Every finding on record at Mesquite Tree Nursing Center

Based on observation, interview and record review, the facility failed to provide each resident with nourishing, palatable, well-balanced diet that meets the resident's nutritional needs for 2 of 5 residents (Resident #1 and Resident #2) reviewed for dietary needs.The facility's kitchen failed to prepare and serve 3 ounces of pork loin as stated on resident meal tickets on 06/24/2026.This failure places residents at risk of not meeting their daily nutritional needs and could result in weight loss or decline in overall quality of health. Findings included:Record review of Resident #1's face sheet, dated 06/24/2026, revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of cerebrovascular disease (condition that impacts blood vessels in the brain). Other pertinent diagnoses include protein-calorie malnutrition.Record review of Resident #1's quarterly MDS, dated [DATE], revealed he had a BIMs score of 14 (indicating intact cognitive function). His active diagnosis included malnutrition.Record review of Resident #1's care plan, undated, revealed he had was on a regular diet and at nutrition and hydration risk related to other chronic conditions. Interventions included to provide and serve diet as ordered.Record review of Resident #2's face sheet, dated 06/04/2026, revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of encounter for surgical aftercare following surgery on the genitourinary system (postoperative care for surgery on organs like the kidney, bladder, or male reproductive organs). Other pertinent diagnoses include nutritional deficiency and moderate protein-calorie deficiency.Record review of Resident #2's quarterly MDS, dated [DATE], revealed he had a BIMs score of 13(indicating intact cognitive function). His active diagnosis included malnutrition.Record review of Resident #2's care plan, undated, revealed he had was on a regular diet, with no restrictions and thin liquid, and he was to have double portions. Interventions included to provide and serve diet as ordered.During an interview on 06/24/2026 at 11:17 AM with Resident #1, he stated that food portions were not large enough. Resident #1 then specifically stated the meat portions were not large enough, but the sides were fine.During an observation on 06/24/2026 at 12:19 PM of the facility's only dining room revealed 29 residents were in the dining room eating lunch. Residents with specially prepared (chopped, minced, pureed, etc) diets had appropriate portion sizes. Residents with regular meals had appropriately portioned sides and one thin slice of pork loin with gravy on their plates. Observation and interview of Resident #1 revealed he had begun eating his lunch but appeared to have 1 small thin slice or pork loin on his plate; he said he only received 1 slice of the pork loin.During an observation on 06/24/2026 at 12:25 PM at the kitchen doorway revealed a hallway meal tray cart prepared to go to one of the resident halls. The cart had resident meal tickets on them. Record review of the meal tickets revealed (unless stated otherwise for an alternative meal) Pork Roast Loin Garlic Herb - 3 Oz. Observation at this time revealed the dietary staff plating resident meals and placing one thin slice of pork loin on each plate for the residents who received regular portions and wanted pork loin.During an observation and interview on 06/24/2026 at 12:38 PM with the DM, he said he sliced the pork loin and each pork loin slice was 3 ounces. When asked about the process of how he knew each slice was 3 ounces, he said he has been a cook for 15 years and that the pork slices were 3 ounces each. He then got the kitchen's only scale that was mechanical and weighed in ounces. He measured the weight of a pork loin slice and it weighed 1.5 ounces. He said the pork loin was typically precut when it was ordered but this time they had to cut it themselves. The DM said he did not now if the scale was accurate; he said he worked for a hospital company that contracted with the facility and he just did what he was told. The DM said it was important for residents to get the right portion sizes in their meals so the resident's could be healthy.During an observation and interview on 06/24/2026 at 1:03 PM with Resident #2, he said he now did not have issues getting proper portions of food because his ticket said double portion. He showed the surveyor his meal ticket that stated Double Portions. Pork Roast Loin Garlic Herb - 3 Oz. He showed the surveyor his meal he had not started eating and he had 3 thin pork loin slices on his plate (approximately 4.5 ounces of pork loin, instead of 6 ounces).During an interview on 06/24/2026 at 2:53 PM with the RD, she revealed that she had been in the kitchen on 06/10/2026 and had a test tray to try the food. She said there were no issues at that time with the portion sizes. The RD said the dietary staff was contracted through a hospital company and the dietary staff followed the menu's provided by the company. She said the risk of residents not receiving the proper portion amount of foods could put resident at risk for various issues, but overall it increased their risk of diseases if they did not meet their nutritional needs, and many resident's already dealt with chronic illnesses. The RD said going forward, she would audit how much protein residents were getting with each meal. Record review of the facility Menus and Nutritional Adequacy policy, dated 7/22/2022, reflected: Policy. Menus are planned to meet the average resident's nutritional needs.Fundamental InformationA pre-planned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average residents nutritional needs.The meal planning guide in the Facility Diet Manual is used as the basis for menu planning.Food Group Minimum Daily ServingsMeat or Equivalent 5 Ounces.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure a bag of dry rolled oats were not sitting on the floor in the kitchen preparation area.The facility failed to ensure raw meat was being thawed properly.The facility failed to ensure food items were not in the same sink compartment as used dishes.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included:Observation on 06/24/2026 at 12:19 PM of the facility's kitchen revealed a 50 lb bag of rolled oats sitting on the kitchen floor leaning up against a food preparation table.Observation on 06/24/2026 at 12:38 PM of the facility's 2 compartment sink, next to the handwashing sink, revealed a large piece of raw pork loin, uncovered and unsealed in a large metal pan, with a food strainer in the 1st compartment. After the surveyor noticed the meat, the DM turned on the cold water to run over the raw pork loin and removed the strainer from that compartment and put it into the 2nd compartment. The 1st compartment continued to have a cup and knife in the sink with the raw pork loin.During an interview on 06/24/2026 at 2:08 PM with the DM, he revealed he worked for a hospitality company that contracted with the facility. The DM said he had turned the water on in sink because the raw pork loin was frozen, and water was needed to get the raw pork loin to thaw. The DM said the dishes should not have been in the same compartment as the raw pork loin due to the risk of cross contamination.During an interview on 06/24/2026 at 2:53 PM with the RD, she revealed she had recently done a sanitation audit of the facility's kitchen. The RD said she did not run into any issues like food items on the kitchen floor or a risk of cross contamination. The RD said raw meat in the sink and used dishes next to it was a risk of cross contamination. The RD said she would work the DM on these things and do in-service training.During an interview on 06/24/2026 at 4:48 PM with the ADM revealed she had been going to the kitchen to check on how things were going but she would now increase how often she went to the kitchen. She said there will be education with the dietary staff. The ADM said the risk of having raw pork loin in the same sink compartment as dishes was the risk of cross contamination.Review of the facility's Food Safety and Sanitation Plan policy, dated 10/24/2022, reflected: PolicyIt is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur. The Hazard Analysis Critical Control Point (HACCP) Plan is an example of such a program.Fundamental InformationHazard Analysis Critical Control Point, commonly referred to as HACCP is a food safety plan designed to prevent the outbreak of foodborne illness. It ensures safe food handling practices from food procurement through food service. While all steps in the handling of food are important, specific steps have been identified as critical in preventing food borne illness. HACCP requires that the critical points are identified and procedures implemented and monitored to ensure proper food handling at each critical point. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices .Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling.Basis of Control and Critical Control Items for HACCP review:.3. Protected During Storage .- Foods are stored off the floor (at least 6 above the floor) and covered .6. Proper Thawing- All potentially hazardous foods must be thawed in such a way as to prevent bacterial multiplication on the surface. Safe methods for thawing include:1. under refrigeration to maintain food temperature at or below 41F2. completely submerged under cold running water that is no greater than 70 F and creates enough agitation to float off loose particles under run off water for no longer than 4 hours and the internal temperature does not go above 41F.3. in a microwave followed by immediate cooking4. as part of the conventional cooking process.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 5 residents (Resident #1 and Resident #4) reviewed for resident assessments.The facility failed to accurately assess and document Resident #1's active medical diagnosis of depression.The facility failed to accurately assess Resident #4's antidepressant medication status.The facility failed to accurately document Resident #4's active medical diagnosis.These failures could place residents at risk of having inaccurate diagnoses and inappropriate identification of care needs.1. Record review of Resident #1's face sheet, dated 05/20/2026 revealed a [AGE] year-old male with a primary diagnosis of encephalopathy (abnormal brain function, lead to cognitive impairment). Other pertinent diagnoses include cerebral infarction (stroke), cognitive communication deficit (impaired ability to communicate), and mild cognitive impairment (noticeable cognitive decline). Record review of Resident #1's quarterly MDS assessment, dated 03/17/2026, revealed he had a BIMS score of 09 (indicating moderate cognitive impairment). In Section I - Active diagnoses of the MDS assessment, depression was not documented as an active diagnosis. In Section N - Medication, Resident #1 was documented as taking an antidepressant. Record review of Resident #1's care plan, dated 05/20/2026, revealed Resident #1 uses psychotropic medications, antidepressants (Fluoxetine). related to depression. Record review of Resident #1's orders, dated 05/20/2026, reflected:- FLUoxetine HCl Capsule 10 MG Give 1 capsule by mouth in the evening for depression Given with 20mg for a total of 30mg. Order Date: 02/06/2026- FLUoxetine HCl Capsule 20 MG Give 1 capsule by mouth in the evening for depression Given with 10mg for a total of 30mg. Order Date: 02/06/2026 Record review of Resident #1's psychiatric evaluation and consultation note, dated 05/01/2026, revealed Resident #1 had a diagnosis of major depressive disorder and was actively treated for depression with the psychoactive medication, Fluoxetine HCI. Record review of Resident #1's recent psychological services notes, dated 05/06/2026, 05/13/2026, and 05/18/2026, all revealed he had a diagnosis of major depressive disorder and was actively treated for depression. Record review of Resident #1's informed Consent for Psychoactive Medications, dated 2/14/2025, revealed Resident #1's RP consented for an antidepressant to be given for depression. During an observation and interview on 05/20/2026 at 10:19 AM with Resident #1 revealed he was in a pleasant mood. Resident #1 mumbled some, during the interview, but was able to state he was doing therapy and it was going very well. 2. Record review of Resident #4's face sheet revealed a [AGE] year-old female, with a primary diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing (bones of upper right leg previously broken and now in healing phase). Other pertinent diagnoses included dementia (brain disease that alters brain function and causes a cognitive decline) and cognitive communication deficit (impaired ability to communicate). Record review of Resident #4's quarterly MDS, dated [DATE], revealed Resident #4 had a BIMS score of 01 (severe cognitive impairment). In Section I - Active Diagnoses, Resident #4 was documented to have depression. In Section N - Medication, active medications did not include antidepressants. Record review of Resident #4's care plan, revised 02/18/2026, revealed Resident #4 uses psychotropic medications, antidepressants (Sertraline) related to depression. Record review of Resident #4's orders, dated 05/20/2026, reflected:- Sertraline HCl Tablet Give 50 mg by mouth in the morning for Depression. Order date: 12/11/2025 Record review of Resident #4's psychiatric evaluation and consultation note, dated 05/01/2026, revealed Resident #4 had a diagnosis of major depressive disorder and was actively treated for depression with the psychoactive medication, Sertraline HCI. Record review of Resident #4's informed Consent for Psychoactive Medications, dated 11/24/2024, revealed Resident #1's RP consented for an antidepressant to be given for depression. Record review of Resident #4's progress note, dated 05/20/2026, reflected: Details: Chief complaint: APSP- Sertraline assessmentHistory of present illness:[AGE] year-old long-term care resident with dementia and depression seen today for APSP follow-up for sertraline. Resident remains on sertraline 50 mg by mouth daily for depression, with 100% adherence per MAR. Resident is a poor historian due to cognitive impairment and limited reliability. Provider [NP]. During an interview on 05/20/2026 at 11:56 AM with Resident #4's RP, she revealed Resident #4 was prescribed Sertraline prior to being admitted to the facility, by a neurologist. The RP said prior to admitting, Resident #4 was not diagnosed with depression but was prescribed an antidepressant to keep Resident #4 from becoming depressed due to her dementia. The RP said it was used as a preventative. During an interview on 05/20/2026 at 12:25 PM with the NP revealed Resident #1 was on an antidepressant due to having a history of depression. She said based on her assessments of his behaviors, psych notes, and his order for an antidepressant, Resident #1 should have a diagnosis of depression. The NP said Resident #4 was taking an antidepressant for depression and should have a diagnosis for depression. The NP said Resident #4 had a flat effect, meaning Resident #4 did not smile and did not show joy; she said Resident #4 had been like that since she admitted and dementia would cause this. The NP said the risk of discrepancies in resident records was staff and healthcare providers would see there was no diagnosis for medication the resident was taking. She said there should be a diagnosis to correlate with the medications taken, because she was treating them for a diagnosis. The NP said she would talk to psych (providers) to make sure residents' medications correlate with their diagnoses. The NP said she understood the question of why a resident would take a medication that there was no diagnosis for. During an interview on 05/20/2026 at 1:03 PM with the LPC, she said Resident #1 was on her caseload. She said Resident #1 did have depression, and she did not know why it was not on his face sheet as a diagnosis. The LPC said that she, psychiatry, and the NP were able to determine if residents had depression. She said she communicated with the DON or the NP about resident who had depression. The LPC said based on her and the NP's assessments, they had agreed Resident #1 had depression. During an interview on 05/20/2026 at 3:14 PM with the DON revealed she did not know why there were discrepancies in the residents' records regarding their treatment for depression, but it could have been a technological issue in the systems. The DON said there were weekly meetings with her, the MDS nurse, therapy, and others to go over residents' care. She said the issue with discrepancies in resident records was resident may not get treated for conditions if their charts did not have all the proper information. The DON said to correct discrepancies, staff would do a review of all residents' medications and make sure there was a correlating diagnosis. During an interview on 05/20/2026 at 4:00 PM with the MDS LVN revealed she was not sure why there with discrepancies in residents' records, but she would start making sure that if a resident was on an antidepressant, there would be a diagnosis to match. The MDS LVN said accurate MDS assessments were important to ensure residents received proper care, and to make sure residents did not take a medication they possibly did not need. During an interview on 05/20/2026 at 4:17 PM with the ADM revealed she recently became the ADM of the facility. She said, to correct the discrepancies in resident records, the facility would need to do an audit and go through resident charts to make sure diagnoses, care plans, and medication all match. The ADM said she would make sure meetings occurred to discuss each patient and diagnoses. Record review of the facility's MDS Accuracy Guidelines, dated 10/24/2022, reflected: PurposeThe purpose of the MDS guideline is to ensure each resident receives an accurate assessment by qualified staff that are familiar with his/her physical, mental, and psychosocial well-being in order to identify the specific needs of the resident in accordance with the RAI Manual. Procedure1. All staff completing sections of the MDS will conduct and complete their assigned section(s) of the MDS within the scope of their practice and according to coding instructions per RAI.2. Each discipline completing sections of the MDS will be certified and/or licensed.4. Section responsibility.d. Section G-J - Licensed RN/LVN.f. Section L-N- Licensed RN/LVN.k. Assigned sections may be completed by a licensed RN or LVN in absence of any of the other disciplines involved.5. All Sections of the MDS will be encoded and signed as accurate and completed as of the date the assessment or portion of the assessment is completed. Back dating is not allowed. 6. The RN Coordinator will either conduct the assessment or coordinate the team of qualified staff who conduct the assessment. Each individual responsible for a portion of the assessment will sign and certify that their portion of the assessment is complete and accurate (to include all necessary parts, elements, or steps).7. The RN will sign and certify that the assessment includes all necessary parts, elements, or steps. By approving and signing the assessment, the RN is certifying that each section was completed by the appropriate person and that the individual is qualified to determine the accuracy of the portion of the resident's assessment he/she completed.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for three residents (Resident #1, Resident #2, and Resident #3) of 11 residents reviewed for care plans.The facility did not develop a comprehensive person-centered care plan to address the discharge plans of Resident #1, Resident #2, and Resident #3.This failure could place residents at risk of not having their discharge goals met.The findings were:Resident #11) Record review of Resident #1's Face Sheet reflected a 56 years-old male who was re-admitted to the facility on [DATE] with diagnoses including in part: sepsis (a life-threatening reaction to an infection), metabolic encephalopathy (a change in how the brain works due to an underlying condition), and multiple sclerosis (a disease where the immune system attacks the brain and spinal cord).Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had an overall goal for discharge to remain in the facility and that active discharge planning was not already occurring for the resident to return to the community.Record review of Resident #1's comprehensive care plan, dated 12/11/25 reflected no focus, goals, or interventions were documented for Resident #1's discharge plans.Resident #22) Record review of Resident #2's face sheet reflected a 74 years-old male who was re-admitted to the facility on [DATE] with diagnosis including in part: sepsis (a life-threatening reaction to an infection), metabolic encephalopathy (a change in how the brain works due to an underlying condition), and pneumonia (an infection that inflames the lungs).Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the MDS did not identify an overall goal for discharge and reflected that active discharge planning was not already occurring for the resident to return to the community.Record review of Resident #2's comprehensive care plan dated 12/22/25 reflected no focus, goals, or interventions were documented for Resident #2's discharge plans.Resident #32) Record review of Resident #3's face sheet reflected a 89 years-old male who was admitted to the facility on [DATE] with diagnosis including in part: intervertebral lumbar disc degeneration with pain (cushioning between the discs of the lower back wear away causing pain), dementia (a group of symptoms affecting memory, thinking and social abilities), and heart failure (when the heart muscle doesn't pump blood as well as it should).Record review of resident #3's Quarterly MDS, dated [DATE], revealed the MDS did not identify an overall goal for discharge and reflected that active discharge planning was not already occurring for the resident to return to the community.Record review of resident #3's comprehensive care plan, dated 12/22/25 reflected no focus, goals, or interventions were documented for Resident #3's discharge plans.In an interview on 3/04/2026 at 02:00 p.m., LVN A confirmed that Resident #1, Resident #2, and Resident #3 did not have discharge plans and goals included on their care plans. She stated that she had worked in the MDS position for approximately 1-2 years and that as the MDS nurse it was her responsibility to add to residents' care plans any item that was triggered by the MDS assessment. She stated it was the responsibility of the DON and ADONs to enter onto the care plan any acute care items such as falls, medications, isolations, antibiotics, and anything else not triggered by the MDS assessment. She stated that when the care plans were updated, the discharge plans and goals should have been added if they were not already included. She stated that the discharge plans and goals being placed on the care plan were important because it, documents the patients' intent or plan to go home or be long-term.In an interview on 3/04/2026 at 02:10 p.m., the DON stated that the MDS nurse, the DON, and the ADONs all contributed to residents' care plans. She stated that Resident #1, Resident #2, and Resident #3 were long-term residents. She stated she would provide the facility policy on residents' care plans.In an interview and record review on 3/04/2026 at 02:30 p.m., RN B stated that Resident #1 had a discharge goal included on his care plan at one point, but that it had been inadvertently resolved. She stated that the discharge plan and goals should not have been resolved but should have remained active on the care plan. She stated the facility had now added a discharge plan and goals to the care plans for Resident #1, Resident #2, and Resident #3. She stated that the Social Workers would be entering the discharge goals on the care plans in the future, and that as an interdisciplinarian team effort, the MDS nurse, the DON, and ADONs will follow up to ensure it was done. She stated that all residents' care plans were now being audited to ensure the inclusion of the discharge plan and goals. She stated the failure to add a discharge plan to the care plans of Resident #1, Resident #2, and Resident #3 was not a risk to these residents as they intended to remain in long-term care, but you always want to give them an option because things can change.Review of the facility policy titled, Comprehensive Care Plans dated 2/10/2021 revealed, The comprehensive care plan will describe, at a minimum, the following: d. The resident's goals for admission desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate.

Based on observation, interview, and record review, the facility to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure Dietary Aide A wore a hairnet.The facility failed to ensure two 32-ounce pitchers of dark red liquid were labeled with the name of the product and dated with the use by date.The facility failed to ensure that meat that was submerged in a bowl full of water in the sink was thawed out under running water.The facility failed to ensure on 03/03/26 1 of 2 drink pitchers that held a dark yellow orange liquid were labeled with the name of the product and dated with the use by date, in 1 of 2 stand-by refrigerators.The facility failed to ensure a 3.5-gallon tea urn was labeled with the name of the product and dated with the use by date.The facility failed to ensure ground meat in a metal bin not in its original package, brown meat in a metal bin not in its original package, and vegetables with meat in a metal bin and not in its original package were labeled and dated with the use by date, in 2 of 2 stand-by refrigerators. These failures could affect residents by placing them at risk for cross-contamination and foodborne intoxication.Findings included: Observation on 03/03/26 at 9:08 A.M., upon entry to the kitchen revealed Dietary Aide A had a baseball cap on with hair that was a little pass her ears and no hairnet. Observation on 03/03/26 at 9:10 A.M., revealed two pitchers containing a dark red liquid covered with plastic wrap, had no label of the product or use by date, sitting on a cart. Observation on 03/03/26 at 9:11 A.M., revealed chicken breast sitting in a metal bowl not in its original package on one side of the sink and submerged in water, but contained no running water from the faucet, and no label or use by date. Observation on 03/03/26 at 9:13 A.M., of stand-by refrigerator 1 of 2 revealed two pitchers of a yellow-orange liquid covered with plastic wrap had no label of the product or use by date. Observation on 03/03/26 at 9:15 A.M. revealed a 3.5-gallon tea urn, with steam coming from the liquid, had no label of the product and use by date, at the back of the food line. Observation on 03/03/26 at 9:17 A.M., of stand-by refrigerator 1 of 2 revealed the following: Ground meat in a metal bin not in its original package, with plastic wrap covering the top of it, had no label. [NAME] meat in a metal bin not in its original package, with plastic wrap covering on the top of it, had no label. Vegetables and meat in a metal bin not in its original package, with plastic wrap covering the top of it, had no label or use by date. In an interview on 03/03/26 at 9:12 AM, Dietary Aide A stated the two tea pitchers with dark red liquid was tea. In an interview on 03/03/26 at 9:20 AM, the DM stated that the meat found in the sink that was submerged in a bowl full of water was chicken breast. The DM stated the two tea pitchers found with yellow orange liquid inside of stand-by refrigerator 1 of 1 was orange juice. The DM stated the ground meat that was found covered with plastic wrap was ground turkey. The DM stated the brown meat found inside the second silver container was breakfast sausage. The DM stated the food with the vegetables found in the third silver container was shepherd's pie that they made yesterday on 03/02/26. In an interview on 03/03/26 at 10:43 AM, the DM stated all employees were expected to have hairnets on when they entered the kitchen if they had hair. The DM stated Dietary Aide A had been told to put on a hairnet before. The DM stated he could not explain why Dietary Aide A did not have a hairnet on. He stated she had been working in the kitchen for 5 years and she was aware she was supposed to have a hairnet on. The DM stated he were responsible for making sure all staff had hairnets on when they were working in the kitchen. He stated the risk of an employee not wearing a hairnet while in the kitchen could cause contamination. The DM stated the chicken breasts were supposed to be thawed out under running water. The DM stated he was not sure why the chicken was just sitting in a bowl full of water, and he stated he had not arrived yet to have an explanation as to why the chicken was not thawed out correctly. The DM stated the risk of the chicken sitting in a bowl full of water without running water over it could cause the chicken to be in the temperature danger zone. The DM stated the two tea pitchers that were found should have been labeled with the product name and use by date and that he should have discarded them. The DM stated the orange juice in the two pitchers that were found in refrigerator 1 of 2 should have been labeled with the product name and dated with the use by date. The DM stated that the ground turkey, shepherd's pie, and breakfast sausage that were found in refrigerator 2 of 2 should had been labeled with the product name and dated with the use by date as well. The DM stated that the freshly made tea in the 3.5-gallon tea urn should have also been labeled with the product name and use by date. The DM stated that all items in the kitchen should be labeled with the product name and dated with use by dates. The DM stated he normally did his rounds in the kitchen to be sure every item was labeled with the product name and use by date, but he had not had the chance to have that done. The DM stated the risk of not having items in the kitchen labeled with the product name and dated with the use by date could cause spoilage of items. In an interview on 03/03/26 at 10:59 AM, Dietary Aide A stated she had been working in the kitchen for 7 years now. Dietary Aide A stated she had not been trained since she first started. Dietary Aide A stated she had always had a hairnet on and if she had a baseball cap on, she had never been told to put on a hairnet. Dietary Aide A stated the DM, her and other employees are responsible for making sure she has a hairnet on. Dietary Aide A stated the risk of not having a hairnet on is hair can fall into someone's food. In an interview on 03/04/26 at 12:54 PM, [NAME] B stated all items in the kitchen are supposed to be labeled and dated in the kitchen. [NAME] B stated everybody that works in the kitchen is responsible for labeling and dating items in the kitchen, but if she had something she needed to put in the refrigerator, she labeled and dated the items before she placed them in the refrigerator. [NAME] B stated the staff may have forgotten to label and date the items because they could have become distracted and started a new task. [NAME] B stated the risk of not labeling and dating items can build in the refrigerator too long and it could spoil and cause food poisoning so it's important to label and date the item so that they know if the item can be served or not. [NAME] B stated when food is thawed out, they are supposed to let the water run on it until it is fully thawed out. [NAME] B stated that she was off the day the items were discovered in the kitchen, and she couldn't say why the chicken breasts were just sitting in a bowl full of water. [NAME] B stated the risk of the chicken being submerged in the water could have caused the chicken to change colors if it's not properly thawed out and it depends on how long it was sitting there because some bacteria could start to grow on the chicken. [NAME] B stated she wears a hairnet all the time, especially with her being the cook she made sure she put one on. [NAME] B stated the risk of someone not wearing a hairnet could cause a hair to fall into the food. When asked if they had any recent training regarding the kitchen, [NAME] B stated all kitchen staff verbally discuss how things are supposed to be conducted in the kitchen, but they had not had any recent training on the kitchen. In an interview on 03/04/26 at 1:07 PM, Dietary Aide C stated that she had been working in the kitchen for 2 years. Dietary Aide C stated they are supposed to label and date products in the kitchen within a 12-day span. Dietary Aide C stated she is not sure why the items in the kitchen were not labeled and dated. Dietary Aide C stated she was trained on the kitchen when she was first hired but had not had any recent trainings. Dietary Aide C stated the risk of items not being labeled and dated could cause food spoilage, contamination, and can get someone sick. Dietary Aide C stated she is not sure how items are supposed to be thawed out because the cook or the DM usually thawed the food out. In an interview on 03/05/26 at 12:00 PM, the ADM stated kitchen staff will need an updated in-service, and she had planned to do that soon. The ADM stated her expectations of staff were all items should be labeled and dated before placing any item in the refrigerator and when items were prepped. She stated the risk of not labeling and dating items in the kitchen could cause staff to give residents something spoiled and, in the elderly, population could cause illnesses. The ADM stated her expectation of meat being thawed out is that staff could have had running water running over the chicken breast. The ADM stated the risk of not thawing food out and cooking it properly could cause food to have bacteria to grow on it. The ADM stated the expectation of staff in the kitchen is that they should always wear hairnets. The ADM stated she had bought all kitchen staff real cloth hairnets for dietary week. The ADM stated the staff in the kitchen had been in-serviced over the kitchen last year. When asked for the in-service that was completed last year, The ADM could not provide it. The ADM stated the risk of kitchen staff not wearing a hairnet could cause a hair follicle to fall into the food and could cause harm to the residents, and she had stated it is unsanitary. Record Review of the facility's Frozen and Refrigerated Foods Storage Policy dated 07/22/22, reflected in part:Potentially hazardous foods should be thawed on a bottom shelf in the refrigerator. Thawing foods must be labeled with the date they were removed from the freezer and a use by date which is 7 days from the date removed from the freezer, unless the manufacturer guidelines are different e.g., shakes may be 14 days. This includes all meats, poultry, fish, vegetables, frozen shakes and thawing PHF/TCS foods.8. Items stored in the refrigerator must be dated upon receipt, unless they contain manufacturer use by, sell by, best by date, or a date delivered. Most pick stickers do have the delivery date on the sticker. They must also be dated with an expiration date unless they have one from the manufacturer (i.e. milk cartons, eggs)11. All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above. Record Review of the facility's Personal Hygiene Policy dated 11/14/17, reflected in part: Dietary employees shall wear hair covering, beard restraint, and clothing that covers body hair. Staff that work serving in the dining room do not need to wear hair restraints. Any staff entering the kitchen must comply with hair restraints and hand washing.

Based on interview and record review, the facility failed to notify the resident and the ombudsman of the transfer or discharge and the reason for the move in writing for 1 of 2 residents reviewed for discharge rights. The facility failed to ensure Resident #1 was notified in writing of the details of the transfer. The facility failed to notify the ombudsman of Resident 1's transfer. This failure could affect all residents who were transferred or discharged to another facility at risk of having their discharge rights violated. Findings included:Record review of Resident #1 Face Sheet. dated 02/15/2025 revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that include Parkinsonism, Depression and Schizoaffective Disorder. Record review of Resident #1 MDS assessment dated [DATE] reflected the resident had a BIMS score of 14 indicating no cognitive impairment. Section Q 0400 reflects no Discharge plan in place. Section Q0610 reflects that there was no referral made to the Local Contact Agency. Section Q0620 reflects the reason why no referral was made to the Local Contact Agency was the discharge date was 3 or fewer months. Attempted interview with Resident #1 by telephone on 02/11/1026 at 10:20 a.m. revealed the contact number listed in the Residents records is no longer accepting telephone calls. Attempted email contact with Resident #1 on 02/11/2026 at 10:22 a.m., an email sent to the email address provided for Resident Number #1. No response was received. Attempted interview with Resident #1's daughter by telephone on 02/11/2026 at 10:25 a.m. The phone did not accept message but requested identification before a message could be left. There was no message left. Interview with the Ombudsman on 02/11/2026 at 11:30 a.m revealed she was concerned that the facility did not notify the resident of why she was moved to the sister facility. She stated that the resident told her she did not know why they moved her. She stated the facility staff had not notified her of any discharge or transfers. She stated she visited another facility and Resident#1 informed her of transfer to that facility. Interview with administrator on 02/11/2026 at 12:30 p.m. revealed the Social Worker was on leave and was the one who arranged the transfer. She stated that they transferred Resident #1 to a sister facility. She stated that they were having ongoing problems with Resident #1 getting along with a roommate and she also desired a private room. She did not qualify for a private room, but there was room at another facility. She stated that the resident agreed to the transfer and was transferred to the facility. She stated that the Resident was in agreement with the transfer. She stated that she was not able to locate any written correspondence notification. She stated that they had not been in the practice of notifying the ombudsman of transfers and discharges unless there were special circumstances. She stated that she will review the policy to confirm the situations in which they have to notify the ombudsman of moves and discharges. Record review of facility policy Transfer and Discharge (including AMA) Dated 10/10/2017 reviewed 09/01/2023 Policy Explanation and Compliance Guidelines:The facility will evaluate and determine the level of care needed for the resident prior to admission toensure the facility's ability to meet the resident's needs The facility permits each resident to remain in the facility and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.The facility may initiate transfers or discharges in the following limited circumstances:The transfer or discharge is necessary for the resident's welfare and the resident's needs cannotbe met in the facility. The resident's health has improved sufficiently so that the resident no longer needs the care and/or services of the facility. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident.The health of the individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility.The facility ceases to operate. 1. Non-Emergency Transfers or Discharges - initiated by the facility, return not anticipated.a. Document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs. Document any danger to the health or safety of the resident or other individuals that failure to transfer or discharge would pose.b. At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident and the resident's representative in writing in a language and manner they understand. (This time frame does not apply if the resident has not resided in the facility for 30 days.)c. Contents of the notice must include:i. The reason for transfer or discharge;ii. The effective date of transfer or discharge;iii. The location to which the resident is transferred or discharged ;iv. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and v. The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care ,including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure physician's orders were written for oxygen use via nasal canula for Resident #1 on readmission [DATE] to 09/16/2025. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident #1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of section J. J1100. Shortness of Breath (dyspnea) revealed: C. Shortness of breath or trouble breathing when lying flat. Review of respiratory treatment C1 oxygen therapy was not market for oxygen use. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected no indication of oxygen use. Record review of Resident #1's electronic medical record on 09/16/25 revealed: 1- No physician's order for oxygen use for readmission on [DATE] to 09/16/2025 2- The MAR did not reflect oxygen use or setting. In an observation and interview on 09/16/25 at 10:37 AM revealed Resident#1 was lying in bed, on oxygen via nasal canula and his oxygen concentrator was beeping with the yellow alarm light flushing. Resident #1 stated he did not feel good. Resident #1's oxygen concentrator float/flow indicator device was not visible inside the flowmeter tube. Observation on 09/16/25 at 11:14 AM revealed LVN B responding to the Resident #1's call light. LVN B checked the oxygen concentrator and turned the knob until the float was visible in the flowmeter. LVN B adjusted the oxygen flow to 2 L/ minutes. Observation revealed LVN B asking Resident #1 how he was feeling, and he replied he was feeling better. Interview with LVN B revealed Resident #1 was on oxygen as needed, and some time Resident #1 liked to adjust the flow rate. LVN B stated, she reeducated Resident #1 not to adjust the oxygen rate for his safety. LVN B stated adjusting the oxygen flow too high or too low could affect the amount of oxygen the resident was receiving and his breathing quality. In interview on 09/16/25 at 2:29 PM the DON stated Resident #1's oxygen was as needed, and sometimes he played with the concentrator flowmeter. The DON stated her expectation was every resident with oxygen must have order, because oxygen was a medication that could be given by the physician order only. The DON stated the risk to Resident #1 for not having a physician's order for oxygen use was respiratory issue. Interview with the Administrator on 09/16/25 at 3:20 PM, she stated orders drive care and she expected nursing staff to obtain orders for care. The Administrator stated she expected Resident #1 to have orders for his oxygen use. Record review of policy titled, Consulting Physician/Practitioner Orders dated 09/28/2021, reflected Policy: The policy provide guidance on receiving and following physician orders. c. Carry out and implement physician orders d. Document resident response to physician order in the medical record as indicated . Record review of policy titled, Oxygen Administration date 01/05/2020, reflected Policy: To describe methods of delivering oxygen to improve tissue oxygenation.during a respirator emergency it is appropriate for nursing to administer oxygen immediately and then notify physician for orders and further clinical guidance. 1.Verify physician order 2. Orders should have when to call the physician parameters.

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, and Resident #2) of 11 residents reviewed for ADLs. The facility failed to ensure:- Resident #1 had his fingernails cleaned and trimmed.- Resident #2 had his fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. 1- Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident#1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of the functional ability section reflected that Resident #1 required substantial assistance with showering and personal hygiene. Record review of Resident #1's Comprehensive Care Plan revised on 07/29/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x[BR1] 1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:37 AM with Resident #1, revealed his fingernails on both hands were dirty with black discoloration underneath the nails and the nails were jagged. The fingernails were 0.5-0.7 centimeter in length extending from the tips of his fingers. Resident #1 stated he would like his nails to be cleaned and trimmed. 2- Record review of Resident #2's Quarterly MDS assessment dated [DATE], reflected Resident #2 was a [AGE] year-old male admitted to the facility with initial admission date of 05 /09/25, with diagnoses of Hypertension (Elevated blood pressure), Asthma, Chronic Obstructive Pulmonary Disease, muscle weakness, and cognitive communication deficit. Resident#2 had a BIMS score of 13 which indicated intact cognition. Review of functional ability section reflected that Resident #2 required substantial/maximal assistance with showering and setup or clean-up assistance for personal hygiene. Record review of Resident #2's Comprehensive Care Plan revised on 07/21/25 reflected, Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Personal Hygiene: Limited x1. Bathing: Dependent x1 Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 09/16/25 at 10:50 AM with Resident #2, revealed his fingernails on both hands were dirty with black discoloration underneath the nails, and the fingernails were 0.4-0.6 centimeter in length extending from the tips of his fingers. Resident #2 stated he would like his nails to be cleaned and trimmed. In an interview/observation on 09/16/25 at 11:00 AM CNA A checked both residents' fingernails and stated they needed to be cleaned and trimmed. CNA A stated CNAs and nurses were responsible for nail care. She stated that nurses were responsible for nail care for diabetic residents. She stated nail care for residents was done on shower days and as needed. She added the risk to the resident for not trimming or cleaning their nails was decreased skin integrity and risk of infections. In an interview on 09/16/2 11:14 AM with LVN B revealed, CNAs were responsible for resident nail care, unless the resident had diagnoses of diabetes, then nurses were responsible for trimming the resident's nails. She stated dirty, long fingernails could expose the residents to the risk of developing infections or skin tears. LVN B further stated that although CNAs were responsible for nail care, it was ultimately the responsibility of the charge nurse to ensure residents' fingernails were always cleaned and trimmed. Interview on 09/16/25 at 2:24 PM the DON stated all the staff were responsible for the residents fingernail care. She stated CNAs should make sure residents' fingernails were cleaned and trimmed all the time, and if the resident had diabetes mellitus it was strictly the responsibility of the nurses to trim their fingernails. She stated the risk to residents, they could be harboring germs underneath the fingernails, they could develop infection and they could injure themselves or others. Record review of the facility policy titled, Activities of Daily Living Guidelines dated 2/11/2021 reflected, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene

Based on observations, interviews and record review, the facility failed to be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 11 residents (Resident #1) reviewed for reasonable accommodations. The facility failed to ensure the call light in the resident room, used by Resident #1, was always within reach. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected Resident #1 was a [AGE] year-old male admitted to the facility on 02 /14/25, and readmission on [DATE] with diagnoses of Cerebrovascular Accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), Seizure Disorder or Epilepsy (a neurological condition characterized by recurrent seizer), Asthma (a chronic lung condition that causes inflammation and narrowing of the airways, leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing), Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), Respiratory Failure, muscle wasting and atrophy (the decrease in size or wasting away of a body part, such as muscle or tissue, due to cell shrinkage or cell death). Resident#1 had a BIMS score of 06 which indicated severe cognitive impairment. Review of functional ability self-care was coded as (2) meaning Resident #1 Needed Some Help - Resident needed partial assistance from another person to complete any activities. Record review of Resident #1's Comprehensive Care Plan revised on [DATE] reflected, Focus: Resident has the potential for falls. Resident with poor safety awareness and impulsive. Goal: Resident will not sustain a fall related injury by utilizing fall precautions through next review date. Interventions: Reeducate the resident to use the call light when wanting to transfer. Place the resident's call light is within reach and encourage the resident to use it for assistance as needed. In an observation and interview on [DATE] at 10:37 AM revealed Resident#1 was lying in bed, on oxygen via nasal canula and his oxygen concentrator was beeping. Resident#1 stated, he did not feel good. Resident#1 was unable to call for help, because his call light was in the closed nightstand drawer. CNA A walked into the Resident #1's room and got the call light button from the nightstand drawer and clipped it to Resident #1's pillowcase. Interview on [DATE] at 11:00 AM CNA A stated, she put the call light button in the nightstand drawer this morning when she changed Resident #1's bed linen, and she forgot to put it within Resident #1's reach before leaving the room. CNA A stated she did not know the call light was not within the reach of the resident. CNA A stated the call light device was used by the residents to alert the staff about the resident's needs, and the call light was expected to be working and within the reach of the resident all the time. In an interview on [DATE] at 2:29 PM with the DON revealed all residents were expected to always have their call light within reach and it was the responsibility of all the employees to ensure the call light was within reach of each resident. The DON stated not having a call light within reach could put a resident at risk for going without incontinent care after a bowel movement, going without care at the time of a health crisis. Interview with the Administrator on [DATE] at 3:20 PM she stated it was her expectation for all the employees to make sure the resident's call light was always within reach and not having the call light within reach could lead to the risk of not getting assistance in a timely manner, it could lead to not receiving incontinent care, skin break. Record review of the facility's Call light response policy dated [DATE] reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The policy reflected the process as follows . All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light . With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied.

Based on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. 1. The facility, licensed for 144 beds, did not employ a full-time social worker from 3/26/25 to 6/11/25. This failure could place residents at risk of social service and psychosocial needs not being met. The findings included: Record review of the facility's Daily Census Report, dated 6/10/25, noted the facility had a total licensed bed capacity of 144. Record review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) date 06/06/25 noted the facility had a total licensed capacity of 144 beds. Record review of an undated document titled Job Details reflected the Previous Social Worker was employed from 7/11/23 to 3/26/25. In an interview on 6/10/25 at 2:37 PM, ADON B stated the facility did not have a social worker and had not had a social worker since the end of March. ADON B stated the Previous Social Worker left on vacation and decided not to return to work. In an interview on 6/10/25 at 2:51 PM, the DON stated there was not a social worker currently employed by the facility and that the social work duties were divided up between different staff members. The DON stated she did not believe it was a risk to the residents due to herself and the Administrator who covered the social worker duties. In an interview on 6/10/25 at 5:05 PM, the Administrator stated the social worker duties were divided between herself and the DON. The Administrator stated she did not think it was a risk to not have a social worker because she and the DON spoke with the residents daily and all appointments were automatically scheduled by a third party. The Administrator continued to state if a resident had an issue arise which required a social worker the resident would tell her about it or a staff member. The Administrator also stated she was advised by her corporate leadership she should contact a social worker from another facility to assist if needed. The Administrator stated she had not contacted another facility's social worker for assistance. Record review of the facility's policy titled Social Services Department Policies and Procedures dated 12/97 reflected: If the social worker is on leave or the position is vacant, the Administrator will develop a plan to cover the department duties.

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #35, Resident #45, Resident#24, and Resident#40) of 16 residents reviewed for ADLs. The facility failed to ensure: - Resident #35 had her fingernails cleaned and trimmed. - Resident #45 had her fingernails trimmed. - Resident #24 had her fingernails cleaned and trimmed. - Resident #40 had her fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1- Resident #35 Record review of Resident # 35's Face Sheet dated, 12/18/24, reflected a [AGE] year-old female admitted to the facility with initial admitted [DATE] with relevant diagnoses of Alzheimer's (brain disorder that gradually decreased memory function), reduced mobility (inability to move around freely or without pain), generalized muscle weakness and dysphagia (difficulty swallowing). Record review of Resident #35's Quarterly MDS assessment dated [DATE], reflected Resident #35 had a BIMS score of 0 which indicated Resident #35's cognition was severely impaired. It also reflected that Resident #35 required substantial assistance with showering and personal hygiene. Record review of Resident #35's Comprehensive Care Plan revised on 9/18/2021 reflected, Focus: [ Resident #35] has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: [Resident #35] has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Interventions: Personal Hygiene: Extensive assistance with 1 staff [member]. Record review of Resident #35's Comprehensive Care Plan revised on 3/8/2023 reflected, Focus: Resistant to Cares: [ Resident#35] is resistant to cares and at risk for injury, a decline in functional abilities, and not having their needs met in a timely manner. Resistance is related to refuses to allow staff to cut her fingernails. Goal: Resistance behaviors will not interfere with ADLs being met in a timely manner on a daily basis through the next review. Interventions: o Approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing cares, allow time for a response, and do not rush. o Give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible. o Discuss the possible outcomes of not complying with therapeutic regime. In an observation and interview on 12/17/24 at 8:47 AM with Resident #35, revealed fingernails on both hands were dirty with black discoloration underneath the nails as well as jagged. The fingernails were 0.5-0.7 centimeter in length extending from the tip of her fingers. Resident #35 stated she had not had her nails cut in a long time and would like her nails to be cleaned and trimmed. 2- Resident #45 Record review of Resident # 45's Face Sheet dated, 12/18/24, reflected an [AGE] year-old female admitted to the facility with initial admitted [DATE] with relevant diagnoses of Heart failure (condition where heart cannot pump enough blood and oxygen to the body organs), Hypertension (high blood pressure), Arthritis (chronic conditions that causes inflammation in the joints). Record review of Resident #45's Admission MDS assessment dated [DATE], reflected Resident #45 had a BIMS score of 13 which indicated Resident #45's cognition was intact. It also reflected that Resident #45 required substantial assistance with showering and personal hygiene. Record review of Resident #45's Comprehensive Care Plan revised on 11/27/24 reflected, Focus: ADLs: [Resident #45] has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: [Resident #45] will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 12/17/24 at 9:07 AM with Resident #45, revealed fingernails on both hands were long, about 0.5-0.75 centimeter in length extending from the tip of her fingers. Resident #45 stated she was new to the facility and had been in the facility for about 4-5 weeks. She stated that neither CNAs nor nurses have offered to cut her nails, she cannot trim her nails by herself and needed assistance with nail care related to diagnoses of arthritis. In an interview on 12/17/24 at 9:20 AM with CNA B revealed CNAs and Nurses were responsible for nail care. She stated that Nurses were responsible for nail care for diabetic residents. She stated nail care for residents were done on shower days and as needed. She added the risk to resident for not trimming or cleaning nails was decreased skin integrity and risk of infections. In an Interview on 12/17/24 11:03 AM with LVN C revealed, CNAs were responsible for resident nail care, unless the resident had diagnoses of Diabetes, then Nurses were responsible for trimming resident nails. He stated dirty, long fingernails can expose the residents to the risk of developing infections or skin tears. LVN C further stated that although CNAs were responsible for nail care, it was ultimately the responsibility of the charge nurse to ensure residents fingernails were always cleaned and trimmed. In another observation and interview on 12/18/24 10:31 AM with LVN C revealed both Resident # 35 and Resident #45 had their nails cleaned and trimmed. LVN C stated that Resident #35 initially refused to cut her nails, however when approached by a different staff member, allowed the staff member to trim and clean her nails. He also stated that he offered Resident #45 to cut her nails. 3-Resident#24 Record review of Resident # 24's Face Sheet dated, 12/20/24, reflected a [AGE] year-old female admitted to the facility with initial admitted [DATE] with relevant diagnoses of Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), reduced mobility (inability to move around freely), generalized muscle weakness and dysphagia (difficulty swallowing). Record review of Resident#24's MDS assessment dated [DATE], reflected Resident#24 had a BIMS score of 09/15 indicating moderately impaired cognition. It also reflected that Resident#24 required substantial assistance with showering and personal hygiene. Record review of Resident#24's Comprehensive Care Plan revised on 9/18/21 reflected, Focus: ADLs: Resident#24 has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident#24 will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Provide shower, oral care, hair care, and nail care per schedule and when needed. Observation and interview on 12/18/24 at 9:13 AM with CNA E, revealed, he looked at Resident#24 fingernails on both hands and stated they are long, and dirty. Resident#24 both hands fingernails were long, about 0.4-0.5 centimeter in length extending from the tip of her fingers, with black matter underneath some of them. CNA E stated he was supposed to check residents' fingernails each time he had encounter with the resident. He stated the risk to residents was they could injure themself, harbor germs in their hands, could swallow them, and develop infection. CNA E stated he received in service on resident care including fingernails during his orientation a month ago. 4-Resident#40 Record review of Resident#40's Face Sheet dated, 12/20/24, reflected a [AGE] year-old female admitted to the facility with initial admitted [DATE] with relevant diagnoses of Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), reduced mobility (inability to move around freely), generalized muscle weakness and dysphagia (difficulty swallowing). Record review of Resident#40's MDS assessment dated [DATE], reflected Resident#40 had a BIMS score of 03/15 which indicated severe cognitive impairment. It also reflected that Resident#40 required substantial assistance with showering and personal hygiene. Record review of Resident#40's Comprehensive Care Plan revised on 05/17/23 reflected, Focus: ADLs: Resident#40 has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Goal: Resident#40 will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Provide shower, oral care, hair care, and nail care per schedule and when needed. Observation and interview on 12/18/24 at 9:20 AM with CNA E revealed, CNA E looked at Resident#40's fingernails, and stated Resident#40's fingernails looked longer chipped, and dirty. CNA E stated Resident#40 was diabetic and the nurses were responsible to take care of her fingernails. CNA E denied letting the nurses know about Resident#40's fingernails status. Resident#40's fingernails on both hands were long, about 0.5-0.6 centimeter in length extending from the tip of her fingers, and some of them were chipped. can E stated each time he had encounter with the residents, he was supposed to check their fingernails, and report the issue to the charge nurse if the resident was diabetic. He stated the risk to residents was they could injure themself, harbor germs in their hands, could swallow them, and develop infection. CNA E stated he received in service on resident care including fingernails during his orientation. Interview on 12/18/24 09:23 AM with LVN F revealed, she stated CNAs were responsible for resident nail care, unless the resident had diagnoses of Diabetes, then Nurses were responsible for trimming resident nails. She stated dirty, long fingernails can expose the residents to the risk of developing infections or skin tears. LVN F further stated the charge nurse for each Hall were responsible to ensure residents fingernails were always cleaned and trimmed. Interview on12/19/24 at 08:31 AM with the ADON G revealed all the staff were responsible for the residents' fingernails care. She stated CNAs should make sure residents' fingernails were cleaned and trimmed all the time, and if the resident had diabetes Mellitus it was strictly the responsibility of the nurses to trim their fingernails. She stated in service on residents' nails care we given a lot to all the staff, and she personally talk to the aides. She stated the risk to residents, they could be harboring germs underneath the fingernails, they could develop infection and they could injure themself. Record review of the facility policy titled, Activities of Daily Living Guidelines dated 2/11/2021 reflected, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene . 48560

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food items in the facility kitchen were covered. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 12/17/24 at 7:58 AM of the walk-in refrigerator revealed sausages were left open in a cardboard box. Observation on 12/17/24 at 8:03 AM of the dry storage area in the kitchen revealed a box of pasta and a box of cream of wheat were left uncovered. In an interview on 12/18/24 at 1:52 PM, the Dietary Manager stated the cooks were mainly responsible for covering all food items in the kitchen. He stated that his expectation was all food items in the kitchen should be covered appropriately even if the food items were in a box. He stated the risk to residents of not covering food items could cause cross contamination resulting in food-borne illness. He added as the Dietary Manager, he conducted an in-service regarding covering food items appropriately on 12/18/24. In an interview 12/18/24 at 2:01 PM, [NAME] A revealed she has worked at the facility for four years. She stated that Cooks were responsible for covering all food items in the kitchen. She stated that she had not worked for the past two days so was unable to talk about the food items in the kitchen that were observed uncovered. She stated not covering food items could cause cross contamination and potentially cause illness in residents. She stated that she had received in-service about covering refrigerated and dry foods from the Dietary Morning on the morning of the interview. Record review of the facility policy titled Frozen and Refrigerated Foods Storage revised 12/5/2017 reflected, (Potentially hazardous/ time temperature control for safety) foods will be properly refrigerated or frozen to reduce the potential for food borne illness and maintain product integrity . Record review of the facility policy titled Dry Food and Supplies Storage revised 11/15/2017 reflected, .7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lids . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for 1 (Resident #55) of 6 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #55 had a person-centered care plan to include significant advance directive code status change from full code to DNR code, when they received Resident#55 consent on [DATE]. This failure could place resident at risk of been resuscitated and not honoring her DNR wishes. Findings included: Review of Resident #55's face sheet dated [DATE] revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses including hypertension (High blood pressure), Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Cerebrovascular accident. Review of Resident#55's quarterly MDS assessment dated [DATE] revealed Resident #55 had a BIMS score of ,d+[DATE] indicating severe cognitive impairment. Review of Resident#55 electronic medical record on [DATE] at 08:11 AM revealed a consent for DNR dated [DATE]. Review of Resident #55's Physician's Order Sheet dated [DATE] revealed Code status: DNR. Review of Resident #55's Comprehensive care plan last reviewed [DATE] revealed Focus. Full Code: Resident has physician's orders that include a status of full code. Goal: Staff will administer CPR if resident has an arrest. Interventions: Ensure Full Code order on chart. Ensure staff is aware of code status through designated systems. Monitor for changes in resident's code status and update as needed. Review at least quarterly. Begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party. Attempted interview and observation on [DATE] at 10:08 AM with Resident#55, revealed she was lying in bed unable to participate in interview. Interview on [DATE] at 08:09 AM with the MDS coordinator, she stated the code status order for the Resident#55 was DNR. She stated according to her the care plan was updated on [DATE] when she got the order, and it stated the resident code status had been changed to DNR. She stated the SW was responsible for the care plan part for the code status of the residents. The MDS coordinator stated the importance of care plan was for the staff to know what kind of care to render to the residents. Interview on [DATE] at 08:31 AM with ADON D, she stated the SW was responsible for that changing, meaning the status code for the residents in the care plan. The ADON stated if the care plan was not updated it can affect the resident's care, and in this case Resident#55 may got resuscitated against her wishes. Interview on [DATE] at 12:33 PM with the Administrator, she stated they thought they had to wait for the order to correct the care plan, and it was supposed to be done whenever they received the resident's consent. The Administrator stated the SW was responsible for the code status part of the care plan update. She stated the risk to the resident it would not following with her wishes by doing t CPR on the Resident#55, who wanted to be a DNR. Interview on [DATE] at 05:31 PM with the SW revealed she was responsible for the care plan code status update for the residents. She stated she did not update Resident#55's care plan after she received the consent, because she was waiting for the nurse to transcribe the order in the Resident#55 e-record. She stated the risk to Resident#55 if the care plan was not updated; Resident#55 could be resuscitated will she was a DNR. Review of facility Document titled Care Plan Guidance's, revised [DATE], revealed, .Care Plan Updates. The IDT will review the care plans Annually, Quarterly, and as needed to ensure all the goals and approaches are appropriate .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #51) of 6 residents observed for infection control. The facility failed to ensure: CNA E donned the appropriate PPE (Personal Protective Equipment) during the transfer of Resident #51 who was on enhanced barriers precautions r/t having an indwelling foley catheter. This failure could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Review of Resident #51's MDS, dated [DATE], revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His BIMS score was 09 out of 15 which indicated moderate cognition impairment. His diagnoses included obstructive uropathy (occurs when urine cannot drain through the urinary tract), diabetes mellitus (high sugar level in the blood), and Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident #51's Care Plan, dated 09/16/24, revealed Focus: The resident requires Enhanced Barrier Precautions d/t Urinary Catheter. Goal: The resident will remain free from active infection with MDROs through the review date. Interventions: . Ensure EBP signage is posted outside the resident room and above the head of the resident bed. Wear down and gloves during high contact resident care activities. Observation on 12/18/24 at 11:36 AM revealed Resident #51 was on EBP. There was signage on the door that informed visitors/staff he was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. CNA E entered Resident #51's room without any form of PPE, there was PPE supplies inside the Resident#51 room on the right side of the room entrance. CNA E washed hands, donned gloves and procced to transfer Residnt#51 from wheelchair to bed without wearing gown. CNA E removed gloved washed hands. Interview on 12/18/24 at 11:43 AM with CNA E, he stated knew he supposed to wear a gown for the resident transfer. He stated he forgot. He stated he was in-serviced regarding different type of infection control during orientation. He stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms was exposing himself and others to the development of infection and spreading germs from one resident to another resident. Interview with ADON D on 12/19/24 at 11:52 AM, she stated all the staff were supposed to wear gown, and gloves going inside the residents on EBP for any high contact care. ADON D stated they used EBP to prevent infection to high-risk residents. She stated in service on EBP was done up on hire, and at least quarterly. Interview on 12/19/24 at 12:33 PM, with the Administrator, she stated staff should gown up, and wear gloves if they were providing care to the resident on EBP, and discard before they come out of the resident room. She stated they do in service for the staff during orientation, and annually. She further stated the EBP just came in this year, so they do in service monthly because it was a new for them. The Administrator stated risk to residents' cross contamination. Record review of the facility's policy, Infection Prevention and Control program, last revised 03/26/24, reflected, EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high -contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following . b .indwelling medical devices (e.g.Urinary catheter .) .During high-contact resident care activities .Transferring

Based on observations, interviews and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #60) reviewed for reasonable accommodations. The facility failed to ensure the call light in resident room [ROOM NUMBER] A used by Resident #60 was always within reach. This failure could place resident at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Review of Resident #60's face sheet dated [DATE] reflected she was an [AGE] year-old female with an admitted [DATE]. Admission diagnoses reflected Resident #60 had a diagnosis of type 2 diabetes, fracture of shaft of left ULNA (fracture of left forearm), cognitive communication deficit (a condition makes it difficult to communicate). Review of the current diagnosis dated [DATE] reflected resident #60 was diagnosed with Enterocolitis due to clostridium difficile (an inflammation of intestines caused by bacteria). Review of Resident #60's MDS assessment dated [DATE] revealed Resident #60 had a BIMS score of 12 which indicates moderate cognitive impairment, required substantial/maximal assistance with toileting hygiene, moderate assistance with transfers, and always incontinent of bowel and urine. Review of Resident #60's care plan dated [DATE] reflected Resident #60 was at risk for unstable blood sugar levels and abnormal lab results, had an ADL selfcare performance deficit and was at risk for not having needs met in a timely manner, resident was incontinent of bowel/bladder. Interview and observation of Resident #60 on [DATE] at 11:39 AM in her room revealed the resident was on isolation for contact and droplet precautions due to Enterocolitis due to clostridium difficile. The resident was lying on her bed, the call light was found on the floor, away from resident's reach. Resident #60 stated she wanted to call the nurse for assistance at that time but noticed the call light was not attached to her pillow/bedsheet, nobody could hear her verbally calling the nurse since the door was closed as she was on isolation. The surveyor observed the call light was lying on the floor, away from the resident's reach. Resident stated she could not remember since how long the call light was not within her reach. Interview with LVN C on [DATE] at 11:44 AM in Resident #60's room revealed he was the charge nurse for Resident #60. Resident #60 was on isolation precaution for enterocolitis due to clostridium difficile. LVN C observed Resident #60's call light was not within reach and was lying on the floor. LVN C stated he did not know the call light was not within the reach of the resident, the call light device was used by the residents to alert the staff about resident's needs and the call light was expected to be working and within the reach of the resident all the time. LVN C stated the absence of a call light device within reach could create several problems for the residents such as not getting changed or cleaned on time, not getting drinks or snacks as needed, not getting help during a health crisis. LVN C stated he had received in-services on call lights on a regular basis, the last time he received an in-service was 2 weeks ago. LVN C sated all the staff working with the resident were responsible to ensure the call light device was working and within reach of the resident. Interview with CNA G on [DATE] at 01:47 PM. She stated it was the responsibility of all the employees to ensure the call light was always within the reach of the residents, not having a call light within reach could lead to fall, injury, dehydration, missing nursing care, incontinent care. CNA G stated she had received in service on call lights within the past few weeks. Interview with ADON D on [DATE] at 10:35 AM revealed all residents were expected to always have their call light within reach and it was the responsibility of all the employees to ensure the call light was within reach of each resident. ADON D stated not having a call light within reach could put a resident at risk for going without incontinent care after a bowel movement, going without care at the time of a health crisis. Interview with the Administrator on [DATE] at 11:27 AM revealed she was not aware the Resident #60's call light was not within reach, she stated it was her expectation for all the employees to make sure the resident call light was always within reach and not having the call light within reach could lead to the risk of not getting assistance in a timely manner, it could lead to not receiving incontinent care, skin break. The Administrator stated all the employees received in service regarding call lights every month and after each incident. Record review of the facility's call light response policy dated [DATE] reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The policy stated the process as follows . All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light . With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied .

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for two of eight residents (Resident #3 and Resident #4) reviewed for ADL care. The facility failed to ensure Resident #3, and Resident #4 had her fingernails trimmed and cleaned. This failure could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Record review of Resident #3's Admission MDS assessment, dated 09/11/2024, reflected Resident #3 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included left-sided hemiplegia (paralysis of left side of the body), Stroke, hypertension (high blood pressure), Gastro esophageal reflux disease (stomach contents leak into the esophagus), hyperlipidemia (high blood lipid levels), Seizure disorder. Resident #3 had a BIMS score of 15, which indicated Resident #3's cognition was intact. Resident #3 required moderate assistance with personal hygiene. Record review of Resident #3's Comprehensive Care Plan, revised 10/02/2024, reflected the following: Focus: Alteration in musculoskeletal status related to contracture left-sided extremities. Goal: [Resident #3] will exhibit adequate coping skills dealing with loss of/loss of use of limb and rehabilitation through the review date. Intervention: Staff will assist [Resident #3] with cleaning and cutting of fingernails on bath days. In an observation on 10/22/24 at 12:26 PM, in the dining room, with Resident #3 revealed the nails on the right hand was approximately 1 centimeter in length extending from the tip of his fingers and had black substance underneath the nails. In an interview on 10/22/24 at 1:18 PM, Resident #3 stated that she would like her nails to be cut and cleaned since she was unable to cut them by herself because of her stroke diagnosis. She stated no one in the facility had offered nail cleaning and cutting since her admission in September. 2- Record review of Resident #4's Quarterly assessment dated [DATE], reflected Resident #4 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Cerebral infarction (disruption of blood flow to the brain), Muscle weakness, Cognitive communication deficit (communication impairment caused by cognition), Repeated falls. Resident #4 had BIMS of 8, which indicated Resident #4 cognitive was moderately impaired. Resident #3 required moderate assistance with personal hygiene. Record review of Resident #4's Comprehensive Care Plan, revised 10/22/2024, reflected the following, Focus: ADLs: [ Resident #4] is at risk for not having their needs meet in a timely manner and refusing grooming at times. Goal: Resident will maintain a sense of dignity by being cleaned, dry, odor free, and well-groomed. Intervention: Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation on 10/22/24 at 12:27 p.m., in the dining room, with Resident #4 had long, jagged, and dirty nails. The fingernails on both hands were approximately 0.5 centimeter in length extending from the tip of his fingers, had black substance underneath and some of them were chipped. In an interview on 10/22/24 at 1:22 PM, Resident #4 stated he would like his fingernails to be cleaned and trimmed. Resident #4 stated that he was not able to clip his nails by himself and needed staff assistance. In an interview on 10/22/24 at 1:29 PM, LVN G stated, both CNAs and Nurses were responsible for nail care during shower days and as needed. He stated if a resident had diagnosis of diabetes, only nurses were allowed to provide nailcare. He stated the risk for not performing nailcare was increased risk of infection and skin breakdown. He stated that Resident #3 was a new admit and he will ensure that the Residents nails were cleaned and trimmed soon after the interview. In an interview on 10/22/24 at 01:38 PM, CNA J stated both CNAs and Nurses were responsible for nail care during shower days and as needed. She stated that unless the resident had diabetes, then CNAs inform staff nurses to provide nailcare. She stated the risk for not performing nailcare was increased risk of infection. In an interview on 10/22/24 at 01:34 PM, the DON revealed her expectation was nail care should be provided every shower day and as needed. She stated both CNAs and Nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare if resident had diagnosis of diabetes. She stated that Resident #4 has history of refusing ADLs at times, she will have staff check residents for nail care once again. She stated as the DON, she or designee rounded residents frequently to check on quality of care provided to the residents. The DON stated residents who had long, and dirty fingernails could be an infection control issue. Record review of the facility's policy titled, Activities of daily living care guidelines revised 2/11/2021 reflected, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene .

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #2) of four residents reviewed for abuse. The facility failed to protect Resident #2 from physical abuse by HA B. On 2/16/24 at 9:45 PM , HA B physically grabbed snacks from Resident #2, then proceeded to grab his arm and became involved in a physical interaction of tugging items back and forth with Resident #2 until Resident #2 fell on the ground without any physical injuries or harm. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 02/16/24 at 9:45 PM and ended on 02/23/24. The facility had corrected the noncompliance before the Incident investigation began on 10/22/24. The facility terminated HA B on 02/16/24, with no other incidents that involved Resident #2, and staff were reeducated regarding Abuse and Neglect on 02/16/24 through 02/20/24. This failure could place residents at risk of serious injury and harm. Findings included: Record review of the facility policy titled, Policy and Procedures: Abuse, Neglect and Exploitation revised 9/6/2024, reflected, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Record review of Resident #2's face sheet, dated 12/23/24, revealed Resident #2 was a [AGE] year-old male, with original admitted [DATE] with diagnoses that included: Paranoid Schizophrenia, hypertension, Cognitive Communication Deficit, Major depressive disorder, and Unsteadiness on feet. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed that he was unable to complete the BIMS with score of 0. Resident #2 was independent for ADL for toileting and personal hygiene. Quarterly MDS also revealed, Resident #2 did not exhibit any behaviors. Record review of Resident #2's Care Plan dated revised on 08/17/2021 reflected, that Resident #2 had been Care planned for Focus: Cognitive Impairment: [Resident #2] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: Psych Diagnosis, Paranoid Schizophrenia, Auditory Hallucinations, Delusional Disorder and Other Amnesia. Goal: Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained through the next 90 days. Intervention . COMMUNICATION: Identify yourself at each interaction. Face resident when speaking and make eye contact. Stop and return if the resident becomes agitated. Record review of Provider Investigation Report (PIR) (Form 3613-A of Texas Health and Human Services) dated 02/23/24 reflected that, Incident date and time as 2/16/2024 on 9:45 PM. Incident report within the PIR completed by LVN E reflected, LVN E was called to dining room, received report that altercation between Resident #2 and staff [HA B], the Resident #2 was sitting on the floor. Upon visual assessment, [Resident #2] noted to be in no distress and [Resident #2] refused for 911 to be called, stating [Resident #2] was alright. [Resident #2] denied hitting his head on the floor or any pain. [LVN E] stayed with the resident in the dining room for safety. [Resident #2] reported that the staff [HA B] push him down while they were going back and forth of altercation. No Injuries observed at time of incident. Incident report within the PIR completed by LVN E also revealed predisposing physiological factors: Gait Imbalance. Incident report within the PIR completed by LVN E reflected, [Resident #2] allowed the [LVN E] to assess his upper body, he refused to allow [LVN E] to assess beyond that point. No Injuries observed at time of incident. The resident was alert and ambulated without assistance. The resident was oriented to time, place, person, and situation. In an observation and attempt to interview on 10/22/24 at 10:09 AM, Resident #2 was standing in the hallway by himself. Resident #2 appeared to be sensitive to noises as evidenced by covered his ears while the housekeeping Staff was vacuuming the floors on the hallway. The writer attempted to speak with Resident #2, resident crossed his arms in X form and walked away. Observed resident had a very slow gait. In an interview on 10/22/24 at 10:23 AM, with CNA M, stated she had worked at the facility for about 5 months. She stated she was familiar with Resident'#2's care and stated he kept to himself, frequently refused ADL care from staff members. She stated Resident #2 was sensitive to voices, usually would walk around the facility, especially the dining room. She stated Resident #2 had an unsteady gait. In another observation and attempt to interview on 10/22/24 at 1:36 PM, Resident #2 was in his room that had 2 beds in the room with door closed. Resident was by himself in the room and sitting on the unoccupied bed with curtains drawn. Resident #2 refused to speak with the writer. In an attempted phone interview on 10/22/24 at 1:53 PM with HA B, left voice message for the staff to call back the writer. In an interview on 10/22/24 at 2:45 PM, RN D revealed that she usually worked the 2 -10 PM shift in the facility. She stated that on her 2-10 PM shift on 02/16/24 around 09:45 PM, she heard loud noises from the dining room. She stated that when she entered the dining room, she saw HA B was speaking loudly with Resident #2. She stated from what she could see was Resident #2's back, before RN D could reach him, Resident #2 staggered backwards and lost his balance and fell to the floor. She then stated that HA B continued to loom over Resident #2 and engaged in loud verbal disagreement with him. RN D and CNA C ensured that HA B and Resident #2 were separated immediately. She stated that at this time, she called Resident #2's assigned nurse [LVN E] to the dining room and it was determined that Resident #2 was fine, and no injuries were sustained. RN D then left the dining hall to care for her residents. In an interview on 10/22/24 at 3:00 PM, LVN E revealed that she was the assigned nurse for Resident #2 on 2/16/24 2-10 PM shift. She stated that she did not witness the incident. She was called to the dining room by a staff member and received report that altercation between Resident #2 and HA B. When she came to the dining room, Resident #2 was sitting on the floor. She stated that upon visual assessment, Resident #2 noted to be in no distress, and he refused to go to the hospital and denied hitting his head on the floor. Resident #2 refused head to toe assessment initially but then allowed LVN E to complete assessment until his back only, after the DON spoke with him. She stated that police came to the facility, but she was not sure if they were able to speak with Resident #2. She stated Resident #2 was alert and oriented, ambulated without assistance. LVN E added she had care for Resident #2 multiple times and was familiar with his care. Resident #2 had a history of unsteady gait and often refused ADL care. She also stated Resident #2 usually kept to himself and did not like anyone invading his personal space. In a phone interview on 10/22/24 at 3:27 PM, HA B started working in the facility on 02/07/24 as a Hospitality Aide. She stated she was on on-the-job training on 02/16/24 on the 2 - 10 PM shift and Resident #2 was one of the residents on her assigned hall. She stated that she no longer worked in the facility. She stated around 9:30 - 9:45 PM on 2/16/24, Resident #2 had taken night-time snacks that belonged to other residents. She asked Resident #2 to give back the snack packets that were in his possession. She stated Resident #2 refused to comply, so she reached for the snacks in his jacket. She stated that when she reached for the snacks, Resident #2 tried to swing at her and stated his rights. She stated that there was verbal argument with Resident #2, and he made threats to her. She stated she tried to remove his possessions and held Resident #2's arm. She added there was a physical tussle between her, and Resident #2 and he then threw hot liquid from his cup on her face. She stated that she called for help from other staff and tried to push him back to maintain distance to protect her safety. Resident #2 started losing his balance and she eased him to the ground. As he was getting to the floor, she saw two other employees reaching the dining room. She stated that called the police to report the incident since she was pregnant. She stated she does not remember if she received training on abuse and neglect when she started her employment with the facility. In an interview on 10/22/24 at 3:39 PM with CNA C who also worked the PM -10 PM shift on 2/16/24 in the facility stated that she was taking the leftover trays to the dining room. She saw Resident #2 standing in the dining room. She stated HA B was a new employee and asked CNA C if she had seen Resident #2. She stated that Resident #2 was in the dining hall and left to take care for her assigned residents. She stated that around 9:45 PM on 2/16/24, she heard someone screaming help, help from the dining room. RN D and herself ran to the dining hall, where HA B was screaming that Resident #2 poured hot water on HA B. She stated that she did not witness this incident. She stated that HA B was talking very loudly to Resident #2 and continued to engage verbally with the resident. CNA C asked HA B to leave the Resident #2 alone, and she was acting like she was trying to push at Resident #2, but he staggered and fell . CNA C stated that LVN E came to dining room and she left the dining room to attend to her residents. In a final attempt to interview on 10/23/24 at 9:52 AM, with Resident #2, he quoted he is not taking any visitors today and to respect his space. In an observation on 10/23/24 at 10:26 AM, the facility camera along with the Administrator, timestamped 2/16/24 21:42:05 (9:42 PM) to 2/16/24 21:45:04 (9:45 PM) revealed during the incident, the camera in the dining room showed Resident #2 standing in the dining room eating snacks. HA B talked with another resident in the dining room and came near to Resident #2. HA B and Resident #2 have some conversation [which could not be heard since the camera only had video footage and no audio] and HA B tried to stick her hand in the pocket of Resident #2's jacket he was wearing. Resident #2 knocked HA B's hand away. The camera further revealed that the two talked again for few seconds and HA B tried to reach for Resident #2's jacket one more time. Resident #2 again tried to knock her hand away and then HA B grabbed the coffee cup that he was drinking out of. Further, camera footage revealed that HA B may have picked multiple of his items, and they tugged back and forth. HA B went ahead to set the cup on the table while continuing to hold one of Resident #2's arm. She took the items from him and had walked away, when Resident #2 picked up his coffee cup and threw the liquid on HA B. At this point, HA B walked back towards Resident #2, grabbed his things, and tussled with him. This went for a brief time, until HA B grabbed Resident#2's arm that made the Resident #2 propel backwards, HA B continued to argue with Resident #2 until he became unsteady on his feet and fell to the floor. The video revealed CNA C and RN D arrived at the incident location while the resident was falling on the ground and had to separate HA B from Resident #2 as she continued to engage verbally with the resident. In an interview on 10/23/24 at 10:30 AM, the Administrator revealed that HA B was a new employee. When she heard about the incident from the facility staff, she immediately reached the facility. She stated she was the designated abuse coordinator for the facility and investigated and reported the incident. She stated that HA B was reaching for Resident #2 jacket for snacks. She stated that HA B made a choice to get the snacks out from Resident #2 by reaching for it physically and was pointing fingers, being verbally aggressive with the resident. She added that further investigation revealed as Resident #2 was about to go to the floor, RN D and CNA C entered the dining room. RN D and CNA C had to separate HA B from Resident #2, while HA B continued to be argumentative. She stated that, later when she had a statement from HA B, who verbalized she was upset and angry with Resident #2 and made a choice to grab his arm after he threw the hot liquid on her. Resident #2 refused to have head to toe assessment initially, then allowed to look at his back only. She stated Resident #2 did not sustain any injuries during or after the incident. She stated that police were called regarding the incident. The Administrator stated, as a result of the investigation, she confirmed the allegation of resident abuse by HA B as evidenced by HA B's physical aggressiveness and abuse towards Resident #2. The administrator verbalized that HA B was first suspended and then terminated on 02/16/24. She stated that her expectation was for all staff to always follow abuse and neglect protocols and policies and maintain resident safety. She stated an in-service for abuse and neglect was conducted for all staff members following the incident. In an interview on 10/23/24 at 11:23 AM, the DON revealed she had been the DON in the facility since December 2023. She stated that it was her expectation that all staff to always follow abuse and neglect protocols and policies as well as report any abuse or neglect to the abuse coordinator immediately. She stated that abuse and neglect in-services / training are done upon hire for all employees. She stated that the Administrator, ADONs and DON were responsible for providing abuse and neglect in-services. She stated she did not remember the incident between Resident #2 and HA B very well, however stated that Resident #2 sometimes displayed behaviors of eating from other residents' tray and getting snacks. She stated that staff were aware of Resident #2's behaviors. She further added that Resident #2 had limited food intake in the past, so the facility let him have snacks as needed. She stated HA B should have let him have the snacks and should not had intruded his personal space by reaching for items in his jacket. She stated HA B made the choice of grabbing items/snacks from Resident #2 physically and continuing to engage with him in a physical tussle. The DON added Resident #2 did not suffer any physical injuries during or after the incident. Record review of detailed police report for Incident 24014324 was requested but not obtained until the exit. Record review of the HA B personnel file revealed HA B was hired on 2/7/24 and terminated from Employment on 2/16/24. The facility had conducted Texas Department of Public Safety Criminal History verification and Employee Misconduct Registry Employability status check without any concerns. Record review of HA B personnel file also revealed resident had completed abuse, and neglect training on 2/7/24. Interviews on 10/22/24 and 10/23/24 across multiple shifts with various staff members (CNA C, RN D, LVN E, LVN F, LVN G, CNA H, MA I, CNA J, CNA K, CNA L, CNA M) over various shifts revealed facility had conducted abuse and neglect in-services on a routine basis and as needed. The above-mentioned staff members were able to verbalize abuse and different forms of abuse and neglect. They also stated that any incidence of alleged abuse and neglect or any abuse and neglect witnessed will be reported to the facility abuse coordinator immediately. They also verbalized that they had the abuse coordinators name and contact number handy to report abuse. Record Review of abuse and neglect in-services conducted by the facility from 2/16/24 to 2/20/24 revealed that the facility staff was trained on abuse and neglect, types of abuse, who is the abuse coordinator and when should abuse be reported. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 02/16/24 9:45 PM and ended on 02/23/24. The facility had corrected the noncompliance before the Incident investigation began. HA B was terminated from employment and Resident #2 had no other incidents. The facility staff were reeducated regarding Abuse and Neglect on 02/16/24 through 02/20/24.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Residents #1) of seven residents observed for infection control. CNA A failed to perform hand hygiene during incontinence care for Resident #1. This failure could place residents at risk for the development and/or worsening of urinary tract infections, cross contamination, and skin breakdown. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old-female admitted to the facility on [DATE]. Her BIMS score was 15 out of 15 which indicated she was cognitively intact, required extensive, one-person assistance for ADLs and was always incontinent of bowel and bladder. Her diagnoses included hypertension (high blood pressure), Seizure or Epilepsy (a chronic brain disease that causes seizures, which are episodes of abnormal electrical activity in the brain), and anxiety. Review of Resident #1's Care Plan dated 10/14/24 reflected Focus. ADLS: Resident has an ADL self-care performance deficit .Resident requires person assist Performance deficit is related to functional limitation in range of motion or decreased mobility Goal: Resident will maintain a sense of dignity by being clean, dry, odor free . Resident#1 was incontinent of bowel, and bladder. The intervention was for the resident to be assisted by staff for incontinent care. Observation on 10/22/24 at 11:54 a.m., revealed CNA A entered Resident #1's room, washed her hands with soap and water and put on clean gloves. CNA A unfastened Resident #1's brief and cleaned Resident #1's front area using one wipe per stoke, front to back. CNA A rolled Resident #1 to her left side and wiped her buttocks area from front to back using one wipe per stoke. CNA A rolled the dirty brief, removed it, and disposed of it in the trash can, then put the clean brief on Resident #1. CNA A rolled Resident #1 on to her back and fastened the brief without changing gloves. CNA A removed her gloves and reached into her pocket to retrieve a pair of gloves donned it without any form of hands hygiene. CNA A helped Resident #1 adjust her gown and covered her. CNA A removed gloves put them in the trash bag, then took the trash bag, and exited the room. CNA A disposed of the trash bag in the soiled room in the Hall and sanitized hands. In an interview with CNA A on 10/22/24 at 12:00 p.m., revealed she knew she was supposed to perform hand hygiene between glove changes, and change gloves with hands hygiene when going from dirty to clean task. She stated she thought she had done it correctly and did not realize she had missed some of the steps. CNA A stated the risk to resident is the development of infection. CNA A stated could not remember the last time she had an in service on hand hygiene, and incontinent care. Interview with the ADON on 10/23/24 at 09:43 a.m., revealed staff were to sanitize their hands before care, when going from clean to dirty and every time they changed their gloves. The ADON stated CNAs should not have gloves in their pockets. The ADON stated the risk to residents' cross contamination, and development of infection. The ADON stated it was her responsibility as the infection control preventionist in the facility to make sure the direct residents care staff follow proper hands hygiene protocol. The ADON stated the last in service was two weeks ago. Interview with the DON on 10/23/24 at 11:30 a.m., revealed staff were to sanitize their hands before care, when going from clean to dirty and after care. The DON stated staff were trained to perform hand hygiene between gloves changes. The DON stated it was her responsibility, and the responsibility of the two ADON in the facility to make sure direct residents care staff follow the proper hands hygiene. The DON stated they do staff training every monthly for one hall, with the goal of doing training for all the staff at least every six months. The DON stated the risk to residents development of infection. Record review of CNA A skills checklist dated 10/20/24 reflected she was checked off on Hand Hygiene and SKILL#21: Provides Perineal Care (Peri-Care) for Female and she was competent in the skills. Review of the facility's Nursing Procedure Manual titled, Incontinent Care dated February 14, 2020, reflected, Enters room .Washes hands, put on non-sterile, latex free gloves .Cleanse peri-area and buttocks .14. Remove linen/under pad and discard 15. Remove and discard gloves 16. Wash hands 17. Apply clean linen/under-pad, brief or other incontinent products, as needed . Review of the facility's policies and procedures titled Hand Hygiene dated November 12, 2018, reflected, .3.Hands Hygiene is indicated and will be performed under the conditions listed in, but not limited to . Before applying and after removing personal protective equipment, including gloves .When during resident care, moving from a contaminated body site to a clean body site .

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure dish machine reached minimum of 120 degrees F for wash and rinse on 10/24/23. 2. The facility failed to ensure food in the kitchen's refrigerator and freezer were stored in sealed containers, labeled, and dated. The facility failed to ensure food item in refrigerator was not spoiled. 3. The facility failed to maintain cleanliness of the inside of the ice machine. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observations on 10/24/23 at 10:07 AM revealed the Dietary Manager ran the dish machine with first two wash/rinse low temperature dish machine reading 100 temp F for wash and rinse. The third time dish machine ran cycle the temperature only reached 110 temp F for wash and rinse. Dietary Manager ran the dish machine two more times with 115 temperature F and 118 temperature. Interview on 10/24/23 at 10:15 AM with the Dietary Manager stated it was a low temp dish machine which should reach at least 120 degrees F for wash and rinse. He looked at the temperature log on the wall and stated they had not checked the dish machine temperature yet this morning. The Dietary Manager stated there had been a couple of loads already ran through prior to checking the dish machine. He stated they will temporarily not use the dish machine until were are able to have it working properly. He stated it was important for the dish machine to reach at least minimum temperature to clean the dishes. Interview on 10/26/23 at 8:48 AM with the Maintenance Director revealed dish machine representative came out on 10/24/23 to look at dish machine on 10/24/23 verifying the dish machine water temperature was not reaching minimum water temperature as required. He stated he had to replace the kitchen's water heater circulator pumps before able to get hot water at minimum temperatures. He stated he was not aware of any issues with the kitchen dish machine water temperatures until 10/24/23 when they contacted dish machine representative. Surveyor requested service order for dish machine. 2. Observation on 10/24/23 at 10:20 AM revealed 1 of 2 freezers had frozen meat not dated or labeled. Observation on 10/24/23 at 10:21 AM revealed 1 of 2 refrigerator contained a sealed plastic food item with shredded purple and yellowish shredded produce labeled green cabbage not labeled or dated. No expiration date was on the item or date on the item. Interview on 10/24/23 at 10:22 AM the Dietary Manager revealed the frozen meat was chicken which should have been labeled and dated when opened. The Dietary Manager stated he thought the item in the refrigerator was coleslaw and looked like it had turned bad. He stated he will throw it away. It should be labeled and dated so they know when item was open and received. He stated if food items were not dated when opened then they will not be able to know how long it will last. 3. Observation on 10/24/23 at 10:26 AM revealed ice machine in the kitchen had dark blackish stains and particles covering about four inch area on the left inner part above the ice. Interview on 10/24/23 at 10:27 AM and 10:34 AM with the Dietary Manager revealed he had not noticed the blackish particles inside the ice machine. He stated it could drip down and contaminate the ice. He stated Maintenance had cleaned it last month when it was not working. He stated Maintenance usually cleaned it monthly at least. Review of facility's policy Frozen and Refrigerated Foods Storage revised 12/5/17 reflected Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered .11. All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above . The facility did not provide a specific policy on the ice machine or the dish machineat the date and time of exit from the facility.

Based on observations, interview and record review, the facility failed to provide a safe, clean, and homelike environment for 2 (Residents #188 and #84) of 24 residents reviewed for environment. The facility failed to provide Residents #188 and #84 a handwashing sink that was not loose and a paper towel dispenser that worked properly without cover coming off in resident bathroom. This failure could place residents at risk for living in an unsanitary and uncomfortable environment. Findings included: Review of Resident #188's face sheet dated 10/26/23 reflected Resident #188 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of displace avulsion fracture of right talus (broken bone in ankle), hypertension, diabetes, post-traumatic stress disorder, neuropathy, and heart disease. Review of Resident #188's other MDS assessment dated [DATE] reflected Resident #188 had a BIMS score of 15 indicating he was cognitively intact. Observation and Interview on 10/24/23 at 10:55 AM with Resident #188 revealed since he had been admitted to the facility, he had noticed the handwashing sink was loose and the paper towel dispenser cover in his bathroom would come off when pulling paper towel out of it. Observations on 10/25/23 at 1:58 PM and 10/26/23 at 8:46 AM revealed Resident # 188 and Resident #84's bathroom had a loose sink and the paper towel dispenser cover was loose would come off when touched. Interview on 10/26/23 at 8:48 AM with the Maintenance Director stated he was not aware of issues with Residents #188 and #84's bathroom sink and paper towel dispenser. He stated housekeeper should have reported the bathroom sink and paper towel dispenser to him. He stated the bathroom sink being loose needed to be fixed with 2 screws to secure it. He stated housekeeping had the paper towel dispenser replacement and would have to give it to him so he could replace it. He stated he can get the bathroom sink fixed and paper towel dispenser replaced. He stated the nurse, CNA and/or housekeeper should report any maintenance issues in the system and then he was notified of maintenance repairs. He stated he was not able to do rounds on all resident rooms and bathrooms and depended on facility staff to report to him any repairs. Interview on 10/26/23 at 11:35 AM with CNA H revealed she was not aware of issues with Residents #188 and #84's bathroom sink or paper towel dispenser. Interview on 10/26/23 at 11:38 AM with CNA D revealed she was not aware of issues with Residents #188 and #84's bathroom sink or paper towel dispenser. She stated Resident #188 used the bathroom and did not voice to her about any concerns with bathroom. Interview on 10/26/23 at 12:52 PM with Housekeeper I revealed about three weeks ago she had noticed Resident #188 and #84's handwashing bathroom sink was loose and paper towel dispenser cover would come off. She stated she told Housekeeper Supervisor about it who filled out a work order. Interview on 10/26/23 at 12:56 PM with Housekeeping Supervisor revealed she had put in a work order when Housekeeper made her aware of Resident #188 and #84's bathroom sink and paper towel dispenser and gave it to Receptionist. She stated receptionist told her she threw them away after they were put in electronic system. Interview on 10/26/23 at 2:18 PM with Receptionist revealed she put in maintenance work orders into system but was not sure what Maintenance did with them afterwards. She did not have a copy of work order for resident bathroom room [ROOM NUMBER]. Interview on 10/26/23 at 2:33 PM with the DON revealed the maintenance work order for room [ROOM NUMBER] (Residents #188 and #84 bathroom) was put in this morning and facility could not locate a maintenance work order prior to today. Review of facility's policy Preventative Maintenance undated reflected 1. The Facility will provide a written or computerized preventative program ensuring inspections are performed on schedule and continuously reviewing the program to make certain that the results are meeting the goals of the program. The preventative maintenance program .will ensure a safe, well-maintained environment for the Residents, Visitors and Staff. 2. The facility will provide a written quality control program that ensures a clean, safe, pleasant and functional environment for the Residents, Staff and Visitors.

Based on interview and record review the facility failed to ensure resident was free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 was free of any significant medication errors by failing to ensure a resident received the correct prescribed intravenous (IV) medication, which resulted in the resident being given an IV medication that she had a known allergy to. This failure resulted in a PNC IJ (Past Non-Compliance Immediate Jeopardy), the IJ (Immediate Jeopardy) started on 08/24/2023 and ended on 08/26/2023. The facility had corrected the IJ (Immediate Jeopardy) prior to entry for abbreviated survey. There was no resident in the facility on IV therapy, facility had completed staff in-service on medication administration and LVN A had been educated on medication administration prior to entry. This failure could place residents at risk of complications from deterioration in health, potential for severe reaction, extended recoveries, hospitalization s, and death. Findings included: Record review of Resident #1's face sheet dated 08/27/23 revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses of acute cystitis (infection of the bladder), chronic kidney disease, cellulitis of right lower limb, pneumonia, hypertension, and anxiety disorder. Also, indicated Resident #1 had allergies to Piperacillin, Vancomycin, Tazobactam and Zosyn. Record review of Resident #1's quarterly Minimum Data Set, dated dated dated [DATE], reflected Section C Brief Interview for Mental Status (BIMS) was 14, which indicated she did not have cognitive impairment. Section G indicated R#1 required extensive assistance with one-person physical assist for bed mobility, locomotion on and off the unit, dressing, eating and toilet use. Record review of Resident #1's Care Plan undated reflected Resident #1 was on Meropenem IV antibiotic therapy related to urinary tract infection. Goal, The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Intervention, administer medication as ordered. Record review of Resident #1's Order Summary dated 08/21/2023 reflected, Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously every 8 hours for UTI (Urinary Tract Infection) for 7 Days Record review of Resident #1's, August 2023 Medication Administration Record (MAR) indicated an order of Meropenem 1 GM (gram) to be reconstituted and administered every 8 hours. The medication was started on 08/21/2023 at 04:00pm. Record review of Resident #1's progress notes dated 08/24/2023 at 10:09AM reflected, This nurse administered the wrong medication (Zosyn) NP notified .who gave the following orders. Benadryl 25 mg, Prednisone 40 mg and Pepcid 20 mg Further a note dated 08/24/2023 at 04:50 PM revealed, .redness noted to face, neck torso and back warm to touch hand and fingertips cool to touch and discolored B/P 78/52 NP in the facility notified of change in skin color NP assessed the resident . order received to transfer to hospital for eval and treatment . Record review of the NP witness form with the date of interview on 08/25/2023 revealed, NP had gone to see Resident #1 for a follow up on UTI, IV pump was beeping LVN A walked after her. After the LVN A disconnected the IV tubing from Resident #1 it revealed a different name on the antibiotic bag, and it was a different medication (Zosyn) that the resident was allergic to. Mild flushing/purplish discoloration to both hands was noted. NP informed the residents primary care provider and orders were placed for the resident. LVN A reported of low B/P and IVF bolus was started but the B/P kept declining and at the time Resident #1 had widespread redness to her back, trunk, neck/face. Body was warm to touch by the extremities; hands, fingers and toes were cold and clammy and pale with purple discoloration. The resident condition was discussed by the primary care provider and the resident was transferred to the hospital. In an interview on 08/27/2023 at 12:35 PM with LVN A he stated he was the nurse in charge for Resident #1. He stated on 08/24/2023 he had administered Resident #1's IV antibiotic around 10 am. LVN A stated when he went to disconnect the IV tubing the NP was in the room with the resident and LVN A realized he had administered the resident a wrong medication which she was allergic to. The NP assessed the resident and ordered Benadryl, Pepcid and prednisone for Resident #1. NP also instructed for the resident to be monitored closely and obtain the resident's vital signs every 15 minutes. LVN A stated the resident was also administered IV (Intravenous) fluids due to low blood pressure, but it did not improve and the NP who was still in the facility. Resident #1 was then transferred to the local hospital for evaluation and treatment. LVN A stated he acknowledged his mistake, he stated he failed to check and make sure he picked the right medication and administered to the right resident. He stated even before starting the IV antibiotic he was supposed to double check again to make sure he was administering the right medication, but he didn't. LVN A stated administering the wrong medication to the resident which she was allergic to could have caused severe allergic reactions and even death. LVN A stated after the incident he received disciplinary action, he was in-serviced on medication administration, and he had a training to complete before returning to work. In an interview on 08/27/2023 at 12:48 PM with ADON revealed she was made aware of the incident on 08/24/2023 around lunch time. Immediately the ADON went and checked on another resident who was on antibiotic therapy on the same hall that LVN A was in charge and revealed the resident had received the right medication. ADON stated Resident #1 was monitored closely until it was determined she was to be transferred to the local hospital. ADON stated she expected the nurse to administer the medication to the right resident and right order. The ADON stated administering wrong medications that the resident was allergic to could cause death and severe allergic reactions. In an interview on 08/27/2023 at 1:35 PM with the Administrator revealed she was made aware of the incident on 08/24/2023 on the day it happened, and she started the investigation. Administrator reported the incident HHS on 08/26/2023. Administrator stated LVN A reported to her on 08/24/2023 that he had administered the wrong medication to Resident #1, and the resident was allergic to the medication that was administered. The NP was with Resident #1 on 08/24/2023 at the time it was identified Resident #1 received the wrong medication. NP assessed the resident and ordered medication for the resident. The resident did not display any acute distress, but she had redness to her body and later her blood pressure dropped. NP recommended the resident to be transferred to the local hospital due to the decline in her blood pressure. LVN A received disciplinary action, he was in-serviced on medication administration and had to complete medication administration training. Administrator stated she expected LVN A to administer the right medication to the right patient. She stated administering the wrong medication could cause severe allergic reactions and even death to a resident who was allergic to the medication. There was no resident in the facility on IV therapy. Administrator stated after the incident all the medication aide and nurses were in-serviced on medication administration. Review of the facility policy dated 01/09/2014, titled Medication - Treatment Administration and Documentation Guideline reflected, 1. Verify labels accurately reflect the physician orders on the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the EMAR three (3) times. Measures that were put in place after the incident and the records were provided and reviewed. All medication aide and nurses were in-serviced on medication administration on 08/24/2023 LVN A will complete a four-week med pass with the ADON LVN A will complete a training on medication administration Two nurses will clarity the orders before medication administration LVN A received a disciplinary action dated 08/24/2023 During an interview on 08/27/2023 between 12:00 PM and 2:30 PM with the charge nurses who were on duty revealed they had been in-serviced on 08/24/2013 on medication administration. Review of IV therapy administration revealed the nurses had completed the training together with LVN A dated 08/27/2023 On 08/27/2023 at 3:15 PM, the administrator was notified of the PNC IJ.

Based on interview, and record review the facility failed to ensure one (Resident #1) of three residents reviewed for pressure ulcers received treatment and care in accordance with professional standards of practice in that: 1. Resident #1 admitted with a pressure ulcer on 12/02/22 and the facility failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until six days later on 12/08/22. 2. The facility failed to ensure Resident #1 was provided with wound care to promote healing until six days after admission on 12/08/22 when he was assessed by the Wound Care Physician (WCP) with an unstageable deep tissue injury to the sacrum. (Unstageable-full thickness tissue loss covered by extensive necrotic (dead skin tissue) tissue or eschar (Eschar-dead tissue that falls off (sheds) from healthy skin). (Deep Tissue Injury-Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal (outer layer of skin) separation revealing a dark wound bed or blood-filled blister). It was determined a past non-compliance Immediate Jeopardy existed from 12/02/22 to 12/08/22. The Immediate Jeopardy was determined to have been removed on 05/01/23 due to the facility's implemented actions that corrected the non-compliance. These failures could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life-threatening infection, which could manifest into other health complications, pain, worsening pressure ulcers and a decreased quality of life. Findings included: Review of Resident #1's closed clinical records revealed an admission MDS assessment dated [DATE]. The assessment reflected the resident was a [AGE] year-old male with an admitted [DATE]. Diagnoses included cerebrovascular accident (stroke), seizure disorder and respiratory failure. The MDS assessment reflected the resident received nutrition via a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) and utilized a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). He required extensive physical assistance of two people for bed mobility, dressing and personal hygiene. Section C related to cognitive patterns was blank. Resident #1 had one Stage IV pressure ulcer that was present on admission, (Stage IV-full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed), (Slough-a mass of dead tissue separating from an ulcer). Review of Resident #1's undated Admission Record reflected a discharge date of [DATE]. Review of Resident #1's admission assessment dated [DATE] reflected he had open wounds. There was no documented assessment, location, description, or characteristics of the wounds in the admission assessment. Review of Resident #1's admission progress notes dated 12/02/22 and timed 6:44 p.m. documented by LVN A revealed the resident was comatose, not responding to verbal stimuli and he had two small open areas to the coccyx (coccyx-small triangular bone at the base of the spinal column). There was no documented assessment, description, or characteristics of the open areas in the progress notes. Review of Resident #1' clinical records revealed there was no documented wound assessment until the WCP visit on 12/08/23, six days after the resident admitted to the facility. Review of Resident #1's baseline care plan dated 12/03/22 reflected Resident #1 had no skin issues, and his skin was intact. Review of Resident #1's care plan dated 12/08/22 revealed he admitted with a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities. The goal was for the pressure ulcer to show signs of healing through the next review date with a target date of 03/08/23. Interventions included providing wound care per physician's orders, routinely evaluating, and documenting the wound dimensions, drainage, and condition of surrounding tissue. Interview with the TN on 05/01/23 at 2:41 p.m., he stated he was not on duty when Resident #1 admitted to the facility and did not see the resident's pressure ulcer until 12/05/22. The TN stated he was unable to recall what the pressure ulcer looked like, but he would check his notes. Interview with LVN A on 05/01/23 at 3:10 p.m., she stated she was the admitting nurse for Resident #1 on 12/02/22 and completed the admission assessment. She stated she did not recall what the open areas looked like just that they were small and did not amount to much. She stated the procedure was to notify the TN when a resident admitted with a wound. LVN A stated she was unable to recall if she had informed the TN of Resident #1's open areas or if she had notified the physician. She stated she recalled the TN being in the facility at the time of Resident #1's admission and the TN was responsible for assessing/documenting and taking care of wounds. Interview on 05/01/23 at 3:52 p.m. with the TN, he stated the admitting nurse was responsible for assessing and documenting a full wound assessment to include a description of the wound and calling the physician to obtain wound care orders. Review of Resident #1's weekly WCP notes/assessments revealed the following: 12/08/22- initial visit-he was assessed with an unstageable deep tissue injury measuring 3.5 centimeter in length, 4.0 centimeters in width and 0.1 centimeters in depth. The assessment reflected a deep tissue injury was noted in and around the wound. 12/14/22-he was assessed with a Stage IV pressure ulcer (Stage IV -Full thickness tissue loss with exposed bone, tendon, or muscle) to the sacrum that measured 8.0 centimeters in length, 5.5 centimeters in width and 0.8 centimeters in depth. The wound's progress was assessed as having deteriorated. 12/21/22-he was assessed a Stage IV pressure ulcer to the sacrum that measured 7.0 centimeters in length, 8.5 centimeters in width and 1.3 centimeter in depth. The wound's progress was assessed as having deteriorated. Resident #1's sacral wound was swabbed to test for the presence of pathogens on 12/21/22. (Pathogen- a bacterium, virus, or other microorganism that can cause disease). 12/28/22-he was assessed with a Stage IV pressure ulcer to the sacrum that measured 5.5 centimeter in length, 5.5 centimeters in width and 0.2 centimeters in depth. The wound's progress was assessed as having improved. The WCP notes reflected results of the swab test performed on 12/21/22 revealed the presence of the pathogens enterococcus faecalis, Bacteroides fragil and staph hemolyticus. Review of Resident #1's consolidated physician orders dated from 12/02/22 to 01/05/23 revealed the following: 12/08/22-Treatment order for hydrogel gel w/silver once a day to sacrum. 12/28/22- The antibiotic Augmentin 875-125 milligrams one tablet was ordered to be administered two times a day for ten days for wound healing. Review of Resident #1's MARS/TARS dated 12/2022 revealed the wound care order dated 12/08/22 had been transcribed to start on 12/09/22 but the wound care orders were not implemented by the facility until 12/10/22. Interview with the TN on 05/02/23 at 9:30 a.m., he stated he was unable to locate any additional assessments of Resident #1's pressure ulcer prior to the WCP visit on 12/08/22. He stated he usually completed and documented a full skin assessment for newly admitted residents. The TN stated he recalled observing the resident's wound on 12/05/22 but was unable to recall exactly what it looked like. He recalled removing the foam dressing from the resident's wound, there was only one area, and he thought the wound was a nickel sized, dark black colored, deep tissue injury. He stated he replaced the same foam dressing and could not recall if he provided wound care for Resident #1 prior to the WCP visit on 12/08/22. He further stated his thinking had been that the WCP was coming to the facility in a few days and could evaluate the wound and provide wound care orders. The TN further stated he did not call the physician to obtain wound care orders and realized he made a mistake and did not know what happened during that time as he usually notified the physician and obtained wound care orders. Interview with the Administrator and DON on 05/02/23 at 10:15 a.m. they stated they had provided in-service training to all licensed nursing staff on 05/01/23 related to wound assessments, obtaining wound care orders and the facility's skin/wound P/P. A QAPI audit was performed for all residents assessed to be at risk for pressure ulcers was completed on 05/01/23 to ensure orders, treatments, and dietary interventions were in place. Interview with the DON on 05/02/23 at 2:14 p.m., she stated she had not been aware Resident #1 had no documented wound assessment on admission or that there were no orders or evidence of wound care until the WCP visited on 12/08/22. She stated her expectations were for nurses to assess residents' wounds and document a full assessment to include exactly what they see to include a full description, location and to call the physician for wound care orders. Interviews with the DON on 05/02/23 at 5:15 p.m., she stated it was important to provide wound care and assess pressure ulcer/wounds to prevent deterioration of the wound and to provide continuity of care. The DON stated if residents' wounds were not assessed and wound care was not provided the resident could experience pain, infection and/or worsening of the wound. Interview with the DON on 05/04/23 at 9:48 a.m., she stated the ADONs were responsible for following up to ensure admission assessments to include wound assessments were completed and wound care orders had been obtained. She stated the ADON responsible for Resident #1's hall was on vacation at the time of the resident's admission and ADON B was responsible for following up on all new admissions. The DON stated she did not know why the lack of an assessment and treatment orders for Resident #1 were missed during the clinical a.m. meetings other than he fell through the cracks and there was no follow through. Interview with ADON B on 05/04/23 at 10:16 a.m., she stated the ADONs were responsible for ensuring admission paperwork was completed. She stated she was responsible for all new admission follow-ups when ADON C was on vacation. She stated an admission checklist was used to ensure all admission orders, assessments and paperwork was completed. She stated she could not recall if she had used the checklist to follow-up on Resident #1's admission and if she had she would have seen the admission assessment reflected the resident had a wound and that would have driven her to check to ensure there were orders and a full wound assessment. ADON B further stated new admissions were discussed in the a.m. meeting to ensure all admission orders, assessments and paperwork were completed and she did not know how Resident #1's lack of a wound assessment and wound care orders were missed. Review of the facility's P/P entitled Pressure Injury Prevention and Management dated 10/24/22 reflected in part: Policy: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure ulcer prevention and management, including prompt assessment and treatment. The attending physician will be notified of the presence of a new pressure injury upon identification. Review of the facility's P/P entitled Skin Prevention and Management Guidelines revised 04/13/23 reflected in part: Guideline Statement: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Review of the facility's P/P entitled Skin Assessment/Evaluation revised 04/13/23 reflected in part: Remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note findings. Documentation of skin assessment includes a description of the wound to include measurements, color, type of tissue in wound bed, drainage, odor, and pain. The facility's P/P entitled Admission Policy revised 02/10/21 included completing clinical evaluations, conducting a complete physical examination, a head-to-toe body audit and documenting findings. Review of the facility's action plan to include education material, training records, and audits related to skin assessments and wound care orders revealed the facility implemented the following interventions: QAPI skin prevention audits completed for all residents with Braden scale (Assessment for predicting the risk for pressure ulcer development) scores of twelve or less pressure indicating risk for impaired skin integrity, to ensure orders, treatments, and other interventions to include nutritional support provided. In-service training provided on 05/01/23 to all licensed nursing staff on facility skin management P/P, skin assessments and wound care orders to included: 1. All nurses must complete a head-to-toe assessment on all new and readmitted residents. 2. Describe what the wound looks like, if there is drainage, what color or an odor. 3. If the resident comes without an order for any wounds, if the wound nurse is not present, call the MD to obtain a treatment order. 4. Notify the wound nurse, DON, and on-call about any new orders. 5. Admission audit tool for all newly and readmitted residents to ensure skin assessment, physician notified, and wound care orders completed and WCP referral to be provided to DON before a.m. meeting. 6. Weekly monitoring of admission audits for one month with a monthly summary. Interviews were conducted on 05/02/23 from 10:29 a.m. to 10:42 a.m., at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff LVN D, LVN E, LVN F, LVN G and RN H. Interviews were conducted on 05/04/23 from 10:16 a.m. to 10:48 a.m. with the TN, ADON B and ADON C. The nursing staff were able to accurately summarize the facility's skin management P/P related to wound assessments and wound care orders they received.