Every finding on record at Highland Meadows

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's environment remained free of hazards as was possible for 4 of 6 residents (Residents #46, #55, #70, and #96) reviewed for accident hazards.The facility failed to ensure Residents #46 and #55 did not have a can disinfectant stored in their room.The facility failed to ensure Resident #70 had her fall mat placed alongside her bed for fall prevention. The facility failed to ensure Resident #96 had physician orders for a scoop mattress (a scoop mattress features raised sides and a concave center) to ensure it was not a hazard for the resident. These failures could prevent the residents from having an environment that was free from accidents, and potential injury.Findings included:Record review of Resident #46's Face Sheet, dated 05/13/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had diagnoses of depression and COPD (difficulty breathing).Record review of Resident #46's Quarterly MDS Assessment, dated 04/22/26, reflected the resident had a BIMS score of 14 (intact cognitive response). The MDS assessment reflected the resident had diagnoses of depression and COPD.During an observation on 05/12/26 at 10:32 a.m., revealed Resident #46 had a can of disinfectant spray on his nightstand.Record review of Resident #55's Face Sheet, dated 05/13/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #55 had a diagnosis of depression.Record review of Resident #55's Quarterly MDS Assessment, dated 03/17/26, reflected the resident had a BIMS score of 6 (severe cognitive impairment). The MDS assessment reflected the resident had a diagnosis of depression.During an observation on 05/12/26 at 10:32 a.m., revealed Resident #55 had a can of disinfectant spray in her bathroom.During an interview and observation on 05/12/26 at 11:16 AM, RN J was shown by the Surveyor Resident #46 and Resident #55 had a can of disinfectant in their room. She stated the resident should not have the disinfectant in their room because it was a hazard to the resident. She stated family members often bring in these items for the resident. Record review of Resident #70's Face Sheet, dated 05/13/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #70 had a diagnosis of repeated falls.Record review of Resident #70's Quarterly MDS Assessment, dated 03/17/26, reflected the resident had a BIMS score of 12 (moderate cognitive impairment). The MDS assessment reflected the resident had a diagnosis of restless leg syndrome.Record review of Resident #70's Comprehensive Care Plan, dated 03/11/26, reflected the resident being a fall risk, and an intervention included having a fall mat placed alongside her bed. During an observation on 05/14/26 at 11:35 a.m., revealed Resident #70 was lying in bed, and the fall mat was observed leaning against a 5-drawer chest. The fall mat was not placed alongside the resident's bed.During an interview and observation on 5/14/26 at 9:12a.m., LVN E stated Resident #70 was a fall risk and needed the fall mat placed alongside her bed. She observed the resident's fall mat leaning on a 5-drawer chest and placed it alongside the resident's bed. She stated the nursing staff often forgot to place the fall mat back in place after providing care to the resident. She stated not having the fall mat alongside the resident's bed result in the resident sustaining a severe injury if she fell out of the bed. Record review of Resident #96's Face Sheet, dated 05/13/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #96 had a diagnosis of shaking.Record review of Resident #96's Quarterly MDS Assessment, dated 04/28/26, reflected the resident had a BIMS score of 2 (severe cognitive impairment). The MDS assessment reflected the resident had a diagnosis of seizure disorder.Record review of Resident #96's Comprehensive Care Plan, dated 05/12/26, reflected the resident being a fall risk, but there was no intervention including the use of a scoop mattress.Record review of Resident #96's Physician's Order, dated 05/13/26, reflected no physician's orders for a scoop mattress.During an observation on 05/14/26 at 11:35 a.m., revealed Resident #96 had a scoop mattress on his bed. During an interview on 05/14/26 at 10:41 a.m., ADON T was informed by the Surveyor of Resident #96 not having physician orders for the scoop mattress on his bed. She stated she was unsure if the resident had physician orders or not. She stated physician orders would be required because it was a care being provided and the physician was aware of the care. She stated it was the ADON and DON's responsibility to ensure the resident had physician orders for the device. During an interview on 05/14/26 at 10:45 a.m., ADON T was informed by the Surveyor of Resident #46 and Resident #55 had a can of disinfectant in their room. She stated the residents were not allowed to have the chemicals in their room because it could be harmful to the residents and were flammable. She stated family members often bring the items in for the residents' use and they had to take them away. During an interview on 05/14/26 at 10:47 a.m., ADON T was informed by the Surveyor of Resident #70 not having the fall mat placed alongside the resident's bed when observed on 05/12/26 and 05/14/26. She was informed the fall mat was observed leaning against the 5-drawer chest in the room. She stated the resident was a fall risk and needed the fall mat placed alongside her bed to reduce the impact of a fall. During an interview on 05/14/26 at 11:48 a.m., the DON was informed by the Surveyor of Resident #46 and Resident #55 with cans of disinfectant in their room. She stated it should not be in their room because it was a hazard for them and they could harm themselves. She stated family members bring them for the resident, and they had repeatedly advised them not to, but they continue to do it. She stated the staff were responsible for checking to ensure they did not have these items in their room when they conducted their rounds. The DON was informed by the Surveyor of Resident #70 not having her fall mat placed alongside her bed while she was lying in it. She stated the resident was a fall risk and staff needed to ensure the fall mat was placed alongside the resident's bed to minimize the risk of injury if the resident fell out of bed. The DON was informed by the Surveyor of Resident #96 having a scoop mattress but no physician orders. She stated the resident was a fall risk and an intervention included the use of a scoop mattress. She stated the physician orders were needed because it was part of the care needed for the resident.Record review of the facility's policy, Falls and Fall Risk, Managing, dated March 2025, reflected Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Record review of the facility's policy, STATEMENT OF RESIDENT RIGHTS, undated, You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate, or retaliate against your for exercising your rights.If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Human Services by calling [PHONE NUMBER].You have a right to:1) All care necessary for you to have the highest possible level of health;2) Safe, decent and clean conditions;

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of seven (Residents #46, #70, and #71) reviewed for respiratory care. The facility failed to ensure Resident #46's nebulizer mask was bagged when not in use on 05/12/26. The facility failed to ensure Resident #70's nasal canula was properly stored in a bag when not in use on 05/12/26.The facility failed to ensure Resident #71's nebulizer and CPAP mask were bagged when not in use on 05/12/26.The facility failed to ensure Resident #71 had physician orders for use of the nebulizer. These failures could place the residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings included: Record review of Resident #46's Face Sheet, dated 05/13/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had diagnoses of depression and COPD (difficulty breathing).Record review of Resident #46's Quarterly MDS Assessment, dated 04/22/26, reflected the resident had a BIMS score of 14 (intact cognitive response). The MDS assessment reflected the resident had diagnoses of depression and COPD.Record review of Resident #46's Physician Order, dated 05/12/26, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5(3) mg/3ml. 3 ml inhale orally via nebulizer. During an observation on 05/12/26 at 10:32 a.m., revealed Resident #46's nebulizer mask on his nightstand unbagged. Record review of Resident #70's Face Sheet, dated 05/13/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #70 had a diagnosis of COPD.Record review of Resident #70's Quarterly MDS Assessment, dated 03/17/26, reflected the resident had a BIMS score of 12 (moderate cognitive impairment). The MDS assessment reflected the resident had a diagnosis of COPD.Record review of Resident #70's Physician Order, dated 05/12/26, reflected Oxygen continuous @ 2-4 LPM via nasal canula.During an observation on 05/12/26 at 10:35 a.m., revealed Resident #70's oxygen tank, attached to her wheelchair, had a nasal canula attached, which was sitting on the seat of the wheelchair under a pair of sneakers, unbagged.Record review of Resident #71's Face Sheet, dated 05/13/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #71 had diagnoses of obstructive sleep apnea and chronic atrial fibrillation (irregular heartbeat).Record review of Resident #71's Quarterly MDS Assessment, dated 04/28/26, reflected the resident had a BIMS score of 2 (severe cognitive impairment). The MDS assessment reflected the resident had a diagnoses of obstructive sleep apnea and chronic atrial fibrillation (irregular heartbeat).Record review of Resident #71's Physician Order, dated 05/12/26, reflected apply CPAP at bedtime and fit mask for patient comfort. The resident had no physician orders for the use of a nebulizerDuring an observation on 05/12/26 at 10:45 a.m., Resident #71's nebulizer mask and CPAP mask were laying on top of the nightstand and unbagged. During an interview and observation on 05/12/26 at 11:16 AM, RN J observed Resident #46's nebulizer mask unbagged, Resident #70's nebulizer and CPAP mask unbagged, and Resident #71's nasal canula unbagged. She stated the devices needed to be bagged to avoid cross contamination. She stated staff should be checking for this when they make their rounds every two hours.During an interview on 5/14/26 at 9:12 a.m., LVN E stated Resident #71 used his nebulizer on an as needed basis and he often refused. She was informed by the Surveyor of Resident #71 not having physician orders for the use of the device. She stated she was new to the facility and was not sure why the resident did not have physician orders for it. She stated the resident needed a care plan for the use of the device but did not state why.During an interview on 05/14/26 at 10:41 a.m., ADON T was informed by the Surveyor of Resident #46, #70, and #71 not having their breathing mask or nasal canula bagged. She stated the items needed to be bagged when not in use to avoid contamination. She was informed Resident #71 did not have physician orders for the use of the nebulizer and she stated Resident #71 needed physician orders for their plan of care and the physician signing off on the care needed. She stated she did not think Resident #71 used a nebulizer and should not have it in his room.During an interview on 05/14/26 at 11:48 a.m., the DON was informed by the Surveyor of Resident #46, #70, and #71 not having their breathing mask or nasal canula bagged. She stated the items needed to be bagged when not in use to avoid cross contamination. She stated staff should be checking to ensure these items were bagged when they made their round. She was informed of Resident #71 not having active physician orders for any medication requiring the use of a nebulizer and she stated she had to research why the resident did not have physician orders. Record review of the facility's policy, Oxygen Administration, dated 2001, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess for any special needs of the resident.3. Assemble the equipment and supplies as needed.

Based on observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for three of seven residents (Residents #29, #46, and #96) reviewed for medication storage. The facility failed to ensure Resident #29 did not have a container of eye drops on his bedside table on 05/12/26. The facility failed to ensure Resident #46 did not have a container of allergy medication and antacid medication on his nightstand on 05/12/26. The facility failed to ensure Resident #96 did not have a container of earwax removal on his nightstand on 05/12/26.These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions. Findings included:Record review of Resident #29's Face Sheet, dated 05/13/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses of dementia (memory decline) and damaged retina.Record review of Resident #29's Quarterly MDS Assessment, dated 02/23/26, reflected the resident had a BIMS score of 13 (intact cognitive response). The MDS assessment reflected the resident had diagnoses of Alzheimer's (cognitive decline) and damaged retina.During an observation on 05/12/26 at 10:32 a.m., Resident #29 had a container of eye drops on his bedside table.Record review of Resident #46's Face Sheet, dated 05/13/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had diagnoses of acid reflux and COPD (difficulty breathing).Record review of Resident #46's Quarterly MDS Assessment, dated 04/22/26, reflected the resident had a BIMS score of 14 (intact cognitive response). The MDS assessment reflected the resident had diagnoses of acid reflux and COPD.During an observation on 05/12/26 at 10:35 a.m., Resident #46 had a container of allergy medication and antacid medication on his nightstand.Record review of Resident #96's Face Sheet, dated 05/13/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #96 had a diagnosis of tremors.Record review of Resident #96's Quarterly MDS Assessment, dated 04/28/26, reflected the resident had a BIMS score of 2 (severe cognitive impairment). The MDS assessment reflected the resident had a diagnosis of seizure disorder.During an observation on 05/12/26 at 10:45 a.m., Resident #96 had a container of earwax removal on his nightstand.During an interview on 05/14/26 at 10:34 a.m., LVN E was informed by the Surveyor of Resident #29 having a container of eye drops on his bedside table, Resident #46 having a container of allergy medication and antacid medication on his nightstand, and Resident #96 having a container of earwax removal on his nightstand. She stated the residents were not allowed to have the medication in their rooms because they could overdose on them or ingest them. During an interview on 05/14/26 at 10:41 a.m., ADON T was informed by the Surveyor of Resident #29 having a container of eye drops on his bedside table, Resident #46 having a container of allergy medication and antacid medication on his nightstand, and Resident #96 having a container of earwax removal on his nightstand. She stated the residents' family members brought in medication and they had to educate the family not to. She stated staff should be checking for this when checking on the residents. She stated they checked for this daily and confiscated them when they see it. During an interview on 05/14/26 at 10:41 a.m., the DON was informed by the Surveyor of Resident #29 having a container of eye drops on his bedside table, Resident #46 having a container of allergy medication and antacid medication on his nightstand, and Resident #96 having a container of earwax removal on his nightstand. She stated the residents' family members brought in medication and they had repeatedly educated the family not to. She stated staff should be checking for this when checking on the residents. She stated the risk of the residents having the medication in their room could result in overdose.Record review of the facility's policy, Storage of Medications, dated November 2020, reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services.The facility failed to properly seal the tea dispenser once the tea had brewed on 05/12/26. The facility failed to ensure the ice scoop, in the kitchen, was thoroughly cleaned on 05/12/26.The facility failed to ensure the sanitizer bucket (red bucket) in the kitchen area had the appropriate level of sanitizer fluid in it on 05/12/26. The facility failed to ensure a large tray of thawing raw meat, in the walk-in refrigerator, was not stored above cooked foods. These failures placed residents at risk of exposure to food contamination and illness. Findings included:Observations on 05/12/26 from 9:11 a.m. to 9:19 a.m. in the facility's only kitchen revealed: The tea dispenser in the kitchen area, had tea in it and was not covered. A large tray of thawing raw meat, in the walk-in refrigerator, was stored above cooked foods. An ice scoop holder storing an ice scoop, located in the kitchen, had white and brownish stains on the bottom of the inside of it. During an interview and observation on 05/13/26 at 11:40 a.m., the DM stated the sanitizer bucket (red bucket) had sanitizer fluid in it and she tested the PPM in the morning. She tested the solution in the container, and the PPM registered at 0, which indicated no sanitizer solution was registered in the mixture. During an interview on 05/14/26 at 9:47 a.m., Dietary Manager and Food Service Supervisor were informed of the concerns observed in the kitchen area. The DM and FSS stated the tea dispenser needed to be covered to prevent something from falling into it. They stated the tray of raw meat needed to be placed on the bottom rack and not on a rack above other foods to prevent anything from contaminating the other foods. They stated they cleaned the ice scoop holder out at least once a week and will ensure it was clean to avoid contamination. The DM stated the sanitizer bucket needed to have the appropriate amount of sanitizer fluid to clean spills and sanitize the serving area if spill occur.During an interview on 05/14/26 at 10:06 a.m., the Administrator was informed of the concerns observed in the kitchen area. She stated she was informed of the concerns in the kitchen by the DM. She stated she was informed by the DM they were in the process of making more tea, which was why the tea was uncovered. She stated her DM informed her the tray of raw meat did have a solid tray underneath it and the bags were sealed so there was no risk of the food under it getting contaminated. She stated she understood ensuring the ice scoop holder was cleaned to avoid contamination. She stated she was informed about the red bucket not having sanitizer fluid in it, but she stated the DM told her they were going to check it prior to using it, if they had to use it.Record Review of the Facility's policy titled Food Receiving and Storage, dated 2001, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). 9. Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Sanitization - The food service area is maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 9. Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution. 10. Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions.Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 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. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 12 residents (Resident #46 ) reviewed for care plan. The facility failed to ensure Resident #46's care plan for fall prevention included the intervention of a fall mat placed alongside bed. This failure could place residents at risk of their needs not being met. Findings include:Record review of Resident #46's Face Sheet, dated 05/13/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had diagnosis of a fractured thigh.Record review of Resident #46's Quarterly MDS Assessment, dated 04/22/26, reflected the resident had a BIMS score of 14 (intact cognitive response). The MDS assessment reflected the resident had pain in unspecified joint.Record review of Resident #46's Comprehensive Care Plan, dated 05/05/26, reflected the resident was a fall risk; however, there was no intervention of a fall mat to be placed alongside his bed. During an observation on 05/12/26 at 10:32 a.m., Resident #46 had a fall mat placed alongside his bed.During an interview on 05/14/26 at 10:41 a.m., ADON T was informed by the Surveyor of Resident #46 observed with a fall mat placed alongside his bed on 05/12/26 at 10:32 a.m., and 05/14/26 at 9:00 a.m.; however, his care plan for fall risk did not include an intervention for the use of a fall mat. She stated she was not sure if the resident used a fall mat. She stated she would have to research this. She later returned on 05/14/26 at 11:15 a.m. and stated the fall mat should not have been there. She was advised by the surveyor of the progress notes dated 03/12/26 indicating the resident was found on his knees on the fall mat. She stated it was the ADON, DON, and MDS nurse's responsibility to ensure care plans were updated and it was important because it showed the resident's plan of care. During an interview on 05/14/26 at 11:48 a.m., the DON was informed by the Surveyor of Resident #46 observed with a fall mat placed alongside his bed on 05/12/26 at 10:32 a.m., and 05/14/26 at 9:00 a.m.; however, his care plan for fall risk did not include an intervention for the use of a fall mat. The DON stated it was the interdisciplinary team's responsibility to ensure care plans were updated. She stated normally it was the ADON's responsibility to ensure the care plan was updated. She stated if the resident's care plan was not updated with the interventions used as part of the resident's plan of care he may not receive the appropriate care. Record review of the facility's policy, Falls and Fall Risk, Managing, dated March 2025, reflected Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Record review of facility's policy, Comprehensive Care Plans, dated 2022, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #144) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #144. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services. Findings included: Review of Resident #144's Face Sheet, dated 03/03/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including aftercare following joint replacement surgery (a period of pain management, physical therapy, wound care, and gradually returning to normal activities), type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin, or the cells become resistant to the effects of insulin, leading to high blood glucose (sugar) levels), and heart failure (a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs). Review of Resident #144's electronic medical records on 03/03/25 reflected a baseline care plan had been initiated on 02/25/25 by LVN F, but the baseline care plan was never completed. During an interview with LVN F on 03/03/25 at 12:54PM, he stated baseline care plans were required to be completed within 48 hours of a resident's admission. He stated he was responsible for completing Resident #144's baseline care plan. He said although he initiated the baseline care plan in the facility's electronic charting system, he forgot to complete the document. During an interview with the Director of Nursing on 03/05/25 at 12:00PM, he stated baseline care plans were required to be completed within 48 hours of a resident's admission. He stated there was not an inherent risk to residents if baseline care plans were not completed within this required timeframe, as facility staff communicated closely regarding resident care and ensured all care needs were still met. Review of the facility's Care Plans - Baseline policy, dated 03/2022, reflected, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .

Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 (Resident #31) of 3 residents reviewed with gastrostomy tubes (g-tubes). CNA A did not inform the nurse to turn off Resident #31's gastrostomy tube feeding prior to providing care. CNA A lowered the head of Resident #31's bed to a flat position for incontinent care while the g-tube feeding continued to infuse. This failure could place residents with g- tubes at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #31's face sheet dated 03/04/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #31 had diagnoses included hypertension, , gastrostomy, dementia, mood disturbance, anxiety, seizures, cognitive communication deficit, anemia, hypothyroidism (a condition that happens when your thyroid gland doesn't make or release enough hormone into your bloodstream), vitamin deficiency, and gastro-esophageal reflux disease. Record review of Resident #31's Annually MDS assessment dated [DATE] revealed Resident BIMS was 12 which indicated no impaired cognition. Resident #31 was dependent of staff assistance with ADL with one staff assistant. Further review revealed the resident had a PEG tube. Record review of Resident # 31's care plan initiated on 05/25/21 revealed Resident #31, Focus, requires tube feeding r/t Dysphagia, Resisting eating, Weight Loss. At risk for complications. Goal, Will remain free of side effects or complications related to tube feeding through review date. Intervention, Monitor/document/report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Record review of Resident #31's physician for February 2025 read in part . Enteral Feed Order as needed Nutren 1.5 @ 50 ml/hr x 22 hrs continuous for a total volume of 1100 ml via pump. May allow 2 hour down time for ADL's, Water Flush at 160cc q 6 hours to run concurrent with Nutren . During an observation on 03/03/25 at 11:27 a.m., revealed Resident #31 was lying on the bed and she placed the call light on and asked to be changed. CNA A was observed put on own and gloves and then lowered Resident #31's head of bed. Resident #31 feeding was infusing while CNA A was providing incontinent care. After care CNA A then elevated the resident's head of bed. In an interview on 03/03/25 at 11:42 am., with CNA A she stated she did not need to inform the charge nurse she was proving care to the resident so the nurse could pause or stop the feeding. CNA A stated while providing care to resident with g-tube the feeding was not paused or stopped during care. CNA A was not aware why the head of bed was not to be lowered when the feeding was infusing. In an interview on 03/03/25 at 12:15 pm., with LVN B revealed she was the charge nurse for Resident #31. LVN B stated Resident #31 did not have pneumonia or aspiration. LVN B stated during incontinent care the aides were supposed to inform the charge nurse so the residents feeding would be turned off. LVN B stated the resident's head of bed was not supposed to be lowered to a flat position while the feeding was infusing. LVN B stated lowering resident head of bed flat while the feeding was infusing would cause aspiration. In an interview on 03/05/25 at 12:24 pm., with the DON he stated the aide was supposed to inform the charge nurse so they could pause the feeding, and the aide was not supposed to provide incontinent care while the feeding was infusing. The DON stated the resident was at risk for aspiration and even pneumonia when head of bed was flat and the feeding infusing. The DON stated CNA A had been in-serviced on providing activities of daily living to residents with a g-tube and had completed skill check off. Requested for a skill check off but was not provided by exit. No policy was provided regarding providing incontinent care on residents who were on continues g-tube feeding. The policy was requested from the DON on 03/05/25. The DON provided a policy dated 03/22, titled Enteral and Parenteral Feeding - Documentation, Orders and Nutrition reflected, . The resident who utilizes enteral or parental nutrition will be free, to the extent possible, from complications related to enteral and parenteral nutrition.

Based on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen (14) days for 1 of 6 residents reviewed for unnecessary medications, in that (Residents #70). Resident #70 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary psychotropic medications. Findings included: Record review of Resident #70's face sheet dated 03/04/25 revealed a [AGE] year-old male was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #70 had diagnoses included, chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease, protein-calorie malnutrition, depression, presence of cardiac pacemaker, orthostatic hypotension, and hyperlipidemia. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #70 had a BIMS score of 14 indicating no severe cognitive impairment. Further indicated the resident had anxiety disorder and he was taking antianxiety medication. Record review of Resident #70's care plan dated 10/07/23 indicated the resident used Ativan for anxiety. The goal was for the resident to show decreased episodes of signs and symptoms of anxiety. Intervention was for the resident to give anti-anxiety medications ordered by physician and monitor/document side effects and effectiveness. Record review of Resident #70's physician's order summary report dated 03/05/25 indicated: Lorazepam oral tablet 1 MG (Lorazepam) give 1 tablet by mouth every 8 hours as needed for anxiety for 6 months, with an order date of 01/09/25 and with a stop date of 07/09/25. Record review of Resident #70's EMAR for the months of February 2015 and March 2025 indicated the resident had not taken Lorazepam medication. Record review of Consultant Pharmacist's Medication Regimen Review dated 1/1/25 and 1/3/25 indicated Resident #70's PRN Lorazepam required 14 days stop date. Can extended with documentation clinical note/rationale, but always required a specific duration or stop date. During an interview on 03/05/25 at 11:10 AM, with ADON D stated Resident #70 received PRN Lorazepam and it was ordered in January 2025. She said she could not show where the medication was re-evaluated every 14 days. She said that type of medication should be re-evaluated every 14 days by the primary care provider because it was a psychotropic medication. She said the risk of not re-evaluating psychotropic medication every 14 days was the resident could be overmedicated. The ADON D stated per the pharmacy notes from January 2025 it indicated the medication needed to be reevaluated every 14 days and ADON E was to follow up. In an interview on 03/05/25 at 01:58 PM with ADON E she stated Resident #70 was on Prn Lorazepam. She stated, she understood if the resident was on hospice they did not require a stop date for psychotropic medication when they were ordered prn. She then stated she realized Resident #70 was no longer on hospice, so she was supposed to follow up with the resident's primary care provider, but she did not. The ADON E stated the medication was supposed to be reviewed every 14 days to check and make sure the resident still required the medication and any changes required to be made, if the resident did not need it then the medication required to be stopped. In an interview on 03/05/25 at 02:23 PM with the DON he stated when any resident was no psych services, he included the psych team. The DON provided the documentation indicating for the resident to be on Lorazepam for 6 months but did not give the rationale for the prolong use of the medication prn. The DON stated review of psychotropic medications every 14 days was to make sure the medication was being used appropriately and to prevent any side effects from the medication. The DON stated he was not aware of the pharmacy recommendation for the medication to be reevaluated. Review of the facility policy revised 7/2022 and titled antipsychotic medication use reflected, Residents will not receive medications that are not clinically indicated to treat a specific condition. 16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare profession has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #31 and #49) of 6 residents reviewed for infection control in that: 1. CNA A failed to complete hand hygiene during incontinent care while assisting Resident #31. 2. CNA C failed to complete hand hygiene and change gloves during incontinent care while assisting Resident #49. These failures could place resident's risk for cross contamination and the spread of infection. Finding include: 1.Record review of Resident #31's face sheet dated 03/04/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #31 had diagnoses included hypertension, gastrostomy, dementia, mood disturbance, anxiety, seizures, cognitive communication deficit, anemia, hypothyroidism (a condition that happens when your thyroid gland doesn't make or release enough hormone into your bloodstream), vitamin deficiency, and gastro-esophageal reflux disease. Record review of Resident #31's Annually MDS assessment dated [DATE] revealed Resident BIMS was 12 which indicated no impaired cognition. Resident #31 was dependent of staff assistance with ADL with one staff assistant and was always incontinent of bowel and bladder. Record review of Resident # 31's care plan initiated on 05/25/21 revealed Resident #31, Focus, requires assist with all adl's and transfers d/t impaired cognition and mobility. Goal, All needs will be met through the next review date. Interventions, Assist with oral care, hair care, nail care, grooming, dressing, toileting and mobility. During an observation on 03/03/25 at 11:27 a.m., revealed Resident #31 was lying on the bed and she placed the call light on and asked to be changed. CNA A was observed to don gown and gloves and then lowered Resident #31's head of bed. Then CNA A proceeded to provide incontinent care to Resident #31. Resident #31 had a bowel movement and during the care CNA A was observed changing gloves but did not complete any form of hand hygiene. In an interview on 03/03/25 at 11:42 am., with CNA A she stated she was supposed to complete hand hygiene after changing gloves, but she forgot. CNA A stated she was supposed to complete hand hygiene to prevent the spread of infection. CNA A stated she completed infection control in-service monthly. 2. Record review of Resident #49's face sheet dated 03/04/25 revealed a [AGE] year-old female was originally admitted on [DATE] and readmitted on [DATE]. Resident #49 had diagnoses included, vascular dementia, psychotic disturbance, mood disturbance, and anxiety, hypertension, anemia in other chronic diseases, major depressive disorder, chronic kidney disease and weakness. Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed Resident BIMS was 10 which indicated mild cognition impairment. Resident #49 was dependent on the staff and was always incontinent of bowel and bladder. Record review of the care plan for Resident #49 initiated 09/28/21 reflected, Focus, [Resident #49] is incont of bowel and bladder At risk for skin breakdown and uti's. Goal, Minimize risk for uti's through the next review date. Intervention, Provide incont care after each incont episode. Observation on 03/03/25 at 12:43 pm., revealed CNA C providing incontinent care to Resident #49. CNA C gloved and started providing care to Resident # 49. Resident was soiled with urine, and after CNA C cleaned the resident, she did not change gloves or complete hand hygiene. With the same gloves, CNA C applied the clean brief, touched the resident's linens and bed remote. In an interview on 03/03/25 at 12: 54 pm., with CNA C she sated stated she was not aware of cleaning hands in between care, unless the resident had a bowel movement. CNA C stated she was required to complete hand hygiene before and after care, to prevent the spread of infection or cross contamination. In an interview on 03/05/25 at 12:20 PM with the DON she stated the staff members were expected to complete hand hygiene during care. The DON stated the aides were to wash hands when they enter the room and after taking care of the resident. Training and monitoring was completed by the infection preventionist. After cleaning the residents, the staff were supposed to complete hand hygiene and don clean gloves. The DON stated the staff were in-serviced on infection control monthly. In an interview on 03/05/25 at 01:10 PM with ADON D she stated she was the infection preventionist. The ADON D stated the aides were supposed to complete hand hygiene after changing gloves and after cleaning the residents. ADON D stated the staff were not supposed to touch resident's items with dirty gloves. The ADON stated the staff were to complete hand hygiene to maintain infection control and prevent the spread of infection. The ADON stated the staff were in-serviced on infection control monthly. Review of the facility policy dated 05/2021 and titled, Infection Control - Prevention and Control Program reflected, The intent of this program is to assure that the home develops, implements, and maintains an Infection Prevention and Control Program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. Review of the facility policy dated 05/2017 and titled, Hand Washing reflected, It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) shall be readily available and convenient for staff use to encourage the compliance with hand hygiene. 1. 1. The use of gloves does not replace proper hand washing.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 1 resident (Resident #1) reviewed for reporting. The facility failed to report an injury of unknown origin that was discovered on 12/27/2024, to HHSC. This failure could place residents at risk for abuse, neglect, and incidents. Findings include: Record review of Resident #1's Care Plan reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. The Care Plan was initialed on 12/30/24 for Wound Management of the lower abdomen. Resident #1 had diagnoses which included constipation (a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces.), hypertension (a condition in which the blood vessels have persistently raised pressure), gastro-esophageal reflux disease without esophagitis (a condition where acid or other contents flow back up from the stomach with no signs of damage to the esophagus) , nausea with vomiting, localized edema (a condition in which there is swelling due to excess fluid to one specific area of the body), gastrointestinal hemorrhage (a condition that covers all forms of bleeding in the gastrointestinal tract), unspecified open wound to the left lower leg, malignant neoplasm of unspecified kidney (cancerous tumor of the kidney), unspecified diastolic (congestive) heart failure (When your left heart ventricle is stiff, it doesn't relax properly between heartbeats), unspecified atrial fibrillation (irregular heart rhythm), unspecified dementia without behavioral disturbance (a condition where a person experiences confusion or mild cognitive impairment that cannot be clearly diagnosed as a specific type of dementia.), psychotic disturbance (cluster of symptoms, not an illness), mood disturbance (characterized by persistent and intense sadness, elation, or anger.), anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome:), morbid (severe) obesity due to excess calories (excessive and unhealthy accumulation of body fat), pulmonary embolism without acute cor pulmonale (blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the deep veins in the legs (deep vein thrombosis), diverticulitis of intestine (inflammation of irregular bulging pouches in the wall of the large intestine), pneumonia (lung inflammation caused by bacterial or viral infection), dysphagia (difficulty swallowing). Record review of Resident #1's Annual MDS (Minimum Data Sheet) Assessment, dated 01/20/2024, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 10, which indicated moderate cognitive impairment. Resident #1 was assessed to require assistance with ADLs (Activities of Daily Living) which included the following: transfers, personal hygiene, showers, and dressing. Record review on 1/31/25 of TULIP (Texas Unified Licensure Information Portal) reflected the facility did not report the injury of unknown origin for the wound that was discovered on 12/27/24. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note, dated 12/27/2024 at 6:39 PM, entered by LVN (Licensed Vocational Nurse) A. The progress note reflected there was a concern made by the family about the resident's care. LVN (Licensed Vocational Nurse) A documented there was an open wound to the groin area. The wound was cleansed with normal saline, pat dry, and had dressing applied. LVN (Licensed Vocational Nurse) A also documented the wound would be monitored. Record review of Resident #1's Skin Assessment, dated 12/27/2024, revealed that Resident #1 did not have a wound to the lower abdominal/groin area when the skin asssessment was performed at 3:38 PM. Record review of a photograph taken of Resident #1's wound revealed the wound was consistent with that of a laceration and not of a pressure/moisture related injury. Interview on 1/31/2025 at 9:40 AM with Director of Nursing B revealed he was very familiar with Resident #1 because he did rounds with her every day. He stated staff were trained to notify the administrator, director of nursing, physician, and responsible party if they found a wound. He stated there was no need to report this incident to HHSC because it was not something they thought was an injury of unknown origin because it was assumed to be a moisture related incident. The facility had an open order for moisture related incidents from the wound care doctor. DON (Director of Nursing) B stated the wound care doctor was notified by LVN (Licensed Vocational Nurse) A of the wound to Resident #1's groin area and that should satisfy reporting requirements even if the primary care physician was not notified of the wound to Resident #1's groin/abdominal. Interview on 1/31/2025 at 12:30 PM with CNA (Certified Nurse Assistant) C revealed she did not know how or why Resident #1 had a wound because she wasn't a resident she was assigned to take care of. She remembered Resident #1's family member yelling in the hallway for help. She stated LVN (Licensed Vocational Nurse) A asked her to assist him treating the wound. She stated the wound was small and they treated it with normal saline. She stated the wound wasn't bleeding but it looked like a clean cut. She stated LVN (Licensed Vocational Nurse) A called the physician and got an order right away. Interview on 1/31/2025 at 2:20 PM with Physician E revealed she did treat Resident #1's wound. She stated the wound was in the lower abdominal/groin area. She stated it was in kind of a fold area. She specified the wound did not look like a pressure related wound. She stated it was different than a moisture associated breakdown. She stated it could be from trauma but it's hard to say for sure but specified that it did not look moisture related. She stated the wound was small. It was .7 by .8 centimeters. She stated she was notified of the wound by LVN (Licensed Vocational Nurse) A on December 27th around 7pm. She told LVN (Licensed Vocational Nurse) A to follow the standing order until she saw it unless LVN (Licensed Vocational Nurse) A had a major concern. Interview on 1/31/2025 at 3:00 PM with LVN (Licensed Vocational Nurse) A revealed he remembered Resident #1's family member asked for someone to come take a look at a wound on Resident #1. He stated he assessed the resident, treated the wound, and notified the wound care doctor. There was no need to contact the family because the family member was the one who discovered the wound. There was no need to report the wound because it was assumed to be a moisture related incident and not an injury of unknown origin. Record review of the Facility Abuse & Neglect Reporting Policy, dated July 2017, reflected All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse will also be reported. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies . An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: A. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. B. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 resident (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's attending physician when an injury of unknown origin was discovered on Resident #1. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings include: Record review of Resident #1's Care Plan reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. The Care Plan was initialed on 12/30/24 for Wound Management of the lower abdomen. Resident #1 had diagnoses which included constipation (a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces.), hypertension (a condition in which the blood vessels have persistently raised pressure), gastro-esophageal reflux disease without esophagitis (a condition where acid or other contents flow back up from the stomach with no signs of damage to the esophagus) , nausea with vomiting, localized edema (a condition in which there is swelling due to excess fluid to one specific area of the body), gastrointestinal hemorrhage (a condition that covers all forms of bleeding in the gastrointestinal tract), unspecified open wound to the left lower leg, malignant neoplasm of unspecified kidney (cancerous tumor of the kidney), unspecified diastolic (congestive) heart failure (When your left heart ventricle is stiff, it doesn't relax properly between heartbeats), unspecified atrial fibrillation (irregular heart rhythm), unspecified dementia without behavioral disturbance (a condition where a person experiences confusion or mild cognitive impairment that cannot be clearly diagnosed as a specific type of dementia.), psychotic disturbance (cluster of symptoms, not an illness), mood disturbance (characterized by persistent and intense sadness, elation, or anger.), anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome:), morbid (severe) obesity due to excess calories (excessive and unhealthy accumulation of body fat), pulmonary embolism without acute cor pulmonale (blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the deep veins in the legs (deep vein thrombosis), diverticulitis of intestine (inflammation of irregular bulging pouches in the wall of the large intestine), pneumonia (lung inflammation caused by bacterial or viral infection), dysphagia (difficulty swallowing). Record review of Resident #1's Annual MDS (Minimum Data Sheet) Assessment, dated 01/20/2024, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 10, which indicated moderate cognitive impairment. Resident #1 was assessed to require assistance with ADLs (Activities of Daily Living) which included the following: transfers, personal hygiene, showers, and dressing. Record review on 1/31/25 of TULIP (Texas Unified Licensure Information Portal) reflected the facility did not report the injury of unknown origin for the wound that was discovered on 12/27/24. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note, dated 12/27/2024 at 6:39 PM, entered by LVN (Licensed Vocational Nurse) A. The progress note reflected there was a concern made by the family about the resident's care. LVN (Licensed Vocational Nurse) A documented there was an open wound to the groin area. The wound was cleansed with normal saline, pat dry, and had dressing applied. LVN (Licensed Vocational Nurse) A also documented the wound would be monitored. Record review of Resident #1's Skin Assessment, dated 12/27/2024, revealed that Resident #1 did not have a wound to the lower abdominal/groin area when the skin asssessment was performed at 3:38 PM. Record review of a photograph taken of Resident #1's wound revealed the wound was consistent with that of a laceration and not of a pressure/moisture related injury. Interview on 1/31/2025 at 9:40 AM with Director of Nursing B revealed he was very familiar with Resident #1 because he did rounds with her every day. He stated staff were trained to notify the administrator, director of nursing, physician, and responsible party if they found a wound. He stated there was no need to report this incident to HHSC because it was not something they thought was an injury of unknown origin because it was assumed to be a moisture related incident. The facility had an open order for moisture related incidents from the wound care doctor. DON (Director of Nursing) B stated the wound care doctor was notified by LVN (Licensed Vocational Nurse) A of the wound to Resident #1's groin area and that should satisfy reporting requirements even if the primary care physician was not notified of the wound to Resident #1's groin/abdominal. Interview on 1/31/2025 at 12:30 PM with CNA (Certified Nurse Assistant) C revealed she did not know how or why Resident #1 had a wound because she wasn't a resident she was assigned to take care of. She remembered Resident #1's family member yelling in the hallway for help. She stated LVN (Licensed Vocational Nurse) A asked her to assist him treating the wound. She stated the wound was small and they treated it with normal saline. She stated the wound wasn't bleeding but it looked like a clean cut. She stated LVN (Licensed Vocational Nurse) A called the physician and got an order right away. Interview on 1/31/2025 at 1:59 PM with Physician D revealed neither the facility nor family brought the wound to her attention. She stated she remembered being notified by LVN (Licensed Vocational Nurse) A of Resident #1 having lower abdominal pain but specified the LVN (Licensed Vocational Nurse) only contacted her to tell her about a hemorrhoid bleeding. She stated she did not know of any injury to Resident #1's groin area. She stated she should have been contacted if there was a change in condition, injury of unknown origin, open wound, or injury. Interview on 1/31/2025 at 2:20 PM with Physician E revealed she did treat Resident #1's wound. She stated the wound was in the lower abdominal/groin area. She stated it was in kind of a fold area. She specified the wound did not look like a pressure related wound. She stated it was different than a moisture associated breakdown. She stated it could be from trauma but it's hard to say for sure but specified that it did not look moisture related. She stated the wound was small. It was .7 by .8 centimeters. She stated she was notified of the wound by LVN (Licensed Vocational Nurse) A on December 27th around 7pm. She told LVN (Licensed Vocational Nurse) A to follow the standing order until she saw it unless LVN (Licensed Vocational Nurse) A had a major concern. Interview on 1/31/2025 at 3:00 PM with LVN (Licensed Vocational Nurse) A revealed he remembered Resident #1's family member asked for someone to come take a look at a wound on Resident #1. He stated he assessed the resident, treated the wound, and notified the wound care doctor. There was no need to contact the family because the family member was the one who discovered the wound. There was no need to report the wound because it was assumed to be a moisture related incident and not an injury of unknown origin. Record review of the Facility Abuse & Neglect Reporting Policy, dated July 2017, states reflected that All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies. F. The residents Attending Physician.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of three residents (Resident #21, #95, and #88) reviewed for infection control. 1. MA A touched medications without gloves and administered to Resident #21. 2. MA A failed to clean the blood pressure machine while checking the blood pressure for Resident #21 and #95. 3. CNA B failed to complete hand hygiene while providing incontinent care to Resident #88. These failures could place residents at risk for contamination and infection. The findings included: Observation on 02/13/24 at 09:45 AM reflected MA A checked Resident #21's blood pressure and then proceeded to prepare the medications for Resident #21 and put them in the medication cart. While getting the medications from the medication bottle, MA A picked up the medications without gloves. MA A than administered the medications to the resident. MA A completed hand hygiene then proceeded to Resident # 95's room and checked her blood pressure. In an interview on 02/13/24 at 10:14 AM with MA A stated she was aware that she was not supposed to touch the medications with ungloved hands, but she forgot. MA A stated her hands were considered contaminated, so she was not supposed to touch medications without gloves. MA A stated she was not supposed to clean the blood pressure machine unless she had residents who were in isolation. She stated since there were no residents on isolation, she did not need to clean the blood pressure machine. MA A stated she was supposed to maintain infection control to prevent the spread of infection from one resident to another. Observation on 02/14/24 at 01:43 PM revealed CNA B providing incontinent care to Resident #88. The resident was in bed, CNA B went in the room gloved and positioned the resident. CNA B proceeded to unfasten the resident's brief and positioned the resident on her side. Resident#88 had small amount of bowel movement, which was loose. CNA B cleaned the resident and then realized she did not have a trash bag. She then ungloved and left the room. CNA B came back in the room and gloved without any form of hand hygiene. She had a packet of wipes in her hands and trash bag. She then continued to clean the resident's bottom area with wipes and took off gloves after cleaning the resident and donned clean gloves without any form of hand hygiene. CNA B proceed to apply the clean brief, fastened the brief, and positioned the resident, then bagged the trash and left the room without any form of hand hygiene. In an interview on 02/15/24 at 12:34 PM with CNA B she stated she was to complete hand hygiene after taking off the dirty gloves before donning the clean gloves, and she forgot during incontinent care. She stated she was supposed to use hand sanitizer or wash hands after taking off the dirty gloves to prevent cross contamination. She stated she had an in-service on infection control last week, on Monday. In an interview on 02/15/24 at 12:42 PM with the (ADON), she stated she was the Infection Preventionist. The ADON stated the In-service for infection control was ongoing and she could not remember the last time the facility completed one. The ADON stated the staff was not supposed to touch medications without gloves, then it was considered contaminated, and the staff was to discard the medications. The ADON also stated the staff was to clean the blood pressure machine between residents. She stated while providing incontinent care, the staff was to complete hand hygiene before donning gloves. The ADON stated hand hygiene was to be completed to prevent the spread of infection and cross contamination. Review of the infection control/hand hygiene in-service reflected the staff were in-serviced on 10/30/23. In an interview on 02/15/24 at 01:01 PM with the DON, he stated the staff were not supposed to touch medications without gloves and give to the resident because it was considered contaminated. The DON stated regardless of the residents being in isolation or not, the staff was supposed to clean the blood pressure machine in between each use, and the staff were supposed to complete hand hygiene after taking off gloves. The DON stated the staff were supposed to maintain infection control to prevent the spread of infection. Review of the facility policy titled, Hand Washing, effective 05/2017 reflected, It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) shall be readily available and convenient for staff use to encourage the compliance with hand hygiene. PROCEDURE Washing hands: 1. The use of gloves does not replace proper hand washing. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . o After removing gloves or aprons;

Based on observations, interviews, and record review the facility failed to follow their policy regarding storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption of the food and beverages for 9 Residents (#7, #54, #264, #92, #33, #21, #55, #10, and #28) out of 9 reviewed for personal food storage. The facility did not have documentation of temperature checks for the resident's personal refrigerators. The facility staff did not label, date, and clean the nourishment refrigerator for the residents. The deficient practice placed one hundred and ten residents who had used the nourishment refrigerators at risk of food borne illness. The deficient practice placed nine residents who had personal refrigerators at risk of food borne illness. The findings included : Observation on [DATE] at 8:00 AM revealed Resident#7 did not have documentation of temperatures for personal refrigerator. Observation on [DATE] at 8:05AM revealed Resident#54 did not have documentation of temperatures for personal refrigerator. Observation on [DATE] at 8:10 AM revealed Resident#264 did not have documentation of temperatures for personal refrigerator. Interview revealed that she does not use her refrigerator that much and she would clean it out. Observation on [DATE] at 8:13 AM revealed Resident#92 did not have documentation of temperatures for personal refrigerator. Observation on [DATE] at 8:17 AM revealed Resident#33 did not have documentation of temperatures for personal refrigerator. Interview revealed grandson brought food and cleaned it out refrigerator. Observation on [DATE] at 8:22 AM revealed Resident#21 did not have documentation of temperatures for personal refrigerator. Observation on [DATE] at 8:24 AM revealed Resident#55 did not have documentation of temperatures for personal refrigerator. Interview revealed she did not know who cleaned out the refrigerator. Observation on [DATE] at 8:28 AM revealed Resident#01 did not have documentation of temperatures for personal refrigerator. Observation on [DATE] at 8:33 AM revealed Resident#10 did not have documentation of temperatures for personal refrigerator. Observation on [DATE] at 8:37 AM revealed Resident#28 did not have documentation of temperatures for personal refrigerator. Observation on [DATE] at: 11:00 AM of the nourishment room refrigerator revealed, the freezer had: *1 open gallon of [NAME] ice cream *1 open pint of vanilla ice cream *1 unopened pint of vanilla ice cream not labeled and not dated. Observation of the nourishment room refrigerator revealed: *1 bowl of pho not labeled or dated *2 bowls (unidentified items- dark red broth and white broth) not labeled or dated * 2 half sandwiches not labeled or dated * 3 pieces of pizza in a Ziploc bag, labeled [DATE] * Yellow and red sticky stains at the bottom of the refrigerator Interview on [DATE] at 11:45 am the Director of Nursing revealed, residents can get sick from eating expired food. The Director of Nursing stated the nursing staff and dietary staff were responsible for cleaning and dating items brought in by the family to the nourishment room. The Director of Nursing stated personal refrigerators in the resident's rooms were the residents and family's responsibility. Interview on [DATE] at 12:00 PM the Dietary Manager stated, she had gone into the nourishment room refrigerator on Monday and cleaned it out. The Dietary Manager stated families were responsible for labeling and dating food. The Dietary Manager stated, family members have access to put items in the nourishment refrigerator themselves. The Dietary Manager stated she would throw out anything that was not labeled and dated. The Dietary Manager stated there was not a schedule in place stating when to clean out the refrigerator in the nourishment room. The Dietary Manager stated residents could get sick from eating expired foods. The Dietary Manager stated she was not responsible for refrigerators in the resident's room . In an interview on [DATE] at 12:20 pm the Assisted Director of Nursing stated, she would assign a Certified Nurse Aide and Medication Aide to clean, check labels, and dates in the nourishment room refrigerator. The Assisted Director of Nursing stated for resident's personal refrigerator a Certified Nurse Aide/Medication Aide are assigned shift duty's and they change every 2 weeks. Assisted Director of Nursing stated it was honestly hard to keep up with the nourishment refrigerator, since families can go in and out of the refrigerator. The residents can be at risk of getting sick from old food. The Assisted Director of Nursing stated this concern could be an Infection control issue because of people not washing their hands. The Assisted Director of Nursing stated temperature logs were the responsibility of the residents and their family to keep up with the temperatures of personal refrigerators. When the managers do rounds daily, they should be checking the temperature logs. Residents could be at risk of eating spoiled food. To have a refrigerator in the room, residents should be able to clean it, and label and date the items in the refrigerator. It really should be just drinks, nothing from the kitchen should be in the personal refrigerator. In an interview on [DATE] at 1:28pm the Licensed Vocational Nurse T stated She had not cleaned the residents personal refrigerators on her hall before. The Licensed Vocational Nurse T stated that the night nurse was responsible for documentation of temperatures and cleaning out the nourishment room refrigerator and resident's personal refrigerator. The Licensed Vocational Nurse T stated residents could get exposed to bacteria if food is not being dated and labeled residents could get sick. In an interview on [DATE] at 1:34pm the Medication Aide A stated it is not in her job description to clean the nourishment room refrigerator or residents personal refrigerator. Medication Aide A stated residents can get sick from eating expired food. Record review of the facility policy titled foods brought by family/visitors, dated, ([DATE]): 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. 6. The nursing staff will discard perishable foods on or before the use by date.

Based on interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 5 residents reviewed for pharmacy services (Resident #1). Resident #1 missed one dose of Cefdinir presribed to treat Resident #1 for a UTI. This failure could place residents at risk of not receiving the therapeutic benefit of the medication or worsening health concerns. Findings included: Record review of Resident #1's face sheet dated 02/07/23 revealed an [AGE] year-old- female admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a hospital visit following a fall at the facility. Her diagnoses included Dementia, Fracture of left femur and Urinary Tract infection. Resident #1 discharged from the facility on 02/06/23. Review of Resident #1's baseline care plan dated 02/04/23 revealed she required one person physical assistance with activities of daily living. Resident #1 was cognitively impaired. Resident #1 was incontinent of bowel and bladder. Resident #1 did not self-administer her medication. Review of Resident #1's physician order summary report dated 02/07/23 revealed an order for Cefdinir oral capsule 300 mg, give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection) for 3 days, the start date of 02/04/23 and end date of 02/07/23 . Review of Resident #1's Medication Administration Record (MAR) for February 2023 revealed Cefdinir oral capsule 300 mg, was to be administered at 7am and 7pm. Further review revealed medication was not provided on 02/06/23 at 7am as documented. The resident was discharged from the facility prior to the second dosage due time. An interview with MA B on 02/07/23 at 10:31 a.m., revealed the medication was not on the cart and was not available to give to Resident #1. MA B stated the facility only had the 500 mg of the medication and not the 300 mg of the medication as ordered by the physician. MA B informed LVN C the medication was not on the cart. She did not document on the MAR the medication was not available. An interview with LVN C on 02/07/23 at 10:51 a.m., revealed she was informed by MA B that Resident #1's medication for the UTI was not in the facility and on the cart. LVN C stated the facility only had 500 mg of the medication and not 300 mg. They contacted the pharmacy and informed them she needed the medication as soon as possible. She contacted the pharmacy on 02/06/23. LVN C did not state she had informed the physician or nurse practitioner of the medication not being in the facility. An interview with the Nurse Practitioner (NP) on 02/07/23 at 12:15 p.m., revealed she was not aware Resident #1's Cefdinir oral capsule 300 mg was not provided because the medication was not available. The NP revealed if the resident did not take the medication in full, it could cause the infection to get worse. She revealed skipping a dose could make the symptoms worse. If the staff would have informed her she would have discussed changing the medication. An interview with the DON at 1:34 pm on 02/07/23 revealed he had not been made aware of Resident #1's Cefdinir oral capsule 300 mg, not being available. He stated the facility did have the 500 mg capsule. The facility had previous issues with the pharmacy delivering the medications timely. An additional interview with the NP on 02/07/23 at 5:25 p.m., revealed she had been made aware of Resident #1 not receiving her Cefdinir oral capsule 300 mg medication. She revealed she had informed the nurse to contact the pharmacy to have the medication delivered as quickly as possible. Resident #1 had discharged from the facility prior to the facility receiving the medication . Record review of the facility's undated 'Stock medication policy revealed If a medication is ordered for a patient that is not in the stock medication, an initial dose will be sent to facility upon request.

Based on interview and record review, the facility failed to conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests, for one of one facility reviewed for COVID-19 testing. The facility failed to conduct follow up outbreak COVID-19 testing of all residents every three to seven days for a period of 14 days until no new cases were identified based on outbreak testing criteria and a positive result of a resident on 01/03/21. This failure placed residents and staff at risk for exposure to COVID-19 (Coronavirus) which could lead to illness, hospitalization or death. Findings include: An interview with the Interim DON on 1/12/21 at 1:19 PM revealed the facility had not tested all residents for COVID-19 since 12/23/20. She confirmed one resident began to show symptoms and only that resident was tested and resulted in a positive result. An interview with the Administrator on 1/12/21 at 3:36 PM revealed the facility had a resident test positive for COVID-19 on 01/03/21. She stated the facility last tested all residents for COVID-19 on 12/23/20. She stated the facility did not have the manpower to conduct COVID-19 testing of the residents. The facility had continued to test all staff twice weekly. Review of the sampled residents clinical record on 01/21/21 did not revealed the facility had documented residents receiving the a COVID-19 test since 12/23/20. Record review of Center for Clinical Standards and Quality/Survey & Certification Group QSO-20-38, dated 08/26/20, revealed: 483.80(h) COVID-19 Testing. The LTC facility must test residents . for COVID-19 . (1) Conduct testing based on parameters set forth by the Secretary, including but not limited to: (ii) The identification of any individual specified in this paragraph diagnosed with [REDACTED].>19 in the facility; (iii) The identification of any individual specified in this paragraph with symptoms consistent with COVID-19 or with known or suspected exposure to COVID-19 Review of the Center for Disease Control guidance dated 1/7/21 revealed nursing facility's should perform expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility. The facility did not provide any additional information prior to exit.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for two (Residents #1 and #2) of six residents reviewed for drug storage. The facility failed to ensure Resident #1 and #2 medications and treatments were stored in locked compartments and not in their room for self-administration. This failure could place residents at risk for misadministration of medications and possible contraindication with current physician ordered medications or treatments. Findings included: 1. Review of Resident #1's Admission Record dated 0[DATE] reflected she was a [AGE] year-old female who admitted to the facility 09/06/19. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had clear speech, was understood by others, and understood others. Her BI[CONDITION] (15) reflected her cognition was intact. She was diagnosed with [REDACTED]. Review of Resident #1's care plans reflected a care plan for pain management dated 09/18/19. The interventions were to give medications as ordered, monitor for effectiveness, and notify physician as needed. An interview and observation of Resident #1 on 01/22/20 at 9:58 AM revealed Resident #1 was administering OTC lubricating eye drops at the start of the interview. Resident #1 stated she used the eye drops when her eyes got dry. A bottle of OTC [MEDICATION NAME] roll-on pain cream was observed on her bedside table. Resident #1 stated she had arthritis and used the lotion on her knees for pain. Review of Resident #1's physician orders dated 01/23/19 reflected an order for [REDACTED]. There were no orders for lubricating eye drops. 2. Review of Resident #2's Admission Record dated 0[DATE] reflected she was a 91 -year-old female who admitted to the facility 03/02/19. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she had clear speech, was understood by others, and able to understand others. Her BI[CONDITION] (14) reflected her cognition was intact. She was diagnosed with [REDACTED]. An interview and observation of Resident #2 on 01/22/20 at 10:18 AM revealed Resident #2 denied being able to keep OTC medications in her room. However, a bottle of fish oil gummy vitamins was observed on her refrigerator. Review of Resident #2's physician orders dated 0[DATE] reflected no physician order for [REDACTED]. 3. An interview with LVN A on 01/22/20 at 2:41 PM revealed residents were not typically able to keep OTC medications in their rooms, but occasionally they would put an order in to ensure all staff were aware of residents who self-administered their own medications. She stated they have allowed topical lotions but not tablets. LVN A stated in order for residents to self-administer medications, the nurse consulted with the physician to get an order if the resident had a history of [REDACTED]. She stated either the facility received an order for [REDACTED]. An interview with the DON on 0[DATE] at 9:22 AM revealed the only way a resident could store medications in their rooms was if the staff completed a self-administration assessment and the resident was approved. She stated they would give the resident a lock box to store the medications in their rooms securely. The DON stated the facility currently had no residents who self-administered their medications and it did not matter if the medications were prescribed or OTC. The DON stated Residents #1 and #2 should not have had medications in their room. A follow-up interview with the DON on 0[DATE] at 11:06 AM revealed the medications were removed from Residents #1's and #2's rooms. She stated the SW contacted the families of both residents and have advised them not to bring any medications to the facility for the residents to be stored in their rooms. 4. Review of the facility's Medication - Bedside Storage policy dated May 2017 reflected, It is the policy of this home that bedside medication storage is permitted for residents who can self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the home's interdisciplinary resident assessment team .all nurse and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.

Based on observation, interview, and record review the facility failed to store all drugs and biological's in locked compartments for two (500/800 Medication cart and 600/700 Medication cart) of eight medication carts reviewed for medication storage. Medication Aide (MA) B failed to lock two medication carts when they were unattended. This failure placed residents at risk for drug diversion. Findings included: An observation and interview on 05/30/19 at 3:10 PM revealed MA B's medication carts (500/800 and 600/700) were parked outside the nurse's station on the north hall, facing away from the nurses station unlocked and unattended. The carts remained unlocked for approximately 5 minutes. When MA B returned to the carts, she locked both and stated she should have locked the carts when she walked away. In an interview on 05/30/19 at 3:20 PM LVN A revealed his expectation was the medication carts should be locked when the medication aide walked away from the cart. In an interview on 05/30/19 at 3:40 PM the DON revealed the medication carts should be locked when the medication aide walked away. Review of the facility's Security of Medication Cart policy revised (MONTH) 2007 reflected . medication carts should be securely locked at all times when out of the nurse's view.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in refrigerator were labeled and dated. 2. The facility failed to remove expired food items from the refrigerator. These failures could affect all 92 residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination. Findings included: Observation on [DATE] at 9:33 a.m. with the Dietary Manager of the facility's refrigerator revealed the following: A pan of cut up fruit - Cantaloupe and honeydew melon, was not labeled and dated. A 32 oz plastic tube of Cottage cheese with a use-by date of [DATE]. A 32 oz of Dairy Thickened pasteurized milk with a use-by date of [DATE]. A 32 oz of Dairy Thickened pasteurized 2% reduced fat milk vitamin A/D honey consistency with a use-by date of [DATE]. A 46 Fl oz thickened sweetened Tea with a use-by date of [DATE]. Observation of Dietary Manager Manager on [DATE] at 9:33 a.m. throwing away the following items listed above that were out of date and not labeled into the trash can during inital tour of the facility refrigerator: Observation on [DATE] at 9:41 a.m. of the facility walk-in refrigerator revealed two food trays of peaches, and whipped cream that was not labeled and dated. Interview on [DATE] at 3:19 p.m. with the Dietary Manager revealed that thicken milk was for residents that required thicken milk for their liquid consistency. She stated that the facility does not use the milk to prepare meals. She stated that she was aware that the cottage cheese was out date, and that she was going to throw it away. She stated that all the staff that work in the kitchen were responsible for checking the dates on the food. She stated that she checks the labels and dates on the food items every day. She stated that she did not know why the cut fruit that was in the refrigerator was not labeled and dated. She stated that staff should label and date food items before placing them into the refrigerator. She stated after three days she throws the food in the trash. Review of the facility's Preventing Foodborne Illness Food Handling policy, revised (MONTH) 2014, reflected, food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Review of the facility's Food date and Label policy, undated reflected, it is the policy of this facility to provide food and beverages that are palatable and safe for all residents. It is the purpose of the facility to ensure time/temperature sensitive food beverage products are dated and labeled according to the manufactures requirements and state/federal regulations. A use-by date is the last date recommended for the use of the product while at peak quality. Review of the U.S. Public Health Service Food Code, dated (YEAR), reflected: ,[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in ,[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,[DATE].17(A), except time that the product is frozen; P (2) Is in a container or package that does not bear a date or day; P or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A). (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or The Form CMS 672, Resident Census and Condition of Residents, signed and dated by the MDS on [DATE], reflected a census of 96 residents, and there were 4 resident that receive tube feedings.

Based on observation, interview and record review the facility failed to accurately reflect the resident's status for one (Resident #82) of 20 residents reviewed for accuracy of their MDS (Minimum Data Set) assessments. The facility failed to accurately reflect the condition of Resident #82's teeth on her Annual MDS assessment. This failure could have affected 74 residents, 55 residents who were on Medicaid and 19 residents on private pay, who had their MDS assessments completed by LVN C, by placing them at risk of not receiving the care and services they required to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings included: Resident #82's Admission Record dated 06/28/18 reflected she was a [AGE] year-old-female admitted to the facility on [DATE]. It further reflected she had [DIAGNOSES REDACTED]. An observation on 06/26/18 at 10:16 AM revealed LVN A knocked on Resident #82's door. Resident #82 looked over and smiled wide, revealing her teeth were grayish black with some observed to be broken and jagged. Resident #82's Nursing Monthly Summary dated 06/04/18 reflected she had Broken loose or cariuos (sic) teeth, required Daily cleaning of teeth/dentures or daily mouth care-by resident or staff and had No dentures. Resident #82's annual MDS assessment dated [DATE] reflected she had no obvious or likely cavities or broken natural teeth, no mouth of facial pain, discomfort or difficulty with chewing. It further reflected she was moderately impaired cognitively. Resident #82's Dental Referral Form dated 06/13/18, signed by the SW and Resident #82's family member, reflected a referral to the dentist, for an evaluation of broken teeth and a routine exam. It further revealed she had broken, sharp teeth in the left side of her mouth. Resident #82's Care Plans dated as completed on 06/14/18 reflected no care plan for mouth care or dental needs/problems. Interview with Resident #82 on 06/28/18 at 10:50 AM revealed when asked if her teeth/mouth hurt, she nodded her head yes. When asked if she had been hurting for a long time, she stated, 1,2,3 and shook her head no. When asked if she had seen a dentist since she came to the facility she stated, 1,2,3 and shook her head no. When asked again if her teeth/mouth had just recently started hurting, she stated, 1,2,3 and nodded her head yes. When re-asked the same questions after talking with her for a few minutes, she gave the same response to each question. When informed her a dental consult had been placed, she smiled and stated 1,2,3. Interview with the SW on 06/28/18 at 1:20 PM revealed Resident #82's teeth had been bad since she admitted in (MONTH) of (YEAR). The SW had addressed the problem with Resident #82 and her family (since she has [MEDICAL CONDITION]) and they had all refused a dental consult at that time. She stated she had recently sent out the facility's annual dental letter (which explained what and how dental was paid) and her family had just recently asked for a referral because she had complained to them about her mouth hurting. She stated she received a doctor's order for a referral and had just completed the referral recently. She also stated she did not fill out the dental section of the MDS. Interview with LVN B on 06/28/18 at 1:30 PM revealed she was responsible for the Medicare MDS's. She stated she (LVN B) had done Resident #82's original MDS as Resident #82 was on Medicare and had not addressed her dental problem as she had so many worse problems at that time. She stated she (LVN B) had not done her MDS since Resident #82 went on Medicaid but that LVN C did the Medicaid and private pay MDS's. Interview with LVN C on 06/28/17 at 1:35 PM revealed she had completed Resident #82's most recent MDS and asked, What did I miss? An explanation was given about the resident's teeth, and LVN C looked up Resident #82's recent nursing monthly assessment and stated, I missed it because it's on the assessment. (Referring to the Nursing monthly assessment dated [DATE]) She also stated she did go look at them but used the monthly nursing assessment as well, and it was her fault as she had missed it on Resident #82's monthly nursing assessment. LVN C said, There is no care plan. Yes, we do the care plan based on the MDS. She also stated, I will update the MDS and add the care plan now. Interview with the DON on 06/28/18 03:40 PM revealed yes Resident #82 has had bad teeth since she admitted . The DON stated she could not believe Resident 82's dental needs were not on any of her MDS assessments. She stated they would not be on the quarterly assessment as it did not ask those questions, but it should be reflected on her admission and annual MDS as well as a care plan. They had to provide mouth care for her every day, so it should have been care planned. She stated she would get right on it and get it fixed. The facility's policy and procedure Resident Examination and assessment dated (MONTH) 2014 reflected the following: The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plans Physical Exam .12. Teeth and Gums: a ; b. missing teeth . The facility's policy and procedure Comprehensive Assessment and the Care Delivery Process dated (MONTH) (YEAR), reflected the following: 2. Assessment and information collection includes (What, Where, and When?) a. Assess the individual. (1) Gather relevant information from multiple sources including: (a) Observation; (b) Physical assessment; (c) Symptom or condition-related assessments . (h) Evaluations from other disciplines . (2) Complete the Minimum Data Set . The facility's Daily Census dated 06/26/18 reflected there were 55 residents on Medicaid and 19 private pay residents.

Based on observation, interview and record review the facility failed to accurately reflect the resident's status for one (Resident #82) of 20 residents reviewed for accuracy of their MDS (Minimum Data Set) assessments. The facility failed to accurately reflect the condition of Resident #82's teeth on her Annual MDS assessment. This failure could have affected 74 residents, 55 residents who were on Medicaid and 19 residents on private pay, who had their MDS assessments completed by LVN C, by placing them at risk of not receiving the care and services they required to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings include: An observation on 06/26/18 at 10:16 AM revealed LVN A knocked on Resident #82's door, Resident #82 looked and smiled real big, she had bright red lipstick on and her teeth were grayish black with some observed to be broken and jagged. Resident #82's Admission Record dated 06/28/18 reflected she was a [AGE] year-old-female admitted to the facility on [DATE]. It further reflected she had [DIAGNOSES REDACTED]. Resident #82's Nursing Monthly Summary dated 06/04/18 reflected she had Broken loose or cariuos (sic)teeth, required Daily cleaning of teeth/dentures or daily mouth care-by resident or staff and had No dentures. Resident #82's annual MDS dated [DATE] reflected she had no obvious or likely cavities or broken natural teeth, no mouth of facial pain, discomfort or difficulty with chewing. It further reflected she was moderately impaired cognitively. Resident #82's Dental Referral Form dated 06/13/18, signed by the SW and Resident #82's family member, reflected a referral to the dentist, for an evaluation of broken teeth and a routine exam. It further revealed she had broken, sharp teeth in the left side of her mouth. Resident #82's Care Plans dated as completed on 06/14/18 reflected no care plan for mouth care or dental needs/problems. Interview with Resident #82 on 06/28/18 at 10:50 AM revealed when asked if her teeth/mouth hurt, she nodded her head yes, when asked if she had been hurting for a long time, she stated, 1,2,3 and shook her head no. When asked if she had seen a dentist since she came to the facility she stated, 1,2,3 and shook her head no. When asked again if her teeth/mouth had just recently started hurting, she stated, 1,2,3 and nodded her head yes. When re-asked the same questions after talking with her for a few minutes, she gave the same response to each question. When informed her a dental consult had been placed, she smiled and stated 1,2,3. Interview with the SW on 06/28/18 at 1:20 PM revealed Resident #82's teeth had been bad since she admitted in (MONTH) of (YEAR). The SW had addressed the problem with Resident #82 and her family (since she has [MEDICAL CONDITION]) and they had all refused a dental consult at that time. She stated she had recently sent out the facility's annual dental letter (which explained what and how dental was paid) and her family had just recently asked for a referral because she had complained to them about her mouth hurting. She stated she received a doctor order for a referral and had just completed the referral recently. She also stated she did not fill out the dental section of the MDS. Interview with LVN B on 06/28/18 at 1:30 PM revealed she was responsible for the Medicare MDS's. She stated she (LVN B) had done Resident #82's original MDS as Resident #82 was on Medicare and had not addressed her dental problem as she had so many worse problems at that time. She stated she (LVN B) had not done her MDS since Resident #82 went on Medicaid but that LVN C did the Medicaid and private pay MDS's. Interview with LVN C on 06/28/17 at 1:35 PM revealed she had done her most recent MDS and asked, What did I miss? Explained about her teeth and she looked up Resident Rose's recent nursing monthly assessment and stated, I missed it because it's on the assessment. She also stated she did go look at them but use the monthly nursing assessment as well and it was her fault as she had missed it on Resident #82's monthly nursing assessment. There is no care plan, yes, we do the care plan based on the MDS. She also stated, I will update the MDS and add the care plan now. Interview with DON on 06/28/18 03:40 PM revealed yes Resident #82 has had bad teeth since she admitted . The DON stated she could not believe Resident 82's dental needs were not on any of her MDS's. She stated they would not be on the quarterly as it did not ask those questions, but it should be reflected on her admission and annual MDS as well as a care plan. They had to do mouth care on her every day, so it should have been care planned. She stated she would get right on it and get it fixed. The facility's policy and procedure Resident Examination and assessment dated (MONTH) 2014 reflected the following: The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plans Physical Exam .12. Teeth and Gums: a ; b. missing teeth . The facility's policy and procedure Comprehensive Assessment and the Care Delivery Process dated (MONTH) (YEAR), reflected the following: 2. Assessment and information collection includes (What, Where, and When?) a. Assess the individual. (1) Gather relevant information from multiple sources including: (a) Observation; (b) Physical assessment; (c) Symptom or condition-related assessments . (h) Evaluations from other disciplines . (2) Complete the Minimum Data Set . The facility's Daily Census dated 06/26/18 reflected there were 55 residents on Medicaid and 19 private pay residents.