Every finding on record at Magnolia Place Health Care

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation.The facility failed to ensure dietary staff used the correct sanitizer test strip for the dishwasher sanitation compliance check on 07/27/2026.This failure could place residents at risk for food contamination and foodborne illness. Findings included:During an observation and interview on 07/27/2026 at 09:38 a.m., Dishwasher Aide C said she had not tested the dishwasher's sanitizer concentration. She proceeded to demonstrate how the sanitizer concentration was tested, however, Dishwasher Aide C requested assistance from another staff member. Dishwasher Aide C placed a chemical test strip in the rinse water during the dishwasher's rinse cycle; the color of the test strip corresponded to 100 parts per million (ppm) on the test-strip container. Observation revealed the facility was not using the appropriate chlorine test strips to verify the dishwasher's final-rinse sanitizer concentration. The available test strips did not measure chlorine concentrations as low as the manufacturer-required specification of 50 ppm and staff were unable to accurately determine whether the final-rinse chlorine concentration was maintained at the required 50 ppm.Record review of the dishwasher sanitizer and temperature logs revealed staff had documented sanitizer concentrations using the incorrect test strips. The documented sanitizer concentrations did not provide evidence that the dishwasher's final-rinse chlorine concentration had been maintained at the manufacturer-required 50 ppm for an American Dish dishwasher model AF-3D.During an interview on 07/28/2026 at 10:24 a.m., DM A said the test strips used on 07/27/2026 had been ordered the previous week and staff began using them during the current week. She confirmed the strips used to test the dishwasher were intended for testing the sanitizer concentration in the three-compartment sink. (After surveyor intervention), DM A said staff had been re-educated on 07/27/2026 around 5:00 p.m. by sanitation company regarding the correct test strips and the proper procedure for testing the dish machine concentration. She said the dishes and utensils were washed in three-compartment sink until around 5:00 p.m. on 07/27/2026 when the sanitation dish machine test strips were delivered and dish machine was tested and had 50 ppm of sanitizer.During an interview on 07/28/2026 at 3:03 p.m., Dishwasher Aide C said she had been responsible for washing dishes for the previous three days and normally served as the backup Dishwasher Aide. She said she had received training regarding the proper operation of the dishwasher. She said the potential risk for residents if dishes were not properly sanitized, was that residents could develop stomach illnesses.During an interview on 07/29/2026 at 10:23 a.m., DM B said she had served as the facility's Dietary Manager for approximately three months during 2026 and said the sanitation company was responsible for ordering the dishwasher sanitizer test strips. She said the facility received the correct test strips yesterday and the dish machine tested correctly. She stated she had not previously experienced a problem with the facility receiving incorrect test strips. She said the potential risk for residents if dishes and utensils were not properly sanitized was residents could develop foodborne illnesses.Interview on 07/28/2026 5:20 p.m., the Administrator said his expectation was for the dietary staff to use the right test strip to obtain the correct results for the sanitizer. He said he expected the DM to let him know if they need items such as test strips. He said the resident risk was foodborne illness.Record review of the facility's undated Commercial Dishwasher Sanitization policy, revealed It is the policy of the facility to ensure that the commercial dishwasher consistently achieves the required sanitizing temperature or chemical sanitizer concentration to effectively sanitize dishes, utensils, and food-contact equipment. Sanitization levels shall be checked and documented at the beginning of each dietary shift and whenever a new rack is tested after maintenance or concerns regarding dishwasher performance.The Food Drug Administration Code dated 2017 indicated . Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. warewashing Equipment, Cleaning Agents. When used for WAREWASHING, the wash compartment of a sink, mechanical warewasher, or wash receptacle of alternative manual WAREWASHING EQUIPMENT, shall contain a wash solution of soap, detergent, acid cleaner, alkaline cleaner, degreaser, abrasive cleaner, or other cleaning agent according to the cleaning agent manufacturer's label instructions. Warewashing Equipment, Determining Chemical Sanitizer Concentration.Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device.

Based on observation, interview, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment to reflect the current condition for 3 of 6 residents reviewed for comprehensive care plans. (Residents #12, #23, and #30) 1.The facility failed to ensure the care plan was updated to indicate Resident #12's discontinued g-tube, tube feedings, medications by g-tube, and EBP. 2. The facility failed to ensure Residents #23 and #30's care plans included noncompliance with HOB elevation due to g-tube. These failures could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. Record review of physician orders for July 2026 indicated Resident #12 was an [AGE] year-old male admitted on [DATE]. His diagnoses included gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube. An order dated 07/08/26 indicated to discontinue g-tube. Record review of a significant change MDS dated [DATE] indicated Resident #12 had minimal difficulty hearing, he had unclear speech, he was sometimes understood, he was able to usually understand others, he had severely impaired cognition with a BIMS of 7 out of 15, he had a feeding tube while a resident, and he received 51% or more of total calories through the feeding tube. Record review of a Care Plan dated 04/01/26 indicated Resident #12 had tube feedings and EBP. During an observation and interview on 07/27/26 at 11:32 a.m. Resident #12 had no EBP on the door. He was in bed in his room. He was asked questions but was hard to understand what he was trying to say. There was no feeding pump in the room. During an interview on 07/29/26 at 11:30 a.m. LVN E said Resident #12's gastrostomy tube was discontinued on 07/08/26 by the hospice nurse. She said the tube feeding and medications via g-tube were also discontinued as well as his EBP. During an interview on 07/29/26 at 12:40 p.m. MDS Nurse F and MDS Nurse G said they were responsible for the care plans. They said care plans were to be updated when a resident had a change so it would reflect them correctly. MDS Nurse F said she was responsible for Resident #12's care plan. She said she should have had his care plan updated to remove the feeding tube and EBP. During an interview on 07/29/26 at 01:35 p.m. the DON said the care plan should reflect the resident's current condition. She said Resident #12's care plan should have been updated to reflect his feeding tube and EBP was discontinued. 2. Record review of physician orders for July 2026 indicated Resident #23 was a [AGE] year-old male admitted on [DATE]. His diagnoses included gastrostomy tube. Record review of a quarterly MDS dated [DATE] indicated Resident #23 had adequate hearing, he had clear speech, he was understood, he was able to understand others, he had moderately impaired cognition with a BIMS of 9 out of 15, he had no impairment to both upper extremities, he had a feeding tube while a resident, and he received 51% or more of total calories through the feeding tube. Record review of a Care Plan indicated Resident #23 had a g-tube feeding placing him at risk for aspiration, altered nutrition, dehydration with intervention to keep the HOB elevated at least 30 degrees at all times date initiated 11/18/24 and reviewed on 06/10/26. The care plan did not address Resident #23 putting the HOB down flat. During an observation and interview on 07/27/26 at 01:32 p.m. Resident #23 had EBP on the door. He was in bed in his room with the head of his bed elevated and his g-tube feeding infusing through the g-tube. Record review of physician orders for July 2026 indicated Resident #30 was a [AGE] year-old male admitted on [DATE]. His diagnoses included gastrostomy tube. Record review of a quarterly MDS dated [DATE] indicated Resident #30 had adequate hearing, he had clear speech, he was understood, he was able to understand others, he had moderately impaired cognition with a BIMS of 9 out of 15, he had no impairment to both upper extremities, he had a feeding tube while a resident, and he received 51% or more of total calories through the feeding tube. Record review of a Care Plan indicated Resident #30 had a tube feeding placing him at risk for aspiration, altered nutrition, dehydration with intervention to keep the HOB elevated at least 30 degrees at all times date initiated 01/21/25 and reviewed on 06/08/26. The care plan did not address Resident #30 putting the HOB down flat. During an observation and interview on 07/27/2026 at 11:30 a.m., Resident #30 had EBP on the door. The resident had a feeding pump at the bedside turned on and administering g-tube feeding. The resident was in his bed with the HOB lying flat. He said he was doing okay. When asked why the HOB was not raised he said he had put it down because he was sleeping and to leave him alone. During an interview on 07/29/26 at 11:30 a.m., LVN E said Residents #23 and #30 were both known to put the head of the bed down when they wanted it down. She said she would educate them both about the importance of not putting the HOB down due to the g-tube feeding and they would acknowledge they understood but they would still do it. During an interview on 07/29/26 at 12:40 p.m. MDS Nurse F said Residents #23 and #30 should have interventions to include they would put the HOB up and down since it was to be elevated all the time to prevent aspiration. She said she was responsible for updating the care plans. During an interview on 07/29/26 at 01:35 p.m. the DON said the care plan should reflect the resident's current condition. She said she did not know about Residents #23 and #30 raising the head of the bed up and down. She said it was the MDS Nurses' responsibility to update the care plans when needed Record review of an undated Policy & Procedure: Resident Care Plans indicated PolicyThe facility shall develop, implement, review, and revise an individualized care plan for each resident in accordance with applicable federal and state regulations. Care plans will reflect each resident's assessed needs, preferences, goals, and services required to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. Procedure. 2. The interdisciplinary team will participate in development and review of the care plan as appropriate. 4. Care plans will include identified problems, measurable goals, and interventions specific to the resident's needs. 8. The interdisciplinary team will review care plans routinely and revise them as necessary to ensure they remain current and effective.

Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 2 of 6 residents reviewed for resident rights. (Residents #12 and #18) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #12 and #18. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: 1. Record review of physician orders for [DATE] indicated Resident #12 was an [AGE] year-old male admitted on [DATE]. His diagnoses included senile degeneration of the brain (progressive disease that destroys memory and other important mental functions). An order dated [DATE] indicated Resident #12 had a DNR order. Record review of a significant change MDS dated [DATE] indicated Resident #12 had minimal difficulty hearing, he had unclear speech, he was sometimes understood, he was able to usually understand others, and she had severely impaired cognition with a BIMS of 7 out of 15. Record review of a Care Plan indicated Resident #12 had a care plan for Code Status: DNR Status initiated on [DATE] and reviewed on [DATE]. Record review of the OOH-DNR form dated [DATE] for Resident #12 indicated the top section had the resident's name, date of birth , and gender. Resident #12's gender was not marked. One of the witnesses on the form was the SW. During an observation and interview on [DATE] at 11:32 a.m. Resident #12 was in bed in his room. He was asked questions but it was difficult to understand what he was trying to say. 2. Review of Resident #18's face sheet, dated [DATE], indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Dementia Disease (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), heart failure (condition in which the heart does not pump blood as well as it should), kidney disease and advance directive of DO NOT RESUSCITATE. Review of Resident #18's Quarterly MDS Assessment, dated [DATE], indicated: Resident #18's BIMS score was 3 of 15, indicating severe cognitive impairment. Review of Resident #18's Care Plan, initiated [DATE], indicated Resident #18 was a DNR status, interventions for no CPR in the event of death and to obtain a written DNR. Review of Resident #18's Order Summary, dated [DATE], indicated orders that Resident #18 was a DNR dated [DATE]. Review of Resident #18's DNR form completed [DATE] indicated: Section B: Resident #18's DNR was signed on [DATE] but there was no check mark identifying the signature as the legal guardian, agent in a medical power of attorney or the proxy in a directive. During an interview on [DATE] at 1:30 p.m., the SW said Resident #12's DNR form missed the residents gender identification and Resident #18's DNR form was missing identification of the signature in section B. The SW said Resident #12 and #18's DNR forms were not complete. The SW said if a DNR form was not completed correctly with accurate dates, signatures and boxes checked the DNR form would be invalid. The SW said it was the SW responsibility to ensure DNR forms were completed accurately to include signatures and dates. The SW said she must not have been looking in detail like she should be when reviewing the DNRs. The SW said she would check all the DNRs for proper completeness of signatures, checked boxes and dates. The SW said a resident's wishes may not have been followed if their advance directive was not completed. During an interview on [DATE] at 1:30 p.m., the DON said DNRs were reviewed by the admitting nurse and social worker to ensure accuracy. The DON said the DNR forms should be completed thoroughly to include checked boxes, dates that the document was witnessed sign and signatures. The DON verified there were no additional advance directives or DNRs for Residents #12 or #18. The DON verified the current DNR forms for Residents #12 and #18 were not completed. The DON said Resident #12's DNR gender was not marked and Resident #18's DNR there was no check mark identifying the signature as the legal guardian, agent in a medical power of attorney or the proxy in a directive. She said that in such a case, staff would be required to initiate CPR, which would go against the resident's expressed wishes. The DON said it was important for the DNR to be completed thoroughly to ensure the documents were legally binding. The DON said if an advance directive was not completed, the resident's wishes may not be honored. The DON said the facility did not have a DNR policy but used the instruction on the back of the DNR form. The DON said she would ensure the DNRs for Residents #12 and #18 were updated as soon as possible and she would check the other residents with DNRs for completeness. Record review of an undated Policy & Procedure titled: Quarterly Do Not Resuscitate (DNR) Audit indicated: Policy: Magnolia Place Health Care LLP shall conduct a comprehensive audit of all resident Do Not Resuscitate (DNR) documentation on a quarterly basis to ensure each resident's code status is accurately documented, supported by appropriate physician orders, completed in accordance with applicable Texas laws and regulations, and readily available to staff during an emergency. The purpose of this audit is to ensure resident wishes are honored, maintain regulatory compliance, and identify documentation deficiencies requiring corrective action. 4. Audit Criteria, Verify resident identification is accurate. Verify a valid physician/practitioner DNR order is present with required signatures and dates. Verify resident or legally authorized representative documentation is complete when applicable. Verify the DNR form is complete, legible, and contains no missing required fields. Record review of the INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER revised [DATE] indicated Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order was for use by qualified persons or their representatives to direct health professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. .Section B – If and adult person is incompetent or otherwise mentally or physically incapable of communication and has a legal guardian, agent in a medical power of attorney, or proxy in a directive to physician, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in section B. .In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 3 residents (Resident #23) reviewed for enteral devices. The facility failed to ensure LVN D administered Resident #23's water flush by gravity instead of pushing it through his gastrostomy tube (placement of a tube into the stomach used for nutrition and medication administration) with a syringe on 07/27/2026. This failure could affect residents receiving enteral nutrition, medications, and hydration by placing them at risk of health complications.Findings included: Record review of Resident #23's face sheet dated 07/27/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included transient ischemic attack (temporary block of blood flow to the brain causing sudden stroke like symptoms short term), cerebral infarction (stroke), encounter for attention to gastrostomy (billing code that covers routine care, maintenance and management of a gastrostomy tube) and dysphagia (difficulty swallowing). Record review of Resident #23's Quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 9, indicated moderately impaired cognition with diagnoses of cerebral infarct, encounter for attention to gastrostomy and dysphagia. Resident #23's MDS assessment indicated the resident had a feeding tube. Record review of Resident #23's Order Summary Report dated 07/27/2026 indicated enteral feeding order flush gastrostomy tube with 60 ml water before and after medication and feeding and 10 ml between medication with a start dated 08/05/2025. Record review of Resident #23's care plan with a target date of 11/26/2026 indicated he had a gastronomy tube due to an altered nutrition risk with interventions including needed assistance with tube feeding ad water flushes and follow physician orders. During an observation and interview on 07/27/2026 at 1:50 p.m., Resident #23 was lying in bed with the head of bed elevated to 45 degrees, he said he received his medication and gastrostomy tube feeding into his stomach. He said he had no problems with his gastrostomy tube. During an observation of medication administration on 07/27/2026 starting at 2:00 p.m., LVN D brought the medication into the room wearing a gown and gloves checked the gastrostomy tube for placement and pushed 60 ml of water through Resident #23's gastrostomy tube slowly with a syringe and plunger. She said she should have inserted the water by gravity instead of pushing it with the syringe and plunger. She said she was educated to give medication and water by gravity. She said she was not sure what happened, she got nervous. She inserted the medication into the gastrostomy tube and allowed it to flow by gravity and followed with 60 ml of water given by gravity. LVN D said the potential resident risk of pushing water by syringe and plunger and not giving by gravity flow was it could potentially cause cramping or abdominal pain to the resident. During an interview on 07/28/2026 at 11:45 a.m., the DON said the nurse giving medication for the gastrostomy tube resident was responsible for giving the medication properly and all the nurses were educated on proper administration of gastrostomy tube medication. The DON said the pharmacy consultant made rounds monthly and observed medication administration by the nurses. She said the potential resident risk of pushing water in a syringe prior to medication administration instead of by gravity flow was not following facility policy. The DON said her expectation was all medication and gastrostomy tube flushes be given according to facility policy. During an interview on 07/28/2026 at 3:22 p.m., the Administrator said the nurse giving medication was responsible for giving gastrostomy tube medication properly. He said all the nurses were educated on gastrostomy medication procedures. The Administrator said the potential resident risk of pushing fluid into the gastrostomy tube instead of being given by gravity was not following facility policy. The Administrator said his expectation was all nurses give medication according to facility policy and procedure. Record review of LVN D's Nurse Competency/Skills Checklist for Initial orientation and Annually, indicated she was checked off on orientation, 05/14/2024 and annually, 05/07/2025 and 05/18/2026 that included enteral feeding and medication administration. Record review of an undated facility policy titled, ' Administration of Medication via Gastrostomy Tube (G-Tube) indicated, . Medication Administration To ensure medications administered through a gastrostomy tube (G-tube), PEG tube, or other gastric feeding tube are delivered safely, effectively, and in accordance with physician orders, manufacturer recommendations, professional nursing standards, and applicable federal and state regulations.Flush with 30 mL of water before administering medications unless otherwise ordered. Medication Administration: Stop enteral feeding if required. Administer medications one at a time. Do not mix medications together or with tube feeding formula. Allow medication to flow by gravity or gently administer with an enteral syringe. Never force medication through the tube. Flush with10-15 mL of water between each medication.

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 10 rooms (room [ROOM NUMBER]) observed for homelike environment.The facility failed to ensure room [ROOM NUMBER] was in good repair and did not have a hole and missing wood exposing the wood frame of the toilet seat on 07/27/26 and 07/28/26.This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included: During an observation on 07/27/2026 at 9:45 a.m. on hall 300:room [ROOM NUMBER], bathroom toilet seat had a complete split, torn peeling paint and a hole that exposed the brown wood. The hole was approximately 4 inches wide and 0.5 inches in length. And the inside of the hole had a build-up of a brown substance. The hole was approximately 2 inches wide and 0.5 inches in length.During an observation on 07/28/2026 at 9:45 a.m. on hall 300 in room [ROOM NUMBER], the bathroom toilet seat had a complete split, torn and peeling paint and a hole that exposed the brown wood.During an observation and interview on 07/28/26 at 9:30 a.m., the Housekeeper said she had been employed at the facility for 8 years. The Housekeeper said she had already cleaned room [ROOM NUMBER] and was not aware of the condition of the toilet seat. When observing and reviewing the toilet seat with the surveyor the housekeeper said this must have just happened because it was not like that when she cleaned the room. The housekeeper said if she noticed anything needing repair she would put in a maintenance request in the maintenance book that was at the nurse's stations or would tell him verbally. The housekeeper said she was confused and had already notified the maintenance worker face to face about room [ROOM NUMBER]'s toilet. The housekeeper said it could potentially negatively affect a resident if building repairs were not completed.During an observation and interview on 07/28/26 at 10:30 a.m., the Maintenance Supervisor said he had been employed at the facility for 22 years, and it was his expectation to try to complete repair issues the day they were submitted unless parts were required that needed to be ordered. The Maintenance Supervisor said he was not aware of the repairs needing to be made to the toilet in room [ROOM NUMBER], he said it had not been logged into the maintenance log binder. He said it would take about 5 minutes to repair, and he would change out the toilet seat.The Maintenance Supervisor said if parts needed to be ordered then repairs were completed once the needed parts came in. The Maintenance Supervisor said he oversaw repairs and scheduling repairs with outside vendors for facility maintenance and repairs. The Maintenance Supervisor said the facility staff put any maintenance requests or needs in the maintenance logbook that was at the nurse's stations or could tell him verbally. The Maintenance Supervisor said he or his maintenance worker would check the logs daily if possible but at a minimum of several times a week. The Maintenance Supervisor said he was responsible for making sure the completion of maintenance requests and building repairs were done. The Maintenance Supervisor said it could potentially negatively affect a resident if building repairs were not completedDuring an interview on 07/28/26 at 10:30 a.m., the maintenance worker said he was not aware of room [ROOM NUMBER] toilet seat condition and it had not been logged into the maintenance log binder or been told he would have changed it out. The maintenance worker said a resident could hurt themselves if building repairs were not completed.During an interview on 07/29/26 at 2:25 p.m., the Administrator said he had been employed with the facility for about 20 years or so. The Administrator said it was his expectation that any facility repair request be communicated via the maintenance log repair binder unless it was an emergency then to call the Maintenance Supervisor or the Administrator. The Administrator said repairs are completed the next day unless parts are needed to complete the repair then as soon as parts come in the repair is completed. The Administrator said Maintenance Supervisor is responsible for checking the maintenance log binder daily and completing facility repairs. The Administrator said he expected the facility to be homelike for the residents. The Administrator said he was responsible for ensuring the facility and resident rooms were homelike. The Administrator said it could negatively impact the residents' quality of life and demeanor.Record review of Maintenance logs for the facility from 02/01/2026 through 07/29/2026 did not indicate room [ROOM NUMBER]'s toilet seat had been reported needing repair.Review of the facility's undated policy titled Maintenance Repairs, read in relevant part Magnolia Place Health Care LLP shall maintain the facility in a safe and functional condition. Maintenance concerns shall be reported, documented, and repaired in a timely manner. Procedure: A Maintenance Log shall be maintained at the nurses' station. Any employee identifying a maintenance issue shall record it in the Maintenance Log. The Maintenance Supervisor or designee shall review the Maintenance Log each workday. Repairs shall be completed within a reasonable timeframe based on the priority and nature of the repair. Repairs affecting resident safety shall receive immediate attention Record review of a facility posting titled Resident Rights, read, .Dignity and Respect: you have the right to: *Live in safe, decent and clean conditions.

Based on observation, interview and record review the facility failed to ensure as part of its infection prevention and control program mandatory training included the written standards, policies, and procedures for the program for 11 of 12 employees, new and existing staff, (Administrator, DON, ADON/IP, LVN E, LVN H, CNA A, CNA B, CNA F, CNA I, CNA J, and CNA K) reviewed for training. 1. The facility failed to ensure the Administrator, DON, ADON/IP were trained on EBP (an infection control strategy that uses gloves and gowns during high- contact resident care to reduce spread of MDRO) (MDRO- bacteria that have become resistant to certain antibiotics) 2. The facility failed to ensure LVN E and LVN H were trained on EBP. 3. The facility failed to ensure CNA A, CNA B, CNA F, CNA I, CNA J and CNA K were trained on EBP. These failures could place residents at risk of illness due to lack of staff training. Findings include: Record review of a facility's in-service on 06/04/25, titled, Enhanced Barrier Precautions, indicated, It is the policy of this facility to implement enhance barrier precautions for the prevention of transmission of multidrug-resistant organisms indicated all nurses and CNAs were educated after surveyor intervention. During an observation and interview of incontinent care on 06/03/25 at 03:05 p.m., CNA A provided incontinent care to Resident #11 with assistance of CNA B. Resident #11 was in his bed. CNA A provided the incontinent care while CNA B assisted by holding Resident #11's shoulder and hip. CNA A and CNA B donned gloves, but they did not put on a gown. There was no EBP sign on the door or in the room. Resident #11 observed with an intact g-tube (small flexible tube surgically inserted through the abdomen and stomach to deliver nutrition to the stomach). When asked did they forget anything or would do anything different CNA A and CNA B said no. During an interview on 6/3/25 at 4:10 p.m., CNA B when asked what EBP was, she said putting a towel across the table and setting everything up for incontinent care when asked the difference between EBP and TBP she said standard precautions was washing your hands and wearing gloves for incontinent care. She said she was unsure what high contact resident care activities would need EBP. CNA B said she had been trained on EBP but did not remember when. During an interview on 6/3/25 at 4:20 p.m., CNA K said she was unsure what EBP was, she said she had been trained on EBP in class earlier this year but unsure when. She said high contact resident care activities included changing and dressing residents. CNA K said the PPE worn depended on the type of infection or isolation the resident was in. During the interview on 6/3/25 at 4:25 p.m., LVN E said she was responsible for halls 100, 200, and 300. She stated she was unsure what EBP was but she knew it included gloves. She said TBP included airborne, contact, droplet precautions but she had not heard anything about EBP. LVN E said for residents on isolation, staff did not remove anything out of a resident's room until it's covered and bagged properly and used hand hygiene properly. LVN E said she was unsure if she was trained on EBP. She said there were no residents on her halls on EBP and if a resident had some kind of infection or a reason to be on isolation precautions they were put in a private room. During an interview on 6/3/25 at 4:28 p.m., CNA A when asked what EBP was, she said putting barrier cream (a topical product to protect the skin's natural barrier) on the resident. She said the nurses tell the CNA's when needed. CNA A said she was unsure of the difference between EBP and TBP. She said high contact resident activities included changing the residents. She said she wore gloves and wash her hands before and during incontinent care. She said she was unsure if she was trained on EBP. During an interview on 6/3/25 at 4:33 p.m., LVN H said she was responsible for halls 400, 500 and 600. She said she was unsure what EBP was. She said the difference between EBP and TBP included use of PPE depending on the type of isolation. She said none of the residents on her halls were on EBP. During an interview on 6/3/25 at 4:40 PM, CNA F said barrier meant the green pad she put down on the table to separate supplies and cream that was put on the resident for skin issues. She said she was unsure of the difference between EBP and TBP. CNA F said she was trained on EBP. She said isolation included putting on a gown, mask and gloves and it must be disposed of properly. CNA F said a few residents on hall 300 received barrier cream when asked if any residents were on EBP. During an interview on 6/3/25 at 4:47PM, CNA I said EBP was putting barrier cream on the resident. She was unsure of the difference between EBP and TBP. She said she received infection control training which included PPE, when to wear it and what kind of isolation needed certain PPE. CNA I said no residents on her halls were on EBP. CNA I said high contact resident care activities included incontinent care. During an interview on 06/03/25 at 4:55 p.m., CNA J said EBP was a way to control infection, staff wore a gown and gloves. She said the difference between TBP was isolation, the resident could not go around in the facility or leave the room and staff must wear complete PPE to enter the resident room. She said for EBP the resident did not have to stay in their room, but staff wore a gown and gloves for direct patient care. CNA J said high contact resident care activities included changing or dressing the resident. She said the charge nurse would notify the CNA's of EBP and TBP, and there would be a sign on the door and PPE on the outside of the door and PPE to use for resident care. CNA J said no residents on her hall received EBP at this time. During an interview on 06/03/25 at 5:00 p.m., the ADON/IP said she was responsible for the infection control program. She said she had not been updated or completed any joint trainings or provider trainings. She said she was not aware of any changes or updates within the last two years. She said EBP did not sound familiar to her and she was not trained on EBP. She said she did not go to any provider or joint trainings. She said she looked on the Texas Health and Human Services website and CDC for changes. She said the DON and Administrator notified her of updates. The ADON/IP said she was responsible for training staff on infection control concerns. She said no residents in the facility were on EBP. During an interview on 06/03/25 at 5:07 p.m., the DON, said EBP was the new CDC recommendations to use face a mask more than just with regular isolation. She was not aware of the specifics but knew it was the new update in infection control. She said she had not been trained on EBP. The DON said she had no luck signing up for the in-person trainings, joint trainings, or classes, they were always full. She said she stayed up to date through emails and provider letters, but it was a lot to sort through. The DON said the Administrator also received provider letters and notified her of them. She said she was unable to say her expectations related to the infection control program and EBP. She said herself and the ADON/ IP worked together to complete the infection control program. The DON said the new regulations changes were on the horizon, but she did not take the class. She said the facility had 3 Residents with g-tubes and two residents with Foley catheters (a thin tube placed in the bladder to drain urine when normal urination id not possible) and they were not currently on EBP. During an interview on 06/04/25 at 3:50 p.m., ADON/ IP after surveyor intervention said she was now educated on EBP. She said she was responsible for the Infection control program now including EBP with DON as back up. She said the risk of a resident that should be on EBP not being on EBP was increased risk of infection. She said she was trained on EBP as of 06/03/25. During an interview on 06/04/25 at 3:53 p.m., the DON after surveyor intervention said she was now educated on EBP on 06/03/25. She said she had reached out to their training company for computer training to add EBP training and added it to orientation. She said the current nurses and CNAs were trained on 06/04/25. She said the ADON/IP was trained on EBP and was responsible for training staff and she was the back up. She said she expected her staff to be educated on EBP on hire and as needed and to follow EBP precautions on all residents identified needing EBP. She said there is no resident risk for staff not following EBP because all residents were treated with universal precautions and if a resident had a risk or active infection they would be on special precautions as needed. During an interview on 06/04/25 at 3:53 p.m., the Administrator after surveyor intervention said he was ultimately responsible for concerns in the facility including infection control education. He said the ADON/IP was responsible for infection control program including EBP and the DON was the back up. He said he expected all staff to be educated on EBP on hire and as needed and to follow EBP precautions on all residents identified needing EBP. He said there is no resident risk for the staff not following EBP because all residents were treated with universal precautions and if a resident had a risk or active infection they would be on special precautions as needed. Record review of the facility's policy titled, Enhanced Barrier Precautions, effective 06/04/2025, indicated, It is the policy of this facility to implement enhance barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, . or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, . even if the resident is not known to be infected or colonized with a MDRO.)

Based on observation, interview, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of all residents reviewed. 1. The Administrator failed to ensure he, the DON, and the IP received training on Enhanced Barrier Precautions. 2. The Administrator failed to implement Enhanced Barrier Precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. This failure could cause residents not to receive appropriate care resulting in an increase in infections. Findings included: During observations on 06/02/25 during initial tour from 09:15 a.m. through 11:03 a.m. there were no resident rooms with any EBP signage on the doors or PPE set up outside or inside the resident rooms. During general observations on 06/02/25 from 11:30 a.m. through 04:00 p.m. there were no resident rooms with any EBP signage on the doors or PPE set up outside or inside the resident rooms. During general observations on 06/03/25 from 08:30 a.m. through 05:00 p.m. there were no resident rooms with any EBP signage on the doors or PPE set up outside or inside the resident rooms. During an interview on 06/03/25 at 5:00 p.m., the ADON/IP said she was responsible for the infection control program. She said she was the infection preventionist and received the CMS training in 2022 and reviewed the CMS and CDC web sites. She said she had not been updated or completed any joint trainings or provider trainings. She said she was not aware of any changes or updates within the last two years. She said she trained the staff. The ADON/IP said she had no back up to double check the infection control program. When asked what enhanced barrier precautions was, she said EBP did not sound familiar to her, and she was not trained on EBP. She said the DON and Administrator notified her of infection control updates. She said no residents in the facility were currently on enhanced barrier precautions. During an interview on 06/03/25 at 5:07 p.m., the DON, when asked what enhanced barrier precautions was, she said the new CDC recommendations to use face mask more than just with regular isolation. She said she was not aware of the specifics but knew it was the new update. She said she was not trained on EBP. The DON said she had no luck signing up for in person trainings, joint trainings, or classes, they were always full. She said the Administrator received provider letters. She said she was unable to say her expectations related to EBP. The DON said she was aware new regulation changes were on the horizon. She said the facility had 3 Residents with g-tubes and 2 residents with foley catheters and they were not currently on EBP. During an interview on 06/03/25 at 5:18 p.m., the Administrator said he was aware briefly of EBP but did not realize there was a provider letter that put EBP into effect. He said he did not receive all the provider letters so he was unsure of the details, but he would pull up provider letters online he thought it was a recommendation not a requirement according to the CDC. During general observations on 06/04/25 from 06:30 a.m. through 12:00 p.m. there were no resident rooms with any EBP signage on the doors or PPE set up outside or inside the resident rooms. Record review of CMS memorandum ref: QSO-24-08-NH dated March 20, 2024 and titled, Enhanced Barrier Precautions in Nursing Homes, indicated, . CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. o EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 6 residents (Residents #9, #11, #51, #53, #58 and #167) reviewed for infection control. 1. The facility failed to ensure Resident #9 who had an indwelling suprapubic catheter (a tube surgically inserted through the lower abdomen into the bladder to drain urine) and an unstageable pressure ulcer/injury to the left heel (a wound caused by pressure from a surface) had Enhanced Barrier Precautions signage and PPE set up before entering his room and failed to ensure staff wore PPE during high contact resident care activities. 2. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions while providing incontinent care to Resident #11, who had a gastrostomy tube (G-tube) (a small flexible tube surgically inserted though the abdomen into the stomach to deliver nutrition to the resident) on 06/03/2025. 3. The facility failed to ensure signage was posted outside of Residents #9, #11, #51, #53, #58 and #167's rooms to notify staff of enhanced barrier precautions. 4. The facility failed to ensure PPE was readily accessible for staff to provide high-contact activities for Residents #9, #11, #51, #53, #58 and #167, residents who identified with wounds or indwelling medical devices. 5. The facility failed to ensure LVN G utilized enhanced barrier precautions with wearing a gown while administering medications through Resident #51's g-tube. Resident #51 had a history of non-targeted CDC MDRO, MRSA and ESBL in his urine. 6. The facility failed to ensure CNA C and CNA D utilized enhanced barrier precautions with wearing a gown while transferring Resident #51. 7. The facility failed to ensure Resident #167, who had a gastrostomy tube (G-tube) (a small flexible tube surgically inserted though the abdomen into the stomach to deliver nutrition to the resident), had Enhanced Barrier Precautions signage and PPE set up before entering his room and failed to ensure staff wore PPE during high contact resident care activities. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: 1. Record review of a face sheet dated 06/03/25 indicated Resident #9 was a [AGE] year-old male admitted on [DATE]. His diagnoses included paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body) and retention of urine (the bladder does not empty completely or at all). During an observation and interview on 06/02/25 at 10:35 a.m. Resident #9 was up in his wheelchair in him room. A catheter bag to drain was noted. The resident said he had a suprapubic catheter. There was no EBP signage or PPE set up noted before entering the room. Record review of Physician Orders for June 2025 indicated Resident #9 had an order dated 01/01/25 for suprapubic catheter change, 20Fr/30ml, 1st of every month and as needed for catheter care. Record review of an MDS dated [DATE] indicated Resident #9 had moderately impaired cognition with a BIMS of 12 out of 15, had an indwelling urinary catheter, had 1 or more pressure ulcer/injuries, and had 1 unstageable pressure injuries presenting as deep tissue injury present at admission. Record review of a care plan dated 04/04/25 indicated Resident #9 had a care plan initiated on 03/22/23 for an indwelling suprapubic catheter. There was no indication of EBP to be used. Record review of a Weekly Wound/Skin Condition Measure & Evaluation form dated 05/30/25 indicated Resident #9 had an unstageable pressure ulcer to the left heel. During an observation and interview on 06/03/25 at 09:55 a.m. Resident #9 had no EBP signage on the door and no set up for PPE. He said staff wore gloves but did not wear gowns when they provided care to him even with the catheter care and the wound care. During an observation on 06/04/25 at 08:35 a.m. Resident #9 had no EBP signage on the door and no set up for PPE. 2. Record review of Resident #11's face sheet, dated 06/04/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included dysphagia (difficulty swallowing) and stroke (damage to the brain from interruption of blood supply). Record review of Resident #11's care plan, initiated 01/21/25, indicated he had a g-tube feeding with interventions of local care to g-tube as ordered and monitor for signs and symptoms of infection and give feeding as ordered. Resident #11 was incontinent bowel and bladder. Record review of Resident #11's quarterly MDS assessment, dated 02/21/25, indicated a BIMS score of 15, which indicated intact cognition. Resident #11 was dependent (helper does all effort) for bathing, dressing, toileting, and hygiene and frequently incontinent of bladder and always incontinent of bowel. Resident #11 had diagnoses of stroke and dysphagia and received nutrition by a feeding tube. Record review of Resident #11's Order Summary Report, dated 06/02/25, indicated clean g-tube site with wound cleanser, apply split sponge and secure daily and enteral feed (nutrition through a tube in the stomach) two times a day of Jevity 1.2 at 65 ml/hr by a feeding Pump for 22 hours by g-tube. The physician orders did not indicate the use of enhanced barrier precautions. During an interview and observation on 06/03/25 at 2:00 p.m., Resident #11 was lying in bed with a g-tube feeding attached. He said when the staff provided incontinent care or care to his gastrostomy tube, they washed their hands and wore gloves but did not wear gowns over their clothes. During an observation and interview of incontinent care on 06/03/25 at 03:05 p.m., CNA A provided incontinent care to Resident #11with assistance of CNA B. Resident #11 was in his bed. CNA A provided the incontinent care while CNA B assisted by holding Resident #11's shoulder and hip. CNA A and CNA B donned gloves, but they did not put on a gown. There was no EBP sign on the door or in the room. Resident #11 was observed with an intact g-tube. When asked did they forget anything or would do anything different CNA A and CNA B said no. During an interview on 6/3/25 at 4:10 p.m., CNA B stated EBP was putting a towel across the table and setting everything up for incontinent care. She said the difference between EBP and transmission-based precautions was standard precautions were washing your hands and wearing gloves for incontinent care. She said she was unsure what high contact resident care activities would need EBP. CNA B said she had been trained on EBP but did not remember when. During an interview on 6/3/25 at 4:28 p.m., CNA A stated EBP was putting barrier cream on the resident. She said the nurses told the CNA's when needed. CNA A said she was unsure of the difference between EBP and TBP. She said high contact resident activities included changing the residents. She said she wore gloves and washed her hands before and during incontinent care. She said she was unsure if she was trained on EBP. 3. Record review of Resident #51's face sheet, dated 06/03/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included gastrostomy tube and extended spectrum beta lactamase resistance (ESBL)(bacteria resistant to antibiotics). Record review of Physician Orders for June 2025 indicated Resident #51 had an order, dated 11/17/25, check feeding tube site every shift. The physician orders did not indicate the use of enhanced barrier precautions. Record review of Resident #51's quarterly MDS, dated [DATE], indicated Resident #51 was moderately impaired cognitively with a BIMS of 9 out of 15. Resident #51 had a feeding tube and received 51% or more of his calories through the feeding tube. Record review of Resident #51's care plan, dated 12/04/24, indicated Resident #51 had MRSA - colonization interventions to notify doctor of significant abnormalities. Care plan, dated 11/18/24, indicated Resident #51 had a gastrostomy tube feeding with interventions of care to gastrostomy tube as ordered and monitor for signs and symptoms of infection and give feeding as ordered. During an observation on 06/02/25 at 9:00 a.m. revealed Resident #51 was in his bed with a gastrostomy tube connected to a feeding pump with Jevity 1.2 which infused at 73 milliliters an hour. There was no EBP signage inside or outside of the resident's room which indicated the type of PPE required and no PPE set up noted before entering the room. During an observation on 06/03/25 at 8:50 a.m. revealed Resident #51 had no EBP signage on the door and no set up for PPE. LVN G prepared Resident #51's morning meds for administration thru his g-tube and did not wash her hands but donned gloves before the start of care. The WC Nurse took her medications into the resident's room and placed it on his bedside table. She turned off his feeding pump, repositioned the resident to expose his abdomen and disconnected the feeding tubing from the residents abdominal g-tube tubing. During medication administration LVN G did not have on a PPE gown and her uniform touched the resident's bed and his left side while she leaned to administer the medications. LVN G removed her gloves and went to her medication cart to obtain a syringe and did not perform hand hygiene. LVN G donned a fresh set of gloves, flushed Resident #51 g-tube with 30cc of water and her uniform was touching the resident's bed and his left side while she leaned to administer the water. During an observation on 06/03/25 at 1:00 p.m. revealed Resident #51 had no EBP signage on the door and no set up for PPE. CNA C and CNA D assisted Resident #51 during transfer care from the bed to the wheelchair. CNA C and CNA D did not wash their hands but donned gloves before the start of care. During the transfer care, CNA C and CNA D did not have on a PPE gown and their uniform touched the resident's bed and his body (one CNA on each side). In an interview on 06/03/25 at 10:30 a.m., Resident #51 said the staff did not wear gowns during his personal care of changing his brief, administering medications or during his showers. In an interview on 06/04/25 at 1:20 p.m., CNA C said EBP was putting barrier cream (a topical product to protect the skin's natural barrier) on the resident. CNA C said no residents on her halls were on EBP. CNA C said high contact resident care activities included incontinent care or feeding residents. She was unsure of the difference between EBP and TBP. CNA C said she received infection control training during orientation, which included PPE, when to wear it and what kind of isolation needed certain PPE, but had not received EBP training until 06/04/25. In an interview on 06/03/25 at 1:30 p.m., CNA D said EBP was putting barrier cream on the resident. CNA D said she was unsure of the difference between EBP and TBP. She said high contact resident activities included changing resident's dirty brief. CNA D said she wore gloves and washed her hands before and during incontinent care. She said she had not been trained on EBP prior to 06/04/25. In an interview on 06/03/25 at 1:55 p.m., LVN G said she was responsible for teaching the CNA class and helping out wherever she was needed. LVN G said she did not know until today when she was in-serviced by the DON what EBP was. LVN G stated she should have worn a gown when she administered g-tube medications to Resident #51, because that was considered a direct contact. She said not wearing a gown increased the risk of spreading infection. LVN G said she should have washed her hand during glove change. LVN G explained she received infection control training on glove changes during orientation. She said the resident could acquire an infection when she did not follow good infection control practices which included washing hands before commencing care. 4. Record review of Resident #53's face sheet, dated 06/03/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic heart failure and hypertension. Record review of Physician Orders for June 2025 indicated Resident #53 had an order, dated 05/30/25, to provide foley catheter for urinary retention, care every shift, and change monthly and as needed. The physician orders did not indicate the use of enhanced barrier precautions. Record review of an admission MDS, dated [DATE], indicated Resident #53 was cognitively intact with a BIMS of 14 out of 15. The MDS did not document a foley catheter. Record review of Resident #53's care plan, dated 12/04/24, indicated Resident #53 had interventions to follow therapeutic regime for elimination of urinary tract infections. During an observation on 06/02/25 at 9:30 a.m. revealed Resident #53 was in her bed. A urinary foley catheter was noted with 200 mililiters of yellow urine in the drain bag. There was no EBP signage or PPE set up noted before entering the room. During an observation on 06/03/25 at 8:40 a.m. revealed Resident #53 was in her bed. A urinary foley catheter was noted with 100 mililiters of yellow urine in the drain bag. There was no EBP signage or PPE set up noted before entering the room. During an observation on 06/04/25 at 9:00 a.m. revealed Resident #53 was in her bed. A urinary foley catheter was noted with 200 mililiters of yellow urine in the drain bag. There was no EBP signage or PPE set up noted before entering the room. 5. Record review of Resident #58's face sheet, dated 06/03/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included cutaneous abscess of right lower limb. Record review of Physician Orders for June 2025 indicated Resident #58 had an order, dated 06/02/25, for right and left heel cleanse with wound cleanser apply medi honey and wrap with kerlix daily. Record review of Resident #58's quarterly MDS, dated [DATE], indicated Resident #58 was severely cognitively impaired with a BIMS of 7 out of 15. Resident #58 had two unhealed stage 3 pressure ulcers. Record review of Resident #58's care plan, dated 10/02/24, indicated Resident #58 had a skin integrity issue with interventions of care to monitor for signs and symptoms of infection. During an observation on 06/02/25 at 9:30 a.m. revealed Resident #58 was in her bed. There was no EBP signage or PPE set up noted before entering the room. During an observation on 06/03/25 at 8:40 a.m. revealed Resident #58 had no EBP signage on the door and no set up for PPE. During an observation on 06/04/25 at 9:00 a.m. revealed Resident #58 had no EBP signage on the door and no set up for PPE. 6. Record review of a face sheet dated 06/03/25 indicated Resident #167 was an [AGE] year-old female who was admitted on [DATE]. Her diagnoses included gastrostomy tube (a small flexible tube surgically inserted though the abdomen into the stomach to deliver nutrition to the resident). During an observation on 06/02/25 at 02:35 p.m. Resident #167 was in her bed. A feeding pump was noted connected to a gastrostomy tube which was going into the resident's abdomen. There was no EBP signage or PPE set up noted before entering the room. Record review of Physician Orders for June 2025 indicated Resident #167 had an order dated 02/24/25 check feeding tube site every shift. The physician orders did not indicate the use of enhanced barrier precautions. Record review of an MDS dated [DATE] indicated Resident #167 was cognitively intact with a BIMS of 13 out of 15, had a feeding tube, and received 51% or more of her calories through the feeding tube. Record review of a care plan dated 04/04/25 indicated Resident #167 had a gastrostomy tube feeding with interventions of local care to gastrostomy tube as ordered and monitor for signs and symptoms of infection and give feeding as ordered. There was no indication of EBP to be used. During an observation on 06/03/25 at 09:55 a.m. Resident #167 had no EBP signage on the door and no set up for PPE. During an observation on 06/04/25 at 08:36 a.m. Resident #167 had no EBP signage on the door and no set up for PPE. During an interview on 06/03/25 at 5:00 p.m., the ADON/IP said she was responsible for the infection control program. She said she was the infection preventionist. She said she was not aware of any changes or updates within the last two years. She said the DON and Administrator notified her of infection control updates. She said no residents in the facility were currently on enhanced barrier precautions. During an interview on 06/03/25 at 5:07 p.m., the DON said enhanced barrier precautions were the new CDC recommendations to use a face mask more than just with regular isolation. She said she was not aware of the specifics but knew it was the new update. She said the Administrator received the provider letters. She said she was unable to say her expectations related to EBP. The DON said she was aware new regulation changes were on the horizon. She said the facility had 3 Residents with g-tubes and 2 residents with foley catheters and they were not currently on EBP. During an interview on 06/03/25 at 5:18 p.m., the Administrator said he was aware briefly of EBP but did not realize there was a provider letter that put EBP into effect. He said he did not receive all the provider letters so he was unsure of the details, but he would pull up the provider letters online, he thought it was a recommendation not a requirement according to the CDC. During an interview on 06/04/25 at 3:50 p.m., ADON/IP said she was responsible for the Infection control program that now included EBP with the DON as back up. She said the risk of a resident that should be on EBP not receiving EBP precautions was increased risk of infection. She said she was trained on EBP on 06/03/25. During an interview on 06/04/25 at 3:53 p.m., the DON said she expected the staff to follow EBP precautions on all residents identified needing EBP. She said there is no resident risk for the staff not following EBP because all residents were treated with universal precautions and if a resident had a risk or active infection they would be on special precautions as needed. During an interview on 06/04/25 at 3:53 p.m., the Administrator said he was ultimately responsible for concerns in the facility. He said the ADON/IP was responsible for the infection control program including EBP and the DON was the back up. He said he expected staff to follow EBP precautions on all residents identified needing EBP. He said there is no resident risk for the staff not following EBP because all residents were treated with universal precautions and if a resident had a risk or active infection they would be on special precautions as needed. Record review of the facility's policy titled, Enhanced Barrier Precautions, effective 06/04/2025, indicated, It is the policy of this facility to implement enhance barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, . or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, . even if the resident is not known to be infected or colonized with a MDRO.)

Based on interview and record review, the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 2 of 5 residents (Residents #6 and #64) reviewed for psychoactive medications. 1. The facility failed to ensure Resident #6 had a completed psychotropic consent from the resident or family for Seroquel (antipsychotic medication) before administering to Resident #6 on 09/09/24. 2. The facility failed to ensure Resident #64 had a completed psychotropic consent from the resident or family for Seroquel (antipsychotic medication) and Cymbalta (antidepressant) before administering to Resident #66 on 01/03/25. These failures could place residents at risk for receiving unnecessary antipsychotic medications without informed consent. Findings included: 1. Record review of Physician Orders for June 2025 indicated Resident #6 was an [AGE] year-old female who was admitted on [DATE]. Her diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs); and adjustment insomnia (sleep disorder where people have difficulty sleeping). She had orders dated 09/09/2024 to receive Seroquel (antipsychotic) daily for major depressive disorder, bipolar disorder, and adjustment insomnia; and Cymbalta (antidepressant) daily for major depressive disorder. Record review of an MDS dated [DATE] indicated Resident #6 had moderately impaired cognition, she was taking an antipsychotic, and she was taking an antidepressant. Record review of a care plan dated 09/09/24 indicated Resident #6 used high risk drugs and was at risk for side effects with antidepressant and anti-psychotic/anti-mania was marked. Record review of the HHSC form 3713 Consent for Antipsychotic or Neuroleptic Medication Treatment for Resident #6's Seroquel dated 09/09/24 indicated the following: Section I The following must be completed by the person prescribing the medication, that person's designee, or the medical director. I have been treating this individual since:[blank] I believe the individual has the following psychiatric condition and/or maladaptive behavior: (ICD Code) [blank] In my clinical opinion: The probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medication(s) are indicated: [antipsychotic was not marked] The above information and statements are to the best of my knowledge truthful and complete. [The person prescribing the medication, that person's designee, or the medical director printed name and signature with date are left blank] Section II The following must be completed by the resident and if appropriate the person authorized to by law, to consent on behalf of the resident. I, [blank] (resident) or [blank] (resident representative) on behalf of [blank] (resident) acknowledge by signing this form, I agree to the following .[The blanks were not filled in] . Record review of the HHSC form 3713 Consent for Antipsychotic or Neuroleptic Medication Treatment for Resident #6's Cymbalta dated 09/09/24 indicated the following: Section I The following must be completed by the person prescribing the medication, that person's designee, or the medical director. I have been treating this individual since:[blank] I believe the individual has the following psychiatric condition and/or maladaptive behavior: (ICD Code) [blank] In my clinical opinion: The probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medication(s) are indicated: [antianxiety was also marked] The above information and statements are to the best of my knowledge truthful and complete. [The person prescribing the medication, that person's designee, or the medical director's printed name and signature with date are left blank] Section II The following must be completed by the resident and if appropriate the person authorized to by law, to consent on behalf of the resident. I, [blank] (resident) or [blank] (resident representative) on behalf of [blank] (resident) acknowledge by signing this form, I agree to the following .[The blanks were not filled in] . 2. Record review of Physician Orders for June 2025 indicated Resident #64 was an [AGE] year-old female who was admitted on [DATE]. Her diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). She had an order dated 01/03/25 to receive Seroquel (antipsychotic) daily for major depressive disorder. Record review of an MDS dated [DATE] indicated Resident #64 had severely impaired cognition and she was taking an antipsychotic. Record review of a care plan dated 04/04/25 indicated Resident #64 used high risk drugs and was at risk for side effects with anti-anxiety/anxiolytic and anti-psychotic/anti-mania marked. Record review of the HHSC form 3713 Consent for Antipsychotic or Neuroleptic Medication Treatment for Resident #64's Seroquel dated 01/03/25 indicated the following: Section II The following must be completed by the resident and if appropriate the person authorized to by law, to consent on behalf of the resident. I, [blank] (resident) or [blank] (resident representative) on behalf of [blank] (resident) acknowledge by signing this form, I agree to the following .[The blanks were not filled in] . During an interview on 06/04/25 at 04:00 p.m., the DON said she was not aware Resident #6 and #64's consent forms were not completed for Cymbalta and Seroquel. She said the psychiatric services would fill out the consent forms for the psychotropic medications. She said the nurse could also fill out the form and have the resident or their RP sign it. She said she and the ADONs would randomly review the resident charts. During an interview on 06/04/25 at 04:10 p.m., the Administrator said he expected the policies and protocols to be followed for psychotropic medication consents, medications, and orders. Record review of Use of Psychotropic Medication(s) policy, dated 02/01/25 indicated: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical chart, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 7. Prior to initiating or increasing psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 8. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 9. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.)

Based on observations, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs were stored in a locked compartments under proper temperature controls, and only permitted authorized personnel to have access to the keys for 1 of 20 resident (Resident #29) reviewed for storage and labeling of medications. The facility failed to ensure Resident #29 did not have over the counter medications, Luden's cough drops, Neosporin and Equate hydrocortisone cream at the bedside. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. The findings include: Record review of Resident #29's face-sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included chronic hepatic failure(liver failure), cirrhosis of liver(hardening of liver) and essential hypertension, Record review of Resident #29's consolidated report of current Physician orders, dated 06/2025, indicated no scheduled or PRN order for Luden's cough drops, Neosporin, Equate hydrocortisone cream, self-administer medications or to leave at bedside. Record review of Resident #29's electronic record indicated there was no Care Plan addressing may keep medications at bedside and no care plan to self-administer medications. Further review of the electronic record, reflected Resident #29 did not have a Self-Administration Medication Assessment initiated or completed. Record review of Resident #29's MDS, dated [DATE], indicated Resident #29 had intact cognition with a BIMS of 15 out of 15. During an observation on 06/02/25 at 9:45 a.m., revealed Resident #29 was not in his room and the door was opened. On his bedside table was an opened and used (25 count drops) bag of Luden's wild cherry flavored cough drops, Neosporin ointment 1 ounce tube, was opened and used, and Equate hydrocortisone cream max strength 2 ounce tube, was opened and used. During an observation and interview on 06/02/25 at 1:00 p.m., Resident #29 said the medication on his table was none of the state surveyors business where he got them. When asked where does he put the medications he and how often does he use it? Resident #29 said on his skin. Resident #29 said he did not report it to the nurses that he had the medication stored in his room because he was a grown man. On his bedside table was an opened and used (25 count drops) bag of Luden's wild cherry flavored cough drops, Neosporin ointment 1 ounce tube, was opened and used and Equate hydrocortisone cream max strength 2-ounce tube, was opened and used. During an observation on 06/03/25 at 11:00 a.m., Resident #29 was not in his room and the door was opened. On his bedside table was the same bag of Luden's wild cherry flavored cough drops, Neosporin ointment 1 ounce tube and Equate hydrocortisone cream max strength 2-ounce tube. During an observation on 06/04/25 at 9:45 a.m., Resident #29 was not in his room and the door was opened. On his bedside table was an opened and used (25 count drops) bag of Luden's wild cherry flavored cough drops, Neosporin ointment 1 ounce tube, was opened and used and Equate hydrocortisone cream max strength 2 ounce tube, was opened and used. During an interview on 06/04/25 at 2:00 p.m., LVN-N said no resident should have medications at their bedside. She said she did not know of any residents having medications in their rooms. She said a physician's order must be on file for the resident to receive the medication as well as to self-administer medications. She said a resident could take inappropriate amounts of the medication or another resident could wonder in the room and get the medication and take it. She said residents could have an allergic reaction or become ill from taking unprescribed medication Interview on 06/04/25 at 2:30 p.m., the RP for Resident #29 revealed she had no concerns with the Medications her family member was taking. The RP said she was the person responsible for bringing in the medications Luden's wild cherry flavored cough drops, Neosporin ointment 1 ounce tube and Equate hydrocortisone cream max strength 2-ounce tube and she had done so approximately 3-4 weeks ago. The RP said she had not notified the nurses about the medications because she was not aware she had to tell them since the medications were over-the-counter medications. The RP also said no one from the facility contacted her about the medications, or that they could not be left out unattended at the bedside. Interview on 06/04/25 at 4:00 p.m. the DON said she was just made aware of the mediations Luden's wild cherry flavored cough drops, Neosporin ointment and Equate hydrocortisone cream at Resident #29's bedside but could not remember who told her. The DON said her expectation was for nursing staff to follow facility policy and procedure and not leave medications at the bedside. The DON said Resident #29 would need a doctor's order and medication self-administration assessment completed before he would be able to keep medications at the bedside and administer them himself. The DON revealed she would have to look in the computer to see if Resident #29 had an order or med assessment. The DON said leaving medications at the bedside put residents at risk of not taking properly or giving it to someone else to take, but she (DON) felt Resident #45 was cognitively intact enough to take the medication correctly and would need to have a MD order or Self-Med Assessment first. The DON stated residents in the facility must have a doctor's order to receive medications and no resident could keep medication in their rooms and were not allowed to self-medicate. She stated there must be a physician's order to leave the medication at the bedside and an order for the resident to self-medicate. Record review of the facility's policy, Resident Self-Administration of Medication, dated March 2, 2024, indicated, in part: Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .5. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary .9. The care plan must reflect resident self-administration and storage arrangements

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #6) reviewed for unnecessary medications. * The facility failed to ensure Resident #6 had an appropriate diagnosis on entered orders for her Seroquel (antipsychotic). This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication. Findings included: Record review of Physician Orders for June 2025 indicated Resident #6 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs); and adjustment insomnia (sleep disorder where people have difficulty sleeping). She had orders dated 09/09/2024 to receive Seroquel (antipsychotic) daily for major depressive disorder, bipolar disorder, and adjustment insomnia; and Cymbalta (antidepressant) daily for major depressive disorder. Record review of an MDS dated [DATE] indicated Resident #6 had moderately impaired cognition, she was taking an antipsychotic, and she was taking an antidepressant. Record review of a care plan dated 09/09/24 indicated Resident #6 used high risk drugs and was at risk for side effects with antidepressant and anti-psychotic/anti-mania marked. During an interview on 06/04/25 at 04:00 p.m. the DON said she was not aware Resident #6 had multiple diagnoses for her Seroquel. She said a resident could receive a medication for the wrong indication. She said the nurse was to verify with the physician what diagnosis was indicated for the medication. She said she and the ADONs would randomly review the resident charts. During an interview on 06/04/25 at 04:10 p.m. the Administrator said he expected the policies and protocols to be followed for psychotropic medication use. Record review of Use of Psychotropic Medication(s) policy dated 02/01/25 indicated: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical chart, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s)

Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 5 residents (Residents #6 and #19) reviewed for PASRR. The facility failed to ensure the accuracy of the PASRR Level 1 (P1) screen for Resident #6 and Resident #19. This failure could place residents who had a mental illness at risk of not receiving individualized specialized services to meet their needs. 1. Record review of the June 2025 Physician Order indicated Resident #6 was an [AGE] year-old female who was admitted on [DATE]. Her diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs); and adjustment insomnia (sleep disorder where people have difficulty sleeping). She had orders, dated 09/09/2024, to receive Seroquel (antipsychotic) daily for major depressive disorder, bipolar disorder, and adjustment insomnia; and Cymbalta (antidepressant) daily for major depressive disorder. Record review of a care plan, dated 09/09/24, indicated Resident #6 used high risk drugs and was at risk for side effects with antidepressant and anti-psychotic/anti-mania marked. Record review of a PASRR Level 1 dated 09/09/24 indicated Resident #6 had a primary of diagnosis of dementia. The MI was not marked. Record review of the EMR for Resident #6 from 09/09/24 through 06/03/25 indicated there was no HHSC form 1012 filled out and there was no physician/NP note indicating the primary diagnosis was dementia. Record review of an MDS, dated [DATE], indicated Resident #6 had moderately impaired cognition. She was taking an antipsychotic, and she was taking an antidepressant. During an interview on 06/03/25 at 04:25 p.m., MDS Nurse M said she pulled the diagnosis from the medical record for Resident #6 upon admission and put on the PASRR Level 1 that it was the primary diagnosis. She said there was no form 1012 or documentation by the physician that the resident's primary diagnosis was dementia. She said she did not verify with the physician the primary diagnosis was dementia therefore the PASRR Level 1 was not correct and needed to be redone and resubmitted. During an interview on 06/04/25 at 04:00 p.m. the DON said she was made aware of the issue with Resident #6's PASRR and MDS Nurse M was working on it. She said she expected the PASRR to be filled out correctly. She said residents could not receive needed services if not coded correctly. During an interview on 06/04/25 at 04:10 p.m. the Administrator said he expected the policies and protocols to be followed for PASRR. 2. Record review of the Resident #19's face sheet, dated 06/04/25, indicated Resident #19 admitted to the facility on [DATE]. Resident #19 was [AGE] years old female with and had diagnoses of which included schizoaffective disorder (a mental health condition with schizophrenia [disconnect from reality] and mood disorder), stroke (damage to the brain due to lack of blood flow), and major depressive disorder (mental illness with sadness and loss of interest). Record review of the Resident #19's admission MDS assessment, dated 05/06/25, indicated Resident #19's was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of the Resident #19's care plan dated 04/30/25, indicated she received anti-psychotic medications. Record review of the Resident #19's P1 dated 04/30/25, indicated she was admitted at the facility for less than 30 days. Record review of the Resident #19's care plan dated 05/02/25, indicated she wished to remain here at to the facility for long term placement. During an interview on 06/03/25 at 10:00 a.m., the MDS nurse L said Resident #19's P1 was completed and when it was transferred to the LIDDA . She said there was a mark to indicate the resident was here at the facility for only 30 days. She said Resident #19 was at the facility for long term placement. The MDS nurse L said she was responsible for Resident #19's P1 and unsure why the form was marked wrong. She said this error could have delayed services. Record review of a the facility's Resident Assessment - Coordination with PASARR Program policy, dated 01/01/24, indicated: Policy: This facility coordinates assessments with the preadmission screening and resident review (P ASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a P ASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs

Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure compliance and ethics training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed compliance and ethics training: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * DON, hire date 01/19/15; * ADON, hire date 05/27/09; * AD, hire date 10/06/97; * MD, hire date 07/01/04; * HS, hire date 02/05/14; * LVN D, hire date 02/08/22; * LVN E, hire date 05/03/12; * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA H, hire date 11/29/17; * CNA J, hire date 09/17/13; * CNA K, hire date 10/25/21; * CNA L, hire date 09/07/23, * CNA M, hire date 01/24/24; and * CNA N, hire date 08/14/23. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames

Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure QAPI training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of employee files indicated QAPI training was not done for the following staff: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * DON, hire date 01/19/15; * ADON, hire date 05/27/09; * AD, hire date 10/06/97; * MD, hire date 07/01/04; * HS, hire date 02/05/14; * LVN D, hire date 02/08/22; * LVN E, hire date 05/03/12; * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA H, hire date 11/29/17; * CNA J, hire date 09/17/13; * CNA K, hire date 10/25/21; * CNA L, hire date 09/07/23, * CNA M, hire date 01/24/24; and * CNA N, hire date 08/14/23. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames

Based on interview and record review, the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for Social Worker (SW). The facility did not employ or contract a SW as required by state regulations. This failure could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings included: During an interview on 05/19/24 at 10:45 a.m., the Administrator said the facility did not currently did not have a SW. He said the SW quit about a month ago. He said they were actively looking for one. Record review of a Social Services Policy dated 01/01/24 indicated Policy: The facility will employ a full/part time Social Worker Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only kitchen reviewed for dietary services. The facility failed to ensure food items were properly labeled with product and expiration date in the refrigerators. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: During an observation and interview with the dietary supervisor on [DATE] at 8:45 a.m. indicated the following: Refrigerator #1 contained *,d+[DATE] browning avocado in a gallon size bag with not labeled or dated. Refrigerator #2 contained *2 single serve sippy cups containing a white colored substance not labeled or dated; *1 single serve covered container with orange slices that was not labeled or dated; *a piece of ham (approximately 4 inches by 3-inches) covered with foil wrap and was not labeled or dated; and *a disposable Styrofoam serving dish containing sliced cucumbers not labeled or dated. The acting dietary supervisor said the sippy cups contained nectar thickened liquids made today but she forgot to label and date them. She said she thought the cucumbers were from yesterday, but she was not sure and threw them away. She said she was unsure when the orange slices were placed in the refrigerator, and she threw them away. ham should have been labeled and dated. The dietary supervisor said all dietary staff were to label and date items, so old food would not be served to residents. During an interview on [DATE] at 2:44 p.m., the Administrator said he was the direct supervisor of all dietary staff until a new dietary manager could be hired. He said he expected for all foods in the kitchen to be stored properly including labeling and dating. He said food not being labeled and dated could result in expired foods being served to residents. Record review of a facility policy titled Food Storage dated 2005 indicated . Refrigerated foods should be covered, labeled, and dated. Record review of the 2022 Food Code dated [DATE] indicated ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date. Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.

Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the acting Dietary Supervisor indicated no documentation that she had completed the certified Dietary Manager course. During an interview on 05/19/24 at 8:45 a.m., the Dietary Supervisor said she had not completed or started the dietary manager classes. She said she was working as dietary supervisor until the facility could hire a certified dietary manager. During an interview on 05/20/24 at 10:45 a.m., the HR staff said the Dietary Supervisor was not a certified dietary manager and had assumed the position on 04/20/24. She said the facility had tried to hire a certified dietary manager or hire staff and have them become a certified dietary manager since April 2024. During an interview on 05/21/24 at 2:44 p.m., the Administrator said his expectation was for the DM to be certified to oversee the dietary services. He said the facility had been actively seeking to hire a certified DM. Record review of a facility policy titled Dietary Manager and dated 01/01/24 indicated .The facility will employ a full-time dietary manager .Minimum requirements include certification as a dietary manager

Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 5 of 17 employees (DON, LVN D, LVN F, CNA K, and CNA N) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by LVN F and CNA N during orientation. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by DON, LVN D, and CNA K annually. These failures could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of employee files indicated the following staff had not completed resident rights and responsibilities of the facility training during orientation: * LVN F, hire date 08/07/23; and * CNA N, hire date 08/14/23. Record review of employee files indicated the following staff had not completed resident rights and responsibilities of the facility training annually: * DON, hire date 01/19/15; * LVN D, hire date 02/08/22; and * CNA K, hire date 10/25/21. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames

Based on interview and record review the facility failed to ensure individuals providing services under a contractual arrangement had trainings consistent with their expected roles and failed to keep records of these trainings for 4 of 4 contracted staff. (Dietician, PT, OT, and ST). The facility failed to ensure required trainings were provided for the dietician working in the dietary department at the facility under a contractual agreement. The facility failed to ensure required trainings were provided for PT, OT, and ST working in the therapy department at the facility under a contractual agreement. This failure could place residents at risk of being cared for by contracted staff who have been insufficiently trained to improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications. Findings included: During an interview on 05/20/24 at 03:30 p.m. the HR said she did not know if there were files for the dietician and therapy staff. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she did not think the facility provided trainings for the contracted staff. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the ADON indicated the facility did not provide training for the contracted staff. She indicated she did not have any trainings for the contracted staff. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames

Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 11 of 17 employees (Administrator, Assistant Administrator, LVN F, RN G, AD, MD, HS, CNA K, CNA L, CNA M, and CNA N) reviewed for training. The facility did not ensure effective communication training was completed by LVN F, RN G, CNA L, CNA M, and CNA N during orientation. The facility did not ensure effective communication training was completed by the Administrator, Assistant Administrator, AD, MD, HS, and CNA K annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed effective communications training during orientation: * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA L, hire date 09/07/23; * CNA M, hire date 01/24/24; and * CNA N, hire date08/14/23. Record review of employee files indicated the following staff had not completed effective communications training annually: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * AD, hire date 10/06/97 * MD, hire date 07/01/04; * HS, hire date 02/05/14; and * CNA K, hire date 10/25/21. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. During an interview on 05/21/24 at 02:20 p.m. the Administrator indicated he expected all trainings required during orientation to be done during orientation. He indicated he also expected trainings to be done annually as required. He indicated the effect of staff not completing the trainings depended on which staff and which trainings not done. During an interview on 05/21/24 at 02:42 p.m. the DON indicated there was an issue in the computer-based trainings and it did not triggered the required trainings for staff for orientation and annually. Record review of a Staff Education policy with date implemented of 2024 indicated Policy: Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs. Policy Explanation and Compliance Guidelines: 1. All levels of employees are expected to complete required trainings within designated time frames

Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *The facility failed to ensure CPR was provided to Resident #69 who was a full code. On [DATE] CPR was not initiated by facility staff after Resident #69 was found not breathing, without a pulse, and unresponsive. *The AED pads had been expired for 730 days (,d+[DATE]). An Immediate Jeopardy (IJ) was identified on [DATE] at 3:31 p.m. While the IJ was removed on [DATE] at 2:03 p.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings included: Record review of the face sheet dated [DATE] indicated Resident #69 was [AGE] years old, admitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #69's face sheet indicated full code (in the event of [CONDITION(S)], CPR will be initiated). Record review of Resident #69's physician orders, dated [DATE], indicated the resident was readmitted to the facility on [DATE]. Resident #69's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #69's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] #69 was admitted to hospice services and Code Status -full. Record review of Resident #69's care plan dated [DATE] indicated Resident #69 code status: Her and her family had chosen not to initiate an advance directive/ She will be a full code status. Approaches for Resident #69 included Provide full CPR measures per wishes in case of emergency. Record review of Resident #69's electronic chart had no evidence of advance directive for DNR (do not resuscitate). Record review of Resident #69's nursing note dated [DATE] at 11:40 p.m., completed by LVN B indicated she called and spoke with Resident #69's responsible party/POA and informed him that resident was found with no heartbeat or respirations. She asked the RP how he wanted to proceed; RP stated to let her go. Spoke with DON and informed her of the situation with resident and RP's request to leave resident. Stated that as long as the RP was adamant that we are not to perform CPR, CPR does not need to be performed. 911 in facility and informed of RP's wishes and they stated that as long as we don't have a DNR in hand, CPR would be started. Record review of Resident #69's nursing note dated [DATE] at 11:58 p.m., completed by LVN A indicated Resident #69 was found unresponsive. Sternal rub still no response. No lung sounds noted, no HR found. 911 was called and RP notified, Hospice notified. 911 arrived and began CPR. Resident left the facility at 1155 p.m. and was being taken to hospital. During an interview on [DATE] on 11:50 a.m., the DON said Resident #69 was found on [DATE] unresponsive in her room and the nurses called 911 and did not initiate CPR, she did not indicate the time the resident was found. She said the family member of Resident #69 wanted no CPR and had not done the advance directive. She said the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on [DATE] at 12:15 p.m., LVN A said she was working night on [DATE], when Resident #69 was found not breathing. She said she checked Resident #69's oxygen saturation and it was in the 80s and she was not responding. LVN A said she did a sternum rub (using fingertips she rubbed on the resident's sternum). LVN A yelled to LVN B, said she was more experienced, knew the resident and had been working here longer. LVN A checked Resident #69 with her stethoscope and heard no heart sounds, no breath sounds. Then LVN B came into the room and checked the resident and LVN B told LVN A to call 911. LVN A said she called 911 and LVN B went to the nurse's station to check the code status for Resident #69 and called DON and Resident #69's RP LVN A said she was certified in CPR. LVN A said she did not initiate CPR. She said she could not remember being trained on CPR at the facility and was not retrained after this event. She denied being counseled about this event. She said when EMTs arrived they started CPR and Resident #69 was transferred to the local hospital. During a telephone interview on [DATE] at 12:25 p.m., LVN B said she was working night on [DATE]. LVN B said Resident #69 resided on Hall 500 and that the nurse (LVN A) assigned to Hall 500 came and asked her to come down her hall. LVN A went into Resident #69's room and she followed LVN A. LVN B said she knew Resident #69 had passed away, because she was nonresponsive and pale. She said she went to the station to check code status and told LVN A to call 911. LVN B said she called Resident #69's family member and he said to let her go. LVN B said she called the DON and she said do not start CPR, if RP said not to start CPR. So then LVN B said she went to Resident's room and CPR had not been started. She said she did not initiate CPR. She said she was CPR certified and had been trained here about code status and CPR. She said when 911 arrived, the 911 service began manual CPR and Resident # 69 was transferred to the hospital. During an interview on [DATE] at 12:35 p.m., the fire chief said he was unable to release details of the call without a subpoena, he was able to release the call time and dispatch and departure and arrival times. He said on [DATE] the calls and times were as followed: at 11:39 p.m., the call for 911 was received. at 11:42 p.m., the ambulance was dispatched. at 11:44 p.m., the ambulance arrived at the facility. at 11:45 p.m., the ambulance staff was at bedside. at 11:58 p.m., the ambulance departed the facility and arrived at hospital. The fire chief said the hospital was really close to the facility. Interview with DON on [DATE] at 1:20 p.m., the DON said events from [DATE] had not been QA'd (Quality Assurance Program) yet. DON said purpose of QA was to review issues or things that needed to be worked on/improved. DON said this was something they would QA. DON said in QA they would breakdown who, what, when, if policy and procedure was followed and determined any training needed. She said the QA program consisted of the admistrative team and the medical director. During an interview on [DATE] at 3:40 p.m., Resident #69's responsible party (RP) said Resident #69 readmitted to the facility on [DATE] and he was going to complete an advance directive on Monday after the holidays. Resident #69 RP said he was her medical power of attorney. He said Resident #69 was a full code and had been transported to the hospital on [DATE]. He said he was able to complete an advance directive at the hospital and she was taken off life support and allowed to pass away. He did not indicate if the resident had a pulse with mecianical ventilation. During an observation on [DATE] at 2:40 p.m., the only available AED for the facility was sitting in a holder that was attached to the wall outside of the nurse's station. The AED had a dusty red zipped case and sealed AED pads with expiration date of ,d+[DATE]. During an observation and interview on [DATE] at 2:43 p.m., the DON removed the AED from the case and said dusty the AED pads were dated ,d+[DATE] exp. The DON verified and said the AED pads were expired by 2 years. She stated the maintenance man was responsible for conducting readiness checks on the AED or documenting those checks which included checking for expired AED pads. The DON said she was not aware that the AED was not ready for use. DON said expired AED pads could cause the AED to not work properly or possibly not deliver a shock. The DON said CPR included the use of the AED. She said if a resident experienced [CONDITION(S)] during the time the AED was not functional, the facility would not have been able to provide full and complete CPR. The DON stated she could not remember the last time a training was done on the AED but that nurses had CPR cards and training included AED. The DON stated she would get with the Administrator to re-place the pads. During an interview on [DATE] at 3:08 p.m., the Administrator said he had not noticed that the AED pads were expired, and the maintenance department was responsible for checking the AED and documenting the results every Friday. The Administrator stated he had just opened and checked the AED pad dated ,d+[DATE] and it was not dried out and was still moist. The Administrator said he believed the pads were still usable, but if dried out they may not get all electricity to the contact. When a policy was requested, the Administrator stated he believed there was a policy, but he was not sure. During observation and interview on [DATE] at 11:30 a.m. the Administrator said the facility did not have a policy on the AED but used the manufacture's manual online. The Administrator handed the surveyor an undated paper titled Maintaining the Healthstart which did not include information on AED pads. The Administrator stated he had replaced the AED pads with a more current expired pads dated ,d+[DATE] and reorder the AED for non-expired AED pads and Administrator provided a purchase order indicating the new unexpired replacement AED pads for the AED would be delivered [DATE]. During an observation on [DATE] at 1:50 p.m., the AED was hanging on the wall outside of the nurse's station; the green light indicating operational readiness was illuminated and had sealed AED pads with expiration date of ,d+[DATE]. During an interview on [DATE] at 3:30 p.m., Maintenance said he had not received instruction from the facility about how to check the AED for expired pads until today. He said he would just pass by once a week to check for a green light which meant it was fine and put a check mark on his checklist, but if the green light was not on, that usually meant the AED was not functional and would get with the Administrator. Maintenance said he now has a form to document green light blinking and pad expiration date and would be responsible for ordering and replacing the pads going forward. He said expired pads could maybe cause the machine to function poorly I guess. Record Review of the facility form titled Weekly Checklist for door modules for the wanderguard system included an handwritten area on the form for HeartStart checks and checks in the boxes for dates [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record Review of an undated list indicated 36 residents wished to be resuscitated in the event of [CONDITION(S)]. Record review of on-line owner's manual for the [NAME] HeartStart AED obtained on [DATE] at 2:00 p.m., at https://www.aedbrands.com/resources/implement/aed-manuals/[NAME]-onsite-aed/ indicated: Check supplies and accessories for damage and expiration dates. Replace any used, damaged or expired items. Use a new maintenance tag to record the pads expiration date for the new installed pads cartridge . PERIODIC CHECKS Other than the checks recommended after each use of the HeartStart, maintenance is limited to periodically checking the following: Check the green Ready light. If the green Ready light is not blinking, see Troubleshooting Tips, below. Replace any used, damaged or expired supplies and accessories .WARNINGS . accessories: . Using damaged or expired equipment or accessories may cause the HeartStartto perform improperly, and/or injure the patient or the user . PRECAUTIONS maintenance: . Improper maintenance may damage the HeartStart or cause it to function improperly. Maintain the HeartStart according to directions . Record review of A publication by the American Heart Association at https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_ 6.pdf , accessed [DATE] at 2:50 p.m., indicated .Immediate cardiopulmonary resuscitation (CPR) and early defibrillation, with and automated external defibrillator (AED), can more than double a victim's chance of survival. In fact, early defibrillation, along with CPR, is the only way to restore the victim's heart rhythm to normal in a lot of cases of [CONDITION(S)]. For every minute that passes without CPR and defibrillation, however, the chances of survival decrease by ,d+[DATE] percent. The 2020 update of AHA's Heart Disease and Stroke Statistics show that 23% of out-of-hospital cardiac arrests are shockable. Record review of the policy dated 2021 for Cardiopulmonary Resuscitation (CPR) indicated Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Procedure: 1. If a resident experience a [CONDITION(S)], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and a. In accordance with the resident's advance directives or in the absence of advance directive or a Do Not Resuscitate order. b. RP should be notified of CPR and or EMS transport. c. Director of Nurses to be notified. Record review of the policy dated 2021 for Residents' Rights Regarding Treatment and Advance Directives indicated Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and formulate an advance directive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:31 p.m. due to the above listed failures. The IJ template was given to the Administrator and requested the facility to send POR to program manager. Record Review of an undated list indicated 36 residents were full code and 31 residents were DNR code status. Record Review of deceased resident list dated [DATE] indicated 6 residents expired in the facility within last 6 months. Immediate Jeopardy in concern was that the facility did not provide life support, including CPR to Resident #69 requiring emergency care prior to the arrival of emergency medical personnel. This IJ concern was received on [DATE] at 3:31pm. The Director of Nurses in-serviced the two Charge Nurses that are currently working on our 2p-10p shift. This was done at 6:30 pm. This in-service included appropriate CPR initiation, honoring code status, and following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Both Charge Nurses on our current shift are CPR certified. The attached literature was also given to both Charge Nurses. This literature included our P&P for Cardiopulmonary Resuscitation, P&P on Residents' Rights Regarding Treatment and Advance Directives and our P&P on following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Weekend Supervisor will in-service the night shift nurses on the same topics and they will receive the same literature before starting their shift tonight ([DATE]). One of the two Charge Nurses tonight are CPR Certified. The Weekend Supervisor will stay until 6am so that she can in-service the morning shift and give them the same literature before the start of their shift. One of the two day shift Charge Nurses are CPR Certified. The staffing schedule will be made so that each shift will have at least one Charge Nurse that is CPR Certified until ALL Charge Nurses can be CPR Certified. We will have the rest of the available licensed nursing staff come to the facility tomorrow ([DATE]) so that the DON can in-service the licensed nursing staff on the same information and they will receive the same literature. All nurses will be in-serviced before they start their shift until all nurses have been in-serviced. The CNA's and CMA's will also be in-serviced. The CNAs and CMAs in-service will include where to find a resident's code status and where to find the needed supplies during a resident emergency. This is only to assist the nurse during an emergency to bring needed supplies and to locate the resident's code status. CNAs and CMAs will be in-serviced on what to do when finding a unresponsive resident, which is to immediately notify a nurse. One of the nurses that was involved in the incident is PRN and is not currently scheduled to work, however the DON called her today and went over the in-service material and the literature will also be emailed to her today. The nurse will also be in-serviced in person before she will be put back on the schedule. The nurse that found the resident unresponsive is off this week due to COVID, however the DON also called her today and went over the in-service material and it will be emailed to her today. She will receive in person training once she recovers from COVID and before she starts her next shift. These in-services will include CPR initiation, honoring code status, and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The nurses can check the code status at the nurses station computers and they also have laptops on all nurses and medication carts. Today([DATE]) we also added a list at the nurses station of all residents in alphabetical order that is color coded that states whether the resident is DNR or Full Code. This list will be updated immediately when there is a change and reviewed every week by our Social Worker. All of today's nursing staff will be in-serviced on this code status list at 2pm today. All other nursing staff will be in-serviced on this information before their shift. This information will also be added to the orientation of new nursing staff (nurses, CNAs, and CMAs). Our Medical Director's Nurse Practitioner will be here by the end of the day to train the DON on CPR initiation, honoring code status, and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the nurses that was involved in the incident is PRN and is not currently scheduled to work, however the DON called her today and went over the in-service material and the literature will also be emailed to her today. The nurse will also be in-serviced in person before she will be put back on the schedule. The nurse that found the resident unresponsive is off this week due to COVID, however The DON also called her today and went over the in-service material and it will be emailed to her today. She will receive in person training once she recovers from COVID and before she starts her next shift. These in-services will include CPR initiation, honoring code status, and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The IJ also stated that the pads were expired on our AED. The pads were replaced at 4:50pm. The AED has a green flashing light, which according to the AED's manual that means that it is functioning properly. The Maintenance supervisor checks the AED every Friday to see that the green light is blinking. He checks this every week while doing his equipment inspection rounds. This is documented every week on a spreadsheet. A column has been added for him to now also check the expiration date on the pads. New pads will be ordered when the current pads are within 60 days of their expiration date and be replaced before the expiration date. The Administrator in-serviced the Maintenance Supervisor on this on [DATE]. All of these actions will be followed up with our Quality Assurance Committee to see that the practices put into place are adequate and to discuss the plan for future ongoing training for nursing staff regarding CPR initiation, honoring code status, and following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's plan of removal as listed above was accepted on [DATE] at 2:03 p.m., and confirmed as follows: During an interview on [DATE] at 3:00 p.m., CNA Student G said resident code status can be checked on the list at the nurse's station. She said emergency supplies are located at the nurse's station and also on hall 5. She said if she found a resident that was unresponsive, she would immediately notify the nurse. During an interview on [DATE] at 3:05 pm interview with CNA H said resident code status can be checked on the list at the nurse's station. She said emergency supplies were located at the nurse's station. She said if she found a resident that was unresponsive, she would go get the nurse. During an interview on [DATE] at 3:07 p.m., DON said she in serviced nurses on ,d+[DATE] shift on CRP initiation, policy, and procedures, unless documented DNR. She was in serviced on following physicians' orders and said she was CPR certified also. During an interview on [DATE] at 3:12 p.m., MA L said she was in serviced on advanced directive and she was to notify charge nurse if she found a resident unresponsive. She said she knew where to find code status in the computer. She said there was a list at nurse station also. During an interview on [DATE] at 3:14 p.m., CNA J said resident code status can be checked on a list on a clip board at the nurse's station. She said residents that were a full code were highlighted in green. She said code status was also listed on the kiosk under each resident. She said emergency supplies were located at the nurse's station by the list of residents' code status. She said if she found a resident that was unresponsive, she would immediately get the nurse. During an interview on [DATE] 3:20 p.m., interview with CNA Student K she said resident code status can be checked on the list at the nurse's station. She said emergency supplies were located at the nurse's station by the code list. She said if she found a resident that was unresponsive, she would get the nurse. During an interview and observation on [DATE] at 3:22 p.m., MA M said she was in serviced on code status. She showed surveyor where it was on the computer. She said the list of Code Status of the residents was at the nurse's station also. She said if she found a resident unresponsive, she was to tell the nurse and grab the back board and AED from the station and assist the nurse. She was in serviced on resident rights and 911. During a phone interview on [DATE] at 3:25 p.m., LVN A said the DON called her and gave her in-service training on honoring code status. LVN A said she can now check code status on a color-coded list located at the nurse's station. She said code status could also be checked on med cart computers and computer at the nurse's station. She said DON had also reviewed when to do CPR, following physician orders, and emergency procedures. LVN A said she also received written material on all this via email. LVN A said she would receive another in-person training before she could return to work at the facility. LVN A said she was not working at this time and was home on sick leave. LVN A said written material received in email contained where to find code status, location of emergency equipment, CPR initiation, honoring resident code status, and following doctor's orders. During an interview on [DATE] at 3:28 p.m., LVN N said she was in serviced on CPR and there was an updated list at the nurse's station to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempted a phone interview with LVN B on [DATE] at 3:35 p.m., and 3:50 p.m., with messages left each time requesting a return call. No call was received back from LVN B. During an interview and observation on [DATE] at 3:36 p.m., Graduate Vocational Nurse (GVN- Unlicensed Vocational Nurse) O said she was in serviced on CPR and following orders. She showed surveyor where the code status of resident was located behind the station and in the computer. She said the code status would be addressed in the admission notes now. She said she was certified in CPR. Record Review of sampled Resident's #303, #304, #305 and #306 indicated the nurses followed the advance directives and physician orders. The nurses notified the responsible parties and DON. The care plans indicated DNR and the residents were on hospice services and expired in the facility. Maintaining Automatic External Defibrillator (AED) *The AED pads replaced at 4:50 p.m. and re-ordered with delivery date [DATE]. * Maintenance supervisor checks the AED every Friday to see that the green light is blinking. He checks his every week while doing his equipment inspection rounds. *Documentation every week on a spreadsheet a column has been added for him to now also check the expiration date on the pad. *New pads will be ordered when the current pads are within 60 days of their expiration date and will be replaced before the expiration date. *The administrator in service the maintenance supervisor on this on [DATE]. *All of these actions will be followed up with our quality assurance committee to see that the practices put into place are adequate to discuss the plan for future ongoing training for nursing staff regarding CPR initiation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: The survey team confirmed the POR by: staff interviews related to CPR, CPR initiation, honoring code status, following physician orders, what to do when finding a unresponsive resident, where to find emergency supplies and code status, and checking AED pads weekly for expiration. Observations of residents were conducted, review of in-services related to CPR, code status and AED inspection was completed. The IJ was lifted on [DATE] at 3:41 p.m. On [DATE] at 3:41 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system. During the exit meeting on [DATE] at 4:35 p.m., the Administrator was given the opportunity to provide additional information related to CPR. No additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan meet professional standards of quality for 1 of 18 residents (Resident #69) reviewed for professional standards: LVN A and LVN B did not provide CPR to Resident #69 as ordered by the physician when the resident was found unresponsive. This failure could place residents at risk of not receiving necessary life-saving measures, decline in health, and even death. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:31 p.m. While the IJ was removed on [DATE] at 2:03 p.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Record review of the face sheet dated [DATE] indicated Resident #69 was [AGE] years old, admitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #69's face sheet indicated full code (in the event of [CONDITION(S)] CPR is to be initiated). Record review of Resident #69's physician orders, dated [DATE], indicated the resident was readmitted to the facility on [DATE]. Resident #69's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #69's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] #69 was admitted to hospice services and Code Status -full. Record review of Resident #69's care plan dated [DATE] indicated Resident #69 code status: Her and her family had chosen not to initiate an advance directive/ She will be a full code status. Approaches for Resident #69 included Provide full CPR measures per wishes in case of emergency. Record review of Resident #69's electronic chart had no evidence of advance directive for DNR (do not resuscitate). Record review of Resident #69's nursing note dated [DATE] at 11:40 p.m., completed by LVN B indicated she called and spoke with Resident #69's responsible party/POA and informed him that resident was found with no heartbeat or respirations. She asked the RP how he wanted to proceed; RP stated to let her go. Spoke with DON and informed her of the situation with resident and RP's request to leave resident. Stated that as long as the RP was adamant that we are not to perform CPR, CPR does not need to be performed. 911 in facility and informed of RP's wishes and they stated that as long as we don't have a DNR in hand, CPR would be started. Record review of Resident #69's nursing note dated [DATE] at 11:58 p.m., completed by LVN A indicated Resident #69 was found unresponsive. Sternal rub still no response. No lung sounds noted, no HR found. 911 was called and RP notified, Hospice notified. 911 arrived and began CPR. Resident left the facility at 1155 p.m. and was being taken to hospital. During an interview on [DATE] on 11:50 a.m., the DON said Resident #69 was found on [DATE] unresponsive in her room and the nurses called 911 and did not initiate CPR, she did not indicate the time the resident was found. She said the family member of Resident #69 wanted no CPR and had not done the advance directive. She said the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on [DATE] at 12:15 p.m., LVN A said she was working night on [DATE], when Resident #69 was found not breathing. She said she checked Resident #69's oxygen saturation and it was in the 80s and she was not responding. LVN A said she did a sternum rub (using fingertips she rubbed on the resident's sternum). LVN A yelled to LVN B, said she was more experienced, knew the resident and had been working here longer. LVN A checked Resident #69 with her stethoscope and heard no heart sounds, no breath sounds. Then LVN B came into the room and checked the resident and LVN B told LVN A to call 911. LVN A said she called 911 and LVN B went to the nurse's station to check the code status for Resident #69 and called DON and Resident #69's RP LVN A said she was certified in CPR. LVN A said she did not initiate CPR. She said she could not remember being trained on CPR at the facility and was not retrained after this event. She denied being counseled about this event. She said when the EMTs arrived they started CPR and Resident #69 was transferred to the local hospital. During a telephone interview on [DATE] at 12:25 p.m., LVN B said she was working night on [DATE]. LVN B said Resident #69 resided on Hall 500 and that the nurse (LVN A) assigned to Hall 500 came and asked her to come down her hall. LVN A went into Resident #69's room and she followed LVN A. LVN B said she knew Resident #69 had passed away, because she was nonresponsive and pale. She said she went to the station to check code status and told LVN A to call 911. LVN B said she called Resident #69's family member and he said to let her go. LVN B said she called the DON and she said do not start CPR, if RP said not to start CPR. So then LVN B said she went to Resident's room and CPR had not been started. She said she did not initiate CPR. She said she was CPR certified and had been trained here about code status and CPR. She said when 911 arrived, the 911 service began manual CPR and Resident # 69 was transferred to the hospital. During an interview on [DATE] at 12:35 p.m., the fire chief said he was unable to release details of the call without a subpoena, he was able to release the call time and dispatch and departure and arrival times. He said on [DATE] the calls and times were as followed: at 11:39 p.m., the call for 911 was received. at 11:42 p.m., the ambulance was dispatched. at 11:44 p.m., the ambulance arrived at the facility. at 11:45 p.m., the ambulance staff was at bedside. at 11:58 p.m., the ambulance departed the facility and arrived at hospital. The fire chief said the hospital was really close to the facility. Interview with DON on [DATE] at 1:20 p.m., the DON said events from [DATE] had not been QA'd (Quality Assurance Program) yet. DON said purpose of QA was to review issues or things that needed to be worked on/improved. DON said this was something they would QA. DON said in QA they would breakdown who, what, when, if policy and procedure was followed and determined any training needed, and that the QA team consisted of administrative staff and their medical director. During an interview on [DATE] at 3:40 p.m., Resident #69's responsible party (RP) said Resident #69 readmitted to the facility on [DATE] and he was going to complete an advance directive on Monday after the holidays. Resident #69 RP said he was her medical power of attorney. He said Resident #69 was a full code and had been transported to the hospital on [DATE]. He said he was able to complete an advance directive at the hospital and she was taken off life support and allowed to pass away, he did not indicate if the resident had a pulse with mechanical ventilation. Record review of the policy dated 2021 for Cardiopulmonary Resuscitation (CPR) indicated Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Procedure: 1. If a resident experience a [CONDITION(S)], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and a. In accordance with the resident's advance directives or in the absence of advance directive or a Do Not Resuscitate order. b. RP should be notified of CPR and or EMS transport. c. Director of Nurses to be notified. Record review of the policy dated 2021 for Residents' Rights Regarding Treatment and Advance Directives indicated Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and formulate an advance directive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:31 p.m. due to the above listed failures. The IJ template was given to the Administrator and requested the facility to send POR to program manager. Record Review of an undated list indicated 36 residents were full code and 31 residents were DNR code status. Record Review of a death in facility list dated [DATE] indicated 6 residents expired in the facility within last 6 months. Immediate Jeopardy in concern was that the facility did not provide life support, including CPR to Resident #69 requiring emergency care prior to the arrival of emergency medical personnel. This IJ concern was received on [DATE] at 3:31pm. The Director of Nurses in-serviced the two Charge Nurses that are currently working on our 2p-10p shift. This was done at 6:30 pm. This in-service included appropriate CPR initiation, honoring code status, and following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Both Charge Nurses on our current shift are CPR certified. The attached literature was also given to both Charge Nurses. This literature included our P&P for Cardiopulmonary Resuscitation, P&P on Residents' Rights Regarding Treatment and Advance Directives and our P&P on following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Weekend Supervisor will in-service the night shift nurses on the same topics and they will receive the same literature before starting their shift tonight ([DATE]). One of the two Charge Nurses tonight are CPR Certified. The Weekend Supervisor will stay until 6am so that she can in-service the morning shift and give them the same literature before the start of their shift. One of the two day shift Charge Nurses are CPR Certified. The staffing schedule will be made so that each shift will have at least one Charge Nurse that is CPR Certified until ALL Charge Nurses can be CPR Certified. We will have the rest of the available licensed nursing staff come to the facility tomorrow ([DATE]) so that the DON can in-service the licensed nursing staff on the same information and they will receive the same literature. All nurses will be in-serviced before they start their shift until all nurses have been in-serviced. The CNA's and CMA's will also be in-serviced. The CNAs and CMAs in-service will include where to find a resident's code status and where to find the needed supplies during a resident emergency. This is only to assist the nurse during an emergency to bring needed supplies and to locate the resident's code status. CNAs and CMAs will be in-serviced on what to do when finding a unresponsive resident, which is to immediately notify a nurse. One of the nurses that was involved in the incident is PRN and is not currently scheduled to work, however the DON called her today and went over the in-service material and the literature will also be emailed to her today. The nurse will also be in-serviced in person before she will be put back on the schedule. The nurse that found the resident unresponsive is off this week due to COVID, however the DON also called her today and went over the in-service material and it will be emailed to her today. She will receive in person training once she recovers from COVID and before she starts her next shift. These in-services will include CPR initiation, honoring code status, and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The nurses can check the code status at the nurses station computers and they also have laptops on all nurses and medication carts. Today([DATE]) we also added a list at the nurses station of all residents in alphabetical order that is color coded that states whether the resident is DNR or Full Code. This list will be updated immediately when there is a change and reviewed every week by our Social Worker. All of today's nursing staff will be in-serviced on this code status list at 2pm today. All other nursing staff will be in-serviced on this information before their shift. This information will also be added to the orientation of new nursing staff (nurses, CNAs, and CMAs). Our Medical Director's Nurse Practitioner will be here by the end of the day to train the DON on CPR initiation, honoring code status, and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the nurses that was involved in the incident is PRN and is not currently scheduled to work, however the DON called her today and went over the in-service material and the literature will also be emailed to her today. The nurse will also be in-serviced in person before she will be put back on the schedule. The nurse that found the resident unresponsive is off this week due to COVID, however the DON also called her today and went over the in-service material and it will be emailed to her today. She will receive in person training once she recovers from COVID and before she starts her next shift. These in-services will include CPR initiation, honoring code status, and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The IJ also stated that the pads were expired on our AED. The pads were replaced at 4:50pm. The AED has a green flashing light, which according to the AED's manual that means that it is functioning properly. The Maintenance supervisor checks the AED every Friday to see that the green light is blinking. He checks this every week while doing his equipment inspection rounds. This is documented every week on a spreadsheet. A column has been added for him to now also check the expiration date on the pads. New pads will be ordered when the current pads are within 60 days of their expiration date and be replaced before the expiration date. The Administrator in-serviced the Maintenance Supervisor on this on [DATE]. All of these actions will be followed up with our Quality Assurance Committee to see that the practices put into place are adequate and to discuss the plan for future ongoing training for nursing staff regarding CPR initiation, honoring code status, and following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's plan of removal as listed above was accepted on [DATE] at 2:03 p.m., and confirmed as follows: During an interview on [DATE] at 3:00 p.m., CNA Student G said resident code status can be checked on the list at the nurse's station. She said emergency supplies are located at the nurse's station and also on hall 5. She said if she found a resident that was unresponsive, she would immediately notify the nurse. During an interview on [DATE] at 3:05 pm interview with CNA H said resident code status can be checked on the list at the nurse's station. She said emergency supplies were located at the nurse's station. She said if she found a resident that was unresponsive, she would go get the nurse. During an interview on [DATE] at 3:07 p.m., DON said she in serviced nurses on ,d+[DATE] shift on CRP initiation, policy, and procedures, unless documented DNR. She was in serviced on following physicians' orders and said she was CPR certified also. During an interview on [DATE] at 3:12 p.m., MA L said she was in serviced on advanced directive and she was to notify charge nurse if she found a resident unresponsive. She said she knew where to find code status in the computer. She said there was a list at nurse station also. During an interview on [DATE] at 3:14 p.m., CNA J said resident code status can be checked on a list on a clip board at the nurse's station. She said residents that were a full code were highlighted in green. She said code status was also listed on the kiosk under each resident. She said emergency supplies were located at the nurse's station by the list of residents' code status. She said if she found a resident that was unresponsive, she would immediately get the nurse. During an interview on [DATE] 3:20 p.m., interview with CNA Student K she said resident code status can be checked on the list at the nurse's station. She said emergency supplies were located at the nurse's station by the code list. She said if she found a resident that was unresponsive, she would get the nurse. During an interview and observation on [DATE] at 3:22 p.m., MA M said she was in serviced on code status. She showed surveyor where it was on the computer. She said the list of Code Status of the residents was at the nurse's station also. She said if she found a resident unresponsive, she was to tell the nurse and grab the back board and AED from the station and assist the nurse. She was in serviced on resident rights and 911. During a phone interview on [DATE] at 3:25 p.m., LVN A said the DON called her and gave her in-service training on honoring code status. LVN A said she can now check code status on a color-coded list located at the nurse's station. She said code status could also be checked on med cart computers and computer at the nurse's station. She said DON had also reviewed when to do CPR, following physician orders, and emergency procedures. LVN A said she also received written material on all this via email. LVN A said she would receive another in-person training before she could return to work at the facility. LVN A said she was not working at this time and was home on sick leave. LVN A said written material received in email contained where to find code status, location of emergency equipment, CPR initiation, honoring resident code status, and following doctor's orders. During an interview on [DATE] at 3:28 p.m., LVN N said she was in serviced on CPR and there was an updated list at the nurse's station to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempted a phone interview with LVN B on [DATE] at 3:35 p.m., and 3:50 p.m., with messages left each time requesting a return call. No call was received back from LVN B. During an interview and observation on [DATE] at 3:36 p.m., Graduate Vocational Nurse (GVN- Unlicensed Vocational Nurse) O said she was in serviced on CPR and following orders. She showed surveyor where the code status of resident was located behind the station and in the computer. She said the code status would be addressed in the admission notes now. She said she was certified in CPR. Record Review of sampled Resident's #303, #304, #305 and #306 indicated the nurses followed the advance directives and physician orders. The nurses notified the responsible parties and DON. The care plans indicated DNR and the residents were on hospice services and expired in the facility. Maintaining Automatic External Defibrillator (AED) *The AED pads replaced at 4:50 p.m. and re-ordered with delivery date [DATE]. * Maintenance supervisor checks the AED every Friday to see that the green light is blinking. He checks his every week while doing his equipment inspection rounds. *Documentation every week on a spreadsheet a column has been added for him to now also check the expiration date on the pad. *New pads will be ordered when the current pads are within 60 days of their expiration date and will be replaced before the expiration date. *The administrator in service the maintenance supervisor on this on [DATE]. *All of these actions will be followed up with our quality assurance committee to see that the practices put into place are adequate to discuss the plan for future ongoing training for nursing staff regarding CPR initiation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: The survey team confirmed the POR by: staff interviews related to CPR, CPR initiation, honoring code status, following physician orders, what to do when finding a unresponsive resident, where to find emergency supplies and code status, and checking AED pads weekly for expiration. Observations of residents were conducted, review of in-services related to CPR, code status and AED inspection was completed. The IJ was lifted on [DATE] at 3:41 p.m. On [DATE] at 3:41 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.