food Establishment Rules provided by DM revealed the following: . A date marking system . may include: . marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . or discarded . Food packaged in a food establishment, shall be labeled . Label information shall include: (A) the common name of the food, or absent a common name, an adequately descriptive identity statement; .

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #13) of 9 residents reviewed for advanced directives in that: Resident #13 had a DNR in her record with no physician information. This failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Record review of Resident #13's face sheet printed [DATE] revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (a group of thinking and social symptoms that interferes with daily functioning), aortic valve deficiency (condition in which the heart's aortic valve does not work properly), cardiac arrythmias (improper beating of the heart, whether irregular, too fast, or too slow), and atherosclerosis (a buildup of fat, cholesterol, and other substances in the artery walls). Section Advance Directives listed Resident #13 as a DNR (Do Not Resuscitate). Record review of Resident #13's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS score of 8 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up to touch assistance with activities of daily living. Record review of Resident #13's care plan with admitted [DATE] revealed the following: Focus: Resident has a DNR on chart. Date initiated [DATE]. Goal: Resident and family wishes will be honored for the next 90 days and ongoing. Date initiated [DATE]. Target date [DATE] Interventions: If resident is found no breathing, do not do CPR . Date initiated [DATE]. Revision on [DATE]. Record review of the clinical record for Resident #13 revealed an Order Summary with active orders as of [DATE] with the following order: DNR (with an order date of [DATE]) Record review of the clinical record for Resident #13 revealed a DNR dated [DATE] (signed by Declaration of the adult person) with the following: Section: Physician's Statement-there is no physician signature, no date for the physician's signature, no printed signature, and no license number. Section: All persons who have signed above must sign below, acknowledging that this document has been completed-there is no attending physician signature. During an interview on [DATE] at 02:50 PM RN A and LVN B both reported all residents in the facility were currently DNR's except for one resident which was not Resident #13 so Resident #13 was currently a DNR. RN A reported that Resident #13 was a DNR which meant that if Resident #13 was to be found not breathing or without a heartbeat they would not perform resuscitative measures and keep her comfortable. LVN C agreed with RN A. Both reported that they would notify the residents family member and the physician. RN A then checked Resident #13's DNR and was unable to find the physicians information. Then RN A asked LVN C to check Resident #13's DNR form. LVN C was also unable to find any physician information on Resident #13's DNR form. RN A and LVN C reported that due to the physician not signing the DNR form for Resident #13 the DNR was invalid and since the resident was currently stable, they would get the form corrected immediately and hope that Resident #13 did not have a decline in her condition but if Resident #13 did have a change in her condition Resident #13 would be considered a full code. During an interview on [DATE] at 12:56 PM AC C reported that the DNR part of resident care was not her department, that nursing takes care of the DNR process. AC C reported that the DNR was not her responsibility. During an interview on [DATE] at 08:51 AM the DON reported that when a resident code's all staff were to verify the code status on the front of the residents MAR and then handle the situation properly. The DON reported that AC C was to verify all paperwork to include the DNR when a resident was admitted and that she (the DON) verifies the DNR's accuracy. The DON reported that with Resident #13's DNR form, it had so many signatures with both witnesses and the notary that the physician section was just missed, it fell through the cracks. The DON reported that the social worker verifies the DNR with each care plan meeting each quarter and that the social worker recently resigned, and their new social worker has not had time to learn the new process. The DON reported that if a DNR was not correctly completed it would be invalid and it would mean the resident would need to be resuscitated (have CPR started) and would be revived. The DON reported that there would be a potential for the resident to be harmed. Record review of the facility provided policy titled Advanced Directives Policy and Procedures undated, revealed the following: It is the policy of the facility to include elements and component that have an impact on the resident's health care in accordance with state law. .the facility will comply with the requirement of state law governing Advance Directives. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchens when they failed to: A. Ensure stored food were properly labeled and dated. B. Ensure that frozen foods were properly labeled and dated C. Ensure that expired foods were not in the pantry, refrigerator, and freezer. These failures could place residents who ate the food at risk for food-borne illness. Findings include: Observation of the refrigerator on [DATE] at 10:00AM revealed the following: 1. Thousand Island dressing opened [DATE] with expiration date [DATE]. 2. 1 gallon of vanilla extract with expiration date [DATE]. 3. 1 gallon of BBQ Sauce with expiration date [DATE]. 4. 1 open 8oz Boost nutritional drink which was not dated. 5. ,d+[DATE] bell pepper in a clear plastic bag which was not dated. 6. 1 2-pound bag of carrots which was not dated. 7. 1 clear bag of cilantro which was not dated. 8. 2 large bags of celery which were not dated. 9. 1 open 12oz. bottle of orange Gatorade, ,d+[DATE] full, which was not dated. Observation of the walk-in pantry on [DATE] at 10:30am revealed the following: 1. 1 Food Service box curly lasagna noodles, which was open to the air and not dated. 2. 1 Food Service bag of Navy Beans opened [DATE] with a best by date of [DATE]. 3. 2 12oz. bottles Balsamic vinaigrette with best by date of [DATE]. 4. 1 Food Service bottle [NAME] food coloring with expiration date of [DATE]. 5. 1 Food Service bottle light corn syrup, open and sitting on pantry shelf, with label which states, Refrigerate After Opening. 6. 1 open Food Service bottle Worchester Sauce, not dated. 7. 1 Food Service bottle red wine vinegar with expiration date of [DATE] and open date of [DATE]. 8. 1 Food Service container unsweetened baking cocoa opened [DATE] with expiration date of [DATE]. Observation of the freezer on [DATE] at 2:00PM revealed the following: 1. One large food service bag of hushpuppies, open to air, not dated. 2. One large food service bag of bread sticks, open to air, not dated. 3. One large food service bag of frozen spinach, open, not dated. 4. One food service bag of frozen cheddar cheese shreds, open, not dated 5. One food service bag of frozen hashbrowns, open, not dated 6. On food service bag of Mozzarella cheese shreds with expiration date of [DATE] 7. One food service box of crinkle cut French Fries with expiration date of [DATE] In an interview on [DATE] at 2:30PM, the Dietary Manager states that all kitchen staff are responsible for keeping the pantry area clean. Staff are trained in making sure expired food is thrown away and in keeping the pantry clean. Dietary manager states the negative outcome of having expired food in pantry is that it can attract bugs or ants. DM states that they do not have a policy and procedure book but follow the Texas Food Establishment Rules dated [DATE]. In an interview on [DATE] at 9:00 am, the Administrator states that they do not have a policy and procedure book but uses the Texas Food Establishment book that the DM has in her office. Administrator states that in the last six months of QAPI meetings they have not discussed any kitchen issues and that no residents have gotten sick due to expired foods.

Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months (92 days) for 13 of 16 residents (Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #17, and Resident #19) whose records were reviewed. The facility failed to complete an assessment (MDS) for residents Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #17, and Resident #19 at least once every 3 months (92 days). This failure could lead to the facility being unable to identify residents' preferences, needs and functional abilities, which could place them at risk of receiving inappropriate care or not receiving necessary care for their condition(s). Findings Include: Record review conducted on 01/27/2022 of Resident #2's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #2's most recently completed MDS assessment, dated 10/13/2021, revealed that the assessment was completed on 10/13/2021, 107 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #3's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #3's most recently completed MDS assessment, dated 09/15/2021, revealed that the assessment was completed on 09/15/2021, 135 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #4's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #4's most recently completed MDS assessment, dated 09/15/2021, revealed that the assessment was completed on 09/15/2021, 135 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #6's face sheet, dated 12/01/2021, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #6's most recently completed MDS assessment, dated 10/13/2021, revealed that the assessment was completed on 10/13/2021, 107 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #7's face sheet, dated 12/01/2021, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #7's most recently completed MDS assessment, dated 09/15/2021, revealed that the assessment was completed on 09/15/2021, 135 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #8's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #8's most recently completed MDS assessment, dated 10/26/2021, revealed that the assessment was completed on 10/26/2021, 94 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #10's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #10's most recently completed MDS assessment, dated 10/13/2021, revealed that the assessment was completed on 10/13/2021, 107 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #12's face sheet, dated 12/01/2021, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #12's most recently completed MDS assessment, dated 09/22/2021, revealed that the assessment was completed on 09/22/2021, 128 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #13's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #13's most recently completed MDS assessment, dated 08/18/2021/2021, revealed that the assessment was completed on 08/18/2021, 163 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #14's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #14's most recently completed MDS assessment, dated 10/20/2021, revealed that the assessment was completed on 10/20/2021, 100 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #15's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #15's most recently completed MDS assessment, dated 10/20/2021, revealed that the assessment was completed on 10/20/2021, 100 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #17's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #17's most recently completed MDS assessment, dated 10/20/2021, revealed that the assessment was completed on 10/20/2021, 100 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #19's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #19's most recently completed MDS assessment, dated 09/08/2021, revealed that the assessment was completed on 09/08/2021, 142 days prior to the day of the record review. During an interview on 01/27/2022 at 9:39 AM, DON reported that she was responsible for resident MDS assessments and that an MDS assessment should be completed on every resident at least every 12 weeks, or 92 days. DON reported that all facility resident MDS assessments were currently past due except for 5 of them because I'm not able to do all the things that I need to do and that there's too much stuff to do. DON reported that MDS assessments are completed to identify conditions that might require intervention, including possible changes in condition, and that not completing them on time could cause them to miss something. Record review of facility provided policy titled Resident Assessment Instrument, dated April 2010, revealed in part: Policy Interpretation and Implementation 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: c. at least quarterly;

Based on interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 of 16 residents (Resident #71) whose records were reviewed. Resident #71 had been admitted longer than 14 days and no comprehensive (MDS) assessment had been completed for him. This failure could lead to the facility being unable to identify residents' preferences, needs and functional abilities, which could place them at risk of receiving inappropriate care or not receiving necessary care for their condition(s). Findings Include: Record review of Resident #71's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of the assessments section of Resident #71's chart revealed that there were no MDS assessments on file or completed for the resident. During an interview on 01/27/2022 at 9:39 AM, DON reported that she was responsible for completing MDS assessments and that an admission MDS should be completed for every resident within 14 days of their admitted . DON reported that no MDS assessment had been completed for Resident #71 yet even though he was admitted over 14 days ago because I'm not able to do all the things that I need to do and that there's too much stuff to do. DON reported that MDS assessments are completed to identify conditions that might require intervention, and that not completing them on time could cause them to miss something. Record review of facility provided policy titled Resident Assessment Instrument, dated April 2010, revealed in part: Policy Statement A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. Policy Interpretation and Implementation 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility;

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 1 medication room reviewed. The facility failed to ensure that an insulin pen was labeled with an open or expiration date when it was opened. This failure could place residents at risk of exposure to medications and/or biologicals that are expired and/or contaminated. Findings include: During an observation and interview on [DATE] at 11:00 AM, there was an insulin pen of insulin [MEDICATION(S)] ([MEDICATION(S)]) 100 units per 1 milliliter in the facility medication room that was open and had 80 units of the medication missing from the container (220 units of the total 300 units remained). The insulin pen was not labeled or dated to indicate when it had been opened or put into use. RN A was present during the observation and reported that the insulin pen did not contain a date to indicate when it had been opened. RN A reported that the insulin pen was currently in use for a resident. RN A reported that it should have been dated with the open date when it was opened by the nurse who initially opened it because the insulin pen expires 28 days after being opened, and the date is needed to know when the 28 days will be reached. RN A reported that the consequences of not labeling insulin with an open date include that no one would know how long ago it was opened so they wouldn't know when it expires or if it was already expired. RN A reported that she did not know why the insulin pen was not labeled with an open date. During an interview on [DATE] at 9:50 AM, DON reported that it is our policy to date all of our insulin (with an open date) to ensure we are getting rid of them in the appropriate time, which is 28 days. DON reported that the potential consequences of not labeling insulins with an open date include that it (insulin) could grow some bacteria or lose effectiveness. DON reported that she did not know why there was an insulin pen in the facility medication room that was open and not labeled with an open date. Record review of facility provided policy titled Labeling of Medication Containers, dated [DATE], revealed in part: Policy Interpretation and Implementation 3. Labels for individual drug containers shall include all necessary information, such as: h. The expiration date when applicable; Record review of facility provided policy titled Insulin Administration, dated [DATE], revealed in part: Steps in the Procedure 4. Check the expiration date if drawing from an opened multidose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening).

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 and to help prevent the development and transmission of communicable diseases and infections of 3 of 3 staff members (LVN A, CNA B and NA C) reviewed for infection control practices. LVN A and NA C were not wearing a mask while sitting at the nurse's station and were not maintaining social distance. CNA B failed to change gloves, wash her hands or use ABHR during incontinent care for 1 of 1 Residents (Resident #1). These failures have the potential to affect all residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: During an observation, 12/11/20 at 9:50 AM, LVN A and NA C were seen at the nurse's station, within 2-3 feet of each other, talking and laughing, while not wearing masks. During an interview, 12/11/20 at 9:57 AM, the Administrator stated expectations of staff is to always wear their mask while in the facility. During an interview, 12/11/20 at 10:05 AM, the DON stated expectations of staff is to always wear a mask unless eating, drinking or blowing their nose, and they are to immediately put the mask back on. The DON also confirmed that LVN A was the only nurse and CNA B was the only CNA caring for all residents on 12/11/20. During an interview, 12/11/20 at 3:15 PM, LVN A stated staff should wear their masks all times, unless eating or drinking. Record review on 12/11/20, of the facility's Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures policy, dated July 2020, states: 2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including: c. Appropriate use of PPE; e. Universal source control (using facemasks or cloth coverings as indicated); Source Control 1.(a) (2) Staff are required to wear face coverings upon entering the facility and prior to leaving the building. a) Cloth face coverings for source control ARE NOT considered PPE. Staff should wear a facemask at all times when in the facility. Personal Protective Equipment 1. Staff wear facemasks at all times while in the facility, except while eating or drinking in designated areas. During an observation, 12/11/20 at 2:22 PM, of incontinent care for Resident #1. CNA B rolled up the front of the dirty brief and pushed it between the legs of Resident #1. CNA B, without separating and wiping Resident #1's labia, turned the resident to her side, took wipes from the hand of NA C and cleaned Resident #1's buttock. CNA B did not wash hands or use ABHR and did not change gloves before taking the clean brief from the hand of NA C. CNA B positioned the clean brief under Resident #1's buttock. CNA B turned Resident #1 to her back and finished securing the clean brief. CNA B did not wash hands or change gloves until after completion of care. During an interview, 12/11/20 at 2:27 PM, CNA B acknowledge she should have wiped Resident #1's labia during care and should have changed gloves and wash hands, after cleaning and before putting on a clean brief. During an interview,12/11/20 at 3:13 PM, DON stated the expectations for staff during incontinent care are to separate female resident's labia and wipe front to back and staff should wash hands or use ABHR and change gloves after completion of cleaning the resident and before placing on a clean brief. Record Review on 12/11/2020, of the facility's policy on Perineal Care, dated September 2005, states: Steps in the Procedure 10. For a female resident: a. Wash perineal area, wiping from front to back. 1. Separate labia and wash area downward from front to back. 2. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side and using downward [MEDICAL CONDITION]. Use clean wipe or area of the wipe for each stroke. Record Review on 12/11/2020, of the facility's policy on Handwashing/Hand Hygiene, dated August 2019, states: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: b. Before and after direct contact with residents;

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 and to help prevent the development and transmission of communicable diseases and infections. -RN A failed to use the proper disinfecting wipes when disinfecting equipment used on isolated residents. This deficient practice has the potential to affect all residents in the facility by exposing them to care that could lead to the spread of [MEDICAL CONDITION] infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: During an observation on 11-8-2020 at 09:54 AM RN A was donning PPE to administer medication to a resident in an isolation room. RN A donned correctly then used the Sipa Antibacterial Wipes to clean the thermometer and the O2 saturation meter. RN A then entered the resident's room and used the equipment on the resident in isolation. At 10:00 AM she doffed her PPE with no concerns. RN A then washed then use the Sipa Antibacterial Wipes to clean her goggles, the thermometer, the O2 saturation meter, and the isolation table. During an interview on 11-8-2020 at 10:03 AM when questioned if the thermometer, O2 saturation meter, and goggles she just cleaned were dedicated to all three resident isolation rooms on B Hall RN A stated, Yes, they are dedicated to these three rooms. During an observation on 11-8-2020 at 10:40 AM it was noted that there was no EPA registration for the Sipa Antibacterial Wipes used for the isolation equipment table for the B-Hall three isolation rooms. This surveyor asked RN A to verify if the wipes used on the thermometer, O2 saturation meter, goggles, and table did kill COVID she looked at the label and stated, I'm not seeing it on the bottle. When questioned as to how long the Sipa Antibacterial Wipes have been used RN A stated, I have worked the last two days and we have been using them. I don't know before that. During an interview on 11-8-2020 at 10:53 AM the administrator stated, I looked up the Sipa Antibacterial Wipes and I can't find anywhere were they kill COVID-19. I don't know how they got in here, but we will remove them right now. Record review of facility provided policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measure revised July 2020, revealed the following: Cleaning and Disinfecting: 1. Dedicated or disposable noncritical resident-care equipment (e/g/ blood pressure cuffs, blood glucose monitoring equipment,) are used, or if not available, then equipment is cleaned and disinfected according to manufactures, instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident. References: EPA List N: Disinfectant for Use Against [DIAGNOSES REDACTED]-CoV-2 Record Review of the EPA List N revealed the following: Sipa Antibacterial Wipes are not on the list for use against [DIAGNOSES REDACTED]-CoV-2

Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 3 out of 5 residents (Resident #1, Resident #2, and Resident #3) whose comprehensive assessment were reviewed. The MDS assessments of Resident #1, Resident #2, and Resident #3 were not completed at least once every 92 days. The last MDS assessments that were completed for Resident #1, Resident #2, and Resident #3 were completed more than 14 days after the corresponding ARDs. This deficient practice could lead to the facility being unable to identify residents needs and functional abilities, which could place residents at risk of receiving inappropriate care or not receiving necessary care for their condition. Findings Include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male with a current admitted [DATE] and [DIAGNOSES REDACTED]. Record review of Resident #1's clinical records revealed that the ARD of his last completed MDS assessment was 09/04/2019 (155 days prior to the date of the investigation). The completion date of the MDS was 10/03/2019, which was 29 days after the ARD of that MDS. Resident #2 Record review of Resident #2's face sheet revealed an [AGE] year-old female with a current admitted [DATE] and [DIAGNOSES REDACTED]. Record review of Resident #2's clinical records revealed that the ARD of her last completed MDS assessment was 08/14/2019 (176 days prior to the date of the investigation). The completion date of the MDS was 09/23/2019, which was 40 days after the ARD of that MDS Resident #3 Record review of Resident #3's face sheet revealed an [AGE] year-old female with a current admitted [DATE] and [DIAGNOSES REDACTED]. Record review of Resident #3's clinical records revealed that the ARD of her last completed MDS assessment was 10/16/2019 (113 days prior to the date of the investigation). The completion date of the MDS was 11/22/2019, which was 40 days after the ARD of that MDS During an interview on 02/06/2020 at 2:20 PM, DON reported that she is responsible for MDS assessments and that she has recently had to work on the floor a lot to cover shifts. She reported that, because of this, she has fallen behind on MDS assessments. She confirmed that the MDS assessments of Resident #1, Resident #2, and Resident #3 were all past due; and that they had not been completed within 14 days of their ARDs. Record review of facility provided policy titled Resident Assessment Instrument, dated (MONTH) 2010, revealed in part: Policy Interpretation and Implementation 1. The assessment coordinator is responsible for ensuring that the interdisciplinary assessment team conduct timely resident assessments and reviews according to the following schedule: c. At least quarterly;

Based on interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 out of 5 residents (Resident #4) whose comprehensive assessments were reviewed. Resident #4's admission MDS assessment was not completed within 14 days of her admitted . This deficient practice could lead to the facility being unable to identify residents needs and functional abilities, which could place residents at risk of receiving inappropriate care or not receiving necessary care for their condition. Findings Include: Record review of Resident #4's face sheet revealed an [AGE] year-old female with a current admitted [DATE] and [DIAGNOSES REDACTED]. Record review of Resident #4's clinical records revealed that there was not MDS assessment completed on the resident, but that she had been admitted to the facility on [DATE] (16 days ago). During an interview on 02/06/2020 at 2:20 PM, DON reported that she is responsible for MDS assessments and that she has recently had to work on the floor a lot to cover shifts. She reported that, because of this, she has fallen behind on MDS assessments. She confirmed that admission MDS assessments are supposed to be completed within 14 days of admission and confirmed that the admission MDS of Resident #4 was late by 2 days. Record review of facility provided policy titled Resident Assessment Instrument, dated (MONTH) 2010, revealed in part: Policy Interpretation and Implementation 1. The assessment coordinator is responsible for ensuring that the interdisciplinary assessment team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility;