Every finding on record at Shinnery Oaks Community

Based on interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 (Resident #9 and #46) residents reviewed for accuracy of assessments. The facility failed to ensure Resident #9 and #46 were coded in the MDS for wander alarm. This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment.The findings included:Resident #9Record review of Resident #9's face sheet dated 12/10/25 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Dementia (cognitive decline), Hypertension (high blood pressure), anxiety (feeling of fear and worry) and muscle weakness. Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 00 indicating Resident #9's cognition was severely impaired. The MDS also indicated Section P - Restraints and Alarms - section P0200 - Alarms E. Wander/Elopement alarm was marked not used. Record review of Resident #9's care plan, dated 11/05/2025, revealed a care plan for dementia/Alzheimer's and required a secure unit related to elopement risk and wanders aimlessly. Interventions revealed implement appropriate security measures, such as alarms, coded doors, and surveillance systems. Wander guard in place and functioning properly. Intervention initiated date 6/28/24 and revised date 7/2/24. Record review of Resident #9's physician orders revealed an order to check wander guard placement every shift for wander guard placement dated 05/22/2024. The physician orders further revealed an order for wander guard functioning properly, every night shift for elopement risk dated 05/22/2024. During an observation on 12/09/2025 at 11:45 AM observed Resident #9 sitting in wheelchair with wander guard bracelet on right ankle. Resident #46Record review of Resident #46's face sheet dated 12/10/25 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Dementia (cognitive decline), Hypertension (high blood pressure), Cerebral infarction (blood flow was block from part of the brain) and muscle weakness. Record review of Resident #46's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 04 indicating Resident #46 cognition was severely impaired.Section P - Restraints and Alarms - section P0200 - Alarms E. Wander/Elopement alarm was marked not used. Record review of Resident #46's care plan, dated 11/05/2025, revealed a care plan for resident elopement related to residents wanting to go to the store. Interventions revealed wander guard in place on left lower extremity dated 11/13/2025. Record review of Resident #46's physician orders revealed an order to check wander guard placement every day and night shift for elopement risk dated 11/13/2025. The physician orders further revealed an order for wander guard placement related to exit seeking behaviors dated 11/13/2025 and an order for wander guard functioning properly, every night shift for elopement risk dated 11/13/2025. During an observation on 12/09/2025 at 11:10 AM observed resident #46 in room sitting in recliner with wander guard bracelet on left ankle. During an interview on 12/10/2025 at 03:00 PM with the MDS nurse, she reviewed Resident #9 and #46's quarterly MDS and stated they both should be marked as use daily. During an interview on 12/11/2025 at 08:50 AM with the MDS Nurse, the MDS nurse stated the purpose of the MDS was to accurately put all resident information. The MDS nurse stated she was not aware the MDS's was not coded correctly. She stated she missed marking the right response and needs to pay closer attention. She stated she had received training on MDS. She stated she was responsible for making sure the MDS was accurate. She stated her expectations was for the MDS to be as accurate as possible. She stated she was not sure how she missed coding the wander alarm. She stated there was a new update on 09/01/2025 and she was still learning all the changes. She stated Residents #9 and #46 had wander guard bracelets at the time of the MDS assessment. She stated the potential negative outcome could possibly affect the resident depending on the situation. During an interview on 12/11/2025 at 08:50 AM with the DON, she stated the purpose of the MDS was collection of data to develop a care plan. She stated she was not aware the MDS's was coded inaccurately. She stated the potential negative outcome could affect the residents by causing an inaccurate care plan.During an interview on 12/11/25 at 09:01 AM with the ADM, he stated the purpose of the MDS was to reflect the resident's condition and care. He stated he was not aware the MDS was not coded correctly. He stated all staff have been trained. He stated the IDT was responsible for accurately coding the MDS. He stated his expectation was for the MDS to be coded correctly. He stated the potential negative outcome could be the potential to not have a proper care plan. Record review of the facility's Quarterly Assessments Policy dated 2001 revealed: Policy Statement - Quarterly MDS assessments are conducted to track the resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Record review of CMS's RAI version 3.0 dated October 2025 revealed section: P0200: AlarmsP0200 Alarms: An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Coding: 0. Not used, 1. Used less than daily, 2. Used daily.E. Wander/elopement alarm.Steps for Assessment:Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if alarms were used during the 7-day look-back period.Coding Instructions:Identify all alarms that were used at anytime (day or night) during the 7-day-look-back period. After determining whether or not an item listed in P0200 was used during the seven day look back, code the frequency of use:Code 0, not used: if the device was not used during the 7-day-look-back period. Code 1, used less than daily: if the device was used less than daily.Code 2, used daily: if the device was used on a daily basis during the look-back period. Coding Tips: .Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, care) or other belongings.Code any type of alarm, audible or inaudible, used during the look-back period in this section.Bracelets or devices worn by or attached to the resident and/or their belongings that signal a door to lock when the resident approaches should be coded in P0200E. Wander/elopement alarm, whether or not the device activates a sound or alerts the staff.

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 3 residents (Residents #13 and #28) reviewed for infection control. 1. RN A failed to wear proper PPE (a gown) when providing wound care for Resident #13 who was on EBP. 2. LVN B failed to wear proper PPE (a gown) when providing wound care for Resident #28 who was on EBP. These failures could place residents at risk for the spread of infection and cross contamination. 1. Record review of Resident #13's face sheet, dated 12/10/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included: Alzheimer's Disease (a progressive brain disorder leading to severe cognitive decline), peripheral vascular disease (a circulatory problem resulting in reduced blood flow, and pressure ulcer of the left ankle. Record review of Resident #13's annual MDS, dated [DATE], reflected an unscored BIMS, due to the resident was rarely or never understood. Section - M - Skin Conditions reflected the resident was at risk of developing pressure ulcers. Section - G - Functional Abilities reflected the resident was dependent on staff for transfers, bathing, and toileting and required substantial/maximal assistance for eating. Record review of Resident #13's Comprehensive Care Plan, dated 10/29/25, reflected the resident had a pressure ulcer to the left ankle. Interventions included: Administer treatments as ordered and monitor effectiveness. EBP in place. Record review of Resident #13's current Physician's Orders, dated 12/10/25, reflected an order with a start date of 11/21/25 to treat the pressure injury to left ankle and apply a dressing. Further review reflected an order for Enhanced Barrier Precautions related to wounds which stated staff members will wear a clean gown and gloves while performing high contact resident care activities. During an observation on 12/10/25 at 9:40 AM, RN A performed wound care to Resident #13's left ankle wound, per physician's orders. RN A put on gloves but failed to put on a gown prior to performing wound care for Resident #13. Enhanced Barrier Precaution signage was noted to the door of Resident #13's room and a supply of PPE was noted inside Resident #13's room. During an interview on 12/10/25 at 2:48 PM, RN A stated she did not put on a gown prior to performing wound care for Resident #13 who was on EBP. She stated she did not think to put on a gown due to being nervous during the observation of wound care. She stated she had been trained on EBP through in-services conducted by nursing administration. RN A stated a gown should be worn when conducting direct care, including wound care, on any resident who was on EBP. She stated a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP was infection. 2. Record review of Resident #28's face sheet, dated 12/10/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #28 had diagnoses which included: atrial fibrillation (a type of irregular heartbeat which makes the heart less efficient at pumping blood), pressure-induced deep tissue damage of other site (a pressure sore), and unspecified dementia. Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 02, which indicated the resident had severe cognitive impairment. Section - M - Skin Conditions reflected the resident was at risk of developing pressure ulcers. Record review of Resident #28's Comprehensive Care Plan, revised 11/25/25, reflected the resident had a DTI to the 3rd digit on the right foot. Interventions included: Administer treatments as ordered and monitor effectiveness. Enhanced Barrier Precautions; staff members will wear a clean gown and gloves while performing high contact resident care activities. Record review of Resident #28's current Physician's Orders, dated 12/10/25, reflected an order with a start date of 11/26/25 to treat deep tissue injury to the 3rd digit of the right foot and apply a dressing daily. Further review reflected an order for Enhanced Barrier Precautions related to wounds and stated staff members will wear a clean gown and gloves while performing high contact resident care activities. An order with a start date of 12/09/25 reflected, Enhanced Barrier Precautions related to wounds. During an observation on 12/10/25 at 9:49 AM, LVN B performed wound care to Resident #28's right foot wound, per physician's orders. LVN B put on gloves but failed to put on a gown prior to performing wound care for Resident #28. Enhanced Barrier Precaution signage was noted to the foot of Resident #28's bed and a supply of PPE was noted inside Resident #28's room. During an interview on 12/10/25 at 2:52 PM, LVN B stated she did not put on a gown prior to performing wound care for Resident #28 who was on EBP. She stated she was unsure why she did not put a gown on before performing wound care. She stated, I guess I was just nervous because I normally put a gown on before doing wound care. LVN B stated she had been trained on EBP approximately quarterly through in-services conducted by nursing administration. LVN B stated a gown should be worn when conducting direct care, including wound care, on any resident who was on EBP. She stated a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP was infection and cross-contamination. During an interview on 12/11/25 at 3:43 PM, the ADM stated he was not aware staff were performing wound care on EBP residents without utilizing proper PPE. He stated a gown should be worn during wound care of a resident on EBP. The ADM stated the nurse performing wound care was responsible for utilizing proper PPE. He stated nursing administration was responsible for monitoring staff to assure EBP guidelines and standards of care were followed. The ADM was asked to state a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP and he stated, I cannot assume what the negative outcome would be. During an interview on 12/11/25 at 3:50 PM, the DON stated the direct care nurse was responsible for utilizing proper PPE during care of an EBP resident. She stated nursing administration was responsible for monitoring, training and assuring staff adhere to EBP guidelines. The DON stated the ADON conducted rounds in the facility to monitor and ensure staff were following EBP guidelines. She stated staff were trained on EBP through in-services conducted by nursing administration. The DON stated a potential negative outcome for failure to utilize proper PPE during direct care of a resident on EBP was the transfer of diseases. Record review of the facility's undated sign posted outside Resident #13's door and on the foot of Resident #28's bed, titled, Enhanced Barrier Precautions, reflected: PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Wound Care; any skin opening requiring a dressing Record review of the facility-provided policy titled, Modified Isolation or Enhanced Barrier Precautions; Based on guidance recommendation from the Centers for Disease Prevention and Control 07/2022, reflected: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDROs to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier: .Wound care: any skin opening requiring a dressing.

Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's face sheet dated 06/16/2025 revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: muscle weakness (decreased strength), muscle wasting and atrophy (loss of strength), unspecified lack of coordination (unable to control movement), osteoarthritis (tissue wears down), genetic related intellectual disabilities (abnormalities in genes or chromosomes), obesity (excessive body fat). Record review of Resident #1's MDS annual assessment dated [DATE] revealed a BIMS score of 15 meaning intact cognitive response. Record review of Resident #1's care plan dated revision date 12/10/2024 revealed Resident #1 is PASRR positive, will participate in quarterly care plan meetings with PASRR representative/social worker, Coordination of PASRR services and Individual Service Plan developed by PASRR representative/social worker. Record review of Resident #1's PCSP dated 12/19/2024 revealed IDT meeting was held on 12/19/2024. Attendees included the resident, the PASRR habilitation coordinator, the Social Worker, MDS RN, and Resident #1. The following NFSS were identified and confirmed: Customized Manual Wheelchair - 3 indicated on-going. During an interview on 06/16/2025 at 9:40 AM, the ADM stated he became aware of a concern with Resident #1's CMWC recently around the end of May 2025. He stated the MDS nurse, and the DOR advised him they were having a hard time getting paperwork completed for Resident #1 for a new customized manual wheelchair. He stated he looked into their concerns and realized they were needing to have the resident assessed for possibly a new wheelchair. He stated the customized manual wheelchair Resident #1 had, was two years old. He stated he was told a recommendation was made during an IDT meeting for a new CMWC. He stated he reached out to the DME company for them to evaluate Resident #1 and the CMWC he currently had. He stated Resident #1 was evaluated by the DME Rehab Tech and Resident #1 did not qualify for a new CMWC. He stated Resident #1 did not have a significant medical change of condition that would qualify for a new CMWC. He stated he sent out an email to the DON, MDS nurse, DOR, SW and BOM about the process for completing information and submitting NFSS forms on 05/30/2025. He stated he did go into the LTC portal and fill out the forms to see the process, but he did not submit the form. He stated the facility did not complete the NFSS form in the LTC portal within the 20 days. During an interview on 06/16/2025 at 10:15 AM, the SW stated she did attend an IDT PASRR meeting for Resident #1 in December 2025 and it was mentioned during the meeting that Resident #1 might benefit from a new CMWC. During an interview on 06/16/2025 at 10:30 AM, the MDS nurse stated it would have been in November or December of 2025 that she attended a PASRR meeting for Resident #1. That during the meeting it was mentioned that therapy would need to start the process for the CMWC for Resident #1 and coordinate with MDS on that process. She stated the DOR was working on a form for the process and he realized he was not qualified to sign the form and that was when they went to the ADM and asked for assistance. During an interview on 06/16/2025 at 12:12 PM, the DOR stated he did not attend the PASRR meeting in December 2025 with Resident #1. He stated he was not familiar with the PASRR process and reached out to colleagues for assistance. He stated he was not qualified to make assessments for CMWC and could not sign the form for the CMWC. He stated the facility did have the DME company evaluate Resident #1 for a new CMWC and at that time the DME company said repairs were needed to the CMWC and once the repairs were made, they would re-evaluate Resident #1 to see if a new CMWC was needed. During an interview on 06/16/2025 at 12:40PM, Resident #1 stated that his wheelchair worked just fine and was comfortable for him. Record review of the email from the ADM dated 05/30/2025 sent to DON, DOR, SW, MDS and BOM for training purposes for PASRR recommendations revealed the following: 3. NFSS Form Completion: The nursing facility provider must complete the NFSS form, including all required information, such. as the resident's demographics, the therapist's assessment findings, and the physician's order. For customized manual wheelchairs, the NFSS form needs to be completed by a licensed therapist. - Worksheet is to be completed by Therapy and that information is to be imputed into SlmplelTC by MDS - MDS will upload the following forms into SimpletlTC - 1. CMWC Signature page - Therapist, Physician and Administrator signature page 2. PT or OT Evaluation or Cert/progress notes signed by physician out of PCC (Therapy to provide) 3. Supplier Acknowledgement page - Rehab Engineer 4. Manufacturers page - Estimate of cost 5. QRP - Rehab Engineer Certificate 6. Once this is completed, we submit forms and wait for response from THHS. Once we have approval for order, it is the facility responsibility to pay for wheelchair upfront and then request for reimbursement - 7. Receipt - CMWC - To be signed by therapist and Administrator after wheelchair is received and both agree that it meets the resident's needs. The completed NFSS form is submitted through the Texas Medicaid and Healthcare Partnership's LTC Online Portal. 5. Authorization and Payment: The NFSS request is reviewed by Texas Health and Human Services and, if approved, the requested wheelchair is authorized, and the nursing facility can proceed with purchasing it. 6. Provider Action Required: If any rejection error messages occur during the workflow process, the provider must take action to correct the request and resubmit it. Record review of the facility policy: Resident Assessment - Coordination with PASRR Program Policy: The facility coordinates assessments with the preadmission screening and resident review PASRR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidance: 7. Recommendations, such as any specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transactions of care.

Based on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 17 (Resident #47) residents reviewed for accuracy of records. 1. The facility failed to document communication between staff and the MD when Resident #47 was attempting to elope from the facility on 8/30/24. 2. The facility failed to record verbal orders in the EHR when the MD ordered Resident #47 be moved to the secured unit. These failures could place residents at risk for not receiving needed care or treatment after an incident occurred. Findings Included: Record review of Resident #47's undated face sheet reflected Resident #47 was an [AGE] year-old female whose admitted to the facility was on 6/17/24. Resident #47 had the following diagnoses: Neurocognitive disorder with Lewy bodies (memory loss); psychotic disorder with delusions due to known physiological condition (mental health condition with false beliefs); restlessness and agitation (inability to relax and be still); dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance (memory loss and a mental health condition that affects the emotional state); major depressive disorder, recurrent severe without psychotic features (mental health condition); dementia in other diseases classified elsewhere, severe, with behavior disturbance (memory loss and disruptive behaviors); hallucinations (false perceptions that were not true); and chronic obstructive pulmonary disease (airflow blockage and breathing-related problems). Record review of Resident #47's Care plan dated 6/28/24 revealed Resident #47 was an elopement risk related to being in a disoriented place and impaired safety awareness. The goal was that Resident #47's safety will be maintained through the review date. Interventions were to distract Resident #47 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Also, to provide Resident #47 with structured activities for toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Record Review of Situation, Background, Assessment Recommendation (SBAR) Communication form and Progress Note for RN's/Licensed Practical Nurses (LPN)/LVN's dated 8/31/24 revealed Resident #47's mental status evaluation (compared to baseline) had an altered level of consciousness, increased confusion or disorientation, new or worsened delusions or hallucinations, and other symptoms or signs of delirium. Additionally, the behavioral evaluation revealed Resident #47 was a danger to self or others, had verbal aggression, physical aggression, a personality change, and had signs and symptoms of agitation. Record review of Resident #47's EHR physician orders dated 9/25/24, revealed there was no order of the verbal orders made by the physician to move Resident #47 to the secured unit on 8/30/24. Record review of Resident #47's progress notes dated 8/26/24 - 9/26/24, revealed no documentation by LVN A of the communication between she and the physician regarding Resident #47's elopement behaviors that occurred on 8/30/24. During an interview on 9/25/24 at 5:58 PM, Family Member #1 stated she received a call from the facility several weeks ago requesting permission to move Resident #47 to the secured unit due to behaviors, and she consented due to Resident #47's behaviors and exit seeking. During an interview on 9/27/24 at 11:50 AM, the SW stated Resident #47 admitted to the facility into a regular room, however, she was recently moved to the secured unit when she began exit seeking. She stated Resident #47 was never able to successfully elope from the facility. She stated Resident #47 was hitting staff, pushing trash barrels at staff, she was agitated, and she threw a water pitcher. She stated Resident #47 pushed her roommate's wheelchair in the hallway into other resident's doorways. She stated Resident #47 was hallucinating and told her she knew she was seeing things that were not real. She stated Resident #47 was moved to the secured unit before she went to the behavior hospital. She stated she contacted Resident #47's family member on 8/30/24 who consented to moving her to the secured unit. The SW stated the facility tried to implement other avenues, such as a wander guard to ensure Resident #47's safety was least restrictive; however, they could no longer do it and it was decided she be moved to the secured unit to ensure her safety. She stated Resident #47 went to the behavior hospital for assessment and returned on 9/18/24. When she returned, she started having behaviors immediately throwing things, crawling on the floor, and undressing. She said they contacted the behavior hospital and were told there was nothing they could do for her due to her diagnosis of Lewy body dementia. She stated she contacted another behavior hospital who also denied her due to the acuity on their unit. She stated the nurse was responsible to contact the physician for orders. She stated nursing staff decided when to place a resident on the secured unit, so she had not received training on what all was needed to place a resident on the secured unit. She stated the department heads trained staff. She stated she did not know what a potential negative outcome could be to the resident for not having written orders before placing a resident on the secured unit. During an interview on 9/27/24 at 11:55 AM, the ADM stated the facility obtained verbal orders from the MD prior to moving Resident #47 to the secured unit but the staff member did not document it in the EHR due to the behaviors that were going on at the time they were speaking to the physician. The ADM stated he was trying to determine which nurse obtained the verbal orders from the physician. The ADM stated the facility did not have a written order, but he was trying to get it and would enter it into the EHR. During an interview on 9/27/24 at 12:01 PM, the MD stated Resident #47 had Lewy body dementia, threw coffee on people, and she was very aggressive. He stated she was sent to a behavior hospital for assessment and returned to the facility after she was discharged . He stated she needed to be on the secured unit because she was very aggressive. He stated he was notified by the nurse and gave verbal orders prior to her being moved to the secured unit. He stated usually the facility sent him the written orders and he signed and returned them. During an interview on 9/27/24 at 1:35 PM, LVN A stated facility policy to place a resident on the secured unit were that they must call the physician to get direction when there were concerns about a resident, the resident must show signs of being an elopement risk, and they must notify the family and ask for permission. LVN A stated this all must be done before the resident was moved to the secured unit. She stated she was the CN on 8/30/24 and she was responsible to call the physician and make notifications for any concerns about residents. She stated the SW could help make notifications. She stated she called the physician on 8/30/24 to talk to him about how Resident #47 was constantly exit seeking as well as her behaviors. She stated the physician gave her verbal orders to move Resident #47 to the secured unit as he felt it was necessary. She stated the SW called the family and told them the physician ordered the resident to move to the secured unit and she asked them for permission, and they consented. She stated she was responsible to transcribe orders on the same day, as well as document her conversation with the physician in the EHR since she was the staff that spoke with him. She stated she was trained to transcribe orders and document all conversations leading up to the order request immediately as soon as they had time when things were settled down and the resident was safe. She stated she believed she failed to do those things because of how hectic things were with Resident #47 during that time. She stated she was trained by the ADON and the DON. She stated she was trained during orientation to document everything as well as the importance of documentation. She stated documentation was also discussed monthly during staff meetings. She stated she had received training on documentation at least five times that year. She stated she was not aware she did not put the order in the EHR until that day. She stated a possible negative outcome was that the physician would not be aware the resident was on the secured unit. She stated being on the secured unit could cause residents to have depression and feel isolated, so it was important for there to be a physician order. During an interview on 9/27/24 at 1:55 PM, the ADON stated in order to place a resident on the secured unit, the facility must complete an assessment on the resident, the resident must be exit seeking or they must be a danger to themselves or others. She stated initially Resident #47 had a wander guard (a sensor placed on the wrist that activates an alarm when exiting the facility) when she was on the regular unit, but her exit seeking got progressively worse where she was trying to find her way out of every exit in the facility by slamming her walker against the exit doors. She stated it was no longer safe for Resident #47 to be on the regular unit. She stated staff must get verbal orders from a physician to place a resident on the secured unit. She stated CNs were responsible to communicate with physicians or she could, if needed. She stated all physician orders go into the EHR. She stated the nurse that got the order must enter it into the EHR as soon as the resident was safe or at least before they leave their shift that day. She stated there must be documentation in the EHR showing information that led up to the order request. She stated all written orders must be scanned and uploaded into the EHR. She stated she and the DON were responsible for training staff on documentation requirements. She stated in-services were done with staff often and this was also discussed during their monthly meetings. She stated they also complete in-services with staff immediately for concerns that needed to be addressed immediately. She stated she expected staff to document any concerns, observations, issues, and orders in the EHR. She stated a negative outcome was that the resident could miss care, medications, or necessary treatment when pertinent information was missing from their EHR. During an interview on 9/27/24 at 2:25 PM, the DON stated facility policy to place residents on the secured unit was that residents must be exit seeking, the facility must complete an assessment, and the facility must get orders from the physician and approval from the family prior to placing the resident on that unit. The DON stated the CN was responsible to obtain verbal orders from the physician and then write the order in the EHR as soon as they get the verbal order from the physician. The DON stated the EHR was the only place to find the orders. The DON stated verbal orders were received for Resident #47 prior to moving her on the secured unit. The DON stated the CN was supposed to document the reasons for the request for the move in the progress notes. She stated herself and the ADON trained staff to document orders and progress notes during monthly meetings and during daily meetings to go over what was missed or was needed. She stated she expected staff to document accurately, timely, and precisely in the EHR because it did not happen if it was not charted. She stated she was not aware the facility did not have signed physician orders for Resident #47 to be moved to the secured unit. She stated Resident #47 went to a behavior hospital and returned on 9/18/24. She stated Resident #47 had Lewy body dementia and was cognitively intact when she admitted on [DATE]. The DON stated she used a walker, she was friendly, and she played bingo. She stated Resident #47 became paranoid within 2 months and she hallucinated. She said Resident #47 got worse, and started going in other resident's rooms, her verbal and physical aggression increased, and then she began trying to elope from the facility. She stated Resident #47 told staff she was going to leave. She stated Resident #47 had a wander guard, but it was determined this was not enough to keep her safe and the facility felt she needed to be moved to the secured unit. The DON stated staff spoke to the family who approved it. The DON stated since then, Resident #47 went to the behavior hospital for assessment and treatment. The DON stated a negative outcome of placing a resident on the secured unit inappropriately was it would isolate the resident and could cause depression due to having less stimuli. The DON stated the facility could face legal issues placing restrictions on residents without physician orders. During an interview on 9/27/24 at 2:41 PM, the ADM stated for a resident to be placed on the secured unit, the facility must determine if the secured unit would create a better well-being for the resident, they must discuss and obtain permission from family, and they must discuss and obtain an order from the physician prior to placing a resident on the secured unit. The ADM stated the facility must try all other least restrictive interventions prior to placing a resident on the secured unit. The ADM stated the CN nurse on duty was responsible to obtain orders from the physician, document the orders, and document the reason for obtaining the order in progress notes in the EHR. The ADM stated then the CN should write and send them out to the physician for a signature. The ADM stated all documentation and orders should be written timely or preferably before they leave for their shift that day. The ADM stated the facility tried to send orders to the physician weekly for signatures. The ADM stated Resident #47 was admitted to the facility on [DATE] and at that time she was cognitively intact, and they had good conversations. He stated within a couple of months, she began making false accusations, she became paranoid, and her aggressive behaviors at night increased. He stated Resident #47 also made comments and attempted to leave the facility. He stated resident #47 had a wander guard (a sensor placed on the wrist that activates an alarm when exiting the facility). He stated the facility determined that due to Resident #47's behaviors and the facility's numerous exits that she be placed on the secured unit to better ensure her safety. He stated Resident #47 was moved to the secured unit on 8/30/24. He stated Resident #47 went to a behavior hospital from 9/5/24 and returned on 9/18/24. The ADM stated he was not aware the facility did not have signed written orders for Resident #47 to be placed on the secured unit. He stated staff were trained to document reasons for obtaining orders, and all communication with physicians. He stated the ADON and the DON were responsible to train staff. He stated the DON and ADON completed documentation training regarding when to document and how to document on a monthly basis with staff. He stated he expected staff to document behaviors, interventions, responses, and contact with family and the physician in the EHR. He stated not having the signed written orders did not have a negative effect on the resident. He stated written orders showed they had actions in place for the resident and provided greater information from staff to staff. He stated having the written order was a paper compliance that they were required to have because the State said they have to. He stated he did not think there was a negative outcome to the resident if they were properly placed there whether the facility had an order or not. Record review of the facility policy, Memory Care Admission Policy (undated), revealed in part the following: Admission Policy for Secured Memory Care Unit Purpose: This policy outlines the criteria and procedures for admitting residents to the secured memory care unit, ensuring a safe and supportive environment for individuals with cognitive impairments. Scope: This policy applies to all admissions to the secured memory care unit of [facility]. Admission Criteria: 4. Admission Order: 1. Admission to the secured unit must be made by a licensed provider. Record review of the facility policy, Charting and Documentation (revised July 2017), revealed in part the following: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. Record review of the facility policy, Telephone Orders (revised February 2014), revealed in part the following: Policy Statement Verbal telephone orders may be accepted from each resident's Attending Physician. Policy Interpretation and Implementation 1. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/[NAME], pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Telephone orders must be countersigned by the physician during his or her next visit. Record review of the facility policy, Verbal Orders (revised February 2014), revealed in part the following: Policy Interpretation and Implementation 4. The individual receiving the verbal order must write it on the physician's order sheet as ''v.o. (verbal order) or t.o. (telephone order). 5. The individual receiving the verbal order will: a. read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed; b. record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.); and c. record the date and time of the order. 6. The practitioner will review and countersign verbal orders during his or her next visit Record review of the facility policy, Medication and Treatment Orders (revised July 2016), revealed in part the following: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

Based on observation, interview and record review the facility failed to establish and maintain an effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 7 of 17 residents ( Resident #24, #32, #33, #46, #47,#49, #53) and for 4 of 4 staff (LVN A & B & CNA A& B ) reviewed for infection control in that: All staff were not trained on expectations of providing care to residents with the COVID 19 virus in the memory care unit. 4 out 4 staff were not wearing proper PPE in accordance with the facility droplet/ contact precautions. Residents were not encouraged or redirected to socially distance, use hand hygiene, or wear a mask exposing other residents that did not have the COVID 19 virus. High touch areas were not regularly sanitized 2 (Resident #24 & #49) out of 7 residents became COVID positive after observations and surveyor intervention. On 08/10/23 at 10:21 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/11/23 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for contracting the COVID 19 virus. Findings Included: Resident #24 Record review of Resident #24's face sheet, dated 08/22/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, Record review of Resident #24's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Resident #32 Record review of Resident #32's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include diabetes, major depressive disorder, dementia and anxiety disorder. Record review of Resident #32's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. RESIDENT #33 Record review of Resident #33's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, repeated falls, abnormal weight loss and psychotic disorder with hallucinations. Record review of Resident #33's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 99, which indicated the resident was unable to complete the interview. RESIDENT #46 Record review of Resident #46's face sheet, dated 08/23/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes, cognitive communication deficit, major depressive disorder, Alzheimer's, and depression. Record review of Resident #46's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 99, which indicated the resident was unable to complete the interview. Resident #47 Record review of Resident #47's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, psychotic disorder with delusions, dementia, restlessness and agitation. Record review of Resident #47's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Resident #49 Record review of Resident #49's face sheet, dated 08/23/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's and mood disorder Record review of Resident #49's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Resident #53 Record review of Resident 53's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia, urinary [NAME] infection, mood disorder and anxiety. Record review of Resident #53's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. During the entrance conference on 08/08/23 at 8:46 AM, the ADM and DON reported COVID-positive residents resided in the memory unit (Residents #32, #33, #46, #47, and #53). The DON said the facility expected the staff to wear masks and goggles while on the unit. She said staff were expected to wear gowns and gloves and use droplet precautions when providing resident care. On 08/08/23 at 12:39 PM, an observation revealed 4 out of 5 COVID-positive residents (Residents #32, #46, #47, and #53) dining with the COVID-negative residents in the dining room in the memory care locked unit. Residents #47 and #53 were seated at the table as the staff entered the dining room. Residents #32 and #46 were seated together at the table at the opposite end of the dining room. There were four residents that were COVID-negative in between the COVID-positive residents. On 08/08/23 at 12:42 PM, LVN B reported the CNAs work the memory care unit and they do not work any other halls. She said she goes back and forth between the memory unit and another hall that houses COVID-negative residents. LVN A stated that Resident #47 and Resident #48 were housed together because of a partition in the room. On 08/08/23 at 12:45 PM, an observation of Residents #47 and #48 room revealed there was one shared bathroom in the room. On 08/08/23 at 1:08 PM, an observation of LVN A and CNA A made full body contact as they adjusted Resident #53 in her wheelchair. Both LVN A and CNA A did not have on gown or gloves. After repositioning, CNA A wheeled Resident #53 down to her room and then donned PPE. On 08/08/23, from 12:25 PM until 1:15 PM, Resident #47 was offered a mask once by LVN A. Resident #47 accepted the mask and wore it temporarily. On 08/08/23 at 12:45, during an interview, Resident #48 was not oriented to time and place. She was aware that there was COVID in the facility. On 08/09/23 at 7:36 AM, an observation revealed Resident #47 was seated at the table with Resident #44 (COVID Negative) and Resident #53 ( COVID Positive). Resident #32 was in the dining room eating breakfast. Two other residents ate in the dining room ( Resident #24 and Resident #13). On 08/09/23 at 07:43 AM, an observation revealed Resident #47 walked up to Resident #24 and said something inaudible. There was no staff redirection. LVN B was present in the nurse's cart. On 08/09/23 at 7:44 AM, an observation revealed CNA A assisted Resident #32 at the dining table and fixed her clothing protector; she did not have on gowns or gloves. On 08/09/23 at 07:45 AM, during an interview, LVN B reported that she was covering the memory care unit and one other hall. On 08/09/23 at 07:46 AM, an observation revealed Resident #46 was talking to Resident #44 within close proximity, and there was no staff redirection. CNA A was in the hallway. On 08/09/23 at 07:47 AM, an observation revealed Resident #47 walked up to the surveyor, and CNA A was present. CNA A did not redirect the resident. On 08/09/23 at 07:48 AM, an observation revealed Resident #47 grabbed CNA A (left arm). CNA A walked Resident #47 down the hall and seated her at the dining table. Although CNA A sanitized, she did not offer the resident a mask or encourage her not to make physical contact with her. CNA A did not have gloves or gowns. On 08/09/23 at 08:01 AM, an observation revealed CNA A adjusted the O2 tubing on Resident #32 face. CNA A did sanitize her hands but did not have on a gown or gloves. On 08/09/23 at 08:04 AM, an observation revealed Resident #47 walked around the table and talked to Resident #44 in close proximity. No staff redirection was made, and LVN B was in the room. On 08/09/23 at 07:52 AM, an observation revealed Resident #47 grabbed CNA A left arm. No sanitation or hand hygiene was conducted at the time of contact. CNA A did not educate, redirect, or encourage mask-wearing. On 08/09/23 at 07:54 AM, an observation revealed Resident #47 approached the surveyor. LVN B was present, and no education, redirection, or mask was offered. On 08/09/23 at 07:59 AM, an observation revealed CNA A removed Resident #32's clothing protector. CNA A did not have gloves or a gown on. On 08/09/23 at 08:10 AM, an observation revealed Resident #47 walked up to the surveyor. LVN B was present, and no staff redirection, education, or masked offered. On 08/09/23 at 08:11 AM, an observation revealed Resident #47 and Resident #44 passed each other a coffee cup. On 08/09/23 at 08:15 AM, an observation revealed CNA A assisting Resident #53, reading her dining card. CNA A was within 2 feet of the resident and did not have gloves or a gown. On 08/09/23 at 08:22 AM Surveyor exited the unit with LVN B. LVN B did not wear a gown or gloves during the surveyor's entire observation on 08/09/23 that started at 7:36 AM. ABHR was used by LVN B prior to exiting the memory unit. On 08/09/23 at 11:24 AM, an observation revealed Resident #33 was in her wheelchair in the common dining area sleeping. LVN B was seated at the desk next to her. On 08/09/23 at 11:30 AM, an observation revealed Resident #47 was holding hands with Resident #44. LVN B was present, and no observation of education, staff redirection, or mask was offered. On 08/09/23 at 11:32 AM, an observation revealed Resident #44 grabbed Resident #24 wheelchair handles and rolled the resident a short way. Resident #44 touched a chair in the dining room and walked away. At 11:33 AM, an observation revealed again Resident #44 pulling on Resident #24's wheelchair. No staff was present. On 08/09/23 at 11:35 AM, an observation revealed Resident #44 and Resident #47 holding hands down the hall. Once at the end of the hall, they attempted to open the door by pulling and pushing on the handles. When unsuccessful, they came back at 11:36 AM, still holding hands. Residents #44 and #47 held hands until 11:37 AM. On 08/09/23 at 11:38 AM, an observation revealed Resident #44 went to Visitor A and shook his hand. Visitor A shook the resident's hand and continue his visit. There was no staff redirection. LVN B was present at the nurse's desk. On 08/09/23 at 11:38 AM, observation of Residents #44 and #47 were holding hands. CNA B walked past Resident #44 and #47 and did not redirect, educate, encourage separation, or encourage mask-wearing. Residents #47 and #44 released their hands briefly but were back holding hands at 11:39 AM. Residents #47 and #44 touch the two center tables in the middle of the dining room. CNA B returned through the dining area; no education, redirection, or mask was offered. On 08/09/23 at 11:40 AM, an observation revealed Resident #47 shook Resident #32 hand. On 08/09/23 at 11:41 AM, an observation revealed Resident #44 ran her hand down the hall railing while holding Resident #47 hand. Staff were observed in and out of residents' rooms. On 08/09/23 at 11:41 AM, an observation revealed Resident #47 and Resident #44 attempted to push the exit door open by pulling and pushing on both doors. On 08/09/23 at 11:43 AM, an observation revealed CNA B passed Resident #44 and #47 holding hands and did not educate, redirect or offer masks. On 08/09/23 at11:44 AM, an observation revealed Resident #44 gave Resident #46 tissue and LVN B present. LVN B did not provide education, redirection, or a mask. On 08/09/23 at 11:45 AM, Resident #44 rubbed on Resident #33's head in the presence of LVN B. There was no staff redirection, education, or hand hygiene offered. On 08/09/23 at 11:45 AM, an observation revealed Resident #44 touched Visitor B's shoulder. Visitor B was not wearing PPE. On 08/09/23 at 11:47 AM, observation revealed Resident #44 and Resident #47 were touching the isolation cart containing PPE, which was located towards the hall's center. Both residents pushed the isolation cart down the hall and left it. LVN B was seated at the desk. On 08/09/23 at 11:48 AM, an observation revealed CNA B pushed the isolation cart back to its original location. Although she sanitized her hands, the isolation cart was not sanitized. On 08/09/23 at 11:49 AM, an observation revealed Resident #44 picked up Resident #33 blanket and placed it on her lap. LVN B present at the desk. No education, staff redirection, or mask was offered. There was no hand hygiene offered. On 08/09/23 at 11:50 AM, observation revealed that Resident #44 touched the isolation cart nearest room [ROOM NUMBER]. LVN B was at the nurse's desk. She did not offer redirection. On 08/09/23 at 11:51 AM, an observation was revealed. Residents #44 and #47 tried to open the entry door to the unit by pushing and pulling on the door. On 08/09/23 at 11:51 AM, an observation revealed CNA B passed Resident #47 and Resident #48 holding hands. CNA B did not offer redirection, education, hand hygiene, or masks. On 08/09/23 at 11:52 AM, an observation revealed The Infection Control Nurse entered the unit and closed the door (the door had not been sanitized). The Infection Control Nurse did not use ABHR. The Infection Control Nurse walked into the office near the dining area, and office grabbed a binder, flipped through it then shut the door to the office. A surveyor could observe through the window in the office, and no hand hygiene was conducted. She exited the office at 11:59 AM. She sanitized at 12:00 PM but touched the door again, which had not been cleaned. On 08/09/23 at 11:54 AM, an observation revealed Resident #44 rubbed on Resident #33 head. LVN B was present, and no redirection or hand hygiene was offered. On 08/09/23 at 11:56 AM, an observation revealed Resident #44 and Resident #47 touching the isolation PPE container nearest the entrance. Both residents were observed pulling out the red isolation bags and touching items in the box. The surveyor observed LVN B look down the hall twice. She did not redirect the residents from the isolation carts. The residents place all of the bags in the box. The staff did not remove the bags the residents touched. On 08/09/23 at 11:58 AM, an observation revealed Resident #44 and #47 in isolation PPE containers near room [ROOM NUMBER] ( the isolation box nearest the nurse's desk). Both residents touched the yellow gowns in the top drawer and then closed it back. LVN B was present at the nurse's desk and did not offer staff redirection. On 08/09/23 at 12:00 PM, the residents' lunch arrived, and at 12:02 PM, an observation revealed Resident #47 pushed Resident #24 in her wheelchair. CNA B passed both residents, and she told the residents to come to the dining room. CNA B did not educate, redirect, or encourage separation or masks. CNA B invited both residents to the dining room. On 08/09/23 at 12:03 PM, an observation revealed LVN B touched the entrance door that was not sanitized to retrieve Styrofoam cups from the kitchen staff. On 08/09/23 at 12:04 PM, an observation revealed CNA A placed a clothing protector on Resident #32. CNA A did not have gloves or a gown. On 08/09/23 at 12:04 PM, observation revealed that Resident #33 woke up coughing and was still in the common area with visitors and other residents. The resident did not have a mask or any other PPE. On 08/09/23 at 12:05 PM, observation revealed that Residents #32 and #46 were seated at the same table for lunch. On 08/09/23 at 12:09 PM, an observation revealed that Kitchen Worker A entered the unit and touched the door plate that had not been sanitized. Although Kitchen Worker A wore a mask, she did not have goggles on. She touched the keypad to exit and left the unit at 12:10. No observation of hand hygiene or ABHR was used. During an interview on 08/09/23 at 3:15 PM with the ADM revealed that courting should only occur with same-status residents. Record review of an email sent to the surveyor on 08/09/23 at 4:57 PM revealed two additional residents tested positive for COVID (Resident #24 and #49). During an interview on 08/09/23 at 6:11 PM, Family Member A revealed that before 08/09/23, he had not been notified about COVID being in the facility. He said he received a voicemail on 08/09/23 but did not finish listening to the voicemail left but would return DON's phone call after he finished the phone call with the surveyor. He said he had not been notified of his mother being in a room with a COVID-positive resident. He said although he trusted the facility's judgment, he would appreciate being notified if his mother shared a room because he worked at a community college and would not want to spread anything to his students. Record review of facility policy titled Isolation- Categories of Transmission-Based Precautions dated September 2022 (revised), revealed the following: Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation 1. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. Contact Precautions Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified. Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). Residents on droplet precautions are placed in a private room if possible. When a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors. When a private room is not available and cohorting is not achievable, decisions regarding resident placement are made on a case-by-case basis after considering infection risks to other residents in the room and available alternatives. Special air handling and ventilation are unnecessary and the door to the room may remain open. Masks are worn when entering the room. Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions. Resident Transport A mask is placed on the resident during transport from his or her room. The resident is encouraged to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets. If the resident can tolerate a mask and control respiratory secretions, some activities outside the room may be acceptable. Record review of facility policy titled Hand Hygiene dated August 2019 (revised), revealed the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. 1. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: 1. Before and after coming on duty; 2. Before and after direct contact with residents; 3. Before donning sterile gloves; 4. After removing gloves; 5. Before and after entering isolation precaution settings; 3. Hand hygiene is the final step after removing and disposing of personal protective equipment. Record review of the following website: https://www.hhs.texas.gov/provider-news/2023/02/09/hhsc-retires-nf-covid-19-response-plan-covid-19-faqs Revealed the following: HHSC Long-term Care Regulation has retired the COVID-19 Response Plan for Nursing Facilities (NFs) and the NF Frequently Asked Questions document, effective Feb. 6, 2023. Facilities can obtain guidance along with resources for infection prevention, control measures, and Personal Protective Equipment through the Infection Prevention and Control Measures for Common Infections in LTC Facilities (PDF) and Infection Control Basics & Personal Protective Equipment for Essential Caregivers (PDF) documents published by HHSC. These resources can be found on the NF Provider Portal page. Record review of the plan: Coronavirus Disease 2019 (COVID-19) Type of precaution: Standard Precautions + Droplet Precautions + Contact Precautions Infective material: Respiratory droplets and sputum Room: Single preferred; cohorting required Duration of precaution: Variable Hand Hygiene: Hand washing with soap and water or antiseptic hand wash or hand rub. Actions required: For Nursing Facilities: o For Core Principles of Infection Prevention, Visitations, Communal activities, Dining, and Resident Outings related rules, please refer to QSO-20-39-NH. o For resident and staff testing rules, please refer to QSO-20-38-NH. Contact Precautions Contact Precautions are used for residents with known or suspected infections that represent an increased risk for contact transmission. Contact transmission happens when a microorganism is transmitted by direct contact with the resident. Contact transmission can occur: o With skin-to-skin contact that occurs when performing resident-care activities, shaking hands, or any activity that requires touching the resident's skin; or o With indirect contact with environmental surfaces or resident-care items in the resident's environment, such as door handles, table surfaces, mobile phones or TV remotes. Droplet Precautions Droplet Precautions are used for residents known or suspected to be infected with pathogens transmitted by respiratory droplets. Droplet transmission occurs anytime a pathogen is transmitted by respiratory droplets that are generated when a person coughs, sneezes or talks. When a resident is on Droplet Precautions, you should follow all of the recommendations previously discussed with Standard and Contact Precautions, including: o Washing your hands between glove changes and after removing PPE; o Wearing clean gloves and a clean gown when entering the resident's room or space; o Wearing a face mask to protect yourself from pathogens which may to carried on droplets from coughing, sneezing, or even talking; and o Wearing eye protection any time splashes or sprays are likely to occur. Take off your PPE before leaving the resident's room/environment and dispose of it properly as instructed by facility staff. On 08/09/23 at 12:38 PM, an observation revealed a sign on the memory unit entry doors stating that someone within the unit was displaying signs or symptoms or testing positive. Another sign on the memory unit door instructed staff and visitors to wear N-95 only. There were no signs notifying visitors or staff that there was active COVID in the facility at the front door of the facility. There were observations of the sign on the front door instructing monitoring of signs and symptoms. During an interview on 08/10/23 at 08:23 AM, the DON said she did not test residents outside the memory unit but only inside because there were already positives in the unit. She said there were no considerations of moving COVID-negative residents off the unit that were not at risk of elopement because the CDC said to limit the movement. She said she expected for staff and visitors should have worn the N95 mask, use hand sanitizer and droplet precautions. She said droplet precautions included keeping your distance if you could. She said she was aware Resident #47 was physically active as she was but she said she was unaware all the residents were dining together. She knew there were a COVID-positive and a COVID-negative resident housed together. She said CDC guidelines said it would be ok if you could not provide a private room. She said she did not have a room available. She said she visited the memory unit daily and had not seen any concerns with infection control. She said she expected the CNAs to sanitize and disinfect along the way and throughout their shift. There was an expectation for CNAs to encourage visitors to wear masks. She said she felt like the goggles and masks were appropriate outside the room. She said gowns and gloves were expected when providing direct care to the residents. She said direct care was hands-on care or any time care was15 minutes or longer. She said when the staff repositioned the COVID-positive resident, the staff should have had on proper PPE (gown and gloves). She said she expected that staff should have redirected the residents and encouraging mask-wearing. The Administrator, Director of Nursing, and Regional Nurse Consultant, were notified of an Immediate Jeopardy (IJ) situation on 08/10/23 at 10:21 AM. The Administrator was provided with the IJ template on 08/10/23 at 10:27 AM. During an interview on 08/10/23 at 10:32 AM, LVN B said that when the first resident was diagnosed with COVID, she was not working. She said she was not notified before her shift but that the DON told her. She said she observed the residents touching the isolation box and did not have a reason for not redirecting the residents. She said she did not consider the visitors as visitors because they are at the facility so much. She said she did not think anything about them being in the unit around the other residents. She said she saw the two residents holding hands and did not think anything of it because they do it all the time, which was pretty common. She said she knew Resident #47 was positive and Resident#44 was not. She said that the residents in the memory unit do not understand social distancing. She said she had not received any instruction about expectations in the memory unit until the day of the interview (08/10/23). She said she was told by the Regional Nurse Consultant. She said they were told to sanitize every 30 minutes. She said she believed this may be unrealistic with all the patients care they have to provide and the nature of the population they are working with. She said the potential negative outcome was that they (residents and staff) could get COVID. She said that although she believed that everyone will get COVID 19 she also stated they should do their best to mitigate the spread of the COVID virus. When asked about Resident #33 being in the common area, she said she believed everyone was just doing what was normal. She said the population in the memory unit was at risk for choking, so they bring them out when they can. She said they could not be everywhere simultaneously, which was why they want everyone in the dining room. She said no one had said not to deviate from the normal routine. She said the only change would have been the use of PPE. 08/10/23 10:42 AM CNA I Said she had no training of expectations in the COVID unit. She said she came on Monday (08/07/23), and no one told her. She said she did not know what to do with the residents. She said she saw the isolation cart and put the PPE on. She said that she was unaware of which residents were positive. She said she did not know that Resident #48 was not COVID positive. She said she noticed the residents' interaction but did not think anything of it. She said they were told at the end of the day on Monday (08/07/23) which specific residents were COVID positive. She said every day has been different. They were told to sanitize every 30 minutes today (08/10/23). She said there was no cleaning schedule prior to 08/10/23. She said the railings were not specified when they were told to clean them. During dining, her system was to place COVID residents with other COVID residents. She said they did encourage visitors to wear masks. She said the potential negative outcome was that they could all get COVID. It could spread outside the COVID unit. She said it sometimes became difficult because the nurse was not always in the room. She said some residents require two people to transfer. During an interview on 08/10/23 at 10:58 AM CNA B said she had yet to be trained on the expectations for the memory unit during the COVID outbreak. She said she used her skills from 2020 when COVID first came into existence. She said she was never given any instructions on how often to clean. She said she remembered moving the isolation cart back. She said she thought it was moved by a resident in a wheelchair. She said she did not think that a resident had touched it, and that was why she did not sanitize the isolation cart. She said she did not encourage separation because all the residents were mixed together in the unit. She said no one knew what to do. She said they did not have specific instructions when she asked the nursing staff. She said she did not know there was COVID in the unit until she came to work on 08/09/23. She said she took a report from another CNA and not from anyone in management. She said that although she had seen signs of COVID, she did not think it was for her unit. She said a COVID-positive resident had been in another hall two weeks ago. She said she received a notification when they came in. She did not know which residents were positive when she entered the unit. She said that over the weekend, there were some signs and symptoms with some of the residents, but the nursing staff thought it was a common cold. On 08/10/23 at 11:00 AM, Housekeeper A said that she had been instructed to clean the unit at the end of the shift. She said she was instructed to wear a mask and goggles when on the unit, but they should wear gowns when in the room. She said she did not know about COVID in the unit until she returned from vacation. She said she was unaware of who had COVID. Looking at the residents in the hallway, she said she would not know who had COVID. On 08/10 [TRUNCATED]

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1) Dietary staff (Dietary Worker A, B and the DM) failed to store, serve or process foods in a manner to prevent contamination, 2) Dietary staff (CNA I, Alternative Dining Worker A, & B) failed to properly wear hair restraints while in the food preparation area, 3) Dietary Staff (Dietary A) failed to exhibit proper handwashing after removal of gloves. These failures could place residents at risk for food contamination and foodborne illness. The findings include: On 08/08/23 at 09:50 AM, an observation revealed a dented can of green beans dated 08/07/23 and a dented can of blueberry filling dated 07/03/23. On 08/08/23 at 10:02 AM, an observation revealed 15 creme pies in a tray. The creme pies were not labeled with a date or a discard date. On 08/08/23 at 10:22 AM, an observation revealed Alternative Dining Worker A and Alternative Dining Worker B, with hair restraints worn improperly. Hair was sticking out along both sides of their face. Alternative Dining Workers A and Alternative Dining Worker B were assisting in plating food to take outside the facility. Alternative Dining Worker A exited the kitchen at 10:24 AM while the DM corrected the Alternative Dining Worker B at 10:25 AM. During an interview on 08/08/23 at 10:15 AM, the DM said all dented cans should be placed in her office. She said she was responsible for ensuring the dented cans were not in the pantry. She said when she received a dented can, she stores them in her office, contacts the vendor, and waits for a refund or the vendor to replace the dented item. She said she must have missed the dented cans when putting the items up from the vendor. She stated the creme pies in the freezer and said those items should have been labeled. On 08/08/23 at 11:26 AM, an observation revealed CNA I entered the kitchen. She did not wash her hands. She had on a hairnet, but all of her hair was not properly restrained. There was hair along the left side of her face that was not restrained with the hair restraint. She enetered the kitchen and obtained juice from the refrigerator. She exited the kitchen after obtaining the juice. On 08/08/23 at 11:35 AM, an observation revealed two trays of cookies stacked on each other. Both trays of cookies were not covered. Half of the bottom tray of cookies was exposed to the bottom of the pan. On 08/08/23 at 11:36 AM, observation revealed that Dietary Worker A shifted the top tray of cookies to the other half of the exposed cookies. On 08/08/23 at 11:39 AM, observation revealed that Dietary Worker A touched the cookies with her bare hand before putting her gloves on. On 08/08/23 at 11:43 AM, observation revealed that Dietary Worker A removed her gloves and did not wash her hands. She walked over to the oven, placed on oven mitts, pulled the pan out of the oven, took the temperature of the food, and placed the food back in the oven. She returned to the workstation with the cookies and placed another pair of gloves on without washing her hands. During an interview on 08/08/23 at 12:19 PM, CNA I said that she had been trained not to enter the kitchen. She said she entered the kitchen because the other workers appeared busy. She stated she did not wash her hands when she entered the kitchen but said she washed her hands before entering the kitchen. She said she was unaware pieces of her hair were sticking out. She said she had been trained to ensure all of her hair was in the hair net. She stated that pieces of her hair were sticking out. During an interview on 08/09/23 at 02:03 PM, the DM said she was responsible for ensuring that hairnets were worn properly. She said the Meals on Wheels staff are trained wherever they come from. She said she did not notice the hair hanging out on both staff. In regard to labeling the food in the fridge, she said the worker that made and or plated the food item would have been responsible for labeling. However, as the DM, she ensured that all food in the fridge and freezers were labeled properly. She said Dietary Worker B was responsible for making the creme pies that were not labeled. In regard to the stacked exposed cookies, she said it was customary that before stacking and pans, the food was not exposed and covered with a liner of some sort. She said she did not notice that those cookies were stacked. She said she had been trained to wash her hands after removing gloves, and her staff had also been trained. She said it was also the facility policy for kitchen staff to wash their hands once they entered the kitchen. She said she did not see the staff touch the cookies with her bare hands or remove her gloves and not wash her hands. She said she did not see the non-kitchen staff enter the kitchen area and retrieve the juice from the fridge. She said the potential negative outcome of unrestrained hair was hair could fall into the food. She said this could affect the resident because it would not be good, and the residents could get sick. She said touching food with bare hands could cause contamination, and the residents could get sick. She said failure to wash hands could cause contamination of the food and could make the residents sick. She said not correctly labeling the Creme pies, staff may not know when the food item was made. She said not knowing when food is made risks the resident getting sick because staff would not know when items were made and if the food item needed to be thrown away. She said she was the only one that received the items from the delivery truck and placed the items in the pantry. She said there were no other systems in place to check for the deficient practice identified outside of her as the DM observed and corrected them as she saw them. During an interview on 08/09/23 at 02:15 PM, Dietary Worker A said she had been trained to wash after she removed her gloves. She said she knew she had not washed her hands but forgot. She knew she had to wash before and after, but she said she was nervous. In regard to touching the cookies with her bare hands, she said she could not remember if she had done that, but it might have happened. She said it was never ok because it was contamination of the food and could get residents sick. Regarding the exposed cookies stacked on each other, she said she was waiting for the cookies to cool down. She said she did not cover them because the paper would stick to the cookies when they were hot. After the incident, she could see what the issue was, but when she did it, she did not think about the cookies on the bottom being exposed to the bottom of the other pan. She said non-kitchen staff was not supposed to come into the kitchen. She said she did not see the non-kitchen staff come into the kitchen. She said the facility process was for the kitchen staff to provide non-kitchen staff with what they need. She said it was the facility process that when entering the kitchen, they should wash their hands first so staff do not risk contamination. During an interview on 08/09/23 at 02:24 PM, Dietary worker B asked about the pies, and she said she believed the label must have fallen off because she remembered that she did label the pies. She said maybe she did not stick it on correctly. She said she had been trained to label all the food in the fridge or the freezer. When asked what the potential negative outcome was, she said labeling the food was to identify what the food was and when it was made. She said that not having the food labeled, staff would notnow what and when to serve. She said if they do not know when the food was placed in the fridge, it could make the residents sick. During an interview on 08/10/23 at 01:26 PM, the ADM revealed he expected anyone within the food service area to have a hair net on and all their hair restrained. He said all dented cans would be inspected upon delivery or before opening. He said the dented cans should be stored separately from the other canned items for resident consumption. He said the location was in the DM office but that he intended to change this location. He was not aware of any issues with hairnets or dented cans. He said handwashing was ongoing. It was never brought to his attention that staff had entered the kitchen area. He said he expected everyone should wash their hands when they enter the kitchen and that a hair net should be properly placed. When asked if there was a system to monitor the kitchen activities, he said he would conduct random checks in the kitchen. He said he usually verified there was a hairnet in place but had never checked to see if any excess hair was hanging out. He said the DM was responsible. He said he could not think of a potential negative outcome for dented cans. He said he also could see a specific negative outcome for the residents for the hair nets, but that hand hygiene was important because that prevented food-borne precautions. He said he did not have a potentially negative outcome for non-kitchen staff entering the food service area because this had never been an issue. He said he expected that non-kitchen staff should ask the kitchen staff what they need in the kitchen. Record review of facility policy titled Food Preparation and Service dated November 2022 (revised), revealed the following: Policy Statement Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food Distribution and Service Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) in food preparation area so that hair does not contact food. Record review of facility policy titled Food Receiving and Storage dated November 2022 (revised), revealed the following: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation (5) When food is delivered to the facility it is inspected for safe transport and quality before being accepted. Cans are inspected prior to use to verify they are not dented. Dented cans will not be used, but will be placed on return shelf for return to food vendor. Refrigerated/Frozen Storage All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Record review of facility policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices dated November 2022 (revised), revealed the following: Policy Statement Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Hand Washing/Hand Hygiene 2. Employees must wash their hands: a. after personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); b. after using tobacco, eating or drinking; c. whenever entering or re-entering the kitchen; d. before coming in contact with any food surfaces; e. after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. after engaging in other activities that contaminate the hands. 3. Gloves and Direct Food Contact 4. Contact between food and bare (ungloved) hands is prohibited. 5. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced: a. after direct contact with residents; b. after assisting with medical treatments; c. between handling raw meats and ready-to-eat foods; and d. between handling soiled and clean dishes. 6. The use of disposable gloves does not substitute for proper handwashing. 7. Gloves are worn when directly touching ready-to-eat foods. 8. Gloves are used when serving residents who are on transmission-based precautions. 9. Gloves are not required when distributing foods to residents at the dining tables or when assisting residents to eat, unless touching ready-to-eat food. 10. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. Hair Nets 11. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. 12. Hair nets are not required when distributing foods to residents at the dining tables or when assisting residents to dine.

Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 14 of 17 residents (Residents #2,#4, #5, #7, #9, #14, #17,#27, #29, #33, #46, #47, #48, and #53) reviewed for care plans as follows: Resident #2 did not have a care plan for visual, behavior, nutritional and pressure ulcer. Resident #4 did not have a care plan for visual, psychosocial wellbeing, falls and psychotropic drug use Resident #5 did not have a care plan for visual function, communication, urinary incontinence, behavior, and dental care. Resident #7 did not have a care plan for visual function, communication, urinary incontinence, and nutritional status. Resident #9 did not have a care plan for urinary incontinence, pressure ulcer and psychotropic drug use. Resident #14 did not have a care plan for visual function, urinary incontinence, nutritional status and pressure ulcer. Resident #17 did not have a care plan for cognitive loss, visual, communication and pressure ulcer. Resident #27 did not have a care plan for cognitive loss, visual function, communication, urinary incontinence, nutritional status and pressure ulcer. Resident #29 did not have a care plan for cognitive loss, visual function, communication, urinary incontinence, psychosocial wellbeing, or falls. Resident #33 did not have a care plan for visual, communication, mood, behavior, falls, nutritional, pressure ulcer. Resident #46 did not have a care plan for visual, communication, urinary, psychosocial wellbeing, activities, pressure ulcer, psychotropic drug use. Resident #47 did not have a care plan for visual and falls Resident #48 did not have a care plan for cognitive loss, urinary, nutritional and pressure ulcer. Resident #53 did not have a care plan for urinary, dehydration and psychotropic drug use. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: RESIDENT #2 Record review of Resident #2's face sheet, dated 08/09/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, urinary tract infection, dementia and mood disorder. Record review of Resident #2's Order Summary report, dated 08/08/23 revealed the following: Regular diet Mechanical Soft texture, Regular/Thin consistency, super cereal with breakfast; house shake with noon/evening meal. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: -Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. -Section E : No significant data was entered for behavior -Section K: No significant data was entered for nutrition. -Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes -Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 09. Behavior 12. Nutrition 16. Pressure Ulcer Record review of Resident #2's care plan, dated 07/11/23, revealed no care plan for vision, behavior, nutritional and pressure ulcer. RESIDENT #4 Record review of Resident #4's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's, major depressive disorder and gout. Record review of Resident #4's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B 1000. Vision Enter Code: 2 - Impaired - sees large print, but not regular print in newspapers/books. Section D Mood: Although the MDS indicated a mood assessment should be conducted the resident was unable to participate in the interview. Section J: Although there was no significant data in the MDS Resident #4 did trigger for falls. Section N Medications N0410. Medication Received B. Antianxiety coded 7 days C. Antidepressant coded 7 days Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 07. Psychosocial Wellbeing 11. Falls 17. Psychotropic Drug Use Record review of Resident #4s Order Summary report, dated 08/08/23 revealed the following medications: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule by mouth two times a day related to anxiety disorder. Order date 06/02/23 -Buspirone Oral Tablet 5 MG Give 1 tablet by mouth three times a day related to dementia. Order date 06/16/23 Record review of Resident #4's care plan, dated 07/06/23, revealed no care plan for visual, psychosocial wellbeing, falls and psychotropic drug use RESIDENT #5 Record review of Resident #5's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include anxiety, cognitive communication deficit (impaired thought process that allow humans to function successfully and interact meaningfully with each other) and hypertension (high blood pressure). Record review of Resident #5's Comprehensive Minimum Data Set, dated dated [DATE], revealed: -Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. -Section B1000. Vision - coded 2 = Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects. -Section E0800. Rejection of Care-Presence and Frequency revealed behavior occurred 1 to 3 days out of the past 7 days. -Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, and dressing was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use and personal hygiene was coded 7 = activity occurred only once or twice with one-person assist. -Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. -Section L Oral/Dental Status revealed mouth or facial pain, discomfort or difficulty with chewing. -Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes -Section N Medications N0410. Medication Received C. Antidepressant coded 7 days -Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 06. Urinary Incontinence 09. Behavioral Symptoms 15. Dental Care Record review of Resident #5's care plan, dated 07/10/23, revealed no care plan for visual function, communication, urinary incontinence, behavior or dental care. RESIDENT #7 Record review of Resident #7's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (lung disease), depression (sadness or loneliness), anxiety (feeling of fear, dread and uneasiness), and muscle weakness. Record review of Resident #7's Comprehensive Minimum Data Set, dated dated [DATE], revealed: -Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. -Section B1000. Vision revealed vision impaired - sees large print, but not regular print in newspapers/books. -Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, walk in room, dressing, eating, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use was coded 8 = activity did not occur in the last 7 days. -Section G0120. Bathing revealed physical help in part of bathing activity and coded 4 = total dependence. -Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. -Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual function 04. Communication 06. Urinary Incontinence 12. Nutritional Status Record review of Resident #7's care plan, dated 07/10/23, revealed no care plan for visual function, communication, urinary incontinence and nutritional status. RESIDENT #9 Record review of Resident #9's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (cognitive loss), hypertension (high blood pressure) and muscle weakness. Record review of Resident #9's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 06. Urinary Incontinence 16. Pressure Ulcer 17. Psychotropic Drug Use Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, dressing, eating, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use was coded 2 = limited assistance - resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance and one-person physical assist. Section G0120. Bathing revealed physical help in part of bathing activity and coded 4 = total dependence. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Section N Medications N0410. Medication Received C. Antidepressant coded 7 days Record review of Resident #9's care plan, dated 08/04/23, revealed no care plan for urinary incontinence pressure ulcer risk and psychotropic drug use. RESIDENT #14 Record review of Resident #14's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental illness), anxiety (feeling of fear, dread and uneasiness), depression (sadness or loneliness), epilepsy (seizure disorder) and muscle weakness. Record review of Resident #14's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was minimally impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual function 06. Urinary Incontinence 12. Nutritional Status 16. Pressure ulcer Section B1000. Vision revealed vision impaired - sees large print, but not regular print in newspapers/books. Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, walk in room dressing and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and one-person physical assist. Eating and toilet use was coded 7 = activity occurred only once or twice in the last 7 days with one-person physical assist. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section M0150. Risk of Pressure Ulcer/Injuries revealed resident #14 was at risk for pressure ulcer. Record review of Resident #14's care plan, dated 07/06/23, revealed no care plan for visual function, urinary incontinence, nutritional status and pressure ulcer. RESIDENT #17 Record review of Resident #17's face sheet, dated 08/09/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, diarrhea, dementia and mood and anxiety disorder. Record review of Resident #17's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident was unable to complete the interview. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive Loss 03. Visual 04. Communication 16. Pressure Ulcer Section B 1000. Speech & Vision Enter Code (Speech clarity):1-Unclear speech- slurred or mumble words Enter Code (Makes Self Understood): 3-Rarely/never understands Enter Code (Ability to Understand others): 3-Rarely/never understands Enter Code (Vision): 3 - Highly Impaired - Object identification in question, but eyes appear to follow objects. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Record review of Resident #17's care plan, dated 07/11/23, revealed no care plan for cognitive loss, visual, communication and pressure ulcer. RESIDENT #27 Record review of Resident #27's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), depression (sadness or loneliness), hypertension (high blood pressure) and muscle weakness. Record review of Resident #27's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive loss 03. Visual function 04. Communication 06. Urinary Incontinence 12. Nutritional Status 16. Pressure Ulcer Section B1000. Vision revealed vision impaired - sees large print, but not regular print in newspapers/books. Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, dressing, toilet use, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section K0100. Swallowing disorder revealed Resident #27 had coughing or choking during meals or when swallowing medications in the last 7 days. Section M0150. Risk of Pressure Ulcer/Injuries revealed resident #27 was at risk for pressure ulcer. Record review of Resident #27's care plan, dated 07/10/23, revealed no care plan for cognitive loss, visual function, communication, urinary incontinence, nutritional status and pressure ulcer. RESIDENT #29 Record review of Resident #29's face sheet, dated 08/08/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), falls and weakness. Record review of Resident #29's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive loss 03. Visual function 04. Communication 06. Urinary Incontinence 07. Psychosocial Well-being 11. Falls Section B1000. Vision revealed vision moderately impaired - limited vision; not able to see newspaper headlines but can identify objects. Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, dressing, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use was coded 2 = limited assistance - Resident highly involved in activity staff provide guided maneuvering of limbs or other non-weight bearing assistance with one-person physical assist. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section G0120. Bathing was coded 3 = Physical help in part of bathing activity with one-person physical assist. Section J1700. Fall risk revealed Resident #29 was at risk for falls and had falls within the last 6 months. Record review of Resident #29's care plan, dated 07/11/23, revealed no care plan for cognitive loss, visual function, communication, urinary incontinence, psychosocial well-being, and falls. RESIDENT #33 Record review of Resident #33's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, repeated falls, abnormal weight loss and psychotic disorder with hallucinations. Record review of Resident #33's Order Summary, dated 08/08/23, revealed: Regular diet Mechanical Soft texture, Regular/Thin consistency, super cereal with breakfast. Record review of Resident #33's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 99, which indicated the resident was unable to complete the interview. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 08. Mood 09. Behavior 11. Falls 12. Nutritional 16. Pressure Ulcer Section B 1000. Speech & Vision Enter Code (Make Self Understood): 2-Sometime understands Enter Code (Ability to Understand Others): 2- Sometime understands Enter Code (Vison): 3 - Highly Impaired - object identification in question, but eyes appear to follow objects. Section D Mood: although the MDS did not reflect significant data Resident #33 triggered for mood in Section V. Section E: Behavior 1. Physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching and grabbing). As indicted by the MDS these behaviors impacted others by putting them at risk for physical injury. Section J: Falls: Although no significant data reflected in the MDS Resident #33 triggered for falls in Section V. Section K: Nutritional: Resident is on a mechanically altered diet Section M Skin Conditions Resident #33 had a pressure reducing device for chair Record review of Resident #33's care plan, dated 07/10/23, revealed no care plan for visual, communication, mood, behavior, falls, nutritional, pressure ulcer. RESIDENT #46 Record review of Resident #46's face sheet, dated 08/23/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes, cognitive communication deficit, major depressive disorder, Alzheimer's, and depression. Record review of Resident #46's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 99, which indicated the resident was unable to complete the interview. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 06. Urinary 07. Psychosocial Wellbeing 10. Activities 16. Pressure Ulcer 17. Psychotropic Drug Use Section B 1000. Speech & Vision Enter Code (Make Self Understood): 2 - Sometimes Understood Enter Code (Ability to Understand Others): 2 - Sometimes Understood Enter Code (Vison): 3 - Highly Impaired - Object identification in question, but eye appear to follow objects Enter Code (Corrective Lenses): 1 - Yes Section H: Bowel and Bladder Enter Code (Urinary Continence): 2 - Frequently incontinent Enter Code (Bowel continence): 1- occasionally incontinent Section D: Mood: Although no significant data in this section Resident #46 did trigger in section V. Section F: Preferences for Customary Routine and Activities Resident prefers: d. shower g. snacks between meals i. family involvement in care discussions. m. listening to music p. doing things with groups of people. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Section N Medications N0410. Medication Received A. Antipsychotic coded 7 days Record review of Resident #46 Order Summary, dated 08/08/23, revealed that she took the following medications: VENLAFAXINE 75 MG CAP Give 75 mg by mouth one time a day related to major depressive dis order. Order date 05/30/23. Melatonin Oral Tablet 10 MG (Melatonin) Give 10 mg by mouth in the evening related to insomnia. Record review of Resident #46's care plan, dated 07/11/23, revealed no care plan for visual, communication, urinary, psychosocial wellbeing, activities, pressure ulcer, psychotropic drug use. RESIDENT #47 Record review of Resident #47's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, psychotic disorder with delusions, dementia, restlessness and agitation. Record review of Resident #47's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 11. Falls Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Section J: Falls: Although there was no significant data reflected in the MDS Resident #47 triggered for Falls in Section V. Record review of Resident #47's care plan, dated 07/11/23, revealed no care plan for visual and falls RESIDENT #48 Record review of Resident #48's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes, anxiety disorder, slowness and poor responsiveness, and dementia. Record review of Resident #48's Order Summary, dated 08/08/23, revealed she took the following medications: Probiotic Oral Capsule (Saccharomyces boulardii) Give 1 capsule by mouth one time a day related to urinary tract infection. Order date 07/05/23. Paxil Oral Tablet (Paroxetine HCl) Give 10 mg by mouth at bedtime related to mood disorder. Order date 07/09/23. Record review of Resident 48's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive loss 06. Urinary 12. Nutritional 16. Pressure Ulcer Section H Bladder and Bowel Enter Code (Urinary Continence): 1 - Occasionally incontinent Enter Code (Bowel continence): 2- Frequently incontinent Section K Nutrition: Although there was no significant data in the MDS Resident #48 triggered for nutrition in Section V. (Please not record review of the order summary did not reflect an altered diet,) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Record review of Resident #48's care plan, dated 07/12/23, revealed no care plan for cognitive loss, urinary, nutritional and pressure ulcer. RESIDENT #53 Record review of Resident 53's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia, urinary [NAME] infection, mood disorder and anxiety. Record review of Resident #53's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 06. Urinary 14. Dehydration 17. Psychotropic Drug Use Section H Bladder and Bowel Enter Code (Urinary Continence): 1 - Occasionally incontinent Enter Code (Bowel continence): 9- Not rated because the resident did not have a bowel movement within the 7 day time period. Section K: Although there was no significant data in this are please not the resident did trigger for dehydration in section V. Section N Medications N0410. Medication Received B. Antianxiety coded 3 days C. Antidepressant coded 4 days Record review of Resident 48's care plan, dated 07/12/23 revealed no care plan for urinary, dehydration and psychotropic drug use. During an interview on 08/09/23 at 08:28 AM, the ADM said that the most recent and updated information should be in EMR A. He said they transitioned to EMR A on 06/01/23 He said they did have a binder with old care plans from EMR B, but if the care plan was in EMR A then that was the most updated one and the one that staff should be using. When asked if there was a list of care plans that had not been updated, he said the MDS Coordinator may have one. During an interview on 08/09/23 at 09:37 AM, the MDS coordinator said if the care plan was in EMR A, it was the most updated one and the one the staff should be using. She said that she had a list of residents' care plans that were not complete. She said all of [NAME] Hall was not complete, and three residents of Ritz Hall were not complete. She said all other care plans for the other residents in the remaining halls were complete. She said once the care plan was completed in EMR A, then the care plan in EMR B was no longer valid. During an interview and record reviews on 08/09/23 at 02:34 PM, the MDS Coordinator said she was responsible for care plans, but other departments entered information into resident care plans. She said all the staff (nurses and CNAs) use the care plans. She said the care plan was how you take care of your resident. She said a care plan included the diagnosis and any assistive devices the resident may use. She said she includes ADLs. She said she does use the MDS and the triggered CAAs. She said if it was triggered in (Section V). said that she tried to avoid duplication when she did care plans, so some of the care plans may include two or more triggered areas of concern. She said no system was in place to help monitor the care plans. She said that after she completed them, no one checked them. She said she did have help with the care plans at one point but would take full responsibility for the care plans. She went over the following residents' care plans in the presence of the surveyor. She said she was unsure why all the care plans were missing. Resident #4 She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (visual, psychosocial wellbeing, falls, and psychotropic drug use). Resident #48: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Cognitive loss, Urinary, nutritional, and pressure ulcer). Resident #2: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Visual, behavior, nutrition, and pressure ulcer). Resident #46: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Visual, communication, psychosocial wellbeing, activities, pressure ulcer, and psychotropic drug use). Resident #53: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Urinary, dehydration, and psychotropic drug use). Resident #33: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (visual, communication, mood, behavior, falls, nutritional and pressure ulcer). Resident #17: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (cognitive loss, visual, communication, and pressure ulcer) During an interview and record review on 08/10/23 at 12:28 PM the MDS coordinator said the facility had used EMR A since 06/01/23 She said the potential negative outcome of incomplete care plans would have been that staff would not know how to care for the residents properly. She said the missing care plans could affect the resident's communication ability, nutrition, and the necessary daily items, such as glasses. She said there was no reason why the care plans were missed. She said she had been trained on how to do care plans. She said she had worked hard on the care plans in EMR B. She stated that EMR A contained the most recent care plans that staff would have used. She went over the following remaining residents' care plans in the presence of the surveyor. Resident #9: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (urinary, PU, and Psychotropic drug use) Resident #5: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (visual, communicat

Based on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 4 of 17 residents ( Resident #40, #45, #46, and #47) reviewed for resident rights . The facility failed to obtain a signed informed consent from responsible party based on information of the benefits, risks, and options available from for Residents #40, #45, #46, and #47 prior to administering melatonin (sleep aide). These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings included: Resident #40 Record review of Resident #40's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), insomnia (sleep disorder), depression (sadness or loneliness), and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #40 was understood (clear comprehension). The MDS revealed Resident #40 had a BIMS of 02 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #40 dated 07/12/23 revealed no care plan for use of melatonin or insomnia. Record review of Resident #40's order summary report dated 08/08/23 revealed the following orders: Melatonin 10mg at bedtime related to insomnia dated 5/31/23. Record review of Resident #40's medication administration record undated for the month of August 2023 revealed resident received Melatonin 10 mg orally at bedtime from August 1st through August 9th. Record review of Resident #40 electronic medical record revealed no consent for melatonin. Resident #45 Record review of Resident #45's face sheet, dated 08/08/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include insomnia (sleep disorder), muscle weakness, and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #45 was understood (clear comprehension). The MDS revealed Resident #45 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #45 dated 07/26/23 revealed no care plan for use of hypnotic or insomnia. Record review of Resident #45's order summary report dated 08/09/23 revealed the following orders: Melatonin 10mg at bedtime related to insomnia dated 05/30/23. Record review of Resident #45's medication administration record undated for the month of August 2023 revealed resident received Melatonin 10 mg orally at bedtime August 1st through August 9th. Record review of Resident #45 electronic medical record revealed no consent for melatonin. Resident #46 Record review of Resident #46's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), Alzheimer's disease (cognitive loss), insomnia (sleep disorder), depression (sadness and loneliness), muscle weakness, and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #46 was understood (clear comprehension). The MDS revealed Resident #46 had a BIMS of 99 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #46 dated 07/05/23 revealed no care plan for melatoin or insomnia. Record review of Resident #46's order summary report dated 08/08/23 revealed the following orders: Melatonin 10mg at bedtime related to other insomnia dated 5/24/23. Record review of Resident #46's medication administration record undated for the month of August 2023 revealed resident received Melatonin 10 mg orally at bedtime August 1st through August 9th. Record review of Resident #46 electronic medical record revealed no consent for melatonin. Resident #47 Record review of Resident #47's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include anxiety (feeling of fear and worry), dementia (cognitive loss), depression (sadness and loneliness), muscle weakness, and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #47 was understood (clear comprehension). The MDS revealed Resident #47 had a BIMS of 03 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #47 dated 07/13/23 revealed no care plan for melatonin. Record review of Resident #47's order summary report dated 08/08/23 revealed the following orders: Melatonin 3mg at bedtime related to restlessness and agitation dated 06/02/23 . Record review of Resident #47's medication administration record undated for the month of August 2023 revealed resident received Melatonin 3 mg orally at bedtime August 1st through August 9th. Record review of Resident #47 electronic medical record revealed no consent for melatonin. During an interview on 08/09/23 at 02:38 PM, the Regional Nurse Consultant stated melatonin was a dietary supplement and does not require a consent per CMS and psychotropic list they were following. During an interview on 08/10/23 at 11:53 AM, the DON stated the nurses were responsible for obtaining the consent for psychotropic medications when they receive the order and then she will follow up. She stated consents were obtained when the order was given. She stated Residents #40, #45, #46 and #47 were taking melatonin for sleep aide. She stated consents were not obtained because it was not on the psychotropic list. During an interview on 08/10/23 at 12:53 PM, the ADM stated the floor nurses were responsible for obtaining consents and the DON follows up. He stated consents should be obtained prior to the first dose. He stated the consents for Residents #40, #45, #46 and #47 were not obtained because he thought melatonin had been removed from the psychotropic list. He stated melatonin was used for a sleep aide. He stated the potential negative outcome would be not providing residents and family member the risk and benefits information. During an interview on 08/08/23 at 01:05 PM with LVN C, she stated melatonin did require a consent. She stated consents were obtained the day of the order. She stated melatonin was used as a sleep aide. She stated potential negative outcome of not obtaining a consent would be family upset because they have not received information about the medication or the possible side effects. She stated she had been trained on obtaining consents. Record review of the facility's Classes of Medications Frequently Used for Psychiatric Indications dated [DATE] revealed: Consent is required for any medication that is used in the treatment of a psychiatric diagnosis or symptom, whether or not the medication is included in this list. Refer to physician order for determination of indication for use. The classification of psychotropic medication is fairly standard, but medications can be used for treatment of illnesses that would be considered listed under a different classification. For example, some medications listed under antipsychotics maybe used as a mood stabilizer . Record review of the facility's policy titled Use of Psychotropic Medication, undated revealed: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics . 4. b. iii. Consent will be obtained from the resident or resident's representative prior to initiation of medication. 5. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions . Record review List of Psychotropic Medication and Side Effects, dated 4/2023 (Revised) from Texas Health and Human Services (hhs.texas.gov) revealed the following: Medication: Melatonin Side Effects: Common - Headache, dizziness, shaking, nausea, or abdominal cramps may occur. Serious but Rare - Mental or mood changes (e.g., depression, confusion). Very Serious but Very Rare - Serious allergic reaction is rare but can occur rash, itching or swelling (especially of the face, tongue or throat), severe dizziness, trouble breathing). 43344

Based on interviews and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 24 residents (Residents #15 and 35) reviewed for PASRR screening, in that: Residents #15 and #35 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of major depressive disorder or schizoaffective disorder. These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #15 Record review of Resident #15 electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, schizoaffective disorder, depressive type. Record review of Resident #15's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of schizoaffective disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 13 indicating the resident was cognitively intact. Record review of Resident #15 most recent care plan, undated, revealed a focus area and diagnosis of schizoaffective disorder, this problem started 09/11/2020. Resident #15 was prescribed Sertraline HCL 100mg to assist with this area of need. Record review of Physician progress notes for Resident #15 dated 08/08/2023 revealed under current medications, Resident # 15 prescribed Sertraline HCL 100mg one tablet once a day for schizoaffective disorder. Record review of Resident #15's Preadmission Screening and Resident Review Level One (PL1) form dated 11/08/2022 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #35: Record review of Resident #35's electronic face sheet revealed an [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Major Depressive Disorder, recurrent and severe. Record review of Resident #35's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Major Depressive Disorder, recurrent and severe. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 11 indicating the resident cognition was moderately impaired. Record review of Resident #35's most recent care plan, undated, revealed a focus area and diagnosis of Major Depressive Disorder, recurrent and severe, this problem started 03/02/2022. Record review of Physician progress notes for Resident #35 dated 08/08/2023 revealed under Current Diagnosis, diagnosis of Major Depressive Disorder, recurrent and severe. Record review of Resident #35's Preadmission Screening and Resident Review Level One (PL1) form dated 3/2/2022 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview on 08/10/23 at 01:00PM with the Administrator, he stated Residents #15 and #35 did not have PL2 evaluations as all their PL1s were negative. The ADM said the purpose of the PL1 screening was to identify if someone needs extra services. He said if it was positive then it gets put into an online system and they reach out to the necessary people to ensure a level two evaluation was done. He said the ADON was responsible for entering the PL1 into the system. He said he thought there have been recent changes with PASRR but was not sure if they changed what diagnoses qualified as a mental illness and said she would have to check. The ADM stated there was potential harm if a resident with a diagnosis of a mental illness who had a negative PL1 and no subsequent level two evaluation as they could potentially go without services. During an interview with the ADON on 08/10/23 at 10:40AM, she stated Residents #15 and #35 did not have PL2 evaluations as all their PL1s were negative. The ADON stated it was her responsibility to ensure every resident admitted to the facility has a PL1. The ADON also stated it was her responsibility to ensure PL1s are completed accurately by comparing them to Resident medical records. The ADON stated there was not a procedure in place to update a PL1 if a resident was diagnosed with a new diagnosis after being admitted to the facility. The ADON stated she did not know a diagnosis of MDD would warrant a positive PL1. The ADON stated she was aware Resident #35 did have a diagnosis of MDD. The ADON also stated she knew Resident #15 had a diagnosis of schizoaffective disorder. The ADON stated the potential harm to a resident without a subsequent PL2 evaluation was the residents will not receive the services they need. During an interview with the DON on 8/10/23 at 11:20am, she stated Residents #15 and #35 did not have PL2 evaluations as all their PL1s were negative. The DON stated it was the ADONs' responsibility to ensure every resident entering the facility had a completed and accurate PL1. The DON also stated it was the ADONs' responsibility to ensure any new mental health diagnosis added after entry to the facility that warrant a new PL1 are completed. The DON stated she was not aware a diagnosis of PTSD or MDD warranted a positive PL1. The DON stated she did not know why Resident 15s' PL1 was not positive due to his diagnosis of schizoaffective disorder. The DON stated the potential negative outcome for residents not having an accurate PL1 and subsequent PL2 are the residents may not be offered the services they may need for their diagnosis. The facility policy for PASARR states all applicants to a Medicaid-certified nursing facility are evaluated for mental health prior to admissions and offered the most appropriate setting for their needs. If the PASARR level one screening indicated the individual may have an Intellectual Disability or a Mental Illness diagnosis the facility will confer with local mental health providers to complete a PASARR level two screening. Following the completion of the level two screening a care plan will be developed by the facility in order to meet the needs of a resident with an Intellectual Disability or a Mental Illness diagnosis.

Based on interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 17 residents reviewed for adequate monitoring of unnecessary medication (Resident #9). The facility did not monitor Resident #9 for side effects of the anti-anxiety medication Lorazepam (an anxiety medication). This failure could place the residents at risk for adverse consequences of medication. Findings included: Record review of Resident #1's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (cognitive loss). Record review of Resident #9's Comprehensive Minimum Data Set, dated dated [DATE], revealed Resident #9 had a BIMS score of 03, which indicated the resident's cognition was severely impaired. Record review of the physician orders dated 08/08/23 indicated Resident #9 was prescribed Lorazepam (an anti-anxiety medication) 0.25 ml every 4 hours as needed for pain related to Alzheimer's disease with a start dated of 07/30/23. The orders did not address monitoring the anti-anxiety medication. Record review of a care plan revised 07/12/23 did not indicate Resident #9 received antianxiety therapy. Record review of MAR undated indicated Resident #9 received Lorazepam 0.25ml every 4 hours as needed on 08/7/23 and 08/08/23 as ordered. Record review of the electronic record for Resident #9 did not reveal the nurses documented on monitoring of side effects of antianxiety daily with medication administration. During an interview with the DON on 08/10/23 at 11:53 AM, she stated anti-anxiety medications need daily monitoring for side effects. She stated monitoring for behaviors should be documented on the treatment administration record or medication administration record. She stated the nurses were responsible for putting in the monitoring order when the medication was ordered, and she followed up to make sure it was done. She stated monitoring of anti-anxiety medication monitoring should start with the first dose. She stated nursing staff had been trained to add the monitoring to anti-anxiety medications. She stated she does not know why it was not done. She stated when asked what the potential negative outcome could be I don't feel comfortable answering that question. That's like making me guess. During an interview with the ADM on 08/10/23 at 12:53 PM, he stated anti-anxiety medications need monitoring for side effects and appropriate effectiveness. He stated monitoring should be documented on the treatment administration record. He stated the DON was responsible for making sure anti-anxiety medications were being monitored for side effects and benefits. He stated anti-anxiety medication monitoring should start on initial dose of medication. He stated he was not aware monitoring of the medication was not being done. He stated the potential negative outcome could be not noticing a reaction or the effectiveness of the medication. During an interview with LVN C on 08/10/23 at 01:10 PM, she stated anti-anxiety medication required monitoring for side effects, adverse reactions and effectiveness. She stated monitoring was documented on the treatment administration record. She stated she was not sure who was responsible for adding the monitoring to the treatment administration record, but it should be added at the time the order for the medication was received. She stated monitoring started with the initial dose. She stated the potential negative outcome could be not being aware of reactions or side effects. Record review of the facility's policy titled Psychotropic Medication Use; revision date July 2022 revealed: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: c. Anti-anxiety medications . 12. Residents receiving psychotropic medications are monitored for adverse consequences.

Based on observations interviews and record reviews, the facility failed to report alleged violations related to neglect or abuse, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency), for 2 of 5 residents (Resident #1 and Resident #2) reviewed for abuse and neglect, in that: 1. The facility did not report to HHSC when Resident #1 acquired a bruise from an unknown origin. 2. The facility did not report to HHSC when Resident #2 acquired a bruise from an unknown origin. This deficient practice could place residents at risk for abuse and neglect. The findings were: Record review of complaint intake, received 07/22/22, revealed On 07/21/22, at 7:35 AM, an anonymous person reported that there was a concern of multiple residents in the dementia unit that had a bruises, that were reported to the Administrator and were not investigated. Resident #1 Record review of Resident #1's face sheet, dated 07/22/22, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS (Section C0500) score of 00, which indicated severe cognitive impairment. Section C700 Short term memory indicated Resident #1 had a memory problem. Section 0900 Mem/Recall ability revealed Resident #1 was unable to recall the current season, location of her own room, staff names and faces, and that she was in a nursing home. Section C1000 Cognitive Skills for Daily Decision-Making revealed Resident #1's ability to make decisions regarding tasks of daily life was moderately impaired (decisions poor; cues/supervision required). Record review of the facility summary report dated 06/2022-07/22/22 revealed on 07/18/22 at 4:29 PM a bruise was identified by LVN A located on right upper elbow. Record review of Resident #1 care plan date 07/14/22 revealed the resident have a problem regarding the category: cognitive loss/dementia, stating that she was at risk for decreased cognition related to Alzheimer disease. Record review of Resident #1 care plan date 06/17/21 revealed the resident have a problem regarding the category: communication, stating that she had difficulty with communication related to cognitive impairment and Alzheimer disease. Record review of Resident #1 care plan date 06/18/21 revealed the resident have a problem regarding the category: cognitive loss/dementia, stating that she had impaired cognitive function/ dementia or impaired thought process related to BIMS score of 0 indicating severe impaired cognitive function and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1 care plan date 06/18/21 revealed the resident have a problem regarding the category: [CONDITION(S)], stating that she was at risk for [CONDITION(S)] as he had periods of disorganized thinking. Record review of Resident #1 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 500 Mg 1 tablet twice a day for unspecified convulsions Record review of Resident #1's Medication Administration History dated 07/01/22-07/22/22 revealed the resident received the medication ([MEDICATION(S)]) every day from the 07/01/22 to 07/22/22. Record review of Resident #1 progress note dated 07/18/22 at 4:30 PM written by LVN A revealed during a skin assessment the nurse noted a small reddish-purple bruise to right upper elbow measuring 2.0 cm x 1.0 x 0.0 cm. The doctor was notified as well as Resident #1 husband. Record review of an undated and untitled document provided by the facility Administrator revealed a website that he reported that he visited. The website is noted as follows: https://www.drugs.com/sfx/[MEDICATION(S)]-side-effects.html Record review of the website revealed the following: Common side effects of [MEDICATION(S)] include: Did not include bruising. Other side effects include: Did not include bruising.00 Applies to [MEDICATION(S)]: oral solution, oral tablet, oral tablet for suspension, oral tablet extended release Side Effects: Incidence not known unexplained bleeding or bruising unusual bleeding or bruising Record review of facility observation detail report dated 07/18/22 at 11:26 AM revealed that the bruise to right upper elbow and was pink, brown etc. Record review of TULIP revealed incident dated 07/18/22 regarding Resident #1 had not been reported to HHSC by the facility. During an interview on 07/22/22 at 12:23 PM, The DON revealed that Resident #1 bruising was reported during a morning meeting on 07/18/22. She stated that the Administrator suggested the [MEDICATION(S)] was the cause of the bruising. She stated in her experience she is not aware of the medication [MEDICATION(S)] causing bruising. She stated she is aware that anticoagulants may cause bruising. She stated that the Administrator is responsible for reporting allegations of abuse. She stated she does not feel like there is an abuse issue but because there was no origin to the bruise it is important to report it and investigate it to rule out abuse. She stated the residents are unable to say what happen to them and if it is unwitnessed no one can say what happened to them for a fact. She stated all suspicion of abuse or injuries of unknown origin should be reported within two hours. She stated that she is unaware if incidents reported to the abuse coordinator have been reported to the state. She stated it is the facility's practice once a bruise is found and if the staff do not know where it come from they are to assess the resident and report it to the abuse coordinator. During a confidential interview on 07/22/22 at 1:35 PM, revealed during the morning meeting on 07/18/22 the bruise located on Resident #2's arm was reported to the Administrator. It was stated that it was mentioned in the meeting that this would not be reported because of the resident taking [MEDICATION(S)]. Confidential Staff B stated in her years of experience she was unaware that the medication would cause bruising. During a confidential interview on 07/22/22 at 1:45 PM, revealed it was reported in the morning stand up meeting on the 07/18/22 it was reported by the ADON that there was a bruise on the back of Resident #1 arm. It was stated that the administrator was suggested to report the incident based on Resident #2 inability to not say where the bruise came from. It was stated LVN B looked at the medications of Resident #2 during the meeting and the Administrator stated that this medication was the cause of the bruising. During this interview it was revealed that there was no evidence that any investigations had been conducted for both Resident #1 and Resident #2 During an interview on 07/22/22 at 2:47 PM, Resident #1 was unable to report what happened to her arm. She was attempting to sleep and just told the DON to shhhhh. An observation was made on 07/22/22 at 2:47 PM of Resident #1 bruise. It was located on the back of her right arm. During an interview on 07/22/22 at 2:53 PM, LVN A said that she did not know where the bruise on Resident #1 came from. She stated that Resident #1 is often confused. She stated the resident will sometimes become agitated. She stated that she reported this information to the DON and the DON reported it to the Administrator and the Supervising Administrator. She stated she does not remember them saying anything. She stated that it is important that unknown bruises are reported just in case it is abuse to the residents. She stated this bruise was odd as it was one single bruise as opposed to it being multiple in a row that could have signified finger prints. During an interview on 07/22/22 at 3:02 PM, The Administrator stated he currently is the abuse coordinator. He stated this means he is the contact for suspicion and witnessed abuse that occurs in the building. He stated the day that Resident #1 bruise was reported it was his first day. He stated he was so new that his name had not even been hung on the wall. He stated he remembered there was a discussion had. He reported the DON had suggested that the bruise had come from Resident #2 leaning on the wheelchair. He stated that he conducted a google search and found that bruising was a side effect of [MEDICATION(S)]. He stated that was the investigation and that there was no documentation to support that an investigation was conducted regarding the bruise reported on Resident #1. He stated he was not familiar with the 2-hour window of reporting abuse. He stated he was familiar with the CMS rule of 24 hours. He stated he is still learning as he comes from New Mexico. He stated he had abuse training but could not recall provider letter 19-17 that provides the time frames for reporting. He stated reporting abuse or unknown injuries were important because just in case it is abuse you need to remove the resident to prevent further abuse or future injuries. Record review of Resident #2's face sheet, (undated/ date cut off), revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS (Section C0500) score of 99, which indicated the resident was unable to complete the interview. Section C600 revealed Resident #2 was unable to complete the BIMS interview. Section C1000 Cognitive Skills for Daily Decision-Making revealed Resident #2's ability to make decisions regarding tasks of daily life was moderately impaired (decisions poor; cues/supervision required). Record review of the facility summary report dated 06/2022-07/22/22 revealed on 07/21/22 at 11:26 AM a bruise was identified by LVN B located on right forearm and origin was unknown. Record review of Resident #2 care plan date 04/13/21 revealed the resident have a problem regarding the category: cognitive loss/dementia, stating that she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #2 care plan date 10/11/20 revealed the resident have a problem regarding the category: [CONDITION(S)], stating that she was at risk for [CONDITION(S)]. Record review of Resident #2 care plan date 06/18/21 revealed the resident have a problem regarding the category: cognitive loss/dementia, stating that she had impaired cognitive function/ dementia or impaired thought process related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #2 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Ibuprofen tablet 200 mg tabs as needed for pain Record review of Resident 2's Medication Administration History dated 07/01/22-07/22/22 revealed the resident had not received the medication (Ibuprofen) from the 07/01/22 to 07/22/22. Record review of Resident #2 progress notes dates 07/21/22 at 11:42 AM written by LVN A revealed that bruise identified from unknown origin. The size was noted as 11 cmx 4 cm dark reddish in color (Location not listed on this form). Resident assessed. DON, Administrator, and doctor notified. Record review of facility event report dated 07/21/22 at 11:26 AM revealed that the bruise of unknown origin to right forearm (11 cm x 4 cm) was dark reddish and bruising of unknown origin. During an interview on 07/22/22 at 12:23 PM, The DON revealed that Resident #2's bruise were reported in the morning meeting by LVN B. She stated that because of this bruise she decided to do a skin sweep of the entire memory unit. She stated Resident #2 is unable to tell what happened and therefore meets the criteria to be reported to the state. She stated that this is the responsibility of the abuse coordinator. She stated in the past she was under the Supervising Administrator he was responsible for making the reports to the state. During a confidential interview on 07/21/22 at 1:35 PM, revealed the bruise was found on the right arm of Resident #2 was reported on 07/21/22. It was stated the standup meetings occur around 9:00 AM. It was sated that the bruise was reported to the administrator the same day during the standup meeting and notified the family. It was reported that Resident #2 was assessed for range of motion and there were no concerns. It was unknown where the bruise came from. There were no knowledge of any investigations being conducted to determine where the bruise came from and to ensure the resident was not being abused. During a confidential interview on 07/22/22 at 1:45 PM, it was revealed that during the standup meeting on 07/21/22 Resident #2 bruise on her right arm was reported. It was stated that this was not reported or investigated, and no justification was given. It was stated it is important to report injuries of unknown origin to protect the residents as this may be abuse. It was also stated that is important to report those in the secure unit as they do not have the ability to cognitively say what happen and this makes the resident vulnerabe. During an interview on 07/22/22 at 2:14 PM, the Medical Assistant stated the resident's doctor was out until 08/01/22. The attempt to speak with the resident's doctor was unsuccessful. During an interview on 07/22/22 at 2:30 PM, the ADON stated she remember that LVN B stated during a standup meeting in the morning that that bruise was found. She stated she cannot remember if it was Resident #1 or #2. She stated that she knew that it was of unknown origin. She stated that it is the facility process to monitor and report it to the Administrator. She said prior to the new Administrator they would report it to the Supervising Administrator. During an interview on 07/22/22 at 2:47 PM, Resident #2 was unable to report what happened to her arm. She never responded to any questions or verbal interactions. She became upset towards the end and yelled at the DON. An observation was made on 07/22/22 at 2:47 PM of Resident #2 bruise. It was located on her right forearm. It appeared to be two separate bruises with a separation in between. During an interview on 07/22/22 at 3:02 PM, The Administrator stated he was not notified until the morning of 07/22/22. He stated that is when he called it into the state. He stated that his DON had did a skin sweep in the memory care unit and reported all bruises found. He stated that he does not remember Resident #2 being brought up any other time. When questioned if he reviews progress notes he stated that he had not reviewed progress notes and did not know this had been documented the day before. During an interview on 07/22/22 at 3:44 PM, during the exit conference the Administrator stated a verbal investigation was conducted regarding Resident #1 by the IDT team that consisted of the DON, Infection preventionist and himself. The DON stated that she was not aware of an investigation being done. She sated she does remember that the idea of [MEDICATION(S)] causing bruising was brought up and it being the cause of bruising and documentation would be provided but that was never done. The Administrator confirmed at this time he does not have any written documentation to support the investigation conducted on Resident #1. Record review of TULIP revealed incident dated 07/21/22 regarding Resident #1 had not been reported to HHSC by the facility. During an interview on 07/26/22 at 9:00 AM, The DON stated the term incidence not known that is listed by the side effects that the Administrator provided on 07/22/22 was a term that she was not familiar with. She stated that the common side effects are listed all together. She said if she had to use her experience that those side effects that are not common or unknown. She stated she still does not know [MEDICATION(S)] having a side effect of bruising. During an interview on 07/26/22 at 11:20 AM, The Administrator stated the term incidence not known that is listed by the side effects that he provided on 07/22/22 means that they have a trend towards that side effect, but they do not have the percentage totals of what that accounts for. He stated in layman's term the researchers see observations, but they do not have a scientific number assigned to that side effect. When asked why researchers would differentiate between incidence not known and listed side effects his response was as follows: He stated he would have to google it. He stated that the official scientific information that he found was that incidence unknown is the side effects are not counted numerically. Record review of the facilities Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating (Revised April 2021), revealed the following: Policy Statement All reports of resident abuse (including injuries of unknown origin that result in serious bodily injury), neglect, exploitation, or theft/misappropriation of resident property are reported to local state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy interpretation and Implementation 1. If resident abuse, neglect, exploitation, misappropriation of the resident property or injury of unknown sources suspected, the suspicion must be reported immediately to the administrator, or administrative staff on call, and other officials according to state law. 2. The administrator slash administrative staff or the individual making the allegation immediately reports his or his suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/ licensing the facility; 3. immediately is defined as a. within two hours of an allegation involving abuse or result in serious bodily injury; Or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property for injury of unknown source, the administrator is responsible for determining what actions if any are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator or administrative staff on call investigations. 2. Investigations may be assigned to an individual train in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is preserved is deemed appropriate 8. upon conclusion of the investigation the investigator records the findings of the investigation and provides the completed documentation to the administrator. Record review of the facilities Abuse Prevention Program (Revised December 2016), revealed the following: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to the freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, in physical or chemical restraint and not required to treat the resident symptoms. Policy interpretation and Implementation (1) Protect our residents from abuse by anyone including, but not necessarily limited to : facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. (3)Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] (6)Identify and assess all possible incidents of abuse; (7)investigate and report any allegations of abuse within timeframes as required by federal requirements; (8)protect residents during abuse investigation;

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 consumed food from 1 of 1 facility kitchen in that: 1) Food was not dated properly in the refrigerator. 2) A grey fuzzy substance was clinging to the top shelf in the walk-in refrigerator. 3) Glasses were found in the drying area upside down on top of trays with moisture trapped in the glasses. 4) Bowls were found stored upside down on trays on a shelf under a prep table with moisture trapped inside the bowls. 5) Two kitchen staff members, Dietary Aide A and Dietary Aide B, failed to perform correct hand hygiene. 6 One single serve ice cream container was on the floor of the walk-in freezer underneath a shelving unit. 7) The temperature of the juice dispenser refrigerated compartment was too hot. 8) Dry goods were improperly stored and unsealed. 9) Food prep tables were grimy on the undersides of the edges. 10) Sanitizing solution in 1 of 2 buckets did not meet the minimum ppm required by manufacturer, according to test strip color. These failures could place residents at risk of foodborne illnesses and cross contamination. The findings included: The following observations were made in the kitchen on [DATE] between 10:00 AM and 11:10 AM: In an observation made on [DATE] at 10:03 AM, Dietary Aide B was observed performing hand washing at the sink near the dishwasher. She did not perform proper hand washing as she touched the automatic paper towel dispenser twice instead of waving her hand in front of the dispenser, thus contaminating the cleaned hand. In an observation made on [DATE] at 10:05 AM, the sanitizing solution in the red bucket for wiping down tables was observed to be cloudy. The kitchen staff tested the solution using test strips. The test strip indicated the solution was below the required ppm ratio. The strip remained the original orange in color, which indicated 0 - 100 ppm of quaternary solution (150 - 200 ppm required by the manufacturer guideline and facility policy Sanitization). In an observation made on [DATE] between 10:07 AM - 10:16 AM of the walk-in refrigerator, a grey fuzzy substance was observed clinging to the front and top of the shelving unit to the left of the door when entering. Three improperly dated foods were in the walk-in refrigerator. The first was a cheese liquid in a steam table pan. It was dated with only one date, [DATE], in marker on the plastic wrap covering. There was no indication of what this date meant, if it was a made on, use by, or expires by date. At least 5 individual, still sealed packages of whipped topping were piled in a large plastic tub which had a date of [DATE] affixed to the tub. Again, there was no indication of whether this was a use by or expires by date. No manufacturer expiration date could be found on the individual packaging. A large block of opened cream cheese was in a zipped bag with a single handwritten date of [DATE] as the date opened, but no expiration date was visible on the zip locked bag. In an observation made on [DATE] at 11:05 AM, one single serve container of ice cream was observed on the floor of the walk-in freezer under the shelving unit and was not stored on a shelf off the floor as required. During an interview on [DATE] at 11:02 with the Dietary Manager, regarding the grey fuzzy substance clinging to a top shelf in the walk-in refrigerator, she said, Well to me it looks like mold. When asked about the items in the walk-in refrigerator that lacked an expiration date, she said that having one date on the items was confusing and made it difficult to determine when an item should be discarded. She then discarded the items in the walk-in fridge that lacked an expiration date. The following observations were made in the kitchen on [DATE] between 10:35 AM and 11:20 AM: In an observation made on [DATE] at 10:40 AM, three trays of upside-down glasses were observed in the dish drying area. 3 of 3 trays had glasses with moisture trapped inside. The trapped moisture was visible as the glasses were made of clear patterned plastic, the bottom tray had 18 containers, the top two trays had approximately 16 containers each. In an observation made on [DATE] between 10:45 AM and 10:50 AM, the curve under edges of all prep tables in the kitchen area were found to be grimy, as measured by running fingers along the inside of the curve. Inside the edges of 4 of the 4 prep tables, there was grime. On 2 of the 4 tables, crumbs were also present on the curved edges on the underside of the preparation tables. A sticky paper with food residue was removed from one table and was visibly soiled. In an observation made on [DATE] at 11:00 AM, an open, unsealed bag of chocolate chips was found in the drawer of the baking prep table. In an observation made on [DATE] at 11:06 AM, the juice dispenser did not have a thermometer inside of the refrigerated portion. Dietary Manager took a thermometer from one of the refrigerators and placed it in the refrigerated portion of the juice dispenser. An observation on [DATE] at 12:00 PM showed the temperature being taken of the juice was 48.3. According to the thermometer, the air inside the refrigerated portion of the juice dispenser was 70 degrees. As a result of the juice being held at a temperature above 41 degrees, the juice was discarded by the Dietary Manager per facility policy Food Service and Preparation. In an observation made on [DATE] at 11:12 AM, two trays of small plastic serving bowls were observed stored upside-down on a shelf under a prep table. 2 of the 2 trays of bowls had moisture in the bowls and on the trays. In an observation made on [DATE] at 11:15 AM, Dietary Aide A was observed having entered the kitchen from the dining room and, without washing her hands, pick up a steam table container and continue to work on preparing food until corrected by the Dietary Manager and told to wash her hands. During an interview on [DATE] at 10:43 AM, the Dietary Manager was asked about glasses that were upside-down on a plastic tray and had moisture trapped inside. She stated that this could cause contamination and that the items should be allowed to drip dry with air flow beneath for proper cleaning and to prevent contamination. During an interview on [DATE] at 10:50 AM the Dietary Manager was asked about the cleaning of the underside of preparation tables, and the Dietary Manager stated the cleaning of all surfaces of the preparation tables is a scheduled cleaning task. She stated that lack of cleaning could cause illness in a resident. During an interview on [DATE] at 11:00 AM when shown the open, unsealed chocolate chips in the drawer of the baking prep table, the Dietary Manager acknowledged that it was unsealed and improperly stored and took the bag and threw it away. She noted it should be sealed with a use by date for proper storage. During an interview on [DATE] at 11:18 AM, the Dietary Manager provided a copy of the walk-in refrigerator cleaning schedule. She said the walk-in refrigerator was cleaned with the sanitizing solution in the red buckets using a white cloth. Referring to the possible negative outcome of mold in the walk-in refrigerator, Dietary Manager stated, Oh, that is no good, somebody could get sick from that and it could just build up in other food. During an interview on [DATE] at 11:27 AM when the Administrator was asked about his expectations of the cleanliness of the walk-in he said, Simple answer, it should be clean. He stated dietary management was responsible for the cleanliness of the walk-in refrigerator. When asked about disposal of expired food or improperly dated food in the walk-in, he stated that the primary responsibility resides with dietary management. He said his expectation regarding dates on food items was that a label gun was used on all pantry items and dated plastic wrap or stickers are used for cold items showing the dates received, opened, and expired. During an interview on [DATE] at 1:50 PM with the Dietary Manager, when asked what a negative outcome could be for food/drink stored at incorrect temperatures could be, the Dietary Manager stated that food or drink stored at incorrect temperature could lead to foodborne illness. She acknowledged that the expired and improperly dated food found in the walk-in refrigerator on Monday [DATE] could lead to illness in residents. She further stated it is the responsibility of dietary staff to ensure correct temperatures and proper labeling and dating of food. When asked about hand hygiene of kitchen staff she said it is a requirement for proper hand hygiene to be performed by every person entering the kitchen from any other room to minimize contamination. She further explained that improper cleaning of the hands could lead to illness for a resident. She stated they do monthly refreshers on hand hygiene, so staff do not become complacent. Record review of the facility policy dated 2008 and titled, Sanitization reflected the following; The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. 4. Sanitizing of environmental surfaces will be performed with one of the following solutions: b. ,d+[DATE] ppm quaternary ammonium compound (QAC) 9. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 13. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 14. The food services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas . Record review of the facility policy dated 2019 and titled, Food Preparation and Service Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area . 4. Appropriate measures are used to prevent cross-contamination. These include: c. Sanitizing towels and cloths used for wiping surfaces in containers filled with approved sanitizing solution (at concentrations specified by the manufacturer of the solution used); and d. Cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines. 5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Food Preparation, Cooking and Holding Time/Temperatures 1. The 'danger zone' for food temperatures is between 41 degrees F and 134 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Food Service/Distribution 1. Proper hot and cold temperatures are maintained during food service. Foods that are held in the temperature 'danger zone' are discarded after 4 hours. Record review of the facility policy dated 2017 and titled, Food Receiving and Storage Foods shall be received and stored in a manner that complies with safe food handling and practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. 9. Refrigerated foods must be stored below 41 degrees F unless otherwise specified by law. 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. Record review of the kitchen cleaning schedule dated [DATE] and provided by Dietary Manager Review of this schedule indicates that the last time the walk-in refrigerator was cleaned was [DATE]. The previous documented cleaning was [DATE]. In addition, all surfaces of the preparation tables were assigned to be cleaned [DATE]. The facility was asked to provide a copy of hand hygiene requirements in the kitchen but failed to produce any guidelines and informed surveyors no such policy exists. An additional opportunity to provide further evidence was given at the exit conference, the facility declined to provide any further documentation at that time.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 2 out of 23 days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 06/04/22 and 06/05/22 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of Employee Roster 06/27/22 revealed five registered nurses. Record review of Registered Nurse B's Payroll Detail dated 06/27/22 for time period 05/27/22 through 06/26/22 revealed the following: 06/03/22: 06:18 PM Clock IN and 06:49 AM Clock OUT on 06/04/22 (6hrs 49 min worked on 6/4/22) 06/04/22: 06:00 PM Clock IN and 07:02 AM Clock OUT on 06/05/22 (7hrs 02 min worked on 6/5/22) During an interview on 06/29/22 at 09:55 AM the Nurse Consultant stated they have always used the RN on the night shift for RN coverage. She stated the DON and ADON's were responsible for scheduling RN coverage. She stated they were supposed to call agency or nurse consultant if they do not have RN coverage. She stated the RN requirement was 8 hours a day. She stated they ensured RN coverage by looking at the schedule. When asked why it was important to have an RN on duty, she stated Beats me, because it's required. When asked what the potential negative outcome for no RN coverage was, she stated, None in my opinion. During an interview on 06/29/22 at 10:16 AM the Administrator stated it is the DON's responsibility to schedule RN coverage. He stated the DON is new and still in training and the June schedule was already made by the former DON. He stated if no RN coverage is scheduled, they are to find coverage using staffing agency or the multiple RN employees. He stated the RN requirement is eight consecutive hours within a 24-hour period. He stated they ensure RN coverage in morning standup meetings. He stated it is important to have RN coverage to ensure you have skills necessary to care for residents and pronounce at times when needed. When asked what the potential negative outcome for no RN coverage could be, he stated I am having a hard time thinking due to other nurses in the building and RN accessibility out in the community. Record review of the provided facility policy labeled Director of Nursing Services, RN Coverage revised August 2006 revealed, Policy Statement: The Nursing Services department is under the direct supervision of a Registered Nurse. Policy Interpretation and Implementation 3. Every 24-hour period will have 8 consecutive hours of coverage by a Registered Nurse.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 of 15 residents (Residents #28) reviewed for care plans as follows: The facility failed to develop a care plan for visual and communication for Resident #28 This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Resident #28 Record review of Resident 28's face sheet (undated) documented a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #28's comprehensive admission MDS (Minimum Data Set) assessment dated [DATE] documented the following: Section B - Hearing, Speech, and Vision B1200. Corrective Lenses No B0200. Hearing 2. Moderate Difficulty- Speaker has to increase volume and speak distinctly B1000. Vision 1. Impaired- sees large print, but not regular print in newspapers/books Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 10 moderately impaired cognitively (Alert and Oriented x time, place, person). Section I Active Diagnosis Vision I6500 [CONDITION(S)], [CONDITION(S)], or [CONDITION(S)] ( Not marked or checked) (Orders did not reflect these diagnoses) Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident Participated in assessment 1 Yes Section V - Care Area Assessment Summary (3) Visual (4) Communication Record Review of Resident #28's Admission Report dated 05/19/22 revealed the following: Hearing: Minimal difficulty- difficulty in some environments Vision: Impaired Sees large print, but not regular print in newspapers Corrective lenses: Yes Record Review of Resident #28's Care Plan (undated) did not reveal a care plan that included measurable objectives, interventions and time frames for visual and communication. Record Review of Resident #28's Care Plan (undated) specifically, the altered mental status care plan did not include any goals, interventions or measurable objectives specific to how to communicate with Resident #28. Record Review of Resident #28's Care Plan dated (undated) did not reveal any data that suggest the resident has any visual impairments. On 06/29/22 at 11:55 AM, an observation was made of an HGTV magazine (regular print) on Resident #28 bedside table. During an interview with Resident #28 on 06/29/22 at 1:29 PM, she said she has a hard time seeing but has glasses. She said that she had not worn them in a while. She did not have a reason why she had not used her glasses but pointed in the direction where she thought her glasses were. She said she could communicate and hoped the staff could understand her. The interview was cut short as the resident stated that she was uncomfortable and in pain. The interview stopped so staff could provide care. During the interview it was difficult to hear the resident. Surveyor had to get close to understand Resident #28. During an interview with the Confidential Staff B on 06/29/22 at 12:03 PM, she stated that she has worked with Resident #28 and has observed her doing puzzles. She stated the resident said that she could barely see. She stated the resident does wear glasses. She stated the resident has not been wearing them because she wears oxygen. She stated she knows a care plan but has never looked at it and does not know where they are located. She said that she gets her information verbally from other staff. She stated that she has worked with the resident long but that communication could be difficult if you do not know her. She stated that the resident speaks very low. You have to get really close to her to hear what her needs are. During an interview with the Confidential Staff C on 06/29/22 at 1:31 PM, she stated she does not know what a care plan is. She stated she had not used a care plan. She said she knows what care the resident needs because she is verbally told by other staff. She said Resident #28 talks really low, and you must pay close attention to her to know she is speaking to you and what she is saying. She stated the resident does wear glasses. She said she has not received specific training on Resident #28 but has worked with her and has gotten to know her. During an interview with the Confidential Staff D on 06/29/22 at 1:33 PM, she said she works with Resident #28. She said the resident does not have a visual impairment that she knows of. She said the resident has changed in and appears to talk more softly, making it difficult to hear her. She said the resident seemed more sleepy. She said that the resident is not communicating as much. She said that she knows a care plan but has never seen one. She said she gets a verbal report from staff about residents. During an interview with the Confidential Staff A on 06/29/22 at 1:38 PM, she said she was the one who gave the resident the HGTV magazine (with regular print) to the resident. She said she has worked with Resident #28 and that the resident has difficulty hearing and speaks very softly. She said Resident #28 could speak for herself and understands, but if you don't know her, you may not know she is talking. She said she was unaware of Resident #28 visual impairment. She said she had not been trained regarding Resident #28 particular need for large print items. During an interview with the Nurse Consultant on 06/28/2022 at 2:58 PM revealed that the facility used MDS consultants to complete the MDS Assessments and the care plans. She reported that she was ultimately responsible for care plans while the new DON was being trained for her new position. During this interview, she did not see a visual care plan for Resident #28. She stated that a negative outcome for a resident that triggered for visual and was not care planned might be that the resident may not recognize who is coming in the room or may not recognize their surroundings. During this interview, she confirmed after looking at the care plan for the resident that a communication care plan had not been completed. She stated that failure to care plan for communication for a resident that triggered would make it difficult for the resident to request their preferences. She reported the care plan is a plan that communicates the plan of care for the resident. She stated that all direct care, such as the nurses, utilize the plan. She said that the nurse completing the care plan decides if care plans can be combined, meaning that more than one care plan can be listed within one individual care plan. She said she is sure this is in their facility policy. She stated she had been trained on care plans. She said she needed more time to review the file. When questioned about the accuracy of the MDS assessment, she said the MDS should be correct to her knowledge. She confirmed that the triggered areas from the MDS would have been accurate based on the MDS assessment to her knowledge. During an interview with the DON on 06/28/22 at 3:22 PM, she stated she had not been in her role very long. She stated a care plan is a plan that includes goals and outcomes for the resident. She said that if a triggered care plan is not addressed, then things can slip through the cracks. During an interview with the Administrator on 06/29/22 at 10:21 AM, he said the care plan is a 1st person's perspective of how to care for a resident. He stated that all staff utilizes the care plan to provide care for the resident. He said that the Nursing Consultant is responsible for care plans. He stated that care plans had been discussed in their weekly stand-up meetings due to a previous survey a month ago. He said he believed they were halfway through checking the residents care plans in the facility. After consulting with the DON, he could not verbally tell the surveyor which resident they were on. He stated that this had been cited a month ago, and as a response to this deficient practice, they conducted an audit (weekly) and an internal audit using consultants monthly. He stated that care plans should be individualized and tailored to the resident. He did not provide an answer specifically to the negative outcome regarding communication stating it depended on the severity of the communication issue. He said regarding Resident #28 visual care plan that if she is supposed to receive large-print reading material, this could inconvenience the resident. When asked if this was important, even though it has nothing to do with nursing directly, he stated this inconvenience is significant because the facility is their home and should not be inconvenienced. He said he expects the care plan fits the resident's needs. During an interview with the Nurse Consultant on 06/29/22 at 10:00 AM, she said she reviewed the file. She said that the resident was able to communicate and understands people. She stated that she was unsure why this was triggered. She stated that the resident was triggered for visual because of [CONDITION(S)], eye pain, and decreased visual acuity. She said she could not attest to the MDS assessment's accuracy as someone else completed it. She stated the resident reads large print. She stated the resident no longer wears her glasses. She stated that the course nurses' aids take teaches them basic care of residents. When asked if providing large print to all residents was a part of the training, she stated the staff would be able to care for the resident's communication and visual needs. She stated she does not feel that there is a negative outcome for the resident at this time. She said that just because the information is not in the care plan does not mean the resident's needs will not be met. When asked what could be the negative outcome for a resident that triggered communication or visual care areas, the nurse consultant responded, I will not talk about hypothetical. She stated that she could not state why the care plans were not done. She stated her expectation for care plans is that all required portions are completed. She said that she expected section v of the MDS, known as the care area assessment, to be addressed in the care plan. At 10:32 AM, she stated in response to the Administrator and DON searching for documentation that reflected the status of the care plan audits, that all care plans had been reviewed and addressed. During an interview with the Co-founder on 06/29/22 at 10:56 AM, he said he was responsible for overseeing all operations. He stated he did not have any additional information regarding care plans because when the facility was first cited, he was out of town. However, he stated that the facility did hire consultants due to being cited on care plans prior to the full book survey. He said as a part of the plan of action, all care plans should have been reviewed, audits should have been completed, and all care plans should have been revised by 06/15/22. When asked about the status of the revision of the care plans and if by the standard of the facility recent action plan, was Resident #28's reviewed and revised, he explained that the definition of revised is edit. He said he could not attest that Resident #28's care plan had been edited or not. During an interview with the MDS Clinical Director on 06/29/22 at 10:58 AM, she stated she is responsible for completing the care plans for the facility at this time. She said that she had personally completed the care plan for Resident #28. She stated a care plan should give staff an idea of the resident's current status. She said that she compares the MDS assessment to the care plan so that she can create the care plan. She said that she recently updated Resident #28 care plan on 06/27/22. She said that if the care area is triggered in the MDS, there is usually a care plan created associated with the triggered care area. She stated if a person triggers for a care area and it was not care planned, staff would not be able to address that area effectively. When asked specifically about adverse outcomes for the resident, she said that she did not feel the resident's care was being affected at the time. She stated she feels the resident communication was addressed under altered mental status. She said that she did not complete a vision care plan. No reason was provided as to why this care plan had not been completed. When asked why a care plan was not completed even though the MDS stated a care plan had been completed, no specific answer was provided. During an interview with the MDS Clinical Director Supervisor on 06/29/22 at 10:58 AM, she said the care plan is based on the MDS. She said that care plans could be combined. She interjected while the interview was being conducted with the MDS Clinical Director and stated that the MDS Clinical Director is trying to say that care plans can be included in other areas if the triggered care area is not a critical need. During an interview with the DON on 06/29/22 at 11:56 AM, she stated she was unsure who left the HGTV magazine (regular print) on Resident #28 bedside table. She said it may have been one of her family members. Record review of the facility policy Care Plans, Comprehensive Person-Centered, (Revised March 2022), revealed the following documentation: Policy Statement: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation (3) The care plan interventions are derived from a thorough analysis of the information gathered as apart of the comprehensive assessment. (6) The comprehensive, person-centered care plan: a. Measurable objectives and timeframes b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . c. Build on resident's strengths; and d. Reflects currently recognized standards of practice for problem areas and conditions

Based on interview and record review, the facility failed to ensure all alleged violations of abuse were reported immediately, but no later than 2 hours after the allegation was made, to the Administrator of the facility and to other officials (including to the State Agency) for 1 of 1 resident (Resident #1) reviewed for Abuse. The facility failed to report to HHSC of an allegation of abuse within prescribed timeframes for Resident #1. This failure could place the residents at risk of injury related to abuse and neglect. Findings included: During an entrance conference interview with the Facility Company Co-Founder and also the Administrator on 5/3/22 at 10:25 a.m., the Co-founder stated that the facility completed an investigation on the incident involving Resident #1. provided a document re: Investigative summary Resident #1 that was marked Confidential: Internal QA Document. Co-Founder stated that it was the complete investigation, and it might assist the investigators with their investigation. Co-Founder stated that it would show that the facility completely investigated the entire situation that started with the phone call between the DON and the family member #1 on 4/20/22 and also the complaint the facility received from RN B on 4/23/22. Co-Founder stated that the facility investigation started after the complaint made by Family Member #1 to RN B on 4/23/22. Administrator stated that she was notified on 4/23/22 by RN B that the family of Resident #1 alleged that staff abused Resident #1 causing bruises on Resident #1. Administrator Stated that the family notified the DON on 4/20/22 that they found bruises on Resident #1 and also that staff entered the room several times but turned off the call light and did not assist Resident #1. Administrator stated that Family Member #1 made no allegation of abuse and the DON investigated and assessed Resident #1 but found no suspicion of abuse. Administrator stated that the facility completely investigated this situation after the allegation of abuse was made to RN B on 4/23/22 and found no abuse by staff on Resident #1 but cannot determine where the bruises came from. Record review of Resident #1's admission Face Sheet, dated 05/04/2022, revealed she was a [AGE] years-old female and was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care plan, dated 1/7/2022 with last revision on 3/16/22 revealed that Resident #1 has a potential for skin breakdowns and directs nursing to complete a skin assessment upon admission and at least weekly, with a short-term goal date of 5/15/2022. Record review of the Event Details, category skin integrity events - bruise dated 3/24/22 at 22:28 completed by LVN A revealed in the short description category as dark purple bruise to right breast 5.0 x 3.0 cm; there was no swelling and mild pain. Activity during bruise occurrence states Other: Pulling up in bed. No possible contributing factors are marked or listed; the interventions/immediate measures are resident is on [MEDICATION(S)] and recently [MEDICATION(S)]. Under notification guidelines it is marked as large bruise associated with known incident and states physician/representative notified yes. In the associated progress note on 3/24/22 at 11:02 p.m. it states .when assisting with bed change resident was noted to have a large purple bruise to right breast purple in color 5.0 x 2.0 cm; resident is on multiple blood thinners and does not know how bruise occurred will continue to monitor. Record review of Resident #1's Medications orders revealed Resident #1 was prescribed on 1/7/22 with no end date, [MEDICATION(S)] ([MEDICATION(S)]) 10mg tablet, 1 tablet by mouth every afternoon for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)]® is a blood thinner medicine (anticoagulant) that lowers blood clotting. During treatment with [MEDICATION(S)]® you are likely to bruise more easily, and it may take longer for bleeding to stop. You may be at higher risk of bleeding if you take [MEDICATION(S)]® and have certain other medical problems. Record Review of Resident #1's skin assessments titled, Pressure Ulcer Documentation: ordered on 1/7/22 with no end date, to be completed every Monday between the hours of 6 a.m. to 6 p.m.; revealed the following skin assessments completed: 1/10/22, 1/17/22, 1/25/22 (one day late), 2/7, 2/14, 2/21, 2/28, 3/7, 3/14, 3/21, 3/28, 4/4, and 4/11, 5/2 Missing skin assessments: 2/1/22 and 4/18/22 Record Review of Resident #1's Braden Scale for Prediction of Pressure Sore Risk created on 4/25/22 and edited on 5/3/22 at 3:58 p.m. completed by DON. Braden Score of 15 meaning at risk for skin issues and breakdowns. Description: Short description: Weekly Skin assessment revealed: Resident #1 has slightly limited mobility, skin is occasionally moist, her ability is Chairfast-ability to walk severely limited, her mobility is slightly limited, nutrition is probably inadequate, friction and shear is a potential problem - moves feebly or requires minimum assist and maintains good position in chair or bed most of time. It showed interventions as nutrition/hydration intervention to manage skin problems, applications of ointments/medications other than to feet; cyclic feedings at night, moisture barrier cream; no referrals are necessary, continue current plan of care. Record review of pressure ulcer documentation description weekly skin created 5/2/2022 17:33 completed by LVN G, showed no pressure ulcer, color of skin - wnl (within normal limits), elastic, dry, cool, no [CONDITION(S)], no skin tears and no rash, abrasions, bruise, [CONDITION(S)], or open [CONDITION(S)]. Record Review of the facility investigation report included Resident/Family Complaint/Concern Form dated 4/20/22. Person expressing concern: FM 1, Resident Name: Resident #1. Complaint/Concern: Stated that CNA C turned off mother's call light and did not change her and mother has a bruise to her right arm. Subject: FM 1 stated that CNA C turned off mother's call light and did not change her and her mother has a bruise to her right arm. Department Follow up: Spoke with CNA C, she was not assigned aide on that hall and she helped CNA D change resident several times because she had loose stools. She said at least (6) times. Resolution: Called FM1 the next day and let her know my findings and she said thank you for letting her know. Encouraged her to notify me of any further concerns. Signed by DON on 4/22/22. (Over for additional documentation): Resident is noted to be on [MEDICATION(S)] 10mg every afternoon which will cause skin to bruise easily. Record review of observation details, full clinical observation dated 4/20/22 11:34 p.m. completed by LVN A stated patient alert, facial muscle strong, upper and lower extremity left and right strong, gums pink/firm, no oral complaints, oral mucosa moist, tongue pink, smooth with no complaints, regular clear left and right lung sounds, no cough, regular heart rate, bilateral pedal pulses present, active bowel sounds, soft abdomen, no [CONDITION(S)], skin status is dry, warm, per usual, peri area without complaint, incontinent of bowel and bladder, use of pads/briefs, urine clear, no nutrition issues, no feeding tube, and physical assessment is unchanged. No bruising noted on this skilled observation. Record Review of Event Details, category skin integrity events - bruise dated 4/21/2022 01:37 by LVN A, short description bruises to upper right extremity, shows a bruise of unknown origin, progress note states 3 bruises to right upper extremity 4.0 x 1.0, 2.0 x 1.0, and one on right forearm 1.0 x 1.0 cm. resident denies pain, loss of range of motion, daughter is present and aware, bruises reported to DON. Record Review of intake # 7 Intake Investigation Worksheet indicated the reporter (Administrator) first learned of the incident of abuse alleged from Resident #1 on 04/23/2022 at 11:15 p.m. and reported the incident to the state agency on 04/24/22 at 1:15 a.m. Record Review of the facility investigation report indicated the incident was reported to HHSC on 04/23/2022 at 11:15 p.m. and reported the incident to the state agency on 04/24/22 at 1:15 a.m. The report included a document that revealed Date of Incident: unknown; Complainant: FM 1; Resident #1. Complaint: 4/23/22 notified by RN B that she received a call from FM 1 at 11:15 p.m. alleging CNA C caused bruises to Resident #1 and she wanted police called as she would be filing charges on CNA C. Alleged staff member identified as CNA C. Document reveals that on 4/20/22 full body assessment by Charge Nurse (LVN A) that resident had 4 bruises on right upper extremity and 1 on right wrist. No distress or complaints of pain noted. Police were notified, Physician and Administrator notified. CNA C suspended pending investigation. Record review of Event Details, category skin integrity events - bruise, short description follow up assessment of bruising noted on 4/2022 completed by RN B on 4/23/22 at 11:45 p.m., location/size of bruises: 1.right upper arm 1.5 cm x 4 cm, 2. 1cm x 4cm, 3. 2 cm x 3 cm, 4 .5cm x 3cm bruise to right forearm; black, blue, bruising from 4/20/2022 Bruising in varies stages of healing. Activity during bruising is unknown, marked as bruising of unknown origin. Record review of Event Details, category skin integrity events - bruise, short description bruise to top left hand completed by LVN G 5/3/2022 5:49 p.m. shows color is other: red/pink; no swelling, no pain, activity during occurrence is other - reaching for drink per resident, no loss of range of motion, contributing factors - nutritional deficiencies - e.g. vitamin C, K, B12, [MEDICATION(S)], intervention - states doesn't hurt, notification - Bruise associated with moderate to severe pain or swelling; and/or loss of ROM is checked. Physician and representative notified - yes. Orders associated with the event show monitor for x72 hrs., elevate affected area to decrease swelling. Record Review of intake # 7 Intake Investigation Worksheet indicated the reporter (Administrator) first learned of the incident of abuse alleged from Resident #1 on 04/23/2022 at 11:15 p.m. and reported the incident to the state agency on 04/24/22 at 1:15 a.m. Record Review of the facility investigation report indicated the incident was reported to HHSC on 04/23/2022 at 11:15 p.m. and reported the incident to the state agency on 04/24/22 at 1:15 a.m. The report included a document that revealed Date of Incident: unknown; Complainant: FM 1; Resident #1. Complaint: 4/23/22 notified by RN B that she received a call from FM 1 at 11:15 p.m. alleging CNA C caused bruises to Resident #1 and she wanted police called as she would be filing charges on CNA C. Alleged staff member identified as CNA C. Document reveals that on 4/20/22 full body assessment by Charge Nurse (LVN A) that resident had 4 bruises on right upper extremity and 1 on right wrist. No distress or complaints of pain noted. Police were notified, Physician and Administrator notified. CNA C suspended pending investigation. The facility investigation report (3613-A), dated 4/29/22 revealed Investigation Summary: CNA denies allegation. This staff member was not on her regularly scheduled unit. Resident #1 is currently on blood thinners and it is unknown how or when bruising occurred. Staff interviewed and there are no recollections of injury by the alleged CNA or anyone else. During an interview and observation of Resident #1 on 5/3/22 at 1:15 p.m.; observed sitting in her recliner with a blanket on her lap and wearing a bathrobe. Resident #1 had family members (FM) #2 and #5 visiting. FM 2 stated that she does not understand where the bruises came from on Resident #1's upper left and upper right arms. Resident #1 smiled but did not respond to verbal prompts. Observed bruising on both upper arms in various colors of healing, purple, yellow, green. Observed dark blue bruises on Resident #1's left hand and forearm. FM #2 stated she took photos of Resident #1's bruises on both upper arms on 4/21/22 and sent them to the state issued cell phone. During an interview with FM #1, of Resident #1 on 5/3/22 at 2:20 p.m.; Stated that she visits her Resident #1 on a daily basis and before 4/20/22 had not seen bruises on Resident #1. Stated that on 4/20/22 she notified LVN A that her mother seemed to be apprehensive about wanting to use the call light for staff to assist her to the restroom. Stated that she was informed by Certified Medical Assistant (CMA F) that earlier in the day on 4/20/22 two CNAs (C and D) went into her mother's room and turned off the call light several times and did not care for her family member when she had diarrhea . Stated she informed LVN A that she was concerned about the CNAs ignoring her family member and not providing care and that she wanted to know where the bruises on her mother's arms came from. Stated that LVN A got her phone and called the DON and handed her the phone. Stated that the DON stated she would ask around to see what happened. Stated she told the DON that someone did this and the bruises would not just appear on their own. Stated that LVN A came back in the room and then measured the bruises on the family member's right arm. Stated that the DON contacted her the next day 4/21/22 about 10:30 a.m. and could not give her an answer about where the bruises came from and would do an in-service with staff. Stated that she was not happy with the response from the DON. Stated she asked the DON so the bruises just appeared on their own and the DON stated, that's not what I said. Stated that on 4/22/22 she contacted RN B on Facebook messenger and asked her about her family member's needs, and she didn't know because she had been off work. Stated she told RN B about the bruises. Stated that RN B contacted her back and told her that the Administrator had no idea about the bruises when RN B notified the ADM about the allegations of abuse. Stated that Resident #1 needs assistance getting up and using the restroom and she was not happy that CNA ignored her family member's needs on 4/20/22. Stated that the family contacted the city police and made a complaint. Stated she does not understand why the DON did not make a report to the state or inform the ADM about the bruises or that CNA C turned off the call light 2 times and left the room before finally going back with CNA D when the call light was pressed a third time. During an interview with CNA D on 5/3/22 at 3:50 p.m.; stated that on 4/20/22 she was not assigned to Resident #1's hall but assisted when CNA E went to break. Stated that it was probably after 3 p.m. Stated that she heard the call light for Resident #1's room and went in to assist. Stated that Resident #1 pointed to the bathroom and she went to get the portable commode. Stated she opened up Resident #1's brief and realized that she had diarrhea and it was leaking. Stated she took off her gloves and went to the hall to get help. Stated she saw CNA C in the hall and asked her to assist. Stated that she and CNA C decided to change Resident #1's brief in her bed because she kept having loose stools. Stated that she uses a gait belt to transfer Resident #1. Stated she never observed any bruises on Resident #1 and if she did, she would report to the charge nurse, DON or Administrator depending on who was in the building. Stated that she was not aware that there was an allegation of abuse until 4/24/22 when she tried to pick up an extra shift and she was informed she was suspended. Stated she did not abuse Resident #1 and never witnessed CNA C abuse Resident #1 either. Stated she has been trained on Abuse and Neglect and to report it. During an interview with CNA C on 5/3/22 at 4:34 p.m.; stated that on 4/20/22 around 4-5 p.m.; I saw CNA D in Resident #1's room and she needed help changing her because she had diarrhea; Stated she assisted with the brief change and that was it. Stated that she typically does not work that hall but was assisting because CNA E was on break. Stated she never observed bruising on Resident #1's arms. Stated that she knows that she did not ignore Resident #1's call light. Stated that she was not aware of the abuse allegation until either on 4/24/22 or 4/25/22 when she was notified via phone by the DON that she was suspended. Stated she does not know how Resident #1 got the bruises because a lot of people work with her. Stated that she did not abuse Resident #1 and did not witness anyone abuse Resident #1. Stated that the Administrator is the abuse coordinator and that she would notify the charge nurse if she found any bruising on a resident. During an interview with CMA F on 5/3/22 at 5:23 p.m.; stated she worked on 4/20/22 from 6 a.m. to 8 p.m. Stated she entered Resident #1's room about 4:15 p.m. to give medications to her roommate. Stated Resident #1 was calling out for help and started throwing up. Stated she pushed the call light for an aide to come and help. Stated that CNA C walks in the room and she told her that Resident #1 had diarrhea. Stated CNA C goes to the restroom and leaves the room. Stated she pushed the light again and CNA C comes in turns off the light and walks out. Stated that at this time she was walking out of the room and is in the hallway. Stated the light came on again for Resident #1 room and she observed CNA D and CNA C go in the room. Stated she did not tell anyone that CNA C turned off the call light and left the room two times. Stated she does not want to get in trouble for not reporting that CNA C ignored Resident #1's need for help or turning off the call light. Stated that FM #1 came to her that evening and wanted to know about the bruises on Resident #1 Stated that FM #1 wanted to know why Resident #1 was scared. Stated she notified LVN A and LVN A came in checks Resident #1 out and took measurements of the bruises. Stated she told LVN A about the earlier incident with the call lights in front of FM 1. Stated I should have reported the neglect, but I didn't want to get in trouble or retaliated against. I will probably be fired for not reporting. Stated she has not observed any physical abuse on Resident #1 or any other resident. Stated she does not know how Resident #1 got the bruises. During a phone interview with DON on 5/4/22 at 1:55 p.m.; Stated that on 4/20/22 she was contacted by LVN A that FM 1 wanted to talk to her. Stated that she spoke to FM 1 on the phone and FM 1 said she was concerned that CNA turned off the call light in her Resident #1's room and walked out of the room and that her mother had bruises on her arm. Stated she told LVN A to complete a full body assessment on 4/20/22 and LVN A sent me photos of the bruises on the upper left arm and the forearm but I was not aware of the bruising on the right arm. Stated that based on LVN A's photos she determined the bruises were not significant injuries. Stated she saw Resident #1 on 4/21/22 in her room but never did look at the bruises. Stated that she cannot say for sure where the origin of the injury occurred. Stated she has been trained on facility policies that include Abuse Neglect Clinical Protocol, Abuse Neglect, Exploitation or Misappropriation- Reporting and Investigating; Abuse Prohibition Policy and Procedure and Long-Term Care Provider Letter that instructs when you report ANE. Stated that she did not believe that Resident #1 had a major injury. Stated a major injury would be fracture, laceration, skin tear, bruise on face, neck, or breast. Stated if a resident had an injury on the face, neck, breast and if resident was on a blood thinner such as [MEDICATION(S)] it would be suspicion and it would be reported to HHSC. Stated she spoke to CNA C and CNA D who stated Resident #1 had several loose stools and they were in her room several times. Stated Resident #1 is on [MEDICATION(S)] which can be related to bruising easily. Stated that she was not aware of the bruise found on Resident #1's right breast on 3/23/22 or why it was not reported. Stated that a bruise the breast should have been reported because it was a suspicious location. During a phone interview with LVN A on 5/4/22 at 7:14 p.m.; Stated that on 4/20/22 she went into Resident #1's room and CMA F entered with her. Stated that FM #1 stated my mom acts like she doesn't want me to leave. Stated CMA F then told FM #1 that CNA C was in there earlier and walked in, turned off the call light and left the room without helping Resident #1. Stated she exited the room and came back in and FM #1 stated that she wanted to talk to someone higher up. Stated that FM #1 stated that they wouldn't change m my mom today and they were rough with her. Look at these bruises they look like fingerprints. Stated she observed bruising to the right arm that were yellow and purple. Stated she (LVN A) then called the DON and handed the phone to FM #1. Stated that she then left the phone with FM #1 and left the room to assist another resident. Stated she returned to Resident #1's room and said that FM #1 handed her the phone back. Stated she had a text from the DON to call her. Stated that she called the DON who told her to document the bruises on the right arm, but she was never instructed to do a full body skin assessment by the DON. Stated the DON asked her to send pictures of the bruises to her cell phone and stated she did. Stated DON then said, thank God she didn't say nothing about abuse, please document the right arm. Stated that she completed the assessment on the right arm and documented it. Stated that she was surprised the DON didn't report the concerns or at least document it in the progress notes. Stated that the DON took the complaint from the FM #1 and she assumed that FM #1 told the DON all of the same concerns that she told her(LVA A). Stated that if she suspects abuse, she passes the information on to the DON or Administrator. Stated that when a bruise is discovered they document an event in the resident chart and then call the person above them, such as the DON or ADM. Stated that I don't know what caused the bruises on Resident #1 and they would be considered an injury of unknown origin. Stated that she was aware of the bruise on Resident #1's breast and she did not have a concern over the bruise because in the past she had witnessed staff pull up the resident by her arms or under her arms when Resident #1 slides to the foot of the bed. Stated that the bruises on the arm are of unknown origin because she doesn't know if the resident recently blood work had, had a fall, or was hurt. Stated that she was notified by RN B on 4/24/22 of the bruises on the right arm. Stated that RN B wanted to know if she knew anything about it. Stated that she informed RN B that she told the DON on 4/20/22 about the bruises and the family spoke to the DON about their concerns. Stated she is not sure if she did something wrong by not reporting directly to HHSC the concerns FM #1 made but that the facility instructs staff to work the chain of command and notify the DON or the Administrator. Stated that she notified the DON and that the DON spoke to FM #1, so she thought it was taken care of. Stated she has been trained on abuse and neglect and that she can make self-reports to the HHSC hotline if she has concerns of abuse or neglect. During a follow-up in person interview and record review with the DON on 5/6/22 at 12:03 p.m.; Requested DON to bring her laptop in during the interview to obtain documentation regarding Resident #1's care plan and weekly skin assessments. DON stated that Resident #1 should have a skin assessment completed weekly and stated after reviewing facility records, DON was unable to locate that a skin assessment for Resident #1 for Monday, 4/18/22. DON stated it is her responsibility to verify that the nurses are completing weekly skin assessments, but she does not always have time. Stated that she instructed LVN #1 on 4/20/22 to complete a full skin assessment on Resident #1 after FM #1 had a concern about a bruise that was found on Resident #1's right upper arm. DON stated that she never verified that the full body skin assessment was completed by LVN #1 and was not aware that Resident #1 had bruising on her upper left arm also. DON stated that the skin assessments should be head to toe assessments and that on 4/25/22 a skin assessment was done but it does not appear that a full body one was completed. DON stated she only saw the bruises on the right arm of Resident #1 on 4/21/22 and did not look at the left arm for bruises. DON stated that none of the skin assessments document the left arm bruises that were observed on Resident #1 on 5/3/22. DON stated that she trusts that her staff will notify her of bruises found on skin assessments and also that they are completing full body assessments. DON stated that if a full body skin assessment would have been completed the bruising on Resident #1's left arm would have been observed and documented. DON stated that the bruising to Resident #1's right breast on 3/24/22 was due to an improper hand position and reposition of Resident #1 in her bed witnessed by LVN A on 3/23/22. Stated that the event shows that it was not an injury of unknown injury. Stated that she confirms after reviewing Resident #1's progress notes, the entry in the progress notes by LVN A that was typed 20 minutes after the event was documented with a large purple bruise to the right breast 5 cm x 2cm, documents that it is not known how the bruise occurred and that they would continue to monitor. Stated that when she spoke to FM 1 on 4/20/22 FM 1 was concerned that the nurse went in and did not change her family member and was concerned that there was a bruise on her family member's arm. Stated that FM 1 never mentioned abuse. Stated that because there was not a significant injury she did not feel the concerns made by FM 1 needed to be reported. Stated she does not know how Resident #1 got the bruises. Stated that she was not aware that Resident #1 had bruises on both upper arms and that it is not documented in any of the skin assessments. Policy, Abuse Neglect Clinical Protocal dated, April 2021, indicated the following: Policy Statement: All reports of resident abuse (including injuries of unknown origin that result in serious bodily injury), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the administrator and authorities. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator , or administrative staff on call, and to other officials according to law. 2. The administrator/administrative staff or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. b. The resident's representative c. Law enforcement officials. d. The resident's attending physician; and /or e. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record Review of the facility policy, Abuse and Neglect-Clinical Protocol) revised in March 2018; revealed the following: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal ab use, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 2. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 3. Sexual abuse is defined as non-consensual contact of any type with a resident. 4. Willful is defined as used in definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Record Review of the facility policy Abuse Prohibition Policy and Procedure revised on 4/1/2019; revealed that 1. Purpose: Resident has the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse from anyone. 2. Definitions: Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes abuse facilitated or enabled through the use of technology. Abuse includes the deprivation by an individual, including a caretaker or provider of goods and services necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 3. The facility prohibits abuse, neglect, involuntary seclusion, and misappropriation of property for all residents by training and providing ongoing supervision of employees and volunteers who provide services. 4. Procedure: B. Orientation is provided upon hire and ongoing training is provided to all employees. Including: -The procedures for reporting allegations of abuse, neglect, exploitation, or misappropriation of resident property, without fear of reprisal. -Understanding of what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 9. Reporting/Response: This facility follows the requirements of senate Bill 9. All alleged incidents are reported to the appropriate local/state/federal agencies immediately as required. Regardless of the time of day, as defined in 19.602 of Title 40 of the Texas Administrative Code, the following incidents will be reported: -Death of a resident; Missing Resident; Abuse Allegations; Neglect Allegations. Policy: Long-Term Care Regulatory Provider Letter; PL 19-17; Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property, and other incidents that a Nursing Facility (NF) Must report to the Health and Human Services Commission. Provider Types: Nursing Faculties (NF) Date Issued: July 10, 2019 1.0 Subject and Purpose: This letter provides guidance for reporting. incidents to HHSC. 2.1 Incidents that a NF must report to HHSC and the Time frames for reporting -Abuse, Neglect, Exploitation, Death due to unusual circumstances, Missing Resident, Misappropriation, Drug theft; Suspicious injuries unknown source5. (Defined in 42 CFR 483.12(c)(1)(F609) Definitions, found in State Operations Manual, Appendix PP. Type of Incident: Abuse (with or without serious bodily injury); or neglect, exploitation, or mistreatment, including injuries of unknown source that result in serious bodily injury. When to report: Immediately but not later than 2 hours after the incident occurs or is suspected. An incident that does not result in serious [TRUNCATED]

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights which included measurable objectives and timeframes to meet resident's medical, nursing, mental and psychological needs for 2 of 5 residents reviewed for care plans. (Resident #1 and Resident #2) 1) The facility did not implement the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could residents at risk for skin breakdowns or injuries of unknown origins. Findings Included: Record review of Resident #1's admission Face Sheet, dated 05/04/22, revealed she a [AGE] years-old and was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care plan, dated 1/7/2022 with last revision on 3/16/22 revealed that Resident #1 has a potential for skin breakdowns and directs nursing to complete a skin assessment upon admission and at least weekly, with a short-term goal date of 5/15/2022. Record review of Resident #1's physician orders, dated 1/7/2022 received by the Director of Nurses (DON) , revealed skin assessments were ordered on a weekly basis to be completed on Mondays between the hours of 6 a.m. and 6 p.m. Record review of Resident #1 nurses' notes revealed no skin assessment was completed on 4/18/22. During an interview on 5/06/22 at 12:03 p.m. with Director of Nurses (DON) regarding Resident #1's care plan and weekly skin assessments, DON stated that Resident #1 should have a skin assessment completed weekly and after reviewing facility records was unable to locate that a skin assessment for Resident #1 for Monday, 4/18/22. DON stated it is her responsibility to verify that the nurses are completing weekly skin assessments, but she does not always have time. Stated that she instructed LVN #1 on 4/20/22 to complete a full skin assessment on Resident #1 after FM #1 had a concern about a bruise that was found on Resident #1's right upper arm. DON stated that she never verified that the full body skin assessment was completed by LVN #1 and was not aware that Resident #1 had bruising on her upper left arm also. DON stated that the skin assessments should be head to toe assessments and that on 4/25/22 a skin assessment was done but it does not appear that a full body one was completed. DON stated she only saw the bruises on the right arm of Resident #1 on 4/21/22 and did not look at the left arm for bruises. DON stated that none of the skin assessments documented the left arm bruises that were observed on Resident #1 on 05/03/22. DON stated that she trusts that her staff will notify her of bruises found on skin assessments and also that they are completing full body assessments. DON stated that if a full body skin assessment would have been completed the bruising on Resident #1's left arm would have been observed and documented. DON stated that she could not locate a completed skin assessment for Resident #2 for 4/1/22. DON stated that the nurses are supposed to complete the skin assessments on the assigned days but it is her responsibility to make sure that they are completed. Record review of Resident #2's admission Face Sheet, dated 05/04/2022, revealed she was [AGE] years-old and was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] ., Insomnia; Essential (Primary) hypertension(abnormally high blood pressure that's not the result of a medical condition); Atrophy of [CONDITION(S)] (end result of either severe [CONDITION(S)] damage or total loss of pituitary stimulation); Gastrointestinal hemorrhage (all forms of bleeding in the gastrointestinal tract). Record review of Resident 2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #2's Care Area Assessment (CAA), dated 4/5/2022, documented falls and pressure ulcer/injury concerns for Resident #2 including care planning for falls and pressure ulcer/injury. Record Review of Resident #2's Care Plan, dated 3/25/22; did not include weekly skin assessments or falls and pressure ulcer/injury concerns. Record Review of Resident #2's skin assessments revealed a missing skin assessment for 4/1/22, all others were completed. Record Review of Resident #2's event history showed on 4/19/22 at 5:20 pm and 5:24 pm, 2 skin integrity events created by LVN G, both described as bruising of unknown origin, one on the left top of foot and one on the right forearm, both described as purplish-black. During an interview on 5/6/22 at 11:30 a.m. with the administrator a request for the policy regarding Care Plans was requested and was not provided prior to exit.

Based on observation, interview and record review, the facility failed to ensure that biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 of 2 medication carts, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in that: Medications were not properly labeled. Medication/Treatment cart was not secured. These problems could result in residents receiving other resident's medications and the theft or misuse of medications. The findings include: Observation on 5-12-21 at 10:40 AM of medication cart A revealed 1 bottle of [MEDICATION(S)] 0.4mg/tab for Resident # 27 that had no name or date on the bottle, only on the box. There was 1 bottle of artificial tears for Resident # 26 that had no name or date on the bottle, only on the box. There was 1 bottle of Dorzolamide ophthalmic drops solution for Resident # 30 that had no name or date on the bottle, only on the box. In an interview on 5-12-21 at 10:51AM, LVN B was asked if she knew that both the bottle and the box had to have the name and date on it, she stated no. When asked if she had been trained in this area, she stated no. Observation on 5-12-21 at 10:53 AM of medication cart B revealed 1 tube of [MEDICATION(S)] eye gel lubricant for Resident # 33 that had no name or date on the tube, only on the box. There were 2 bottles of artificial tears for Resident # 37 and Resident # 21 that had no name on the bottle, only the box. There was 1 Breo inhaler for Resident # 10 that had no name or date on the inhaler, only on the box. In an interview on 5-12-21 at 10:57 AM, LVN A was asked if she was aware these needed to both be labeled, she stated she did know but just didn't pay attention. When asked if she had been trained, she said yes. In an interview on 5-12-21 at 11:30 AM, the DON stated she expected the nurse who opens the medication to properly label it. When asked, she stated nurses had been trained on proper labeling of medications. Observation on 5-12-21 at 2:11 PM revealed the nurse's treatment cart unlocked and unattended in the hallway. In an interview on 5-12-21 at 2:12 PM, LVN A confirmed the nurse's treatment cart was unlocked and unattended in the 200 Hallway. LVN A opened the drawers and insulin syringes were observed in the top drawer and medications/creams were observed in the third drawer. LVN A stated, I was supposed to lock the treatment cart when I walked away. LVN A stated they received training on medication/treatment carts and are trained to lock the cart when they walked away. In an interview on 5-12-21 at 2:31 PM, DON stated she expects the medication carts or nurse's treatment cart to be locked when unattended. Record review of the facility policy dated 2019 and titled Labeling of Medication Containers reflected the following: Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Policy interpretation and Implementation: 6. Labels for over-the-counter drugs shall include all necessary information, such as: b. The resident's name Record review of the facility policy and procedure titled, Storage of Medications with a revised date of November 2020 reflected the following: Policy heading: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. .6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medications carts are not left unattended

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 4 of 15 residents (Resident #8, #10, #36, and #38) reviewed for advanced directives. Residents #8, #10, #36 and #38 were listed as a DNR but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #8 Record review of the clinical record for Resident #8 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the clinical record for Resident #1 revealed an annual MDS completed on [DATE] with a BIMS of 3 indicating she was severely cognitively impaired, and she had a functionality of requiring two-person assistance with most activities. Record review of the clinical record for Resident #8 revealed her undated face sheet listed her as Do Not Resuscitate. Record review of Resident 81's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the Two Witness no printed name for witness 1 and no county or date for notary. Resident #10 Record review of the clinical record for Resident #10 revealed an [AGE] year-old male resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the clinical record for Resident #10 revealed an annual MDS completed on [DATE] with a BIMS of 2 indicating he was severely cognitively impaired, and he had a functionality of supervision with most activities. Record review of the clinical record for Resident #10 revealed his undated face sheet listed him as Do Not Resuscitate. Record review of Resident #10's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Two Witness a notary signature with no date. Resident #36 Record review of the clinical record for Resident #36 revealed a [AGE] year-old female resident admitted originally on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the clinical record for Resident #36 revealed a quarterly MDS completed [DATE] with a BIMS of 99 indicating she was severely cognitively impaired, and she had a functionality of requiring two-person physical assistance with activities. Record review of the clinical record for Resident #36 revealed her undated face sheet listed her as Do Not Resuscitate. Record review of Resident #36's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Physician's Statement no date of when the physician signed the form and no printed physician's name. The final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, under Attending Physician's Signature was no signature. Resident #38 Record review of the clinical record for Resident #38 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the clinical record for Resident #38 revealed an admission MDS completed on [DATE] with a BIMS of 8 indicating she was moderately cognitively impaired, and she had a functionality of one-person assistance with most activities. Record review of the clinical record for Resident #39 revealed her undated face sheet listed her as Do Not Resuscitate. Record review of Resident #38's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Person's full legal name no male or female was selected. Under B. Declaration by legal guardian, agent or proxy revealed no selection. The final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, under Attending Physician's Signature was no signature. During an interview on [DATE] at 11:00 AM with DON stated that she and the SW makes sure the DNR are filled in correctly. Stated the SW has done an audit of all DNR's in the DNR book. Stated if they are not able to completely fill out the DNR they will start a new one. Stated an incomplete DNR is not a vailed. During an interview on [DATE] at 11:20 AM LVN A stated her process for confirming a resident's code status is she would look in computer at the face sheet and the DNR book that is kept in the medication room. Stated if the DNR is not complete it is not valid. Stated she was not sure if she would honor the DNR or not and that she would have to find that out. During an interview on [DATE] at 11:30 AM LVN B stated she would check the computer and the DNR book. Stated if DNR is incomplete it is not valid. Stated if she has an incomplete DNR she would contact family. When ask about the time it would take, she stated, well I don't know. Stated it's a catch 22 because if you do CPR and the DNR is no complete and is invalid that could be a problem and if you honor the DNR and it is invalid that could be a problem. During an interview on [DATE] at 03:00 PM DON stated she agreed there was missing information on the DNR's for residents #8, #10, #36 and #38. Stated as a nurse she would look for name and physician signature and not the technicality of the form. On [DATE] at 08:21 AM Call placed to SW no answer and was not able to leave message due to voice mail full. During an interview on [DATE] at 09:27 AM when asked why the DNR's were incomplete, DON stated I don't know how to answer that question. Stated, I can tell you we did a complete audit last night and have identified all the missing information and have a plan to get that corrected . During an interview on [DATE] at 09:45 AM corporate nurse st ated We follow the instructions on the back of the DNR form. We do not have a specific DNR policy and procedure. Record review of DNR form provided by facility titled Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) Order Texas Department of State Health Services Revised [DATE] revealed the following: In Addition: . The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 39 of 39 residents; in that: a)Staff were not social distanced (at least 6 feet apart) during meetings/gatherings. Staff were not social distanced during a meeting and while gathering in the Business Office, b) PPE was not worn appropriately. Staff did not have her mask covering her nose and mouth while other staff were present in the Business Office, and c)Linens were not handled and stored in a manner to prevent the spread of infections. Adequate relative negative air pressure was not provided on the soiled side of the laundry and was not effectively monitored. These problems could result in the spread of infections in the facility. The findings include: On 11/30/20 at 9:47 AM The entrance conference was held with the Administrator. She stated that there were three residents in quarantine and they had no COVID-19 positive residents. She further stated that Dietary Staff #1 had tested positive yesterday. She stated that CNA #2 tested positive in the facility last week Thursday and that last week Monday Occupational Therapist #1 tested positive in the facility. She added that there had not been a two-week period between (COVID-19) cases in the facility. ~Policy: Record review of the Centers for Disease Control and Prevention website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) revealed the following documentation, . Healthcare Workers .Preparing for COVID-19 in Nursing Homes . Core Practices .Implement Source Control Measures. HCP (Health Care Personnel) should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others Additional Strategies Depending on the Facility's Reopening Status. Implement Social Distancing Measures. Implement aggressive social distancing measures (remaining at least 6 feet apart from others) . Remind HCP to practice social distancing and wear a facemask (for source control) when in break rooms or common areas . Record review of the facility policy labeled Laundry and Bedding, Soiled, Revised October 2018, revealed the following documentation, Policy Statement. Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control . On 11/30/20 at 2:35 PM the following poster was observed on the wall in the screening room and rotunda/lobby area: Wear your mask at all times! Team up and stop the spread. Practice social distancing! Stay 6 feet apart from each other! Wash your hands! a) On 11/30/20 at 11:20 AM an observation was made of hall 100 which was the quarantine and COVID-19 unit. LVN #1 stated, Resident #1 who just came back from the hospital. She has a dry cough and has increased confusion after coming from the hospital. At that time, the resident could be heard coughing in the room. Resident #2 and Resident #3 who were using oxygen. LVN #1 stated, They just came out of the hot zone and were COVID-19 positive and they moved here. They were in quarantine 10 days. They had no symptoms. ~ Inadequate Social Distancing and PPE Improperly Worn: b) -On 11/30/20 at 9:40 AM an observation was made of the activity directors office. At that time the Administrator and at least eight other staff were in the room and were not social distanced. All were within 2' to 3' of each other in the meeting. There were at least five staff, including the Administrator, seated next to each other at the tables and 4 were standing across from the tables, near the entrance wall, but next to each other. On 11/30/20 at 2:37 PM the tables in the activity director's office were measured. These were the tables where staff were sitting in the staff meeting earlier in the visit. Three tables were 36 in. and square and one table was 30 inches and was square. -On 11/30/20 at 11:30 AM ADON #1 was observed in the Business Office Manager's office along with the Business Office Manager (BOM) and CNA #1. At that time ADON #1 was leaning over the shoulder of the BOM and had her face close to the BOM. ADON #1 did not have her mask covering her nose and mouth (below her mouth on her chin) and was not social distanced from the BOM. The BOM was seated behind her desk and the CNA #1 was seated across from the BOM facing her. c) On 11/30/20 at 10:15 AM an observation was made of the laundry room. At this time the exhaust fans were checked in the soiled side area, barrel storage room, and washer room. A tissue was held to the vent to check for suction. The exhaust fan was operational in the soiled linen barrel storage room but not operational in the washer area room. On 11/30/20 at 10:20 AM the Maintenance Supervisor stated that he checked exhaust fans monthly. He added, I will check to see if this exhaust fan (washer room) is on the same system. He then stated, Do you want me to check it? On 11/30/20 at 10:55 AM the Housekeeping Laundry Manager was asking if she or the staff ever check the exhaust fan to see if it was working on the soiled side of the laundry. She stated, No I haven't checked it. This is the first time I saw that. On 11/30/20 at 1:58 PM the Maintenance Supervisor stated that he had no documentation related to specifically checking exhaust fans in the facility. He stated, I check air filters and walk each hallway and check the fire doors. I checked air filters but there's no documentation of checking the exhaust at that time. It's been that way since I've been here. When asked about the malfunctioning exhaust fan on the soiled side of the laundry he stated, The valve was turned down almost turned off. It was almost cut completely off.

Based on observation, interview and record review the facility failed to provide food that was palatable and attractive, in that: a) Five of 10 residents in the confidential Resident Council Meeting (Residents A, B, C, D and E) and 1 of 7 individual residents interviewed confidentially (Resident F) voiced concerns of food having poor texture and flavor (tough and dry); and b) Nine of 16 foods sampled on the 6/12/19 lunch meal test tray had flavor and/or texture issues; These problems could result in a decline in resident consumption of food and cause resident weight loss. The findings include: 1. One of 7 residents interviewed confidentially (Resident F) voiced concerns with the food served. Resident F was asked about the food served in the facility. The resident stated that the she could not cut up the whole leaf lettuce and the bacon was undercooked. She added that the soft tacos only had a tablespoon of meat and the meat was cooked too long. Resident F further stated that the meat served in the facility was dry and tough. 2. On 6/11/19 at 1:45 PM the confidential Resident Council Meeting was conducted. The residents were asked their opinion of the food that was served. Five of the 10 residents stated that they had concerns about the flavor and texture of the food served. Resident C stated that the pork and chicken are dry and that she sees a lot of it left after meals. Resident D stated she had seen residents having a hard time cutting the food. She stated that she has seen one lady sawing on a piece of meat trying to cut it at one meal. She further stated that they had overcooked a small steak that was served one evening. Resident [NAME] stated that the chicken was dry, and the steak fingers were tough. When asked about food palatability as a group 5 of the 10 agreed that the meat was too dry and tough (Residents A, B, C, D and E). 3. Record review of the Resident Council Minutes dated 3/11/19 revealed the following documentation, .Dietary: How is the food? Not as good as it used to be, tough meat, need better cooks . Record review of the Resident Council Minutes dated 5/01/19 revealed the following documentation, .Dietary: What needs improvement? . Rolls not cooked all the way . Record review of the Resident Council Minutes dated 6/05/19 revealed the following documentation, .Dietary: How is the food? Fair . with no further explanation. 4. An observation at the end of the evening meal on 6/11/19 at 6:00 PM revealed there was a plate with a breaded hamburger on it on the center long dining table in the main dining room. The Surveyor attempted to cut it and it was dry and hard to cut. 5. On 6/12/19 at 11:00 AM a kitchen observation was made. At this time the Surveyor requested a test tray for the noon meal. Meal service started at 11:44 AM with trays being produced for the security unit first. The last tray served in the dining room was at 12:20 PM. Staff prepared the test trays at 12:21 PM. The test trays arrive to the survey room at 12:25 PM and the sampling of the test tray began on 6/12/19 at 12:26 PM with the following results: -Puréed Lemon Pepper Chicken - too tart/spicy and had little chicken flavor. The tartness overpowered the chicken flavor. (on regular/puree diets per Wednesday (facility) FW 1819 - Week - 5 menu) -Puréed Seasoned Broccoli had an elevated black pepper taste which overpowered the flavor of the broccoli. (on regular/puree diets per Wednesday (facility) FW 1819 - Week - 5 menu) -Ground Lemon Pepper chicken - dry and lacked flavor/bland (on regular/mechanical Soft diets per Wednesday (facility) FW 1819 - Week - 5 menu) -Seasoned Broccoli - overcooked, mushy (on regular and regular mechanical soft diets diets per Wednesday (facility) FW 1819 - Week - 5 menu) -Green Beans - bland, canned with no flavor/seasoning -Oven Browned potatoes - bland and dry (on regular and regular mechanical soft diets per Wednesday (facility) FW 1819 - Week - 5 menu) -Regular Lemon Pepper chicken - dry (on regular diets per Wednesday (facility) FW 1819 - Week - 5 menu) -Bread Stick - dry and lacked flavor. (on regular diets per Wednesday (facility) FW 1819 - Week - 5 menu) -Regular Banana Cream Pie -1 of 2 servings provided was partially frozen. (on regular and regular mechanical soft diets per Wednesday (facility) FW 1819 - Week - 5 menu) Nine of 16 foods sampled on this lunch meal test tray had palatability issues. The 9 foods encompassed 3 of 3 food forms served in the facility (regular, mechanical soft and pureed). Record review of the Order Report Category: 5/12/19 - 6/12/19 Diets revealed that the facility served 3 forms of foods, regular mechanical soft and pureed. 6. On 6/12/19 at 1:16 PM The Food Service Supervisor was interviewed regarding the palatability of the test trays. The Food Service Supervisor was asked when the staff started to cook the broccoli. She stated about 11 a.m. or a little before. The FSS was also asked about the texture of the meat and that residents had complained that the meat was dry and tough. She stated, I am trying different meats to satisfy the residents. We tried to marinade it, the chicken. The residents said it was better. When asked about the bland flavor of the green beans she stated, The green beans didn't have any seasoning. I'm going to talk to them about it. ~ Policy: Record review the facility policy labeled Food And Nutrition Services, Revised (MONTH) (YEAR), revealed the following documentation, Policy Statement. Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation . 7. Food and nutrition services staff will inspect food trays to ensure that . the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the charge nurse/food service manager so that a new food tray can be issued .

Based on observation, interview, and record review, the facility failed to ensure residents received care and treatment, consistent with professional standards of practice, to promote healing of existing pressure ulcers and prevent further development of pressure ulcers, for 2 Residents (Resident #37 and #53) of 3 residents reviewed for pressure ulcers. 1) Resident #37 had a Stage II pressure injury to the left heel. Facility staff did not monitor and assess left foot to prevent wound from worsening. 2) Resident # 53 had a Stage III pressure injury to the coccyx. Facility staff did not monitor and assess skin to prevent wound from forming and worsening. This failure could place all 4 residents with pressure ulcers at risk for worsening of existing pressure ulcers or development of new pressure ulcers. The findings included: Resident # 37 Record review of #37's Admission record revealed an [AGE] year old female who admitted [DATE] with the following Diagnoses: [REDACTED]. postprocedural pain; atrophy of [MEDICAL CONDITION] (acquired); urinary tract infection, site not specified; Vitamin D deficiency, unspecified; [DIAGNOSES REDACTED]; pure [MEDICAL CONDITION], unspecified; iron-deficiency [MEDICAL CONDITION] secondary to blood loss (chronic); constipation; [MEDICAL CONDITION]; nausea; encounter for [MEDICATION NAME] measures, unspecified; pain in left shoulder' displaced intertrochanteric fracture of left femur; subsequent encounter for closed fracture with routine healing. On 05/24/18 at 3:25 PM observed Resident #37 in low bed, awake, socks on feet, and not floated on a pillow. Record review of Resident #37's Physician order [REDACTED]. Start Date: 3/30/18 open ended. Cleanse wound to LT heel with wound spray, pat dry, apply Santyl ointment to wound bed, cover with foam, secure with [MEDICATION NAME] wrap and secure with tape q day (one-time day) and PRN. Once a day 06:00 -18:00. Review Record review of Resident # 37's 03/12/18 PPS 60-day MDS documented the following: Section C - Cognitive Patterns: Brief Interview for Mental Status (BIMS) C0500. Summary Score = 09 (which indicates Moderately Impaired) Section E - Behavior E0800. Rejection of Care - Presence and Frequency Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Answer = 0. Behavior not exhibited. Section G - Functional Status G0110. Activities of Daily Living (ADL) Assistance A. Bed Mobility: Self-performance 3 = Extensive assistance, Support 2 = one-person physical assist B. Transfer: Self-performance 3 = Extensive assistance, Support 2 = one-person physical assist . F. Locomotion of Unit: Self-performance 1 = Supervision - oversite encouragement or cueing, Support 2 = one-person physical assist . G-0600. Mobility Devices: C. = Wheelchair D. Section M - Skin Conditions Section M0150 Risk of Pressure ulcers: Is this resident at risk of developing pressure ulcers = 1. Yes Section M0210 Unhealed Pressure Ulcer(s): Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? Answer: = 1. Yes Section M0300. Current Number of Unhealed Pressure Ulcers at Each Stage: B. Stage 2: Partial thickness of loss of dermis presenting as a shallow open ulcer with a red or oink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. 1. Number of Stage 2 pressure ulcers: Answer = 1 2. Number of these Stage 2 pressure ulcers that were present upon admission/reentry: Answer = 0 3. Date of oldest Stage 2 pressure ulcer: Answer = (YEAR)0308 Section M0700. Most Severe Tissue for Any Pressure Ulcer: Answer = 2. Granulation tissue - pink or red tissue with shiny, moist, granular appearance. Section M0800. Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or PPS) Indicate the number of current pressure ulcers that were not present at a lesser stage on prior assessment (OBRA or PPS) = Answer: A. Stage 2. = 1 Record review of Resident #37's Event Report dated 03/08/18 at 09:56 AM DESCRIPTION: Pressure lt (left) heel PHYSICAL OBSERVATION: Lt (left) heel 4cmx3cm with bruising around area Stage II - Partial thickness/loss of skin layers that presents clinically as an abrasion blister, or shallow crater. Granulation tissue - pink or red tissue with shiny, moist, granular appearance. Record review of Weekly Pressure Skin report documented the following: Record review of Resident #37's 3-29-18 WEEKLY PRESSURE INJURY QI LOG documents the following: Facility Acquired = yes Site: left heel Stage: Stage II Size: 4cmx4cm LxW; /depth = (blank); Odor: no; Drainage: No; Culture: No Treatment: Alginate Record review of Resident #37's 4-5-18 WEEKLY PRESSURE INJURY QI LOG documents the following: Facility Acquired = yes Site: (blank) Stage: Unstageable eschar Size: 3cmx4cm LxW; /depth = (blank); Odor: no; Drainage: Small; Culture: No Treatment: Santyl ointment Record review of Resident #37's 4-5-18 WEEKLY PRESSURE INJURY QI LOG documents the following: Facility Acquired = yes Site: (blank) Stage: Unstageable eschar Size: 3cmx4cm LxW; /depth = (blank); Odor: no; Drainage: Small; Culture: No Treatment: Santyl ointment Record review of Resident #37's 4-12-18 WEEKLY PRESSURE INJURY QI LOG documents the following: Facility Acquired = yes Site: (blank) Stage: Unstageable eschar Size: 2cmx0.5cm LxW; /depth = (blank); Odor: no; Drainage: Small; Culture: No Treatment: Santyl ointment Record review of Resident #37's 4-19-18 WEEKLY PRESSURE INJURY QI LOG documents the following: Facility Acquired = yes Site: (blank) Stage: Unstageable eschar Size: 3cmx3c LxW; /depth = (blank); Odor: no; Drainage: Small; Culture: No Treatment: Santyl ointment Record review of Resident #37's Care Plan dated 1-28-18 revealed the following: Problem: Category: Pressure Ulcer At risk for skin breakdown/pressure ulcers r/t (related to) cognitive/mobility impairment. Goal: Long Term Goal Target Date: 04-28-18 Resident will have minimal to no skin breakdown/pressure ulcers through review period. Approach Start Date: 01-28-18 1. Assist to degree necessary to shower/bathe 3x weekly and PRN (as needed) 2. CNA to assess for skin breakdown when assisting with ADL'. Report any skin breakdown to nurse. 3. Monitor for incontinent episodes of bowel/bladder. 4. Answer call lights promptly, assist to toilet as needed and check frequently and as needed for incontinence. 5. Provide incontinence care after each incontinent episode and apply moisture barrier as needed. 6. Monitor oral intake for any decline and report to nurse/physician as needed. 7. Provide assistance to degree necessary with transfers and bed mobility. 8. Reposition frequently as resident allows. 9. Use pillows/cushions for positioning as needed. 10. Avoid friction and shearing using lift or sheets to assist with turning and transfers as needed. 11. Skin assessment weekly and PRN changes in condition. Notify physician of presence of skin breakdown. Record review of Resident #37's acute Care Plan dated 3-8-18 revealed the following: Problem: Resident has current skin concern: Pressure ulcer to left heel Goal: Area will heal without complications through review period. Approaches: 1. Perform treatment per orders, if no improvement x 2 weeks - or acute changes report to M.D. 2. Monitor areas for increase breakdown, s/s of infection - report to M.D. as needed. 3. Monitor for pain, give med per order, monitor for relief. 4. Encourage p.o. and fluid intake with in dietary limits 5. Assess skin weekly and record findings in clinical record. 6. Assess skin daily, report any acute changes report to M.D. Date(s) reviewed 3/10/18 Improving, 3/17/18, 3/24/18, 3/31/18, 4/7/18 developing eschar, 4/16/18, 4/21/18 improving, 4/28/18. Resident #53 Review of the face sheet for Resident #53 revealed an admission date of [DATE]. Resident #53's [DIAGNOSES REDACTED]. Observation on 05/22/18 at 08:14 AM during initial tour of the facility revealed Resident #53 sitting in wheelchair in the dining room with a tab alarm attached to her clothing. There was no pressure relieving cushion in her chair. Observation on 05/23/18 at 10:11 AM during incontinence care revealed Resident #53's bed had a pressure alarm in place and fall mat on left side of bed. Her bed did not have an air mattress or pressure relieving mattress. Observation on 5/23/18 at 3:00 PM with LVN #1 during wound care to Resident #53 revealed a center wound with a circumference of a pea. The wound edges were white. There was a large peri wound (area surrounding the main wound) which was red and macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) and had scant serous (thin and clear) drainage. This area was the size of a playing card. Interview with LVN #1 confirmed the peri wound was new. She stated she has not done the treatment for [REDACTED]. Record review of physician orders [REDACTED]. 1. Cleanse coccyx area and pat dry. Apply zinc oxide, cover with calcium alginate, apply [MEDICATION NAME] dressing. Date ordered 9/3/17. 2. Clean area above coccyx with wound spray, pat dry. And apply a small amount of [MEDICATION NAME] cream 0.1% to coccyx area and cover. Date ordered 2/3/18. Record review of the Admission Minimum Data Set ((MDS) dated [DATE] for Resident #53 documented the following: Section C. Brief Interview for Mental Status (BIMS) C0500. BIMS Summary Score; Resident # 53 scored a 7 out of a possible 15, indicating cognitive impairment. Section G-Functional Status G0110-Activities of Daily Living Assistance(ADL) A. Bed mobility-how resident moves to and from line position, turn side to side, and positions body while in bed or alternate sleep furniture. This was coded as extensive assist by one staff member. Extensive assist-resident involved in activity, staff provide weight-bearing support. B. Transfer-how resident moves between surfaces including two are from bed, chair, wheelchair, standing position. This was coded as extensive assist by one staff member. I. Toilet use-how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; changes ostomy or catheter; and adjust clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag. This was coded as extensive assist by one staff member. G0400-Functional limitation and range of motion. This was coded as impairment on one side of upper extremity. Section H-Bladder and Bowel H 0300-Urinary Continence. This is coded as occasionally incontinent (less than 7 episodes of incontinence). H0400-Bowel Continence. This is coded as frequently incontinent (two or more episodes of bowel incontinence, but at least one continent bowel movement). Section M-Skin Conditions M0150-Risk of pressure ulcers. This is coded as yes. M0300-Current number of unhealed pressure ulcers at each stage. This is coded as 0. Record review of quarterly MDS dated [DATE] documented the following: Section C. Brief Interview for Mental Status (BIMS) C0500. BIMS Summary Score; Resident # 53 scored a 5 out of a possible 15, indicating severe cognitive impairment. Section G-Functional Status G0110-Activities of Daily Living Assistance(ADL) A. Bed mobility-how resident moves to and from line position, turn side to side, and positions body while in bed or alternate sleep furniture. This was coded as extensive assist by one staff member. Extensive assist-resident involved in activity, staff provide weight-bearing support. B. Transfer-how resident moves between surfaces including two are from bed, chair, wheelchair, standing position. This was coded as extensive assist by one staff member. I. Toilet use-how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; changes ostomy or catheter; and adjust clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag. This was coded as extensive assist by one staff member. Section H-Bladder and Bowel H 0300-Urinary Continence. This is coded as occasionally incontinent (less than 7 episodes of incontinence). H0400-Bowel Continence. This is coded as frequently incontinent (two or more episodes of bowel incontinence, but at least one continent bowel movement). Section M-Skin Conditions M0150-Risk of pressure ulcers. This is coded as yes. M 0300-Current number of unhealed pressure ulcers at each stage. This is coded as 1 pressure ulcer at a Stage II. Stage II is partial-thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. They also present as an intact or open/ruptured blister. Record review of the event report dated 9/3/17 through 4/23/18 documented the following: 9/3/17 suspected deep tissue injury measuring 5.0 cm x 5.0 cm with open area stage II in the center 1.0 x 1.5 cm. 9/3/17 at 10:55 AM-when doing resident's treatment to coccyx area noted to be open in the center, area to coccyx appears to be a pressure ulcer. Physician contacted, new orders were received. 1/5/18-tunneling noted at the 12 o'clock position 1.5 cm. Message left for physician. 1/19/18-continues to have brownish drainage noted undressing daily continues to have tunneling noted at 12 o'clock position, 0.5 cm above coccyx. 4/9/18 resident tolerating wound care the wound above coccyx without any problems noted. Measurements 0.2 x 0.1 x 0.1 cm. Wound bed is pink, skin intact surrounding wound. Record review of weekly nursing skin assessment for Resident #53 documented the following: 3/19/18 wound to Coccyx measured 0.2 cm x 0.1cm x 0.1 cm, staged as a Stage II, surrounding tissue intact, no exudate. 4/16/18 wound to coccyx measured 0.3cm x 0.1 cm., staged as a Stage II, surrounding tissue intact, no exudate. 4/23/18 wound to coccyx measured 0.1cm x 0.1 cm, staged as a Stage II, surrounding skin intact, no exudate. 5/7/18 wound to coccyx measured 1cm x 1cm x 0.3 cm staged as a Stage II, surrounding skin with [DIAGNOSES REDACTED] (redness) Record review of weekly pressure skin report documented the following: Record review of Resident #53's 5/3/18 WEEKLY PRESSURE INJURY QI LOG documents the following: Status: improving Date first noticed: 8/31/17 Site: coccyx Stage: Stage II Size: 1.5cmx0.5cmx 0.2cm Facility Acquired: yes Treatment: [MEDICATION NAME] cream Record review of Resident #53's 5/4/18 WEEKLY PRESSURE INJURY QI LOG documents the following: Resident #53 was not listed. Record review of Resident #53's 5/11/18 WEEKLY PRESSURE INJURY QI LOG documents the following: Status: improving Date first noticed: 8/31/18 Site: coccyx Stage: II Size: 1.5cmx0.5cmx 0.2cm Treatment: [MEDICATION NAME] cream Record review of Resident #53's 5/18/18 WEEKLY PRESSURE INJURY QI LOG documents the following: Status: declining Date first noticed: 8/31/18 Site: coccyx Stage: III Size: 2.0cmx1.5cmx 0.7cm with surrounding wound measuring 7.6cm x 12.7cn x0.7cm. The area surrounding the wound, (peri wound) is excoriated, red and hot Treatment: [MEDICATION NAME] cream Resident # 53 was not listed on the weekly pressure skin report from 3/1/18 through 5/3/18. Record review of comprehensive care plan documented the following: Problem: At risk for pressure ulcers related to mobility impairment. Goal: Resident will experience minimal to no skin breakdown related to urinary incontinence through the review period. Approach: 1. Avoid shearing resident skin during positioning, transferring, and turning. 2. CNA to assess skin when assisting with ADLs. Report any signs of skin breakdown (sore, tender, red, or broken areas). 3. Conduct a systematic skin inspection weekly. Pay attention to the voting prominences. Report any signs of skin breakdown to the physician. 4. He clean and dry as possible. Minimize skin exposure to moisture. 5. Keep linens clean, dry, and wrinkle free. 6. Maintain the head of the bed at the lowest degree of elevation possible. 7. Providing incontinence care after each incontinent episode. Avoid hot water and using mild cleansing agent that minimizes irritation and dryness of the skin, avoid friction to skin. 8. Use absorbent, skin friendly pads/briefs to maintain personal hygiene and dignity. Interview on 5/25/18 at 11:36 AM with DON revealed she was concerned about the number of in- house wounds. She stated they used to have a wound care nurse, but don't anymore. DON stated she has not had time to look into the issue because she has had to be on the floor so much. She stated she measured all the wounds when she first started at the facility and does the weekly measuring. There was no policy and procedure provided by the facility. ~ Review of the facility submitted CMS form 672 (Resident Census and Conditions of Residents) dated 5/25/18 confirmed a census of 54.