Every finding on record at Port Lavaca Nursing and Rehabilitation Center

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 disease and infection for 3 of 18 residents (Residents #2, #7 and, #24) reviewed for infection control: 1. The facility failed to ensure MA B sanitized the blood pressure cuff in between use with Residents #24 and #7 on 06/18/2026.2. The facility failed to ensure LVN C sanitized the blood pressure cuff before using it on Resident #2 on 06/18/2026 These failures could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #24's face sheet dated 06/18/2026 revealed an admission date of 07/03/2025 with re-admit on 08/02/2025 and with diagnoses which included: Cerebral infarction (death of brain tissue due to lack of blood flow), Major depressive disorder (severe and persistent low mood, profound sadness, or a sense of despair), Alcoholic cirrhosis of liver (liver disease caused by alcohol), Vascular dementia (problems with blood flow to the brain, leading to cognitive decline) and Hypertension (Hight blood pressure). Record review of Resident #24's Physician orders, for June 2026, revealed an order for Lisinopril-hydrochlorothiazide Oral Tablet 20-25 MG (Lisinopril & Hydrochlorothiazide) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD FOR SBP (systolic blood pressure) LESS THAN 100, DBP (diastolic blood pressure) LESS THAN 50. Record review of Resident #7's face sheet, dated 06/18/2026, revealed an admission date of 06/11/2024 with re-admit on 03/14/2026, with diagnoses which included: Chronic kidney disease (Gradual loss of kidney function), Cellulitis (bacterial skin infection), Type 2 diabetes mellitus (elevated blood sugar level) and Hypertension (high blood pressure). Record review of Resident #7's Physician orders, for June 2026, revealed an order for Metoprolol Tartrate Oral Tablet 25 MG(Metoprolol Tartrate) Give 0.5 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) *GIVE 0.5 OF 25MG TAB TO EQUAL 12.5MG; HOLD FOR SBP LESS THAN 100 AND/OR DBP LESS THAN 50; HOLD FOR HR LESS THAN 60. Observation of medication pass on 06/18/2026 at 8:42 a.m. revealed MA B checked Resident #24's blood pressure prior to administering her oral medications, and then proceeded to Resident #7's room, where she sanitized her hands, but did not sanitize the blood pressure cuff before checking Resident #7's blood pressure with the same cuff she had checked Resident #24's blood pressure with. During an interview with MA B on 06/18/2026 at 08:45 a.m., MA B stated she knew she was supposed to sanitize the blood pressure cuff in between uses with different residents but just forgot. She stated that by not sanitizing equipment in between uses with different residents it could spread infection. MA B stated she had received training in infection control. 2. Record review of Resident #2's face sheet, dated 06/18/2026, revealed an admission date of 05/31/2024 with re-admit on 03/24/2026, with diagnoses which included: Hemiplegia (paralysis on one side of the body), Aphasia (language disorder), Dysphagia (difficulty swallowing), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (high level of fats, also known as lipids, in the blood) and, Hypertension (high blood pressure). Record review of Resident #2's Physician orders, for June 2026, revealed an order for Metoprolol Tartrate Oral Tablet 50 MG(Metoprolol Tartrate) Give 1 tablet enterally two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold if sbp is less than 110 and/or pulse is less than 60. Observation of medication pass on 06/18/2026 at 8:53 a.m. revealed LVN C checked Resident #2's blood pressure prior to administering his enteral medications. LVN C was observed prior to providing care for Resident #2, coming from another room with the Blood pressure cuff in hand. LVN C sanitized her hands but did not sanitize the blood pressure cuff before checking Resident #2's blood pressure. During an interview with LVN C on 06/18/2026 at 08:57 a.m., LVN C stated she had used the blood pressure cuff on another resident before using on Resident #2. She knew she was supposed to sanitize the blood pressure cuff in between uses with different residents but just forgot. She stated that by not sanitizing equipment in between uses with different residents it could spread infection. LVN C stated she had received training in infection control. Interview with the DON on 06/18/2026 at 4 p.m. revealed all blood pressure cuffs need to be sanitized in between uses with each resident to prevent the spread of infection. She stated all staff received infection control training within the current year. Record review of the facility policy titled Infection prevention and control program , dated 05/13/2023, revealed All reusable items and equipment requiring cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedure governing the cleaning and sterilization of soiled or contaminated equipment

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 Residents (Resident #24) whose records were reviewed. The facility failed to include Resident #24's diagnosis of vascular dementia in her comprehensive care plan including care and services the facility would provide between the dates of 8/1/2025 and 6/17/2026. This deficient practice could result in residents not receiving the care and services needed.The findings include: Record review of Resident #24's admission sheet dated 6/18/2026 revealed she originally admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female with primary cerebral infarction (ischemic stroke caused by a blockage in brain blood vessels, leading to tissue damage without a specified location or cause) and vascular dementia, mild, with mood disturbance (disrupts cognitive and emotional functioning including depression, apathy, and emotional lability). Record review of Resident #24's Quarterly MDS assessment dated [DATE] documented a BIMS score of 15 of 15 indicating the resident was cognitively intact and an active diagnosis of non-Alzheimer's dementia (e.g. lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases). Record review of Resident #24's care plan dated 6/2/2026 revealed the lack of the diagnosis of vascular dementia with the focus, goals, and Interventions. During an interview on 6/19/2026 at 11:11 AM, the MDS Nurse #1 stated the diagnosis of vascular dementia was added to the EMR on 8/1/2025. She said the care plan should have been updated on 8/1/2025. She said the care plan was updated on 6/18/2026. She stated I can't tell you why at that time. I know I have a process of what I update. Possibly just overlooked. The dashboard has a diagnosis notification. When somebody adds the diagnoses, we should not clear the notification without verifying the care plan has been updated. We also look at the meds to determine CP additions. MDS Nurse #1 said regarding the impact to a resident was It is very important for resident care like medications and the idiosyncrasy. She said the impact to staff wound be The staff know where the diagnosis area so they will still be informed.Record review on 6/18/2026 of the facility policy Comprehensive Care Plans with an implemented date of 10/24/22 revealed: Policy:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being; andPolicy Explanation and Compliance Guidelines:3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment.5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observation, interview and record review, the facility failed to ensure residents who needed tracheostomy care were provided such care, consistent with professional standards of practice, for tracheostomy care for 1 of 1 residents (Resident #4) reviewed for tracheostomy care. The facility failed to ensure RN A provided tracheal care and suctioning according to professional standards for Resident #4 on 06/18/2026. These deficient practices could result in the residents not receiving the care and services ordered by the physician and a decline in health status and infection. Findings included: Record review of Resident #4's face sheet, dated 06/18/2026, revealed an admission date of 08/29/2023 and, a readmission date of 11/16/2024, with diagnoses that included: Anoxic brain damage (damage caused to the brain due to a lack of oxygen), Contractures (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), Aphasia (result of a Stroke or Brain injury that affects a person's ability to communicate), Vascular dementia (memory and cognitive impairments related to decreased blood flow to parts of the brain), Chronic respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in the body), Quadriplegia (symptom of paralysis that affects all a person's limbs and body from the neck down), Hypertension (High blood pressure) and, Tracheostomy status (surgically created hole, or stoma, in the trachea (windpipe) that allows air to pass directly into the lungs). Record review of Resident # 4's Quarterly MDS assessment dated [DATE], revealed Resident #4 was nonverbal. Resident #4 was dependent of the staff for all of her activities of daily living; she had an indwelling catheter and was always incontinent of bowel . Resident #4 was coded as having a tracheostomy (opening in the trachea (windpipe) to facilitate breathing) care. Record review of Resident #4's care plan, dated 09/29/2023, revealed a problem of has a tracheostomy r/t (related to) anoxic brain damage. and, an intervention of Provide trach care as ordered. Record review of Resident #4's physician orders for June 2026 revealed TRACH: Change disposable trach SHILEY/SIZE 6 inner cannula every day shift. Observation on 06/18/2026 at 2:15 p.m. revealed while providing tracheostomy care for Resident # 4, RN A placed the sterile field on the side table and positioned the normal saline used to clean the tracheostomy of the resident on the top left of the sterile field. By doing so every time she reached for saline the non-sterile part of her arms crossed over the sterile field, as a result breaking the sterile field. Further observation revealed RN A had rolled up the sleeves of her PPE gown exposing her arms and Resident #4 was on enhanced barrier precaution due to the tracheostomy and indwelling Catheter. During an interview with RN A, on 06/18/2026 at 2:28 p.m., RN A stated she had broken the sterile field but did not realize she was doing it. She stated she had received training for tracheostomy care and infection control with the year. During an interview with the DON, on 6/18/2026 at 4 p.m., the DON stated tracheostomy care should be done using sterile procedure and not maintaining sterile technique could result in respiratory tract infection. The DON stated crossing the sterile field with the non-sterile part of the arms constituted breaking the sterile field. The RN was qualified to do tracheostomy care, and her skills were checked annually by the DON. Record review of the facility policy, titled Tracheostomy care competency assessment, dated 12/21/2025, revealed remove the inner cannula and place it in the container of sterile water (discard inner cannula if disposable and replace with new one using sterile technique). Review of Nursing Skills - 2e Copyright (C) 2023 at https://wtcs.pressbooks.pub/nursingskills/chapter/4-4-sterile-fields/ revealed Open sterile kits away from your body first, touching only the very edge of the opening flap.Using the same technique, open each of the side flaps one at a time using only one hand, being careful not to allow your body or arms to be directly above the opened drape. Take care not to allow already-opened corners to flip back into the sterile area again.

Based on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Kitchen 1) reviewed for food safety requirements. The facility failed when a sink for hand washing was not accessible at all times when the food service staff placed rolling carts for clean dishes in front of the hand sink dish room used by kitchen staff making the sink inaccessible for use on 6/16/2026 and 6/19/2026. These failures could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life.The findings included: During an observation on 6/16/2026 at 11:11 AM, the hand sink in the dish room was blocked by two rolling carts making the only hand sink in the food preparation room inaccessible. During an observation on 6/18/2026 at 9:17 AM, the hand sink in the dish room was blocked by two rolling carts making the only hand sink in the food preparation room inaccessible. During an interview on 06/19/2026 at 11:21 AM, the [NAME] stated the hand sink should be accessible at all times. She stated the reason the sink was blocked was When they are doing dishes, they are running out of space. She said the impact to a resident was There is cross-contamination that can occur from not handwashing. Record review of the facility's policy, Hand Washing dated October 1 2018 with Policy Number 04.002 revealed: Policy:The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness.Procedure:1. Hand-washing Stationsa. Make sure hand washing stations are located in food preparation areas to encourage employees to wash their hands frequently.b. Make sure there are hand-washing stations in all areas that employees' hands may become contaminated, including food preparation areas, service areas, dishwashing areas and rest-rooms. Record review of the FDA Food Code 2022, https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 6/9/2026 revealed: 5-205 Operation and Maintenance5-205.11 Using a Handwashing Sink.(A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. Pf(B) A HANDWASHING SINK may not be used for purposes other than handwashing. Pf

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators reviewed. The personal refrigerator in the resident's #84 room contained an unlabeled, undated food item. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food. The findings were: Record review of Resident #84's face sheet, dated 6/16/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Chronic obstructive pulmonary disease (lung disease, which causes breathing difficulties due to obstructed airflow), and major depressive disorder (is a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) and Alcohol-related dementia (is a type of brain damage caused by years of heavy drinking. It happens when alcohol harms the brain's nerve cells, making it harder to think, remember, and move). Record review of Resident #84's BIMS assessment, completed 2/10/26, revealed a BIM score of 12, which indicated cognition was moderately impaired. Observations on 6/16/2026 at 10:20 a.m. revealed that the personal refrigerator for Resident #84 contained an unlabeled, undated container with grilled chicken and Spanish rice. Further observations on 6/16/2026 at 11:00 a.m. of the personal refrigerator of Resident # 84 revealed that the unlabeled, undated storage container was still present. An interview with Resident #84 on 6/16/2026 at 11:15 a.m. revealed she was unaware the unlabeled, undated container containing grilled chicken and Spanish rice was in her personal refrigerator. She recalled that on 6/13/2026, the family came to visit and must have dropped off the food. Resident #84 stated, She stored snacks in her personal refrigerator but forgot the container was even there . Interview on 06/16/2026 at 11:20 p.m. with CNA D, who stated she was assigned to resident #84 and stated that the personal refrigerator in Resident #84's room contained an undated container containing grilled chicken and Spanish rice. She did not know who was responsible for checking the president's personal refrigerator for expired food but would check with the charge nurse. Interview with LVN C on 6/16/2026 at 11:35 a.m. revealed she was the assigned nurse for resident # 84 and stated the presence of an unlabeled/undated container containing grilled chicken and Spanish in Resident 84's personal refrigerator. She added that nursing and administrative staff assisted Residents in removing undated and unlabeled food items from residents' personal refrigerators daily; she did not check them today. Resident # 84 risked some form of food-borne illness by possibly consuming food that was unlabeled and undated. During an interview with the DON on 06/16/26, at 12:30 p.m., the DON stated that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food. The DON stated that all nursing and administrative staff were responsible for removing undated, unlabeled food items from residents' refrigerators daily, including assisting families in labeling and dating food items brought in. The DON stated that families sometimes bring food for residents without notifying the nursing staff. She added that her charge nurses were responsible for overseeing this task, and her ADONs would be monitored at random. Record review of the facility policy, Food Brought in by Family / Visitors , dated 1/27/2023, revealed: All food items that are prepared by the family or visitor must be labeled with content and dated

Number of residents sampled: Number of residents cited: Based on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 1 of 4 residents (Resident #83) whose medical records were reviewed for accuracy. The facility failed to ensure the accuracy of Resident #83's clinical record. Review of the medical record revealed a diagnosis of benign prostatic hyperplasia (BPH) despite the resident being female. The presence of inaccurate diagnoses in the medical record has the potential to affect clinical decision-making, care planning, and treatment interventions. Findings included: Record review of Resident #83's face sheet, dated 6/18/2026, revealed a [AGE] year old famale admitted to the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (a long-term respiratory condition that progressively limits airflow, making it difficult for affected individuals to fully exhale, often leading to shortness of breath, chronic cough, and wheezing), heart failure (a chronic condition in which the heart is unable to pump blood effectively to meet the body's needs), and cirrhosis of the liver (a chronic condition in which healthy liver tissue is gradually replaced by scar tissue, leading to impaired liver function and eventual liver failure). Record review of Resident #83's face sheet on 6/18/2026 revealed a diagnosis of BPH (benign prostatic hyperplasia), a condition affecting only males that involves enlargement of the prostate gland. Record review of Resident #83's BIMS assessment, completed 3/3/26, revealed a BIMS score of 7, indicating severe impairment. Interview with Resident #83 on 6/18/2026 revealed she identified as female and was assigned female at birth. Interview with the MDS nurse on 6/19/26 at 9:05 a.m. revealed that the admitting nurse, who no longer works at the facility, must have entered the diagnosis incorrectly. The MDS nurse stated she had audited the resident's face sheets for accuracy, but this one must have fallen through the cracks. She added that the BPH diagnosis should not have been on the face sheet and that its presence may have resulted in Resident #83 not receiving proper care. During the interview on 6/19/2026 at 10:25 a.m., the DON stated that audits are assigned by corporate MDS nurses and that she was unaware why Resident #83's face sheet contained inaccurate information. The DON noted that listing BPH on Resident #83's face sheet could cause confusion among other providers and may result in the resident not receiving appropriate care. She explained that MDS nurses are responsible for conducting these audits, with ADONs performing random monitoring. Record review of the facility's policy documentation in the medical record, dated 10/24/2022, revealed: Documentation shall be factual, objective, and resident centered.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to store plastic cups and bowls to allow for air-drying in the dish room. 2. The facility failed to ensure the tabletop can opener blade and base were free of grime and debris. 3. The facility failed to discard a bag of salad mix dated 03/24/2025 containing brown and rotted leaves in the reach-in cooler. 4. The facility failed to ensure an opened bag of grits in the dry storage room was properly sealed. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 04/15/2025 at 10:41 AM revealed two plastic trays each with approximately 18 overturned plastic drinking cups and four trays each with approximately 12 overturned plastic bowls on the clean side of the dish machine. The plastic trays were damp with moisture and there were no air-drying nets separating the cups and bowls from the trays to allow for air circulation. During an interview on 04/15/2025 at 11:00 AM, the DM stated the wet, plastic cups and bowls should not have been placed face-down on a wet trays without an air-drying net separating them from the trays to prevent the potential accumulation of bacteria which could lead to food borne illness. Staff working in the dish room were trained on how to store clean but damp dishware. They were trained upon hire and periodically throughout there year. The facility used to have an ample supply of air-drying nets and she did not know what happened to them. 2. Observation on 04/15/2025 at 10:42 AM in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade portion of the can opener, the adjustable bar, and also surrounded the base that was affixed to the table with screws. During an interview on 04/15/2025 at 11:05 AM, the DM stated that the can opener blade, bar, and base were covered in sticky grime and should not have been. The DM stated the cooks were responsible for ensuring the can opener and area surrounding the base remained clean and free of debris, and that failing to do so could result in contamination of food from bacteria lingering on the blade and potential foodborne illness. 3. Observation on 04/15/2025 at 10:48 AM in the reach-in cooler revealed 5-lb. bag of salad mix with a handwritten date of 03/24/2025. The bag was sealed and approximately 15% of the salad leaves had turned brown or were rotten. During an interview on 04/15/2025 at 11:10 AM, the DM stated the salad mix should have been discarded. All dietary staff were responsible for properly labeling and dating food items stored in the cooler and discarding items past their use-by dates. 4. Observation on 04/15/2025 at 10:57 AM in the dry storage room revealed a plastic case containing five 5-lb. bags of quick-cook grits on a rack. The case had been torn open and there was a small pile of loose grits inside the plastic case in front of the bag on the right approximately 4 high that had likely been left from a bag of grits removed from the case. During an interview 04/15/2025 at 11:12 AM, the DM stated the spilled grits should have been cleaned up by dietary staff. All kitchen staff stored food in the dry storage room, and failing to ensure food was properly sealed and the dry storage room was free from debris could result in deterioration in food quality and potential contamination from pests. Record review of facility policy 04.006 Mechanical Cleaning and Sanitizing of Utensils and Portable approved 10/01/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 9. Air dry all equipment and utensils after sanitizing. Handle cleaned and sanitized equipment and utensils and all single-serve articles in a way that protects them from contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. Record review of facility policy 04.009 Can Opener approved 10/01/2018 revealed, Policy: The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. 1. Hand held or table top. a. Remove can opener shank from base. b. Wash shank in sink with warm water and detergent or in the dishwasher. c. Give close attention to the blade and moving parts. d. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. f. Air dry. g. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. h. Rinse with clean cloth soaked in clear hot water. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the 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. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, O. Retail Food Protection Program Information Manual: Recommendations to Food Establishments for Serving or Selling Cut Leafy Greens. Following 24 multi-state outbreaks between 1998 and 2008, cut leafy greens was added to the definition of time/temperature for safety food requiring time-temperature control for safety (TCS). The term used in the definition includes a variety of cut lettuces and leafy greens. Record review of facility policy 03.003 Food Storage revised 06/01/2019 reveled, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 (500 Hall) of 7 hallways reviewed for environment, in that: The storage room on 500 Hall was not secured and contained potentially unsafe items. This deficient practice could result in residents coming into contact with potentially unsafe items. The findings were: Observation on 04/15/2025 at 11:50 a.m. revealed the storage room on 500 Hall was unlocked. Further observation revealed the storage room contained items for use during resident showers including body soap, shampoo, and disposable razors. The soap and shampoo containers were labeled, eye irritant. During an interview with the Housekeeping Supervisor on 04/15/2025 at 11:51 a.m., the Housekeeping Supervisor confirmed the storage room on 500 Hall was unlocked, contained items labeled eye irritant, and should have been secured. During an interview with the DON on 04/18/2025 at 12:50 p.m., the DON stated her expectation was for storage rooms to remain locked when not in use to protect residents from coming into contact with potentially unsafe items. During an interview with the Administrator on 04/18/2025 at 1:30 p.m., the Administrator stated the facility did not have a policy regarding physical environment.

Based on interview and record review, the facility failed to maintain medical records that were accurate and complete for 1 (Resident #240) of 25 residents reviewed for accuracy and completeness of records in that: Resident #240's facesheet did not include a list of diagnoses. This deficient practice could result in unmet resident needs due to missing information. The findings were: Record review of Resident #240's facesheet, dated 04/17/2025, revealed the resident was admitted to the facility on [DATE]. Further review revealed no diagnoses were listed on the resident's facesheet. During an interview with the DON on 04/18/2025 at 12:50 p.m., The DON stated the admitting nurse was generally responsible for entering diagnoses into the record with the ADONs or the DON responsible for checking and completing the document. The DON stated the process was interrupted because the survey began on 04/18/2025. The DON stated her expectation was that resident records be complete and accurate and updated in timely manner so that the newly admitted resident's needs could be fully addressed.

Based on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 6 resident (Resident #84) reviewed for privacy, in that: CNA A and CNA B did not close Resident #84's privacy curtain while providing incontinent care on 4/17/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #84's face sheet, dated 04/17/2025, revealed an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Hypertension (High blood pressure), Asthma (Condition making breathing difficult), Dysphagia (Difficulty swallowing) and Heart failure (The heart muscle doesn't pump blood as well as it should). Record review of Resident #84's Significant change MDS assessment, dated 03/21/2025, revealed the resident had a BIMS score of 11, indicating he was moderately impaired. Resident #84 was occasionally incontinent of bladder and always incontinent of bowel. Record review of Resident #84's care plan, dated 03/11/2025, revealed a problem of has bladder incontinence and does not always recognize the need to toilet.,, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 04/17/2025 at 2:26 p.m. revealed CNA A and CNA B did not completely close the privacy curtain while they provided incontinent care for Resident #84, exposing the resident's genital area during care. The resident's end of the bed was completely uncovered and the resident's roommate was in the room at the time of care. During an interview with CNA A and CNA B on 04/17/2025 at 2:34 p.m., CNA A and CNA B confirmed the privacy curtain was not completely closed while they provided care for Resident #84 but it should have been. They confirmed they received resident rights training within the year. During an interview with the DON on 04/18/2025 at 12:52 p.m., the DON confirmed privacy must be provided during nursing care and Resident #84's privacy curtain should have been closed completely. She confirmed the staff had received training on resident rights within the year and the training was provided by the ADON and herself. They also checked the staff skills annually and as needed. Review of the facility's policy titled Statement of Resident Rights, undated, revealed, You have a right to: privacy, including privacy during visits and telephone calls.

Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 27 residents (Resident #188) reviewed for advanced directives, in that: The facility failed to ensure Resident #188's Out of Hospital Do Not Resuscitate (OOH-DNR) dated [DATE] was signed by a physician, which made the document invalid. This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #188's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included a wedge compression fracture of T11-T12 vertebrae, essential hypertension (high blood pressure), and chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe. The Advance Directive was identified as DNR (Do Not Resuscitate). Record review of Resident #188's comprehensive care plan, updated [DATE] revealed the focus area indicating the resident was a DNR, date initiated: [DATE]. The goal was the facility will comply with resident/family wishes. Date initiated: [DATE]. Interventions were to ensure a signed DNR was in the resident's medical record. If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification. Record review of Resident #188's Order Summary Report, dated [DATE], revealed the following: DNR (Do Not Resuscitate), Communication Method: Verbal, Order status: Active, Order Date: [DATE], no end date. Record review of Resident #188's OOH-DNR revealed it was signed by the resident and two witnesses on [DATE]. Under the section, Physician's Statement the physician's name was printed but there was no signature. In the section, All persons who have signed above must sign below, acknowledging that this document has been properly completed the resident's signature and those of the two witnesses were present; the attending physician's signature line was blank. During an interview on [DATE] at 11:14 AM, MDS LVN F, the OOH-DNR form was out for the physician's signature, it was valid without a physician's signature, but she would need to read the back of the form. During an interview on [DATE] at 11:20 AM, the facility's SW stated the facility knew the resident's desire was DNR, but EMS may choose not to follow that if the form was not signed. The facility always uploaded DNR forms into resident's electronic health records pending physicians' signatures. During an interview on [DATE] at 11:40 AM, the CNC RN stated the physician gave a telephone order for DNR and the facility would honor the resident's desire for DNR even if the OOH-DNR form had not yet been signed by the physician. Record review of Out of Hospital Do-Not-Resuscitate (OOH-DNR) Order form revealed, Instructions for Issuing an OOH-DNR Order .In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses .making an OOH-DNR Order by nonwritten to the attending physician, who must sign in Section D and also the physician's statement section. Record review of Texas Department of State Health Services Frequently Asked Questions for DNR, undated, revealed, Can a physician's assistant or nurse practitioner sign the physician's statement? No. Only the attending physician can sign in this section. Why does everyone have to sign twice? All persons who have signed the DNR form must sign at the bottom of the page to acknowledge that the document has been properly completed. What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Filling out the Out-of-Hospital Do-Not-Resuscitate Form: Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. Signatures: The statute requires that everyone who signed the form MUST sign the form again in the bottom section to acknowledge that the form has been completed. https://www.dshs.texas.gov/sites/default/files/emstraumasystems/FAQsforDNR.pdf

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 6 medication carts (Hall 600 Medication Cart) reviewed for storage. During medications administration, RN D left Hall 2600 Medication cart unlocked on 1 occasion (04/17/2025). This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications. The findings included: Observation on 04/17/2025 at 8:21 a.m. revealed RN D was administering medications to residents. RN D was seen entering room [ROOM NUMBER]. The medication cart was left unlocked and out of sight of RN D who was behind the privacy curtain. Inside the unlocked cart were blister packs, bottles, and vials of medications for the residents. During an interview with RN D on 04/17/2025 at 8:24 a.m., RN D confirmed the medication cart was left unlocked while she was administering medications in the resident's room. RN D confirmed she knew she had to keep the cart locked and had forgotten. During an interview with the DON on 04/18/2025 at 12:52 p.m., the DON confirmed the medication cart should have been kept locked. The DON confirmed the nursing staff received training about drug diversion including keeping their cart locked at all times when not in use to prevent drug diversion. The DON revealed one possible outcome of drug diversion was the resident's missing doses of medications. Record review of the facility's policy titled, Medication carts and supplies for Administering Meds, dated 10/01/2019, revealed The medication cart is locked at all times when not in use.

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 10 residents (Resident #39) whose assessments were reviewed. Resident #39's significant change MDS assessment incorrectly documented the resident as not using tobacco. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings included: 1. Record review of Resident #39's face sheet, dated 04/17/2025, revealed an admitted [DATE] and, a readmitted [DATE] with diagnoses that included: Hepatic encephalopathy (brain dysfunction caused by liver dysfunction), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) and Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood). Record review of Resident #39's Smoking safety screen, dated 02/26/2025, revealed Resident is an unsafe smoker. Record review of Resident #39's Significant change MDS, dated [DATE], revealed the assessment indicated Resident #39 did not use tobacco. During an interview with MDS nurse C on 04/17/2025 at 2:45 p.m., the MDS nurse verbally confirmed she had completed the MDS. MDS nurse C confirmed Resident #39's Significant change MDS was coded as the resident not using tobacco when Resident #39 was a smoker. MDS nurse C revealed she did not know why she had not coded the resident as a smoker. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.19.1, October 2024, revealed, J1300: Current Tobacco Use (cont.)3. [ .] Coding Instructions Code 0, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on interview and record review, the facility failed to create a baseline care plan within forty-eight hours of admission for 1 (Resident #240) of 1 residents reviewed for baseline care plans, in that: Resident #240 admitted to the facility on the evening of 04/14/2025, and her baseline care plan was not in place as of the afternoon of 04/17/2025. This deficient practice could result in newly admitted residents having their needs unmet. The findings included: Record review of Resident #240's clinical record as of 04/17/2025 revealed the resident was admitted to the facility in the evening of 04/14/2025 and a baseline care plan was not present in the record. During an interview with the DON on 04/17/2025 at 12:12 p.m., the DON confirmed Resident #240's baseline care plan had not been initiated and should have been. The DON stated the admitting nurse was generally responsible for initiating the baseline care plan with the ADONs or the DON responsible for checking and completing the document. The DON stated the process was interrupted because the survey began on 04/18/2025. The DON stated her expectation was that baseline care plans be initiated and completed in a timely manner so that the newly admitted resident's needs could be fully addressed.

Based on observations, interviews, and record review, the facility failed to follow menus for 2 of 2 resident meals reviewed for menus in that: The facility failed to follow the menu for residents on regular and modified diets for the lunch meals on 04/15/2025 and 04/16/2025 This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: Record review of the weekly menu provided by the facility revealed the lunch meal scheduled for Tuesday, 04/15/2025, Day #23 of the 5-week menu cycle, was peppered pork loin, tricolor spiral pasta, herbed green beans, wheat roll and seasonal fresh fruit. The menu scheduled for Wednesday, 4/16/2025, Day #24 of the menu cycle, was baked fish in lemon butter, baked potato wedges, creamed peas, wheat roll, and strawberries with whipped topping. There was no sign posted indicating any deviations from the daily or weekly menus. Record review of the Menu Substitution Approval Form provided by the facility revealed the following entry only for the lunch meals on 04/15 - 04/16/2025: 4/16 Meal: Lunch, Item on Menu: Mushrooms, Substitution: Sauteed onion & bell peppers, Reason for Substitution: Residents dislike mushrooms. The entry was initialed by the DTR. Observation on 04/15/2025 at 12:10 PM of the lunch meal served to residents in the dining room revealed they were served the lunch meal scheduled for the Monday of that week, Day #22 of the menu cycle, which was Mexican meatballs En Salsa, rice, sauteed mushrooms, wheat bread, and chilled blushing pears. Observation on 04/16/2025 at 12:30 PM of the lunch meal served to residents in the dining room revealed they were served the meal scheduled for the previous day, per the weekly menu (pork loin with pasta, green beans, and seasonal fresh fruit). During an interview on 04/16/2025 at 12:03 PM, the consultant RD stated she discussed how to substitute items and meals with the DM, and the changes would have to be posted properly in the dining room so residents would know what they should be served. During an interview on 04/16/2025 at 12:30 PM, the administrator stated she was not aware the facility was not serving meals as posted on the weekly menu. She was also not aware changes needed to be logged on a menu substitution approval form and approved by either the RD or DTR. During an interview on 04/16/2025 at 1:30 PM, the DTR stated she did not know why the menus had been shifted down one day for both days, but it was important to follow the menu as posted so residents knew what to expect. During an interview on 04/17/2025 at 10:40 AM, the DM stated she usually followed the menu and having the lunch meal scheduled for Monday, 04/14/2025 served on Tuesday, 04/15/2025 and the lunch meal scheduled for Tuesday, 04/15/2025 on Wednesday, 04/16/2025, was a mistake. She was unsure how the error occurred but believed it had to do with wanting to serve fish on Friday. She knew she had to log any menu changes on the Menu Substitution Approval Form and she failed to do so for the changes in meals served the week of 04/14/2025. It was her responsibility to ensure meals were served according to the menu posted and signed by the consultant RD or changes documented properly on the form and also in the dining room so residents could be apprised of the changes. Record review of the facility policy, Menu Substitutions, policy number 01.007, revised 06/01/2019, revealed: Policy: The facility believes that a well-balanced menu, planned in advance and served as posted, is important to the well-being of its residents. The menus will be served as planned except for emergency situations when a food item is unavailable. Procedure: 1. The menu will be served as written unless an emergency situation arises. 5. The consultant RD/DTR will review the Menu Substitution Approval form with the dietitian on each visit to determine trends in substitutions and accuracy of substitutions so that the appropriate training can be provided if needed. 6. The dietitian will initial off the Menu Substitution Form after review.

Based on observation, interview, and record review the facility failed to immediately inform the resident,consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there a significant change in the resident's physical, mental, or psychosocial status for 2 of 4 residents (Residents #1 and #2) reviewed for notification of change of condition, in that: The facility failed to ensure the MD was notified of a missed dialysis appointment when Resident #1 and Resident #2 missed scheduled dialysis appointments on 3/30/24 due to transportation being late. This failure could place residents at risk for not having their change of condition addressed appropriately by their attending physician which could cause serious harm. Findings include: 1. Record review of Resident #1's electronic medical record, dated 4/2/2024, reflected a [AGE] year old male with an original admitted [DATE] with readmission on 11/1/2023 with diagnoses including: end stage renal disease(kidney failure)with dependence of renal dialysis, difficulty in walking, hypertensive heart, and Diabetes Mellitus type 2. Record review of Resident #1's MDS Assessment, dated 2/2/2024, reflected he had rejected dialysis care at times within the assessment period and received had dialysis treatments while a resident. Further review revealed the resident's cognitive status was documented in section C for BIMS score of 13 indicating cognitive stability. Record review of Resident #1's Care Plan reflected initiated date of 5/3/2022 and revision on 2/26/24 with focus of renal failure r/t end stage disease, resident is dependent on hemo-dialysis. Interventions included: encourage resident to go to dialysis if he refuses. Record review of Resident #1's order Summary dated 3/6/2024 reflected the following entry: Dialysis days are Tuesday, Thursday, and Saturdays at 5:00 am. Record review of Resident #1's Progress notes from 3/29/2024 to 4/2/2024 at 11:49 am revealed no entries to reflect MD notification of Resident #1 not going to dialysis on scheduled day. no documentation reflecting Resident #1 missed dialysis appointment due to transportation being late. Record review of facility's 24-hour nursing report revealed no documentation of Resident #1 missing dialysis on 3/30/2024. Record review of Resident #1's Dialysis Binder revealed Dialysis Communication Form for 3/30/2024 was blank. During an observation and interview on 4/2/2024 at 12:45 p.m. at Resident #1 was observed to be in his room lying in bed. He was easily aroused and alert. He stated he received dialysis on Tuesday, Thursday and Saturdays. He stated on Saturday March the 30th he did not go to dialysis due to the transport van driver oversleeping. He further stated he and another resident meet at the front of the building for the driver to pick them up for dialysis at 4:30 am. He said the driver had not shown up by 6:00 am so he told the facility he wasn't going to dialysis. He said the facility nurse was trying to get another driver but he refused to go, because it was to late. He further revealed he received dialysis on 4/2/2024 and did not have any ill effects from not getting dialysis on Saturday March the 30th. 2. Record review of Resident #2's electronic medical record, dated 4/2/2024, reflected a [AGE] year old male with an original admitted [DATE] with diagnoses including: end stage renal disease(kidney failure),Diabetes Mellitus Type 1, and hypertensive heart disease. Dependence on renal dialysis. Record review of Resident #2's MDS assessment dated [DATE] reflected he had not rejected any care within the assessment period and received dialysis treatments while a resident. His cognitive status was documented in section C for BIMS score of 14 indicating cognitively stable. Record review of Resident #2's Care Plan reflected an initiated date of 3/1/2024 Focus: Resident has potential to be verbally aggressive(cusses) and is irritable (short responses, isolates) to staff related to ineffective coping skill when there is a change in his routine. Interventions: the resident triggers for verbal aggression happen when there is a change in routine as evidenced by late bus schedule, dialysis wait time. Attempt to de-escalate by reassuring resident of time of event happening. Record review of Resident #2's order Summary dated 3/8/24 reflected the following entry: Dialysis days are Monday, Wednesday, and Friday at 5:00 a.m Days may vary based on holidays and dialysis center schedule. Changed to Tuesday, Thursday, and Saturday. Record review of Resident #2's Progress notes 3/30/2024 7:53 am revealed a Late entry: due to delay in transportation, resident refused to go to dialysis today. Resident highly encouraged and educated on the importance of going however continues to refuse. No documentation of physician being notified. Record review of facility's 24-hour nursing report revealed no documentation of Resident #2 missing dialysis on 3/30/2024. Record review of Resident #2's Dialysis Binder revealed Dialysis Communication Form blank. During an observation and interview on 4/2/2024 12:53 p.m. Resident #2's was observed to be in his room sitting on bed. Alert and oriented. During interview Resident #2 stated he did not go to dialysis on Saturday March the 30th because the van driver had overslept. Resident #2 stated, I got tired of waiting for almost 2 hours to go and told them I wasn't going. He said he did not feel sick from missing the Saturday treatment and he did go today (4/2/2024). During an interview with facility Van Driver on 4/2/2024 at 1:27 p.m. she stated she had overslept on 3/30/2024. She stated she received a text from facility ADON about 5:30 am asking her if she was coming to transport the 2 residents to dialysis. She further revealed she text back but did not speak with ADON that she had overslept. She stated she did not confirm if residents had a ride or if she still need to come in. During interview Van Driver stated she should have called to see if someone was taking the residents to dialysis. She further revealed it was her scheduled day to come in and take residents to dialysis and have them to the dialysis center by 5:00 am. During an interview with facility DON on 4/2/2024 at 1:10 p.m. revealed Resident #1 and Resident #2 should have been transported to dialysis on 3/30/2024 at the scheduled 4:30 am time and when they did not go their physicians should have been notified to determine if a new treatment plan should be done. She stated dialysis is very important for residents' health. She further revealed she was notified by the ADON who manager on call was, that she was coming in to take the residents to dialysis, but the residents had decided they were not going due to the time being late. During an interview with Administrator on 4/2/2024 at 1:20 p.m. he stated he would have come in to take the residents to dialysis if the staff would have let him know in time. During an interview with facility ADON on 4/2/2024 at 1:56 p.m. revealed she was the manager on call on 3/30/2024. She stated she was notified about 5:30 am that 2 residents had not been picked up at 4:30 am for dialysis. She further revealed she called the van driver but there was no answer, and she sent a text. She stated she received a phone text from the van driver about 5:30 am that she had overslept. ADON said she was going to the facility to take the residents and was called by the day shift nurse to not come because both residents said they were not going because it was too late. On 4/2/24 at 5:00 p.m. and 4/3/24 at 8:20 am. telephone interviews were unsuccessful for LVN C. During a telephone interview on 4/3/24 at 8:27 am Physician A for #1 stated he was not notified until a later date of 4/2/2024 that Resident #1 had refused to go to dialysis due to not having the scheduled van driver be on time. He stated residents should have dialysis and if they do not other interventions may have to occur. During a telephone interview on 4/3/2024 at 9:00 am Physician B for Resident #2 stated he was not notified until a later date of 4/2/2024, Resident #2 had refused to go to dialysis due to not having the scheduled van driver be on time. During an interview on 4/3/2024 at 10:00 am the Administrator and DON stated there was no policy related to dialysis services and transportation. Record review of the facility's policy provided by DON, titled Notification of Changes with an implemented date of 10/24/22, reflected in section Compliance Guidelines: Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment. The facility must still contact the resident's physician.

Based on interview and record review, the facility failed to maintain in accordance with accepted professional standards and practices medical records on each resident that were complete and accurately documented for 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of medical records. in that: The facility failed to ensure Electronic Medical Records documented of Residents #1 and #2 not receiving transportation to dialysis treatment on 3/30/2024. This deficient practice could place Residents at risk for errors in care and treatment. The findings were: 1. Record review of Resident #1's electronic medical record, dated 4/2/2024, reflected a [AGE] year old male with an original admitted [DATE] with readmission on 11/1/2023 with diagnoses including: end stage renal disease(kidney failure)with dependence of renal dialysis, difficulty in walking, hypertensive heart, and Diabetes Mellitus type 2. Record review of Resident #1's MDS Assessment, dated 2/2/2024, reflected he had rejected dialysis care at times within the assessment period and received had dialysis treatments while a resident. His cognitive status was documented in section C for BIMS score of 13 indicating cognitive stability. Record review of Resident #1's Care Plan reflected an initiated date of 5/3/2022 and revision on 2/26/24 with focus of renal failure r/t end stage disease, resident is dependent on hemo-dialysis. Interventions included: encourage resident to go to dialysis if he refuses. Record review of Resident #1's order Summary dated 3/6/2024 reflected the following entry: Dialysis days are Tuesday, Thursday, and Saturdays at 5:00 am. Record review of Resident #1's Progress notes from 3/29/2024 to 4/2/2024 at 11:49 am reflected no entries to reflect MD notification of Resident #1 not going to dialysis on scheduled day. no documentation reflecting Resident #1 missed dialysis appointment due to transportation being late. Record review of facility's 24-hour nursing report reflected no documentation of Resident #1 missing dialysis on 3/30/2024. Record review of Resident #1's Dialysis Binder reflected Dialysis Communication Form for 3/30/2024 was blank. 2. Record review of Resident #2's electronic medical record, dated 4/2/2024, reflected a [AGE] year old male with an original admitted [DATE] with diagnoses including: end stage renal disease(kidney failure),Diabetes Mellitus Type 1, and hypertensive heart disease. Dependence on renal dialysis. Record review of Resident #2's MDS Assessment, dated 1/22/24, reflected the resident had not rejected any care within the assessment period and received dialysis treatments while a resident. His cognitive status was documented in section C for BIMS score of 14 indicating cognitively stable. Record review of Resident #2's Care Plan reflected an initiated date of 3/1/2024 Focus: Resident has potential to be verbally aggressive(cusses) and is irritable (short responses, isolates) to staff related to ineffective coping skill when there is a change in his routine. Interventions: the resident triggers for verbal aggression happen when there is a change in routine as evidenced by late bus schedule, dialysis wait time. Attempt to de-escalate by reassuring resident of time of event happening. Record review of Resident #2's Order Summary, dated 3/8/24, reflected the following entry: Dialysis days are Monday, Wednesday, and Friday at 5:00 a.m Days may vary based on holidays and dialysis center schedule. Changed to Tuesday, Thursday, and Saturday. Record review of Resident #2's Progress notes 3/30/2024 7:53 a.m. reflected a Late entry: due to delay in transportation, resident refused to go to dialysis today. Resident highly encouraged and educated on the importance of going however continues to refuse. No documentation of physician being notified. Record review of facility's 24-hour nursing report reflected no documentation of Resident #2 missing dialysis on 3/30/2024. Record review of Resident #2's Dialysis Binder revealed Dialysis Communication Form blank. During an interview with facility DON on 4/2/2024 at 1:10 p.m. revealed nursing staff should document in the resident's electronic medical record when a resident did not attend dialysis and notification of physician. This is to ensure communication between medical professionals. During an interview with facility ADON on 4/2/2024 at 1:56 p.m. revealed she was the manager on call on 3/30/2024. She further revealed nursing staff should document in the resident's electronic medical record when a resident does not attend dialysis and also notification of physician.

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 1 of 1 kitchen. 1. Dietary Aide D was not properly wearing a hair restraint. 2. A food item in the kitchen storage area was not properly dated and labeled. 3. A refrigerator shelve was broken 4. The floor in the dish machine room had broken floor tiles. 5. The vent inside the dish machine was dirty with grease. 6. The ceiling vent across from the dish machine had mold around the edges of the vent. 7. The wall above the dish machine tray line had mold on the wall surface. 8. The bilateral floor moulding leading into the kitchen storage area was missing. 9. The ceiling vent in the office of the Food Service Director was dirty. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area. The findings included: Observation on 03/05/2024 from 9:30 a.m. to 10:10 a.m. during the kitchen tour revealed the following: a. Dietary Aide D was working in the kitchen wearing a hair restraint that did not fully cover the back of her head with visible exposed hair. b. There were 4 one gallon containers of ice cream in the refrigerator that were not dated. c. There was a refrigerator shelve drawer which measured approximately 4x2 foot holding ice cream that was unsecured inside the refrigerator. d. There were 4 pieces of broken floor tile which each measured 4x4 inches that were broken. e. The vent inside the dish machine which measured 1.5x1 foot had grease residue on the vent. f. The ceiling vent which measured 1.5x1 foot across from the dish machine had mold on the ceiling surface around the vent. g. The wall measuring 6x2 feet directly above the dish machine tray line had mold residue on the wall surface. h. The bilateral floor moulding which measured 4x8 inches on each side of the entrance to the kitchen storage area was missing. i. The ceiling vent which measured 1x6 inches located in the office of the Food Service Director had dirt particles on the vent. During an interview with the Dietary Aide D, during the kitchen tour, on 03/05/24 at 9:35 a.m. Dietary Aide D stated that she understood the hair restraint had to totally cover her hair from falling onto the kitchen floor surface. During an interview with the Cook E on 03/05/24 at 9:00 a.m., Cook E stated that he did not know why the four 1 gallon containers of ice cream were not dated or how long they were in the refrigerator. Cook E stated he was unsure how long the refrigerator shelf holding the ice cream was broken. During an interview with the Food Service Director and the Administrator on 3/05/24 from 11:30-11:55 a.m., the Food Service Director stated that not wearing the hair restraint potentially would allow hair to fall onto the kitchen floor. She stated that the ice cream containers should have been dated to show the expiration date. The Food Service Director stated that the broken refrigerator shelve unit was to be repaired by the Maintenance Director. She stated that any dirt or mold on the ceiling vents and on the wall would impact the kitchen's sanitation. The Administrator stated that the floor tiles, floor moulding, vents, and the wall beside the dish machine would all be repaired by a planned remodel of the kitchen. Record review of the facility's policy # 04.001 titled, Employee Sanitation, dated 10/1/18, revealed, Hair nets or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Record review of the facility's policy # 03.003, titled Food Storage, dated 10/1/18, revealed, All containers must be labeled and dated. Record review of the facility's policy # 04.008 titled, Cabinets, Drawers, and Shelving dated 10/1/18, revealed, The facility will maintain cabinets, drawers, and shelving to minimize the risk of food hazards. Record review of the facility's policy # 04.013 titled Floors, Tables, and Chairs dated 10/1/18, revealed, The facility will maintain floors, tables, and chairs in a clean and sanitary condition to minimize the risk of food hazards. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Non-food-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 28 residents (Residents #47) reviewed for care plans. 1. The facility failed to care plan Resident #47's diabetes insulin administration. This failure could have placed residents at risk of not having their needs met. The findings were: 1. Record review of Resident #47's face sheet, dated 3/6/24, revealed an admitted [DATE] with diagnosis that included: cerebral infarction unspecified (a condition in which not enough blood supply was reaching the brain), type 2 diabetes (a condition in which the body's blood sugar was not controlled), and anxiety disorder unspecified (a condition in which the person's fears were disruptive). Record review of Resident's #47's Admission MDS assessment, dated 1/30/24, revealed a BIMS score of 9 which indicated moderately impaired cognition; the MDS also noted Resident #47's diabetic condition and use of insulin. Record review of Resident #47's Physician Orders for March 2024 revealed an order for Novolog Injection Solution 100 ml insulin with a start date of 1/18/24. Record review of Resident #47's Quarterly care plan dated 3/6/24 revealed that the Resident's insulin medication administration was not documented in the care plan. During an interview with LVN-MDS-A on 3/6/24 at 10:20 a.m., she stated that insulin treatment for Resident # 47 should have been on the care plan so that the medications the resident was taking was documented. During an interview with the DON on 3/6/24 at 10:35 a.m., she stated that Resident 47's insulin administration should have been documented on the care plan so that the resident's medication treatments were documented. Record review of the facility's policy titled, Comprehensive Care Plans, dated 10/24/22, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights that includes measurable objectives and time frames to meet a residence medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . when developing the comprehensive care plan, facility staff will, at a minimum, use the minimum data set to assess the residents clinical condition, cognitive and functional status, and use of services

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 6 resident (Resident #50) reviewed for incontinent care, in that: While providing incontinent care for Resident #50, CNA B did not clean between Resident #50's buttocks'' cheeks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #50's face sheet, dated 03/08/2024, revealed an admitted [DATE], with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety (A group of mental illnesses that cause constant fear and worry), Hypertension (High blood pressure) and, Obstructive and reflux uropathy(Hindrance of normal urine flow). Record review of Resident #50's Quarterly MDS assessment, dated 02/20/2024, revealed Resident #50 has a BIMS score of 5, which indicated severe cognitive impairment. Resident #50 was indicated to always be incontinent of bowel and had an indwelling catheter. Record review of Resident #50's Optional State assessment dated [DATE] revealed Resident #50 required extensive assistance to total care with his activity of daily living. Review of Resident #50's care plan, dated 11/20/2023, revealed a problem of Has bowel incontinence R/T (related to) to inability to always recognize need for toileting D/T (due to) cognitive decline., with intervention of Provide pericare after each incontinent episode Observation on 03/07/24 01:07 p.m. revealed, while providing incontinent care for Resident #50, CNA B cleaned the surface of the buttocks but did not clean the anal area or the intergluteal cleft (between buttocks). During an interview on 03/07/2024 at 1:20 p.m. CNA B revealed she thought she had cleaned between Resident #50's buttocks' cheeks but confirmed she did not. She confirmed she should have cleaned the anal area. She confirmed receiving training for infection control and incontinent care within the last year. During an interview with the DON on 03/08/2024 at 09:20 a.m., the DON confirmed that during incontinent care the anal area of the buttocks needed to be cleaned. The facility was doing annual infection control, incontinent care training and annual skills checks. Review of annual skills check for CNA B revealed CNA B passed competency for Perineal care/incontinent care on 12/05/2023. Review of facility policy, titled Perineal care, dated 10/24/2022, revealed Cleanse buttocks and anus, front to back [ .] scrotum to anus in males.