Every finding on record at Matador Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure PRN orders for anti-psychotic drugs were limited to 14 days unless the attending physician or prescribing practitioner evaluates the resident beyond 14 days for one (Resident #2) of three residents reviewed for freedom of abuse, in that:The facility failed to stop a psychotropic medication, Lorazepam (an anti-anxiety medication), which was ordered for Resident #2 to be administered PRN after 14 days without the physician's authorization. Resident #2 was administered 12 additional doses without a physician's order.The deficient practice placed residents at risk of being chemically restrained, sedated, and altered mental status.Findings included: Record Review of Resident #2's undated face sheet reflected [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including non-Hodgkin lymphoma, psychotic disorder with hallucinations, major depressive disorder, other specified disorders of brain, acute respiratory failure with hypoxia, hypertension, benign prostatic hyperplasia, intermittent explosive disorder, urinary tract infection, pulmonary embolism, cellulitis, repeated falls, facture of first lumbar vertebra, encounter for fracture with routine healing.Record Review of Resident #2's MDS assessment, dated 7/31/25, reflected a BIMs score of 12 for cognitive awareness for daily decision making, had inattention and disorganized thinking, with hallucinations and delusions, had behavior symptoms directed towards other and himself but not on a daily basis with significantly interferes with the residents care and the residents participation in activities or social interactions, puts others at significant risk for physical injury and significantly disrupts care or living environment, rejected care occurred 1 to 3 days in the look back period, with his current behavior status has worsened since prior assessment. Record review of Resident #2's care plan, dated 1/29/25, reflected resident appears lethargic and had decreased cognition related to disease process leukemia and lymphoma, resident was on a PRN anxiety medication for anxiety, transferred to a behavioral hospital on 7/7/25 for hallucinations, delusions and paranoid behaviors, had delirium or an acute confusional episode on 8/6/25 with change in condition of unknown origin, had a psychosocial well-being problem related to cancer and long term care placement, resident had little or no activity involvement related to disinterest, resident was on EBP precautions for wounds to bilateral feet, resident had current skin issues to right elbow, coccyx, right heel, left heel, and back of left foot, Resident was on Hospice Care - 9/19/25, on narcotic pain medication for air hunger and pain related to end of life care, resident has declined since admission in self-performance and had increase safety concerns, had depression related to disease process lymphoma and depression, and stated he would be better off dead.Record Review of Resident #2's physician's orders, on 8/21/25, reflected the following order:Lorazepam 0.5 mg by mouth every hour as needed for anxiety - start date 8/21/25 - a stop date was not listed.The Lorazepam medication was documented as being administered on the Medication Administration Record on the following dates:September 6, 2025 - one timeSeptember 14, 2025 - one timeSeptember 17, 2025 - three timesSeptember 19, 2025 - one timeSeptember 21, 2025- one timeSeptember 22, 2025 - two timesSeptember 23, 2025 - one timeSeptember 24, 2025 - two times for a total of 12 doses. An observation on 9/23/25 at 10:38 a.m. revealed Resident #2 was asleep in his room in a low bed. During an interview on 9/25/25 at 10:37 a.m., the DON stated she did not know why Resident #2's PRN lorazepam order was not dropped off after 14 days. The DON stated they talked about psychotropic medications in the morning meeting and stopping PRN medications after 14 days. Record review of the facility's policy titled. Unnecessary Drugs documented it was the policy of this facility to appropriately utilize and monitor the use of medications throughout the tenure of a residents stay. Procedure: The facility will ensure each resident's drug regimen is free from unnecessary drugs. A drug may be considered unnecessary when used:1. In excessive dose (including Duplicate drug therapy: or2. For excessive duration; or3. Without adequate indications for its use; or4. Without adequate monitoring; or5. In the presence of adverse consequences which indicate the does should be reduced; or6. Any combination of the reasons listed above (points 1 - 5) Record review of the facility policy titled, Psychotropic Drugs documented - Procedure: The facility will ensure, through a comprehensive assessment of a resident, the following:4. PRN orders for psychotropic drugs will be limited to 14 days unless the prescriber believes that the medication should be extended past 14 days and has documented their rationale in the medical record including the duration for the PRN order.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure food was properly stored, labeled and dated.2. The facility failed to discard expired food items.These failures could place residents at risk of foodborne illness. Findings included:On 09/23/25 at 10:36 AM an observation of the reach-in refrigerator revealed: Individual jelly packets in rectangular plastic tub with no label or date Individual butter packets in rectangular plastic tub with no label or date Individual ranch dressing packets in rectangular plastic tub with no label or date Individual sour cream packets in rectangular plastic tub with no label or date Individual ketchup packets in rectangular plastic tub with no label or date Individual mustard packets in rectangular plastic tub with no label or date On 09/23/25 at 10:38 AM an observation of the walk-In refrigerator revealed: small steam table pan with plastic bag loosely over the top so white contents (1/4 full) was open to air with no label or date brown plastic tray labeled* roast beef 08/28 and two unopened plastic packages of sliced roast beef. box with one packaged ham and water product. Box dated 08/28 blue plastic tray with two logs of what appeared to be ground meat in original, sealed packaging labeled* ground beef 09/18/25. box of beef patties no date blue plastic tray with what appeared to be large pork loin sealed in original packaging labeled* pork loin 09/18/25 box of eggs no date Plastic tub of potato salad 2/3 gone dated 09/19/25 box cobbler crust dough sheet dated 3-13 plastic opaque square tub labeled* pineapple 9/21 plastic opaque square tub labeled* ham 09/09 appeared to be sliced ham plastic opaque square tub labeled* salsa 09/10 1/3 full plastic opaque square tub of what appeared to be sliced pickles no label, no date 16 oz tub whipped topping no date plastic opaque square tub labeled* shred cheese 09/06 single serving chocolate nutrition shake no date, stick brown substance around the screw top and down the side of the bottle. potato salad tub 1/3 full of brownish liquid labeled* simple syrup 02/23/25 plastic tub of Pimento spread 1/4 full dated 08/21 1 can buttermilk biscuits popped open biscuits dried and flecked with brown spots dated best by 12/16/24 1 can buttermilk biscuits dated best by 12/17/24 small tub of mayonnaise best by 08/23/25 small plastic tub of mild salsa which read consume within 7 days of opening and was dated 07/24/25 with an expiration date of 09/05/25 plastic bottle of siracha best by 03/21/24 metal tray lined with parchment paper layered with sausage links covered with parchment paper open to air labeled for breakfast 09/22/25 zip top plastic bag 1/2 full of what appears to be scrambled eggs no label, no date plastic opaque square tub labeled* pancake mix 9/2025 1/6 full plastic opaque square tub labeled* liquid eggs 9/11 1/4 full box of sausage links open to air On 09/23/25 at 10:56 AM an observation of the pantry revealed the following: 3 boxes of buttermilk biscuit mix with an expiration date of 09/03/25 On 09/23/25 at 11:02 AM an observation of the walk-in freezer revealed the following: one undated plastic bag with two giant pretzels inside with visible round green spots the size of nickels across both pretzels On 09/25/2025 at 10:37 AM an observation of the walk-in refrigerator revealed the following: square opaque plastic tub labeled* shred cheese 09/06; metal tray lined with parchment paper layered with sausage links covered with parchment paper open to air labeled for breakfast 09/25/25; single serving chocolate nutrition shake no date, stick brown substance around the screw top and down the side of the bottle; potato salad tub 1/3 full of brownish liquid labeled* simple syrup 02/23/25; plastic tub of Pimento spread 1/4 full dated 08/21; 1 can buttermilk biscuits popped open biscuits dried and flecked with brown spots dated best by 12/16/24; 1 can buttermilk biscuits dated best by 12/17/24 ; small tub of mayonnaise best by 08/23/25; small plastic tub of mild salsa which read consume within 7 days of opening and was dated 07/24/25 with an expiration date of 09/05/25; plastic bottle of siracha best by 03/21/24; plastic opaque square tub labeled* pineapple 9/21; blue plastic tray with two logs of what appear to be thawed ground meat in original, sealed packaging and one log of what appears to be frozen ground meat in original sealed packaging labeled ground beef 09/18/25; brown plastic tray labeled* roast beef 08/28 and two unopened plastic packages of sliced roast beef;*All items noted had a sticky label with a Use By section. This section was blank.During an interview on 09/23/25 at 01:57 PM DM A stated she had trained her kitchen staff in labeling and dating food. She expressed frustration with staff not labeling and dating food correctly. She stated she had taught staff to label leftover food with the date it was made and 6 days later is the expiration date.During an interview on 09/25/25 at 09:59 AM ADON stated residents could get a stomach bug if food in the kitchen was not properly labeled and dated and expired food was not thrown out timely.During an interview on 09/25/25 at 10:03 AM DON stated residents could get ill if food in the kitchen was not properly labeled and dated and expired food was not thrown out timely.During an interview on 09/25/25 at 10:11 AM MDS LVN stated residents could be fed old food if food in the kitchen was not properly labeled and dated and expired food was not thrown out timely. She stated this could affect residents negatively in an unknown way. She was unable to clarify what way residents could be negatively affected.During an interview on 09/25/25 at 10:21 AM ADM stated residents could get something that was expired if food in the kitchen was not properly labeled and dated and expired food was not thrown out timely.During an interview on 09/25/25 at 10:44 AM DA C stated she did not label or date food in the kitchen. She stated her boss was responsible for labeling and dating food. She stated she had not been trained in labeling or dating food. She stated residents could get food poisoning if food in the kitchen was not properly labeled and dated and expired food was not thrown out timely.During an interview on 09/25/25 at 10:47 AM DM B stated the cooks were responsible for labeling and dating food and cleaning expired food out of the refrigerator and pantry. She stated she was trained in labeling and dating food when she received her food safety manager's training. She stated when food arrived in the facility from the delivery truck it was dated the day it was received. DM B stated when she took food out of the freezer to thaw, she made a label and put it on a tray and put the frozen food on the tray in the refrigerator. She stated the label was dated the day she took the food from the refrigerator and use by (date) is 5-6 days from then. She stated food taken out of the freezer was good for 6 days maximum. DM B stated regarding leftovers, We don't usually have any leftover food but if we do we put the date on it and 5 days from there and if not used by then we dump (the leftover food). She stated cooks were responsible for cleaning out the refrigerator. She stated they did not have a specific day or time they cleaned out the refrigerator. DM B stated, The cooks always look (for expired food) usually when we go in there (the refrigerator). She stated leftover food was dated the day it was made and the use by date which was 5-6 days after the day it was made. DM B stated residents could get sick if food in the kitchen was not properly labeled and dated and expired food was not thrown out timely. She stated, They have compromised immune systems anyway, I take that very seriously.During an interview on 09/25/25 at 11:01 AM DM A stated the cook or whoever is there was responsible for labeling and dating food. She stated she had trained kitchen staff on labeling and dating food and discarding expired food, but she did not document the training. She stated food taken from the freezer was labeled the day it was taken from the freezer and a week after that day. DM A stated, It (food taken from the freezer) expires in a week. She stated leftover food was dated the day it was made and 2 days after that which was the use by date. She stated residents could be served spoiled food if food in the kitchen was not properly labeled and dated and expired food was not thrown out timely.Record review of an undated facility policy titled Storage of Food in Refrigeration revealed the following: . 4. All containers must be labeled with the contents and date food item was placed in storage. 5. Previously cooked foods can be held in refrigeration . for 3 days-being discarded by day 4.Record review of an undated facility policy titled Dry Storage and Supplies revealed no mention of expired foods.Record review of the 2022 Food Code U.S Food and Drug Administration revised January 18th 2023 revealed the following: . Food Labels . Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identify statement; . Food Storage Containers, Identified with Common Name of Food. The mistaken use of food from unlabeled containers could result in chemical poisoning. Based on a predictive growth curve modeling program for Listeria monocytogenes, ready-to-eat, time/temperature control for safety food may be kept . (41oF) a total of 7 days. Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 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.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #24) of 12 residents reviewed for comprehensive care plans.The facility failed to include Resident #24's AVAPS machine in her care plan.This failure could lead to residents not receiving needed care and/or receiving improper care/treatment.Findings Included:Record review of Resident #24's admission record dated 09/24/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure and respiratory failure.Record review of Resident #24's MDS front sheet in the EHR revealed her last annual MDS had an ARD of 12/27/24.Record review of Resident #24's quarterly MDS completed on 09/19/25 revealed a BIMS score of 15 which indicated intact cognition. Section J Health Conditions revealed Resident #24 had no issue with shortness of breath. Section O Special Treatments, Procedures, and Programs revealed Resident #24 utilized a non-invasive mechanical ventilator while a resident.Record review of Resident #24's care plan completed on 07/08/25 revealed no mention of her AVAPS machine. She was noted to receive O2 therapy as needed to maintain O2 saturation at 90% or higher. The goal was: Resident will have proper oxygenation through the review date. The intervention was: Resident will voice concerns related to breathing to nurse on duty. Resident #24 was noted to have shortness of breath. One of the goals was: [Resident #1] will have no complications related to SOB through the review date.Record review of Resident #24's Order Summary dated 09/24/25 revealed the following order with corresponding start date:01/08/25 AVAPS to be worn at HS and PRN to improve respiratory function. every night shift for sleep apnea (common condition in which breathing stops and restarts many times while sleeping, can result in body not getting enough oxygen)Record review of Resident #24's TAR from 06/24/25 to 09/24/25 revealed she wore her AVAPS the following dates:06/02/25-07/04/25,07/07/25-07/13/25,07/15/25-07/20/25,07/23/25-07/26/25,07/28/25-08/02/25,08/04/25-08/05/25,08/07/25-08/14/25,08/16/25-08/31/25,09/02/25-09/03/25,09/07/25, and09/09/25-09/23/25.During an observation and interview on 09/23/25 at 11:28 AM Resident #24 had an AVAPS machine on her bedside table. She stated she used the AVAPS machine at night to keep from having a buildup of CO2 in her lungs.During an interview and observation on 09/24/25 at 03:04 PM Resident #24's AVAPS machine was on her bedside table. Resident #24 stated she used the AVAPS machine every night since her last trip to the hospital. She could not recall the date of her trip to the hospital. She stated the AVAPS machine seemed to be working as her O2 saturations had been anywhere from 90-100 percent.During an interview on 09/25/25 at 09:51 AM CNA D stated Resident #24 had her AVAPS machine since CNA D began working for the facility in March of 2025.During an interview on 09/25/25 at 09:54 AM LVN E stated Resident #24 had had her AVAPS machine for about a year. She stated she turned the machine off in the mornings for Resident #24 because Resident #24 could not reach the button. LVN D stated MDS LVN and ADON were responsible for care plans. She stated she did not think an incomplete care plan would negatively affect resident care. LVN E stated, I don't go off of that (care plan) I go off of the orders.During an interview on 09/25/25 at 09:59 AM ADON stated she and MDS LVN did resident care plans as a team. She stated Resident #24's AVAPS machine should be in her care plan, and she was not sure why it was not. ADON stated she did not think having an incomplete care plan would negatively impact a resident's care.During an interview on 09/25/25 at 10:03 AM DON stated she and ADON were responsible for care plans. She stated she was shocked Resident #24's AVAPS machine was not in her care plan. She stated at the last care plan conference they discussed Resident #24's reluctance to use her AVAPS machine every day as ordered with Resident #24's family member. She stated there was not a negative outcome for a resident if a care plan was incomplete.During an interview on 09/25/25 at 10:11 AM MDS LVN stated she and ADON were responsible for care plans. She stated new orders for a resident should be reflected in that resident's care plan. She stated she did not think a resident's care would be negatively impacted by an incomplete care plan.During an interview on 09/25/25 at 10:21 AM ADM stated the nursing team was responsible for completing care plans. She stated ADON did the bulk of the work on care plans. ADM stated a resident's care plan should be updated to reflect new physician's orders. Regarding an incomplete care plan having a negative effect on resident care, ADM stated, I don't feel like that because it is just not something that is utilized for actual resident care.Record review of an undated facility policy titled Comprehensive Care Plans revealed the following: . 1. The facility will develop and implement a comprehensive person centered care plan for each resident, . to meet a resident' [sic] medical, nursing, . needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being .Record review of an undated facility policy titled Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP0, Non-Invasive Ventilatory Support revealed the following: . The Facility ensures adequate staff and competency for the provision of non-invasive ventilatory support modalities, . The Facility establishes policy to ensure safe and uniform standards of practice for the application of NIV in adult patients and residents. 4. A licensed staff member with demonstrated competency with NIV treatment modalities documents: . g. Care plan, including: i. Type of equipment and settings ii. When to administer .

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #8) of 12 residents reviewed for respiratory care.The facility failed to ensure Resident #8 received O2 via NC at the rate of 2-3 lpm as ordered by her physician.This failure could place residents who receive oxygen at an increased risk of hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath.Findings Included:Record review of Resident #8's admission record dated 09/23/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), chronic respiratory failure (respiratory system fails in gas exchange function), pulmonary hypertension due to lung diseases and hypoxia (below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath), acute and chronic respiratory failure (respiratory system fails in gas exchange function) with hypoxia (below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath), and acute pulmonary edema (sudden buildup of fluid in the lungs).Record review of Resident #8's quarterly MDS completed on 09/11/25 revealed a BIMS score of 8 which indicated moderately impaired cognition. Section J Health Conditions revealed Resident #8 had shortness of breath with exertion and when lying flat. Section O Special Treatments, Procedures, and Programs revealed Resident #8 received O2 therapy while a resident.Record review of Resident #8's care plan completed 09/22/25 revealed a focus area of, Resident is on oxygen therapy to maintain o2 saturation at 90% or greater. The goal was, Resident will be free of illness related to low oxygen saturation. The intervention was, Oxygen administered as prescribed. The care plan revealed a focus area of, [Resident #8] has altered respiratory status/difficulty breathing r/t allergies, CHF and is Oxygen dependent. The interventions were to Administer medication as ordered and Keep O2 via nasal cannula on to maintain O2 level.Record review of Resident #8's order summary dated 09/23/25 revealed the following order with corresponding start date:11/18/22 Oxygen at 2-3 L/min via NC to keep O2 sats 90 or higher. every shiftRecord review of Resident #8's TAR from June 25th to September 25th revealed she received O2 therapy every day.During an observation on 09/23/25 at 12:13 PM Resident #8 was seated in her wheelchair receiving O2 via NC at 3.5 lpm. She appeared to get breathless while speaking, pausing often and closing her eyes and breathing through pursed lipsDuring an observation on 09/24/25 at 09:41 AM Resident #8 was seated in her wheelchair receiving O2 via NC at 3.5 lpm.During an observation on 09/24/25 at 03:00 PM Resident #8 was lying on her back on her bed receiving O2 via NC at 3.5 lpm.During an interview on 09/25/25 at 09:51 AM CNA D stated nurses were responsible for setting flow rates on oxygen concentrators.During an interview on 09/25/25 at 09:54 AM LVN E stated nurses were responsible for setting flow rates on O2 concentrators. She stated the physician's order for O2 determined flow rate. She stated the goal was to keep the flow rate set as low as possible while keeping the resident's O2 saturation in the range spelled out by the order. LVN E stated if a resident received O2 at higher rates than ordered by the physician, It could decrease their respiratory drive.During an interview on 09/25/25 at 09:59 AM ADON stated nurses were responsible for setting flow rates on O2 concentrators. She stated nurses referred to physician's orders for the flow rate. ADON stated a resident could have over oxygenation if they received O2 at higher rates than ordered.During an interview on 09/25/25 at 10:03 AM DON stated nurses were responsible for setting flow rates on O2 concentrators. She stated the nurses referred to physician's orders to determine the correct flow rate. DON stated as an ER nurse she did not think there could be a negative outcome for a resident receiving O2 at higher rates than ordered.During an interview on 09/25/25 at 10:11 AM MDS LVN stated nurses were responsible for setting flow rates on O2 concentrators. She stated the flow rate was based on physician orders and O2 saturation. MDS LVN stated a resident could have CO2 retention if they received O2 at higher rates than it was ordered.During an interview on 09/25/25 at 10:21 AM ADM stated nurses were responsible for setting flow rates on O2 concentrators. She stated the flow rate was based off of the physician's order. ADM stated receiving O2 at higher rates than ordered could knock out their (residents') drive to breath.Record review of facility policy titled Oxygen Administration and dated March 2004 revealed the following: . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan .

Based on interviews and record review; it was determined the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, and readily accessible for 1 of 6 residents reviewed for clinical records (Resident #1) in that: The facility failed to conduct a fall risk assessment for Resident #1. This failure could place residents at risk of increased falls. The findings included: Record review of Resident #1's Face sheet, dated 02/13/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to, Hemiplegia and hemiparesis (weakness in one leg, arm or side) the left dominant side following cerebrovascular disease (stroke), anemia and hypertension. Record review of Resident #1's quarterly MDS assessment, dated 02/04/2025, revealed he had a BIMS of 12 out of 15, which indicated he had mild cognitive impairment. Resident #1 needed maximal assistance for sit to stand and chair to bed transfer. Resident #1 needed moderate assistance for toilet transfer. Resident #1's assessment also revealed he had fallen since admission to the facility. Record review of Resident #1's care plan, updated on 02/04/2025, revealed the following: Resident #1 is a high risk for falls related to CVA with interventions anticipating and meeting resident's needs. Record review of Resident #1's clinical record relating to Fall Risk Assessment revealed the last Fall Assessment conducted for Resident #1 was on 11/18/2023 as a post fall assessment, which indicated he was a moderate risk for falls. There was no documentation relating to quarterly fall assessments in Resident #1's clinical record . In an interview and observation on 2/13/2025 at 4:35 PM, revealed Resident #1 was sitting in his wheelchair eating dinner, Resident #1 stated he had not fallen in a while and had no concerns. In an interview on 02/13/2025 at 7:09 PM, the DON stated she could not find any quarterly fall risk assessments for Resident #1. The DON stated Resident #1's fall risk assessments were overlooked because the EHR system did not trigger the assessment because he had been a resident for some time. The DON stated fall risk assessments were only triggered at admission or after a fall. The DON stated she was responsible for ensuring charge nurses completed admission, quarterly and as needed Fall Risk Assessments on each resident and a possible negative outcome for not completing one would be a resident could get hurt . In an interview on 02/13/2025 at 7:14 PM, RN A stated charge nurses were responsible for ensuring fall risk assessments were completed on residents. RN A was unsure when the assessments were to be completed. RN A stated a possible negative outcome for not doing an assessment would be a resident could get hurt. In an interview on 02/13/2025 at 7:20 PM, LVN B stated a possible negative outcome for not doing a risk assessment for falls would be a resident could get hurt if there were no interventions. LVN B did not know when fall risk assessments were to be completed. In an interview on 02/13/2025 at 7:40 PM, the ADM stated charge nurses were the ones responsible for completing fall risk assessments, but she was the one ultimately responsible for ensuring the documentation was completed. The ADM stated a possible negative outcome for not having the fall risk assessments completed would be a resident could be overlooked as a fall risk. Record review of the facility's, undated, Fall and Post Fall Management Policy revealed the following: Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for resident as well as staff safety. Fall Risk Assessment: .The interdisciplinary team will complete the following: 1. Complete a Fall Risk Assessment a. Upon admission b. Following any significant change of status of fall c. Quarterly documentation assessment

Based on interview and record review the facility failed to provide pharmaceutical services to include the accurate dispensing and administering of drugs to meet the needs for 1 of 5 residents (Resident #1) reviewed for physician orders. The facility failed to accurately enter physician orders for Seroquel(anti-psychotic medication) and Trazodone(insomnia medication) for Resident #1. The deficient practice could place residents at risk of not receiving medications as prescribed and/or deterioration in their condition. Findings included: Record review of Resident #1's face sheet dated 08/28/24 revealed an [AGE] year old male was originally admitted to the facility on [DATE] and was sent to the hospital and readmitted on [DATE] with diagnoses to include but not limited to Alzheimer's disease(memory loss), atherosclerotic heart disease of native coronary artery(narrowing of arteries), vascular dementia, unspecified severity, without behavioral disturbance(breakdown of thought process), psychotic disturbance, mood disturbance and anxiety, delusional disorder, psychotic disorder with delusions due to known physiological condition, mood disorder due to know physiological condition with major depressive like episode and Vascular dementia, unspecified severity, with other behavioral disturbance(breakdown of thought process causing disruptive behavior). Record review of Resident #1's last completed Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 03 out of 15 indicating that he had severe impairment. Resident #1's functionality was independent from sitting to lying down, sitting to standing and chair/bed transfer with setup assistance with eating, oral hygiene, and upper and lower body dressing. Resident #1 had occasional bowel and urinary incontinence. Record review of Resident #1's care plan start date 08/08/2022 revised on 08/20/2024 revealed that Resident #1 had a history of depression and took antidepressants with interventions to encourage and assist resident to attend activities and provide medication as ordered. Care plan also indicated Resident #1 had a diagnosis of Alzheimer's/Dementia with interventions to encourage and allow resident to verbalize needs and concerns and provide medications as ordered. The care plan did not address Resident #1's insomnia or antipsychotic medication. Record review of Resident #1's discharge orders from the Rehab Hospital dated 08/15/2024, indicated Resident #1 was admitted on [DATE] and released back to the facility on [DATE] and revealed the following orders: Quetiapine ER (Seroquel XR) Give 100 mg (2tablets) by mouth at bedtime DO NOT CRUSH. Start date/Time: 07/31/2024 at 9:00 PM and Stop Date/Time: 09/28/2024 9:00 PM Active Days: 16 Trazodone (Desyrel) Give 50 mg (1 tablet) by mouth at bedtime PRN for Insomnia Start date/Time: 07/31/2024 at 9:02 PM and Stop Date/Time: 09/28/2024 9:02 PM Active Days: 16 Record review of Resident #1's orders listed as Discontinued Orders entered on 08/15/2024 and discontinued on 08/18/2024 revealed the following: Seroquel Oral Tablet 50 MG-Give 2 tablet by mouth two times a day related to psychotic disorder with delusions due to known physiological condition. Trazodone HCI Oral Tablet 50 mg-Give 1 tablet by mouth at bedtime for Insomnia. Record review of Resident #1's orders listed as Active Orders entered on 08/18/2024 revealed the following: Seroquel XR Oral Tablet Extended Release 24-hour 50 mg (Quetiapine Fumarate) Give 2 tablet by mouth at bedtime related to Psychotic disorder with delusions due to known physiological condition. Trazodone HCI Oral Tablet 50 mg (Trazodone HCI) Give 1 tablet by mouth every 23 hours as needed for insomnia (Use only at bedtime). Record review of the MAR dated August 2024 revealed that Resident #1 took Seroquel Oral Tablet 50 mg (Quetiapine fumarate) Give 2 tablet by mouth two times a day. Resident #1 was given the medication on 08/15 at 8:00 PM, 08/16 and 08/17 at 8:00 AM and 8:00 PM, and 08/18 at 8:00 AM. The MAR also revealed that Resident #1 was given Trazodone HCI Oral Tablet 50mg-Give 1 tablet by mouth at bedtime for insomnia on 08/15, 8/16, and 08/17/2024. Interview on 08/28/2024 at 11:45 AM, Resident #1 stated that he was doing well and that they fixed his medications. Resident #1 stated he did not know what medications he was taking but he did not feel drunk anymore. Interview on 08/28/2024 at 12:45 PM, LVN C stated the nurses were responsible for putting in the orders when a new admission was admitted to the facility. LVN C stated that she was told that when Resident #1 was sent to the hospital that they were looking at lowering his medication and was wondering about the medications. LVN C stated she looked at the discharge orders from the Rehab Hospital from 08/15/2024 and noticed that the orders that were put in the system did not match the discharge orders from the Rehab Hospital. LVN C stated she contacted her DON immediately and put the correct orders in the system on 08/18/2024. LVN C stated that the LVN that put the orders in wrong was no longer employed at the facility. LVN C stated that a possible negative outcome for not having the correct orders would be that it could cause the resident harm. Interview on 08/28/2024 at 1:38 PM, LVN A stated that the nurse on duty at the time of a resident's admission was responsible for entering the orders from the doctor/hospital. LVN A stated that a possible negative outcome for putting orders in wrong would be that a death could occur if too much medication was given. Interview and observation on 08/28/2024 at 1:51 PM, LVN B opened the medication cart where Resident #1's medication was stored. LVN B stated that when the new medications that were ordered were the same medication but a different dose, a label was put on the blister pack that identified the new order in the system. LVN B pulled out the labels that were used to put on the blister packs that identified new orders. LVN B stated that a possible negative outcome for putting orders in wrong would be that a resident's side effects could get worse, or they could become lethargic and hurt themselves. Interview on 08/28/2024 at 2:45 PM, the DON stated that Resident #1 was already taking Seroquel and Trazodone so when he returned to the facility, they were able to use the medication on hand. The DON stated that a possible negative outcome for not having correct documentation for orders would be that a resident could die or become injured due to confusion. Record Review of Medication Administration Policy (no date) revealed the following: . Follow the six rights of medication administration(Right Patient, Right Drug, Right Dose, Right Route, Right Time, Right Documentation) . . Read the label 3 times as your prepare a medication, carefully checking the drug label against the Medication Administration Record (MAR, med card or physician orders) .

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 the facility's only kitchen reviewed for dietary services. The facility failed to ensure the designated Dietary Manager completed the required dietary managers certification course or had 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 Dietary Manager revealed she was hired on 10/31/23 as a cook. There was no documentation in the personnel file that indicated that she had completed the required training for Dietary Manager and was a Certified Dietary Manager. Record review of the facility's Dietician documentation revealed that the Dietician was contracted and not full-time. In an interview on 8/12/24 at 10:15 am, the DM stated she was hired as a cook in the kitchen and had been the DM for about 2 months. She stated her duties as dietary manager were to supervise the kitchen staff and ensure all dietary functions were carried out. tShe stated she was not working on her certification for the DM as she cannot afford to pay for it and the owner will not pay for it. She stated she has never been employed as a DM before and does not have a degree in food service. In an interview on 8/12/24 at 12:40 pm the RD stated the owner has a DM certificate. She stated she had never been in the building. She further stated she had never seen the owner in the kitchen. In an interview on 8/12/24 at 1:45 pm, the RD stated she is only allowed by the owner to provide 20 hours a week of dietary consultation. In an interview on 8/13/24 at 9:40 am the ADM stated the Dietary Manager was not a certified DM and had not taken the required DM course. The ADM stated the DM must pay for the certification herself and she does not have the money to do it. She stated the owner will allow the staff to do it at their expense. The ADM stated the owner's wife is a DM. When asked if the owner's wife was in the kitchen supervising the kitchen, she said no. She stated she expected the Dietary Manager to become certified. The ADM stated she expected the DM to be certified to manage the kitchen effectively. The ADM stated the consequences of not being certified could be poor resident satisfaction with meals and not being knowledgeable about important dietary issues. In an interview on 8/13/24 at 9:55 am, the DM stated she had never met the owner's wife who had a DM certificate. She stated the owner's wife had never been in the kitchen or trained staff. The DM stated the owner's wife orders coffee for the facility and reviews the kitchen budget. In an interview on 8/14/24 at 8:28 am Dietary Aide B stated she had never seen the owner's wife in the kitchen and the DM runs the kitchen. In an interview on 8/14/24 at 8:30 am CNA C stated she had never seen the owner's wife in the kitchen and the DM runs the kitchen. Record Review of the undated facility policy titled Dietary Service revealed if a qualified dietician is not employed full time the facility will designate a person to serve as a Director of Food Service. The director of food service must be at least a person who has completed a state agency approved 90 hour course in food service supervision.

Based on observation, interview, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed all residents for 1 of 2 meals observed. 1. The facility did not serve a biscuit or any bread products to any residents for the lunch meal on 8/12/24 as directed by the menu. These failures could place all residents who received food from the kitchen, at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status, Findings included: Record review of the diet spreadsheet, approved by the facility Dietitian, for Lunch- Monday 8/12/24, Week 1, revealed residents were to receive: honey garlic chicken thighs, cheesy rice, steamed broccoli, strawberry shortcake and 1 biscuit. In an observation on 8/12/24 at 11:55 am, [NAME] A was observed plating and serving lunch. There were no rolls or biscuits on the serving line and no biscuits were served to any residents on any of the noon meal trays prepared for lunch. During an observation on 8/12/24 at 12:20 p.m., of the lunch meal in the dining room and residents who ate in their rooms revealed none of the residents received a biscuit or any bread for the lunch meal as listed on the menu. During an interview on 8/12/24 at 12:40 pm, the RD stated if a food item was on the menu, it should have been served. She stated she expects that if a food is listed on the menu it is served. She stated she has trained the DM for kitchen practices. She stated the consequences of residents not getting what is listed on the menu could be weight loss and lack of nutrients in their diet. During an interview on 8/12/24 at 1:40 pm, the DM stated she was aware that none of the residents received a biscuit for the lunch meal and they should have gotten a biscuit for lunch. She stated she did not know why a biscuit or bread was not served. She stated the consequences of not having all the food items listed on the menu could lead to weight loss and hunger. In an interview on 8/12/24 at 1:45 pm, the RD stated she was aware that there was no biscuit served for the noon meal. The RD stated there should have been a biscuit served at the noon meal. During an interview on 8/12/24 at 1:55 pm, [NAME] A stated none of the residents received a biscuit for the lunch meal and they should have gotten a biscuit for lunch. She stated she just forgot to make the biscuits and did not put bread on the trays. She stated the consequences for the residents could be hunger at the end of the meal. [NAME] A stated she had been trained by the DM for work in the kitchen. Record Review of the undated facility policy titled, Dietary Services revealed the facility menu will meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council Record Review of the undated facility policy titled, Food Service revealed the facility menu will meet the nutritional needs of each resident; provide a well-balanced, flavorful, and varied food service program. All meals will meet USDA guidelines for the major food groups using the nutritional pyramid. Record Review of the undated facility policy titled ' Menus' documented menus will be prepared in advance, be nourishing, palatable, well balanced and will meet the daily nutritional dietary needs of the residents, If the meal service varies from the planned menu, the change and the reason for the change will be noted in the record used solely for recording such changes.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and contained. B. Ensure general cleanliness was maintained. C. Ensure all food service staff used proper hand hygiene and use of gloves during meal preparation. D. Ensure temperatures were taken at the beginning of the meal service. E. Ensure substitution list, cleaning list and temperature logs were utilized. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: Observations on 8/12/24 at 10:25 am, on initial kitchen rounds of the pantry revealed: 1. Crumbs in the bin holding chips 2. 5 bags of cereal, no label or date, not in original box. 3. A bin holding powdered milk was sticky and grimy to the touch. The lid was not secured. 4. Trash, food packets and crumbs were observed in the floor of the pantry Observations on 8/12/24 at 10:30 am, on initial kitchen rounds of the walk-in freezer revealed: 1. A bag of frozen biscuits was unsecured, unlabeled, undated, not in the original box and open to air. 2. A box of chocolate chip cookie dough was unsecured and open to air. 3. A box of rolled dough was unsecured and open to air. 4. A box of breadstick dough was unsecured and open to air. 5. A box of meat patties was unsecured and open to air. 6. Trash, food packets and food particles in the floor of the walk- in freezer. Observations on 8/12/24 at 10:35 am, revealed the walk-in cooler had trash, food packets and food particles in the floor of the cooler. Observations on 8/12/24 at 10:40 am, of the main kitchen prep area revealed walk-in freezer revealed: the white plastic bins holding thickener, flour, rice and sugar were sticky and grimy to the touch. There was a brown grimy film surrounding the lips of each bin. The sides and tops of each bin were sticky to the touch and food particles were stuck to the tops of each bin. The lids for each bin were not tight fitting and did not seal. The sugar had brown spots inside the bin on the top of the sugar. In an observation and interview on 8/12/24 at 11:40 am, [NAME] A washed her hands, plugged the blender into the electrical outlet and picked up the canister for the mixer. [NAME] A then put gloves on her hands. [NAME] A picked up a bowl and tongs and walked to the food steam table. [NAME] A used the tongs to put the chicken into the bowl. [NAME] A scooped 2 lades of sauce into chicken and walked to the prep table. [NAME] A pureed the chicken then took the lid off the blender with her gloved hands and set the lid on the counter. [NAME] A walked across the kitchen, picked up the loaf of bread and carried it to the prep table where she was blending the chicken. [NAME] A opened the bread wrapper, and pulled out a piece of bread with her gloved hand. [NAME] A put the piece of bread into the blender with her gloved hand. [NAME] A then put the lid on the blender and pureed the chicken. [NAME] A then took off the lid of the blender and pulled out another piece of bread, tore the bread in half with her gloved hands and added a half slice of bread to the blender. [NAME] A blended the chicken. [NAME] A then picked up the other half of the bread with her gloved hand and added it to the blender. [NAME] A did not wash her hands or change her gloves. [NAME] A stated she did not realize she touched the bread with her contaminated hands. She stated she had gloves on. She stated she did not realize she touched other surfaces in the kitchen. She stated she should have changed her gloves. When asked about the consequences to the residents she stated she did not know. In an observation on 8/12/24 at 11:55 am, [NAME] A was observed serving lunch. The temperatures of the foods on the steam table were not taken prior to the first plate being served. In an interview on 8/12/24 at 12:50 pm, [NAME] A stated she did not take temperatures of the food before serving. She stated she takes the temperatures as she cooks. [NAME] A was asked about the biscuits not being served at the noon meal. She stated she forgot. She stated she did not put any bread on anyone's tray. She stated the DM had trained her for her kitchen duties. [NAME] A stated residents would be hungry if they did not get all the menu items listed. In an interview on 8/12/24 at 1:40 pm, the DM stated she was aware that there was no biscuit served for the noon meal. The DM stated there should have been a biscuit served at the noon meal. She stated the consequences of residents not getting a bread at lunch was not enough to eat. In an interview on 8/12/24 at 1:45 pm, the RD stated she was aware that there was no biscuit served for the noon meal. The RD stated there should have been a biscuit served at the noon meal. She stated the kitchen does not have a substitution list or a cleaning schedule. The RD stated she is only allowed to provide 15 hours of service a month and she trains when she is in the facility. She stated she looks at cleanliness when she is in the facility. She stated some of the things she looks at was whether the floor and countertops were sticky, whether the shelf holding spices was clean and the spices were closed. She stated she also looks at the hood vent and whether the top of the dishwasher was clean. She stated she was aware there was no substitution list or cleaning list. The RD stated she was aware the kitchen staff had not been taking food temperatures and she had discussed this with the DM. In an observation on 8/13/24 at 9:55 am, the kitchen revealed the same cleanliness conditions in the kitchen and the same food storage issues in the pantry floor, pantry storage Items in the walk-in freezer were still opened to air. There was still trash and food particles in the floor of the walk-in freezer and walk in cooler. The plastic bins holding thickener, rice and sugar still had grime and crumbs on the containers. [NAME] spots were observed in the sugar. In an interview on 8/13/24 at 10:10 AM, the DM stated she did not have a cleaning schedule or a substitution list. She stated she expected staff to clean as they go. She stated right now she is the one cleaning. When told about [NAME] A using her hands to touch the bread while pureeing the chicken, she nodded her head OK. The DM stated she expected all kitchen staff to use tongs and proper hand washing. In a walk-through of the kitchen with the DM, on 8/13/24 at 8:30 am, cleanliness issues were pointed out and observed to still be an issue. Record Review of the undated facility policy titled ' Dry Storage and Supplies ' documented all facility storage areas will be maintained in an orderly manner [NAME] preserves the condition of the food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects. Dry bulk food (flour, sugar) is stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are cleaned regularly. Opened packages of food are stored in closed containers with tight covers and dated as to when opened. Storeroom floors should be swept and mopped to be maintained in a sanitary manner. Record Review of the undated facility policy titled ' Cleaning ' documented all equipment, food contact surfaces and utensils shall be cleaned whenever contamination may have occurred. Record Review of the undated facility policy titled ' Storage Refrigerators' documented food must be covered when stored, with a date, and label identifying what is in the container. Record Review of the undated facility policy titled ' Daily Food Temperature Control' documented prior to meal service, the cook shall take the temperature of all hot and cold food. Temperatures are recorded on the temperature log form. Record Review of the undated facility policy titled ' Menus' documented menus will be prepared in advance, be nourishing, palatable, well balanced and will meet the daily nutritional dietary needs of the residents, If the meal service varies from the planned menu, the change and the reason for the change will be noted in the record used solely for recording such changes. Record Review of the undated facility policy titled ' Storage of Food in Refrigeration' documented food items that remain sealed from the supplier may be held until the expiration date if unopened. Food returning to storage after cooking or preparing must be covered. Record Review of the undated facility policy titled ' Food Safety' documented all staff will be aware of proper food handling and storage procedures. Food will be served in such a way as to prevent growth of bacteria. All food service staff will wash their hands when moving from one food prep area to another. Temperatures of food will be monitored at each meal. Use sanitized utensils and avoid hand contact. Avoid cross contamination of foods. Food must be covered when stored, with a date.

Based on interview, and record review the facility failed to conduct a periodic comprehensive assessment of each resident's functional capacity for 3 of 14 residents (Residents #7, #9, and #20) whose records were reviewed for assessments. The facility failed to complete a comprehensive assessments for Resident #7, #9, and #20 every 3 months. This failure could place residents at risk for not getting an accurate assessment and could result in lack of care. Findings include: Resident #7 Record review of Resident #7 face sheet dated 8-13-2024 revealed she was admitted on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), convulsions (a sudden, violent, irregular movement of a limb or of the body caused by involuntary contraction of the muscles and associated especially with brain disorders such as epilepsy), hypertension (a condition in which the force of the blood against the artery walls is too high), diabetes(a chronic condition that affects the way the body processes blood sugar (glucose), and malnutrition (lack of proper nutrition). Record review of Resident #7's last completed MDS dated [DATE] listed her with a BIMS score of 00 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for all her activities of daily living. Record review of Resident #7's MDS tracking record revealed the last completed MDS was a quarterly completed on 4-26-2024. The next MDS listed was a quarterly 7-27-2024 that was in progress and listed as 3 days overdue. Resident #9 Record review of Resident #9's face sheet dated 8-12-2024 revealed she was admitted [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D), hypertension (a condition in which the force of the blood against the artery walls is too high), and malnutrition (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #9's last completed MDS dated [DATE] listed her with a BIMS score of 12 indicating she was moderately cognitively impaired, and she had a functionality of requiring supervision/touching assistance with most of her activities of daily living. Record review of Resident #9's MDS tracking record revealed the last completed MDS was a quarterly completed 3-20-2024. The next MDS listed was a quarterly 6-20-2024 that was in progress and listed as 40 days overdue. Resident #20 Record review of Resident #20 face sheet dated 8-14-2024 revealed he was admitted to the facility originally on 4-4-2023 and readmitted on [DATE] with diagnoses to include diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), hypertension (a condition in which the force of the blood against the artery walls is too high), peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), malnutrition(lack of proper nutrition), and intermittent explosive disorder(a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand),. Record review of Resident #20's last completed MDS dated [DATE] listed him with a BIMS score of 9 indicating he was moderately cognitively impaired, and he had a functionality of requiring supervision/touching assistance with most of his activities of daily living. Record review of Resident #20's MDS tracking record revealed the last completed MDS was an admission completed 3-31-2024. The next MDS listed was a quarterly 6-30-2024 that was in progress and listed as 30 days overdue. During an interview on 08-13-2024 01:45 PM the DON reported that the facility was currently completing all MDS offsite due to the sudden loss of their ADON/MDS nurse. They both confirmed that in the meantime they have been having to scramble to cover the MDS's and care plans. During an interview on 08-132024 at 02:14 PM the CMDS Coordinator reported that all late MDS assessments were currently due to the situation with the ADON/MDS Coordinator which resulted in the facility contacting her facility to ask for assistance with MDS coordination, that any late MDS is currently due to her facility waiting on additional information from this facility such as therapy notes for a resident so they can finish the MDS and submit it. The CMDS Coordinator reported that all the late MDS's will result in issues such as late plans of care, late care plans, and will result in delay of facility reimbursement. The CMDS Coordinator reported that she does not feel this will affect the residents care because she personally knows the two owners of this facility and they would not let the resident do without what they need because of the delayed reimbursements. During an interview on 08-13-2024 at 02:06 PM the CMDS Coordinator reported that the policy followed to complete the MDS to include timing for the MDS to be completed was the RAI manual.

Based on observation, interview, and record review the facility failed to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation of bed rails for 4 (Residents #5, #13, #24, and #25) of 14 residents reviewed for bedrails. The facility failed to inform Residents #5, #13, #24, and #25 or their representatives of the use of bed rails and obtain consent for the use of bed rails. This failure could place all residents with bed rails at risk for injuries such as abrasion, fractures, and entrapment. Finding include: Resident #5 Record review of Resident #5's clinical record revealed an [AGE] year-old female admitted to the facility originally on 6-8-2022 and readmitted on [DATE] with diagnoses to include atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), polyosteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic respiratory failure (a long-term condition that occurs when the body's respiratory system cant exchange oxygen and carbon dioxide properly), muscles spasms(an involuntary and forceful contraction of a muscle or group of muscles that can't relax), muscle weakness (a lack of muscle strength), and pain in shoulder. Record review of Resident #5's clinical record revealed her last MDS was a quarterly completed 6-25-2024 which indicated her BIMS score was 10 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up/clean-up with most activities of daily living. Record review of Resident #5's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #5's care plan with date of admission 2-15-2023 revealed the following: Focus: Resident uses a positioning bar on the right side of her bed for increased bed mobility and positioning. Date initiated 10-26-2022. Intervention: Ensure consent is on chart prior to initiating . During an observation on 08-12-2024 at 10:50am Resident #5 was not present. Noted a bed rail on the right side of Resident #5's bed. During an interview on 08-12-2024 at 02:23 PM Resident #5 stated that she was able to get in bed with the assistance of her bed rail but has gotten weaker since the last CHF flare up. Resident #13 Record review of Resident #13's clinical record revealed a [AGE] year-old male admitted to the facility originally on 4-18-2023 and readmitted on [DATE] with diagnoses to include displaced fracture (a type of complete fracture that occurs when the ends of a broken bone are out of alignment), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), intermittent explosive disorder (a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand), muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), and muscle weakness (a lack of muscle strength). Record review of Resident #13's clinical record revealed his last MDS was a quarterly completed 6-25-2024 which indicated his BIMS score was 12 indicating he was moderately cognitively impaired, and he had a functionality of requiring partial/moderate assistance with most activities of daily living. Record review of Resident #13's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #13's care plan with date of admission 8-1-2024 revealed the following: Focus: May have grab bars on bed to promote independence with bed mobility as needed. Date initiated 8-12-2024. During an observation on 08-12-2024 at 10:52 AM Resident #13 was lying in his bed. Resident #13 had bedrails on the side of his bed. During an interview on 08-13-2024 at 09:39 AM Resident #13 revealed that he used his bedrails to help himself turn over. Resident #13 stated that he does need assistance transferring into his w/c from staff. Resident #24 Record review of Resident #24's clinical record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), history of fractures, fall history, and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #24's clinical record revealed his last MDS was a quarterly completed 6-3-2024 which indicated his BIMS score was 04 indicating he was severely cognitively impaired, and he had a functionality of requiring supervision/touching assistance to partial/moderate assistance with most activities of daily living. Record review of Resident #24's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #24's care plan with date of admission 9-19-2022 revealed the following: Focus: May have grab bars on bed to promote independence with bed mobility as needed. Date initiated 8-12-2024. During an observation and interview on 08-12-2024 at 10:51 AM Resident #24 sat up in his bed with the assistance of a bedrail on the side of his bed. Resident #13 did not voice any concerns and stated, I'm fine, and did not need anything at this time. Resident #25 Record review of Resident #25's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include hemiplegia (partial paralysis), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), morbid obesity (a disorder involving excessive body fat that increase the risk of health problems), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension, (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #25's clinical record revealed her last MDS was a quarterly completed 6-20-2024 which indicated her BIMS score was 15 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with most activities of daily living. Record review of Resident #25's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #25's care plan with date of admission 12-29-2022 revealed the following: Focus: May have grab-bars on bed to promote independence with bed mobility as needed. Date initiated 8-12-2024. During an observation and interview completed on 08-12-2024 at 10:31 AM Resident #25 was in her room in her bathroom in her wheelchair initially. Resident #25's bed was made with bilateral 1/8 bedrails up and locked in place. Resident #25 reported that she used her bedrails to steady herself in bed and that she had been trained on the use of the bedrails. During an interview on 08-14-2024 at 08:27 AM the administrator reported that the facility did not have the proper consent forms for the four residents reviewed for bedrails. The administrator verified that they did have orders for the bedrails, ongoing monitoring for the bedrails via care plans and review at each care plan meeting but that the consents were not completed prior to installation or the resident moving to a bed with bedrails. The Administrator reported that residents or resident representatives who were not educated on the risks and given the opportunity to consent would be at risk for injuries and harm. During an interview on 08-14-2024 at 08:58 AM the DON verified that all 4 residents did not have a consent for the use of a bedrail and reported that a resident could be affected negatively and have an injury especially if they were not educated on the risk and use of a bedrail. Record review of the facility provided polity titled Bed Rails undated, revealed the following: Procedures: 2. Review the risk and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. 47854

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 18 days out of 31 (05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23,06/24/23) 07/6/24, 07/13/24, 07/20/24, 07/21/24, 08/03/24, 8/10/24 and 8/11/24 ) days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 05/4/24, 05/5/24, 05/11/24, 05/18/24, 05/19/24, 05/25/24, 05/26/24, 06/23/24, 06/29/24, 06/30/24, 07/04/24, 07/6/24, 07/13/24, 07/20/24, 07/21/24, 08/03/24, 8/10/24 and 8/11/24. This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster undated revealed there were five RN's employed at the facility. Record Review of time sheet provided by the Administrator for the time period 05/01/24-08/11/24 revealed the following dates did not have RN coverage for at least 8 hours a day for the following days: 05/4/24, 05/5/24, 05/11/24, 05/18/24, 05/19/24, 05/25/24, 05/26/24. 06/23/24, 06/29/24, 06/30/24, 07/04/24, 07/6/24, 07/13/24, 07/20/24, 07/21/24, 08/03/24, 8/10/24 and 8/11/24. During an interview on 08/12/24 at 3:45 pm, the DON stated the administrator and DON were responsible for RN coverage. She stated she only clocks in for her shift and does not clock out. She stated she cannot prove that she was in the facility for 8 hours each day she clocked in. She stated the consequences of not having an RN in the building could cause poor care for the residents. During an interview on 08/13/24 at 1:55 pm, the Administrator stated the DON only clocks in for accountability to the owner. She stated she could not prove the DON was in the facility for 8 consecutive hours or more on the days she just clocked in. A policy was requested from the ADM but never furnished.

Based on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 1 of 14 residents (Resident #31) whose records were reviewed for assessments. Resident #31 was on CPAP therapy while in the facility and it was not addressed in his MDS. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for not receiving correct care and services. Finding include: Record review of Resident #31's face sheet dated 8-12-2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation(an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Record review of Resident #31's admission MDS completed 6-24-2024 listed him with a BIMS of 15 indicating he was cognitively intact, and he had a functionality from being independent with some of his activities of daily living to requiring substantial/maximal assistance with his activities of daily living. Section O Special Treatment, Procedures, and Programs: -Respiratory Treatments G-Non-Invasive Mechanical Ventilator (BiPAP/CPAP)- neither while not a resident or while a resident is mark as the resident having either one of these therapies. Record review of Resident #31's care plan with admitted [DATE] revealed the following: Focus: The resident has COPD and uses O2 PRN and should use CPAP at night. Date initiated 7-1-2024. Record review of Resident #31's order summary report with active orders as of 8-12-2024 revealed the following order: CPAP to be worn at HS, every night shift. Active Date - 6-19-2024 Record review of Resident #31's TAR (Treatment Administration Record) for 6-2024 revealed that Resident #31 received CPAP therapy nightly from 6-19-2024 through 6-24-2024, 6 days prior to the 6-24-2024 admission MDS assessment. During an observation and interview on 08-12-2024 at 10:52 AM Resident #31 was noted to have a CPAP machine on his bedside dresser that Resident #31 reported he had for years and he used daily. Resident #31 reported that the facility helped him with all his needs to include the CPAP and the care of the CPAP equipment such as cleaning, adding water, replacing the tubing. During an interview on 08-13-2024 at 01:45 PM the DON reported that the facility was currently completing all MDS's offsite due to the sudden loss of their ADON/MDS nurse. They both confirmed that in the meantime they have been having to scramble to cover the MDS's and care plans. During an interview on 08-13-2024 at 01:56 PM the DON reported that if a resident does not have their CPAP addressed on the MDS she would not know if it would affect the resident in any way because she does not know enough about the MDS's to answer any questions. During an interview on 08-13-2024 at 02:06 PM the CMDS Coordinator reported that she had not dealt with Resident #31's MDS when the CPAP therapy was missed, that that was completed by the facility's ADON/MDS Coordinator of which she (the CMDS Coordinator) did not know why the ADON/MDS Coordinator missed the CPAP. The CMDS Coordinator did report that the CPAP should have been addressed on the admission MDS if the CPAP was documented in Resident #31's chart. The CMDS Coordinator reported that the MDS affects the care plan and that if the MDS was not accurate then the care plan will not be accurate and the care plan drives the resident's care. The CMDS Coordinator reported that the policy followed for the MDS was the RAI manual. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17, dated October 2019 revealed the following: Section O0100 Special Treatment, Procedures, and Programs- o O0100G, Non-invasive Mechanical Ventilator (BiPAP/CPAP) Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support his or her own spontaneous respiration by providing enough pressure when the individual inhales to keep his or her airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes his/her own BiPAP/CPAP mask/device.

Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 2 (Resident #18 and #20) of 16 residents reviewed for preadmission screenings. A. The facility failed to perform a PASRR for Resident #18 until 4 months after admission. B. The facility failed to perform a PASRR for Resident #20 until 2 months after admission. This failure could place residents at risk of receiving inadequate care. Findings Included: Record review of Resident #18's admission record dated 08/13/24 revealed Resident #18 was an 81year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to dementia ( a group of thinking and social symptoms that interferes with daily functioning), anxiety ( a feeling of worry, nervousness or unease), depression (a mood disorder that affects how a person thinks feels and acts) and anemia( a condition in which the blood does not have enough healthy red blood cells and hemoglobin) Record review of Resident #18's MDS completed 04/29/24 section C revealed a BIMS score of 8 indicating cognition was moderately impaired. Section E revealed Resident #18 had no behaviors. Record review of Resident #18's care plan completed on 04/22/24 revealed Resident #18 used a wheelchair for mobility and was incontinent. Record review of Resident #18's PASRR Level 1 Screening revealed it was completed on 08/13/24. Record review of Resident #20's admission record dated 8/13/24 revealed Resident #20 was a 64-y o male admitted to the facility on [DATE] with diagnoses of diabetes (a group of diseases that result in too much sugar in the blood), anemia ( a condition in which the blood does not have enough healthy red blood cells and hemoglobin) and (hypertension ( a condition where the pressure in your blood vessels is consistently higher than normal). Record review of Resident #20's quarterly MDS completed 06/30/24 section C revealed a BIMS score of 9 indicating cognition was moderately impaired. Section E revealed Resident # 20 had no behaviors. Record review of Resident #20's care plan completed on 03/25/24 revealed Resident #20 used a walker for mobility, was hard of hearing and at risk of depression due to his situation. Record review of Resident #20's PASRR Level 1 Screening revealed it was completed on 06/24/24. During an interview on 08/13/24 at 9:26 am, the ADM stated she was responsible for ensuring PASRRs on new admits were completed. She stated PASSR's were to be done immediately at admission or before admission. She stated both Resident #18 and Resident #20 came from the community and not from a hospital setting when admitted . She stated the PASSR's were done late. She stated a possible negative outcome of not having PASSRs completed prior to or at admission could result in not getting needed services. Record review of the undated facility policy titled Preadmission Screening and Resident Review revealed the policy of this facility is to ensure all residents are screened and appropriately addressed via the PASSR process as outlines by regulations. The facility designated staff will review all potential admission for possible positive PASSR conditions and ensure that CMS Preadmission guidelines are followed.

Based on interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #31) of 14 Residents reviewed for comprehensive care plans. -The facility failed to include a care plan for Resident #31's smoking. This failure could affect residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding include: Record review of Resident #31's face sheet dated 8-12-2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation(an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Record review of Resident #31's admission MDS completed 6-24-2024 listed him with a BIMS score of 15 indicating he was cognitively intact, and he had a functionality from being independent with some of his activities of daily living to requiring substantial/maximal assistance with his activities of daily living. Record review of Resident #31's care plan with admitted [DATE] revealed no care plan for smoking. Record review of Resident #31's Smoking Assessment completed 6-17-2024 revealed the following: D. Frequency 4. How often does the resident smoke per day? 2-5 times During an interview on 08-12-2024 at 10:52 AM Resident #31 confirmed that he was a smoker. During an interview on 08-13-2024 at 01:45 PM the DON reported that the facility was currently completing all MDS's offsite and that she (the DON) has been attempting to complete care plans due to the sudden loss of their ADON/MDS nurse. They both confirmed that in the meantime they have been having to scramble to cover the MDS's and care plans. The Administrator reviewed Resident #31's chart and confirmed that he had no care plan for smoking. The DON reported that she has been learning how to complete the care plans since July 4th, 2024, with no training and reported that it probably was her fault that the smoking care plan was missed. The DON confirmed that smoking should be in a resident's care plan, that missing this smoking care plan would not be an issue due to this resident was independent and does not need any help. The DON reported that if the smoking is not addressed in the care plan, then direct care staff will not know how to address the resident's needs. The DON reported that if a resident wishes to smoke and the facility wishes to keep that resident safe then the facility needs to address that need on that resident's care plan. During an interview on 08-13-2024 at 01:58 PM the Administrator reported that since Resident #31 was an independent person not addressing his smoking on his care plan really was not a problem but if the resident was not independent then it would be a problem and that could affect a resident negatively if they did not receive the proper care. Record review of the facility provided policy titled Comprehensive Care Plans undated, revealed the following: 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles when applicable on 1 (Hall 100 and half of Hall 300) of 2 medication carts reviewed. Two Loose pills found in the medication drawers of the medication cart for Hall 100 and half of Hall 300. This failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: Observation and interview on 08/12/24 at 11:07 AM revealed 2 loose pills in the bottom of medication drawer in medication cart for Hall 100 and half of Hall 300. LVN B was able to identify the pills, the red pill was identified as Plavix. The yellow pill was identified as Bethanechol Chloride unsure who the medications belonged to. Interview on 08/12/24 at 11:16 AM with LVN B revealed that a negative outcome for having lose medications in the medication carts would be that the medication could be mistaken for something else. Interview on 08/14/24 at 03:09 PM with DON revealed that a negative outcome for having lose medications in the medication carts would be that staff could assume what they are and give to a resident, and they are no longer clean. DON stated that she was aware of the loose medications and a in-service/training has been provided to the staff. Record review of facility policy titled, Storage of Medications , undated, states the following, but not limited to: Purpose: Ensure that medications are stored in a safe, secure, and orderly manner. Procedure: 1. Medications are stored in the containers in which they are received. .3. No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed. 47854

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection in 1 of 1 dining rooms. -CNA C failed to perform hand hygiene before assisting Resident #32 with eating. This failure had the potential to affects residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Observation on 08/12/24 at 12:18 PM revealed CNA C playing with hair while waiting on Residents food to be delivered to table in the dining room. Observation on 08/12/24 at 12:24pm revealed CNA C playing with hair again and no hand hygiene was performed before touching Resident #32's napkin or silverware to assist Resident #32 with eating her lunch meal. Interview on 08/12/24 at 02:40 PM CNA C revealed that a negative outcome from playing with hair and then feeding a resident could lead to germs being transferred to the Resident. Interview on 08/14/24 at 03:09 PM with DON revealed that a negative outcome for not performing hand hygiene before assisting residents to eat could contaminate the resident's food. Record review of facility policy titled, Hand washing , undated, stated the following, but not limited to: Purpose: Hand washing will be regarded by this facility as the single most important means of preventing the spread of infections. Procedure: 1. All personnel will follow the facility's established handwashing procedures to prevent the spread of infection and disease to other personnel, residents, and visitors. 2. Hands should be washed 20 seconds under the following conditions: . .i. After using the toilet, blowing or wiping the nose, smoking, combing the hair, etc.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 8 out of 30 (05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23) days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster undated revealed there were three RN's employed at the facility. Record Review of time sheet provided by the Administrator for the time period 05/28/23-06/25/23 revealed the following dates did not have RN coverage for at least 8 hours a day for the following days: 05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23. During an interview on 06/27/23 at 12:30 PM with the Administrator, she stated the DON and Administrator were responsible for RN coverage. She stated if there was not an RN available, the staff was to contact the administrator or DON. She stated the facility's policy on RN coverage was to have a RN 8 hours every day. She stated the importance to have an RN on duty was because there was thing in their scope of practice that LVN's cannot do. She stated the potential negative outcome could be if there was something they needed and the LVN cannot do, it would affect them in that way. She stated they have advertising on Facebook and indeed. She stated they could use agency if needed. She stated her expectations was to have an RN in the building every day . She stated there was no system in place to monitor RN coverage. She stated the scope of the nurse was different between the RN and LVN . She stated the DON's working hours was Monday through Friday 8am-5pm, but that was subject to change if he was needed to work the floor. During an interview on 06/27/23 at 12:50 PM with LVN B, she stated if there is not a RN in the building, she would call the DON for any needs. She stated the scope of practice is different between the RN and LVN. She stated she is not able to do higher-level assessments, IV's or pronounce residents. She stated most of the time, they call the hospice nurse to pronounce if there is not an RN in the building. During an interview on 06/27/23 at 01:45 PM with the DON, he stated the administrator and DON were responsible for RN coverage. He stated he could not find any days he worked on the weekend. He stated he does not have a RN that works the weekend. He stated he knew the requirement was to have an RN 8 hours every day but was told him being on call was enough. He stated the importance of an RN was for assessments that LVN's was not allowed to do, wound staging, and higher-level assessments. He stated the potential negative outcome could be residents not receiving the proper treatment. He stated they have not had been advertising for a RN weekend nurse, but were now . He stated an ad for weekend RN was put on Facebook and Indeed on 6/27/23. He stated they used agency in the past but have not used them since he started in February. He stated his expectations was to have an RN 8 hours a day. He stated his working hours are 8-5 or 9-5 Monday through Friday. Record review of RN job posting on indeed.com (undated) did not specify the facility was seeking a weekend RN. The Job posting specifically stated they were seeking a full time RN charge nurse. Record review of the facility's policy, RN Coverage, undated, revealed: The facility will ensure there is registered nurse coverage at least eight(8) hours per day, seven (7) days per week.

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 thefacility's only kitchen reviewed for dietary services. The facility failed to ensure the designated Dietary Manager completed the required dietary managers certification course or had 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 Dietary Manager revealed a document titled Change In Status. The document stated, Date of change, 5/29/23 and stated that the Dietary Manager's position in housekeeping had now been changed to the Dietary Supervisor. The document was signed 5/30/23 by the Dietary Manager. Further record review of the personnel file for the Dietary Manager revealed a listing of education. There was nothing listed in the area titled Vocational or trade training. The Former Employers listed revealed that in 2022 the Dietary Manager had worked as a chef from 2/2022 through 3/2023 and 3/2021 through 3/2022. There was no documentation in the personnel file that indicated that she had completed the required training for Dietary Manager and was a Certified Dietary Manager. Record review of the facility's Dietician documentation revealed that the Dietician was contracted and not full-time. Record review of the Food Handlers documentation/certification revealed that the Dietary Manager had completed the Food Handlers of Texas Food Handlers Program successfully on 7/28/22; date of expiration 7/28/24. On 6/25/23 at 4:38 PM, an interview was conducted with the Administrator regarding the Dietary Manager qualifications. She stated, the Dietary Manager had not taken the required DM course. She stated she started in the housekeeping department. On 6/26/23 at 8:15 AM, an interview was conducted with the Dietary Manager. Regarding the status of her Dietary Manager course, she stated, she had not completed payment for the course and had been Dietary Manager approximately two months. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding the Dietary Manager qualifications, she stated the person responsible was the Administrator. She stated she expected the Dietary Manager to become certified. As far as the result of this issue affecting residents, she said the Dietary Manager not being as knowledgeable about important dietary issues. Record review of the undated facility document titled Job Description. Dietary Service Manager, revealed the following documentation, The following is a non-exhaustive criteria that relates to the job of a dietary service manager, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for Dietary Service Manager, and or related to the functions that are essential to the job of a Dietary Service Manager. Basic knowledge: current Certified Dietary Managers license. Statement: this position reports directly to the Administrator .

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 in 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to ensure Dietary staff used pasteurized eggs in under cooked egg dishes (soft cooked/sunny side up/over easy eggs), 2) The facility failed to ensure Dietary staff stored foods in a manner to prevent contamination, 3) The facility failed to ensure Dietary staff maintained adequate chlorine sanitizer levels in the low temperature dish machine. 4) The facility failed to ensure Dietary staff ensured food contact surfaces were clean, 5) The facility failed to ensure Dietary staff performed sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 6) The facility failed to ensure Dietary staff used good hygienic practices (personal foods in food storage and prep areas), 7) The facility failed to ensure Dietary staff stored personal items in a manner to prevent contamination of food contact equipment. 8) The facility failed to ensure Dietary staff ensured that foods were not held past the manufacturers recommended expiration date. These failures could place residents at risk for food contamination and foodborne illness. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 11:22 AM and concluded at 12:35 PM: There were three flies, crawling on the toaster oven while the fly zapper/electronic extermination unit was on. Dietary Staff A was washing her hands. She turned off the water with her bare hands, then dried her contaminated hands on a paper towel and donned on a pair of gloves. She then poured coffee and handled sugar packets. The Dietary Manager was observed washing her hands and she turned off the water with a paper towel, but then she dried her hands and arms with the soiled paper towel. During an observation and interview on 6/25/23 at 11:32 AM. The Dietary Manager tested the dishwasher and she attempted to test the dishwasher sanitizing rinse with a quaternary sanitizer test strip. At the time, the Dietary Manager was not aware that the dishwasher was a low temperature chlorine sanitizing dish machine until the surveyor pointed out that the sanitizer container label documented that it was a chlorine sanitizer. The Dietary Manager stated that the sanitizer for the dishwasher was quaternary sanitizer. She then stated this sanitizer was not the same as at another facility. She then looked at the quaternary test strips and asked, What are these used for? This was after the surveyor told her that there were different (chlorine) test strips for the dishwasher. The dishwasher was then tested by the dietary manager a third time with chlorine test strips and the temperature was 110 F and the level of chlorine sanitizer rinse was 200 ppm which was a toxic level of chlorine. During an interview with the Dietary Manager on 6/25/23 at 11:37 AM, she stated she had not seen the dishwasher being serviced in the last two months that she had been there. Record review of the dishwasher test log revealed the last time the dishwasher was tested was 6/22/23. The Dietary Manager again washed her hands, turned off the sink with a paper towel and then dried her hands and arms with the soiled paper towel. Observation of the walk-in freezer revealed that there were 12 bags of ice on the floor and there was available shelf space to place these bags of ice on a shelf. Observation of the walk-in refrigerator revealed that there was a pan containing large tubes of raw hamburger that were thawing. There was pooling blood in the pan. The pan was stored above bottles of drinking water that were stored on the floor. There was room available to move these bottles of water away from the pan of thawing meat. There was a personal drink on an upper walk-in rack with bread that was labeled with [Dietary Staff D]. name. There was a buildup of dirt on the underside of the racks in the walk-in refrigerator. In the walk-in refrigerator, there was half a case of Sysco Strawberry Banana Shakes that had a date on the box of 4/6/23. There was also a full case of Sysco Strawberry Shakes that was dated 4/20/23. There was a case of Sysco Chocolate Shakes label 4/6/23 also present. The underside of the upper shelf of the stove had dried spills. On 6/25/23 at 11:58 AM, an interview was conducted with the Dietary Manager. Regarding the flies in the kitchen, she stated the flies increased in the past month. Regarding what caused the fly increase, she stated, the big back door was open at times and then there were a lot of donations coming in due to the tornado. There were 4 flies crawling on a prep table and the fly zapper in the kitchen and at the back door entrance in the auxiliary hall were on. While taking temperatures on the service line, the Dietary Manager took temperatures of the chicken and bite-size chicken by picking up the individual pieces with her gloved hands then placed it back in the pan to be served. - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 4:43 PM and concluded at 5:06 PM: One of two drink guns was submerged in a liquid in a red bucket. During an interview on 6/25/23 at 5:04 PM, Dietary staff A was asked what was in the red bucket. She stated, it was just water. There was an accumulation of dry spills on the underside of the steam table top. - The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 8:05 AM and concluded at 8:40 AM: During an interview and observation on 6/26/23 and 8:09 AM, the Dietary Manager stated that the Maintenance Supervisor had placed a call to the dishwasher machine repairman about the chlorine level of the dishwasher. She further stated, the cook had checked the level last week and stated it was OK. A large bowl and a pan had been washed in the dishwasher. The level was tested and 200 ppm chlorine. During an interview on 6/26/23 at 8:11 AM, the Dietary Manager stated she was not aware that the bowl and pan had been washed in the dishwasher that morning. She further stated that she had not conducted any in-service for the dietary staff since taking the position as Dietary Manager. The Dietary Manager was observed walking in the stove area, drinking a bottle of water. She placed the bottle on a dirty dish cart at the three-compartment sink and then started doing the dishes. Observation of the walk-in refrigerator revealed that the pan with thawing, bloody hamburger meat was still stored above bottles of water and there was even more blood in the pan. Observation in the walk-in refrigerator revealed a case of raw eggs present was not pasteurized eggs. During an interview on 6/26/23 at 8:20 AM, the Dietary Manager stated she used the raw eggs to prepare over easy eggs every morning for Resident #17. During an interview on 6/26/23 at 8:22 AM, the Dietary Manager stated she thought the eggs she received were pasteurized. On 6/25/23 at 8:25 AM, the Dietary Manager stated the dishwasher sanitizer level should be 50 to 100 ppm chlorine. She stated that she was not aware that 200 ppm Chlorine was a toxic level. On 6/26/23 at 8:30 AM, an interview was conducted with the Dietary Manager. Regarding the dates on the boxes of shakes, she stated the dates were the time that the shakes came in and were placed in the walk-in. She stated that the two resident who used the shakes did not drink them. She further stated she was not aware of the labeling on the shakes that documented once thawed the shakes should be used within 14 days per manufacture instructions. - The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 11:53 AM and concluded at 12:19 PM: There was a personal drink in a red cup, covered with a small Styrofoam plate. The cup was located on a lower shelf of a food preparation table and next to bags of potato chips and corn chips. There were flies landing on food equipment. - The following observations were made, and interviews conducted during a kitchen tour on 6/27/23 that began at 9:26 AM and concluded at 9:30 AM: There was a cell phone lying on the prep table and leaning against a bag of pasta. There was a fly crawling on the sugar bin and another one flying around in the kitchen. There was a personal drink on the lower shelf of a preparation table at the service line and covered with a small Styrofoam plate. On 6/27/23 at 9:30 AM interviews and observations were conducted with a Dietary Manager regarding issues found in the dietary department. Regarding pasteurized eggs, she stated pasteurized eggs were expensive, and the facility only had one person eating them. She was then explained that the nursing home had a highly susceptible population and that raw eggs cannot be used for sunny side up type dishes. She stated, Sunday was the last time Resident #17 received over easy eggs. Regarding the last time that the walk-in refrigerator racks were cleaned, she stated staff had not cleaned them in the last two months. She added, she was in the middle of creating a chores chart and the cleaning of the racks was not on it. Regarding the shakes and the expiration on them, she stated she was not aware of the 14-day limit. She further stated that she had not trained any new employees yet. Regarding the flies, she stated, the flies had been at this level for the two months she had been here. She added then the tornado came the facility had people bringing in donations, and the problem worsened. At that time, the dishwasher was tested , and it dispensed 50 ppm chlorine and the temperature was 110 F. Observation of the gauge/temperature label documented, Wash/rinse 120 F minimum. The Dietary Manager stated that she was not aware that the hot water needed to be 120 F. Regarding how the issues in the dietary department could affect residents, she stated, unhygienic practices and germs. The dishwasher not working could spread germs around; residents could get sick. Regarding whom was responsible for ensuring that dietary duties were conducted correctly, she stated, herself and staff. She added that she had not taken the required Dietary Manager course. Regarding why she felt these issues happened, she stated, leadership, and not staying on top of things. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding dietary sanitation, she stated that the Dietary Manager and Administrator were responsible. She stated she expected staff to know the correct dietary procedures. She also stated that nursing home residents were highly susceptible and could be affected from those issues related to dietary sanitation in the dietary department. Record review of the Dish Machine Log for June 2023 revealed that the last time the dishwasher was checked was on 6/22/23 dinner meal where the wash was 120 F. The rinse was 120 F and the parts per million chlorine was 100. Further record review of this document revealed the following, .Standards . Chemical sanitizing low temp: Wash: 120 to 140 F. Rinse: 120 to 140 F . Manufacture recommended PPM: (blank). No documentation in this area. The document further stated, . Always defer to manufactures guidelines regarding temperature and correct chemical concentration for use . Record review of the Code Of Federal Regulation, Title, 21, Volume 3, CITE: 21, CFR 178.1010, TITLE 21 - FOOD AND DRUGS, CHAPTER 1 - FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES, SUBCHAPTER, B - FOOD FOR HUMAN CONSUMPTION (CONTINUE), PART 178 - INDIRECT FOOD ADDITIVES: ADJUVANTS, PRODUCTION AIDS, AND SANITIZERS, Subpart B - Substances Utilize To Control The Growth Of Microorganisms, SCC. 178.1010 Sanitizing Solutions, current as of 7/06/23, revealed the following documentation, .Sanitizing solutions may be safely used on food-processing equipment and utensils, and on other food-contact articles as specified in this section, within the following prescribed conditions: (a) Such sanitizing solutions are used, followed by adequate draining, before contact with food. (b) The solutions consist of one of the following, to which may be added components generally recognized as safe and components which are permitted by prior sanction or approval. (1) An aqueous solution containing potassium, sodium, or calcium hypochlorite, with or without the bromides of potassium, sodium, or calcium . c)The solutions identified in paragraph (b) of this section will not exceed the following concentrations: (1) Solutions identified in paragraph (b)(1) of this section will provide not more than 200 parts per million of available halogen determined as available chlorine. Record review of the Sysco shakes cartons revealed the following documentation, Handling instructions: store frozen. Thaw under refrigeration, (40 F or below). Shake well before using. Open top, then pour and serve. After thawing, keep refrigerated. Use within 14 days after thawing. Record review of the website document, Food Safety in Nursing Homes: A Beginner's Guide (https://foodsafepal.com/food-safety-nursing-homes/) . January 30, 2023, revealed the following documentation, . Guidelines for Food Safety in Nursing Homes. Regardless of the population you serve, following safe food handling practices is essential. However, because nursing home residents are considered a highly susceptible population, there are additional food safety precautions you must take to reduce the risk of foodborne illnesses . Raw and undercooked eggs, meats, and seafood. Eggs have the potential to carry Salmonella, which can survive if they are not cooked through. For this reason, you cannot serve eggs where the yolk is runny like over-easy or sunny-side-up eggs to nursing home residents. However, you can make them using pasteurized eggs, which are heat-treated to kill off Salmonella and other bacteria that may be present . Record review of the current undated policy titled Employee Hygiene. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Employee Hygiene. Procedure: 1. Employees must keep their hands, arms and fingernails clean. 5. Employees may not eat, drink or use tobacco in any area where food preparation is occurring. Employees may drink from a closed container if the closed container prevents contamination. Record review of the undated facility policy, titled Storage of Food and Refrigeration, . Section 9 - Dietary/Food Services, revealed of the following documentation, Policy: Storage of Food and Refrigeration. Procedure: 1. 2. Store raw meats on the bottom shelf to prevent contamination of other perishable items. 4. All containers must be labeled with the contents and the date food item was placed in storage. 6. Food items that remain sealed from the supplier may be held until the expiration date if unopened . Record review of the undated facility policy, titled Thawing Food. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Thawing Food. Procedures: food that is frozen, should be thawed in such a manner as to prevent the temperature of the food from rising above 41 F. Method for thawing food. 1. Under for refrigeration. b. Meats to be thawed must be placed on the lower shelf in the refrigerator to prevent contamination of other foods with meat juices . Record review of the undated facility policy, titled Section 9 - Dietary and Food Service, revealed the following documentation, Policy: Equipment Sanitation. We will provide clean and sanitized equipment for food preparation. Facility will clean all food service equipment in a sanitary manner. Procedure: 1. Equipment must be thoroughly sanitized between using different food preparation task (E. G. Salad, preparation, raw meat, cutting and cooked meat cutting). 6. Pots and pans. f. All equipment and utensils shall be sanitized by one of the following methods: . h. Immersion for a period of at least one minute in a sanitizing solution containing: at least 50 ppm of available chlorine at temperature not less than 75 F . 7. Facilities should use an approved test kit to measure the parts per million of the chemical solutions in a pot sink on a daily basis. Records of test results shall be kept on the temperature/chemical log. Any abnormal test results shall be reported to the dietary service manager, and the solution shall not be used until at the correct ppm.