Every finding on record at Sedona Trace Health and Wellness Center

Based on record reviews and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 (Resident #1) of 3 residents reviewed for safe transfer or discharge.The facility failed to ensure the safety of Resident #1 when she was discharged on 04/26/26 with FM B. This failure could result in the safety of the residents who are discharged from the facility.Findings included:Record review of Resident #1's face sheet dated 05/12/26 revealed a [AGE] year-old female, admitted on [DATE] with diagnosis of pneumonia, anemia, major depressive disorder, muscle weakness, reduced mobility and need for assistance with personal care. It was also revealed that FM A was one of the two POAs for financial, care and emergency contact #1 and FM B the emergency contact #2 ,sharing POA rights with FM A.Record review of Statutory Durable Power of Attorney executed on 09/14/2010, duly signed by Resident #1 revealed that FM A was her primary POA while FM B would act as the alternate POA for Resident #1. The document reflected that FM A s would be Resident #1's agent (attorney-in-fact) to act for her in any lawful way and FM B should act as her substitute or successor agent only if FM A for any reason fail or ceases to act as her POA.Record review of Resident #1's discharge MDS dated [DATE] revealed a BIMS score of 14, indicating her cognition was intact. The MDS indicated that she needed supervision with showering and used manual wheelchair for mobility. It was also revealed that she was frequently incontinent with bowel and bladder.Record review of Resident #1's care plan dated 04/07/26 revealed she wished to return/be discharged to her home. The interventions for a safe discharge were:Establishing a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed.Making arrangements with required community resources to support independent post-discharge.Preparing and giving resident, family member and care giver contact numbers for all community referrals, andProviding any needed support by the staff.The care also revealed Resident #1 had ADL Self Care Performance Deficit r/t generalized weakness . The relevant intervention was providing one staff assistance.Record review of the 'Resident admission Agreement' dated 04/09/26 revealed the source of payment was Medicare.Record review of the Notice of Medicare non-coverage dated 04/15/26 revealed the Medicare coverage for the current skilled nursing facility services would end on 04/17/26. The Notice of Medicare non-coverage dated 04/22/26 revealed the Medicare coverage for the current skilled nursing facility services would end on 04/24/26.Record Review of a progress note of Resident #1 dated 04/26/26 at 8:00pm, authored by RN C reflected: [FM B] requested for discharge and DON notified of the decision and she said resident can go home with meds and discharge instructions given and home meds given. Resident left with the family members in good condition. v/s within normal limit.During a telephone interview conducted on 05/12/26, at 9:55 a.m., FM A stated that he resided in a city distant from the facility. He reported that the second appeal regarding the NOMNC, dated 04/26/26, was denied. He said, as the primary POA he determined that Resident #1 should remain at the facility until a reliable home health care arrangement could be organized. He said he undertook the financial responsibility for retaining Resident #1's bed at the facility until a safe discharge arrangement was done. FM A said although FM B resided in close proximity to the facility and expressed willingness to care for Resident #1 at her home, he was dissatisfied with that arrangement. He stated that Resident #1 required specialized care due to her age and complex medical needs, which FM B was not qualified to provide. He stated he was not happy with the discharge of Resident #1 to FM B on 04/26/26 noting that the discharge occurred without consulting him, despite his role as the primary POA. He stated that the facility neither sought nor received his input before or after the discharge. He learned of the discharge on ly when FM B took Resident #1 home. FM A stated that the lack of communication was unacceptable and raised concerns about the Resident #1's well-being. He said had the facility contacted him prior to the discharge he would not have authorized FM B to take Resident #1 home, as he knew FM B did not have the capacity to look after Resident #1. He stated that was also the reason he decided to keep Resident #1 at the facility despite Medicare's denial of coverage, which led him to pay out-of-pocket for the nursing facility expenses after the appeal was rejected. FM A stated the discharge was unsafe, as FM B lacked the necessary resources, skills and capabilities to care for Resident #1, a [AGE] year-old with multiple complex medical and physical conditions requiring skilled nursing care. During an interview on 05/12/26 at 10:35 a.m., the SW stated that he had begun working at the facility approximately one month prior and was aware of Resident #1 and her discharge. He indicated that he had met FM A once previously and discussed Resident #1's care at that time; however, there was no discussion regarding the discharge. The SW reported that both FM A and FM B were actively involved in Resident #1's care and unlike FM A , FM B visited her regularly at the facility. He said that both FM A and FM B served as the POA for Resident #1. The SW stated that FM A wished for Resident #1 to remain at the facility and had been paying out of pocket for her stay since 04/24/26, when Medicare ceased coverage. The SW stated conversely, FM B preferred to discharge Resident #1 to her home. The SW stated he had noticed some family dynamics influencing the decision-making process regarding Resident #1's care. He stated that Resident #1 was discharged on 04/26/26 and FM B took her into a flat located on the 2nd floor of her apartment . The SW stated he was unaware of the condition of the apartment or if the building had an elevator as he neither inquired about it with anyone nor visited the residence to observe the living arrangement. He stated that he did not consult FM A regarding the discharge plan; however, he informed him of the discharge on [DATE]. The SW expressed the opinion that the facility should have sought FM A's permission before discharging Resident #1, especially considering that FM A was the primary POA and the designated emergency #1 contact, and there were family dynamics involved in the situation. During an interview at 3:20pm, when clarified with SW that Resident #1 lived in her own house and FM B in a trailer, contrary to his understanding during the discharge process, the SW stated he was sure that FM B reported to him that she lived in an apartment and Resident # 1 was going to live there. He stated he was not aware of any independent house owned by Resident #1 and if the house was in a livable condition. During an interview on 05/12/26 at 10:50 a.m., the DC stated that he had a supportive role in handling discharge activities and had processed the discharge of Resident #1. He indicated that based on the decision made by the IDT Resident #1 was discharged on 04/26/26, to FM B's home, as FM B wanted to take her. The DC reported that according to FM B she resided on the second floor of an apartment. He said that he was unsure how Resident #1 would access the first floor in case of an emergency and was also uncertain whether an elevator was available in the building. Additionally, he stated he did not verify whether FM B actually lived in an apartment, despite her assertion to that effect.The DC stated that he did not consider potential safety concerns related to Resident #1 living on the second floor of an apartment. He mentioned that he provided all relevant information regarding post-discharge services to FM B. He also stated that he never contacted FM A regarding Resident #1's discharge as FM B was there with her who also a POA.During a phone interview one 05/12/26 at 11:00 a.m., FM B stated that she resided in a trailer and that Resident #1 lived in her own independent house close to her trailer. She explained that other family members, friends, and herself took turns caring for Resident #1. FM B stated that she had never lived in an apartment and was unaware of the source of the incorrect information indicating that Resident #1 lived on the second floor of an apartment. She further stated that FM A was not directly involved in Resident #1's care, as he lived out of the city and preferred that Resident #1 remain at the facility. FM B stated however her desire to take Resident #1 home, in accordance with Resident #1's wishes.During an interview on 05/12/26 at 11:35 a.m., the ADON stated that she was well acquainted with FM B and her family. She reported having a close professional relationship with FM B, as another family member of FM B was also a long-term resident at the facility whom the ADON used to care for personally. She stated that FM B used to visit her regularly at the facility. The ADON stated there were significant family dynamics influencing the situation between FM A and FM B. She said she had noticed that FM A appeared more sensible and responsible, strongly preferring that Resident #1 remain at the facility. The ADON stated In contrast, FM B wished to discharge Resident #1 and take her home. The ADON mentioned that FM A was even willing to pay out of pocket to ensure Resident #1's continued stay at the facility when Medicare coverage was denied. The ADON said that Resident #1 was discharged to her own house, not an apartment, and expressed ignorance regarding the origin of the information suggesting Resident #1 was living on the second floor of an apartment. The ADON stated she was under the impression that the SW, DC and DON were all aware of Resident #1's actual living arrangement.The ADON also reported that FM B told her that one day a person from LEA appeared on her doorstep, asked questions, and she was unsure of the reason for their visit. She stated that given FM A's role as the primary emergency contact and his active involvement in Resident #1's care including financial matters, the facility should have consulted with him prior to making the discharge decision.During an interview on 05/12/26 at 12:30 p.m., the DON stated that she was not aware that Resident #1 had been discharged to an independent house. She said that based on discussions with other healthcare professionals Resident #1 was believed to have been discharged to a flat situated on the second floor of an apartment. The DON said that she was not informed of any involvement by LEA following the discharge, as no personnel at the facility reported such an incident to her. The DON stated that discharging Resident #1 to FM B was the correct decision, citing that FM A lived far away in another city, whereas FM B resided nearby and was capable of caring for Resident #1 at home. She also stated that the EHR incorrectly listed FM A as the primary emergency contact, asserting that it should have been FM B. She stated that she decided to discharge Resident #1 with FM B because FM B was the designated POA #1 as per understanding, and she did not believe it was necessary to inform FM A of the discharge, considering his distant location. When the investigator pointed out that it the POA document reflected FM A was the primary POA, the DON stated she could check out the documents in EHR and confirm it. She said there were significant family dynamics between FM A and FM B and indicated that the facility should have verified Resident #1's living and safety conditions and the appropriateness of the discharge destination before proceeding, rather than relying solely on the information provided by FM B.During a follow-up telephone interview conducted as a return call on 05/13/26 at 7:36 a.m., FM A stated that Resident #1 resided in her own house. He explained that FM B and other family members, who previously lived in a trailer, now resided with Resident #1 to provide care. FM A expressed uncertainty regarding the arrangement and voiced concerns about Resident #1's safety. FM A further stated that no representative from the facility contacted him before or after the discharge. He indicated that he would not have been informed of the discharge at all if FM B had not notified him. He stated that the facility's lack of communication and professionalism was a type of neglect, asserting that it disrupted his plans for Resident #1's comfortable and safe living environment. Additionally, FM A reported that he contacted the local LEA to conduct a wellness check on Resident #1 to make sure that the house was in a living condition without any safety hazards. He said the LEA subsequently contacted him after their visit, informing him that the house was currently livable and that Resident #1 was safe. FM A explained that he was aware of FM B's limitations in caring for Resident #1, he recently organized a home health agency to provide her with necessary care, bearing the associated expenses himself. He stated that since the discharge, Resident #1's condition has deteriorated, receiving hospice care as she was nearing towards the end of her life. FM A stated that FM B and her family continued to live with Resident #1 in her home, assisting with her needs.Record review of the facility policy Discharge Planning Process revised in January 2026 reflected: It is the policy of the facility that the discharge planning process focuses on the resident's discharge goals involving the residents as active partners. The discharge process should effectively transition them to post discharge care and minimize clinical or other factors which are related to the possibility of a readmission.Procedure:The facility's discharge planning process shall:a. provide and document sufficient preparation and orientation to residents in a form and manner that the resident can understand to ensure safe and orderly transfer or discharge from the facility.b. Ensure that the discharge needs of each resident are identified on admission and that a discharge plan for each resident is developed and implemented in a timely manner.e. Consider caregiver/support person availability and resident's or caregiver's/support person's capacity and capability to perform required care . as part of the identification of discharge needs.f. Involve the resident and resident representative when necessary in the development of the discharge plan and inform the resident and resident representative of the final plan. Record review of Resident admission agreement dated 04/09/26, duly signed by Resident #1 reflected : XI. TERMINATION, TRANSFER, OR DISCHARGE(A). Involuntary Transfer or discharge: The Facility shall not involuntarily transfer or discharge the Resident, except if. (5) the Resident, Resident Representative, family member, or legal representative of the Resident, if known to the Facility, requests a voluntary transfer or discharge.(C). Voluntary discharge: The Resident, or Resident Representative to the extent legally authorized, shall have the right at all times to voluntarily discharge the Resident from the Facility, provided that the Administrator of the Facility is given prior notification in order that a proper transfer or discharge can be effected. The Facility requires fourteen (14) days advance written notice of a planned discharge or transfer and the Resident may be charged for such days.

Based on observation, interview, and record review, the facility failed to ensure the resident's responsible party has the right to exercise the resident's rights for one (Resident #1) of seven residents reviewed for resident rights.The facility failed to ensure Resident #1's POA, FM A, notified when the resident was discharged from facility with FM B.This failure could place residents at risk of not having their preferred responsible party represent them in a medical, nursing care and safe discharge decisions.Findings included:Record review of Resident #1's face sheet dated 05/12/26 revealed a [AGE] year-old female, admitted on [DATE] with diagnosis of pneumonia, anemia, major depressive disorder, muscle weakness, reduced mobility and need for assistance with personal care. It was also revealed that FM A was one of the two POAs for financial and care and emergency contact #1 and FM B the emergency contact #2 ,sharing POA rights with FM A.Record review of Statutory Durable Power of Attorney executed on 09/14/2010, duly signed by Resident #1 revealed that FM A was her primary POA while FM B would act as the alternate POA for Resident #1. The document reflected that FM A s would be Resident #1's agent (attorney-in-fact) to act for her in any lawful way and FM B should act as her substitute or successor agent only if FM A for any reason fail or ceases to act as her POA.Record review of Resident #1's discharge MDS dated [DATE] revealed a BIMS score of 14, indicating her cognition was intact. The MDS indicated that she needed supervision with showering and used manual wheelchair for mobility. It was also revealed that she was frequently incontinent with bowel and bladder.Record review of Resident #1's care plan dated 04/07/26 revealed she wished to return/be discharged to her home. The interventions for a safe discharge were:Establishing a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed.Making arrangements with required community resources to support independent post-discharge.Preparing and giving resident, family member and care giver contact numbers for all community referrals, andProviding any needed support by the staffThe care also revealed Resident #1 had ADL Self Care Performance Deficit r/t generalized weakness . The relevant intervention was providing one staff assistance.Record review of the 'Resident admission Agreement' dated 04/09/26 revealed the source of payment was Medicare.Record review of the Notice of Medicare non-coverage dated 04/15/26 revealed the Medicare coverage for the current skilled nursing facility services would end on 04/17/26 . The Notice of Medicare non-coverage dated 04/22/26 revealed the Medicare coverage for the skilled nursing facility services at that time would end on 04/24/26.Record Review of the progress note of Resident #1 dated 04/26/26 at 8:00pm , authored by RN C reflected : [FM B ] requested for discharge and DON notified of the decision and she said resident can go home with meds and discharge instructions given and home meds given. Resident left with the family members in good condition. v/s within normal limit.During a phone interview on 05/12/26 at 3:00pm RN C stated on 04/26/26 FM B approached her and requested the discharge of Resident#1. RN C said she got the permission from DON over the phone and sent Resident #1 with FM B. She stated she did not let FM A know about the discharge before or after the discharge as Resident #1 was going with her FM who was also a POA.During a telephone interview conducted on May 12, 2026, at 9:55 a.m., FM A stated that he resides in a city distant from the facility. He reported that the second appeal regarding the NOMNC, dated April 24, 2026, was denied. He said, as the POA, he determined that Resident #1 should remain at the facility until a reliable home health care arrangement could be organized. He said he undertook the financial responsibility for retaining Resident #1's bed at the facility until a safe discharge arrangement was done. FM A said , although FM B resides in close proximity to the facility and expressed willingness to care for Resident #1 at her home, he was dissatisfied with this arrangement. He stated Resident #1 requires specialized care due to her age and complex medical needs, which FM B was not qualified or able to provide. He stated he was not happy with the discharge of Resident #1 to FM B on April 26, 2026 noting that the discharge occurred without consulting him, despite his role as the primary POA. He stated the facility neither sought nor received his input before or after the discharge. He learned of the discharge on ly when FM B took Resident #1 home. FM A stated that this lack of communication was unacceptable and raised concerns about the Resident #1's well-being. He said, had the facility contacted him prior to the discharge, he would not have authorized FM B to take Resident #1 home, as this was not his intended plan. This was also the reason he decided to keep Resident #1 at the facility despite Medicare's denial of coverage, which led him to pay out-of-pocket for the nursing facility expenses after the appeal was rejected. FM A stated that the discharge was unsafe, as FM B lacked the necessary resources and capabilities to care for Resident #1, a [AGE] year-old with multiple complex medical and physical conditions requiring skilled nursing care.During an interview on 05/12/26 at 10:35 a.m., the SW stated that he had begun working at the facility approximately one month prior and was aware of Resident #1 and her discharge. He indicated that he had met FM A once previously and discussed Resident #1's care at that time; however, there was no discussion regarding the discharge. The SW reported that both FM A and FM B were actively involved in Resident #1's care and FM B visited her regularly than FM A at the facility. He said that both FM A and FM B served as the POA for Resident #1. The SW stated that FM A wished for Resident #1 to remain at the facility and had been paying out of pocket for her stay since April 24, 2026, when Medicare ceased coverage. Conversely, FM B preferred to discharge Resident #1 to her home. The SW stated he had noticed some family dynamics influencing the decision-making process regarding Resident #1's care. He stated that Resident #1 was discharged on April 26, 2026, and FM B took her to her apartment in a flat located on 2nd floor. He stated that he did not consult FM A regarding the discharge plan; however, he informed him of the discharge on [DATE]. The SW expressed the opinion that the facility should have sought FM A's permission before discharging Resident #1, especially considering that FM A was the primary POA and the designated emergency #1 contact, and there were family dynamics involved in the situation. The SW stated he contacted FM A next day after the discharge and informed him about the discharge details.During an interview on 05/12/26 at 10:50 a.m., the DC stated that he had a supportive role in handling discharge activities and had processed the discharge of Resident #1. He indicated that, based on the decision made by the IDT, Resident #1 was discharged on April 26, 2026, to FM B's home, as FM B wanted to take her. He also stated that he never contacted FM A regarding Resident #1's discharge. He also stated that he never contacted FM A regarding Resident #1's discharge as FM B was there with Resident #1 during the discharge who also a POA.During a phone interview on 05/12/26 at 11:00 a.m., FM B stated that FM A was not directly involved in Resident #1's care, as he lives out of the city and preferred that Resident #1 remain at the facility. FM B stated however her desire to take Resident #1 home, in accordance with Resident #1's wishes.During an interview on 05/12/26 at 11:35 a.m., the ADON stated there were significant family dynamics influencing the situation between FM A and FM B. She said she had noticed that FM A appeared more sensible and responsible, strongly preferring that Resident #1 remain at the facility. In contrast, FM B wished to discharge Resident #1 and take her home. The ADON mentioned that FM A was even willing to pay out of pocket to ensure Resident #1's continued stay at the facility when Medicare coverage was denied. She stated that, given FM A's role as the primary emergency contact and his active involvement in Resident #1's care, the facility should have consulted with him prior to making the discharge decision.During an interview on 05/12/26 at 12:30 p.m., the DON stated that she was not aware that Resident #1 had been discharged to an independent house. The DON stated that discharging Resident #1 to FM B was the correct decision, citing that FM A lives far away in another city, whereas FM B resides nearby and was capable of caring for Resident #1 at home. She also stated that the EHR incorrectly listed FM A as the primary emergency contact, asserting that it should have been FM B. She stated that she decided to discharge Resident #1 with FM B because FM B was the designated POA #1 as per understanding and she did not believe it was necessary to inform FM A of the discharge, considering his distant location. When the investigator pointed out that it was clearly evident from the POA document that FM A was the primary POA , the DON stated she could check out the documents in E H R and confirm about this.During a follow-up telephone interview conducted as a return call on 05/13/26 at 7:36 a.m., FM A stated that Resident #1 resides in her own house. FM A further stated that no representative, including SW from the facility contacted him before or after the discharge. FM A stated that he had made numerous phone calls to the facility and left messages related to Resident #1's care , financial issues and discharge plans, however for none of them he received a return response. He indicated that he would not have been informed of the discharge at all if FM B had not notified him. He stated that the facility's lack of communication and professionalism was a type of neglect, asserting that it disrupted his discharge plans for Resident #1 for a comfortable and safe living arrangement. He expressed a desire to hold the facility accountable for these actions.Record review of facility policy Federal Resident Rights revised on 02/24/22 reflected : As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States.receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language you understand a decision to transfer or discharge you from the facility; .Record review of the facility policy Discharge Planning Process revised in January 2026 reflected: It is the policy of the facility that the discharge planning process focuses on the resident's discharge goals involving the residents as active partners. The discharge process should effectively transition them to post discharge care and minimize clinical or other factors which are related to the possibility of a readmission.Procedure:The facility's discharge planning process shall:.f. Involve the resident and resident representative when necessary in the development of the discharge plan and inform the resident and resident representative of the final plan.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 (100/200-Hall) medication room reviewed for pharmacy services. The facility failed to ensure expired medical supplies were removed from 100/200-hall medication storage room on 07/24/2025. This failure could place residents at risk of receiving medication using expired medical supplies, increased pain due to dull needles, and/or infection due to contamination of expired medical supplies. Findings included: Observation on 07/24/2025 at 11:13 AM of the 100/200-hall medication room revealed the following:One 24G x 3/4 in. safety IV catheter with an expiration date of 03/31/2024,One disposable syringe without needle with an expiration date of 11/10/2024,One 20G x 1 in. safety IV catheter with an expiration date of 12/22/2024,Three 1-ml tuberculin safety syringe with needle with expiration dates of 12/31/2024, andTwo hypodermic needle 25G x 0.625 with expiration dates of 07/16/2025. During an interview on 07/24/2025 at 11:16 AM, MA A stated the ADON was responsible for checking for expired medications and supplies in the 100/200-hall medication room. He stated expired supplies should not be used on residents. MA A stated he was unsure of the effect of using expired supplies on residents because the supplies found in the medication room were not supplies, he used on residents. During an interview on 07/24/2025 at 02:22 PM, the ADON stated she was responsible for checking the 100/200-hall medication room for expired medications and supplies. She stated she checked the medication room daily with her morning rounds. She stated the DON was her oversight and followed behind her to ensure completion of her work. The ADON stated if the expired supplies were used on the residents, the needles may not be as sharp, but she was unsure how the expired syringe could affect the residents. During an interview on 07/24/2025 at 02:42 PM, the DON stated the medication aides were responsible for checking for expired medications and supplies daily. She stated the ADON was responsible for following up to ensure no expired medications or supplies remained in the 100/200-hall medication room. The DON stated the expired supplies could be contaminated and potentially cause an infection to the residents if used. She stated the needles may be dull and could potentially cause an increase in pain with administration of medication. During an interview on 07/24/2025 at 03:10 PM, the ADMIN stated the ADON was responsible for checking for expired medications and supplies in the 100/200-hall medication room. The ADMIN stated she expected the nurses to be checking the 100/200-hall medication room also. She stated she expected the ADON and the nurses to check the medication room daily. The ADMIN stated the expired needles could potentially cause more irritation with injections if used beyond the expiration date on the residents. The ADMIN stated the syringes, or sterile supplies may have been contamination that could potentially lead to sickness if used on residents beyond the expiration date. Record review of the facility's, undated, policy titled Medication Access and Storage reflected: Policy:It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications:Procedures:.13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.

Based on interview and record review, the facility failed to provide specialized habilitation services and failed to obtain specialized durable medical equipment for one (Resident #1) of three residents reviewed for PASRR (Preadmission Screening Resident Review) services. The facility failed to request a customized mattress within 20 business days after the IDT meeting for Resident #1. This failure could put resident at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified convulsion (involuntary muscle contraction caused by abnormal brain activity. They can be symptom of epilepsy, fever, infection, injury or medication), Developmental Disorder of scholastic skills (group of conditions that hinder the acquisition of fundamental academic abilities), cognitive communication deficit (difficulties in communication that stem from disruptions in cognition process such as attention, memory, reasoning and executive function), unspecified intellectual disabilities, Review of Resident #1's quarterly MDS assessment, dated 04/15/25, reflected a BIMS score of 10, indicating he had moderate cognitive impairment. Review of Resident #1's quarterly care plan, initiated 3/04/2025 reflected he had been identified as having PASRR positive status related to an intellectual disability (ID) with interventions Specialized services CMWC/DME will be provided as determined by IDT meeting, therapy services as ordered. Review of Resident #1's IDT Care Conference, dated 01/21/25, reflected the following summary: PASRR Care Plan Meeting, Special Treatments, Procedures and Devices-WC, On PT, OT Goal is to keep strengthening and walking. Review of Resident #1's IDT Care Conference, dated 05/1/25, reflected the following summary: On PT, OT, ST PT: Working on balance, gait, strengthening OT: Working on ADLs and fine motor skills ST: Resident #1's IDT meetings did not address the use of supportive mattress. During a phone interview on 06/16/2025 at about 11:00 am the Resource Nurse / MDS Nurse stated Resident #1 was positive for PASRR due to ID and was being skilled by PT/OT/ ST. The Resource Nurse also stated Resident #1 was being skilled upon admission therefore his PASRR services were not approved until his Medicaid was approved. She stated Resident #1's services were based on the initial IDT meeting held on 4/15/2025 after his PASRR approval. The Resource Nurse stated specialized services should be provided to the Resident by the 20th day after IDT meeting. During an interview on 06/16/2025 at about 11:27 am, the DOR stated Resident #1's PASRR meeting was held on 1/21/2025 while he was still being skilled. The DOR stated the IDT team discussed customized wheelchair and mattress (pressure relieving). The DOR stated Resident #1 was skilled from 12/04/2025 through 2/3/2025. She stated she submitted a referral for PASRR services on 2/4/2025 and she kept getting push backs for so many reasons. The DOR stated Resident #1's customized wheelchair was delivered on 5/15/2025, the mattress would have been delivered earlier but was not ordered duet to safety reasons (there was another resident on the same mattress who kept falling off). The DOR stated she did not document in Resident #1's records why the mattress was not ordered. The DOR stated PASRR forms should be submitted by day 20. The DOR stated she communicated to the PASRR representative why she did not order the mattress but did not note it in Resident #1's Portal profile. During a telephone interview on 06/16/2025 at 12:23 pm, the PASRR Program Specialist stated when a resident was admitted and was PASRR positive, an IDT meeting was held, and services were recommended. The facility then had 20 business days to send the NFSS out for approvals. She stated Resident #1's facility did not send the form within 20 business days. She stated that was when she sent out a courtesy email encouraging compliance. She stated if she received no response from that, she then made a complaint to HHSC. She stated if the facility did not document within the timeframe, regardless of what the issue was the facility was not in compliance. She stated the facility was responsible to document in the long-term portal the services recommended and if those services were provided for the resident within the timeframe. During an interview on 06/16/25 at 12:34 pm, the Administrator stated she after the PASRR IDT meeting, it was the expectation that the facility communicates with PASRR and provide the services as was discussed in the IDT meeting. During another interview on 6/16/2025 at about 1:28 pm, the DOR stated during the 1/21/2025 meeting, the team discussed about the mattress, but she could not see it documented on the facility's side. The DOR stated she could only see the discussion of the wheelchair. The DOR stated Resident #1's Habilitation Coordinator asked if she wanted Resident #1 to have a specialized WC and mattress and she accepted. She stated Resident #1 needed the wheelchair and the team along with Resident #1 and his family wanted him to try the mattress. Review of the facility titled PASRR POLICY AND PROCEDURE undated reflected: The facility will designate an individual to follow up on ALL residents have received a PASRR Level I screening. If Facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation. C. Coordinate with the local authority to ensure that the individual is properly assessed for any specialized services recommended in the Level II evaluation as being needed when a determination of ID, DD, or MI is made. (Under 40 TAC Chapter 19, the NF is responsible for assessing the individual for PT, OT, and ST needs and for Durable Medical Equipment. If specialized services are assigned, the NF MUST: A. Certify that they can provide, arrange for, or support services recommended in the Level II evaluation. B. Document the roles and responsibility of the NF in carrying out that specialized service in the Comprehensive care plan. C. Provide training to NF staff on their roles and responsibilities in ensuring that the specialized service is provided. D. Document in the individual's clinical record that the specialized service is provided consistent with the care plan.

Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for one (Resident #1) of three residents reviewed for discharges, in that: The facility failed to readmit Resident #1 and provide or document sufficient preparation for an orderly discharge when Resident #1 was sent to a behavioral health hospital on 05/22/24. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge, injury, and rehospitalization . Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that gets worse over time) with early onset, personal history of Traumatic Brain Injury, schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), major depressive disorder, and other personality and behavioral disorders. Review of Resident #1's quarterly MDS assessment, dated 03/28/24, reflected a BIMS of 3, indicating a severe cognitive impairment. Section E (Behavior) reflected she had hallucinations and delusions as potential indicators of psychosis and physical and verbal behavioral symptoms directed towards others. Review of Resident #1's care plan, revised 03/01/24, reflected she had the potential to demonstrate physical behaviors with an intervention of when she became agitated to guide away from source of stress and engage calmly in conversation. Review of Resident #1's quarterly IDT meeting notes, dated 04/18/24, reflected her RP participated in the meeting. Resident #1's diet, activity preferences, psychiatric services, and therapy services were discussed with no changes. The discharge goal was to remain in long-term care. Review of Resident #1's progress notes, documented on 05/22/24 by LVN A, reflected the following: [Resident #1] was discharged to (psychiatric hospital) in (city), taken by facility transport . Review of Resident #1's Court Motion for Protective Custody, dated 05/22/24, reflected the following: . Wherefore, premises considered, Movant prays that the Court issue an Order of Protective Custody. Ordering [Resident #1] to be taken into protective custody by a peace officer or other designated person, to be immediately transported to (facility) for observation, evaluation, and examination, and to be detained pending probable cause hearing or further Court order. During an interview on 06/24/24 at 9:43 AM, Resident #1's RP stated there had not been any discussion of a behavioral hospital placement. She stated she was not notified of the transfer until the day she was sent to the hospital, 05/22/24. She stated after her treatment she was sent to a long-term care facility in Waco without any discussion with her. During an interview on 06/24/24 at 12:27 PM, the SW stated Resident #1 had quite a bit of self-harming behaviors and would physically try to strangle herself with her hands. She stated she was aggressive towards staff and other residents and they could no longer safely keep her at the facility. She stated she submitted the OPC and was ordered to send her to a behavioral hospital. She stated the hospital was notified that the facility could not take her back and the hospital staff told them (facility staff) that they could help with placement after her discharge. She stated the hospital had not provided the facility with an update of her treatment. She stated it was not best practice to send a resident to the hospital and not allow them to come back unless there was a legitimate cause such as not being safe to come back. She stated she was not sure if staff had been in-serviced on difficult residents or redirection techniques. During an interview on 06/24/24 at 1:19 PM, the DON stated Resident #1's behaviors had been escalating. She stated she would state that she was going to kill herself and would put her hands around her throat. She stated on one of her more recent hospital visits, the hospital recommended a memory care unit and their facility did not have one. She stated in the past they would be able to tell when she was going to have a behavior and would be able to utilize non-pharmaceutical interventions such as snacks or listening to country music. She stated more recently, there had not been any indications and she would just snap. She stated they had discussed with Resident #1's RP prior to the behavioral health hospital admission regarding finding a better facility that was more suitable to meet her needs, but her RP was not interested in transferring her. She stated she was admitted to the psychiatric hospital and it was discussed with them prior to admission if they would be able to find placement for her after treatment. She stated the facility was under the impression she would have somewhere to go to after treatment. She stated the plan when she was admitted to the psychiatric hospital was for her not to be readmitted to the facility. She stated normally when you send a resident out, the goal was for them to get the help the need and then return to the facility. She stated their psychiatrist had maxed out on medications and the providers felt she was not appropriate for their facility. She stated they did not provide a 30-day discharge notice to the resident or family. During an interview on 06/24/24 at 2:05 PM, the ADM stated her expectation for the discharge process was if a resident was sent out to the hospital, they would give out a bed-hold notice, would review updates from the hospital, would look at their baseline after they were stabilized, and would readmit them if they could still meet their needs. She stated with Resident #1, she was not appropriate for their facility and they were unable to meet her needs. She stated she spoke to a staff at the psychiatric hospital a day or so after she was admitted (05/22/24) and gave them options of facilities with locked units. She stated she had been sent out to the hospital on two occasions for suicidal ideations and had returned with her behaviors being much worse. She stated she was very impulsive and would hit and kick staff. She stated their IDT met with her RP, NP, and psychiatrist and they discussed that she was no longer appropriate for their facility and needed a higher level of care where psychiatric services were provided in-house daily. Review of the facility's Admission, Transfer, and Discharge Policy, revised 01/2024, reflected the following: 9. If the facility determines that a resident, who was transferred with an expectation of returning to the facility, cannot return to the facility, this constitutes a discharge and this policy shall apply.

Based on observations, interviews, and record reviews, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member to a centralized staff work area for 2 (Resident #34 and 48) of 6 residents reviewed for call lights, in that: The facility failed to ensure Residents #34 and 48's bathroom and shower call lights operated on 06/11/24. An IJ was identified on 06/11/24. The IJ template was provided to the facility on [DATE] at 7:32 P.M. While the IJ was removed on 06/13/24, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because of the facility need to evaluate the effectiveness of its corrective actions. This failure could place residents at risk for injury, accidents, not having needs met, and death. Findings included: Record review of Resident #34's Admission Record, dated 06/11/24, revealed an [AGE] year-old female who was admitted on [DATE], 02/28/23 , and diagnoses including : cerebral infarction, vascular dementia, urgency of urination, pain in unspecified joint and left elbow, other abnormalities of gait and mobility, cognitive communication deficit, difficulty in walking, unsteadiness on feet, generalized muscle weakness, other lack of coordination, other reduced mobility, and need for assistance with personal care. Record review of Resident #34's Quarterly MDS Assessment, dated 04/11/24, revealed Resident #34 had a BIMS score of 15, which indicated she was cognitively intact. Resident #34 also required partial/moderate assistance with toileting and showering. Record review of Resident #34's Care Plan, dated 05/02/24, revealed Resident #34 had ADL self-care performance deficit and required staff participation to use toilet and with bathing. Record review of Resident #48's Admission Record, dated 06/12/24, revealed a [AGE] year-old female who was admitted on [DATE], readmitted [DATE], and diagnoses including: unspecified dementia, other lack of coordination, generalized muscle weakness, unspecified Alzheimer's disease, muscle wasting and atrophy, other abnormalities of gait and mobility, unsteadiness on feet, and cognitive communication deficit. Record review of Resident #48's Comprehensive MDS Assessment, dated 05/03/24, revealed Resident #48 had a BIMS score of 1, which indicated she had severe cognitive impairment. Resident #48 also was dependent on toileting and showering. Record review of Resident #48's Care Plan, dated 05/08/24, revealed Resident #48 had ADL self-care performance deficit and required one staff participation to use the toilet and bathe/shower three days a week and as necessary. An observation and interview of Resident #34's bathroom on 06/11/24 at 10:30 A.M. revealed the emergency call light next to the toilet did not work. Resident #34 revealed the call light in her bathroom was not working. Resident #34 stated the bed call light was currently working, but the call light had stopped working about one month ago. An observation of Resident #48 on 06/11/24 at 3:16 P.M. revealed she was sitting on the toilet in the bathroom. Resident #48's RP was standing next to her. During an interview on 06/11/24 at 3:21 P.M., Resident #48's RP revealed she was Resident #48's POA. RP stated the emergency call light in Resident #48's shower area does not work and had been broken for one month. RP explained she informed a CNA, day shift nurse and MS. RP went on to explain MS attempted to repair the emergency call light, but it was still broken. RP stated she visited Resident #48 daily for at least 5 hours a day. RP explained she helped Resident #48 go to the toilet and other tasks because Resident #48 was blind. RP stated Resident #48 required assistance with all ADLs due to her blindness and Alzheimer's disease. RP stated Resident #48 was not able to use the call light because she was blind, could not see the call light, and did not have the cognitive capacity to know how to use it. RP explained the ADON told her that the nurses checked on residents every two hours and knew this was not done mostly during night shift because she had electronic monitoring in place in Resident #48's room. An observation and interview of Resident #48's bathroom on 06/11/24 at 4:00 P.M. revealed the call light next to the toilet and in the shower did not work. Resident #48's RP revealed Resident #1's emergency call light next to the toilet also did not work and they reported to staff. An observation of the call light testing system on 06/11/24 at 4:39 P.M. revealed Resident #34's and Resident #48's call lights did not populate as inoperable in the call light testing system. During an interview on 06/11/24 at 4:39 P.M., MS revealed he tested residents' call lights. MS stated he had an issue with call lights in residents' rooms. MS explained this issue had been ongoing for the last six months. MS also stated he had been resetting call lights to troubleshoot the issue. MS stated residents' shower and toilet emergency call lights should be working. MS also stated there was one call light he needed to troubleshoot and one call light he resolved 1-2 months ago. MS explained the call light company the facility used had changed one month ago. MS stated he tested call lights once monthly. MS also stated he pulled status reports at the call light box located at the nursing stations to determine which call lights were not working. MS stated he logged call light testing. MS also stated he installed doorbells for dependent and severely cognitively impaired residents. MS stated residents' health or safety could be affected if their call lights did not work. An observation of Resident #48's bathroom on 06/11/24 at 4:43 P.M. revealed MS tested the toilet and shower call light, and it did not work. An observation and interview of Resident #34's bathroom on 06/11/24 at 4:48 P.M. revealed MS tested the toilet and shower call light, and it did not work. MS stated, Oh that's not working. During an interview on 06/11/24 at 4:49 P.M., MS stated Resident #48's call light had been having issues since 04/29/24, he tested Resident #48's call light on 04/29/24, he has not tested residents' call lights in June 2024, and the call light company last came out to troubleshoot call lights on Resident #48's and 34's hallways on 06/04/24. During an interview on 06/11/24 at 5:00 P.M., CNA M revealed she was not aware of any call lights that were not working at the time of the interview. CNA M stated residents' call lights were all working. When asked if she was made aware of a call light not working, CNA M stated she would tell MS or the nurse. CNA M also stated that she checked on residents every 30 mins. During an interview on 06/11/24 at 5:04 P.M., MA N revealed she was not aware of any call lights that were not working at the time of the interview. During an interview with Administrator on 06/11/24 at 5:04 P.M., Administrator revealed a call light company came to the facility last week (06/04/24) to repair call light system. Administrator stated she did not know how many residents' call lights were repaired. Administrator also stated the facility had 2-3 residents' call lights continuously not working. Administrator explained residents probably went a few days without call lights not working. Administrator stated she did not know how long call lights were not working in residents' rooms and bathrooms and that she would need to get with the MS to find out. Administrator also stated if the call lights were not working at night, then the staff would call the MS or herself. Administrator stated there had been issues with the call lights every now and then, but she did not know how long there had been problems with residents' call lights not working in residents' rooms or bathrooms. Administrator also stated the call light status report system did not show residents whose call lights were not working when MS tested the system on 06/11/24. Administrator stated she was not aware call light status report showed no results of residents' call lights not working despite there being results in the past. During an interview on 06/11/24 at 5:05 P.M., LVN O revealed all residents' call lights on the hall Resident #48 resided on were working at the time of the interview . LVN O stated that if she was made aware of a call light that was not working, there was an email she could send, and she would let maintenance know. LVN O also stated that they have call bells they can provide the residents and then they would check on the resident every hour. LVN O stated that no residents had a call bell at the time of the interview that she was aware of. During an interview on 06/11/24 at 5:05 P.M., CNA P revealed she was assigned to 12 rooms on the hallway Resident #34 resided on. CNA P stated all residents' call lights were working okay at the time of the interview. CNA P also stated when there were issues with call lights, staff were trained to notify Maintenance through a work order system. CNA P stated when call lights were not working, staff provided residents with call bells. CNA P also stated resident rounds were conducted every 30 minutes. During an interview on 06/11/24 at 5:10 P.M., RN Q revealed there were resident call light issues one week ago. RN Q explained when call lights were inoperable, the residents used call bells. RN Q stated she checked on residents every 30 minutes if residents could not use the call bell. RN Q also stated she received training on call lights. During an interview with Director of Nurses on 06/11/24 at 5:10 P.M., Director of Nurses revealed she would come to the facility and educate the staff on using call bells instead of call lights and increasing on making rounds for residents whose call lights did not work. Director of Nurses stated she would educate staff to be near residents' rooms due to being able to hear call bells if their call light did not work. Director of Nurses also stated if she did in-service staff on what to do when the residents' call lights were not working, then it would be in the facility's in-service book. During an interview on 06/11/24 at 5:22 P.M., CMA R revealed there were issues with residents' call lights. CMA R explained residents' call lights did not work when it rained. CMA R stated the residents have call bells in their rooms that they rang when they needed assistance. CMA R also stated she checked on the residents every 1-2 hours, and there was always someone available in the hallway. CMA R stated she has received in-servicing on call lights. Attempted to contact CNA J on 06/11/24 at 6:40 P.M. Left a voicemail and call back number. CNA J did not return the call prior to exit. Attempted to contact CMA K on 06/11/24 at 6:42 P.M. Left a voicemail and call back number. CMA K did not return the call prior to exit. During an interview on 06/11/24 at 6:43 P.M., RN A revealed all of the call lights were working on her shift today (06/11/24) on the hall Resident #48 resided on. RN A stated that if she became aware the call lights were not working, she would usually provide small bells for residents to use until their call lights were repaired. RN A also stated there were some call lights not working about two weeks ago and it was about three residents' rooms. RN A stated Resident #48's call light in her room was not working during that time. RN A also stated staff would increase rounds on those residents whose call lights were not working to make sure their needs were met. During an interview on 06/11/24 at 6:45 P.M., CNA H revealed she was trained on accidents, rounding, and call lights. CNA H stated she had not been in-serviced on call lights. CNA H also stated she would report to a nurse, MS or both if a resident's room call light did not work. CNA H stated one residents' room call light did not work a few days ago on the hallway Resident #34 resided on. CNA H also stated she learned this information when she came back to work (she did not know when, but believed it was a few days ago and did not know who told her). CNA H stated she gave the resident a little bell and tried to fix the call light as soon as possible according to the Director of Nurses on a specific day she could not remember. CNA H also stated residents' room, shower, and toilet call lights were working good today (06/11/24) that she noticed on the hall Resident #34 resided on. CNA H stated residents health and safety could be affected if their call lights did not work because they could hurt themselves and residents would not be able to get help. CNA H stated she was not aware Resident #34's bathroom call light was not working today (06/11/24). CNA H stated she checked on residents every 30 minutes. Record review of MS's Call Light Logbook Report, from 06/30/23 through 05/31/24, revealed MS documented on 05/31/24 that half of Resident #34's call lights in the room were inoperable and scheduled a technician to visit the facility on 06/03/24 to repair the call lights. MS documented on 04/30/24 that bathroom and call lights were inoperable in one resident room who resided on the same hallway as Resident #34 and three resident rooms who resided on the same hallway as Resident #48, who was one of the three rooms with inoperable call lights. MS documented on 03/31/24 that he was having problems with two resident rooms on the same hallway as Resident #34, who was one of the two rooms with inoperable call lights. Record Review of Work Order Report log, dated 12/11/2023 through 06/11/2024, revealed 31 different complaints of residents' call lights not working. Record review of the facility's Call Light Company work order, dated 05/03/24, revealed they troubleshooted and repaired the nurse call system on all four halls. Record review of the facility's Call Light Company work order, dated 05/13/24, revealed they made some repairs on the hallway Resident #34 resided on. Record review of the facility's Call Light Company work order, dated 05/23/24, revealed MS showed them that half of Resident #34's hallway had call lights that were not working. The company troubleshooted the system, found a bad cord shorting the system, replaced the cord, and system went back to normal. Record review of the facility's Call Light Company work order, dated 06/04/24, revealed they found that the nurse call station was down due to power overload. They also found some bad nurse cords, replaced them, advised the facility that they needed to order more, made some programming adjustments, tested the system, and everything worked as it should. Record review of the Staff In-Services for the past 3 months revealed staff were trained on call lights on 05/20/24 by unknown. The training covered having the call lights within reach and answering call lights in a timely manner . There were 9 staff members who attended the training. Record review of the facility's Call Lights policy and procedure revealed if the call light/bell was defective, staff were required to report the information to the unit supervisor. Record review of the facility's Accident Intervention policy and procedure's Accident Prevention and Safety section revealed staff were required to report call lights that did not work. This failure resulted in the identification of an IJ on 06/11/24. The Administrator was notified and provided with the IJ template on 06/11/24 at 7:32 P.M. The following Plan of Removal was submitted by the facility and accepted on 06/13/24 at 4:15 P.M.: Facility Plan of Removal Version 1 Resident Call System Per the information provided in the IJ Template given on 06/11/24, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from [Resident #48's and #34's] toileting and bathing facilities. Immediate Action 1. The Medical Director was notified on IJ on 06/11/24 at 9:00 P.M. by DON. 2. [Resident #48 and #34] refused to move rooms with functioning call systems. Care plans updated on both residents reflecting resident preference by MDS nurse. 1:1 will be provided for [Resident #48 and #34] until call lights are fixed and functioning. DON or designee will ensure 1:1 coverage is scheduled and is reflected on staffing sheet. Staff member responsible for 1:1 will utilize floor staff for break coverage. Staff member responsible for break coverage will be reflected on the staffing sheet. 3. All rooms were assessed to ensure call light system was working on 06/11/24 by interdisciplinary team to include [MS], [DOR], [ADON], and Assistant Business Office Manager. 4. Vendor for call system was called on 06/11/24 and will be at facility on 06/12/24 to address concerns in [Resident #48 and #34's room]. Results of assessment showed two additional rest rooms affected, both residents moved to rooms with functional call lights on 06/11/24. 5. In-services conducted with all staff on proper procedure of notifying leadership when call light system fails and how to educate residents/staff on using bells for communicating and identification of rooms with non-functioning call system on 06/11/24 by [Administrator] who was in serviced prior by clinical resource on 06/11/24 at 8:00 P.M. This training will be completed by 06/12/24. Any staff who are unable to complete this will be in-serviced prior to working their next shift. 6. An ad hoc meeting regarding items in the IJ template will be completed on 6/12/24. Attendees will include the Medical Director, Clinical Resource, [Director of Nursing] & Administrator and will include the plan of removal items and interventions. 7. The [MS] or designee will check call light system daily by manually testing bedside, toilet, and shower call light to ensure functioning properly until substantial compliance is met. 8. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 9. Maintenance resource will train [MS] and/or designee on call light inspection and responsibilities. Designee will be trained on proper testing of call light system by 6/13/2024. [MS] will be in-serviced and trained upon hire on proper testing of call light inspection. Training time will be based upon previous experience and needs. 10. The ED/designee will ensure that the [MS] or designee is inspecting and maintaining the call light functionality. The Plan of Removal was monitored on 06/14/24 as followed: During an interview on 06/14/24 at 11:15 A.M, Administrator revealed the other three residents who were identified as having inoperable call lights did not have care plans revised because the residents opted to immediately move to a new room that had working call lights. Administrator stated Resident #48 and #34's care plans were initially revised to reflect preferences of staying in rooms with 1:1 monitoring until repairs were completed and deleted care plan interventions after call lights were repaired and in working condition. An observation of Life Safety Resource Manager on 06/14/24 from 11:19 A.M. through 11:35 A.M. revealed he tested all five identified residents' rooms, bathrooms, and shower call lights, which were all in working condition and turned on. During an interview on 06/14/24 at 11:35 A.M., Life Safety Resource Manager revealed he worked at the facility since 2018. Life Safety Resource Manager revealed the MS that was newly hired that had not started. Life Safety Resource Manager explained the former MS was terminated. Life Safety Resource Manager stated he trained four other maintenance workers on call light inspection and responsibilities on 06/13/24 and in-serviced on call light inspection, which was ongoing. Life Safety Resource Manager stated room assessments started on 06/16/24 and been ongoing. Life Safety Resource Manager no other residents were identified as having call lights not working. An observation of Resident #34's door on 06/14/24 at 11:50 A.M. revealed she had a posting indicating the empty bed in the room had a non-functioning call light. During an interview on 06/14/24 at 11:51 A.M., CMA S revealed she was in-serviced on call lights by the charge nurse. CMA S stated she learned the call light procedure, report to a nurse or the Administrator when call light does not work, if call light not working to also put in a work order, call light sign and bell usage, and identifying rooms with non-functioning call light systems. CMA S stated one male resident was moved to another room because his call light in his original room was not working and could not recall what day the move occurred. During an interview on 06/14/24 at 11:57 A.M., Resident #34 revealed she refused to move rooms despite her call light not functioning because she did not want all her equipment moved to another room. Resident #34 stated it was her preference not to move rooms. Resident #34 also stated staff provided her with a call bell and answered her call bell during the time her call light was repaired. During an interview on 06/14/24 at 12:01 P.M., CNA T revealed she was in-serviced on call lights, what to do when call lights go out, and same stuff been reviewed by the Administrator and Director of Nursing . CNA T stated she learned to check if the call lights worked by going into rooms, pressing call lights, and seeing if functioning, what to do when call lights did not work, and to be quick. CNA T also stated she was taught to notify a supervisor/charge nurse if call lights did not work. CNA T stated she was taught to ask residents if they want to move rooms, provide call bell, and make sure everything is in reach and checking on residents often (every 15min). An observation and interview of Resident #48 on 06/14/24 at 12:06 P.M. revealed she was sleeping in her wheelchair. Resident #48's family revealed staff did not offer Resident #48 with a new room, did not provide any way of being able to communicate to staff needs during time of call light not functioning, and call light been functioning good. During an interview on 06/14/24 at 12:24 P.M., CNA U revealed she was in-serviced on call light by the ADON or Director of Nurses and checked on residents often (every 30min) for those who had non-functioning call lights. CNA U stated she was taught to notify nurse when there was a non-functioning call light and putting in a work order, call bell usage, and identifying broken call lights through testing. During an interview on 06/14/24 at 12:28 P.M., LVN V revealed he was in-serviced on call lights online and by the Director of Nurses. LVN V stated he was taught how to report non-functioning call lights, call bell usage, and how to identify rooms with non-functioning call lights using signs and testing. During an interview on 06/14/24 12:30 P.M., CNA E revealed he was in-serviced on call lights by online. CNA E stated he was taught to report if seen non-functioning call lights, put in work order or report, post sign on door, and call bell usage. During an interview on 06/14/24 at 12:39 P.M, the Medical Director revealed he was notified of the IJ on 06/11/24 by the Director of Nurses and attended an Ad Hoc QAPI meeting on 06/12/24. During an interview on 06/14/24 at 12:43 P.M., DOR revealed she assisted in conducting room assessments for residents' call lights on 06/11/24. Attempted to contact the Assistant Business Office Manager on 06/14/24 at 12:44 P.M. Left a voicemail and call back number. The Assistant Business Office Manager did not return the call. During an interview on 06/14/24 at 12:47 P.M., the Call Light Company revealed they were called on 06/11/24 and addressed call lights at the facility on 06/12/24 and it was ongoing work. Attempted to contact Clinical Resource on 06/14/24 at 12:50 P.M. Left voicemail and call back number. The Clinical Resource did not return the call prior to exit. Attempted to contact ED on 06/14/24 at 12:51 P.M. Left voicemail and call back number. The ED did not return the call prior to exit. During an interview on 06/14/24 at 12:53 P.M., ADON revealed she assisted in conducting room assessments for residents' call lights on 06/11/24. During an interview on 06/14/24 12:57 P.M., Director of Nurses revealed she notified the MD of the IJ on 06/11/24. Director of Nurses stated she assigned staff to Resident #34 and #48 in shifts and documented on staff sign in sheet of those who provided 1:1 monitoring, and no issues reported. Director of Nurses also stated she attended Ad-Hoc QAPI meeting on 06/12/24. During an interview on 06/14/24 at 1:00 P.M., Administrator revealed there were two identified residents on 06/11/24 who immediately moved to another room following non-functional call light identification and no issues were reported since then. Administrator stated she was in-serviced by clinical resource on 06/11/24. Ad Hoc QAPI meeting was held on 06/12/24. No new identified residents with non-functioning call lights aside from the 2 residents identified . Record review of Resident #48 and #34's initial care plan revisions revealed staff revised the care plans to reflect preferences during the time their call lights were not functioning. Record review of call light sign revealed staff used a sign indicating, Non-Functioning Call Light, to indicate a call light that was not functioning in a resident's room. Record review of staff daily assignment sheets on 06/11/24, 06/12/24, and 06/13/24. Resident #48 and #34's 1:1 monitoring assignment was listed too. Record review of the facility's resident call light system room assessment completed on 06/11/24 revealed one resident's bedroom call light was not working and two residents, Resident #48's and #34's bathroom and shower call lights were not working. Assessment completed on 06/12/24 revealed the same residents were identified. Assessment completed on 06/13/24 during the A.M. shift revealed the call light company was in the building working on call lights and no residents were identified as having call lights not working. Assessment completed on 06/13/24 during the P.M. shift revealed no residents were identified as having call lights not working. Record review of the facility's Call Light Assessment revealed staff identified four rooms that had defective call lights on 06/11/24. Two of the four rooms were Resident #48 and #34's bathrooms. The other two rooms were each located on the hallways Resident #48 and #34 resided on. Record review of the facility's call light staff instructions revealed staff were trained o n the following, If a call light was not working properly, staff should immediately notify their supervisor and put a work order in the work order system (Tels). Tels was the facility's system used to report any maintenance concerns. All staff members were responsible for residents' safety. If a call light was not working properly some of the interventions used are offering a different room or a bell/whistle. The way to identify a room with a non-working call light is a sign on the door with a bell and statement saying, Non-functioning call light. Record review of the in-services revealed the Administrator and Director of Nurses were in-serviced on 06/11/24 by two people on Call Lights. The facility's call light staff instructions were taught to the Administrator and Director of Nurses. The Administrator and Director of Nurses were also quizzed on what to do when a call light was not working properly, what system the facility used to report any maintenance concerns, who was responsible for resident safety, what were some of the implementations staff used when a call light was not working properly to ensure residents were safe and needs were being met, and how could staff identify rooms the call light system was not working. 33 staff members were also in-serviced and quizzed on the previously mentioned from 06/11/24 through 06/12/24. Record review of the staff in-services revealed staff were trained on Call Light Testing on 06/13/24. The following was covered, Testing of Call Light System; Bedside - Push button on Call Light Pendant; Toilet - Pull the Pull String next to toilet; Shower - Pull the Pull String in the Shower; The toilet and shower call light systems turned on a red light; Verify that it is notifying at the monitor at the nursing station; If not working properly or faulty notify Supervisor and put in work order (Tels). Record review of the Survey Remediation training revealed 2 staff completed the training on 06/12/24 and 1 staff on 06/13/24. Record review of the facility's undated Call Light policy and procedure revealed staff reviewed and revised policy to reflect if the call light/bell is defective, immediately report this information to the unit supervisor. Record review of the QAPI meeting on 06/12/24 revealed the Medical Director, Administrator, Director of Nurses, another Administrator, 3 RNs, and SW attended the meeting to discuss the facility's POR, in-servicing, and IJ. The Administrator and Director of Nursing were notified on 06/14/24 at 1:12 P.M. that the IJ was removed. The facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because of the facility need to evaluate the effectiveness of its corrective actions.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart and ensure infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and including infection control practices for mechanical ventilation/tracheostomy care including the use of humidifiers were followed by staff for 3 (Residents #5, #36, and #77) of 7 residents reviewed for respiratory care, in that: The facility failed to ensure Resident #5, #36 and #77's nasal cannulas and tubing were properly stored when not in use. This deficient practice could place residents at risk of cross-contamination and illness. Findings included: Record review of Resident #5's Admission Record, dated 06/13/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE], readmitted [DATE], and diagnoses including: unspecified dementia, unspecified Alzheimer's disease, acute respiratory failure with hypoxia, need for assistance with personal care, and cognitive communication deficit. Record review of Resident #5's Comprehensive MDS Assessment, dated 05/12/24, revealed Resident #5 had a BIMS score of 2, which indicated she had severe cognitive impairment. Resident #5 also required oxygen therapy. Record review of Resident #5's Order Summary Report, dated 06/09/24, revealed Resident #5 had an order for Oxygen 1 lpm via simple mask or nasal canula PRN if tolerated by her that was ordered on 05/09/24. There was no start date. Record review of Resident #5's MAR for May and June 2024 revealed Resident #5 did not receive any of her order for Oxygen 1 lpm via simple mask or nasal canula PRN if tolerated by her from 05/09/24 through 06/14/24. Record review of Resident #36's Admission Record, dated 06/13/24, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and diagnoses including: unspecified dementia, cognitive communication deficit, Alzheimer's disease with late onset, need for assistance with personal care, and dementia in other diseases classified elsewhere. Record review of Resident #36's Quarterly MDS Assessment, dated 04/25/24, revealed Resident #36 had a BIMS score of 11, which indicated he had moderate cognitive impairment. Record review of Resident #36's Order Summary Report, dated 06/13/24, revealed Resident #36 had an order for PRN oxygen 3l/min via nasal cannula with oxygen <90% every 8 hours as needed for SOB that was ordered and started on 06/09/24. Record review of Resident #36's MAR for June 2024 revealed Resident #36 had his PRN oxygen 3l/min via nasal cannula with oxygen <90% every 8 hours as needed for SOB last administered on 06/10/24 at 6:59 A.M. Record review of Resident #77's Admission Record, dated 06/13/24, revealed she was a [AGE] year-old female who was admitted on [DATE], readmitted on [DATE], and diagnoses including: unspecified asthma with acute exacerbation, unspecified down syndrome, unspecified psychosis, shortness of breath, and cognitive communication deficit. Record review of Resident #77's Quarterly MDS Assessment, dated 05/20/24, revealed Resident #77 had a BIMS score of 2, which indicated she had severe cognitive impairment. Resident #77 also required oxygen therapy. Record review of Resident #77's Order Summary Report, dated 06/13/24, revealed Resident #77 had an order for change nebulizer tubing/mask/mouthpiece every night shift every Sunday for change tubing/mask that was ordered on 05/17/24 and started on 05/19/24, change O2 tubing and humidifier bottle every night shift every Sunday for change tubing ordered on 05/17/24 and started on 05/19/24, and O2 at 2 L/MIN via NC as needed for SOB, respiratory distress, cyanosis and labored breathing ordered and started on 05/17/24. Record review of Resident #77's MAR for May and June 2024 revealed Resident #77 had his nebulizer/tubing/mask/mouthpiece and O2 tubing last changed on 06/09/24. Resident #77 did not have O2 at 2 L/MIN via NC as needed for SOB, respiratory distress, cyanosis (Bluish or grayish color of the skin, nails, lips, or around the eyes) and labored breathing administered in May and June 2024. An observation of Resident #5's room on 06/11/24 at 9:02 A.M. revealed there was tubing and nasal cannula that were sitting on the top of her bedside table. An observation of Resident #77's room on 06/11/24 at 11:06 A.M. revealed the oxygen tank attached to the back of her wheelchair was not on. Resident #77 was wearing the tubing and nasal cannula attached to the oxygen tank. There was oxygen tubing that sat on top of the dresser that was across Resident #77's bed. There was also an oxygen machine in front of Resident #77's recliner that was next to the bed and not on. There was tubing and nasal cannula that were attached to the machine and sitting on the recliner. During an interview on 06/11/24 at 11:06 A.M., Resident #77 stated staff did not check on her, did not bag her tubing and nasal cannula sitting on her dresser and recliner chair and she last used her oxygen machine 20 minutes ago. An observation of Resident #36's room on 06/11/24 at 2:55 P.M. revealed there was a nasal cannula and tubing sitting on Resident #36's bedside table that was next to his bed. During an interview on 06/11/24 at 2:55 P.M., Resident #36 stated he did not know when he last used his oxygen machine, staff checked on him, and he had no concerns or issues. During an interview on 06/13/24 9:50 A.M., Administrator stated the facility did not have a policy on oxygen tubing and nasal cannula storage when oxygen machine and tanks were not in use. During an interview on 06/13/24 at 1:00 P.M., RN A stated she was trained on respiratory care and in-serviced by the ADON monthly. RN A stated if the oxygen machine was not in use, nurses were to bag tubing in a plastic bag with dates and a label. RN A also stated residents' health could be at risk if the oxygen tubing and nasal cannula was not bagged when the oxygen machine was not in use. RN A stated the DOR, ADON, and MS people round in the morning and ensure oxygen tubing and nasal cannula was stored away when not in use. RN A stated she also rounded every morning and mid-afternoon during her 8-hour shifts. RN A stated she did not know Residents #5, 36, and 77's tubing and nasal cannula were not stored away when their oxygen therapy was not in use. During an interview on 06/13/24 at 1:13 P.M., LVN L stated he was last trained on respiratory care online in October 2023. LVN L stated it had been a while since he had that training provided to him. LVN L also stated he was trained on how to follow oxygen orders and perform respiratory therapy. LVN L stated staff were supposed to look at the condition of oxygen machines weekly. LVN L also stated the oxygen tubing, concentrators, and water bottles were to be checked and changed weekly. LVN L stated nurses were to bag tubing and nasal cannula. LVN L also stated tubing and nasal cannula needed to be in a container or bag to prevent it from pathogens when the oxygen machine or tank not in use. LVN L explained if nasal cannula was lying on a resident's bed, he would inspect the tubing, use nursing judgment, discard the tubing, replace the tubing, bag the new tubing, date the bag, ensure tubing condition was good, notify a nurse if tubing was not in use and lying on bed, and document in progress notes. LVN L stated residents' health could be at risk if tubing and nasal cannula were not bagged when oxygen therapy was not in use because it was a respiratory risk. LVN L also stated he did not know Residents #5, 36, and 77's tubing and nasal cannula were not stored away when their oxygen therapy was not in use. During an interview on 06/13/24 at 1:28 P.M., CNA E stated she was trained and in-serviced by the ADON on rounding and ADL care. CNA E also stated she rounded (checked on residents) every hour. CNA E also stated CNAs and nurses bagged tubing and nasal cannula when oxygen therapy was not in use. CNA E stated Residents could affect health if tubing not bagged because of airborne pathogens and water could get in tubing. CNA E also stated she did not know Residents #5, 36, and 77's tubing and nasal cannula were not stored away when their oxygen therapy was not in use. During an interview on 06/13/24 1:37 P.M., CNA H stated she was trained and in-serviced by the ADON on ADL care and rounding. CNA Hstated she rounded on residents every two hours during her 8-hour shift. CNA Halso stated would notify a nurse if a residents' oxygen tubing and nasal cannula was sitting on the bed when the oxygen machine was not in use. CNA Hstated nurses bagged oxygen tubing and nasal cannula. CNA Halso stated residents could get an infection or develop bacteria if oxygen tubing and nasal cannula were on the ground and not bagged when oxygen therapy was not in use. CNA Hstated she did not know Residents #5, 36, and 77's tubing and nasal cannula were not stored away when their oxygen therapy was not in use. 06/13/24 01:58 PM During an interview, ADON revealed she was trained and in-serviced on respiratory care by the facility annually. ADON stated the facility faxed reeducation to staff annually. ADON also stated that she was taught to bag and date oxygen tubing and nasal cannula if the oxygen therapy was not in use. ADON stated the nurses bag residents' oxygen tubing and nasal cannula. ADON also stated she told the CNAs to be mindful and bag the oxygen tubing and nasal cannula when not in use. ADON stated the Director of Nurses, Treatment Nurse, SW, and Dietary department conducted room checks every morning to ensure no issues with care, such as respiratory care and she was trained report to the Administrator of any findings. ADON also stated residents' health could be affected if oxygen tubing and nasal cannula was lying out on the floor when the oxygen machine was not in use because could it cause an infection. ADON stated she did not know Residents #5, 36, and 77's tubing and nasal cannula were not stored away when their oxygen therapy was not in use and that oxygen tubing should have been bagged up. During an interview on 06/13/24 2:10 P.M., Director of Nurses revealed she was trained on respiratory care annually and as needed. Director of Nurses stated she learned to store oxygen tubing and nasal cannula in bags and change the tubing and nasal cannula weekly. Director of Nurses also stated she taught staff same practice on hire and reeducated staff PRN. Director of Nurses stated there were guardian angel rounds that were done daily to ensure tubing and nasal cannula were bagged. Director of Nurses also stated CNAs and nurses can bag tubing and nasal cannula. Director of Nurses stated residents could be at risk for an infection if the oxygen tubing and nasal cannula were not bagged. Director of Nurses also stated she was not aware Residents #5, 36, and 77's oxygen tubing and nasal cannula were not bagged and did not know why they were not bagged. Director of Nurses stated staff rounds every two hours and as needed. Record review of the facility's Oxygen Administration (Mask, Cannula, Catheter) policy and procedure, undated, revealed there were no procedures related to who, when, where, and how oxygen tubing and nasal cannula were to be stored when oxygen machine or tank was not in use.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and sanitation, in that: 1. The facility failed to ensure kitchen staff secured their hair in hairnets in the kitchen. 2. The facility failed to clean the inside of the one ice machine. 3. The facility failed to discard expired food and beverage items in the walk-in refrigerator. 4. The facility failed to ensure the freezer unit in the walk-in freezer was maintained in safe operating condition . These deficient practices could place residents at risk of foodborne illness. Findings included: An observation of the kitchen on [DATE] 9:12 A.M. revealed [NAME] G's hairnet was sitting on top of her head. The hairnet covered the top half of [NAME] G's hair, leaving the bottom half not protected or covered. An observation of the ice machine on [DATE] at 9:17 A.M. revealed there were black spots on the top ceiling inside the ice machine. An observation and interview of CNA H at the ice machine [DATE] on 9:19 A.M. revealed she was scooping ice from the ice machine into two ice chests sitting on carts. CNA H revealed stated there were three ice chests for the entire facility that staff use to provide residents with ice water. CNA H stated there was one ice chest per hallway. An observation of the walk-in refrigerator on [DATE] at 9:22 A.M. revealed revealed there was an opened gallon jar of mayonnaise with an expiration date of [DATE], an opened gallon jar of Caesar salad dressing with an expiration date of [DATE], an opened gallon jar of ranch salad dressing with an expiration date of [DATE], and an opened gallon of lime juice with an expiration date of [DATE]. An observation of the walk-in freezer on [DATE] at 9:27 A.M. revealed revealed there was a build-up of ice on the bottom of the freezer unit mounted to the ceiling. There were two boxes of dark meat that were stacked on top of each other and sitting on the shelf just below the freezer unit, soaked on one side of the box base, and bending. An observation of the kitchen on [DATE] 12:12 P.M. revealed DA I was standing in front of the meal service station. DA I had her hair net covering the top half of her head, leaving the bottom half not covered or protected. Record review of the dietary cleaning schedule revealed there was no scheduled maintenance days for the cleaning the inside of the ice machine and freezer unit. There were also no scheduled maintenance days for checking food and beverage items in the walk-in freezer and refrigerator. An observation on [DATE] at 12:13 P.M. revealed DA I walked to the food preparation area and rearranged her hair net to cover all her hair. An observation of the ice machine on [DATE] at 9:09 A.M. revealed there were black spots on the top ceiling inside the ice machine. During an interview on [DATE] at 9:24 A.M., DM revealed the ice buildup on the freezer unit was not from the freezer unit. DM stated the buildup of ice on the bottom of the freezer unit in the walk-in freezer occurred because the kitchen staff were not securely closing the walk-in freezer door at the beginning of [DATE]. DM stated she had maintenance install a latch on the walk-in freezer door and trained staff on how to secure the latch. DM stated her and the kitchen staff have not had any issues after maintenance installed the door latch and she trained staff on how to secure the door with the latch. DM also stated she discarded food and beverage items stored in the refrigerators daily based on the best by date labeled on the product and checked the walk-in freezer unit daily. DM stated she did not have logs or documentation reflecting that she was checking and discarding expired food and beverage items from the refrigerator and freezer and that she was checking the freezer unit in the walk-in freezer . DM stated she did not know there were expired food items in walk-in refrigerator. DM also stated residents could be at risk of becoming sick if they ate meals prepared with expired food. An observation of the walk-in refrigerator on [DATE] at 9:28 A.M. revealed two-gallon jars of ranch dressing with expiration dates of [DATE] and [DATE], one opened gallon jar of Caesar dressing with expiration date of [DATE], one opened gallon jar of mayonnaise with an expiration date of [DATE], and one opened gallon of lime juice with an expiration date of [DATE]. An observation of the ice machine on [DATE] at 9:50 A.M. revealed there were black spots on the inner ceiling inside the ice machine. The DM observed the black spots on the inner ceiling inside the ice machine. During an interview on [DATE] at 9:50 A.M., DM revealed there were no ice machine maintenance records from the kitchen. DM explained the MS drained and cleaned the inside of the ice machine every quarter. DM stated MS might have a policy on ice machine draining and interior maintenance. DM stated she cleaned the exterior and scooper of the ice machine. DM stated the ice machine exterior and scooper were cleaned weekly. During an interview on [DATE] at 9:51 A.M., DM revealed there were no cleaning sheets for the freezer unit. DM stated she conducted daily rounds on the freezer unit. DM stated there was no policy on cleaning the freezer unit. During an interview on [DATE] at 9:56 A.M., DM revealed there was no policy on food storage and discarding food. DM stated staff were required to wear hairnets, at all times in the kitchen. DM also stated she observed and instructed [NAME] G about her hair net not being properly placed on her head covering all her hair, but she did not know about DA I was not wearing a hair net properly as well. DM stated the facility followed the TFER on hair net policy. During interviews with two DAs and two Cooks in the kitchen on [DATE] at 10:43 A.M., the kitchen staff revealed they all knew they needed to wear a hair net at all times when in the kitchen and all hair should be covered. Attempted interview with DA I on [DATE] at 11:44 A.M., via telephone. Left a voicemail and call back number. DA I never returned the call prior to exit. During an interview on [DATE] at 11:59 A.M., [NAME] G revealed that she received training on proper hair restraints and kitchen duties. [NAME] G stated that proper hair restraint would be to have all hair covered by the hair net. [NAME] G also stated that she was told to put her hair in a ponytail and then put it in the hairnet. [NAME] G stated her problem was that she has very long hair with deadlocks. [NAME] G described that she would have to wrap her hair in a ponytail 8 times and then she put the hair net on. [NAME] G stated people think that she did not have a hair net on because her deadlocks are extremely long and fray like. [NAME] G also stated that there was concern for cross contamination and hair getting into the food, which can make the residents sick, if proper hair restraints were not used. When asked why she was observed without proper hair restraints, [NAME] G stated, I try to do my best to keep it wrapped up or I'll have to find a new job. [NAME] G asked what she can do and stated that the DM told her to ask for help if she was not able to get all her hair in the hairnet. [NAME] G stated she had to ask for help with using a hair net to cover all her hair. Record review of the facility's kitchen quarterly work history report revealed MS checked filters, cleaned coils, sanitized interior, and delimed as necessary on the ice machines and ice bins chests last on [DATE]. Record review of the TFER provided by the DM on [DATE] at 12:24 P.M. revealed the following: Food employees shall wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that covers the body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on interviews and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 3 residents (Resident #50 and Resident #71) reviewed for advanced directives. The facility failed to ensure Resident #50's out of hospital do-not-resuscitate (OOH-DNR) form included the resident's printed name and date signed. The facility failed to ensure Resident #71's Medical Power of Attorney (MPOA) included all pages and was signed, dated, and witnessed or notarized to confirm it was valid. These failures could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention due to confusion regarding authority to make medical decisions on behalf of the resident. Findings included: Record review of Resident #50's face sheet dated 06/13/2024 reflected an initial admitted [DATE] with diagnoses of unspecified dementia, hypertensive chronic kidney disease, and major depressive disorder. Review of Resident #50's care plan dated 08/19/2022 reflected the residents elected DNR status. Review of physician's orders for Resident #50 revealed an order for DNR with a start date of 07/13/2023. Record review of Resident #50's clinical record revealed an OOH-DNR which lacked the resident's printed name and date signed under section A. Record review of Resident #71's face sheet reflected an admitted [DATE]. Review of Resident #71's undated MPOA revealed this document did not include Resident #71's signature witnesses by two individuals or a notary therefore rendering it incomplete and invalid. During an interview with Resident #50 on 6/12/2024 at 9:12 AM, he stated that he had an OOH-DNR in place. During an interview on 6/12/2024 at 2:46 PM, the SW stated that an OOH-DNR should be dated and have the printed name of the resident. SW answered no when asked if it was missing the date and resident's printed name. SW reviewed Resident #71's MPOA and acknowledged it was missing signature of Resident #71 and witness or notary signature. SW stated that Resident #71's daughter does not live close by, and the document was what was provided. SW stated that she does not have a signature page for #71's MPOA document. SW stated she believed the MPOA needs to have the signature page to be valid. SW did not have a response when asked how she knew the MPOA was valid without the signature page. During an interview on 06/13/2024 at 2:15 PM, the DON stated that the facility social worker was in charge of advanced directives. The DON stated that an OOH-DNR was absolutely not valid if it was missing dates or the printed name of the resident. When asked if a MPOA was complete or valid if it was missing signature pages, the DON stated no it was not valid or complete. The DON stated that it was her expectation that all advanced directives entered into the resident's record be valid. The DON stated that the potential outcome of having incomplete or invalid advanced directives was that a resident's wishes have the potential to not be honored and the facility may not be aware of who to contact. During an interview on 06/13/2024 at 2:48 PM, the ADM stated that the SW was responsible to ensure advanced directives were complete and valid. The ADM answered no when asked if and advanced directive and/or MPOA was complete if it was missing a signature page. When asked if an OOH-DNR was considered valid if it was missing a date or printed name, the ADM answered no. The ADM stated that the facility could go against the resident's wishes as a potential outcome if the resident had an invalid document. Review of facility policy titled Advanced Directives and Associated Documentation with revision date of 01/2023 revealed it is the policy of this facility to implement the resident decisions and directives that are in compliant with State and/or Federal Law and the policies of this facility. Further review revealed that it is the facility's policy to review the Advanced Directive to validate the document reflects the resident choices and that the document is signed and dated by the resident or responsible agent. Review of health and safety code 166.083(b)(3) revealed an OOH-DNR form must contain the printed or type name of the person. Review of Texas DSHS Instructions for Issuing an OOH-DNR Order revealed if an adult person was competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Review of health and safety code 166.154(a)(b)(c) dated 09/01/2009 revealed the medical power of attorney must be signed by the principal in the presence of two witnesses or have the signature acknowledged by a notary public; witnesses must also sign the document.

Based on observations, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of eight residents (Resident # 20, Resident #39, and Resident #72) reviewed for quality of life. 1. The facility failed to ensure Resident #20 and Resident #39's nails were cleaned. 2. The facility failed to ensure Resident #72's nails were cleaned and did not have rough edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident #20's Face Sheet dated, 06/13/2024, revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of need for assistance with personal care (providing care that is related to the patient's body, appearance, hygiene, and movement), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), muscle weakness (lack of muscle strength), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Record review of Resident #20's Quarterly MDS Assessment, dated 05/17/2024, reflected the resident had a BIMS score of 4 which indicated her cognitive status was severely impaired. Resident #20 was assessed to require assistance with personal hygiene, dressing, showers, toileting, oral hygiene, and transfers. Resident #20 did not refuse care. Record review of Resident #20's Comprehensive Care Plan, dated 05/02/2024 reflected Resident #20 was at risk for impaired cognitive function or thought process. Intervention: give step by step instructions on at a time as needed to support cognitive function. Resident #20 had ADL self-care performance deficit related to impaired mobility and weakness. Intervention: Bathing- check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation on 06/11/2024 at 9:57 AM Resident #20 was in her room sitting in her wheelchair and watching television. Resident had blackish substance underneath all her fingernails on her right hand. Resident #20 was not interviewable. Record review of Resident #39's Face Sheet dated, 06/13/2024, reflected a [AGE] year-old male admitted to the facility with diagnoses of: lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), generalized muscle weakness (lack of muscle strength), and malaise (general feeling of discomfort, illness, or lack of well-being). Record review of Resident #39's Quarterly MDS Assessment, dated 05/07/2024, reflected Resident #39 had a BIMS score of 8 which indicated Resident #39's cognition was moderately impaired. Resident #39 did not reject care. He required assistance with ADLs such as: personal hygiene, dressing, showers, toileting, and transfers. Record review of Resident #39's Comprehensive Care Plan, dated 05/22/2024, reflected Resident #39 had ADL self-care performance deficit related to impaired mobility. Intervention: Resident required assistance with bathing and dressing. Observation on 06/11/2024 at 10:07 AM Resident #39 was lying in bed in his room. He had hard thick blackish substance underneath his middle, index, and fore fingernails on his right hand. Interview on 06/11/2024 at 10:10 AM Resident # 39 stated he asked someone who worked there two times if someone would clean his nails. He stated it was approximately two days ago. Resident #39 stated that after he asked the same person twice to clean his nails, she stated she would do it later in the day, and he did not see her anymore that day. He stated he did not ask anyone else. Resident #39 stated he would clean his nails himself, but he was not able to do this by himself. 2. Record review of Resident #72's Face Sheet, dated 06/13/2024 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of muscle weakness (lack of muscle strength), unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), type 2 diabetes mellitus without complications (a condition that happens because of a problem with the way the body regulates and uses sugar as fuel), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (loss of partial or total body function on one side of the body, whereas hemiparesis is characterized by one sided weakness, but without complete paralysis). Record review of Resident #72's Quarterly MDS Assessment, dated 05/01/2024, reflected Resident #72 had a BIMS score of a 4 indicated his cognition was severely impaired. Resident #72 did not reject care. Resident #72 required assistance with eating, toileting, shower, dressing, personal hygiene, and transfers. Record review of Resident #72's Comprehensive Care Plan, dated 05/11/2024, reflected Resident #72 had diabetes mellitus. Intervention: Resident #72's nails should always be cut straight across, and never cut corners. Resident #72's rough edges of the nails should be filed with emery board. Resident #72 had ADL self-care performance deficit. Intervention: He required assistance with personal hygiene, skin inspection, and bathing. Observation on 06/11/24 at 11:18 AM Resident #72 was lying in bed. The tip of Resident #72's nails were not trimmed evenly on his right and left hands. Resident #72 had a blackish substance underneath his nails on his forefinger, middle finger, and index finger on his right hand. In an interview on 06/11/2024 at 11:22 AM Resident #72 stated he wished someone would do something with his nails. He stated his nails were dirty. Resident #72 did not respond verbally or with gestures when asked if he requested his nails to be cleaned and /or filed. In an interview on 06/13/24 11:20 AM. RN A stated the nurses and CNAs were responsible for nail care. He stated the nurses were responsible to clean, trim, and file all resident's nails with a diagnosis of diabetes. RN A also stated it was the CNA's responsibility to trim, clean, and file all other residents' nails. He stated the CNAs usually completed nail care during the residents' showers or as needed. He stated the blackish substance possibility could possibly be feces or any type of bacteria underneath the resident's nails. RN A stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. He also stated a resident may become dehydrated. RN A stated he had been in- serviced on nail care- cleaning, filing, and trimming residents' nails. RN A stated if a resident's nails were not smooth and was rough around the edges there was a possibility the resident may scratch themselves and develop a skin tear. He stated he was not aware of Resident #39, Resident #20, or Resident #72 refusing nail care. He stated he was assigned to be their nurse numerous times. RN A stated he had been an employee at the facility approximately 1 year. In an interview on 06/13/24 at 11:50 AM, CNA C stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually cleaned, cut, and filed residents' nails during showers or as needed. CNA C stated the nursing staff were expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails, and trim or file if the nail was not smooth. She stated the blackish substance may be bacteria from feces underneath the residents' nails. CNA C stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated there was a possibility a resident may need to be assessed at the emergency room if they became severely ill. CNA C stated if a resident's nails were not smooth and was rough on top of the nail, there was a possibility the resident may scratch their hand, arm, or face. She also stated it was a possibility the resident may cause a skin tear on themselves or another resident if they accidentally scratched another resident's hand. CNA C stated she was assigned care to Resident #72, Resident #20, and Resident #39 and from her knowledge these residents did not refuse nail care. She stated she had given nail care to all three of these residents and did not recall how many times. She stated she had been in-serviced and trained on nail care but did not remember the dates of the in-service. In an interview on 06/13/24 at 12:05 PM, CNA D stated she would report to a nurse if a resident with diagnosis of diabetes needed any type of nail care such as: cut, cleaned, or filed. She stated the CNAs were responsible for all other resident's nail care such as cleaning, trimming, and filing the nails. She stated nail care was usually completed during showers or as needed. CNA D stated nail care was to be completed daily if a resident's nails were dirty. She also stated if a resident had a blackish substance underneath their nails, it could be any type of germs. She stated there was a possibility a resident may eat with their hands and the blackish substance may transfer from residents' hands to the food. She stated the resident may develop stomach problems such as nausea and vomiting. She stated it was a possibility a resident may need to be assessed at a hospital if it was severe. CNA D stated if a residents' nails were rough there was a possibility a resident may scratch themselves and develop a skin tear or could scratch any part of their body and cause some type of skin infection. She also stated she had been in- serviced to clean and trim residents' nails in the shower and/or as needed except for diabetic nails. CNA D also stated she did not recall when the last in-service on nail care was given by nurse supervisors. She stated she had given care to Resident #20, Resident #39, and Resident #72 and she was not aware of them refusing nail care. In an interview on 06/13/24 at 12:20 PM, the Director of Nurses stated if a resident had dirty nails such as a blackish substance there was a possibility of bacteria on their fingers and/or underneath the resident's nails. She stated there was a potential a resident could ingest bacteria from their fingernails into their mouth. The Director of Nurses stated it depended on the type of bacteria of what type of illness a resident could receive from the bacteria. She stated a resident potentially could become ill with stomach issues or any type of infection. The Director of Nurses stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection if the residents' nails were not trimmed properly. The Director of Nurses stated it was the nurse supervisor's responsibility to monitor nursing staff to ensure residents were receiving proper nail care. She stated the CNA's or Nurses were responsible to cut, trim, and clean residents' nails. She stated the nurses were responsible for the residents with a diagnosis of diabetes. She stated the staff were required to trim, cut, and clean nails during their showers and as needed. In an interview on 06/13/2024 at 12:35 PM, the Administrator stated the CNAs were responsible for nail care during the residents' showers and as needed except for the residents with a diagnosis of diabetes. She stated the nurses performed all fingernail care for the diabetic residents. The Administrator also stated if a resident swallowed any type of blackish substance and it was determined to be bacteria, there was a potential a resident may become ill with a stomach infection. She also stated the resident may have symptoms such as diarrhea and vomiting. She stated it was the nurse supervisor's responsibility to monitor nail care. The Administrator stated there was a potential for a skin tear if a resident's nails were not smooth and the resident scratched themselves anywhere on the body. Record review of the Facility's Policy on Quality of Care (ADL, Services to carry out), reviewed 01/2024 reflected, It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Procedures: 1. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff. 2. Bathing will be offered at least weekly, and PRN per resident request. 3. Residents will be involved in decision making and given choices related to ADL activities as much as possible.

Based on interviews and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness, developmental disability, or intellectual disability, were provided with a PASRR Level II assessment for 1 (Resident #86) of 3 residents reviewed. The facility failed to ensure Resident #86 received a PASRR level 2 evaluation. This failure could place residents at risk for not receiving necessary mental health services to reach their highest practicable level of well-being. Finding included: Record review of Resident #86's face sheet dated 6/12/2024 revealed an admitted [DATE] with diagnoses of unspecified fracture of left femur (traumatic injury to femur), acute respiratory failure (when one does not receive sufficient oxygen throughout the body), schizophrenia (a mental disorder characterized by disruptions in thought process), and bipolar disorder (serious mental illness that causes unusual shifts in mood). Record review of Resident #86's MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated a moderate cognitive impairment. Section I of Resident's MDS reflected active diagnosis of bipolar disorder and schizophrenia. Record review of physician's orders for Resident #86 revealed an order for Seroquel indicated for Schizophrenia. Record review of Resident #86's care plan dated 4/13/2024 reflected that [Resident #86] is at risk for impaired thought processes [related to diagnoses of] schizophrenia/bipolar. Record review of Resident #86's PASRR Level 1 screening dated 4/12/2024 revealed no was selected under Section C read in part .is there evidence or an indicator this is an individual that has a mental illness? Record review of undated document titled Active Residents with PASRR Positive PE revealed Resident #86 was not listed. During an interview with LVN Won 6/13/2024 at 12:30 PM, LVN W reviewed PASRR Level 1 for Resident #86. LVN W stated that it indicated a negative (all questions indicated as no) on the PASRR level 1 but Resident #86 had a diagnosis of bipolar disorder. LVN W stated that with a diagnosis of bipolar disorder and schizophrenia, the PASRR level 1 should be positive. LVN W stated if the PASRR level 1 was incorrect upon a Resident's admission, staff should talk with the MD, and confirm the diagnoses. After admission and a diagnosis was confirmed by an MD, a correction form should have been submitted. During an interview on 6/13/2024 at 1:20 PM, LVN X stated that she was the MDS coordinator and responsible for the MDS assessments. LVN X stated that the MDS coordinator was also responsible for reviewing PASRR Level 1 screenings for new admissions. LVN X stated that if a resident had a diagnosis of schizophrenia or bipolar disorder without a diagnosis of dementia the PASRR level 1 should have been positive. LVN X stated that if PASRR level 1 was incorrect it should have been corrected via form 1012 after the diagnosis was confirmed by the MD. On 6/13/2024 at 2:11 PM, the DON stated that she has been the DON at the facility for five years. She stated that the facility's process for identifying residents with a possible mental illness, intellectual disability, or related condition prior to admission was reviewing the PASRR level 1 from the hospital, reviewing the resident's medical chart, and possible interview with the family. The DON stated that facility's MDS nurse notified staff if there was a newly identified diagnosis after admission and any changes made to care would have been relayed to the floor staff. The DON stated that the MDS nurse and social worker work together to make the referral to the appropriate state-designated authority when a resident was identified to have an evident or possible MD, ID, or related condition. On 6/13/2024 at 2:47 PM with the ADM, she stated that if a PASRR level 1 was not accurate it could result in a resident's needs potentially not being met. Review of undated document titled Policy: PASRR POLICY AND PROCEDURE reflected, The facility will designate an individual to follow up on ALL residents have received a PASRR Level I screening. If facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation.

Based on interviews and record review, the facility failed to complete a comprehensive, accurate, and standardized reproducible assessment for 2 (Resident #86 and Resident #88) of 3 residents reviewed for comprehensive assessments. The facility failed to include Resident #86's cancer diagnosis in the comprehensive assessment. The facility failed to include Resident #88's depression diagnosis in the comprehensive assessment. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. Findings included: Record review of Resident #86 face sheet dated 6/12/2024 revealed an admitted [DATE] with diagnoses of unspecified fracture of left femur (traumatic injury to femur), acute respiratory failure (when one does not receive sufficient oxygen throughout the body), schizophrenia (a mental disorder characterized by disruptions in thought process), bipolar disorder (serious mental illness that causes unusual shifts in mood), and unspecified lump in the right breast. Record review of Resident #86's MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated a moderate cognitive impairment. Section I of MDS reflected that cancer was not selected as an active diagnosis for Resident #86. Record review of physician's orders for Resident #86 revealed an order for Anastrozole Tablet indicated for breast cancer. Record review of Resident #86's care plan reflected no information regarding her cancer diagnosis. Record Review of Resident #88's face sheet reflected an admitted [DATE]. Further review reflected diagnoses of nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and membrane that covers it), unspecified dementia (dementia without a specific diagnosis), anxiety disorder (mental health condition in which a person may respond to situations with fear or dread), and cognitive communication deficit (trouble reasoning and making decisions while communicating). Record review of Resident #88's quarterly MDS reflected a BIMS score of 03 which indicated severe cognitive impairment. Section I of Resident 88's quarterly MDS reflected that depression was not selected as an active diagnosis. Resident #88's quarterly MDS reflected an active diagnosis of anxiety disorder. Record review of Resident #88's physician orders revealed an order for Amitriptyline indicated for depression with a start date of 05/14/2024. Further review revealed an order for Mirtazapine indicated for depression with a start date of 05/14/2024. Resident #88 was also prescribed Xanax as needed for anxiety/agitation with a start date of 06/06/2024. Physician's orders for Resident #88 included for staff to monitor for anti-anxiety side effects and targeted behavior with a start dates of 05/14/2024, and to monitor for anti-depressant side effects and targeted behavior with start dates of 05/15/2024. Record review of Resident #88's care plan dated 05/15/2024 reflected a focus for antidepressant medication use related to depression diagnosis. Further review revealed a focus for anti-anxiety medication use related to anxiety disorder dated 05/15/2024. During an interview LVN X she stated she was the MDS coordinator. She stated that if a resident was admitted with a diagnosis, it should have been indicated on section I of the MDS. LVN X stated that she read through the NP and psychology/psychiatry notes for any updated diagnosis to determine if the resident had a change or update to their diagnoses. LVN X stated that she also received information through meeting with the IDT. LVN X stated that the residents care plan and the MDS should match with accurate information. During an interview on 06/13/2024 at 2:15 PM, when asked if an MDS assessment accurately reflects a resident's status if admitting diagnosis are missing, the DON answered no. The DON answered yes when asked if information from residents' assessments should be accurately reflected on their care plan and MDS assessments. During an interview on 06/13/2024 at 2:46 PM, when asked if an MDS assessment accurately reflected a resident's status if admitting diagnoses are missing, the ADM answered no. The ADM answered yes when asked if information from residents' assessment should have been reflected on their care plan and MDS. During an interview on 06/13/2024 at 2:19 PM, the ADM stated that MDS does not have a related policy and the facility follows the RAI manual. Review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023, reflected the intent of Section I: Active Diagnosis was to code diseases that have a direct relationship to the resident's currents current functional status, cognitive status, mood or behavior status, medical treatments, and nursing monitoring. It also reflected that the MDS assessment was to provide an updated, accurate picture of the resident's current health status. Further review reflected to document active diagnoses on the MDS such as cancer and psychiatric/mood disorder.

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 6 of 10 residents reviewed for the usage of Blood Pressure Monitors (Resident #28, Resident #73, Resident #41, Resident #75, Resident #84, and Resident #198) as indicated by: The facility failed to ensure MA B, MA C and LVN A disinfected the blood pressure monitors between the residents. These failures could place the residents at risk for cross contamination and infection. Findings included: Review of Resident #28's face sheet on 05/10/23 reflected the resident was an [AGE] year-old female and was admitted to the facility on [DATE].The diagnoses included Heart failure, Hypertension (High Blood pressure) , History of Falling, Insomnia, Anemia, Major Depressive Disorder, Vitamin D Deficiency, Retention of Urine, Hyperlipidemia (Excess fat in blood), Seasonal Allergic Rhinitis(Common Allergy) , Type 2 Diabetes Mellitus, Muscle Weakness, Cognitive Communication Deficit, Dysphagia (Difficulty in swallowing), Dementia, Psychotic Disturbance, Mood Disturbance and Anxiety. Record review on 05/10/23 of Resident #28's MDS assessment dated [DATE] revealed a BIMS score of 07 out of 15 indicating the cognition of the resident was severely impaired. Record review on 05/10/23 of Resident #28's MAR of May,2023 reflected: Carvedilol Tablet 25 MG. Give 1 tablet by mouth two times a day for HTN hold for SBP <110, HR <60. Review of Resident #73's face sheet on 05/10/23 reflected the resident was a [AGE] year-old male and was admitted to the facility on [DATE]. The diagnoses included Muscle weakness, Cognitive Communication Deficit, Abnormalities of Gait and Mobility, Dysphagia (Difficulty in swallowing), Muscle Wasting and Atrophy (Decrease in muscle size), Pain, Dementia, Psychotic Disturbance, Mood Disturbance, Anemia, Type 2 Diabetes Mellitus, Hyperlipidemia (Excess fat in blood), Chronic Constipation, Depression, Chronic Obstructive Pulmonary Disease (Breathing Difficulties) and Age-Related Physical Debility. Record review on 05/10/23 of Resident #73's MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 indicating the cognition of the resident was moderately impaired. Record review on 05/10/23 of Resident #73's MAR of May,2023 reflected: Carvedilol Oral Tablet 3.125 MG (Carvedilol), Give 1 tablet by mouth two times a day for HTN hold for SYT <110 <60 During an observation on 05/10/23 at 10:00 AM revealed MA B was administering medications to the residents in Hall 200. MA B used a wrist blood pressure monitor to take blood pressure of Resident #28 and then administered the ordered medications. After that he moved on to Resident#73 and took blood pressure using the same blood pressure monitor. MA B did not sanitize the blood pressure monitor before and after using it on Resident#28 and after the completion on Resident#73. During an interview on 05/10/23 at 10:30 AM, MA B stated he forgot to sanitize the blood pressure monitor before and after he used it on residents. He said sanitizing the monitor was necessary to minimize the spread of transmittable diseases. When the investigator asked about the training or in-services she received, MA B stated there were in-services on infection control every now and then. However, he did not remember if he received any in-service specific to sanitization of medical equipment. Review of Resident #41's face sheet on 05/10/23 reflected the resident was an [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Unsteadiness on feet, Anoxic Brain Damage (Brain damage due to lack of oxygen supply), Epilepsy(seizure disorder), Muscle Weakness, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Hypertension, Cognitive Communication Deficit, Dementia, Agitation, Anxiety Disorder, Insomnia and Major Depressive Disorder. Record review on 05/10/23 of Resident #41's MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 indicating the cognition of the resident was moderately impaired. Record review on 05/10/23 of Resident #41's MAR of May,2023 reflected: Lisinopril Tablet 5 MG. Give 1 tablet by mouth one time a day for HTN Hold if SBP<110, P<60 Review of Resident #75's face sheet on 05/10/23 reflected the resident was an [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Hypertensive Heart Disease, Acute Embolism and Thrombosis (Blood clot in blood vessel and moving this clot through the blood stream) , Pain in right leg, Unsteadiness on Feet, Other abnormalities of gait and mobility, Muscle Weakness, Dysphagia (Difficulty swallowing), Cognitive Communication Deficit, Dementia, Anxiety, Schizophrenia, Major Depressive Disorder and Dysuria (Painful Urination). Record review on 05/10/23 of Resident #75's MDS assessment dated [DATE] revealed a BIMS score of 99 out of 15 indicating the cognition of the resident could not determine. Record review on 05/10/23 of Resident #75's MAR of May,2023 reflected: Lisinopril Tablet 5 MG. Give 1 tablet by mouth one time a day for HTN Hold if SBP<110, P<60. During an observation on 05/10/23 at 11:00 AM revealed LVN A was administering medications to the residents in Hall 400. LVN A used a wrist blood pressure monitor to take the blood pressure of Resident #41 and then administered the ordered medications. After that she moved on to Resident #75 and took blood pressure using the same blood pressure monitor. LVN A did not sanitize the blood pressure cuff before and after using it on Resident #41 and after the completion on Resident #75. During an interview on 05/10/23 at 1:00PM, LVN A stated she was aware that sanitizing medical equipment before and after the use on residents was important to control the infections that were transmittable. LVN A said she was in a hurry and forgot to sanitize the blood pressure monitor. When the investigator asked about the training or in-services she received, LVN A stated she did not remember any in-service she received on sanitization of medical equipment in the past. Review of Resident #84's face sheet on 05/10/23 reflected the resident was an [AGE] year-old male and was admitted to the facility on [DATE]. The diagnoses included Encephalopathy (disease of the brain that alters brain function), Heart failure, Retention of Urine, Hyperlipidemia (Excess fat in blood), Hypertension, Cerebral Infarction (stroke), Muscle Wasting, Lack of Coordination, Unsteadiness on feet and Lower back Pain. Record review on 05/10/23 of Resident #84's MDS assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating the cognition of the resident was moderately impaired. Record review on 05/10/23 of Resident #75's MAR of May,2023 reflected: Cozaar Oral Tablet 25 MG (Losartan Potassium). Give 1 tablet by mouth two times a day for HTN hold if SBP<110 p<60. Amlodipine Besylate Oral Tablet, 10 MG (Amlodipine Besylate), Give 1 tablet by mouth one time a day for HTN hold if SBP <110 p 60. Hydrochlorothiazide Oral Tablet 25 MG (Hydrochlorothiazide), Give 1 tablet by mouth one time a day for HTN hold for SBP <110 p<60. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate), Give 1 tablet by mouth one time a day for HTN hold if SBP<110 p<60. Review of Resident #198's face sheet on 05/10/23 reflected the resident was a [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Hyperlipidemia (Excess fat in blood), Diabetes Mellitus, Constipation, Hypertension, Schizophrenia, Major Depressive Disorder, and Pain Record review on 05/10/23 of Resident #198's MDS assessment dated [DATE] revealed that Resident #198 was a newly admitted resident (on 05/03/23), and the BIMS was not completed. Record review on 05/10/23 of Resident #75's MAR of May,2023 reflected: Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate), Give 0.5 tablet by mouth two times a day for HTN Hold for SBP<110 or DBP<60. An observation on 05/10/23 at 11:30 AM revealed MA C was administering medications to the residents in Hall 100. MA C used a wrist blood pressure monitor to take the blood pressure of Resident #84 and then administered the prescribed medications for blood pressure as per the order. After that she moved on to Resident #198 and took the blood pressure using the same blood pressure monitor. MA C did not sanitize the wrist blood pressure monitor before and after using it on Resident#84 and after the completion on Resident #198. During an interview on 05/10/23 at 1:30PM, MA C stated she forgot to sanitize the pressure monitor before and after using it. She said sanitizing pressure monitor in between the residents was important to control infections. When the investigator asked about the training or in-services she received, MA C stated she received in-services on infection control every month. She said she did not receive any in-service on sanitization of medical equipment in the recent past. During an interview with DON on 05/11/23 at 3:00 PM, DON stated the staff followed the instructions in the facility policy. DON stated medical equipment should be sanitized before and after and in between the residents to minimize the spread of transmittable diseases. The staff who were non-compliant to the policy were identified by observation and then provide in-services. During an interview with ADM on 05/11/23 at 3:30PM, she stated staff was required to follow facility policy. When the investigator asked how the facility ensured an effective infection control at the facility, ADM said the facility achieved that through tracking, infection control auditing and clinical meetings. When ADM was requested to further elaborate, she explained staff were constantly observed and monitored by DON who was the Infection Preventionist to identify deficiencies in infection control. She stated the identified staff were trained and an in-service was conducted for all the staff members. Record review of the facility's in-services conducted at the facility as of 04/05/23, since 01/01/23, reflected there were no in-services on disinfection of medical Equipment. Record review on 05/11/23 of the facility's policy IPCP Standard and Transmission-Based Precautions revised in 10/22 reflected: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . . Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . . 2. Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. (e.g., MDROs) . . c. Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.

Based on observations, interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for one (Resident #62) of four residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to provide Resident #62 with her food preferences with consistency, for breakfast and lunch during her entire stay at the facility from the day of admission (11/08/22). Resident #64 requested not to have tomatoes, sausage, and eggs. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for adverse effect from food, frustration, not enjoying meals, and weight loss. Findings included: Review of Resident #62's face sheet on 05/10/23 reflected the resident was a [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Displaced subtrochanteric fracture of right femur (fracture of the top of the thigh bone), Dementia, Psychotic Disturbance, Anxiety, Type 2 Diabetes Mellitus, Hyperlipidemia (Excessive fat in blood), Chronic Kidney Disease, Cognitive Communication Deficit, Dysphagia (Difficulty in swallowing), Muscle Weakness, Repeated Falls, Heart Disease, Hypertension, Vitamin D Deficiency and Chronic Kidney Disease. Record review of the MDS assessment dated [DATE] revealed Resident #62 had a BIMS of 15 which indicated intact cognition and required supervision for transfers, personal hygiene, and eating. Record review on 05/11/23 of Resident #62's care plan dated 11/15/22 revealed that there was no care plan for Resident #62's food preferences. Record review on 05/11/23 of the progress note for Resident #62 by RD dated 11/30/22 and 02/02/23 stated: . Would like no sausage, no eggs, no coffee, no pancakes, no tomatoes, no orange juice. Would like oatmeal and milk at breakfast. During an interview on 05/09/23 at 12:45 PM with Resident #62, she stated she had complained multiple times to the facility about non consideration of her food preferences. Resident #62 stated that issue persisted since her day of admission at the facility (11/08/22). Resident #62 stated her report to the nursing staff and the dietician at various occasions did not yield any positive outcome. Resident #62 stated, at that time, she used her refrigerator in her room to store the food of her choice as some days, the facility served food that she did not want. Resident #62 stated she had a history of stomach ulcer and tried to avoid anything acidic and the kind of food that generate too much gastric acid. She stated she was frustrated due to the inaction from the facility and started storing her choices of food in the refrigerator as an alternative solution. Interview on 05/11/23 at 11:00 AM with the MDSN revealed she was the Guardian Angel (Care Coordinator) of Resident #62. She stated on 05/11/23, the facility served sausage and eggs and later this was substituted with oatmeal and milk on resident's request. MDSN stated she was under the impression that all these days, the kitchen was serving the food the resident had requested. Interview on 05/11/23 at 1:00 PM with the DS revealed, on 5/11/23 Resident #64 was served with sausage and egg for breakfast and on 5/10/23, BBQ pork Riblet with BBQ sauce on top of it, Cole Slaw, and Pinto beans for lunch. DS said on both days Resident #62 declined the food served. When investigator asked about Resident #62's food preferences, DS stated she was unaware of any restrictions on food. She said she understood residents' food choices through the instructions by RD and personal interviews. DS stated she started working at the facility about two months ago and yet not interviewed Resident #62. RD said she never received any instructions from DS about Resident #62's food preferences. During the interview over the telephone on 05/11/23 at 2:00 PM with family member of Resident #62 it was revealed Resident #62 did not eat eggs, sausage, and anything too acidic like tomatoes. He stated Resident #62 had history of stomach ulcer and was on food restrictions. He said the food restrictions were already there somewhere on Resident #62's medical records. He said Resident #62 was somewhat shy to express her needs assertively and had the nature of looking for alternative solutions instead. During the interview on 05/11/23 at 2:30 pm, the SRD revealed she was the supervisor of RD and RD was no longer working with the facility. SRD said she was aware of RD's lack of communication in general with DS and other staff members about residents' food choices, preferences, and restrictions. SRD stated it must have been frustrating for Resident #62 as her preferences were not addressed properly for a very long period. SRD stated this aspect of the care was taken care of already and the new RD for the facility would not repeat the same mistake. During the interview on 05/11/23 at 3:00 PM, the DON stated it was the responsibility of the facility to respect Resident #62's food preferences. She stated it was frustrating for the resident when her needs were not met in a timely manner. When investigator asked about care planning, the DON stated Resident #62's food preferences should have been in the care plan. She stated the lack of a care plan was one of the reasons for that issue. During an interview on 05/11/23 at 3:30 PM, the ADM stated she expected the staff at the facility to honor resident food preferences. When investigator asked about the potential negative outcome, ADM stated it would affect residents' health and quality of life, Dignity, and a possibility of weight loss. Record review on 05/11/23 of Facility policy Food and nutrition Services revised in 09/2017 reflected: It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices including their nutritional, religious, cultural, ethnic and including liberalizing diet needs while using established national guidelines. 1. Menus prepared will reflect facility's reasonable efforts to include religious, cultural, and ethnic needs of the resident population with input received from residents and resident groups. Record review on 05/11/23 of Facility policy Leadership, Nursing Services revised in 05/2007 reflected: . Nursing service staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhance each resident's dignity and respect in full recognition of his or her individuality . . Resides and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered . . Chooses activities schedules and health care consistent with his or her interest, assessments, and plans of care and makes choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, interviews, and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, for 1 of 4 residents (Resident #84) reviewed for a homelike environment. The facility failed to ensure the dents and scuffs on the interior wall of Resident #84's room were repaired and painted. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Review of Resident #84's face sheet on 05/10/23 reflected the resident was an [AGE] year-old male and was admitted to the facility on [DATE]. The diagnoses included Encephalopathy (damage or disease that affects the brain), Heart failure, Retention of Urine, Hyperlipidemia (too much fat in the blood), Hypertension (High Blood Pressure), Cerebral Infarction (stroke), Muscle Wasting, Lack of Coordination, Unsteadiness on feet and Low back Pain. Record review of the MDS assessment dated [DATE] revealed Resident #84 had a BIMS of 14 which indicated intact cognition and only required supervision for bed mobility, transfers, and eating. During an observation on 05/10/23 at 10:00 AM, it was revealed there were two parallel vertical dents on one of the walls with 4-inch (approx.) space in between them. Each dent was measuring approximately 24-inch L x 3inch W x 1.5-inch or less D (max. at the middle of the dent). There were also scuff marks of various sizes and shapes at various places of the walls. During an interview on 05/10/23 at 10:00 AM, Resident #84 said his only concern about living at the facility was his ugly looking room due to the dents and scuff marks on the wall. Resident #84 stated he had reported the problem multiple times to different staff members since he was admitted to the facility on [DATE]. Resident #84 stated he was very disappointed that no one came into his room to address the issue. Resident #84 stated he saw maintenance people fixing things in his hall (Hall 100) on many occasions. However, nobody cares to come and repair the damages on the wall in his room. During an interview on 05/10/23 at 11:30 AM, AS stated she was the Guardian Angel (Care Coordinator) for Resident #84. AS stated, she started her job as AS on 04/10/23. She said Resident #84 complained to her about the damaged wall sometime in the 2nd week of April 2023. AS stated, as the condition of the wall needed repair work, she immediately filled out the facility 'Guardian Angel Complaint Sheet stating about the damaged wall and handed over to ADM. When investigator asked about the follow up on the complaint AS stated she did not do any follow up on it. During an interview on 05/11/23 at 11:00 AM., MAINT stated he started working at the facility about three months ago. MAINT stated he was unaware of the damage on the wall as it was not communicated to him by anyone. MAINT said he created a maintenance log based on reports from various sources including reports from staff. MAINT said he interview residents individually as well to know their requirements and had not yet interviewed Resident #84. The investigator requested a copy of the log however, MAINT was unable to produce it. He stated the log was saved on his mobile phone and did not know how to make a copy. MAINT stated he had some maintenance works two weeks ago in Hall 100. However, he did not go to Resident #84's room since he was unaware of the issue. During an interview on 05/11/23 at 3:00 PM, DON stated it was the responsibility of the staff to make the facility a homelike environment. She stated this was achieved by allowing residents to have their personal belongings as much as possible and providing clean, neat, and tidy environment at the facility all the time including individual rooms of the residents. DON stated the damage on Resident #84's wall had to be serviced as soon as resident reported about it. When the investigator asked about the reporting, DON stated any staff who noticed the issue should have reported it to MAINT. During an interview on 05/11/23 at 3:30 PM., ADM said she received the Guardian Angel Report from AS about the damaged wall in Resident #84's room. ADM said she did communicate about it with MAINT as the repair work in Resident #84 was important to create a comfortable environment for the resident at the facility. When investigator asked about the follow up on the repair, ADM stated she did not do any follow up to make sure the work was completed and reported that MAINT was already started working on it Review on 05/11/23 of facility policy Resident Rights and Responsibilities revised in 01/2022 reflected: It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility . . Safe Environment: You have a right to a clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations, interviews, and record reviews, the facility failed to have the results of the most recent survey of the facility posted in a place readily available to all residents, family members, and legal representatives for the facility reviewed for residents rights. The facility failed to post the facility's most recent inspection reports. This deficient practice prevented residents from exercising their rights and placed them at risk of having no awareness of the facility's inspection history and any plans of correction the facility should have in place. Findings included: During a confidential interview on 5/10/23 at 10:40 am, 10 confidential interviewees said they were not sure if the results of the most recent survey of the facility were available to read. The confidential interviewees also said they did not know where the results of the most recent survey of the facility were posted in the facility. During an observation on 5/10/23 at 2:58 pm, postings regarding residents' rights, local ombudsman's contact information, infection preventionist contact information, and abuse coordinator's contact information were posted on a wall near the RCPT's desk in the front entrance area. The results of the most recent survey of the facility were not posted on the same wall. During an interview on 5/10/23 at 3:04 pm, the RCPT said he did not know where the results of the most recent survey of the facility were posted in the facility. The RCPT said he knew the results of the most recent survey of the facility were supposed to be available to all residents, family members, and legal representatives of residents. The RCPT said he would ask the Operations Manager where the results of the most recent survey of the facility were. During an interview on 5/10/23 at 3:07 pm, the Operations Manager said he was looking for the results of the most recent survey of the facility. The Operations Manager said the results of the most recent survey of the facility was in a binder that usually sat on a table across from the RCPT's desk. The Operations Manager said he believed the binder might be with a resident or family member. The Operations Manager said the ADM was responsible for ensuring the results were posted in a place readily accessible. During an interview on 5/11/23 at 3:16 pm, the ADM said the results of the most recent survey of the facility was in a binder that was usually kept on a table across from the RCPT's desk. The ADM said she believed the facility's corporate office representatives were reviewing the binder as part of their mock survey process and did not return the binder to the table. The ADM later said she found the binder in her office on one of her shelves. The ADM said she was responsible for ensuring the results were posted in a place readily accessible. A Federal Residents Rights policy and procedure revised on 2/24/22 stated under the Information and Communication Section, You have the right to: ? examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

Based on observation, interview, and record review, the facility failed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 staff observed for wearing a mask correctly (Staff A). Staff A was observed with his N95 mask pulled down to his chin exposing his nose and mouth area. This failure could place residents at risk of acquiring infectious diseases including COVID 19, leading to illness and possible hospitalization . Findings Included: Record review of R1 medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8-11-22 at 9:35 AM, AD stated there were 3 COVID-19 positive residents in the hot unit. On 8-11-22 at 4:21 PM, Staff A was observed walking down the hallway, pushing his laundry bin with his N95 mask pulled down to his chin exposing his nose and mouth area. Staff A walked within a few feet of R1 and R2 who were not wearing masks. During an interview on 8-11-22 at 4:25 PM, Staff A stated that he had been trained in PPE. Staff A stated that N95 masks are mandatory and had to be worn as soon as you walk into the building. Staff A stated the correct way to wear a mask was it had to cover the nose and mouth. Staff A stated the reason he was not wearing his mask correctly was that it was too hot. Staff A stated the importance of wearing a mask correctly was to stop the spread of COVID-19 and keep the staff and residents safe. Staff A stated he was aware that there were COVID-19-positive residents in the facility. A record review of the facility-provided record of in-service dated 6-8-22 titled Infection Control revealed CDC literature titled How to Properly Put on and Take off a Disposable Respirator- Cup the respirator in your hand allowing the headbands to hang below your hand. Hold the respirator under your chin with the nosepiece up. The top strap goes over and rests at the top back of your head. During an interview on 8-12-22at 11:15 AM, ADON stated all staff had been trained in PPE. ADON stated that training included online computer, verbal demonstrations, and handouts from the CDC that showed how to correctly wear PPE. ADON stated the facility mask policy was that all staff must wear masks at all times when inside the facility no exceptions. ADON stated the correct way to wear a mask was it must cover the nose and mouth no exceptions. ADON stated staff must always wear a mask correctly, especially when in the presence of residents, no exceptions. ADON stated there was no reason why any staff member should not be wearing a mask correctly while inside the facility. ADON stated if a staff member needs to take a breath they can go outside to catch their breath. ADON stated that it's too hot is not a reason not to wear a mask correctly. ADON stated it is important to wear masks correctly to stop the spread of COVID-19 and protect the residents and each other. During the interview on 8-12-22 at 11:55 AM, AD stated all staff had been trained in PPE. AD stated that staff had been given online-computer, verbal demonstrations, CDC literature, and one-to-one PPE training. AD stated everyone who comes into the building must wear masks at all times. AD stated the correct way to wear a mask was it had to cover the nose and mouth. AD stated it was important to wear a mask correctly to protect the patients and staff from COVID-19 and respiratory illnesses. AD stated that there was not any reason why any staff member should not have been wearing their mask correctly. A record review of facility-provided Infection Control and Prevention Policy dated 3-9-2020 revealed-Personal Protective Equipment-HCP must receive training on and demonstrate an understanding of when to use PPE; what PPE is necessary; how to properly don, use, and doff PPE in a manner to prevent self-contamination. Respiratory Protection-Use respiratory protection (respirator) that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering facepiece respirator before entry into the patient room or care area.

Based on observation and interview 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 food items in the refrigerator were not expired. The facility failed to ensure food items in the refrigerator were dated and labeled appropriately. These failures could place residents at risk for food-borne illness, and food contamination. Findings included: Observations of the refrigerator in the kitchen on [DATE] at 10:00 A.M. revealed that the following items were expired: One tray of pork stew with prepared date [DATE] and used by date [DATE]. One 0.5-gallon lemon juice bottle (contains ¼th lemon juice) with Best by [DATE]/22 printed on it. The following items were not dated and/or labeled: One plastic container with a brown colored thick liquid dated [DATE] and had no name and use by date. One steel container with a brown liquid had no name, prepared, and use by date. One square plastic container with a brown substance looks like minced tuna had no name, prepared date and use by date. One bundle of sliced cheese with no opened and use by date. One block of ham in a plastic zipper bag had opened date [DATE] however no use by date. One block of shrink-wrapped ham had no dates. Observations of the kitchen's dry storage area on [DATE] at 10:00 A.M. revealed that the following items were expired: One ½ filled jar of Kikkoman Soy Sauce with Refrigerate after opening for quality and Best by 30 [DATE] printed on it. One ½ filled jar of Kikkoman Soy Sauce with Refrigerate after opening for quality and Best by 30 [DATE] printed on it One ,d+[DATE]th filled one gallon jar of pan cake and waffle syrup with 'store in a cool, dry place' printed on it. The opened date was [DATE]. The jar was puffed up with gas. The Executive Director (ED) who was the Acting Director of Dining Services (ADDS) on [DATE] at 11.00 A.M. toured with INV- A and INV-B and observed the above-mentioned items and deficiencies. During the interview ED said that they did not have a facility policy and procedure and follow the guidance from Texas Food Establishment Rules (TFER) for storing, preparing, distributing, and serving food. The ED said that they are in the process of recruiting Director of Dining Services (DDS) . She believes that with the proper leadership of a DDS such failures could be eliminated. During the interview over the phone with Dietary Resource Person (DRP) on [DATE] at 1pm stated that the facility follows the guidelines from Texas Food Establishment Rules (TFER) for storing, preparing, distributing, and serving food. The expectations were, any leftovers would be thrown away after 72 hours of preparation, expired items must be discarded appropriately, and every item received must be stored after writing the received date. She also said every item in use should have a sticker with the name of the item, date opened and use by date.

Based on observation, 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 reviewed in that: 1. A reach-in refrigerator did not have a thermometer inside. 2. Nozzle of drink dispensing machine for thickened and regular consistency beverages was on the ground, not connected to drink mix. 3. The walk-in freezer was not maintaining a temperature of 0 degrees Fahrenheit and the coils were frozen over. 4. There were food items inside the walk-in freezer and walk-in refrigerator that were not labeled/dated and nor sealed properly. 5. Black-brownish slimy residue and build-up on can opener. 6. The fryer was uncovered while not in use. 7. 2 dented cans found on the canned storage rack. 8. Clean bowls were not stored facing upward which revealed brown and yellow crumbs. 9. Steam table wells had reddish-brown residue buildup. These deficient practices can place residents who ate food from the kitchen at risk for food borne illness. The findings were: 1. During an observation and interview on 4/12/2022 at 9:25 A.M. in the kitchen, revealed a temperature gauge outside the reach-in refrigerator which read 35-degrees Fahrenheit. Observation inside the reach-in revealed no internal thermometer gauge. Sister facility CDM said she could not find a thermometer inside the reach-in and that there should be one. Inside refrigerator appeared to have a dirty residue along the bottom edge. Record review on 04/14/2022, of reach-in refrigerator temperature log revealed ranges of temperatures from 34 - 40 degrees Fahrenheit. 2. During an observation on 04/12/2022 at 9:26 A.M., with Cook A in the kitchen, there was a drink dispensing machine for thickened and regular consistency beverages. Drink nozzle was on the ground, not connected to drink mix or placed in a safe non-contained area for holding. During an observation and interview with Cook A, on 04/12/2022 at 9:50 A.M., thin liquid nozzle of fountain machine was not coming off, signs of red stain or residue build-up on nozzle. Cook A said the nozzle is cleaned weekly. Record review on 04/14/2022 of facilities dietary cleaning schedule had no indication of when nozzles for fountain machine are cleaned. 3. During an observation on 04/12/2022 at 9:28 A.M., ice build-up on walk-in freezer fans. Noted at 9:29 A.M. that ice build-up was on floor of walk-in freezer and discoloration to the freezer walls. During an observation on 04/13/2022 at 3:55 P.M., walk-in freezer outside temperature gauge blinking AH with a number. Record review on 04/13/2022 at 3:58 P.M., Regional CDM and sister facility CDM reviewed manufactures instructions on freezer. AH meaning Air High no other information available on American Panel Walk-in Freezer discussing what AH indicated. During an observation on 04/13/2022 at 3:54 P.M., walk-in freezer temperature inside read 25 degrees Fahrenheit. Noted soften vegetables at time of walk through. In an interview on 04/13/2022 at 3:56 P.M., a sister facility CDM who was at current facility providing aid during survey, said that they called maintenance around 11:11 am on 04/13/2022 to come inspect the walk-in freezer. At time of interview, she called on maintenance supervisor (MS) to come assess freezer and contact Direct Supply for service request. In an interview on 04/13/2022 at 3:58 P.M., Regional CDM said that they are not sure if regular scheduled maintenance of walk-ins is done. They would contact maintenance to ask. Record review on 04/14/2022, revealed that temperature logs for walk-in freezer starting on April 1, 2022 through April 14, 2022 had temperatures above desired range. March 2022 temperature log indicated walk-in freezer was at zero or below degrees Fahrenheit. Record review of the Texas Food Establishment Rules, dated January 2021, S554.1111 Certified Food Protection Manager and Food Handler Requirements S554.1111 (g) revealed: (g) The facility and all food service personnel must meet the standards imposed by local, state, and federal codes regarding food and food handling. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: . Stored frozen FOODS shall be maintained frozen Record review on 04/14/2022, work order between facility MS and Direct Supply technician revealed parts needed for Walk-in freezer. Record review on 04/14/2022, email notes from 12/2021 work order placed for walk-in freezer. Issue with walk-in freezer revealed unit evaporator motor not working, evaporator frozen, compressor making loud noise, dirty coils and low on 404A. Direct Supply revealed they replaced motor, cleaned condenser coils, and charged unit with 404A. In an interview at 3:47 P.M. on 04/13/2022, Regional certified dietary manager (RCDM) said that the Texas Food Establishment Rules (TFER) are the policies and procedures the facility follows. In an interview on 04/13/2022 at 4:03 P.M., MS said that they perform maintenance checks on outside connections. In an interview on 04/13/2022 at 4:04 P.M., MS said that the walk-in freezer coil was frozen in the back located behind the fans. MS will call Direct Supply as an emergency work order. Per MS with emergency call made they come within 3 hours to assess issue. In an interview on 04/13/2022 at 4:06 P.M., Sister facility CDM said that they will continue to check the temperature of freezer while they wait for Direct Supply. Sister facility CDM said alternative plan will be to send food to her facility (sister facility) that is nearby to keep food at appropriate temperatures. In an interview on 04/14/2022 at 10:03 A.M., Sister facility CDM said they had removed all frozen food items out of walk-in freezer the night before. They are waiting for a part Direct Supply needed to fix freezer. In an interview on 04/14/2022 at 10:03 A.M., Sister facility CDM said Direct Supply came at 5:00 P.M. on 04/13/2022, stated a part needed to be ordered. Per Sister facility CDM decided to ship all food items to sister facility close by. In an interview on 04/14/2022 at 10:16 A.M., MS said that there is an open order for a repair with Direct Supply. MS said that no one before sister facility CDM notified him of issue with walk-in freezer. In an interview on 04/14/2022 at 10:18 A.M., MS said that the issue with the walk-in freezer is the electrical board inside is bad, handles defrosting of the fans and reason for ice build-up. In an Interview on 04/14/2022 at 4:08 P.M., Administrator said that a negative outcome can occur when temperatures of walk-in freezer are not kept at appropriate temperatures harm to residents can occur. Said that this is not a high risk of potential harm due to the sister facility being able to take food items and hold until kitchen needs it. 4. During an observation and interview with sister facility CDM on 04/12/2022 at 9:28 A.M., in the walk-in freezer with the sister facility CDM revealed an unknown unlabeled frozen vegetable and an unknown unlabeled bin of vegetables. Further observation revealed a bin with an open plastic package of tator tots spilling out into bin. The bin also had other unknown frozen food items, package was unlabeled and undated. The sister facility CDM said that all the food items in the freezer are supposed to be labelled and dated, as well as sealed properly. During an observation on 04/12/2022 at 9:31 A.M., an undated open container of ricotta cheese was in walk-in refrigerator. During an observation on 04/12/2022 at 9:33 A.M., an open, undated block of cheese was in walk-in refrigerator. During an observation on 04/12/2022 at 9:34 A.M., a best if used by date on sour cream dated 04/11/2022 was in walk-in refrigerator. Record review of the Texas Food Establishment Rules, dated January 2021, S554.1111 Certified Food Protection Manager and Food Handler Requirements S554.1111 (g) revealed: (g) The facility and all food service personnel must meet the standards imposed by local, state, and federal codes regarding food and food handling. Review of The Food and Drug Administration Food Code, dated 2017, reflected, . (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: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf . 5. During an observation and interview with Cook A, on 04/12/2022 at 9:36 A.M, there was residue and build-up on can opener blade and holding device. Cook A said that it is cleaned 3 times per day. Record review on 04/14/2022 of facilities dietary cleaning schedule revealed no indication of routine cleaning of can opener blade or holding device. 6. During an observation on 04/12/2022 at 9:56 A.M., Fryer was uncovered with buildup of brownish residue. Stove next to fryer had build-up of similar brownish residue. Record review on 04/14/2022, cleaning schedule did not reveal how often or when fryer is cleaned. 7. During an observation and interview with sister facility CDM, on 04/12/2022 at 9:37 A.M., there were 2 dented cans on can rack. Sister facility CDM said dented cans should be placed in CDM office. Record review of the Texas Food Establishment Rules, dated January 2021, S554.1111 Certified Food Protection Manager and Food Handler Requirements S554.1111 (g) revealed: (g) The facility and all food service personnel must meet the standards imposed by local, state, and federal codes regarding food and food handling. Review of The Food and Drug Administration Food Code, dated 2017, reflected, . Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard 8. During an observation on 04/12/2022 at 9:43 A.M., there were bowls with residue and debris stored right next to clean dishes. During an observation on 04/14/2022 at 11:01 A.M., bowls with residue stored right next to other clean dishes. Bowls were not turned over to prevent potential contamination of debris. Sister facility CDM walked by and notice bowls with debris. Sister facility CDM took the bowls and placed them in dishwashing area. Record review of the Texas Food Establishment Rules, dated January 2021, S554.1111 Certified Food Protection Manager and Food Handler Requirements S554.1111 (b) revealed: (b) The facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Services food service sanitation requirements. 9. During an observation and interview with Cook A, on 04/12/2022 at 9:45 A.M., reddish-brown like residue in wells of steam table. Cook A said wells are cleaned in A.M. and P.M. daily. Record review on 04/14/2022 of facilities dietary cleaning schedule revealed requires daily cleaning of steam table. In an interview on 4/14/2022 at 4:03 P.M., Administrator noted that policies and procedures for kitchen follow the Texas Food Establishment Rules (TEFR). In an interview on 04/14/2022 at 4:06 P.M., Administrator said that whoever the cook is for the shift is responsible for making sure all necessary items are being cleaned per schedule and the manager who comes in verifies that cleaning had been done.

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for 2 of 4 meals reviewed for meal accuracy. The facility failed to follow the menus, notify residents of changes, and did not note/update the menus of the changes for lunch services on 04/12/2022 and 04/14/2022 for the regular, mechanical soft, and puree texture diets. This failure could affect residents who received regular textured, mechanical soft texture, and puree texture diets by placing them at risk for weight loss and nutritionally unbalanced meals, thus not receiving the correct intake of nutrients. The findings were: Review of facility diet spreadsheet tiled Week 1, dated 04/12/2022 (Tuesday) revealed residents with regular textured diet, mechanical soft textured diet, and puree textured diet were to receive Chicken Fried Chicken Breast, Cream Gravy, Mashed Potatoes, Squash Medley, Sherbet, Wheat dinner Roll/Margarine, Beverage of Choice, Water. During an interview in the kitchen on 04/12/2022 at 09:47 A.M., Cook A pulled open the lid on the steam table to reveal food items in the steam. Cook A reported the items on the steam table were mixed vegetables and mechanical soft turkey. During an interview on 04/12/22 at 10:07 A.M., Cook A Meal for day: Turkey with brown gravy and mixed vegetables; alternatives grilled cheese, chicken noodle soup and tomato soup Observation on 04/12/2022 at 12:49 P.M., revealed residents in dining room were eating either ham or turkey, mixed veggies, buttered noodles, roll, and pudding. During an interview on 04/12/22 at 12:49 p.m. with the Regional CDM and sister facility CDM reported the residents for lunch were served reported turkey with brown gravy, mixed vegetable, a roll and pudding. The Regional CDM and sister facility CDM reported they swapped Tuesday with Thursday menu's protein choice because they could not find the chicken for the chicken fried steak. The Regional CDM and Sister Facility CDM also noted that the menu for Tuesday stated residents were to receive mashed potatoes, squash and sherbet medley. They noted that they did have mashed potatoes on hand etc.; did not have green beans; pudding instead sorbet. During an interview on 04/12/22 at 12:52 P.M., Regional CDM orders for facility; breaks down Thursday order for (Saturday-Tuesday); Monday order for Wednesday-Friday. The Regional CDM reported that as per the purchase invoice the chicken had been received on 4/08/2022 but they could not find it in the facility, and it may have been used for another meal. The Regional CDM stated that she would write the substitutions on the substitution log. Record review of delivery invoice indicated received on date of 04/08/2022, revealed Chicken Breast Patty Breaded Fried Chicken was delivered to facility. During an interview on 04/12/22 at 12:56 P.M., Spoke with Cook A on reasoning why chicken was not served at Tuesday's Lunch Meal. Cook A stated that chicken was not available and switched with Thursday's protein. During an interview on 04/13/22 at 03:47 PM RCDM noted they use the TEFR for their policy and procedures. Record review of the Texas Food Establishment Rules, dated January 2021, S554.1107 Certified Food Protection Manager and Food Handler Requirements S554.1107 (d and e) revealed: (d) The facility must retain records of menus served, including substitutions, and food purchased for 30 days. A list of residents receiving special diets and a record of their diets must be kept in the dietary area for at least 30 days. (e) The facility must post the current week's menu: (1) in the dietary department, including therapeutic diet menus, so employees responsible for purchasing, preparing, and serving foods can use it; and (2) in a convenient location so the residents may see it. Review of facility diet spreadsheet tiled Week 1, dated 04/14/2022 (Thursday) revealed residents with regular textured diet, mechanical soft textured diet, and puree textured diet should have received Turkey Pot Roast, Brown Gravy, Parslied Buttered Pasta, Italian Green Beans w/Pimento, Garlic Bread Stick, Raspberry Pears, Beverage of Choice, Water. However, residents received Week 1 Tuesday's meal of Chicken Fried Chicken Breast, Cream Gravy, Mashed Potatoes, Squash Medley, Sherbet, Wheat dinner Roll/Margarine, Beverage of Choice, Water. Observation on 4/14/2022 at 10:09 A.M. Breaded chicken patty waiting in sheet pans to be placed in oven for lunch service. Record review of substitution log revealed the following entries: On 04/12/2022 replacement of complete meal with 04/14/2022 meal. Reason noted was product not in. However, this same record does not address substitution for green beans with mixed vegetables, nor pudding in place of sherbet for 04/12/2022 meal. Record review of resident council meeting minutes on 04/13/22 at 09:25 A.M., Revealed pattern of meal issues. Residents not knowing what is going to be served, not getting the food they want, not being able to get coffee at night. During resident council interview on 04/13/2022 at 02:14 P.M., Resident # 41 stated I am diabetic and is always served bread even after verbalizing to staff he does not want bread on his plate. During resident council interview on 04/13/2022 at 2:39 P.M., Resident #21 stated that there has been no snacks given in about 3-4 months. He states when he is hungry, and staff say there is no snacks to give. Resident stated that he was served a terrible burrito today and the food is not good. Resident states that food is served cold when it is served in room or in dining room. During an interview on 04/14/2022 at 4:03 P.M., the Administrator indicated that menus are verified and appropriate alternatives for facility are reviewed by manager who is coming to the facility that day. The manager will look ahead to help make sure no gaps between food deliveries and items in stock for facility. Working a month, a head she noted. If a manager is not at a facility the kitchen staff will contact a manager via phone to verify appropriate substitution or alternative. During an interview on 04/14/2022 at 4:05 P.M., Administrator indicated she was unaware of the switch of protein at lunch meal. Noted that she will follow up and see what happened on Tuesday of why the meats were switched. During an interview on 04/14/2022 at 4:09 P.M., the Administrator indicated that not 100% sure which days food and supply shipments arrive, possibly Tuesday and Friday and that managers are the ones to check items delivered.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections to 15 out of 15 residents (Resident # 1- Resident #15) reviewed for infection control, in that: A. The facility failed to set up and utilize a COVID-unknown unit in adherence with the CDC guidelines. B. The facility failed to perform hand hygiene and don and doff gowns, gloves, and face shields correctly when entering and exiting COVID-unknown and COVID-positive resident rooms. C. The facility failed to frequently sanitize equipment and high-touch surfaces, or to ensure that staff were able to identify appropriate disinfecting procedures. D. The facility failed to immediately place nine residents (Resident #7 - Resident #15) on the COVID-unknown unit who were potentially exposed to [MEDICAL CONDITION] by a COVID-positive staff member. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 1/22/2021 at 4:30 PM. While the IJ was removed on 1/25/2021 at 11:15 AM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures could place residents at risk for contracting healthcare-acquired infections. Findings include: A. During an interview on 1/20/21 at 8:35 AM with the ADM, she stated that they currently had 45 residents that had tested positive for COVID. She stated that seven were in the hospital, and 38 were residing in their two COVID-positive units. She stated they had a total of 23 staff members that were currently positive. Observation on 1/20/21 at 12:18 PM on the COVID-unknown unit revealed all resident doors to be open. There was no signage on the doors of resident rooms indicating that transmission-based precautions were required, or that these residents were in quarantine. There was no PPE observed outside or near the rooms that would necessary to don before entering a COVID-unknown room. The COVID-unknown unit was adjacent to the COVID-positive unit with no physical barrier between them. Observations from 1/20/21 9:00 AM to 1/22/21 at 3:00 PM, revealed the resident room doors open on the COVID-unknown unit, which is not in adherence with the CDC guidelines. B. Observation on 1/20/21 at 12:20 PM revealed disposable isolation gowns hanging above and touching biohazard bins inside the rooms on the COVID-unknown unit. During an interview on 1/20/21 at 1:36 PM, RN stated that she had concerns about having to reuse the disposable isolation gowns. These gowns were hung right next to and touched one another inside of the rooms. She stated that on the first day of their work week they received a new gown and on the last day of the work week the gown was put in the biohazard bin. She stated that that there is no way of knowing if your gown has been contaminated or if another staff member has worn used your gown. Review of Resident #1's medical chart reflected a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/20/21 at 1:30 PM revealed RN performing wound care on Resident #1. RN failed to perform hand hygiene and apply clean gloves after removing the soiled dressing. Observation on 1/21/21 at 11:09 AM revealed RA standing in Resident #1's room on the COVID-unknown unit at the foot of the bed. CNA was not wearing an isolation gown. During an interview on 1/21/21 at 11:12 AM with RA, she stated that she is supposed to wear a gown, gloves, mask, and a face shield or goggles when going into a COVID-unknown resident room. She stated that she was educated on this during multiple in-services. Observation on 1/21/21 at 11:19 AM revealed RA going into Resident #1's room on the COVID-unknown unit. She brushed against the privacy curtain and then moved the curtain with her hands. She was not wearing gloves or an isolation gown. Observation on 1/22/21 at 12:55 PM revealed RN walk into Resident #1's COVID-unknown room with medications and a cup of Med Pass liquid. RN was not wearing gloves or an isolation gown. She started to set the medications on the over-bed table, which was situated over the resident while she was eating her lunch. RN then noticed the Surveyor was in the room. RN then turned around and went to the doorway where she donned her gown and gloves without performing hand hygiene. Review of Resident # 2's medical chart reflected a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/20/21 at 4:40 PM revealed MA B use the door handle to enter Resident # 2's room on the COVID-positive unit without wearing gloves or performing hand hygiene. During an interview on 1/20/21 at 4:44 PM with MA B, he admitted that he did not wear gloves or perform hand hygiene when entering Resident #2's room. He stated that he entered the room to deliver medications to the resident. He stated that he had been in-serviced on the donning and doffing of gloves. Review of Resident #3's medical chart reflected an [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/20/21 at 1:28 PM revealed RN go into Resident #3's room on the COVID-unknown unit with medication and a cup of fluid without donning gloves or a gown. She placed these items on Resident #3's bed-side table, which was situated over the resident who was sitting up in bed. Review of Resident #4's medical chart revealed [AGE] year-old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/20/21 at 4:44 PM revealed MA B use the door handle to enter Resident #4's room on the COVID-positive unit without wearing gloves or performing hand hygiene. Review of Resident #5's medical chart revealed a [AGE] year-old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/21/21 at 4:14 PM revealed MA B removing gloves and exiting Resident #5's room on the COVID-positive unit. Without performing hand hygiene, he opened a closet and retrieved a pillow. MA B then went to the linen cart and retrieved a pillow case. He then returned to Resident #5's room and donned a new pair of gloves. Review of the facility's most recent in-services reflected the following: 01/03/2021 Infection control Hand washing, donning/doffing, wearing shield, social distance (27 signatures) 01/19/2021 Hand washing, donning/doffing, handwashing, hand sanitizer, disinfecting (25 signatures) Observation on 1/20/21 at 12:34 PM revealed CNA B passing meals trays on the COVID-negative unit. CNA B went into a resident's room, set up the meal tray, exited the room and picked up another tray and entered another resident's room. CNA B did not perform hand hygiene between residents. During an interview on 1/20/21 at 12:41 PM with CNA B, she stated that she didn't perform hand hygiene because she did not physically touch the resident when setting up the meal tray. Observation on 1/20/21 at 12:42 PM revealed HSK B walking down the main hall wearing a KN95. Observation on 1/20/21 at 1:45 PM revealed MA C wearing a cloth face mask. During an interview on 1/20/21 at 1:45 PM MA C stated the cloth mask was approved as there was a N95 mask under it. He took off his cloth mask revealing a pocket on the inside. There was an N95 mask folded in half inside a pocket of the mask. He stated that he wore the mask in this manner because it was more comfortable. Observation on 1/20/21 at 2:02 PM revealed the NP at the nurse's station wearing a KN95 mask with ear loops. Observation on 1/21/21 at 12:03 PM revealed a staff member on the COVID-positive unit standing and charting. Her N95 mask was pulled down exposing her nose for several minutes. Observation on 1/21/21 at 12:52 PM revealed MA C coming out of a pharmacy room on the COVID-unknown unit wearing a cloth face mask. Review of the facility's most recent in-services reflected the following: 01/05/2021 Positive Building Everyone must wear N95 mask (29 signatures) 01/05/2021 N95 Proper way to wear N95 (28 signatures) During an interview on 1/20/21 at 2:05 PM with the ICS, she stated she was made aware of the masks being worn by HSK B, MA C, and the NP and immediately went to address the issue. She stated that it is the facility's policy that everyone in the facility is wearing an N95 mask. HSK B, MA C, and the NP were observed wearing N95 masks for the remainder of the day. During an interview on 1/20/21 at 2:40 PM with CNA C, she stated that this was her first day working at the facility. She stated, I didn't know where to get a clean gown, so I just used the one hanging on the 2-10 PM CNA hook. Observation on 1/20/21 at 3:45 PM revealed MA A and LVN B on the COVID-positive unit wearing fanny packs over their coveralls. They were observed going in and out of resident rooms. During an interview on 1/21/21 at 4:00 PM with MA A and LVN B on the COVID-positive unit, they stated that thy wore fanny packs over their coveralls so they could have a place for their keys, phone, a pen, etc. They stated that they do not don a gown over the fanny pack and coveralls before entering resident's rooms. They stated that they did not sanitize their fanny packs in-between resident contacts. During an interview on 1/20/21 at 3:45 PM with MA A, he stated that he wore his coveralls in the break room. He stated there were no isolations gowns on the COVID-positive unit. MA A stated that they doffed the coveralls by themselves with no assistance. During an interview on 1/21/21 at 4:20 PM with CNA E in the COVID-positive unit, she was asked to describe the procedure to doff the coveralls. CNA E stated that first she would go into the doffing room. CNA stated, First I would take off everything else, the face shield, bonnet, mask and gloves if I was wearing gloves, but I'm not. She went on to say, Then I would unzip and start rolling it down. She demonstrated unzipping with both hands. She stated that she had to take her shoes off last in order to get the coveralls all the way off. She denied having an observer or helper when doffing the suits. CNA E stated that she does not put on a clean coverall every time she came in from smoke break. During an interview on 1/21/21 at 4:28 PM, LVN D stated she did not wear the coveralls in the break room. She stated she doffs in the doffing room then moves to the break room. LVN D stated they used the same coveralls for the entire shift, indicating that she would don the same coverall after her break. During an interview on 1/22/21 at 10:00 AM with ICS, who is also the facility's ADON, she stated that the staff were not in-serviced on donning and doffing coveralls. She stated that gowns would be acceptable for the COVID-positive unit, but the staff felt safer wearing the coveralls. She stated that she was aware of staff wearing fanny packs over their coveralls, but believed they were sanitizing them at the end of their shifts. She stated that her expectations were that the staff were donning a new coverall after their break. During an interview on 1/21/21 at 9:51 AM, the CSD stated that he believed the facility had an adequate supply of PPE on hand. He stated they were currently using about 100 gowns per day now. He stated prior to the outbreak they were using around 100-150 gowns per day. He stated that the staff were not reusing isolation gowns, because there would be no reason to, as there was not a shortage of gowns. During an interview on 1/21/21 at 11:28 AM with CNA D, she described the procedure for donning and doffing PPE. To don PPE CNA D stated, Wash hands then put on gloves, then gown, and then the mask. To doff the PPE CNA D stated she would, Take off the gown and roll it up, take off the gloves, then do hand hygiene. Review of the facility's donning and doffing policy, which was to follow CDC guidelines, reflected that when doffing and donning PPE, gloves are to be put on last, and removed first. C. During an interview on 1/20/21 at 12:56 PM, DA stated that he cleaned the food tray carts with a spray that kills germs instantaneously. The pink solution was in a clear spray bottle and was labeled 6836-7A-1677. Observation on 1/20/21 at 1:58 PM revealed DA spraying the cart with the pink solution and immediately wiping it down. During an interview on 1/20/21 at 1:36 PM with RN A, she stated she had concerns about sanitizing equipment, the BP cuff in particular. The facility had wrist cuffs that had a soft porous surface. She stated that she used the Micro-Kill wipes, EPA # 1839-1974. She stated the that she didn't have time to wait for the cuffs to dry, so she used them wet on the next resident. Observation of shift change on 1/20/21 from 1:44 PM until 2:15 PM revealed the staff did not sanitize the medication carts or nurse's station. Two MA's were observed conducting narcotic count at a medication cart. Neither MA was observed sanitizing the cart before or after. Observation of shift change on 1/21/21 from 1:50 PM to 2:10 PM revealed no sanitizing of the work stations, computers, or med carts. Review of a facility in-service, dated 1/5/21, reflected that staff was to clean and disinfect their work space before and after each shift, which included equipment such as computers, phones, charting kiosks, etc. During an interview on 1/20/21 at 3:45 PM with MA D, she stated she did not know the dry time for the Micro-Kill sanitizing wipes. During an interview on 1/20/21 at 3:46 PM, LVN B stated that she did not know the dry time of the Micro-Kill sanitizing wipes on the unit and added, I don't really use them. She stated that sometimes she used the pink spray, 6836-7A-1677. During an interview on 1/20/21 at 3:47 PM with MA A, MA D and LVN B on the COVID-positive unit, they all stated that there was no sanitizing schedule but MA A added that he tried to clean his med cart at least twice a shift. During an interview on 1/21/21 at 9:30 AM, the HRM stated that their Housekeeping Manager had been out due to being exposed to COVID, so she was the acting liaison for housekeeping. She stated that the housekeepers should be sanitizing high-touch surfaces every two hours, but she was not aware of any kind of log or check-off to ensure this was being done. She stated that housekeepers were in the facility from 8:00 AM to 4:00 PM. She stated after 4:00 PM, there was not anyone in the facility designated to sanitize resident rooms or high-touch surfaces. During an interview on 1/21/21 at 2:52 PM, LVN C stated that she cleaned vital sign equipment between residents using the Micro-Kill wipes. She stated she did not know the dry time of the disinfecting wipes. During an interview on 1/21/21 at 3:00 PM with LVN A, he stated that he cleaned the med cart and his equipment at the beginning and end of each shift. He stated that he used Micro-Kill wipes. He went to the nurse's station to show the Surveyor the wipes but was unable to find any. He stated that he would ensure he located some by the end of his shift. Observation on 1/21/21 at 3:10 PM revealed MA E using Micro-Kill wipes to sanitize a thermometer and pulse oximeter and immediately about to enter a resident's room. During an interview on 1/21/21 at 3:11 PM with MA E, she stated she had no idea what dry time or kill time meant. She stated she cleaned the resident equipment, such as blood pressure cuff, pulse oximeter, and thermometer, and would then move on to the next resident. During an interview on 1/21/21 at 4:06 PM, HSK C stated that she used wipes or the pink spray to sanitize the COVID-positive unit. She stated that the kill time for the spray was 30 minutes. Review of Resident #6's medical chart revealed a [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/21/21 at 4:16 PM revealed LVN D completing a blood sugar check on Resident #6 in his room. After completing the procedure, LVN D set the glucometer on the med cart. She wiped the top and sides of the glucometer with an alcohol swab, instead of a disinfecting wipe that is on the EPA approved list. During an interview on 1/22/21 at 11:00 AM with the ICP, she described dry time as, How long they have to wait before using the equipment again. She stated that staff training on PPE and disinfection/sanitization was her responsibility. Review of the EPA website reflected that the spray, 6836-7A-1677, has a three-minute kill time. Review of the facility's most recent in-services reflected that there weren't any notes or documentation attached to reveal the specific education given on those dates. Review of the facility's Coronavirus Disease Pandemic Prevention and Response Plan, last revised 6/25/20, reflected the following: The Infection Control Specialist is to: 7. Ensures implementation of appropriate infection control measures/precautions and isolation in accordance with CDC, State/Local Health Department recommendations. 8. Ensures infection control supply available on unit(s). 9. Ensures timely staff education/re-education regarding appropriate infection control measures/precautions and isolation. 10. Provides guidance to respective departments to: a. Employs physical barriers to prevent respiratory dissemination; b. Employs judicious hand-washing with soap and water and hand sanitation with alcohol-based hand sanitizer; . d. Frequently cleans/sanitizes surfaces that are touched frequently (side rails, bedside tables, counters, handrails, doorknobs, telephones, equipment, etc. with approved disinfectants. Review of the facility's COVID-19 Pandemic Prevention and Response Plan, last revised 6/25/20, reflected the following: E. 7. Ensures implementation of appropriate infection control measures/precautions and isolation in accordance with CDC, State/Local Health Department recommendations. G. 10. Provide guidance to respective departments to: o Frequently clean/sanitize surfaces that are touched frequently (side rails, bedside tables, counters, handrails, door knobs, telephones, equipment, etc.) with approved disinfectants. D. Review of the facility's census, staffing sheets, and a list of positive residents indicating the date they tested positive and what room they were moved to reflected the following: - CNA A last worked her 6AM - 2 PM shift on 1/18/21 on the 200 hall (rooms 216-224), which at that time, was a COVID-negative hall. - Later that day (1/18/21), the facility received positive test results for several residents, but there wasn't bed availability on their COVID-positive unit (400 hall). - In order to cohort the newly COVID-19 positive residents, they moved nine COVID-negative residents (Resident #7 - Resident #15) from rooms 216-224 to a COVID-negative hall, hall 100. - The facility then moved the newly positive COVID-19 residents into rooms 216-224, creating another COVID-positive unit. - On 1/19/21, CNA A tested positive for COVID-19 during the facility's mandatory testing. The facility failed to ensure the nine residents that were possibly exposed by CNA A were then quarantined or treated as COVID-unknown. During an interview on 1/22/21 at 3:15 PM, the ADM did not have an answer as to why Resident #7 - Resident #15 were not moved to a COVID-unknown unit. She admitted that they had not properly completed contact tracing. It was her belief that the facility had been following their policy as well as adhering to the guidance of HHSC. The Administrator and DON were notified on 1/22/2021 at 4:30 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on 1/22/2021 at 4:40 PM. A Plan of Removal was first submitted by the Administrator on 1/22/2021 at 10:30 PM and the following POR was accepted on 1/23/2021 at 3:00 PM: (Facility) Plan of Removal January 22, 2021 Revised January 23, 2021 The 10 identified residents have been placed on transmission-based precautions or moved to the appropriate unit and are being screened three times daily to identify any signs and symptoms of COVID 19, Transmission-based precautions are now being utilized properly and at the proper time: The doors of the quarantine rooms on the COVID-unknown unit are being kept closed. Bins are now outside the rooms for PPE accessibility Signage has been placed on the doors identifying transmission-based precautions Signage placed at the beginning of the quarantine unit identifying the rooms designated as quarantine rooms. Director of nursing and administrator were re-educated by the Regional Vice President of Operations and the Clinical Consultant on 1/22/21: the proper utilization of transmission-based precautions including initiating when a resident has potentially been exposed or know to be exposed to a positive roommate or employee Doors in the quarantine unit will be closed at all times, have signage with transmission-based precautions displayed Bins are to be outside rooms to have PPE readily available for donning and doffing Reviewing testing results to determine if a there is a positive employee and place residents in transmission-based precautions and screen three times daily The Director of Nursing / designee will re-educate licensed nurses and Certified Nursing Assistants, therapists, housekeeping department and interdisciplinary team regarding the following beginning on 1/22/2021: Transmission-based precautions are to be initiated on residents with suspected or known exposure to COVID 19 communicated by the Director of Nursing / designee and will be documented in the progress notes and added to the 24 hour report by Director of Nursing / designee Residents with suspected or known exposure to COVID 19 are to be screened using the resident screening tool three times daily to monitor for signs and symptoms of COVID 19 and the MD contacted if any signs and symptoms are identified. Resident room doors on the quarantine unit are to be closed at all times. Resident rooms on the quarantined hall will have proper signage related to isolation and full PPE available outside each room placed by a member of the interdisciplinary team as directed and validated by the administrator or Director of Nursing. Equipment such as glucometers, pulse oximeters and blood pressure cuffs are will be sanitized between uses / between residents using an effective disinfecting wipe. Kill time will be included in the education. High touch areas including handrails, door knobs, lobby door and nursing station surfaces will be cleaned and disinfected by the housekeeping department during normal working hours. After housekeeping hours, the charge nurse on each unit will assign and validate frequent cleaning and disinfecting high touch areas. The charge nurse will document on the 24-hour report to communicate to the Administrator / designee cleaning has been completed. The charge nurses will be educated on this process and expectation of completion by the Director of Nursing, Administrator or designee Donning and Doffing of PPE and hand hygiene competencies will be completed on licensed nurses and Certified Nursing Assistants by the Director of Nursing/designee beginning 1/22/ 21. A current roster of employees will be used by the Director of Nursing to validate that those currently employed/actively working will be observed. Agency staff will be included. Any staff not receiving this information by 1/23/21 will receive prior to their next scheduled shift, this will include any staff on FMLA, sick days or vacation. This information will also be presented to agency staff before reporting to assigned area. Surveillance rounds will be made three times daily for 7 days, then daily for 2 weeks to validate that staff are donning in full PPE for those on transmission-based precautions, that the proper signage is displayed on the rooms for those in transmission-based precautions and the doors on the quarantine unit remain closed at all times. The results of testing on the schedule for the county's positivity rate will be reviewed and if any employee tests positive, if residents have been in the care of that employee, those residents in that employee's care will be placed in transmission-based precautions and screened 3 times daily using the resident screening tool to monitor for signs and symptoms of COVID 19. Any concern identified will be addressed at the time of discovery. The Medical Director was notified on 1/22/21 at 8:31 pm of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting with the Administrator, Director of Nursing and Clinical Consultant and medical director was held on 1/22/21 to discuss contents of this plan and will be reported by the administrator to Quality Assurance Performance Improvement committee monthly for review and recommendations until pandemic plan no longer necessary. The survey team monitored the plan of removal from 1/23/21 to 1/25/21 as follows: Observation on 1/24/21 at 12:25 PM revealed the Receptionist sanitizing the front door frame and handle. During an interview on 1/24/21 at 12:30 PM with the Receptionist, she stated that she sanitized both front doors each time after a staff member entered the facility. She stated that the wipes have a one-minute dry time, which meant that the area must stay wet for one minute for it to truly be disinfected. Observation on 1/24/21 at 1:00 PM revealed the COVID-unknown unit to have proper signage on resident's doors regarding contact isolation and PPE. These doors were closed. There were bins full of PPE outside of each door. All residents that had been possibly exposed by CNA F were now quarantined. During an interview on 1/24/21 at 1:15 PM, MA F stated that he was educated one-on-one by the DON before he started his shift that day. They went over properly wearing PPE, sanitizing the med cart frequently, and hand hygiene. He was able to properly identify the kill time of the sanitizing wipes. During an interview on 1/24/21 at 1:22 PM with the ADM, she stated that she and the DON and ADON met with their Regional Vice President of Operations and the Clinical Consultant to be re-educated on the proper utilization of transmission-based precautions, guidelines for a COVID-unknown unit, and contact tracing. She stated that they have also created an educational form regarding these issues, and each staff is educated before coming into the facility for their shift. They will continue this process until every employee has been given this re-education. They have also created sanitization/cleaning logs that are to be filled out by housekeeping staff each shift. The staff in the COVID-positive unit have been re-educated on donning and doffing the coveralls. During an interview on 1/25/21 at 9:00 AM, the ADON stated that she tested all of the COVID-negative and COVID-unknown residents earlier that morning and all were negative. Observation on 1/25/21 at 9:20 AM revealed HSK D donning a gown and gloves appropriately before entering a resident's room on the COVID-unknown unit. Observation on 1/25/21 at 9:26 AM revealed staff on the COVID-positive unit wearing disposable gowns over their fanny packs. Observations from 1/24/21 at 1:00 PM to 1/25/21 at 11:00 AM revealed all of the resident doors closed on the COVID-unknown unit. During an interview on 1/25/21 at 9:45 AM with HSK A, she stated that she had been re-educated on the proper use of PPE, and the cleaning of high-touch areas. She stated that it is to be done every two hours, and they now had a checklist to complete. During an interview on 1/25/21 at 10:42 AM with MA B on the COVID-positive unit, he stated that he would remove his disposable gown and put on a clean one if it was visibly soiled or if it had a rip or tear. He stated that he had been re-educated on properly donning and doffing the coverall. He stated that he would take off the coverall before his break, and it would be hung up in the doffing area while on break. He stated that there was ample PPE on the unit. Observation on 1/25/21 at 10:49 AM revealed LVN D at a med cart sanitizing a blood pressure cuff and thermometer. During an interview on 1/25/21 at 10:50 AM with LVN D, she stated she was using the wipes with the purple top to sanitize her blood pressure cuff, thermometer, pulse-oximeter, and glucometer, which had a one-minute kill time. She stated that she also used the wipes to sanitize all surface areas such as the med cart, laptop, laptop mouse, and mechanical lift. She stated that their housekeeper was sanitizing high-touch areas such as hand rails and counter tops every 30 minutes. Review of the recent education provided to staff revealed all staff that had worked any shift from 1/23/21 - 1/25/21 had received re-education on appropriate sanitizers and kill times, PPE usage, and hot/warm/cold units. The house-keeping staff had additional education on their new high-touch sanitization check-off list. The ADM and DON were notified that the IJ was removed on 1/25/21 at 11:15 AM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness.