Every finding on record at Songbird Lodge

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 3 dietary staff (DS G) reviewed for qualified dietary staff. The facility failed to ensure the facility's DS G met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses.Record review of DS G on 12.10.2025 revealed no evidence of a food handler's certificate. During an interview on 12.09.2025 at 05:40 p.m. the DM stated one of the dishwashers did not have a food handler's certificate. She stated he only washed dishes and did not handle any food for the residents. She stated she was not sure why he had not gotten the certificate. She stated she did not feel like this could cause any harm to the residents. She stated she was responsible for monitoring the staff to ensure that they had the proper training to work in the kitchen During an interview on 12.10.2025 at 12:22 p.m. the ADMN stated that all dietary staff should have a food handler's certificate. She stated there could be a potential for infection to the residents who eat out of the kitchen if the staff had not had the food handler's course. She stated the DM should be monitoring that all kitchen staff have completed the food handler's course. She stated she did not know who this failure occurred.During a telephone interview on 12.10.2025 at 01:03 p.m. the Dietician stated her expectations were that all kitchen staff have a food handler's certificate. She stated any staff that did not have a food handler's certificate should be monitored by the DM. She stated she did not feel that a dishwasher not having a food handler's certificate would pose any harm to the residents.On 12.11.2025 before exit conference at 08:00 p.m. was conducted, the facility did not provide a policy regarding dietary staff requirements for a food handler's certification.

Based on observations, interviews the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen staff (DS F) did not prepare food with an active infection. This deficient practice could place residents at risk for infection and cross contamination. Findings include: During an observation on 12.09.2025 at 05:30 p.m. observed dietary aide F in the kitchen with a mask below his nose and only covering his mouth. Dietary aid F had on gloves and was lying out tortillas on a plate and placing cheese on top of the tortillas. During an interview on 12.09.2025 at 05:32 p.m., Dietary aid F stated he had a note from his doctor stating for him to not work due to a respiratory infection. He stated he had given the note to his DM, and she told him had to work and he could not leave. During an interview and record review on 12.09.2025 at 05:35 p.m. observed a return to work/school note from a local medical center that stated the dietary aid F was seen on 12.09.2025 and may return to work on 12.15.2025. The note was signed by a local PA (Physician's Assistant). The DM stated that Jesus (dishwasher) did not have a food handler's certificate. She stated he only washes dishes and did not handle any of food for the residents. She stated she was not sure why he had not gotten the certificate. She stated she did not feel like this could cause any harm to the residents. During an interview on 12.09.2025 at 05:40 p.m. DM stated she thought since the dietary aid F was wearing a mask it was okay for him to work. She stated if a kitchen staff member was sick and served food to the residents, it could cause the residents to get sick. During an interview on 12.10.2025 at 12:22 p.m. the ADMN stated when she was informed a dietary aid F was working in the kitchen and had an infection, she asked dietary aid F to leave the facility. The ADMN stated this failure could cause a potential for infection for any resident that eats out of the kitchen. The ADMN stated she did not know what caused this failure. The ADMN stated the DM is responsible for ensuring the kitchen staff are not infectious and working in the kitchen. During a telephone interview on 12.10.2025 at 01:03 p.m. the Dietician stated her expectations were that kitchen staff that come to work sick should have been told to leave. She stated it was not appropriate for a kitchen staff member to work sick. She stated the staff member should not have been in the building. She stated the DM had not informed her of a staff member being sick. She stated this failure could have been potential for residents to become sick if food was being prepared and served by a person who was sick. She stated the DM should have been monitoring the kitchen staff daily. She stated she comes to the facility two times a month to monitor the kitchen. Review of the facility's policy titled, Guidelines For Work Restrictions For Persons With Infectious Diseases (not dated) revealed: Disease/Problem Group A streptococcal disease-Relieve from direct resident contact-Yes, Partial work restriction blank Duration Until 24 hours after adequate treatment is started.

Based on interview and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement an appropriate action plan to address identified quality deficiencies for 1 of 1 facility. The QAPI committee failed to implement the corrective actions outlined on the Plan of Correction dated 03/14/2025 for deficient practice F728 for 3 (SNA J, SNA M, and SNA N) of 4 SNAs reviewed. This failure placed residents at risk for substandard quality of care due to the failure of the facility to act on an identified problem affecting resident safety. Findings include: Review of a CMS 2567 dated 03/14/2025 revealed that, based on observation, interviews, and record review, a deficient practice was cited at F728 (Facility Hiring and use of a Nurse) during an abbreviated survey that began on 03/13/2025. Interviews and records revealed that the facility failed to ensure SNA A (SNA M) was certified within the required time. Review of the facility's 03/15/2025 Plan of Correction which was submitted in response to the 03/14/2025 abbreviated survey revealed the facility's plan as:Corrective Action for Affected Residents: On 3/13/25, Area Director of Operations in-serviced Administrator and HR on auditing and tracking the compliance of Student Nurse Aide certifications. SNA A (SNA M) had completed the certification program. Since 3/14/25, SNA A (SNA M) has received additional support in preparation. Systemic Changes to Prevent Recurrence: On 3/13/2025, the facility implemented a monthly monitoring and tracking system for the SNA certification process to ensure SNAs are aware of the certification requirements and deadlines, and to help monitor their progress for facility compliance. Monitoring of Corrective Actions: HR/ADMN/DON designee will report to QAPI as needed for 3 months any concerns.During an interview on 12/11/2025 at 6:50 PM, the ADMN stated she had followed up during QAPI meetings and were supposed to have been followed up with the DON, but she failed to do so. She stated that SNA M had taken her exam and failed it and has one more time to take it before she would be unable to continue to take it. The ADMN stated there was a continued monitoring log for SNAs and NAs had monitoring for 90 days, and the DON and HR were going to do the tracking afterwards but did not follow through. She stated that her DON and HR changed in the middle of that. The ADMN stated that she was to monitor the tracking but had not. During an interview on 12/11/2025 at 6:58 PM the RDO stated her expectations were to inspect and monitor staff where needed. She stated she felt the ultimate failure occurred because the previous DON had not followed through with the policy and protocols. She stated her ADMN would have followed through verbally but felt the DON was not up front with her about this situation. Review of the facility's policy revised 9/2022, titled, Quality Assurance Policy and ProcedurePurpose: The Quality Assurance and Performance Improvement Program is a data driven and proactive approach to quality improvement. All members of our organization, including residents, are involved in continuously identifying opportunities for improvement. Gaps in systems are addressed through planned interventions with the goal of improving the overall quality of life and quality of care and services delivered to nursing home residents.5. Systematic Analysis and Systematic Action: Root cause analysis will be used to determine when in depth analysis is needed to fully understand a problem/event, its causes, and the implications of a change. The committee will review all involved systems to prevent future events and promote sustained improvement. The facility will focus on continued training, learning and continuous improvement.QAA Meeting: In addition to the QAA Meeting the Facility conducts Quality Reviews daily, weekly, and periodically throughout the month. The Interdisciplinary Team will report its findings to the QAA Committee for review. The QAA Committee may assign the QAPI Sub-Committee(s) to address specific areas as needed.Training/Competency.QAPI Plan Follow-up and Oversight: The Facility QAA Committee under the direction of the Administrator is responsible for verify Action Plans and Performance Improvement Plans are in place for areas that require improvement. The Administrator will notify the Area Director of Operations, and Area Compliance Nurse of concern or need for assistance as needed.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 17 residents (Residents #2, Resident #7, and Resident #64) reviewed for care plans.The facility failed to ensure Resident #2 had a care plan in place that included fluid restriction.The facility failed to ensure Resident #7, and Resident #64 had a care plan in place that included a fall mat.These failures could place residents at risk of not receiving individualized care and services to meet their needs.Findings included:1. Record review of Resident #2's electronic face sheet, dated 12/08/2025, reflected he was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (inability of kidneys to filter toxins out of the blood) and dependence on renal dialysis (having to have blood filtered by a machine due to kidneys not working correctly).Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 07 indicating severe cognitive impairment. Further review of the MDS reflected he needed setup assist with eating, he was on a therapeutic diet and received dialysis while a resident. Record review of Resident #2's physician orders, electronically accessed on 12/08/2025, reflected an order, dated 12/2/2025, reflecting a fluid restriction no greater than 32 oz a day related to renal dialysis.Record review of Resident #2's care plan, electronically accessed on 12/08/2025 reflected a focus area, dated 5/29/2025, Resident #2 had potential for fluid deficit. The interventions included encouraging the resident to drink fluids of choice, inviting the resident to activities that promoted additional fluid intake, and informing the nurse if the resident refused to drink fluids. Further review of the care plan reflected a focus area, dated 9/10/2025, Resident #2 needed hemodialysis (having blood filtered by a machine due to kidneys not working correctly) related to renal failure (inability of kidneys to filter blood to get rid of waste) with no interventions for fluid restriction. During an observation and interview on 12/07/2025 at 2:26 p.m., Resident #2 was sitting up in a recliner with his foot elevated. There was a prothesis beside his chair and a wheelchair in reach. He stated he had a left below the knee amputation. He stated he had no complaints with the staff at the facility. He stated she was supposed to be on a fluid restriction, but he drank what he wanted. Resident #2 did not state if he was able to obtain fluid himself or if the staff had educated him on complying with physician ordered fluid restrictions. He stated he continued to receive dialysis treatments. During an interview on 12/09/2025 at 1:47 p.m., LVN D stated she was Resident #2's charge nurse and Resident #2 went to dialysis on Monday, Wednesday, and Friday. She stated sometimes he went more often if he had too much fluid intake. LVN D stated fluid restrictions should be on the resident's care plan and did not know why it was not. She stated not putting fluid restriction on the care plan could cause Resident #2 to receive too many fluids causing him to go into fluid overload (body has too much fluid (mostly water) in it. This extra fluid can build up in places it shouldn't, like your lungs, legs, or belly.) She stated she did not know who was responsible for updating the care plans. She did not state whether she knew of about Resident #2's fluid restrictions or what system was in place for monitoring Resident #2's fluid intake.During an interview on 12/09/2025 at 2:00 p.m., the interim DON stated fluid restrictions should have been on a resident's care plan. She stated if the fluid restrictions were not care planned, staff could have given Resident #2 too much fluid. She stated if Resident #2 received too much fluid, he could have gone into fluid overload and would have required an extra day of dialysis. She stated the DON should have monitored the care plan to ensure it was accurate.2. Record review of Resident #7's electronic face sheet, dated 12/09/2025, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including unsteadiness on feet and muscle weakness. Record review of Resident #7's Kardex (a quick-reference summary of a resident's essential information in a long-term care or nursing facility managed through the electronic record system) electronically accessed on 12/09/2025 reflected no evidence of a fall mat was to be placed beside the bed.Record review of Resident #7's care plan, electronically accessed on 12/09/2025, reflected a focus area, dated 12/27/2024, indicating she was at risk for falls, and refused to wear shoes. The goal was for Resident #7 to not sustain serious injury through the review date. Target date listed was 9/08/2025. There was no evidence that the fall mat was addressed in the care plan.Record review of Resident #7's quarterly MDS, dated [DATE], reflected a BIMS score of 03 which indicated she had severe cognitive impairment. Further review of the MDS reflected she needed supervision or touching assistance with transfers from the bed to a chair and had two or more falls with no injuries.Record review of Resident #7's physician orders accessed on 12/09/2025 reflected an order, dated 6/18/2025, for fall mat to bedside for injury prevention related to falls.Record review of Resident #7's incident note documentation dated 11/17/2025 reflected Resident #7 was observed lying on floor beside bed. On 11/18/2025 note written by the interim DON which reflected keep bed in lowest position and fall mat in place.During an observation on 12/07/2025 at 10:39 a.m., Resident #7 was sitting in a chair in her room with the call light attached to the chair. Observed between the chair and her bed was a fall mat lying on the floor to the left of her bed. Resident #7 had her eyes closed and no distress was observed.During an attempted telephone interview on 12/08/2025 at 3:29 p.m., Resident #7's RP did not answer the telephone.3. Record review of Resident #64's electronic face sheet, dated 12/08/2025, reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (seizure activity) and failure to thrive (inability to maintain body weight). Record review of Resident #64's Kardex (a quick-reference summary of a resident's essential information in a long-term care or nursing facility managed through the electronic record system) electronically accessed on 12/08/2025 reflected no evidence that a fall mat was to be placed beside bed.Record review of Resident #64's care plan on 12/08/2025 reflected focus, dated 10/29/2025, reflecting she was at risk for falls. The goal was for Resident #64 to not sustain serious injury through the review date. Target date listed as 1/07/2026. There was no evidence the fall mat was addressed in the care plan.Record review of Resident #64's quarterly MDS, dated [DATE], reflected a BIMS score of 02 which indicated she had severe cognitive impairment. Further review of the MDS reflected she needed substantial assistance with transfers from the bed to a chair and had no falls since the prior assessment.During an observation and interview on 12/07/2025 at 10:39 a.m., Resident #64 was lying in bed. The bed was in the low position and there was a fall mat to the left of the bed. She smiled when being talked to and stated she had no concerns with her care. She did not have any skin issues such as bruising or wounds.During an interview on 12/10/2025 at 2:12 p.m., CNA H stated she looked up a care plan on the kiosk. She stated she had never noticed a fall mat on any resident's care plans. She stated a fall mat helped prevent injury by cushioning a resident during a fall. She stated she knew who needed a fall mat by the mat being in the resident's room or a nurse told her. She stated Resident #64 should have a fall mat beside her bed but stated the fall mat was not in the care plan.During an interview on 12/11/2025 at 3:00 p.m., the RRN stated fall mats should have been on the care plan if they were being utilized. She stated the DON, ADON, and MDS coordinator were responsible for maintaining the care plans. She stated the care plans were monitored by the same staff during morning meetings. She did not know why fall mats were not on the care plans.During an interview on 12/11/2025 at 5:38 p.m., the DON in training stated she started working for the facility on 12/08/2025. She stated a fall mat should have been on the care plan if it was being utilized. She stated she expected the intervention to be put on the care plan as soon as possible. She stated she did not know why the fall mats were not on the care plans. She stated failure to put on the care plan could prevent direct care staff knowing that a fall mat was to be used. She verified that herself, the ADON, and the MDS coordinator all updated the care plans and monitored that they were accurate. Facility policy titled Comprehensive Care Planning, undated, reflected, Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Care planning drives the type of care and services that a resident receives.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 3 (SNA M, SNA N, and SNA O) of 4 student nurse aides reviewed for nursing services. The facility failed to ensure SNA M, SNA N, and SNA O were certified within the required time. This failure could place residents at risk for receiving inappropriate care from individuals whose skill level was not known.Findings included: Record review on 12/09/2025 of the facility's employee files revealed: -SNA M had a hire date of 4/18/2023 and worked full time as of 12/11/2025 An employability status check dated 12/11/2025 indicated SNA M had a CNA certification expiration date of 5/22/15. -SNA N had a hire date of 4/18/2023 was currently working full time. An employability status check dated 12/11/2025 indicated SNA M had no CNA certification. -SNA O had a hire date of 3/26/2025 was currently working full time. An employability status check dated 12/11/2025 indicated SNA O had no CNA certification. During an interview on 12/10/2025 at 11:00 a.m. the RCN stated her expectation was when NAs were hired, they were enrolled in classes within 30 days and were certifiable at 60 days. She stated the facility had no policy on NA's and that there was no time limit other than what the NATCEP requirements were, being 4 months after hire, NA's should have been hired and certified with their CNA. The RCN stated she felt the failure was due to the previous DON who was no longer there. During an interview on 12/11/2025 at 10:51 AM the ADMN stated as of yesterday she changed three of the SNAs to Hospitality Aides because they worked for four months or more. During an interview on 12/11/2025 at 5:29 PM, the ADMN stated SNAs should have been certified within 4 months of hire. She stated the DON was not keeping up with monitoring and tracking of the certification. She stated they had been performing direct care with residents even after the 4-month allotted time frame. The ADMN stated the DON had been responsible for monitoring the nurse aides, but she was no longer at the facility. The ADMN stated she felt the failure occurred with the previous DON not following up and completing the task she was given. She stated there was potential harm for residents if staff were not trained properly in not knowing what out of the range signs and/or symptoms to look for. Record review of the document provided by the DON titled Job Description for a SNA dated 2010, and signed on 4/18/23 by SNA M stated the following [in part] :Knowledge Base - Must provide written proof of the completion of 16-hour ADL training by authorized school instructor. Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics .Applicant declaration: I have read the qualifications and requirements of the position of student nurses' aide; I understand this position is not permanent but limited to 120 days in which I am required to test and obtain certification. I understand and certify that the foregoing is a non-exhaustive criterion that is consistent with the needs of this facility and is a legitimate measure of the qualifications for a Certified Nursing assistant and relates to the functions essential to a certified nursing assistant. Record review of the document provided by the ADMN titled Job Description for a SNA dated 2014, and signed on 2/6/25 by SNA N stated the following [in part] :Knowledge Base - Must provide written proof of the completion of 16-hour ADL training by authorized school instructor. Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics .Applicant declaration: I have read the qualifications and requirements of the position of student nurses aide; I understand this position is not permanent but limited to 120 days in which I am required to test and obtain certification. I understand and certify that the foregoing is a non-exhaustive criterion that is consistent with the needs of this facility and is a legitimate measure of the qualifications for a Certified Nursing assistant and relates to the functions essential to a certified nursing assistant. Record review of the document provided by the ADMN titled Job Description for a SNA dated 2010, and signed on 4/18/23 by SNA O stated the following [in part] :Knowledge Base - Must provide written proof of the completion of 16-hour ADL training by authorized school instructor. Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics .Applicant declaration: I have read the qualifications and requirements of the position of student nurses aide; I understand this position is not permanent but limited to 120 days in which I am required to test and obtain certification. I understand and certify that the foregoing is a non-exhaustive criterion that is consistent with the needs of this facility and is a legitimate measure of the qualifications for a Certified Nursing assistant and relates to the functions essential to a certified nursing assistant.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 5 halls (B hall) reviewed for food and nutrition services. The facility failed to ensure 68 of 68 residents receiving a lunch meal from the kitchen received pecan pie as posted on the weekly menu for lunch on 12/07/2025. The facility failed to ensure 3 of 18 residents receiving a meal from the kitchen on B hall received lunch menu items roasted pork loin and mashed sweet potatoes on 12/07/2025. These failures could place residents at risk of poor intake from being disappointed they did not receive the menu items listed.Findings includeDuring an observation on 12/07/2025 at 12:02 p.m., the lunch menu written on the white board outside the kitchen reflected roasted pork loin, gravy, mashed sweet potatoes, parmesan brussel sprouts, honey roll, and vanilla pudding. Weekly menu posted at the rear of the dining area reflected roasted pork loin, gravy, mashed sweet potatoes, parmesan brussel sprouts, honey roll, and pecan pie. During an observation on 12/07/2025 at 1:00 p.m., kitchen staff were plating food for the last three residents. There were mashed potatoes being served and Italian sausage on the last 3 trays. During an observation on 12/07/2025 at 1:15 p.m., the last of the hall trays were being passed out to residents on B hall. Three of the trays were observed having mased potatoes instead of mashed sweet potatoes. Three of the trays were observed having a different protein product instead of the roasted pork.During an interview on 12/07/2025 at 1:19 p.m., [NAME] I stated when she was prepping the sweet potatoes, a lot of them were bad so she could not use them. She stated she thought she had enough of them prepped but had ran out and that was why she substituted with instant mashed potatoes. During an interview on 12/07/2025 at 1:25 p.m., the DM stated the pecan pie was not served because the items were not received on the shipment truck. She stated sometimes the kitchen had to make changes due to what was delivered on the truck. She stated the residents were notified of the substitution. She stated some residents had not gotten mashed sweet potatoes because the kitchen had run out of sweet potatoes. During a follow-up interview on 12/08/2025 at 12:36 p.m., the DM stated sometimes the kitchen had to make changes due to what was delivered on the truck. She stated the residents were notified of the substitution by writing on the whiteboard outside of the kitchen. She stated she did not know how the residents that did not get out of their room for meals had been notified of dessert change. She stated she did not know if residents had been notified of potato and protein substitutions. She stated she did not notify the dietician of the potato and protein substitution. She stated both she and the dietician had been working with [NAME] I to make sure she was preparing the right amount of food product, not too much or not enough. She stated some of the issues were not all the sweet potatoes were usable but had no idea of why the kitchen ran out of protein item. She stated not providing residents with menu items could cause them to be unhappy after having an image of one food on their mind then being served another. She stated she monitored the kitchen staff and food service during meals. She stated the cook was responsible for making sure enough products had been prepared. During a telephone interview on 12/10/2025 at 12:57 p.m., the dietician stated she expected menus to be followed. She stated mashed potatoes had the same nutritional value as mashed sweet potatoes. She stated different proteins would have the same nutritional value as roasted pork loin. She stated different desserts had the same nutritional value. She stated the negative outcome would be that residents could have been upset the food they were served was different than what they had expected. She stated the DM was responsible for making sure the menus were followed. She stated she had not been notified of the food substitutions. She stated she monitored the food served at the facility twice a month and the DM was ultimately responsible for monitoring that all menu items were served. During a confidential group meeting at a confidential time, 8 of 8 residents voiced they were unhappy that items served during meals were not the items that were posted. 8 of 8 residents stated no one informed them of the menu changes when the items were different then what was posted. 8 of 8 residents stated the DM had come to the confidential meeting in the past to go over their concerns but nothing changed after that meeting. Record review of facility policy titled Menu Approval and Honoring Resident Special Requests, and Food Brought to the Facility From Unapproved Sources with no date reflected Every attempt will be made to honor resident food preferences. The facility has a five-week cycle menu that can be modified by the dietary manager to meet the preferences of the majority of the residents. There was no evidence on following menus.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access for 1 of 5 (Medication Cart #1) medication carts reviewed for . The facility failed to ensure Medication Cart #1 was locked when unattended by nurse. This failure could place residents at risk of harm or decline in health due to lack of potency of medications/biologicals or misappropriation of medications. Findings included: During an observation on 12/10/2025 at 1:15 p.m., Medication Cart #1 was left unattended and unlocked, medication cart keys were inserted and hanging from the narcotic box. During an interview on 12/10/2025 at 1:17 p.m. RN E stated Medication Cart #1 was his responsibility, as well as the medication cart keys inserted and hanging from the narcotic drawer. RN E stated the medication carts were supposed to be always locked while not in use. RN E stated there was a resident falling, and he had to help her to her room. He stated, it still should have been locked prior to helping the resident. He stated there were residents that could have easily opened the cart and had access to medications as well as the scissors that were in the opened medication cart. RN E stated there were 15 residents' medication on the medication cart including:Crestor a cholesterol lowering medication; Melatonin a supplement to help induce sleep; Mirtazapine an anti-depressant; Eliquis a blood thinner (medication that interferes with blood clotting); Metoclopramide a medication that increases the speed the stomach empties into the intestines. Lyrica a medication used to treat nerve pain; Calcium / Magnesium / Zinc supplement; Atorvastatin a cholesterol lowering medication; Trazodone an antidepressant that can help with sleeplessness; Baclofen a medication that helps reduce muscle spasms; Carvedilol a medication that is used to help heart and circulation of blood; Famotidine a medication that decreases the amount of acid in the stomach; Keflex an antibiotic for infection; Seroquel an anti-psychotic medication used to treat psychosis; Senna-S a medication used to treat constipation; Buspirone an anti-anxiety medication; Sertraline an anti-depressant; Metoprolol a medication used to treat high blood pressure or elevated heart rate; Potassium chloride a supplement; Ticagrelor a medication that lowers risk for heart attack and helps lower risk of blood clots; Carisoprodol a medication to help relax muscles and reduce nerve pain; Amitriptyline a medication that helps lower depression; Metformin a medication used to help lower blood sugars in Type 2 diabetics; Gabapentin a medication used to help reduce nerve pain; Omeprazole a medication used to lower stomach acid; Donepezil a medication used to treat dementia. Antipsychotics, seizure, bowel, urinary, anxiety, OTC medications, inhalers and allergy meds. In the narcotic box behind one lock was: tramadol, used to treat moderately severe pain; morphine, used to treat moderate to severe pain when alternative pain relief medicines are not effective or not tolerated; lorazepam gel syringes, manage anxiety disorders and for short-term relief of anxiety symptoms associated with depression; Hydrocodone, used to treat pain; Alprazolam , used to treat anxiety and panic disorders; and diazepam gel, used to treat anxiety, muscle pain and seizures.RN E stated the narcotic medications should have been behind two locks. During an interview on 12/10/2025 at 1:35 a.m. the RDO stated the medication carts should have been locked if not in use by the nurse. She stated the keys should have been with the nurse in charge of that cart. During an interview on 12/10/2025 at 1:42 p.m., the RCN stated the keys should have never been left unattended on the medication carts. She stated no medication cart should have been left unlocked because residents could access the medications in the cart. The RCN stated there could have been great harm to residents if the wrong medications were ingested such as choking or an allergic reaction. She stated the failure, she felt was from their previous DON that was terminated. The RCN stated the previously terminated DON had not followed up on training and in particular in-services such as this. Review of the facility's policy titled Medication Storage in the Facility dated 2025 revealed: Policy: Medication sand biologicals are stored safely, securely, and properly.The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.Procedure:.9.ALL classes of controlled substances be stored in the lockbox located in the medication cart to adhere to the required double locked/secured storage.

Based on interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 (Resident #32) of 17 reviewed for accuracy of assessments. The facility failed to ensure the MDS dated 11.27.2025 reflected Resident #32 did not have a diagnosis of pneumonia. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.Findings included:Record review of Resident #32's electronic face sheet, dated 12.09.2025, revealed a [AGE] year-old female admitted [KA1] on 11.23.2024, readmitted 12.08.2025, with diagnoses of pneumonia, unspecified organism, history of falling, unspecified dementia, hypertension (high blood pressure), iron deficiency anemia (blood disorder), presence of cardiac pacemaker. Record review of Resident #32's Annual MDS, dated 11.27.2025, revealed: Section C - Cognitive Patterns Resident #32 had a BIMS score of 03 (meaning severely impaired cognition). Section I-Active Diagnosis revealed Resident # 32 had pneumonia during the past seven days of the look back period. Record review of Resident #32's physician orders, dated 12.01.2025, revealed no current orders for antibiotic therapy for a diagnosis of pneumonia. Record review of Resident #32's care plan, dated 09.11.2025, revealed no evidence of a focus, goal or intervention for the diagnosis of pneumonia. During an interview on 12.10.2025 at 02:10 p.m. the Regional Reimbursement Nurse stated her expectation was all MDSs were accurate for the residents. She stated if the resident did not have a current diagnosis of pneumonia, it should not have been triggered (checked )by the MDS. She stated she did not know how the failure occurred and that she was responsible for monitoring MDSs for accuracy. She did not know how often she monitored the MDSs. During an interview on 12.10.2025 at 02:20 p.m. the Regional Nurse stated her expectation was the MDSs were completed and accurate. She stated if a resident did not have a diagnosis of pneumonia in the last seven days, then it should not have been on the MDS. She stated she did not know how this failure occurred, except for human error. She stated this failure would not have affected the care of the residents. She stated the MDS coordinator was responsible for the accuracy of the MDS, and the DON was responsible for signing the MDS and ensuring accuracy as well. During an interview on 12.10.2025 at 3:12 p.m., the LVN MDS Coordinator stated if a resident did not have a current (within the last seven days) diagnosis of pneumonia then it should not have triggered (checked) on the MDS. She stated this failure would not cause any harm to residents or change the reimbursement status. She stated this failure was due to human error and that it did not change the reimbursement to the facility. She stated she and the DON monitored the MDS for accuracy when the RN signed the MDS. Review of the facility's policy titled, Resident Assessment, not dated, reflected: A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI).The assessment will include at least the following:a. Medically defined conditions and prior medical historyb. Medical status measurementc. Physical and mental functional status.l. Cognitive status. RAI assessments must be conducted within 14 days after the date of admission: promptly after a significant change in the resident's physical or mental condition.The facility will examine each resident and review the minimum data set expanded core elements specified in RAI no less than once every three (3) months and as appropriate. Results must be recorded to assure continued accuracy of the assessment.The results of the assessment are used to develop, review and revise the resident's comprehensive plan of care. Each assessment will be conducted or coordinated with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and certify the completion of the assessment.Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment. Each resident will be reassessed at regular intervals related to the course of treatment or when the resident's physical, psychosocial, functional or nutritional status significantly changes. Reassessment will occur quarterly thereafter or in response to a change in the residents' condition. Documentation reflecting assessment and changes in the plan of care will be reflected in the resident's medical record and/or plan of care. [KA1]It is not necessary to state what is understood to the reader. The reader understands the resident was admitted to the facility.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #64) of 17 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation that included certificate of terminal illness to ensure that the needs of the residents were addressed and met 24 hours per day to ensure Resident #64 received adequate end-of-life care.This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings include Record review of Resident #64's electronic face sheet dated 12/08/2025 reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including failure to thrive (inability to maintain body weight) and protein calorie malnutrition (when a person does not consume enough protein and calories to meet their body's nutritional needs). Record review of Resident #64's quarterly MDS, dated [DATE], reflected a BIMS score of 02 which indicated she had severe cognitive impairment. Further review reflected Resident #64 was not on hospice. Record review of Resident #64's medical record accessed on 12/09/2025 reflected significant change MDS had been initiated but not completed on 12/05/2025.Record review of Resident #64's care plan on 12/08/2025 reflected no focus or interventions for hospice services.Record review of Resident #64's physician orders dated 11/25/2025 reflected may admit to hospice for diagnosis of protein calorie malnutrition.Record review of Resident #64's medical record documents on 12/08/2025 reflected no evidence of hospice election form, physician certification of terminal illness, hospice medication information, OOHDNR form, or hospice physician orders.During an observation and interview on 12/07/2025 at 10:39 a.m., Resident #64 was lying in bed. The bed was in the low position and there was a fall mat to the left of the bed. She smiled when being talked to and stated she had no concerns with her care.During a telephone interview on 12/08/2025 at 4:46 p.m., Resident #64's RP stated Resident #64 had only been on hospice services for several weeks. She stated when Resident #64 had been signed up for hospice services on 11/25/2025, an OOHDNR form had been signed on 11/25/2025 during hospice admission. She stated she was put on hospice services because at this point no one knew what to do with her and she was losing weight.During an interview on 12/09/2025 at 10:22 a.m., LVN L stated Resident #64 was recently admitted on hospice services. He stated hospice documents should have been stored in the electronic medical record under documents if there was no Hospice binder behind the nurses station. He verified that there was no Hospice binder behind the nurses' station for resident number 64. He stated that he would look up a code status in the profile of the resident during an emergency. He pulled up Resident #64's profile and stated she was listed as a full code. LVN L stated he could write a physician's order to change the code status when he had a completed OOHDNR form in front of him and he had verified it was completed. He stated that once he wrote the physician's order in the system, the profile code status would be automatically updated. He stated the resident's profile was viewable in the electronic record and on the medication administration record. He voiced the Hospice binder may have been in resident # 64's room but could not find it in her room at this time.During an interview on 12/09/2025 at 11:25 p.m., hospice RN stated the facility should have hospice documents. She stated the hospice company usually left hospice paperwork in a binder that was kept behind the nurses' station. She stated Resident #64 did have an active OOHDNR on record with the hospice. She stated she would get ahold of her office and get the required documents sent to the facility. She stated the first IDG care plan meeting was for going over the admission of the resident yesterday on 12/08/2025 and after the physician signed all of the paperwork, the facility would get those care plan notes. She stated the OOHDNR, CTI and hospice election agreement would have been sent to the facility by the end of the day.During an interview on 12/11/2025 at 4:05 p.m., the DON stated she had worked for the facility since 12/08/2025. She stated she was still learning all the documents that were needed from the hospice company. She stated she would have expected the facility to have the OOHDNR if it had been completed by the hospice company. She stated she did not know who was responsible for communicating with the hospice companies. She stated the charge nurses communicated with the hospice nurse when that nurse was in the facility. She did not know where the communication documentation would have been kept. She stated not having required documents could have affected end of life treatments that were to be provided including cardiopulmonary resuscitation.During an interview on 12/11/2025 at 7:35 p.m. the RRN stated she could not code life expectancy of less than 6 months on the MDS unless she had supporting information from the hospice physician and it depended on the hospice company whether she had that information. Review of the facility's policy titled, Hospice Services, no date, reflected 7. The DON or designee will be responsible for immediately notifying the hospice of any significant changes in condition. Notification will be documented in the medical record. 8. The legally binding agreement will have provisions for joint procedures for ordering medications that ensure that the proper payer is billed and for reconciling billing between the nursing facility and the hospice. 9. The DON of designee will be responsible as needed for contracting the hospice prior to filling a new prescription. 10. The DON or designee will be responsible for ensuring that drugs unrelated to the terminal illness are ordered through the Vendor Drug Program. 11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (#3071) Texas Medicaid Hospice-Nursing Facility Assessment Form (#3073) Physician Certification of Terminal Illness (#3074) Medicare Election Statement (if dual eligible) Verification that the recipient does not have Medicare Part A Hospice Plan of Care Current interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period. 12. The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of the hospice, nursing facility, the recipient, and legal representative to the extent possible. 13. The plan of care must include directives for managing pain and other uncomfortable symptoms. The plan must be revised and updated as necessary to reflect the resident=s current status.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent surveys and investigations of the facility including any plans of correction, without identifying information about complainants or residents, for 1 of 1 facility reviewed for resident rights. The facility failed to ensure the investigations that occurred on 3/14/2025, 5/29/2025, and 10/2/2025 with plans of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. This failure could place residents and the residents' family members or representatives at risk for violation of the right to review the facility's survey and investigation findings without asking the facility to review the reports. Findings included:During an observation on 12/09/2025 at 8:40 a.m., the last survey results dated 9/06/2024 were in a binder in a bin on the right wall in front of the entrance into the facility. There was a sign informing the public of the binder's location. Review of the survey results binder reflected no results for investigations performed on 3/14/2025, 5/29/2025, and 10/02/2025. During an interview on 12/9/2025 at 8:43 a.m., the ADMN stated she was responsible for updating the survey binder with the most recent survey results. She stated there was no information in the binder after the last standard recertification survey dated 9/06/2024. She stated she thought she put the investigation findings for the investigations performed on 3/14/2025, 5/29/2025, and 10/02/2025 in the binder. The ADMN stated she found the binder out of the bin at one time and put it back, where it was stored after that time. She stated she was unsure if she was to provide the investigation findings in the binder. She stated the facility was investigated on 3/14/2025 with citations written. She also stated the facility was investigated on 5/29/2025 and 10/2/2025 and no citations were written. She stated she would look for a policy on required postings related to the survey binder. During an interview on 12/09/2025 at 9:13 a.m., the ADMN stated she was supposed to have the past investigation survey results with and without citations in the survey binder. She stated she was continuing to look for a policy on survey binder results.During an observation on 12/09/2025 at 9:25 a.m., there was a resident rights posting outside of the ADMN's office which reflected, The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.During an interview on 12/11/2025 at 4:41 p.m., the ADMN stated she thought only the last standard survey results needed to be in the survey binder. She stated the survey binder was to provide visitors with information about the facility. She stated there was no policy on the survey binder.During an interview on 12/11/2025 at 4:43 p.m., the RDO stated she monitored the survey binder to ensure results from the last surveys were in the binder. She stated she knew how to look for the last standard survey results but did not know survey results from investigations needed to be in the survey binder. She stated the facility did not have a policy on the required posting for the survey binder.

Based observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 2 (Resident #4 and Resident #5) of 7 residents reviewed for label and storage of drugs and biologicals. The facility failed to ensure Resident #4's and Resident #5's medications were locked when unattended. The facility failed to ensure Resident #4's respiratory treatments were not left at bedside and used unsupervised. This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions.Findings included:Resident #4Review of Resident #4's Face Sheet, dated 10/30/2025, revealed a [AGE] year-old female, admitted [DATE], readmitted [DATE], with diagnoses included UTI (Urinary Tract Infection), metabolic encephalopathy (a brain dysfunction caused by metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), malnutrition, constipation, and depression.Review of Resident #4's Annual MDS, dated [DATE], revealed in Section C - C0500, Cognitive Patterns, Resident #4 had a BIMS Summary Score was a 7, which indicated severe mental impairment. Section N0415, High Risk Medications, revealed Resident #4's High-Risk Drug Classes: Use and Indication1. Is taking Antianxiety, Antibiotics, Opioids, and Antiplatelet medications.Review of Resident #4's Comprehensive Care Plan, dated04/09/2022 and reviewed/revised on 10/28/2025, revealed the following focused areas: Resident #4 was on Hypnotic Therapy r/t insomnia, antidepressant medication was used. Resident #4's interventions included, Administer medications as ordered.Record Review of Resident #4's physician orders, with a start date of 4/9/2022 revealed: Patient may have Tylenol ER and Tramadol 50 mg Q 6 hours PRN for pain.Acetaminophen ER Tablet Extended Release 650 MG, Give 1 tablet every 6 hours as needed for pain.Albuterol Sulfate Nebulization Solution (2.5 MG/3 ML), Give 3 milliliter inhale orally via nebulizer every 4 hours as needed for Shortness of Breath.Alprazolam Tablet 0.5 MG, give 1 tablet by mouth every 6 hours for Anxiety.Aspirin 81 MG, give 81 mg by mouth one time a day for Anticoagulant Therapy.Bisacodyl EC Tablet Delayed Release 5 MG.Breztrl Aerosphere Inhalation Aerosol 160-9-4.8 MCG/ACT 2 puff inhales orally two times a day for COPD.Buspirone HCI Tablet 10 MG Give one tablet by mouth three a day for shortness of breath.Fluticasone Proplonate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for Nasal Congestion.Folic Acid Oral Tablet 400 MCG, Give 1 tablet by mouth one time a day for vitamin deficiency.Gabapentin Capsule 100 MG Give 1 capsule by mouth three times a day for neuropathic pain.Hydroxyzine HCI Oral Tablet 25 MG Give one tablet by mouth at bedtime.Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally four times a day for SOB.Record review of Resident #4's electronic medical record on 10/30/2025 revealed no evidence of a completed assessment for self-administering of medication. During an observation on 10/30/2025 at 11:20 AM, Resident #4 was found to have medications in a pill cup on her bedside table. Also observed were breathing treatments and two inhalers at bedside.During an interview on 10/30/2025 at 11:22 AM, Resident #4 stated Medication Aids always left her medications for her to take without them there. Resident #4 stated she did not know what the medications were in the pill cup. She stated she always had her breathing treatments and inhalers in her room. Resident #5Record Review of Resident #5's Face Sheet, dated 10/20/2025, revealed a [AGE] year-old female, admitted [DATE], readmitted [DATE], with diagnoses including unspecified dementia, psychotic disturbance, mood disturbance and anxiety.Record review of Resident #5's Annual MDS. dated 09/19/2025, revealed in Section C - C0500, Cognitive Patterns, Resident #5 had a BIMS Summary Score of a 14 indicating the resident was cognitively intact.Review of Resident #5's physician orders with a start date of 11/27/2022 revealed: Amlodipine Besylate Tablet 2.5 MG, Give 1 tablet by mouth one time a day for HTN.Calcium Carbonate-Vit D Tablet 600-400 MG-UNIT, Give 1 tablet by mouth one time a day for vitamin deficiency.Esomeprazole Magnesium Oral Capsule 20 MG, Give 20 MG by mouth one time a day for GERD.Furosemide Tablet 20 MG, Give 1 tablet by mouth one time a day for Edema.Lisinopril Tablet 20 MG, Give 1 tablet by mouth one a day for HTN.Lorazepam oral Tablet 0.5 MG, Give 0.25by mouth one time a day for anxiety.During an observation and interview on 10/30/2025 at 11:30 AM, Resident #5 had an open pill cup with six medications on her bedside table. Resident #5 she must have been asleep, and the nurse left them there . Resident Record review of Resident #5's electronic medical record on 10/30/2025 revealed no evidence of a completed assessment for self-administering of medication.During a confidential interview on 10/30/2025 at 11:35 AM, she stated the medication aids had left her medications on her bedside table multiple times and walked out of the room without them being administered to her. She stated she felt the staff should not have left medications without making sure they were taken. The confidential resident stated she thought the rules must've changed.During a second confidential interview on 10/30/2025 at 11:52 AM, a resident stated she had seen multiple residents on her hall with pill cups with medications left at multiple residents' bedside without the supervision being provided. During an interview on 10/30/2025 at 2:40 PM, the MA stated the protocol for medication that was refused or if resident was unable to take them was to go back and try again. If the resident refused three times she should waste the medication afterwards. The MA stated the possible harm in leaving medications in resident rooms without being supervised when taking them could have been, another resident taking the wrong medication, and the possibility of resident having an adverse reaction to medication. During an interview on 10/30/2025 at 1:59 PM, the DON stated she heard there were tums left at a resident's bedside. She stated, if there were residents with medications at bedside, they should have an assessment noting they were allowed to do so, and if they were able, they should be in a lock box, so no other residents were able to take them. The DON stated it should also have been addressed in their care plan if they were allowed to administer their own medications. She stated Resident #4 and Resident #5 had not had self-administration assessments. The DON stated the med aids, and the charge nurses were responsible for monitoring medications. The DON stated she performed a monthly set of trainings for staff to complete, associated with their discipline. She stated the potential harm to the residents was an adverse effect such as an allergic reaction. She stated her expectations were for medications to never be left at bedside, and if the resident refused the MA or nurse should hold them. The DON stated the failure was the nurses had not monitored the medications if the resident refused or was unavailable.Record Review of facility policy, Medication Administration and General Guidelines, dated 2025, revealed, Policy-Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure-.9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. 10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med must be given 30 minutes after the specified time. Unless otherwise specified by the physician, routine medications are administered precisely as ordered. Unless otherwise specified by the physician medications are administered according to the established medication administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, (e.g. resident not in facility at scheduled dosed time, initial dose of antibiotic) .13. Medication supplied for one resident are never administered to another resident. 14. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR is flagged with tags, colored plastic strips, or paperclips/or if electronic the system will alert personnel to the missed medication(s). After completing the medication pass, the nurse returns to the missing resident to administer the medication. This must be done during the 1 hour before or 1 hour after medication pass time.Checklist for completing proper steps in the administration of medications; .Observes the resident take the medication.

Based on interview and record review the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 1 (SNA A) of 3 student nurse aides reviewed. The facility failed to ensure SNA A was certified within the required time. This failure place residents at risk for receiving inappropriate care from an individual whose skill level was not known. Findings include: Review of the facility's employee files revealed: -SNA A had a hire date of 4/18/2023 and worked full time. - An employability status check dated 8/27/24 indicated SNA A had a CNA certification expiration date of 5/22/15. During an interview on 03/12/2025 at 6:30 PM , SNA A stated she had been working continuously at the facility since April of 2023. She stated she performed the duties of a CNA on the 6 PM to 6 AM shift. She stated that she had taken her certification test and failed the skills test about 2 months ago. She stated she felt like she failed the test because she would ask the ADON (no longer employed at the facility) to help her with her skills and she didn't want to help her. She stated she did not tell the DON or Administrator that she needed assistance. She stated the adverse outcome that could result from her failure to be certified would be the resident might not get the care that they should receive, and that might affect their health and overall wellbeing. She stated she had not registered to take the test again because she had to pay for it herself . She stated the facility paid for the first attempt at passing the CNA certification , but if the SNA failed on the first attempt, it was the responsibility of the SNA to pay for the certification retesting. During an interview on 3/13/2025 at 2:47 p.m., the DON stated that her expectation would be for the facility to have certified nurse assistants. She stated that she recently took on the responsibility of monitoring and ensuring the CNAs tested and became certified. She stated she was aware that SNA A was working without certification but didn't know there was a limit on how long she could work before becoming certified. She stated she knew that SNA A would have to pay for the retesting for the skills portion of her test. She stated the company would only pay for the first test. She stated SNA A had not requested her assistance to prepare for the test. She stated no negative effect had occurred to residents due to care received from a non- certified NA, but an adverse outcome could be that a resident could not receive appropriate care. She stated it was the responsibility of the prior ADON to monitor training and certifications, but going forward it was her responsibility. Record review of a document titled How To Become a Certified Nurse Aide (CNA) in Texas not dated stated in part: - Complete NATCEP Training (Nurses aide Certification and Evaluation Training program) - Submit an application through TULIP (Texas Unified Licensure Portal) - NATCEP approval - based on successful completion of training; Successful background check Student not listed on the EMR - Schedule and pass the exam : Student schedules and passes both the written and skills exams Record review of the document provided by the DON titled Job Description For A SNA dated 2010, and signed on 4/ 18/23 by SNA A stated the following [in part] : Knowledge Base - Must provide written proof of a completion of 16-hour ADL training by authorized school instructor. Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics . Applicant declaration: I have read the qualifications and requirements of the position of student nurses aide; I understand this position is not permanent but limited to 120 days in which I am required to test and obtain certification. I understand and certify that the foregoing is a non-exhaustive criterion that is consistent with the needs of this facility and is a legitimate measure of the qualifications for a Certified Nursing assistant and relates to the functions essential to a certified nursing assistant.

Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of the review for 1 (SNA A) of 6 SNAs and CNAs whose records were reviewed, by failing to ensure: SNA A had an annual performance review and completed 12 hours annual in-service education in 2024 and 2025 which was based on a performance review. This facility failure could affect the residents by placing them at risk for a physical decline in their health status. The findings included: In an interview with the Administrator on 3/13/2025 at 12:30 PM she stated it was her expectation that employees were responsible for taking monthly scheduled training in a program on the computer -based program She stated it was the responsibility of each department head to monitor to see that the employees kept their trainings requirements current and their certification current. She stated failure to complete required training could result in residents not receiving adequate care In an interview on 3/12/2025 at 2:30 PM, the DON stated she could only provide documentation of one new employee orientation in-service training was held. It was dated 4/18/23. She also stated that SNA A did not have a performance review every 12 months or 12 hours of annual training based on her performance review. She stated it was the responsibility of each department head to monitor to see that the employees kept their trainings requirements current and their certification current. She stated failure to complete required training could result in residents not receiving adequate care. She stated she would be monitoring to see that inservices were completed in a timely manner in the future. During an interview on 03/12/2025 at 6:30 PM , SNA A stated she had been working continuously at the facility since April of 2023. She stated she performed the duties of a CNA on the 6 PM to 6 AM shift. She stated that she had taken her certification test and failed the skills test about 2 months ago. She stated she had not completed her 12 hours of Inservice education that is required annually in the Brand XXX training program. She stated she did not realize that it was a state or federal requirement . She stated she did not really know of a negative outcome that could affect the resident due to her not completing her monthly inservices. Review of the facility employee list with hire dates and positions, and the staff in-service sign in sheets for SNA A provided by the DON, revealed documented annual in-service hours, during the last 12 months, as follow: SNA A - date of hire 4/18/2023, - 0 hours of documented in-service since 4/18/2 and no performance evaluation since 4/18/23 Record review of the document provided by the DON titled Job Description for a CNA dated 2014, and signed on 4/ 18/23 by SNA A stated the following [in part] : Knowledge Base - Ability to perform technical procedures and record information, Ability to comply with employee responsibilities, ability to comply with facility safety policies and procedures . Record review of the document provided by the DON titled Job Description for a SNA dated 2010, and signed on 4/ 18/23 by SNA A stated the following [in part] : Knowledge Base - Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics Record review of an Inservice which was given by the DON and Administrator. dated 3/12/25 at 2 PM reflected the following: Brand XXX Inservice training program used by the facility) is mandatory. Continuing education is required by the state and federal government. Training is not optional The trainings must be completed by the due dates. There are new in-services assigned monthly and occasionally inservices are assigned as needed. Get with your department supervisor to discuss how you will get these completed if you are having issues. Each staff member is responsible for their training. Working on this a little every day (10-15 minutes per day) while you are at work will keep your continuing education up to date. This is your education on completing Inservice training in Brand XXX. This is a required task . disciplinary action will be the next step if the training is not completed.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Residents #38 and #61) reviewed for respiratory care. The facility failed to ensure Residents #38 and #61's nasal cannula and nebulizer were kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: 1. Record review of Resident #38's face sheet, dated 09/06/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included Hypertension (high blood pressure), Shortness of breath, Depression, Anxiety , chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #38's MDS admission assessment, dated 05/17/2024, reflected a BIMS score of 06, which indicated severe cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #38's Physician Orders, dated 05/17/2024, reflected an order for Oxygen at 3 - 4 liters per minute via nasal cannula and nebulizer treatments two times daily. Change oxygen and nebulizer tubing weekly on Sunday. Record review of Resident #38's quarterly Care Plan, 06/24/2024, reflected a care plan for has COPD (obstructive pulmonary disease) - Oxygen at 2- 4 liters per minute continuously. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation on 09/04/2024 at 10:30 AM, revealed Resident #38 was lying in bed her nasal cannula was uncovered and hanging over the bed rail in her room with the nasal prongs lying on floor . 2. Record review of Resident # 61's face sheet, dated 08/06/2024, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #61 had diagnoses which included dementia (memory loss), Hypertension (high blood pressure), Pneumonia (Inflammation of the air sacs in the lungs), Muscle wasting, Shortness of breath, chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). Record review of Resident #61's MDS admission assessment, dated 07/29/2024, reflected a BIMS score of 12, which moderate cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #61's Physician Orders dated 08/07/2024 revealed an order for Oxygen at 3 liters per minute via nasal cannula and nebulizer treatments every six hours as needed. Change oxygen and nebulizer tubing as needed. Record review of Resident #61's admission Care Plan, dated 08/14/2024, reflected a care plan for [Shortness of Breath #61] has COPD (obstructive pulmonary disease) - Oxygen at 3 liters per minute continuously. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation and interview on 09/04/2024 at 09:45 AM, during initial rounds, Resident #61 was lying in his bed receiving oxygen via nasal cannula at 3 liters per minute. His nebulizer was sitting on the nightstand uncovered. In an interview on 09/06/2024 at 2:06 p.m., the administrator stated, she expects the nebulizer mouth pieces and oxygen nasal cannulas to be stored in a plastic bag when not in use. She further stated, by not cleaning and storing the nebulizers and oxygen nasal cannulas in a plastic bag could cause cross contamination and make the resident sick. In an interview on 09/06/2024 at 3:06 p.m., the DON stated, it is her expectation that the nebulizer tubing and mouthpiece be kept in a plastic bag when not in use and that it is the charge nurses responsibility to ensure that this is done. She further stated, if the nebulizers and oxygen tubing is not kept in plastic bag this could cause cross contamination and the resident could become ill. Record review of the facility policy Respiratory Therapy -Prevention of Infection, dated 2001 revised November 2011, revealed the following [in part]: Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Procedure: Product: Oxygen delivery devices (no-aerosol producing) Ex: venturi masks, nasal cannulas, oxygen supply tubing. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag between uses. 9. Discard the administration set-up every seven (7) days as needed.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 2 (Hall A and Hall E ) of 5 medication carts observed for medication storage. The facility did not ensure Hall A and Hall E Medication Carts was locked and secure. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings include: Observation on 9/5/2024 at 11:36 AM, revealed the Hall E medication cart was unlocked and unattended, the cart was parked in hall and nurse was in resident room. Nurse was not in line of sight of medication cart. Present in medication cart included over the counter medications, prescription medications, insulin, breathing treatment medication, narcotic drawer was locked by one lock. During an observation and interview on 09/05/24 at 4:30 PM , the medication cart was observed to be unlocked and unattended on Hall A with a resident within 6 feet away of open cart. In an interview on 09/05/2024 at 4:30 PM, LVN B stated that she did not know anyone had been close to the medication cart and knew she was to have it within eyesight if left unlocked. LVN B further stated if residents was to obtain medications from the medication carts that was not theirs, they could have an allergic reaction. Interview with LVN A on 9/5/2024 at 11:40 AM, revealed Normally I would have turned the cart away in the door way so I let go of my cart and went to her. I didn't think correctly. LVN A further stated the medication cart was not in her line of sight and it was not locked. LVN A stated the medication cart should be locked if not in use or line of sight and that lack of locking medication cart could lead to resident getting into cart causing drug diversion. Interview with DON on 9/5/24 at 11:38 AM revealed her expectation is for medication carts to be locked when nurse is not in front of cart or utilizing cart for medication pass. The DON also stated if cart is not locked residents could get into cart and have a possibility of drug diversion. In an interview on 9/5/24 at 12:28 PM the ADM stated should be locked according to our guidelines regarding expectation for medication cart security. ADM continued stating that lack of securing medication carts could potentially allow the wrong person to get in cart and get medications. Record review of policy Medication Carts from Pharmacy Policy and Procedure Manual 2003 revealed the following [in-part]: 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse.

Based on interview, and record review the facility did not make sure that residents receive adequate dialysis care for for 2 (Resident #25 and Resident # 43) of 3 residents in that: The facility failed to ensure physician orders were written for Resident #25 and Resident #43. This failure could place residents at risk of having errors in care and treatment. Findings include: Review of Resident # 25's face sheet dated 07/11/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of which included chronic kidney disease. Review of Resident #25's Quarterly MDS, dated [DATE], revealed Section C - Cognitive behavior a BIMS score of 9, which meant she had moderate cognitive impairment. Review of Resident #25's physician orders revealed no evidence of orders for dialysis. Review of Resident #43's face sheet, dated 07/11/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and dependence on renal dialysis. Review of Resident #43's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Behavior, a BIMS score of 13, which meant she was cognitively intact. Review of Resident #43's physician orders revealed no evidence of orders for dialysis. During an interview on 07/09/23 at 3:44 PM, Resident # 25 stated she received dialysis three days per week. During an interview on 07/11/23 at 1:56 PM, the DON stated she did not think there should have been an order for dialysis but was not sure what the policy stated. After the DON reviewed the policy she stated there should have been an order for dialysis per their policy. The DON stated her expectation was staff followed the policy. The DON stated what led to failure was the lack of knowledge on the DON's part. The DON stated there was no negative impact on the residents. The DON stated she was responsible for monitoring resident charts for accuracy. The DON confirmed that Resident #25 and Resident #43 had been receiving dialysis weekly. Review of the facility MDS Resident Matrix, dated 07/09/2023, revealed Resident #25 and Resident #43 received dialysis. Review of the facility policy titled, Dialysis, dated November 2013, revealed, Procedure 1. Review and confirm the physician's order for dialysis. Follow the specifications of the medical regiment including dietary restrictions and medical management.

Based on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 2 (Resident #25 and Resident # 43) of 3 residents reviewed for resident records. The facility failed to ensure physician orders were written for Resident #25 and Resident #43. This failure could place residents at risk of having errors in care and treatment. Findings include: Review of Resident # 25's face sheet dated 07/11/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of which included chronic kidney disease. Review of Resident #25's Quarterly MDS, dated [DATE], revealed Section C - Cognitive behavior a BIMS score of 9, which meant she had moderate cognitive impairment. Review of Resident #25's physician orders revealed no evidence of orders for dialysis. Review of Resident #43's face sheet, dated 07/11/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and dependence on renal dialysis. Review of Resident #43's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Behavior, a BIMS score of 13, which meant she was cognitively intact. Review of Resident #43's physician orders revealed no evidence of orders for dialysis. During an interview on 07/09/23 at 3:44 PM, Resident # 25 stated she received dialysis three days per week. During an interview on 07/11/23 at 1:56 PM, the DON stated she did not think there should have been an order for dialysis but was not sure what the policy stated. After the DON reviewed the policy she stated there should have been an order for dialysis per their policy. The DON stated her expectation was staff followed the policy. The DON stated what led to failure was the lack of knowledge on the DON's part. The DON stated there was no negative impact on the residents. The DON stated she was responsible for monitoring resident charts for accuracy. The DON confirmed that Resident #25 and Resident #43 had been receiving dialysis weekly. Review of the facility MDS Resident Matrix, dated 07/09/2023, revealed Resident #25 and Resident #43 received dialysis. Review of the facility policy titled, Dialysis, dated November 2013, revealed, Procedure 1. Review and confirm the physician's order for dialysis. Follow the specifications of the medical regiment including dietary restrictions and medical management. 44728

Based on observation, interview and record review the facility did not make sure that resdients withloss of bladder control received treatment or services to prevent infections and help get normal bladder control for 1 of 18 resident (Residents #30) reviewed in that: CNA-A failed to provide incontinent care in a manner to prevent potential spread of infection. This failure could place residents at risk for the spread of infection and skin complications. Findings include: Record review of Resident #30 Annual MDS, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE] with an active DX list that included: CAD (CAD Acronym or abbreviation to medical concept or diagnosis of coronary artery disease - common type of heart disease), Hypertension (High Blood Pressure), Hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), Neurogenic Bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem) and MS (a long-lasting [chronic] disease of the central nervous system). Resident #30 had a BIMS of 15, which meant the resident was cognitively intact. Resident #30 required ADL care needs of 2-person physical assistance. He had always been incontinent of bowel and bladder During observation on 07/10/2023 at 10:18 AM of peri care, the CNA-A performed peri care for Resident #30. While resident was on his side for peri care, CNA-A wiped the resident from back to front with a sanitary wipe. During interview on 07/10/2023 at 1:10 PM, CNA-A stated the procedures for peri care were to wipe the resident with sanitary wipes from front to back with one swipe and throw away. She stated when performing resident care, she should have never cleaned a resident from back to front with not being taught any other way. She stated it was a habit to perform perineal care the way she did. CNA-A stated if the resident was not wiped in the right direction it could cause the resident harm such as infection. During interview on 07/10/2023 at 1:17 PM, the DON stated while performing peri care on a resident, the staff member should wipe with a sanitary wipe once and throw away and definitely did not teach to wipe from back to front. She stated she did not teach her staff those procedures any other way. She stated best procedure for perineal care would be to wipe front to back. The DON stated there could be a negative impact to a resident of possible contamination. She stated the failures were that her CNA was nervous. Her expectation was to do perineal care correctly the first time as well as every time. She stated her trainings were done by observing her staff as well as having one on one, telling them they should carry out completely with each resident the right way, every time. Record review of the facility policy titled Perineal Care, dated 04/27/2022, revealed: .male Resident . 21. Gently perform care to the buttocks and anal area working from front to back without contaminating the perineal area.

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received necessary respiratory care and services that was in accordance with professional standards of practice for 3 of 6, (Resident # 61, 34, 53) residents reviewed for respiratory services. Resident #61 did not have signage on doorway indicating oxygen use, oxygen tubing and humidifier bottle undated, tubing laying in floor while not in use. Resident #34 did not have signage on doorway indicating oxygen use, oxygen tubing was dated 5/28. Resident #53 did not have signage on doorway indicating oxygen use, oxygen tubing and/or humidifier bottle was dated 5/29. These failures could place residents that used oxygen at risk of respiratory distress. Findings included: Resident #61 Record review of Resident #61's Facesheet dated 6/16/22 revealed an [AGE] year-old female admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #61's MDS dated [DATE] revealed a BIMS score of 7 meaning severely impaired cognition. Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . SOB: SOB with exertion, SOB when lying flat. Special treatments: Oxygen therapy while a resident. Record review of Resident #61's Care plan revised 6/13/22 revealed: The resident has oxygen therapy. The resident will have no signs or symptoms of poor oxygen absorption through the review that. Oxygen per NC. Notify the nurse if the oxygen is off the resident. Record review of Resident #61's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change respiratory tubing, mask, bottled water, clean filter every 7 days, every night shift every Sunday, start date of 1/23/22. Check O2 every shift and PRN as needed, start date of 1/20/22. Record review of Resident #61's TAR for June 2022 revealed: Oxygen saturation levels ranging from 97% to 93% in the daytime to 97% to 92% in the evening time. Change respiratory tubing, mask, bottled water, clean filter every 7 days, every night shift every Sunday, with a staff signature for 6/5/22 and 6/12/22. During an observation on 6/14/22 at 11:18AM of Resident #61's room revealed, Resident did not have signage on doorway identifying oxygen use. Resident was not wearing oxygen at that time. The oxygen tubing with NC was laying on the floor near oxygen concentrator. There was no date on resident's humidifier bottle and/or tubing. There was not a bag present to place oxygen tubing inside while not in use. During an observation on 6/15/22 at 9:43AM of Resident #61, she was not wearing O2 at that time. The oxygen tubing was in a bag and the humidifier bottle had a date of 6/12/22. Resident #34 Record review of Resident #34's Face sheet dated 6/16/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's MDS dated [DATE] revealed a BIMS of 14 meaning no cognitive deficits. Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Special Treatments: Oxygen therapy not selected while or while not a resident of the facility. Record review of Resident #34's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change respiratory tubing, mask, bottled water, clean filter q7d every nightshift every Sun with a start date of 12/30/2021. Check O2 sat Q shift and PRN as needed with a start date of 12/30/2021. Record review of Resident #34's TAR for June 2022 revealed: change respiratory tubing, mask, bottled water, clean filter q7d every nightshift every sun. Nurse signed off 6/5/22 and 6/12/22. During an observation and interview with Resident #34 on 6/14/22 at 11:22AM, she had O2 via NC at 3LPM. Her oxygen tubing had a date of 5/28/22. Resident #34 said she wore O2 on a continuous basis and did not know when the facility staff last changed her O2 tubing. Resident #34 did not have signage on her doorway to indicate that she used O2. During an observation and interview with Resident #34 on 6/15/22 at 10:03AM, her O2 tubing was dated 5/28/22. She said the facility staff had not been in to change her O2 recently. During an observation and interview with Resident #34 on 6/16/22 at 9:41AM, her O2 tubing was dated 5/28/22. She said facility staff had not changed her O2 tubing recently. Resident #53 Record review of Resident #53's Facesheet dated 6/16/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #53's MDS dated [DATE] revealed a BIMS of 15, meaning no cognitive deficits. Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Special Treatments: Oxygen therapy while a resident of the facility. Record review of Resident #53's Care plan last revised 1/12/22 revealed: Resident has O2 therapy. The resident will have no signs of poor O2 absorption. O2 per NC. Record review of Resident #53's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview with Resident #53 on 6/14/22 at 10:57am, her humidifier bottle on her O2 concentrator was dated 5/29/22, with no date on the O2 tubing. Resident did not have signage on her doorway to indicate O2 usage. She said it was about time to change her tubing. During an interview with LVN M on 6/16/22 at 8:55AM, he said night shift changed O2 equipment weekly, and both the tubing and bottle should be dated with a bag for the tubing when not in use. He said there should have been O2 signs on all doors that O2 was being used. LVN M said nurses and administration were responsible for ensuring signs were in place. He said the failure of not changing O2 equipment weekly could hibernate bacteria, cause discomfort for the resident if water ran out of the humidifier out and cause potential nose bleeds. He said the signs were meant to help staff and EMS know who had O2. During an interview with the DON on 06/16/22 at 10:31 AM, she said it was a standard nursing practice that the equipment, tubing, and bottle would be changed out weekly. She said it would also be a standard that it all got changed out at the same time, so the date on 1 item such as the bottle would be the date that the bottle and tubing was replaced. She said that differences could have been the night nurse was changing all residents O2 and missed Resident #61 and then when they came back from their day off, seen the equipment together in their cart and changed it all out, not changing the dates they already had prepared originally. During an interview with DON on 06/16/22 at 10:40 AM, she said the O2 policy addressed changing O2 equipment weekly but not specifically that an order to change the O2 equipment was needed. She said, she might have the nurses put a date all equipment including tubing and bottle to avoid that type of confusion again. DON said Resident #34 and #53 both wore continuous oxygen, so she wondered why they especially did not have recent dates. She said Resident #34 had a lot of nasal drainage routinely. During an interview with LVN E on 6/16/22 at 10:55AM, she said night shift staff changed out O2 equipment weekly. She said the resident should have a sign outside the door to indicate that O2 was in use in the room and to not smoke. Failure to change the O2 equipment weekly could cause their nose to get dry, cause distress, and the water in the humidifier to become stagnant. During an interview with ADM on 06/16/22 at 11:21 AM, she thought all the residents that used O2 had signs up on their doorway prior to survey entrance. She said she used to go through the facility and audit and make sure the signs were there. Record review of facility policy labeled Oxygen Administration last revised 2/13/07 revealed: Oxygenation administration disposable equipment should be changed weekly and PRN . Place NO SMOKING signs in area when oxygen is administered.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (Hall A med cart, Hall B med cart) reviewed for medication labeling and storage. The A Hall medication cart contained one vial of [MEDICATION(S)] R insulin for Resident #62 with an open date of 05/01/2022. The A Hall medication cart contained one [MEDICATION(S)] flex pen insulin for Resident #52 with no open date. The B Hall medication cart contained one [MEDICATION(S)] flex pen insulin with an open date of 04/29/2022 and one [MEDICATION(S)] flex pen insulin with no open date for Resident #75. The B Hall medication cart contained one vial of [MEDICATION(S)] R insulin for Resident #67 with an open date of 05/01/2022. The B Hall medication cart contained one vial of Insulin [MEDICATION(S)] for Resident #229 with no open date. These failures could place residents who receive insulin at risk of exposure to medications and/or biologicals that are expired and/or contaminated. Findings Included: Record review of the electronic face sheet for Resident #62 reveled admitted [DATE]. Resident was [AGE] years old female with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 2u; 251 - 300 = 4u; 301 - 350 = 6u; 351 - 400 = 7u, Subcutaneously Four Times A Day. Record review of the electronic face sheet for Resident #52 reveled admitted [DATE]. Resident was [AGE] years old male with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the electronic face sheet for Resident #75 reveled admitted [DATE]. Resident was [AGE] years old male with a diagnose of diabetes. Record review of electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 2 U; 201 - 250 = 4u; 251 - 300 = 6u; 301 - 350 = 8u; 351 - 400 = 10u, Subcutaneously. Record review of the electronic face sheet for Resident #67 reveled admitted [DATE]. Resident was [AGE] years old female with a diagnose of diabetes. Record review of electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 unit; 401 - 450 = 12 units, subcutaneously before meals for DM AND Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units, subcutaneously at bedtime for DM. Record review of the electronic face sheet for Resident #229 reveled admitted [DATE]. Resident was [AGE] years old female with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401+ = 10 units, subcutaneously two times a day for diabetes. During on observation on 06/14/2022 at 10:10 AM of the B Hall medication cart with LVN A, a [MEDICATION(S)] flex pen insulin with an open date of 04/29/2022 and one [MEDICATION(S)] flex pen insulin with no open date for Resident #75 was found. Further observation revealed one vial of [MEDICATION(S)] R insulin for Resident #67 with an open date of 05/01/2022 and one vial of Insulin [MEDICATION(S)] for Resident #229 with no open date. During on observation on 06/14/2022 at 10:20 AM of the A Hall medication cart with LVN A, a vial of [MEDICATION(S)] R insulin for Resident #62 with an open date of 05/01/2022 and a [MEDICATION(S)] flex pen insulin for Resident #52 with no open date was found. During an interview on 06/14/22 at 10:50 AM, LVN A stated insulin should be dated upon opening or breaking the seal because Insulin was only good for 28 days after opening. He stated a lot of the outdated insulins were PRN and were hardly ever given was why it was missed. He stated nurses check the dates when giving the medication. During an interview on 06/14/22 at 03:36 PM the DON stated all insulins must be dated when opening and Insulins must be discarded within 28 days of opening. She was unsure why the failure occurred. She stated it was the nurse's responsibility to check dates prior to administration. She stated the nurses should audit the med carts weekly. She stated negative harm could be residents receiving expired medications and not receiving the desired effect of the medication. Record review of policy titled, Medication Storage and Labeling, last revised 02/2017 read in part . Multi-dose vials which have been opened or accessed (e.g., needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial .

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident # 1) of six residents reviewed for accidents and supervision. Resident #1, who had a known history of wandering, exited the facility on 9/16/17 at 4:30 PM through the front door. The resident had a wanderguard attached to the wheelchair but went outside unnoticed. The resident was left outside alone for approximately 30 minutes during in which time he sustained 2nd degree sunburns to his lower legs, arms, abdomen and chest covering 8 % of his body and was diagnosed with [REDACTED]. This failure could place 11 residents who scored at risk to wander or high risk to wander for serious injury if outside unsupervised. The findings included: Review of face sheet undated documented Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #'s1 Brief Interview for Mental Status (BIMS) scores revealed the following: 9/9/17 scored a 2 8/26/17 scored a 3 7/17/17 scored a 6 Review of the BIMS scores above show 0-7 indicated the resident was severely impaired. Review of Care Plan dated 7/14/17 revealed Resident ID #1 was at risk for injury related to identification of elopement risk factors and/or exit seeking behavior as evidenced by: impaired cognition, length of stay less than a year, independent locomotion, decreased safety awareness, exit seeking, and an elopement episode. Review of an Resident ID #1's incident report dated 7/14/17 at 8:22 PM revealed the resident was found outside of the building lying in the grass. Review of Resident ID #1's nurses notes dated 7/14/17 at 8:22 PM revealed the resident was observed outside laying on the grass in front of the building on his right side. Documentation stated that the resident's wheelchair was in the driveway. The resident had swelling to his right wrist. The physician was on scene and evaluated the resident decided to send him to the emergency room for evaluation. The responsible party was contacted at that time and the facility attempted to get a consent for a wanderguard bracelet but the responsible party refused the resident to have one at that time. The facility did not put the resident on any special supervision or checks at that time. Review of the nurse's notes (approximately 2 months later) for Resident ID #1 on 9/16/17 revealed that the resident was in the hallway by the med cart approximately 4:10 PM that afternoon, according to LVN E. At 4:30 PM, CNA F reported that the resident was outside sitting in his wheelchair out front. The CNA immediately went to get the resident back in the facility and the nurse's notes documented the resident was not his normal self. The nurses notes stated the CNA alerted the nurse and the resident appeared to be lethargic with his skin temperature elevated and redness to his extremities. The facility called the EMS and the resident was transferred to the emergency room at that time. Review of Weekend RN D nurse's notes for Resident ID #1 on 9/16/17 at 7:45 PM (recorded as a late entry for 4:45 PM) revealed that the resident was found outside the building and was very hot. The residents oxygen saturation was 88% on room air (normal is 95-100 %). The EMS was called and the facility applied wet washcloth to the resident's body, under his arms and back. Record Review of the EMS notes revealed they arrived at the facility at 5:00 PM and Resident ID #1's temperature was 102 F. The documentation stated the EMS arrived on scene and was told by the nursing staff the resident was found unresponsive in his wheelchair outside in the direct sunlight. It was unknown the amount of time he'd been sitting outside. The EMS transferred the resident to the local ER at that time. Interview with LVN E on 9/19/17 at 12:10 PM revealed on 9/16/17 she was the charge nurse for Resident ID #1. LVN E stated that around 4:10 PM she was getting ready to do her med pass and saw Resident ID #1 pass by her med cart. She stated the next thing she knew was CNA F came in and stated that Resident ID #1 was outside and she told CNA F Oh no, go get him it's time for dinner. LVN E stated that CNA F yelled for help the resident was not responding. LVN E stated he had a T-shirt and a pair of shorts on. He also had socks on his feet. LVN E stated his extremities were very red, his skin very hot and that he was moaning. The nurse also stated that the resident had very fair skin. The nurse stated she had to pick Resident ID #1's feet up from the wheelchair and she and CNA F wheeled the resident back down to his room to assess him. She stated that LVN G from Hall B came to help and she also went to call 911. LVN E stated the EMS arrived very quickly and he was sent to the emergency room for evaluation. Interview with CNA F on 9/19/17 at 12:45 PM revealed she was the aide taking care of Resident ID #1 the day he was found outside the facility. She stated she went to lunch around 3:30 PM, and was coming back from lunch around 4:30 PM as she noticed him outside the front driveway. CNA F stated she went into the facility, clocked in, set her drink down, and was told by LVN E that she needed to go get Resident ID #1 due he had a wander guard on and should not be outside by himself. CNA F stated she was unaware that they had gotten the consent for the wanderguard but knew that he needed one due to a past elopement. CNA F stated she went outside and noticed that Resident ID #1 was not talking and making groaning noises. CNA F stated she immediately wheeled the resident back into the facility and yelled for help. CNA F stated Resident ID #1 was very hot to the touch. She stated the staff took him back down to his room and started sponging him off with washcloths from the tap water. CNA F stated that 911 was called and the resident was transferred to the emergency room . Record review of the weather forecast for Brownwood Texas according to the weather bug application it was 100° on 9/19/17 at 4 PM the day the resident was found outside. (website www.city-data.com/crime-Brownwood-Texas. htm.) Record review of the emergency room documentation dated 9/16/17 at 5:30 PM revealed the resident was found outside in his wheelchair for approximately 30 minutes or longer to heat exposure. The emergency room documented that the resident was confused decreased responsiveness and trouble concentrating possibly due to sun exposure. The emergency room documented the resident's vital signs were blood pressure 96/50 (normal 70-150), pulse 162 (normal 60-100), respirations 34 (normal 12-24), temperature 102.2 F.(normal 98.6), and oxygen at 98% on a non-rebreather oxygen mask. The resident's temperature at 5:43 PM did peak at 104.9 F. Documentation stated that the resident's skin appeared to be hot with 1st° burns covering approximately 8% of the total body surface. Documentation stated that the resident had significant episodes of evidence of sunburn/rash. Review of the emergency room discharge on 9/17/17 at 12:33 AM revealed the resident was transferred to a larger hospital. Review of the progress notes for Resident ID #1 the next day on 9/17/17 at 11:43 AM revealed the resident had extensive blistering in sun exposed areas including anterior upper extremities as well as anterior lower extremities. The resident has bilateral blistering with no crusting at that time. Review of a Pharmacokinetic Initial Note dated 9/17/17 at 2:58 PM revealed Resident ID #1 was on the medication vancomycin, patient was diagnosed with [REDACTED]. Interview with the administrator on 9/19/17 and 9:40 AM revealed that the family would not agree on a wanderguard the first time the resident got out of the building in July but reluctantly signed a consent form for the wanderguard the first of September. Review of the wandergaurd consent revealed it was signed on September 9th 2017. The administrator stated the facility had been keeping an eye on the resident and not letting him go outside alone due to safety issues prior to getting the wanderguard. The administrator also stated resident was sent to a large hospital due to a gastrointestinal bleeding not related to the elopement. He stated the resident would not be returning to the facility. Observation of the wanderguard system on 9/19/17 at 10 AM revealed that the front door had a security code box attached to the wall and the administrator stated that the system was not connected to the front door or the back door. The administrator stated if the wanderguard bracelet became within 10 feet the alarm, it would go off and would continue to go off until someone punched in the security code. The administrator went on to say that the day Resident ID #1 left the building, no one heard the alarm go off. Review of Residents that had orders for the wandergard alerts provided by the DON on 9/19/17 documented 11 residents who were at risk to wander.