Every finding on record at Senior Care Health & Rehabilitation Center - Wichi

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that:1. The low temperature dish machine was operated without the chlorine sanitizer level being checked prior to washing the breakfast dishes on 4/19/2026. When the chlorine sanitizer level was checked by Dietary Aide B, the chlorine sanitizer test strip did not react, indicating there was no chlorine sanitizer content present. 2. Bulk storage bins used to store panko, flour, granulated sugar, and food thickener had exterior top surfaces of the storage bin lids that were lightly soiled with grease. A plastic scoop was inside the bin containing granulated sugar.3. The rehabilitation unit bistro dining room had an ice maker with a water dispenser that had a build-up of water mineral deposits on its surface, a bread toaster soiled with dried crumbs, and a refrigerator with a freezer drawer compartment with a spilled frozen red substance in its bottom interior surface.4. [NAME] K and Dietary Aide D did not wear beard restraints to cover their facial hair during the evening meal preparation on 4/21/2026.5. The rehabilitation unit's nourishment room microwave oven was soiled on the inside with splattered dried food particles and oatmeal.6. The dish machine wash and rinse cycle water temperatures did not consistently reach 120 degrees F when operated according to the manufacturer's recommendations for minimum water temperatures. These failures placed the residents at risk for foodborne illness and compromised health status.The findings included: Observation and interview on 4/19/2026 at 8:55 AM revealed DA B was operating the low temperature dish machine. Observation of the manufacturer's recommendations on the front of dish machine indicated minimum wash and rinse cycle water temperatures of 120 degrees F and a minimum chlorine sanitizer level of 50 ppm. The wash cycle water temperature was at 110 degrees F and the rinse cycle water temperature was at 118 degrees F. DA B ran the dish machine a second time and the wash cycle water was 112 degrees F and the rinse cycle water was 118 degrees F. DA B used a chlorine test strip to measure the chlorine sanitizer level. Her gloves were wet and the strip kept breaking off into small pieces. DA B stated she had only checked the sanitizer level 1 or 2 times before now and someone else usually did it. DA B dipped the test strip into the dish machine final rinse water and it did not react. She pressed the primer switch and no chlorine sanitizer was going through the tube to empty into the dish machine. DA B checked the sanitizer bottle level and it was full. DA B removed the cap connected to the tubing and a plastic insert inside the neck of sanitizer bottle was observed. (The tube did not go inside the bottle.) DA B stated the sanitizer was sucked into the tube connected to the bottle cap when the dish machine was running. DA B replaced the cap and ran the dish machine again, tested the sanitizer level again with a test strip, and it did not react. She stated she would get the morning cook on duty. During an interview and record review on 4/19/2026 9:05 AM, after [NAME] C entered the dish room and the situation with chlorine sanitizer not reacting to test strip was explained, she stated the daily dish machine temperature and sanitizer log was on a clip board hanging on the wall. Review of the Temperature and Sanitizer Log, dated April 2026, indicated the wash and rinse water temperatures and sanitizer levels were documented 3 times daily for breakfast, lunch, and dinner. On 4/18/2026 the dinner meal documentation revealed the water temperature for the wash cycle was 100 degrees F, the rinse cycle was 120 degrees F, and the sanitizer level was illegible. The water temperatures and sanitizer level were not initialed by the person who documented them. [NAME] C stated DA D and DA E had worked last night (the evening shift on 4/18/2026). [NAME] C stated she would call the dietary supervisor and the Maintenance Supervisor. During an interview and observation on 4/19/2026 at 9:06 AM, DA B stated she would get another bottle of sanitizer from the chemical supply room. She returned to the dish room with 2 full bottles and replaced the 2 bottles on the shelf under the counter to the left side of the dish machine. She stated she replaced the detergent and rinse aid because they were almost empty. She stated she did not replace the sanitizer bottle because it was full. DA B stated she had not checked the sanitizer level before beginning to wash dishes after breakfast that morning. She stated she had forgotten to do it. DA B indicated she had already washed the following: a stack of dinner plates in the plate warmer appliance; 3 racks filled with inverted beverage glasses; a tray with inverted cereal bowls; and a stack of thermal plate holders. In an interview on 4/19/2026 at 9:10 AM, DA A stated he had worked the past 3 days (4/16/26 - 4/18/26) for the breakfast and lunch meals. He stated he had checked the dish machine water and sanitizer levels and wrote them on the daily dish machine log. He stated the temperatures and sanitizer levels had been ok. DA A stated he did not check the dish machine that morning (4/19/2026) because he had been in the dining room and had cleared the tables. In an interview on 4/19/2026 at 9:12 AM, [NAME] C stated she had called the DM and she did not answer. She stated she called the Maintenance Supervisor and he was coming to the facility. In an interview on 4/19/2026 at 9:14 AM, [NAME] C stated she had called the DM again and she answered. [NAME] C stated she told the DM the problem with the dish machine not sanitizing and the DM said she knew how to fix it and she was coming to the facility. Observation and interview on 4/19/2026 at 9:24 AM revealed the DM arrived at the facility and entered the dish room. She proceeded to start the low temperature dish machine. The dish machine filled with water for the wash cycle. The DM pressed each of 3 primer switches located at the front of the machine. The dish washing detergent and rinse aid both came through the attached tubing and emptied into the dish machine water. The chlorine sanitizer did not come through attached tubing and did not empty into the dish machine water. The DM removed the bottle with chlorine sanitizer from the shelf to the left of the dish machine and removed the cap connected to the tubing. She stated the plastic insert inside the bottle neck was to suction the sanitizer into the tubing to empty into the dish machine. The DM instructed DA B to get another new bottle of chlorine sanitizer from the kitchen chemical supply closet. Observation and interview on 4/19/2026 at 9:36 AM revealed DA B returned to the dish room with a new bottle of chlorine sanitizer. The DM removed the cap connected with the tubing for the dish machine from the current non-working bottle with sanitizer and screwed the cap onto the new bottle of sanitizer. The DM primed the chlorine sanitizer switch and the chlorine sanitizer was observed moving through the tube and emptying into the dish machine water. She proceeded to start the dish machine. The wash cycle water temperature at 117 degrees F, rinse cycle water temperature at 117 degrees F, and chlorine sanitizer level was tested with a chlorine test strip by the DM and was at 100 ppm. The DM instructed DA A to record the water and sanitizer levels on the daily dish machine log for the morning of 4/19/26, which he did as instructed. The DM stated the sanitizer had been provided by the company that had been servicing the dish machine and supplying the chemicals. She stated a few months ago there had been the same problem with another new bottle of chlorine sanitizer. The DM stated the facility dish machine would be serviced by a different company starting later this month. The DM stated DA D and DA E were the evening dietary aides and they came into work at 12:00 PM. She stated they were both scheduled to work today and would be in the facility. Observation on 4/19/2026 at 9:43 AM revealed 4 bulk storage bins/containers were on a shelf beneath the food preparation counter. The bins contained panko, flour, granulated sugar, and food thickener. The bin lids were lightly soiled with grease and a scoop was inside the storage bin containing sugar. In an interview on 4/19/2026 at 12:16 PM, RN F stated she was the day shift charge nurse for Hall 500 and half of Hall 400 - the odd room numbers. She stated there had been no reports of residents with symptoms of gastro-intestinal distress - no nausea, vomiting, or diarrhea. In an interview on 4/19/2026 at 12:18 PM, the Maintenance Director stated there had been faulty dish machine sanitizer bottle caps during the past. He stated he would talk with the dish machine service technician about the dish machine water temperature. In an interview on 4/19/2026 at 12:20 PM, RN G stated she was the day shift charge nurse for Hall 600 and half of Hall 400 - the even room numbers. She stated there had been no reports of residents with symptoms of gastro-intestinal distress - no nausea, vomiting, or diarrhea. She stated the nurse aides would have told her if the residents were vomiting or having diarrhea. In an interview on 4/19/2026 at 12:23 PM, LVN H stated she was the facility Staffing Educator. She stated there had been no reports of residents with symptoms of gastro-intestinal distress - no nausea, vomiting, or diarrhea. In an interview on 4/19/2026 at 12:26 PM, CNA I stated she was working on Hall 400. She stated she had worked Friday through Sunday and no residents had nausea, vomiting, diarrhea, or complained of an upset stomach. She stated she would tell the nurse if a resident had any symptoms or complaints of an upset stomach. In an interview on 4/19/2026 at 12:59 PM, MA J stated he was the Medication Aide for Halls 100 and 200. He stated there had been no reports of residents with symptoms of gastro-intestinal distress - no nausea, vomiting, or diarrhea. In an interview on 4/19/2026 at 1:01 PM, the ADON for LTC Unit stated there were 2 residents who received tube feedings and both residents received meal trays from the kitchen. The ADON stated one resident received pleasure feedings but did not eat much and the other resident had improved and gained weight. In an interview on 4/19/2026 at 1:15 PM, DA D stated he had been employed in the facility for 1 year, and DA E stated he had been employed in the facility for 5 or 6 months. Both DAs stated they worked on the 12:00 PM - 8:00 PM shift and prepared desserts, drinks, and snacks, and washed dishes. DA E stated he served the residents who ate meals in the rehabilitation unit bistro dining room. Both dietary aides stated they had worked the previous night on 4/18/26 (Saturday). DA D stated he had checked the low temperature dish machine wash and rinse cycle water temperatures and chlorine sanitizer the previous night and wrote them on the dish machine log. He stated he must have forgotten to add his initials. DA D stated the previous night there had been just enough chlorine sanitizer in the bottle to finish washing the dinner dishes. He stated he went to the chemical supply closet and got a new bottle of chlorine sanitizer and connected it to the dish machine after they were finished washing the dishes. He stated he always ran the dish machine empty at the end of the shift so it would be clean for the morning shift and the dish machine doors would be closed. He stated he usually checked the chlorine sanitizer level after connecting a new bottle of sanitizer to the tubing cap, but he had not done it the previous night as it had been time to go. DA D stated the dish machine had still been running when he left. DA D stated there had been a problem with a chlorine sanitizer bottle not suctioning a couple months ago. Observation on 4/20/2026 at 9:01 AM of the rehabilitation unit bistro dining room, located on Hall 100, revealed the following: - The beverage station counter had an ice maker with a water dispenser. The front exterior surface of the ice maker was soiled with water mineral deposits. The ice maker drip tray had a metal grill cover that was rusted and the plastic drip tray top surface was soiled with water mineral deposits. - The food service line counter had a bread toaster and its top surface was soiled with crumbs.- The residential style refrigerator had a bottom freezer compartment drawer and the interior bottom surface of the freezer compartment drawer was soiled with a spilled and frozen red substance. Observation on 4/202/2026 at 9:17 AM revealed the DM was in the rehabilitation unit bistro dining room and cleaned the counters for the beverage station and food service line. In an interview on 4/20/2026 at 11:52 AM, the Administrator and Maintenance Director stated the kitchen had a water heater that supplied hot water to only the kitchen. The kitchen water heater temperature was turned up and the dish machine wash and rinse temperatures were at 120 degrees F. In an interview on 4/20/2026 at 3:27 PM, the Maintenance Director stated he had turned up the water heater for the kitchen to 160 degrees F and the dish machine wash and rinse water did reach 120 degrees F but then went down again. He stated he told the dietary staff to be sure to check the chlorine sanitizer and run the dish machine before starting to wash dishes. In an interview on 4/21/2026 at 3:58 PM, the DM stated that all residents received a meal tray with food prepared in the kitchen, including the 2 residents who received tube feedings. Observation on 4/21/2026 at 3:59 PM revealed [NAME] K was completing the dinner meal preparations. [NAME] K was wearing a beard restraint, which fit loosely and slipped off his nose and exposed his moustache. He stated he had his own personal beard cover that fit better and he would use it during the future. Observation on 4/21/2026 at 4:35 PM revealed DA D was in the kitchen. He was not wearing a beard restraint to cover his facial hair/goatee. The DM instructed him to use a beard restraint, which he did put on. Observation on 4/21/2026 at 4:50 PM revealed the DM operated the low temperature dish machine. The wash and rinse water temperatures were at 118 degrees F. The DM used a test strip and measured the chlorine sanitizer level at 50 ppm. In an interview on 4/22/2026 at 8:58 AM, the DM stated the expectation for the dietary staff's operation of the low temperature dish machine was for the staff to run the dish machine first thing at the start of the day and check the water temperatures and chlorine sanitizer level. She stated the dish machine was to be ran with water temperatures and sanitizer levels checked 3 times daily for each meal before washing any dishes. She stated a possible outcome from not properly operating the dish machine and checking the sanitizer could be that the residents get sick, or there could be a foodborne illness outbreak. The DM stated if dishes are not properly sanitized anything could happen. Observation on 4/22/2026 at 9:15 AM revealed the rehabilitation unit's nourishment room, located on Hall 100, had a microwave oven on a counter. The interior surface of the microwave oven was soiled with splattered dried food and oatmeal. In an interview on 4/22/2026 at 9:19 AM, the Administrator stated the expectation for dietary staff operating the low temperature dish machine was for the dish machine to be operated according to the manufacturer's suggestions/recommendations and to be in compliance with state and federal guidelines for prevention of foodborne illness. Record review of the facility's Dietary Services Policy, not dated, specified [in part]:Dishwashing:Food preparation equipment, dishes, and utensils are effectively sanitized according to manufacturer's directions for the dishwashing equipment used in the facility. Dishes and utensils are stored in a protective manner to protect from disease-carrying organisms.Procedures for dish/utensil washing and sanitizing will be posted in appropriate areas. All procedures will be in compliance with Federal, State, and local health codes. Dietary staff will be trained in operation of the mechanical dish machine and checking for the correct wash temperature (posted on the dish machine) and chemical sanitization solution for the correct amount of solution in the final rinse cycle (at least 50 ppm). Chemical test strips will be maintained on-site and available for continuous use by dietary staff . Record review of the facility's facility policy and procedure for Sanitizing Agents - Acceptable Levels and Testing Methods for Sanitation, dated as revised 1/01/2010, specified [in part]:Policy:Chemical sanitizers within the Nutrition Services Department will be monitored to ensure proper concentration for sanitation to prevent food borne illness and cross-contamination.Procedure:Acceptable Sanitizer Levels1.All items will be sanitized by one of the following methods:a. Washed and sanitized through use of the dish machine . Testing Procedures:1.Facilities will use an approved test kit to measure the parts per million (PPM) of the chemical solutions in the pot/pan sinks, temperature dish machines, and all other sanitizing solutions three times per day.2. Record of the test results will be kept on file for at least 90 days.3. Any abnormal test results will be reported immediately to the Food Service Manager. Record review of the Food and Drug Administration Food Code 2022 specified [in part]: Chapter 2. Management and Personnel2-4 Hygienic Practices2-402 Hair Restraints2-402.11 Effectiveness. (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers 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.Chapter 4. Equipment, Utensils, and Linens4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A)A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 2 of 2 dining rooms reviewed for environment. The facility failed to ensure the Main dining room and Bistro dining room floors were thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Interview on 04/21/2026 at 3:07 PM Resident #40 stated that the floors in both dining rooms were always dirty and not swept after meals and when the next meal came, they had to tolerate the mess under the tables. Interview on 04/21/2026 at 3:10 PM Resident #61 states she did not eat in the dining room but did activities in there and food was always on the floor from breakfast, lunch or dinner when she went in and had to move her wheelchair through the mess. Observation on 04/21/2026 at 3:20 PM Main dining hall, at end of Halls 300 & 40 revealed food on the floor and under tables to include cereal, tater tots, meat. Observation on 04/21/2026 at 3:30 PM 2nd dining room Bistro down 100 Hall revealed food on the floor and under tables to include tater tots, meat was seen Interview on 04/21/2026 at 3:35 PM, the Dietary Manager states that after breakfast and lunch housekeeping is to sweep and mop the dining floors. The Dietary Manager states that after dinner that evening it is dietary's job to sweep and spot mop the dining room floor. The Dietary Manager states that food being left on the floor and under tables is unappealing and does not promote a home-like environment. Interview on 04/21/2026 at 3:50 PM the Housekeeping Supervisor states that it is housekeeping task to sweep and mop dining rooms after breakfast and lunch. The Housekeeping Supervisor states that it does not promote a sanitary environment when food is left under tables and floors. The HKS states dining rooms will be cleaned immediately. Interview on 04/21/2026 at 4:04 PM the Administrator states that it is his expectation that the dining rooms be cleaned and floors swept and mopped after each meal to promote a sanitary and clean environment for the residents.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services that determines that drug records were in order and that an account of all controlled drugs are maintained and periodically reconciled for 5 of 65 residents (Resident #8, 32, 36, 93, and 383), reviewed for pharmacy services. The facility failed to accurately and timely complete documentation of controlled drug administration for 5 resident's (Resident #8, 32, 36, 93, and 383) and monitoring of controlled medications stored on 2 (Hall 100 and Hall 600) medication carts checked for narcotic reconciliation. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes. Findings included: Resident #8 Record review of Resident #8's Admission MDS dated [DATE], revealed Resident #8 was admitted to the facility on [DATE] with the following diagnoses: Arthritis due to other bacteria right knee and primary generalized osteoarthritis (arthritis of joints). Resident #8 received PRN medication or was offered and declined pain medications in the last 5 days. Section N- Medications revealed Resident #8 had used an opioid during the last 7 days. Record review of Resident #8's active physician orders as of 02/12/2025, included the following controlled drug, Norco 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #8's medication administration record on 02/12/2025 revealed Resident #8 had received Norco 5-325 mg tablet by mouth at 7:55 AM. Record Review of Resident #8's narcotic count sheet for Norco 5-325 mg tablet on 02/12/2025 revealed the documented count of the Norco 5-325 mg was 42 tablets. In an observation of the medication cart for Hall 100 on 02/12/025 at 8:40 AM revealed Resident #8's narcotic sheet for Hydroco/APAP 5-325 mg (Norco) to have a documented count of 42 tablets; however, the medication card contained 41 tablets. Resident # 383 Record review of Resident #383's Admission MDS dated [DATE], revealed Resident #383 was admitted to the facility on [DATE] with the following diagnoses: Encounter for surgical aftercare following surgery on 01/31/2025 for a circulatory system. Section J-Health Conditions, Resident #383 received PRN medication or was offered and declined pain medications in the last 5 days. Section N- Medications revealed Resident #383 had used an opioid during the last 7 days. Record review of Resident #383's active physician orders as of 02/12/2025, included the following controlled drug, Tramadol 100 mg give 1 tablet by mouth every 6 hours for pain. Record review of Resident #383's medication administration record on 02/12/2025 revealed Resident #383 had received Tramadol 100 mg (two 50 mg tablets) by mouth at 7:55 AM. Record Review of Resident #383's narcotic count sheet for Tramadol 50 mg tablets on 02/12/2025 revealed the documented count of the Tramadol 50 mg was 22 tablets. In an observation of the medication cart for Hall 100 on 02/12/2025 at 8:40 AM revealed Resident #383's narcotic sheet for Tramadol 50 mg to have a documented count of 22 tablets; however, the narcotic card contained 21 tablets. Resident #32 Record review of Resident #32's Admission MDS dated [DATE], revealed Resident #32 was admitted to the facility on [DATE] with the following diagnoses: Generalized muscle weakness and other lack of coordination, and abnormal posture. Section J-Health Conditions, Resident #32 received PRN medication or was offered and declined pain medications in the last 5 days. Section N- Medications revealed Resident #32 had used an opioid during the last 7 days. Record review of Resident #32's active physician orders as of 02/12/2025, included the following controlled drug, Acetaminophen-Codeine 300-30 mg give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #32's medication administration record on 02/12/2025 revealed Resident #32 had received Acetaminophen-Codeine 300-30 mg tablet by mouth at 8:55 AM. Record Review of Resident #32's narcotic count sheet for Acetaminophen-Codeine 300-30 mg tablet on 02/12/2025 revealed the documented count of the Acetaminophen-Codeine mg was 80 tablets. In an observation of the medication cart for Hall 100 on 02/12/2025 at 8:40 AM revealed Resident #32's narcotic sheet for Acetaminophen-Codeine 300-30mg to have a documented count of 80; however, the medication card contained 79 tablets. Resident #93 Record review of Resident #93's Quarterly MDS dated [DATE], revealed Resident #93 was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia (symptoms affecting memory, thinking and social abilities). Section N- Medications, Resident #93 had used an antianxiety medication during the last 7 days. Record review of Resident #93's active physician orders as of 02/12/2025, included the following controlled drug, Xanax 0.25 mg give 1 tablet by mouth two times a day for anxiety. Record review of Resident #93's medication administration record on 02/12/2025 revealed Resident #93 had received Xanax 0.25 mg tablet by mouth at 8:00 AM. Record Review of Resident #93's narcotic count sheet for Alprazolam 0.25 mg (Xanax) tablet on 02/12/2025 revealed the documented count of the Alprazolam 0.25 mg (Xanax) mg was 19 tablets. In an observation of the medication cart for Hall 600 on 02/12/2025 at 9:00 AM revealed Resident #93's narcotic sheet for Alprazolam 0.25 mg (Xanax) to have a documented count of 19 tablets; however, the narcotic card contained 18 tablets. Resident #36 Record review of Resident #36's Quarterly MDS dated [DATE], revealed Resident #36 was admitted to the facility on [DATE] with the following diagnoses: Pain in right shoulder, restless leg syndrome (irresistible urge to move the legs), and unspecified polyneuropathy (nerve damage). Section J-Health Conditions, Resident #36 received PRN medication or was offered and declined pain medications in the last 5 days. Section N- Medications revealed Resident #36 had used an opioid during the last 7 days. Record review of Resident #36's active physician orders as of 02/12/2025, included the following controlled drug, Pregabalin 50mg give 1 capsule by mouth two times a day for neuropathy. Record review of Resident #36's medication administration record on 02/12/2025 revealed Resident #36 had received Pregabalin 50mg capsule by mouth at 8:00 AM. Record Review of Resident #36's narcotic count sheet for Pregabalin 50 mg capsule on 02/12/2025 revealed the documented count of the Pregabalin 50 mg was 46 tablets. In an observation of the medication cart for Hall 600 on 02/12/2025 at 9:00 AM revealed Resident #36's narcotic sheet for Pregabalin 50 mg to have a documented count of 46 capsules; however, the narcotic card contained 45 capsules. In an interview on 2/12/25 at 8:50 am with LVN A, she reported that the facility policy was to sign narcotics out as we go. She stated that she did not sign out the narcotic sheet for Residents #383 and Resident #8 because she, writes their name down on her note pad and goes back later to fill out the narcotic sheets. She stated the count for Resident #13 was inaccurate because she signed out the narcotic but did not give the medication due to resident going to therapy. When asked what negative outcome could occur by not following the policy, she stated Someone could come behind me and give out another one. In an interview on 2/12/25 at 9:10 am with LVN B, she reported the facility policy was to document as we go. She stated she failed to sign out the narcotic sheet for Residents #93 and Resident #36 because she moved on to another resident's medications. When asked what negative outcome could occur by not following the policy, she stated they can get over medicated. In an interview on 02/12/2025 at 9:15 AM with ADON A who was present during the audit of the medication cart assigned to Hall 600, she stated the facility policy was the nurses are supposed to sign narcotics out as they go, and narcotics are to be counted during any change of keys . Failure to do so could result in medication errors occurring. In an interview on 2/12/25 at 9:23 the DON and Regional Nurse, reported the facility policy was that narcotics must be signed out immediately by the administering nurse once removed from the blister pack and anytime medications were omitted, the narcotic log must reflect this. When asked if any negative outcomes could occur from not following the policy, the DON stated, Not really because only one person is on that cart. Record review of the facility's Policy and Procedure titled Narcotic Count not dated revealed To provide record of correct narcotic dispensing and record of narcotic count .5.The nurse (CMA) reading the narcotic count sheet will confirm the number of pills, after the last recorded dose was given, matches the number of narcotics on hand. a. Any discrepancy will immediately be reported to the charge nurse and/or ADON, who will attempt to reconcile the discrepancy. b. The ADON will notify the DON if any discrepancy cannot be reconciled . There was no information regarding procedure for documentation during administration of medications within the policy and procedure, it only addressed oncoming and off-going nurses or medication aides reconciling the carts at end/start of shifts.

Based on interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 Licensed Nurses (LVN A) reviewed for competent nursing, in that: LVN A was not supervised as per the Texas Board of Nursing agreed order. This deficient practice places residents at risk for being provided care by staff who do not have the skills to provide necessary . The Findings include: Record review of employee files on 02/27/2024 revealed that LVN A had nursing stipulations from the Texas Board of Nursing that were signed on December 13th, 2020, which revealed the following terms of the order: Findings: 7. On or about June 1, 2020 while employed as an LVN, and providing care for Patient Medical Record #2297001, Respondent failed to report out of range Prothrombin Time and International Normalized Ration lab results to the patients cardiologist who managed the patient's Coumadin dosage based on PT/INR lab results. Respondent's conduct places the patients at risk from the lack of medical treatment for elevated PT and INR lab results. 8. On or about June 8, 2018, while employed as an LVN, and providing care for Patient Medical Record #2297001, Respondent failed to timely provide the patient with the physician's new Coumadin order, including a new written order that the Coumadin should be held for 2 days and then restarted a 2mg daily, rather than continuing the current dosage of 3 mg. 9. On or about June 8, 2018, while employed as an LVN, and providing care for Patient Medical Record #2297001, Respondent falsely reported to the patient's cardiologist that the patient's Coumadin 3 mg daily, had been held for 2 days and then restarted at 2mg daily, per the physician's order. Respondent conducted a false report upon which the cardiologist relied for the medical management of the patient's Coumadin dosage. Employment Requirements: C. Indirect Supervision: Respondent shall be supervised by a Registered Nurse, if licensed as a Registered Nurse, or by a Licensed Vocational Nurse, if licensed as a Licensed Vocation Nurse, who is on the premises. The supervising nurse is not required to be on the same unit or ward as a respondent but should be on the facility grounds and readily available to provide assistance and intervention if necessary. The supervising nurse shall have a minimum of two years of experience in the same or similar practice setting to which the respondent is currently working. Respondent shall work only regularly assigned, identified, and predetermined units. Respondents shall not be employed by a nurse registry, temporary nurse employment agency, hospice, or home health agency. Respondent shall not be self-employed or contract for services. Multiple employers are prohibited. D. Nursing performance evaluations: respondent shall call each employer to submit, on forms provided to the respondent by the board, periodic reports as to respondent's capability to practice nursing. These reports shall be completed by the individual who supervises the respondent, and these reports shall be submitted by the supervising individual to the office of the board at the end of each three month quarterly. For four quarters one year of employment as a nurse. Interview and Record on 02/27/2024 at 4:00 PM with the BOM revealed that a review of LVN A's Personnel Files reflected LVN A was hired on 11/14/2018 and received an annual background check. The last background check was pulled on November 2023, which notified the facility that LVN A had stipulations. The BOM stated that she became aware that LVN A had stipulations and was able to access the records online from the BON website. She stated that she brought the order and discussed them with the DON. She revealed that she did not discuss the stipulations with LVN A. She revealed that she did not complete any employment verification for the BON concerning LVN A, she did not realize she was supposed to. She stated this failure could cause the facility to employe nurses that are not following the BON orders to protect the residents from errors. The BOM revealed that she was responsible for employment verification. She revealed that the stipulations were not followed due to the facility not recognizing that they needed to. Interview on 03/01/2024 at 3:30 PM with the DON revealed that she was the only one responsible for supervising LVN A. She revealed that she supervised her but did not follow the BON stipulation to be readily available in the event that LVN A needed assistance while working. She stated she was unsure why they did not follow them. She revealed that the facility failed to complete the forms that the BON required from LVN A's employer. She revealed that she works days and the LVN A worked nights.

Based on interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 2 of 4 (Resident #2 and Resident #3) residents reviewed for clinical records in that: The facility failed to document in Resident #2's MAR when they administered Hydroco/APAP on 02/02/2024 through 02/07/2024. The facility failed to document in Resident #3's MAR when they administered Hydroco/APAP on 02/03/2024 through 02/11/2024. This failure could place residents at risk for having records that were inaccurate/incomplete Finding included: Record review of Resident #2's Face Sheet, dated 2/27/2024, revealed a [AGE] year-old female, admitted to the facility on [DATE] with an admitting diagnosis of Fracture of the shaft of the humorous (break in the upper arm bone). Record review of a Resident #2's Discharge MDS assessment, dated 02/26/2024, revealed the following: Section C (BIMS)- Resident had a BIMS score of 15, which indicated she was cognitively intact. Section N (Medications)- Resident was receiving opioids. Record review of Resident #2's MAR dated 02/27/2024 revealed the following: Order for Hydroco/APAP Tab 7.5-325. Directions: Take 1 tab by mouth every 4 hours as needed. Administered on the following: 02/03/2024 x1 administered. 02/07/2024 x1 administered. Record review of Resident #2's Controlled Substance Disposition Record revealed the following that was not documented on the MAR: Order for Hydroco/APAP Tab 7.5-325. Directions: Take 1 tab by mouth every 4 hours as needed. Administered on the following: 02/02/2024 x2 administered. 02/03/2024 x4 administered. 02/04/2024 x 3 administered. 02/05/2024 x 5 administered. 02/06/2024 x 6 administered. 02/07/2024- x2 administered. Record review of Resident #3's Face Sheet, dated 2/27/2024, revealed a [AGE] year-old male, admitted to the facility on [DATE] with an admitting diagnosis of lower abdominal pain (pain in the stomach areas), spinal stenosis (abnormal narrowing of the spinal canal that results in pain, numbness and pressure). Record review of a Resident #3's Admission MDS assessment, dated 01/26/2024, revealed the following: Section C (BIMS)- Resident had a BIMS score of 09, which indicated severed cognitive impairment. Section J (Pain Interview)- Resident answered 10 for a pain intensity scale of 0-10, with 10 being the worst, Section N (Medications)- Resident was receiving opioids. Record review of Resident #3's MAR dated 02/27/2024 revealed the following: Order for Hydroco/APAP Tab 10-325. Directions: Take 1 tab by mouth every 6 hours as needed. Administered on the following: 02/08/2024 x1 administered. Record review of Resident #2's Controlled Substance Disposition Record revealed the following that was not documented on the MAR: Order for Hydroco/APAP Tab 10-325. Directions: Take 1 tab by mouth every 6 hours as needed. Administered on the following: 02/03/2024 x3 administered. 02/04/2024 x4 administered. 02/05/2024 x 3 administered. 02/05/2024 x 4 administered. 02/06/2024 x 5 administered. 02/07/2024 x 3 administered. 02/08/2024 x 4 administered. 02/09/2024 x 4 administered. 02/10/2024 x 3 administered. 02/11/2024 x 3 administered. In an interview on 2/27/2024 at 10:30 AM, the DON revealed her expectations are for nursing staff to sign the drugs out on the Controlled Substance Disposition Record and document the administration on the MAR. She revealed that failure could place the resident at risk for a drug diversion or a duplicate medication being administered. She stated that she had trained nursing staff to always document electronically. She revealed that it was her responsibility to ensure that medication sheets and records on Controlled Medications were done accurately. She revealed that she reviews the medication sheets for accuracy but did not compare it to the EMAR. Record review of the facility's policy covering Medication Administration, not dated, revealed the following: - PRN's should be given by the charge nurse. The Narcotic log should match the MAR.

Based on interview, and record review the facility failed to have a system to account for the disposition and accurate accounting for controlled substances for 4 ( Resident #'s 1, 2, 3 and 4) of 12 residents reviewed for pharmacy records, in that: . The ADON and DON failed to review the medication sheets for medication discrepancies. The facility failed to have 2 signatures on medication sheets when a controlled drug was wasted. These failures could place the residents at risk of a drug diversion which could result in delayed healing. Findings Include: During a record review on 2/27/2024 at 10:30 AM, the following medication sheets revealed the following information: - Resident #1's Controlled Substance Disposition Record. Order- Hydroco/APAP Tb 10-325Mg, take 1 tablet by mouth every 6 hours, as needed. 2/7/2024- no time entered- 1 wasted- LVN A signature, second signature missing. 2/10/2024- no time entered- 1 wasted- LVN A signature, second signature missing. 2/11/2024- no time entered- 3 wasted- LVN A signature, second signature missing. 2/12/2024- no time entered- 4 wasted- no nursing signature. - Resident #2's Controlled Substance Disposition Record. Order- Hydroco/APAP Tb 7-325Mg, take 1 tablet by mouth every 4 hours, as needed. 2/9/2024- 5pm- 1 wasted- LVN A signature, second signature missing. 2/9/2024- no time entered- 2 wasted- LVN A signature, second signature missing. 2/10/2024- no time entered- 2 wasted- LVN A signature, second signature missing. 2/11/2024- no time entered- 11 wasted- LVN A signature, second signature missing. - Resident #3's Controlled Substance Disposition Record Order- Hydroco/APAP Tb 10-325Mg, take 1 tablet by mouth every 6 hours, as needed. No date (in between 2/6/2024 dates)- no time entered- 1 wasted- LVN A signature, second signature missing. 2/6/2024- no time entered- 1 wasted- LVN A signature, second signature missing. 2/9/2024- no time entered- 1 wasted- LVN A signature, second signature missing. 2/10/2024- 6:45pm- 1 wasted- no signature. 2/11/2024- 12:45am- LVN A signature, second signature missing. - Resident #3's Controlled Substance Disposition Record. Order- Hydroco/APAP Tb 10-325Mg, take 1 tablet by mouth every 4 hours, as needed. 2/1/2024- 3 wasted- no time entered- 1 wasted- LVN A signature, second signature missing. 2/2/2024- 1 wasted- no time entered- 1 wasted- LVN A signature, second signature missing. - Resident #4's Controlled Substance Disposition Record. Order- APAP/Codeine Tablet 300-30Mg, take 1 tablet by mouth every 6 hours, as needed. 1/18/2024- time not legible- 1 given- No nursing signature. 1/19/2024- 6AM- 1 given- No nursing signature. 1/28/2024- no time entered- 1 wasted- LVN A signature, second signature missing. 1/29/2024- no time entered- 1 wasted- LVN A signature, second signature missing. 1/30/2024- no time entered- 2 wasted- no time entered- 1 wasted- LVN A signature, second signature missing. During a record review on 2/27/2024 at 2:30 PM, the following statement revealed the following information: DON notes from 02/14/2024 at 10:54AM- I met with LVN A and HR. The narcotic sheet was reviewed with LVN A where she wasted several narcotic. She admitted that all of the wasted entries were, in fact hers. In an interview on 2/27/2024 at 10:30 AM the DON revealed that she had not been checking the medication sheet in its entirety. She stated that they had just been checking the last line, which was the count number and total. She stated that all nursing staff complete in-service that when a medication is wasted, there must be 2 signatures to waste the medication. She stated that once she realized it was not being completed, she reported it to state. She revaled that after her investigation and record review, all of the medications that were wasted were from 1 nurse, which was LVN A. She revealed that she had interviewed LVN A and LVN A reported that the medications were wasted by her, she failed to have another nurse verify that it was wasted by her. She reported that she had completed a full staff in-service on wasting controlled medications and following the facilities policies and procedures. In an interview on 02/27/2024 at 5:11 PM the ADON revealed that the wasted med sheets should have been reviewed better and that the facility expectations are that they should be reviewed at shift change She stated that they should have been completing 2 signatures for the wasted medications. She said that this could result in a medication diversion. Record review if the facility's policy titled Medication Administration not dated, revealed the following: Process for wasting narcotics: - a narcotic should only be wasted if it has been dropped on the floor, resident refused medication, etc. - It is required to have a witnessing nurse when wasting narcotics. You must waste the med together, and both nurses sign in narcotic log. - When wasting a medication, it should be crushed and put in the sharp's container. - The supervisor should then be notified. Every Med cart must be counted each time the keys switch hands. Ensure that the number of meds on the narcotic log matches the number of meds in the card/bottle. PRN's should be given by the charge nurse. Their narcotic log should match the MAR. Record review of the facility's policy entitled; Controlled Substances not dated, revealed the following: The purchase, storage, distribution of controlled drugs will be done in accordance with all federal and state laws and standards of professional practice, to maintain optimal quality control over high-risk substances and to prevent divergence. The facility will adhere to the controlled substance act. All scheduled two drugs are kept secured under a double lock. A transaction record for all controlled substances will be maintained. All controlled drugs will be maintained for the period required by law can be readily retrievable. A separate record will be maintained for each drug covered by scheduled II, III, IV of the Control Substance Act. The record will contain the prescription number, name, and the strength of the drug, date received by the facility, date and time administered, name of the resident, dose, physician's name, signature of the person administering the dose, an original amount dispensed with the balance of verifiable by drug inventory at every shift.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for residents who received their meals in the Rehab Dining Area and Rehab Kitchen area on Hallway 100, by failing to ensure: A. Countertops were clean. B. Floors were clean. C. Cabinet drawers were clean. This failure could affect residents by placing them at risk for food-borne illness and food contamination. The findings included: In an observation on 01/08/24 at 12:34 PM, of the Rehab Dining Area on Hallway 100, revealed the following: - 4 cabinet drawers out of 6 observed that was used for storage of coffee, condiments, and miscellaneous items were soiled with dirt, dried colored water spots, hair and food crumbs. - The Rehab Kitchen door connected to the Rehab Dining Area was opened during lunch. Inside the Rehab Kitchen, the floor was sticky and soiled with dirt and food crumbs. The exterior countertop and shelves were soiled with dust, food crumbs and dried white-water spots. In an interview and observation on 01/11/24 beginning at 11:11 AM with the Corporate Dietary Manager and the Dietary Manager, the 4 cabinet drawers in the Rehab Dining area were observed which were soiled with dirt, dried colored water spots, hair and food crumbs, the Corporate Dietary Manager said he could not refute that. The Rehab Kitchen area was observed, the floor was sticky and soiled with dirt and food crumbs. The exterior countertop and shelves were soiled with dust, food crumbs and dried white-water spots. The Corporate Dietary Manager said the area was no longer used for food prep and used for storage. He said the area was dirty. The Corporate Dietary Manager said this failure had the potential to attract bugs and roaches and make an unsanitary area for the residents. In an interview on 01/10/24 at 4:32 PM, the Administrator said his expectation was for the Rehab Dining area and Rehab Kitchen area to be clean . He said the area is going to remolded and the cabinet drawers were going to be taken out. Record review of the facility policy Cleaning Cabinets and Drawer, dated as revised on 01/01/10 revealed the following [in part]: Policy: Cabinets and drawers will be clean and organized. Procedure: Weekly: 3. Be sure to clean inside and outside of doors and drawers. Record review of the facility policy Cleaning the Floor, dated as revised on 01/01/10 revealed the following [in part]: Policy: The floor will be kept in a clean and sanitary condition. The floor to be mopped includes storerooms, office space, dish room, janitor closet and rest room.

Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment, and include to the extent practicable, the participation of the resident and the resident's representative(s) for 2 of 4 residents (Resident #'s 45 and 80) whose records were reviewed for assessments and care plans. Resident #45 did not have a comprehensive care plan meeting or an updated care plan after the Significant Change MDS dated [DATE]. Resident # 80 did not have a comprehensive care plan meeting or an updated care plan after the SignigficantSignificant Change MDS dated [DATE] This failure placed the residents at risk for not having individual needs identified and care and services provided to meet their needs, promote quality of care, feelings of well-being and quality of life. The findings included: Review of Resident #45's face sheet, dated 01/11/24, revealed a [AGE] year-old female, with a current admitted [DATE]. Diagnosis included: hypertension (high blood pressure), seizures, major depressive disorder. Review Resident #45's MDS assessment history revealed a quarterly assessment dated [DATE] and a significant change assessment dated [DATE]. Review of Resident #45's comprehensive care plan revealed it was last Reviewed/Revised on 11/20/23. There was no documented evidence that a care plan meeting was conducted for this care plan. In an interview on 01/09/24 at 01:26 PM Resident #45 said she had never been invited to a care plan meeting to discuss her care with facility staff. Review of Resident #80's face sheet, dated 01/11/24, revealed a [AGE] year-old female, with a current admitted [DATE]. Diagnosis included: Hypertension (high blood pressure), seizure disorder, chronic lung disease, and malignant neoplasm of the lung (cancerous tumor) Review Resident #80's MDS assessment history revealed a significant change assessment dated [DATE]. Review of Resident #80's comprehensive care plan revealed it was last Reviewed/Revised on 10/24/23. There was no documented evidence that a care plan meeting was conducted for this care plan. Record review of Resident #80's EMR revealed an IDT Care plan conference was last held on 7/25/23. In an interview on 01/09/24 at 02:49 PM, Resident # 80 stated she had never been invited to a care plan meeting about her care with facility staff. Interview with the Social Worker on 01/11/24 at 1:16 PM revealed the following: She stated that she was responsible for scheduling care plan meetings and sending invitations to the resident and resident representatives. She stated a care plan meeting should have occurred for resident #45 after the significant change assessment dated [DATE], and a care plan meeting should have occurred for Resident #80 after the significant change MDS dated ,d+[DATE].23. She said care plan meetings were missed because the facility had a new system, and it was supposed to send a notice the care plan meeting was due, but it did not, and the care plan was missed. She stated corporate was aware of the system failure and was working to correct it. Interview with the DON on 01/11/24 at 1:32 PM revealed that she did not do the care plans or schedule the care plan meetings. She said that the Social Worker was responsible for that. She stated she expected care plan meetings to be held quarterly and she did expect all required members to attend and the resident or their representative be included. Review of the facility's policy and procedure for Care Plans - Comprehensive, (not dated), revealed the following [in part]: Purpose: 1. To identify resident real and potential needs. 2. To set achievable short- and long-term outcome goals. 3. To document interdisciplinary interventions to achieve stated goals. 4. To evaluate, review, and revise goals and approaches. Procedure: 1. M.D.S./C.P. nurse and Care Plan Team members will utilize the R.A.P. Summary to identify triggered problems, real and potential. 4. Approaches/Interventions will state specific items the interdisciplinary team will do assist the resident in meeting goals and ensure care needs are met. 5. Care plans will be updated to reflect changes in resident needs. 6. Care plan goals and approaches will be reviewed and revised at least every 90 days. New admissions will have a comprehensive care plan in place by day 21. A new care plan will be written annually.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #66 and #276) reviewed for infection control. The facility failed to ensure Occupational Therapist E, the Maintenance Director, and visitors donned Personal Protective Equipment (PPE) as required for residents who were on transmission-based precautions (TBP). This failure could place residents at risk for infections. The findings include: 1. Record review of Resident #66's face sheet, dated 11/22/22, revealed a [AGE] year-old male, who was admitted to the facility on [DATE]. He had a diagnosis that included Enterocolitis due to Clostridium Difficile (C-Diff, an infection of the large intestine). Record review of physician orders, dated 11/22/22, revealed Resident #66 had an order for: Isolation - Transmission-based precautions (contact, droplet, and/or airborne) were in effect every shift, with a start date of 11/07/22. Record review of Resident #66's Care Plan, initiated on 11/07/22, revealed a care plan for Clostridium Difficile and isolation due to infection. In an observation on 11/21/22 at 11:16 AM revealed, Resident #66's door was closed, there were PPE supplies hanging in the doorway, and signage which informed the resident was on Transmission Based Precautions and full PPE was required. In an observation and interview on 11/21/22 at 3:27 PM, Resident #66's family member was in the room visiting the resident, she did not don PPE. She said she was given the choice by the facility if she wanted to wear PPE. Record review of Resident #276's face sheet, dated 11/22/22, revealed an [AGE] year-old female, initially admitted to the facility on [DATE]. She had a diagnosis which included Enterocolitis due to Clostridium Difficile (C-Diff / infection of the large intestine (colon) caused by the bacteria Clostridium difficile) after returning from the hospital on 11/15/22 and place on Transmission Based Precautions (TBP). Record review of physician orders, dated 11/22/22, revealed Resident #276 had an order for: Isolation - Transmission-based precautions (contact, droplet, and/or airborne) were in effect every shift, with a start date of 11/15/22. Record review of Resident #276's Care Plan, initiated on 11/16/22, revealed a care plan for Clostridium Difficile and isolation due to infection. In an observation on 11/21/22 at 10:26 AM, Resident #276's door was closed and had PPE supplies hanging on the doorway, and signage which informed the resident was on Transmission Based Precautions and full PPE was required. In an observation and interview on 11/21/22 at 2:30 PM, Resident #276 was receiving occupational therapy in her room. Occupational Therapist E was not donned in full PPE, she did not have a gown on . Resident #276's family member was also in the room and did not don PPE. Occupational Therapist E said she should have had a gown on but did not put one on. Occupational Therapist E donned a gown after she was asked about it. Resident's #276's family member said she was given the choice by the facility of donning PPE and didn't have to wear any PPE if she did not want too. In an interview on 11/21/22 at 2:35 PM, LVN A said Occupational Therapy was aware Resident #276 was on transmission-based precautions and they should be in full PPE when they provided therapy. She said family members who visited residents on Transmission Based Precautions should be in full PPE and were not given the choice if they wanted to wear PPE. She said family members had not been compliant and she had educated them about wearing PPE. In an interview on 11/21/22 at 2:44 PM, the DON said if a resident was on Transmission Based Precautions, visiting family members should be donned in full PPE and were not given the choice if they wanted to wear PPE. She said the occupational therapists should be donned in full PPE when they provided services. She said staff received education on Transmission Based Precautions and the need to wear full PPE. In an observation, on 11/21/22 at 3:44 PM, the Maintenance Director was observed going into Resident #276's room without donning PPE. In an interview on 11/21/22 at 4:20 PM, the DON said Resident #276's daughter has been educated about the need to wear PPE. She said the Maintenance Director should have donned PPE before going into Resident #276's room. The DON said, I educate, what else can I do?. In an interview on 11/23/22 at 8:58 AM, the Director or Rehabilitation, said she expected staff who provided services to be in full PPE if a resident was on Transmission Based Precautions. She said Occupational Therapist E knew she should have been in full PPE. She said the reason Occupational Therapist E did not have on full PPE was the family member is very demanding and that she forgot to put a gown on. In an interview on 11/23/22 at 9:14 AM, the Maintenance Director said he should have put on PPE but was not paying attention as he was looking at his work order and just walked into the resident's room. Record review of the facility's, undated, policy Isolation, Contact, revealed the following: Purpose: 1. To prevent the spread of infection. 2. To reduce the risk of transmission. Equipment: 1. Gloves, 2. Gowns, 5. Mask. Procedure: 8. Wear gloves, gown and mask when coming into direct contact with resident or linens.

Based on observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for Resident #121 reviewed for pharmaceutical services. 1. The facility failed to ensure LVN F administered medications to Resident #121 according to physician's orders. 2. The facility failed to ensure LVN-F did not leave Resident #121's medication with her at her bedside to take at a later time. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. The findings included: Record review of the Resident #121's face sheet, dated 11/21/22, revealed the resident was admitted to the facility on [DATE]. Her diagnoses included: Chronic Pulmonary Disease with Acute Exacerbation (chronic inflammatory lung disease that causes obstructed airflow flow the lungs), Pneumonia (fluid in the lungs), Acute/Chronic Respiratory Failure (inadequate gas exchange, lungs cannot get enough oxygen to the blood), Acute Pulmonary Edema (excessive liquid accumulation in the tissue and air space of the lungs) and shortness of breath. Record review of Resident #121's, physicians' orders, dated 11/22/22, documented an order for Budesonide Suspension 0.5 MG/2ML inhale orally two times a day for shortness of breath. In an observation and interview on 11/21/22 at 9:27 AM, Resident #121 was sitting up in her bed watching her television She stated earlier that morning LVN F went into her room and gave her morning nebulizer treatment but set it on her nightstand to take when she was finished eating. Resident #121's nebulizer was out, and medication was in the nebulizer cup for treatment. Treatment had not been done by the resident or LVN F. Resident stated the nurse always left her medicine for her to take when she was ready and she takes it after she ate her food Record review of the medication administration record revealed Resident #121's Budesonide Suspension 0.5 MG/2ML inhale orally two times a day for shortness of breath, was initialed as treatment being administered when the medication remained in the nebulizer machine at her bedside. In an interview on 11/21/22 at 9:40 AM with LVN F, who was assigned med pass during the observation, stated she left the medication for the resident to take after she was finished eating breakfast. She stated residents should be observed to ensure the medication was taken by the correct resident at the correct time. She stated the medication should not be documented as taken unless the nurse actually watched them take the medication. LVN F observed the medication was still in the nebulizer, and she discarded the medication. In an interview on 11/22/22 at 2:20 PM, the DON stated the person who administered the medication should always verify medication with the resident, date, time, and route with medication being given. When medication is given to a resident the nurse who provided the medications should always witness the medication taken by the resident for whom it was ordered and taken per the orders given. She stated the nurse was not a new nurse and was trained to watch and stay with the resident until the medication treatment was completed . Record review of the facility policy statement on Administration of Drugs stated Proceed with cart to resident's room and identify the resident, read medication orders on medication sheet and have medication ready, remove prescribed liquid medication from appropriate place and pour prescribed amount into calibrated cup, make appropriate entry on the electronic medical records, wash hands and leave resident who is to receive medication. [sic]

Based on interview and record review the facility failedto ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents needs, as identified through resident assessments, and described in the plan of care for 1of 3 staff (Medication Aide C) reviewed for competency and proficiency of nursing staff.: The facility failed to ensure Medication Aide C reported and elevated pulse rate when Resident #59 had an elevated pulse of 154. This failure could place residents at risk of adverse effects, or inadequate therapeutic effect of medications and a decline in health status. The findings were: Record review of Resident #'59's face sheet, dated 11/23/22, indicated a [AGE] year-old male with an admitted [DATE]. Resident #59 had diagnoses which included chronic respiratory failure with low blood oxygen, shortness of breath, atrial fibrillation (rapid irregular heart beat the commonly causes poor blood flow) heart failure, kidney failure, syncope, and collapse (a temporary loss of consciousness caused by a drop in blood pressure). Record review of Resident #59's significant change MDS, dated [DATE], indicated a BIMS of 11, which indicated mild to moderate cognitive impairment. Record review of Physician Orders for Resident #59, dated 11/21/22, indicated the following, metoprolol tartrate 25 mg 2 times a day PO (Hold if pulse is less than 60 and notify physician), diltiazem capsule extended release 24-hour/300 mg give one capsule one time a day for hypertension by mouth (if systolic blood pressure is less than a hundred or diastolic blood pressure is less than 50 hold and notify physician, or if systolic blood pressure is greater than 180 or diastolic blood pressure is greater than 110 notify a physician). Record review of Resident # 59's vital sign readings for the month of 11/22 revealed the residents pulse readings had ranged from 60 to 115 beats/minute. In an observation and interview on 11/22/22 at 7:30 AM, Resident #59 was sitting on the side of his bed . Medication Aide C administered medications to Resident #59. She obtained his blood pressure and pulse, using a wrist type blood pressure cuff. The resident's blood pressure was 113/65 and his pulse was 154. The resident stated to Medication Aide C he had just taken a breathing treatment earlier and maybe that was why his pulse was higher than normal. Medication Aide C administered the resident's medications and did not report the elevated pulse to the charge nurse. On 11/22/22 at 8:30 AM an interview with LVN D revealed Medication Aide C had not reported to her that Resident #59 had a pulse rate of 154 during his medication administration. She stated it was her expectation the medication aide reported any vital sign which was out of range ( normal pulse range 60-100). She stated CNAs were taught in their training of the abnormal signs and symptoms to report to a licensed nurse which included the normal range for a resident's pulse. She stated a pulse rate of 154 would be abnormal and she would expect the pulse to be reported to the chare nurse. She also stated she would assess the resident if an abnormal pulse rate was reported to her. In an interview on 11/22/22 at 8:40 AM LVN D stated that she had assessed the resident and pulse was regular and within normal limits. During an interview the ADON on 11/23/22 at 8:35 AM, she said she would expect a pulse of 154 to be reported to the nurse. She stated Resident #59 had an unstable cardiac and respiratory status and he could go downhill quickly. She stated his pulse should be re-checked by the charge nurse an if it was still elevated it should be reported to his physician by the charge nurse. On 11/23/22 at 8:55 AM an interview with Medication Aide C revealed she did not report the elevated pulse of Resident #59 because the resident did not seem alarmed and stated he had just had a breathing treatment which might have caused his heart rate to increase. She stated there were low parameters for 2 of the medications but no instructions to report a pulse higher than a certain rate. She stated she would have reported a reading outside of the stated parameters if there had been a high parameter on the physician orders. She stated she had been trained to take a pulse in her training and to report abnormal readings but she though the pulse rate was higher because the resident said it was due to his breathing treatment. Record review of Medication Aide C's employee file revealed she had been observed for competency while administering medications on 07/06/22 and 11/17/22. The observation form revealed she had met the expectation of obtaining vital signs for residents with parameters before administering the medication. There was no documentation of training in recognizing abnormal pulse rates in the competency checks. The DON provided an employee corrective action form dated 11/23/22 which stated: [C.M.A.C] obtained vital signs per medication regimen requirements; resident pulse noted to be 154. CMA failed to directly relay abnormal pulse to Charge Nurse directly instead of relying on the EMR clinical alert to notify the charge nurse. Record review of the Texas Curriculum for Certified Nurse's Aides In Long Term Care Facilities published by the Texas Department Of Health and Human Services, dated revised January of 2022, revealed in part: Procedural Guideline for Manual Pulse: Locate the radial pulse by placing the tips of your first 3 fingers on the thumb side of the resident's wrist. Do not press hard. Count the pulse for one minute. Report to the nurse pulse rate below 60 or above 100/minute (normal is about 76 and regular).

Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the residents' status for 1 of 7 residents (Resident #77) reviewed for accurate MDS assessments. The facility failed to ensure Resident #77's MDS accurately reflected the resident's range of motion in upper and lower extremities. This failure could place residents at risk for not having individual needs identified, a decline in health status, and decreased feelings of well-being. The findings include: Record review of Resident #77's Admission Record, dated 11/23/22, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #77 had diagnoses which included aphasia (loss of ability to understand or express speech caused by brain damage), cerebral hemorrhage (bleeding in the brain), high blood pressure, and dysphagia (inability to swallow). Record review of Resident #77's Quarterly MDS Assessment, dated 09/26/22, revealed she was assessed as having no impairment to range of motion in her upper extremities, and no impairment in range of motion in her lower extremities. Record review of Resident #77's care plan revealed documentation that the resident was at risk for contracture and had a goal of no contractures in the next 90 days. Interventions included assist with ADL's and mobility as needed, monitor for pain with ADL's and movement, monitor for stiffness of joints, range of motion per staff, reposition resident every 2 hours and as needed. In an interview on 11/21/22 at 3:43 PM, Resident #77's family member stated Resident #77 had contractures to her right and left arm, hands, her right and left foot and legs. In an interview and observation on 11/23/22 at 10:30 AM, Resident #77 was noted to have contractures to her upper and lower extremities. The ADON was present during the observation and stated Resident #77 had contractures to her upper and lower extremities. She stated it should have been documented in the EMR and it was the nurse's responsibility to ensure assessment findings were accurately documented. She stated she did not know why the resident contractures were not documented. In an interview on 11/22/22 at 11:00 AM, the DON stated she was aware of the contractures to the bilateral upper and lower extremities for Resident #77. She stated the person completing the MDS and the nurses were responsible for ensuring the EMR contained accurate information regarding the residents' assessments. She stated the MDS assessment should reflect what the nurses observe, and this should be documented accurately in their medical record. In an interview on 07/07/22 at 4:05 PM, MDS Nurse B stated she did the MDS assessments for the Resident #77 and all the Medicaid and long-term care residents at the facility. She stated she needed to do a correction to the MDS for Resident #77 and document the contractures to her upper and lower extremities. She stated she was not aware the resident had limitations in Range of Motion in her upper and lower extremities. She stated she depended on the documentation by the nurses in the EMR to complete the MDS assessments. She stated the error occurred because she had looked in the medical record of Resident #77 and did not see any documentation of limited Range of Motion in the upper and lower extremities. Record review of the facility's, undated, policy Resident Assessment, stated: Purpose: To ensure consistent and accurate assessments of all residents. To identify resident strengths and potential areas of concern. Procedure: MDS Nurse will do an assessment on each resident within 14 days of initial admission, within 14 days of identified significant change per Health Care Financing Administration guidelines, and every 90 days thereafter using the quarterly MDS form. MDS Nurse will review resident record for further information and to locate supporting documentation.

Based on observation, interviews and record review, the facility failed to ensure that all alleged violations of abuse, and neglect, were thoroughly investigated and to prevent further abuse while the investigation is in progress for 1 (residents #1) of 1 resident reviewed for abuse, neglect, and misappropriation of property. The facility failed to investigate an allegation of sexual harassment allegations by resident #1 during a complaint investigation. This failure could place residents at risk for abuse, and neglect which could result in diminished quality of life. Findings included: Review of Resident #1's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's inital MDS dated [DATE] revealed she had a BIMS 12 indicating she was able to make her needs know. Section G (Functional Status) revealed she required extensive assistance from 2-person transfer. During initial tour interview on 10/07/2022 at 10:50 AM, Resident #1 revealed she was sexually assaulted one night at the facility during a conversation regarding her care. She said some men came in and had sex with her. Surveyor asked if she told anyone, she said no, then changed her story saying she was more likely sexually harassed by staff who were on twitter. She said they wrote about her on her twitter feed (revealed on her cell phone) which made several comments related to sexually explicit performances. The surveyor asked if she told any staff about what happened, and she said she called the police but the nurse on duty told them (police) not to come. She said the charge nurse told her she was making up the story. Resident #1 said the charge nurse that was on duty who she told the story to was terminated for other reasons. Resident #1 said she could not remember the charge nurses name, and no one heard her conversation as far as she knew. During an interview on 10/07/2022 at 1:30 PM, the DON said she was made aware of claims resident #1 (during the admission process) made regarding sexual harassment by the last facility resident #1 was at prior to coming to their facility. The last facility told DON, resident #1 also made allegations of sexual harassment at their facility prior to that facility. Because of hear-say allegations she did not believe anything happened to resident #1. Surveyor asked the DON on 10/07/2022 at 1:30 PM if she was aware of anything called The Virtual Reality Club because resident #1 said that was the way she was harassed, and it was from staff at the facility. The DON said she did not believe any of the allegations related to sexual harassment (if they were made but was not brought to her attention and were not). The Surveyor told DON Resident #1 did make claims of being sexually harassed to him. During an interview on 10/07/2022 at 3:00 PM, the Ombudsman returned surveyor telephone and said she was familiar with Resident #1, and she was not aware of any allegations of sexual harassment at other facilities and was not aware of any complaints made by Resident #1. During an interview on 10/10/2022 at 7:45 AM, the DON said she did not self-report the complaint notifying her of the potential sexual harassment revealed by the surveyor on 10/07/2022 at 1:30 PM. She said she did not take the allegations seriously. During an interview on 10/10/2022 at 7:50 AM, the Administrator said the DON told him when surveyor revealed to the DON on 10/07/2022 at 1:30 PM resident #1 was saying something about sexual harassment but they did not take her seriously(because these allegations were reported by two other facilities prior to the present facility). He said he would talk to Resident #1 about it this morning. During an interview with resident #1 on 10/10/2022 at 9:20 AM, she said she received more twitter messages from people in the Virtual Reality Club (shown to surveyor). Resident #1 said that the people on twitter were other residents who live in the facility and not staff. During an interview with Administrator on 10/10/2022 at 9:30 AM, he said he talked to Resident #1 this morning (at no specific time) and she said that she was inseminated virtually on twitter, and it was residents who live at the facility who were on twitter and make harassment statements. He said he will investigate the allegations at this time. He said it was difficult to take Resident #1 seriously. Review of the facility's undated policy and procedure titled, Operational/Resident Care Policies revealed the following: The resident, responsible party, and/or legal guardian receive Statement of Resident Rights, Rights of the Elderly Human Resources Code Chapter 102 and Resident Bill of Rights which outline their right to be free from any type of abuse, neglect, and exploitation. In addition, the facility informs families on how and to whom they may report concerns, incidents, and grievances without fear of retribution, and provide feedback regarding their concerns that have been expressed. The administrator or his/her designee will report the allegations of abuse immediately to the state agency (HHSC) and to the proper authorities. An immediate investigation will be investigated by the director of nursing. The director of nursing will ensure that facility completes the appropriate investigated forms and forward a copy of the investigation to (HHSC) within 5 working days.

Based on observations, interviews, and record reviews the facility failed to ensure that all alleged violations including allegations of sexual harassment are reported immediately, but not later than 2 hours after the allegation is made to other officials (including to the State Survey Agency) for 1 of 1 (Resident #1) facility incidents reviewed for reporting in that: The DON did not report allegations of sexual harassment for resident #1 within 2 hours. This could affect residents and result in abuse, neglect, and decrease in care. Findings included: Review of Resident #1's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's inital MDS dated [DATE] revealed she had a BIMS 12 indicating she was able to make her needs know. Section G (Functional Status) revealed she required extensive assistance from 2-person transfer. During initial tour interview on 10/07/2022 at 10:50 AM, Resident #1 revealed she was sexually assaulted one night at the facility during a conversation regarding her care. She said some men came in and had sex with her. Surveyor asked if she told anyone, she said no, then changed her story saying she was more likely sexually harassed by staff who were on twitter. She said they wrote about her on her twitter feed (revealed on her cell phone) which made several comments related to sexually explicit performances. The surveyor asked if she told any staff about what happened, and she said she called the police but the nurse on duty told them (police) not to come. She said the charge nurse told her she was making up the story. Resident #1 said the charge nurse that was on duty who she told the story to was terminated for other reasons. Resident #1 said she could not remember the charge nurses name, and no one heard her conversation as far as she knew. During an interview on 10/07/2022 at 1:30 PM, the DON said she was made aware of claims resident #1 (during the admission process) made regarding sexual harassment by the last facility resident #1 was at prior to coming to their facility. The last facility told DON, resident #1 also made allegations of sexual harassment at their facility prior to that facility. Because of hear-say allegations she did not believe anything happened to resident #1. Surveyor asked the DON on 10/07/2022 at 1:30 PM if she was aware of anything called The Virtual Reality Club because resident #1 said that was the way she was harassed, and it was from staff at the facility. The DON said she did not believe any of the allegations related to sexual harassment (if they were made but was not brought to her attention and were not). The Surveyor told DON Resident #1 did make claims of being sexually harassed to him. During an interview on 10/07/2022 at 3:00 PM, the Ombudsman returned surveyor telephone and said she was familiar with Resident #1, and she was not aware of any allegations of sexual harassment at other facilities and was not aware of any complaints made by Resident #1. During an interview on 10/10/2022 at 7:45 AM, the DON said she did not self-report the complaint notifying her of the potential sexual harassment revealed by the surveyor on 10/07/2022 at 1:30 PM. She said she did not take the allegations seriously. During an interview on 10/10/2022 at 7:50 AM, the Administrator said the DON told him when surveyor revealed to the DON on 10/07/2022 at 1:30 PM resident #1 was saying something about sexual harassment but they did not take her seriously (because these allegations were reported by two other facilities prior to the present facility). He said he would talk to Resident #1 about it this morning. During an interview with resident #1 on 10/10/2022 at 9:20 AM, she said she received more twitter messages from people in the Virtual Reality Club (shown to surveyor). Resident #1 said that the people on twitter were other residents who live in the facility and not staff. During an interview with Administrator on 10/10/2022 at 9:30 AM, he said he talked to Resident #1 this morning (at no specific time) and she said that she was inseminated virtually on twitter, and it was residents who live at the facility who were on twitter and make harassment statements. He said he will investigate the allegations at this time. He said it was difficult to take Resident #1 seriously. Review of the facility's undated policy and procedure titled, Operational/Resident Care Policies revealed the following: The resident, responsible party, and/or legal guardian receive Statement of Resident Rights, Rights of the Elderly Human Resources Code Chapter 102 and Resident Bill of Rights which outline their right to be free from any type of abuse, neglect, and exploitation. In addition, the facility informs families on how and to whom they may report concerns, incidents, and grievances without fear of retribution, and provide feedback regarding their concerns that have been expressed. The administrator or his/her designee will report the allegations of abuse immediately to the state agency (HHSC) and to the proper authorities. An immediate investigation will be investigated by the director of nursing. The director of nursing will ensure that facility completes the appropriate investigated forms and forward a copy of the investigation to (HHSC) within 5 working days.

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 for kitchen storage and sanitation in that: 1. A black substance (mold) was found under the kitchen sink covering a large part of the pipe fixture and the surface. 2. An unlabeled and undated containers of Cole slaw and Jelly was in the freezer 3. The back of the ice machine was completely covered with dust These failures could place residents who received meals from the Kitchen at risk for food borne illness. The findings included: 1. Observation on [DATE] at 11:37 a.m. in the kitchen revealed a black substance covering the pipe fixture and surfaces under the sink. 2. Observation on [DATE] at 11:40 a.m. revealed a large container of Cole slaw in the freezer, unlabeled, undated, and partially sealed. 3) Observation on [DATE] at 11:40a.m revealed unlabeled and undated large container of Jelly. 4) Observation on [DATE] at 11:43a.m revealed a brown substance (what appear to be dust) completely covering the back of the ice machine including the filter During interview and observation with DM on [DATE] at 2:12p.m, he stated was the Dietary Manager and has been employed in the facility for 4 years. Surveyor showed DM what appeared to be mold under the kitchen sink and the dust on the ice machine. He was asked what the black substance covering underneath the sink look like. He said it was a mold. DM explained he was not aware of the mold but will make plans to remove it and clean the ice machine. He was also informed of the unlabeled and undated Cole slaw and Jelly. He stated he recently hired a new staff and had not gotten a chance to train them. He said the prepared foods should be labeled and dated to prevent food borne illness to residents. In an interview with KA A on [DATE] at 2:25 p.m., she said she had been in the facility for less than 2 months. She explained she came in at 12 noon and was not aware of the unlabeled and undated Cole slaw or jelly. KA A said prepared food should be labeled and dated to avoid giving residents bad food and prevent hospital visits. During interview with KA B on [DATE] at 2:30 p.m., she said today was her second day in the facility. She explained she was not aware of the unlabeled and undated food items because she came just before lunch time. She said she had been in the food business and knew to label and date food to avoid serving expired meals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed ,d+[DATE].13 Nonfood-Contact Surfaces, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed ,d+[DATE].17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, revealed (A) .food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold or discarded when held at a temperature 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. And (B) .refrigerated, ready-to-eat time/temperature controlled 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 .and .(2) The day or date marked by the food establishment ay not exceed a manufacturer's used-by date if the manufacturer determined the use-by date based on food safety. Review of the facility dietary services policy undated reflected, The facility will provide each resident with nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident Sanitary Conditions: Food in unlabeled or damaged containers shall not be accepted or retained. Orientation: It is the responsibility of the dietary services supervisor to orient all new dietary employees to the facility policies and procedures and the dietary policies and procedures.

Based on observation, interviews and record reviews the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of infection for 2 of 3 residents reviewed for incontinent care (Resident # 11 and # 38). The facility failed to ensure: A. CNA A and CNA B thoroughly cleaned the head of Resident # 11's penis and pushed the foreskin back in place. B. CNA B and CNA A cleaned feces from the inner thighs of resident # 38 during incontinent care. This failure could affect residents requiring incontinent care and/or catheter care by placing them at risk of the development and/or worsening of urinary tract infections and skin breakdown. The findings include: Resident # 11 Review of Resident # 11's Face Sheet, dated 09/08/2021, revealed he was a [AGE] year-old admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 11 's MDS dated [DATE] revealed he required extensive assistance for bed mobility, toileting, and was incontinent of bowel and had a urinary catheter. Resident ID #11's BIM score was 9 out of 15, indicating a moderate cognitive deficit. In an observation on 09/08/2021 at 1:30 PM, during provision of incontinent care, CNA A retracted the resident's foreskin and began to cleanse a thick white discharge that was located beneath the foreskin and on the head of resident # 11's penis. Two open excoriated areas were noted on his penis. Resident # 11 was then turned to his right side by CNA A. CNA B assisted her to turn the resident. Resident # 11's buttocks were then cleaned, and a new brief was applied . CNA A did place the foreskin back over the head of the penis. White residue remained on the head of the penis The resident did not verbalize discomfort during the procedure. In an interview on 09/08/2021 at 1:50 PM, CNA A and CNA B stated they had completed the procedure and were ready to leave the room. They did not indicate they would do anything differently. They were not aware of the excoriated areas prior to providing the incontinent care. In an interview on 09/08/2021 at 1:50 The LVN Education Nurse stated the CNA A should have cleaned all the residue off of the head of Resident # 11's penis to prevent further skin breakdown and infection and report the open areas to the charge nurse. She stated she would do further instruction on peri care with both CNAs. Interview on 09/08/2021 at 3:00 PM, the DON stated she expected the CNAs should clean residents thoroughly when providing incontinent care and follow the facilities policy and procedure. She sated she was responsible for monitoring incontinent care. Resident # 38 Review of Resident # 38's Face Sheet, dated 09/09/2021, revealed he was a [AGE] year-old admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 38's MDS dated [DATE] revealed he required extensive assistance for bed mobility, toileting, personal hygiene, and was frequently incontinent of bowel, and had a foley catheter. Resident # 38's BIMS score was 13 out of 15, indicating a mild cognitive deficit. In an observation on 09/08/2021 at 2:30 PM, during provision of incontinent care, CNA B and CNA A did not clean feces from the right and left inner thigh area of Resident # 38. They turned the resident and cleansed the buttocks area and applied a new brief and stated they were done. The surveyor asked CNA B and CNA A to open the brief back up and look at the inner thigh area. They acknowledged feces remained on the right and left inner thigh. The resident was then cleaned appropriately, and a new brief applied. In an interview on 09/08/2021 at 2:30 PM, CNA B and CNA A acknowledged that there was feces on the right and left inner thigh area of Resident # 38. They stated they had not seen the feces on Resident # 38's inner thighs until the surveyor brought it to their attention. In an interview on 09/08/2021 at 3:00 PM, the LVN Education Nurse stated CNAs A and B revealed to her that they were unsure if they should clean the remaining thick white discharge from the head of Resident # 11's penis and that they did not see the feces on the inner thighs of resident # 38 until it was pointed out by the surveyor. She stated she was going to do additional education to ensure that the infection control issues that were identified would be corrected. Review of the he facility's policy and procedure, titled, Perineal Care , not dated, documented [in-part]: Male: Pull back the foreskin of the uncircumcised male to clean the area (being careful to push the foreskin back in place after drying well). After the front is clean, dry the resident. Assist the resident to a side lying position. With a clean washcloth, clean the rectum by wiping from the front to the back using a different part of the cloth with each stroke. Dry the resident. Apply a new incontinent pad to the resident. .

Based on interview and record review, the facility failed to notify the Ombudsman of facility initiated resident transfers or discharges for two of two months reviewed. The facility did not have a policy to address informing the Ombudsman of facility-initiated transfers or discharges and facility staff were unaware this was a requirement. This could place residents at risk of being inappropriately discharged or transferred from the facility without access to the Ombudsman to act as an advocate and inform them of their options and rights. The findings include: Review of spreadsheet supplied by Director Of Nurses on COVID residents that are facility-initiated transfers revealed 80 residents had been transferred or discharged from the facility between November 16, 2020 and January 8, 2021. In an interview with the area Ombudsman on 01/12/2021 at 11:00 AM regarding notification of transfer or discharge she revealed that she has not been notified by facility of any transfers or discharges. In an interview on 01/12/2021 at 1:00 PM with Director of Nurses and Administrator both denied knowledge that this was a requirement. In an interview with Social Worker A from Sister facility on 01/12/2021 at 1:35 p.m. social Worker A stated, I started in October and have not notified Ombudsman of transfers or discharges regarding any residents. Review of Facility policy regarding Discharge/Transfer of Resident not dated revealed it did not address the required notification of Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure CNA A and CNA B were able to demonstrate competency in skills and techniques to care for resident's needs for 1 of 2 residents (Resident #1) reviewed for incontinance care. CNA (Certified Nurse Aide) A and CNA B failed to perform hand hygiene and change their gloves at the appropriate times while providing incontinence care for Resident #1. These failures could place residents at risk for the spread of infection. Finding include: Review of Resident #1's face sheet, dated 10/08/2020, revealed the resident was an 87- year- old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 09/25/20, revealed Resident #1 required extensive assistance with most activities of daily living (ADL)) and one person assist. Resident #1 was always incontinent of bowel and frequently of bladder. Review of Resident #1's care plan, dated 06/25/20, revealed the resident was planned for being incontinent of bladder and bowel. The goal was for resident to be clean and free of odors. Interventions include to give resident peri care when resident is incontinent. Observation on 10/08/20 at 2:24p.m revealed Resident #1 was sitting on a wheelchair when surveyor requested to observe incontinent care. The observation revealed the resident clothes and brief was completely soiled with urine penetrating through to her wheelchair. There was a distinct urine odor emanating from the resident. Observation of incontinence care for Resident #1, on 10/08/20 at 2:40 p.m., revealed CNA A did not wash hands but donned gloves before transferring Resident #1 from chair to bed. As she lifted the resident, her clothes and brief were completely covered with urine which penetrated through the wheelchair. There was also a distinct urine odor. She used proper transfer technique. CNA B walked into the room, washed hands and put on gloves to assist CNA A. CNA A realized she needed a draw sheet to replace the one soiled with urine. She doffed her gloves, washed hands before exiting the room. CNA A reentered the room, washed hands and donned gloves before continuing care. Resident #1 was soiled with urine and fecal matter. She wiped the resident from front to back in the perineal area. CNA A gloves were visibly soiled with urine. She did not wash hands, change gloves or perform hand hygiene before retrieving a clean brief and putting it underneath Resident #1. Meanwhile, CNA B was assisting CNA A to provide care to Resident #1. Both repositioned the resident. CNA B cleaned the resident's coccyx area. He did not washed hands, change gloves or perform hand hygiene before fastening Resident #1 clean brief. CNA A and CNA B washed hands before leaving Resident #1's room. In an interview, on 10/08/20 at 2:51p.m., with CNA A she stated she had been employed in the facility since August 2020. CNA A explained cross contamination was using the same gloves from going from dirty to clean. CNA A acknowledged she should have washed hands, changed gloves or perform hand hygiene before retrieving Resident #1 clean brief. She added Resident #1 could get sick for not using good infection control practice. Interview with CNA B, on 10/08/20 at 2:54 p.m., revealed he had been employed in the facility for about 5 years. He stated cross contamination was transferring germs from one place to another. CNA B acknowledged she should have washed hands, change gloves, or perform hand hygiene before fastening Resident #1's clean brief. He said when asked, resident could get infection for not changing gloves. During an interview with the DON (Director of Nursing) on 10/08/20 at 3:40 p.m., she stated the aides were expected to follow appropriate hand hygiene when providing incontinent care. She said they should know to change gloves before placing clean brief on resident. Review of hand washing, and continent care procedure and evaluations policy undated revealed, Hand washing is required before and after a procedure that involves direct and indirect contact with a resident, after contact with any waste or contaminated material, before handling any food or food receptacle, or any time the hands are soiled The procedure includes wash hands and put on gloves .

Based on observation, interviews and record review the facility failed to provide each resident with necessary respiratory care consistent with professional standards of practice, for 5 of 5 residents (Residents #1, #2, #3, #4, and # 5) reviewed for respiratory care, by failing to ensure: A. Resident #1's nebulizer tubing and mask was changed and dated every week. B. Resident #2's oxygen tubing was changed and dated every week. C. Resident #3's oxygen tubing was changed and dated every week. D. Resident #4's oxygen tubing was changed and dated every week. E. Resident #5's oxygen tubing was changed and dated every week. This failure could affect the residents by placing them at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen and supplies. Findings included: Resident #1 Record review of resident #1's face sheet, dated 06/23/20, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on 06/23/20 at 11:25 AM, Surveyor escorted by LVN A to resident's room revealed resident was not in his room, but his nebulizer tubing and mask were hanging in a clear, plastic trash bag off of his nightstand. The mask and the tubing were not dated. Record review of resident #1's physician orders, dated 4/16/20, revealed orders to clean nebulizer and change tubing every week on Sunday night shift. Resident #2 Record review of resident #2's face sheet, dated 06/23/20, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on 06/23/20 at 11:35 AM, resident was in his room. Oxygen tubing and humidifier bottle not dated. Record review of resident #2's physician orders, dated 2/23/20, revealed orders to clean oxygen concentrator and change humidifier bottle daily on night shift, and change tubing every week on night shift every Sunday. Resident #3 Record review of resident #3's face sheet, dated 06/23/20, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation made on 06/23/20 at 11:33 AM revealed resident # 3's oxygen tubing was not dated, and humidifier bottle was dated 4/19/20. Record review of resident #3's physician orders, dated 2/22/20, revealed an order to change oxygen concentrator and tubing and set up every Sunday on night shift. Resident #4 Record review of resident #4's face sheet, dated 06/23/20, revealed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Observation on 06/23/20 at 11:43 AM revealed resident lying in bed receiving continuous oxygen. Oxygen tubing was not dated. Record review of resident #4's physician orders, dated February 5/20/20, revealed to change tubing every week on Sunday on night shift. Resident #5 Record review of resident #5's face sheet, dated 06/23/20, revealed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Observation of resident on 06/23/20 at 11:32 AM revealed resident #5 had tubing with no date. Record review of resident #5's physician orders, dated 1/12/20, revealed orders to be on oxygen at 2-4 lpm via NC or 5-8 lpm via mask for SOB, but the facility failed to write orders with care instructions for tubing. Review of the facility's policy and procedure, not dated, titled Administration of Oxygen revealed, section A-8, ( .Oxygen cannula, tubing, and humidifier bottle should be changed weekly and prn .) Review of the facility's policy and procedure, not dated, titled Nebulizer Treatment, in section N-10 revealed ( .Weekly change to new nebulizer and mouthpiece .)

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one of eight residents on one of four halls (Resident #1 on hall 300) reviewed for storage of medications. Resident #1 who has a [DIAGNOSES REDACTED]. This failure could affect residents by placing them at risk of consuming unsafe medications. Findings included: Resident #1 Record review of Resident #1's face-sheet, dated June 23, 2020, revealed a [AGE] year-old male, with an admission date of [DATE]. Resident's [DIAGNOSES REDACTED]. Record review of Resident #1's current MDS dated [DATE] revealed Resident's vision was impaired. Further review of MDS revealed Resident's BIMS score of three, indicating severe cognitive impairment. Record review of Resident #1's care-plan, not date, revealed in part .Focus: (Resident #1) has impaired visual function . Further review revealed .(Resident #1) has Long Term Memory Impairment, as well as Short Term Memory Problems, Decision poor and Requires supervision and cueing, and has a Respiratory infection related to pneumonia . Record review of Resident #1's Physician orders, dated 06/23/2020, revealed an order for [REDACTED]. Observation and interview on 06/23/20 at 11:25 AM. LVN A escorted surveyor into Resident #1's room where at that time it was discovered that resident had nebulizer medication sitting on top of his bedside table and eye drops and nasal spray in top drawer of his bedside table. When asked about the medications that were left at the resident's bedside, she stated Residents must have an order for [REDACTED]. Interview with DON on 06/23/20 at 1:20 PM, she stated that medication is not supposed to be left at bedside, unless there is an order to do so, but that she didn't believe the facility had any residents with orders to keep medication at the bedside at this time. Facility Policy and Procedure for medication administration was requested on 06/23/20 at 1:25 PM but was not provided to surveyor prior to exit.