Every finding on record at St. Catherine Center

Based on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status for one (Resident #50) of four residents reviewed for change of condition. The facility failed to recognize a change in condition in Resident #50 on 3/13/2026 after she was reported to the CNA to be experiencing stroke like symptoms and Resident #50 was not transported to the hospital until 3/14/2026. This deficient practice could place residents at risk for injury and harm.Findings included: Record review of Resident #50's admission's record dated 4/28/2026 revealed Resident #50 was an [AGE] year-old female who was initially admitted on [DATE] was diagnosed with of unspecified sequelae of cerebral infarction (long-term complications or residual effects that occur after a stroke, when the specific consequences are not clearly identified), idiopathic peripheral autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions), hypertension (a common condition where the force of blood against the artery walls is consistently too high), gastro-esophageal reflux disease (stomach acid flows back up into the esophagus and causes heartburn). Record review of Resident #50's Quarterly MDS assessment dated [DATE] revealed Resident #50's BIMS score of 07- indicated severe impairment. Resident #50 needed substantial/maximal assistance with ADLs. Record review of Resident #50's care plan revision date on 03/20/2026 revealed The resident is at risk and/or has impaired communication related to: Change in environment. Review of a progress note dated 03/14/2026 at 2:19pm by LVN J revealed, CNA requested resident be assessed d/t change in condition. Resident has rt sided weakness, facial drooping on right side, slurring words, and per CNAs, resident is unable to assist with transfers per her usual. Resident's emergency contact was at resident's bedside. She stated that she informed staff that there was something wrong with residents yesterday. Called EMS for transport, they arrived at 2:11pm and left facility with resident at 2:15pm. In an interview on 04/28/2026 at 10:30am with Resident #50's FM, she stated that she was visiting Resident #50 on 3/13/2026 around 10 am. The FM stated she noticed Resident #50's mouth was drooping; she was slobbering and was slurring her words. She stated she told CNA L that she came to visit Resident 50 and that she looked like she was having a stroke. She stated she went to the nurses' station, and the person at the nurse's station stated it was a result of Resident #50's Parkinsons, and that there was no staff followed up by checking her vitals. She stated on 03/14/2026 Resident #50 admitted to the hospital for a stroke. In an interview on 4/28/2026 at 11:53 am, LVN A stated he was the nurse manager on Resident #50's floor. He stated Resident #50 did not have Parkinsons after looking up her diagnosis. He stated that signs of a stroke were weakness to one side and facial drooping. He stated there was no verbal or written communication of Resident #50 having any signs or symptoms of a stroke on 3/13/2026. He stated they called EMS on 3/14/2026 and she went to the hospital at 2:15 PM. In an interview on 4/28/2026 at 1:23 pm, with the IP, she stated she administered Resident #50 medications at bedtime, and she was able to swallow and take them with no problems. Resident #50 had no changes from when she previously seen her, which was several weeks ago when she was on a different floor (2nd floor). The IP went into Resident #50 room and reviewed her eye drops with her. There were no facial drooping or no deficits. Resident #50 had no signs and symptoms of a stroke. It was about 7:30 to 8:30 pm when she administered pills. In an interview on 4/28/2026 at 2:12 pm, the RA stated she worked with Resident #50 on the 2nd floor, and she did not notice any changes. The RA walked with Resident #50, and when the RA spoke with a CNA, did not remember which CNA, and they stated they had issues with her transferring to the wheelchair to bed and to toilet to the bed. She noted it in her notes. The RA noted Resident #50 was not feeling very well, and she was having difficulty walking. She spoke to the nurse, and she does not remember what nurse she advised of the COC with the resident. The RA stated she did not have Resident #50 too long, and it was the weekend and a relative stated they noticed something was going on. When she saw her on the second floor, she was hard to transfer then. She noticed slow speech, but it was not a whole lot. In an interview on 04/28/2026 at 3:15pm, the DON stated the family of Resident #50 had some concerns regarding a delay in seeking care. He stated that the nursing staff sent the resident to the hospital the next day. He stated that he hoped if signs and symptoms were observed of a stroke, they would have contacted the MD, which was done on the 14th. He stated that he did not interview any of his staff, he just reviewed Resident #50's chart. He said that the family brought it to the attention of a nurse (he guessed on Friday night), and the nurse told them that was a diagnosis of Parkinson's. He stated that the nurse supervisor told him that too. He stated since Resident #50's CVA she had deficits that she was working on with therapy. In an interview on 04/28/2026 at 3:15pm, the MD stated that the resident, if symptoms were identified as a stroke within 4.5 hours, it would have to be caught within a short timeframe, to determine if she would have been a candidate for the clot buster medication. He stated young people could benefit from clot busters, but for Resident #50, her age may be a contraindicator. He stated that once stroke signs and symptoms were recognized, a provider should be notified. He stated that Resident #50 had an acute CVA. In an interview on 4/30/2026 at 10:31 am, CNA L stated Resident #50 did not look right. And she advised LVN J to go check on her and she did. She said later around lunch time; she was about to take Resident #50 to the dining area, and she advised LVN J to check on her again because it appeared as if she needed to go to the hospital. CNA L stated Resident #50 appearance had changed especially her speech, it was slurred. She stated she was talking better earlier. She stated LVN J took Resident #50's vitals and assessed the resident, and they prepared to send her to the hospital. Review of the facility's policy titled Change in a Resident's Condition or Status dated 01/2026 reflected, The nurse will notify the resident health care provider or physician on call when there has been a (an):1. Accident or incident involving the resident.4. significant change in the residents' physical/emotional/mental condition.C. Prior to notifying the health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 6 residents (Resident #65 and Resident #137) reviewed for resident rights.The facility failed to ensure CNA B knocked on Resident #137's door before entering the resident's room.The facility failed to ensure CNA E knocked on Resident #65's door before entering the resident's room.The facility failed to ensure CNA F knocked on Resident #65's door before entering the resident's room.These failures could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress.Findings included:Record review of Resident #65's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #65 diagnosis included cerebral infarction (stroke) affecting the left non-dominant side and unsteadiness in the feet.Record review of Resident #65's quarterly MDS assessment, dated 04/17/2026, revealed Resident #65 had a BIMS score of 12, which indicated moderate cognitive impairment.Record review of Resident #137's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #137 diagnosis included Transient cerebral ischemic attack, unspecified (mini stroke), and limitation of activities due to disability. Record review of Resident #137's quarterly MDS assessment, dated 04/17/2026, revealed Resident #137 had a BIMS score of 11, which indicated moderate cognitive impairment.In an observation and interview on 04/28/2026 at 10:43 AM with Resident #65 in her room, CNA F entered the room without knocking. Resident #65 stated that sometimes the staff knocked, and sometimes they did not.In an observation and interview on 04/28/2026 at 11:05 AM with Resident #137 in her room, LVN G entered the room without knocking. Resident #137 stated that there were times when the staff did not knock before entering. Resident #137 stated that she had not made a complaint to anyone.In an observation on 04/28/2026 at 11:23 AM of the 200 hall, CNA B was observed entering Resident #137's room without knocking.In an interview on 04/28/2026 at 11:21 AM, CNA B stated she was supposed to knock on the door before going into the room. CNA B stated that she was in a hurry and forgot. CNA B stated that if they did not knock on the door, it would be a resident rights issue. CNA B stated that the resident may be in the middle of receiving care, so they should knock on the resident's door before entering the room. CNA B stated that she had in-service training on resident rights about a month ago.In an interview on 4/30/2026 at 10:34 AM, LVN G stated that the only time you would not knock on the door was if there was an emergency. LVN G stated that if the door was open, staff still needed to knock and introduce themselves. LVN G stated if you did not knock on the door, you could have walked in while the resident was receiving patient care. LVN G stated that failing to knock on the door violated residents' rights. LVN G stated that the only reason she did not knock that time was that she had just been in that room for something else. LVN G stated that she had received in-service training on resident rights, and the last time was about a month ago.In an interview on 4/30/2026 at 10:49 AM, RN H stated he was the charge nurse for the second floor. RN H stated all staff were expected to knock on the resident's door before entering the resident's room. RN H stated he ensured this by doing rounds to make sure staff were knocking on residents' doors. RN H stated they also brought this up during their huddle before each shift. RN H stated they do yearly training and training in the education binder. RN H stated he ensured new staff were aware that they must knock on the resident door before entering. He said new staff are made aware of this in their onboarding education and training. RN H stated he had not seen any staff knock on residents' doors before entering. RN H stated if he saw that, he would remind them to knock on the resident's door. RN H stated he would re-educate staff members who did not knock on the door. RN stated he had not had any complaints from residents about staff not knocking on the door.In an interview on 4/30/2026 at 11:00 AM , CNA C stated that staff should never enter the room without knocking. CNA C stated if the door was open, she would knock on the door or the wall and verbally let them know she was going inside. CNA C stated knocking was necessary if the resident was receiving patient care at the time. CNA C stated that she had not witnessed any other staff member fail to knock on the door before entering a residents' room. CNA C stated that if she saw another staff member not knocking before entering a room, she would remind them. CNA C stated that she had in-service training on residents' rights about a month ago.In an interview on 4/30/2026 at 11:08 AM, CNA D stated that staff were instructed to always knock unless there was an emergency. CNA D stated that even when the resident's door was open, staff still knocked and identified themselves to the residents. CNA D stated she had not witnessed staff failing to knock on doors, residents' doors, and if she did, she would remind staff to knock. She said resident's rights and privacy were discussed a month ago. She stated when rushed, she had at times forgotten to knock.In an interview on 4/30/2026 at 11:15 AM, LVN A stated he was the charge nurse on the third floor, and he did random rounds to check and observe staff knocking on residents' doors. LVN A stated he had not witnessed staff not knocking on doors before entering the residents rooms. LVN A stated he had in-serviced on resident rights last year. LVN A stated that all new staff were made aware of this policy during orientation upon hire. LVN A stated he had not witnessed any staff failing to knock on doors before entering rooms. He stated if he witnessed a staff member not knocking on the door, he would remind them and then reeducate them. LVN A stated he had not heard any complaints from residents, saying that staff were not knocking on their doors.In an interview on 04/30/2026 at 11:27 AM, the DON stated that all staff were expected to knock on residents' doors before entering. The DON stated if staff were not knocking on doors, it was a resident rights and privacy issue because residents could be in the middle of patient care. The DON stated he made rounds to ensure staff were following these procedures. The DON stated that in the past, there was an issue with staff not knocking on doors, but he had not heard of anything recently. The DON stated that he had not witnessed any staff not knocking on doors, but if he saw staff not knocking on doors, he would stop them and remind them. The DON stated he would conduct education with the staff, about the importance of knocking on resident's doors before entering.Review of the facility's policy titled 'Quality of Life - Dignity', dated 12/2021 reflected, 1. Associates will knock and request permission before entering residents' rooms.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed. The facility failed to ensure Dietary Staff performed good hand hygiene within the context of food handling and sanitation. This failure could place residents at risk of cross contamination and the potential transmission of infectious organisms. Findings included: An observation on 04/28/2026 at 11:45AM during lunch DA M was observed picking up a hamburger patty with her hands. It was observed that she was not wearing any gloves or using any utensils to remove the meat from the pan. In an interview on 04/30/2026 at 10:13AM, DA M stated her job description stated her job description is to set up trays, serve the residents, and clean the dining area. She started to pick up the meat rushing. She stated at some point they told them they did not have to wear gloves. She stated that it is not normal practice to pick up food with her hands. She stated a negative outcome could spread germs and someone can get sick. In an interview on 04/30/2026 at 10:18 AM, DA N stated her job description is to serve the residents, check temperatures on the food, fixing drinks, making sure their food trays match their meal tickets, clean the dining area, sweep and wipe the tables. She stated they should wear gloves while handling food and washing their hands before, during and after handling food. She stated a negative outcome was that someone could get sick and get cross-contamination. In an interview on 04/30/2026 at 10:45 AM, CK O stated her job duties include but are not limited to cooking all diets such as regular, mechanical, and puree diets, she starts lunch meats and gravies. She stated sometimes you might forget to put gloves on, but you are handling food so you should wash and put gloves on immediately. She stated she tries to watch everyone when they are handling food to make sure, they have on gloves. She stated that it is not normal practice to handle food without gloves. CK O stated handling food inappropriately can cause cross-contamination, and you will have messed up a whole pan of food. She stated her expectations for her staff is to be the best. She stated she would help them out. She tells them if they will not eat it don't give it to anyone else. In an interview on 04/30/2026 at 11:05 AM, the DIR stated his job duties included keeping the kitchen a flow, making sure the right food was going in and out of the kitchen to the residents, and making sure the right staff was in place to do the job. The DIR stated a couple of months ago, they came out with a new rule they wanted all staff to use tongs, and they did not have to wear gloves. He stated then corporate came back and said it was a mistake and to continue wearing gloves. He stated that was why DA M might have been confused. He stated no food should have been picked up with her bare hands. A negative effect could be cross-contamination, germs, bacteria, sickness, or worse. The DIR stated his expectation from has staff was to always be prepared and wear their gloves. Clean their utensils. This is older folks and their immune system is not what it used to be. Review of facility policy titled Food Handling Guidelines (HACCP) revision date January 2024, stated Food should be protected against cross-contamination by appropriately separating types of raw animal products such as beef, lamb, pork and poultry during storage and processing with the use of separate equipment or areas or by scheduling and cleaning; and appropriately separating raw (potentially hazardous) foods from ready-to-eat food products during storge, preparation, and/or service. Raw, unwashed produce is stored separately from washed, ready-to-eat foods. Cutting boards and other food contact surfaces are cleaned and sanitized between different food preparation steps. The following three-color cutting board system is standard: green boards are used for washed produced, red for all raw animal foods, and white for all cooked and ready-to-eat foods. Chemicals, including red buckets sanitizer solutions, are not stored where food is prepared (example, on the food preparation table). 1.) Hands should be scrubbed following appropriate hand-washing techniques according to facility/community policy (e.g., after toilet use, between food preparation tasks, before putting on gloves, etc.).

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #119) of seven residents reviewed for ADL care.The facility failed on 04/28/2026 to ensure they cleaned Resident #119's motorized wheelchair for an indeterminant amount of time. This failure could place residents at risk of infection, and loss of dignity.Findings included:Record review of Resident #119's comprehensive MDS assessment dated [DATE] reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Diagnoses included: coronary artery disease (narrowing or blockage of the coronary arteries due to plaque buildup), high blood pressure, kidney failure, diabetes mellitus (chronic condition where the body cannot properly use blood sugar), high cholesterol (elevated levels of cholesterol in the blood), legal blindness, and morbid obesity. Resident #119 was coded under functional abilities as having impairment on both sides of his lower extremities, he used a motorized wheelchair. Resident #119 had a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #119's comprehensive care plan dated 04/29/2026 reflected Resident #119 was at risk for acquiring or transmitting infection due to wounds, at risk for pressure ulcers and/or impaired skin integrity, and he needed assistance with daily ADL care.In an observation and interview on 04/28/2026 at 10:59 AM, Resident #119 was observed with 2 above the knee amputations. He was sitting in a motorized wheelchair that was visibly soiled with debris all over the footrest, the arm rests, the plastic above the wheels, and the visible portion of the seat cushion. Resident #119 stated he was legally blind. He stated he was not receiving rehabilitation presently, because they were waiting on his inner left thigh wound to heal. He stated the staff did not normally clean his wheelchair, nor did they offer to clean it. He stated he had not asked staff to help him clean it because he did not know they would do that for him. He stated at home he would get on the ground and clean it off, but since he did not have his left leg anymore, he could no longer do that on his own. He stated he dropped a piece of meat on it yesterday. An observation of a golf ball sized red/brown goo was observed at the bottom of the wheelchair near the footrest. He stated he had been using his motorized chair for 7 months, and he did not recall anyone offering or telling him they were cleaning his wheelchair. He stated he felt partly responsible for it being dirty because he did not ask anyone to clean it for him. In an interview on 04/30/2026 at 10:15 AM, the IP stated she could not remember the exact protocol for cleaning and disinfecting resident-owned equipment like motorized wheelchairs, but she knew they needed to be cleaned once weekly on a certain shift, by CNA's. She stated from an infection control standpoint, she had not identified any issues with equipment cleanliness, but that all staff were educated on cleaning and disinfecting shared equipment between resident use. She stated that appropriate cleaning supplies were readily available in the shower rooms. She stated that barriers to cleaning motorized wheelchairs could be the electronic components, and the residents being in their chairs a lot. In an interview on 04/30/2026 at 1:45 PM, LVN A stated he had worked at the facility for 21 years. He stated he was unsure if they had a policy on cleaning motorized wheelchairs, but the protocols they had in place was that they were cleaned at night, by CNA's. He provided a schedule that had rooms assigned on certain days, for the wheelchairs in those rooms to be cleaned. He stated that those schedules were posted at every nurse's substation. He stated there was nowhere the CNA's indicated that the task had been completed, whether on paper or on the computer. He stated he ensured the wheelchairs were being cleaned by spot checking them during rounds. In an interview on 04/30/2026 at 2:10 PM, CNA I stated she had worked at the facility for approximately 6 months. She stated that most of the time she would clean wheelchairs if she noticed they were dirty, but technically it was night shift CNA's responsibility to clean. She stated she recalled prior shifts she worked where she had washed off Resident #119's chair while he showered himself, and that was about 3 weeks ago. She stated the importance of cleaning resident wheelchairs would be so they worked properly, resident dignity, and risk of infection since Resident #119 has sores on his leg. She stated she was still learning the charting system so she was not familiar with a place to notate it. In an interview on 04/30/2026 at 2:17 PM, LVN J stated she had worked at the facility for a little over a year. She stated nightshift CNA's were responsible for cleaning resident wheelchairs. She stated they did not write down that the task was completed. She stated that she had never noticed Resident #119's wheelchair being dirty, and she was not sure when it was last cleaned. She stated that if she noticed it was dirty she would delegate the task to one of the CNA's. She stated there were sanitary issues if it was not cleaned, and risk of infection because his skin touched the wheelchair, and he had diabetic ulcer's. In an interview on 04/30/2026 at 2:25 PM, CNA K stated she worked at the facility for approximately 2 years. She stated that everybody was responsible for cleaning wheelchairs if they were noticeably dirty, but night shift was primarily responsible. She stated that it had been awhile since she had worked with Resident #119, but that his wheelchair got dirty a lot because he had vision impairments and would drop food on himself and the chair. She stated that he had visitors and would go outside and it would get dirty from being outside, but she was unsure how often he went outside. She stated that dirty wheelchairs could cause infection, especially when he got in and out of the chair, he could scrape over the food and it was unsanitary. She stated there was nowhere to document that they had cleaned resident wheelchairs, there was a wheelchair cleaning chart, but it was not used for documentation. In an interview on 04/30/2026 at 2:34 PM, the DON stated he had worked at the facility for 18 years. He stated their policy did not specify the cleaning and disinfecting requirements for resident-owned equipment like motorized wheelchairs, but their procedure was to wash resident wheelchairs once a week, at night by the CNA's. He stated they had a schedule by room number, that they went by for wheelchair cleaning. He stated they monitored cleanliness through general spot checks and rounding. He stated they could not show how it was being implemented for Resident #119, because they did not have staff document the task. He stated that negative impacts could be dignity issues, because despite Resident #119's vision impairment, he could tell when his wheelchair was dirty, and it was an infection control issue. Review of the facility policy titled 'Cleaning and Disinfection of Resident-Care Items and Equipment' dated 06/2025 reflected: Resident-care equipment can be a source of indirect transmission of pathogens. 3. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable).

The facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration, was provided with such care, consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed. The facility failed to apply Resident #1's APAP (Automatic Positive Airway Pressure- a type of non-invasive mechanical ventilator) machine at HS (Hour of Sleep) for 15 days out of 29 for the month of October. This failure could place residents who require respiratory care at risk of distress including respiratory failure leading to hospitalizations or even death.Findings include: Record review of Profile Face Sheet dated 10/29/2025 reflected Resident #1 was admitted on [DATE] with diagnosis of Cerebral Palsy, Spastic Quadriplegic Cerebral Palsy, Muscle Weakness, and Dysphagia.[JM1] Record review of Resident #1's Physicians Orders reflected an order to Apply APAP (Automatic Positive Airway Pressure) machine at HS (Hour of Sleep) dated 04/24/2025. Record review of Resident #1's care plan dated 10/02/2025 reflected Problem: PULMONARY: Resident #1 has potential for SOB[JM2] and/or respiratory complications related to recent respiratory failure now with order for APAP at HS. Goal: [NAME] [JM3] will have no respiratory complications or signs or symptoms of shortness of breath. Intervention: Provide treatment per physician's orders and monitor for response. Observe for side effects and inform physician. The Care plan also reflected that Resident #1 Required total assistance with ADLs including mobility and transfers, Record review of Resident #1s MDS dated [DATE] reflected he had a BIMS of 06 indicating impaired cognition. The MDS also reflected Resident #1 used a noninvasive mechanical ventilator. Record review of Treatment record Dated October 2025 reflected that Resident #1s APAP machine was applied at HS with no documented refusals each night. Record review of Resident #1s progress notes for October 2025 reflected there were no documented refusals of APAP application. Record review of Resident #1s APAP Compliance Calendar Report (an internal device report) for the month of October 2025 provided by The Respiratory Company showed that Resident #1 had 15 days without his APAP device usage. This report indicated that the device was not turned on or used for dates 10/01/25, 10/02/25, 10/07/25, 10/08/25, 10/09/25, 10/10/25, 10/11/25, 10/12/25, 10/15/25, 10/18/25, 10/22/25, 10/24/25, 10/25/25, 10/25/25, and 10/26/25. In an interview on 10/29/25 at 9:00am Resident #1's responsible party stated she had received a call from the supply company of the APAP machine. The RP stated they were concerned for Resident #1s condition due to no usage data shown from the internal report x15 days for the month of October. The RP stated she asked the Unit Supervisor and was told Resident #1 sometimes refused his APAP machine. She stated the unit manager said that Resident #1 had been more compliant over the last couple of weeks. The RP stated the machine was very important for Resident #1 to wear because without it he could stop breathing and have respiratory failure. The RP stated she was unsure if he refused one time, they were going back to offer the machine again to ensure he is wearing it. The RP stated the nurses must place the face mask on and turn the machine on due to Resident #1s limited mobility related to cerebral palsy. In an observation on 10/29/25 at 2:00pm Resident #1was sleeping in his bed with the head of the bed raised. He appeared comfortable and clean. In an interview on 10/29/25 at 2:33pm with The Respiratory Therapist stated there were 15 days Resident #1 did not have the APAP machine in use.[JM4] The Respiratory Therapist stated Resident #1 had a diagnosis of Spastic Quadriplegic Cerebral Palsy, and breathing muscles and lungs required extra help to maximize lung expansion to receive as much oxygen as needed within the body. Resident #1 was not as aware at night when sleeping he should be breathing. The APAP machine is a noninvasive ventilator provided tidal volume (an amount of air that is forced in and out of the lungs) and back up breaths, forcing the lungs to remain open and prevent any co2 (Carbon Dioxide) build up within the lungs that could cause respiratory failure. The Respiratory therapist stated the negative effects of not wearing the machine include hospital readmission, and respiratory failure. In an interview on 10/29/25 at 3:15pm- The Unit Supervisor stated Resident #1 was supposed to wear the APAP mask every night. Some nights Resident #1 had refused to wear the mask, but not lately. The Unit Manager stated the nurses were responsible for placing the mask on Resident #1s' face and turning the machine on. The Unit Manger stated if Resident #1 refused to wear the mask, then it should be documented on the treatment record and within the Progress notes. The Unit Manger stated the purpose of the APAP was to assist Resident #1 breath while sleeping and the negative effects from not wearing the machine were respiratory issues decreased oxygen levels and co2 build up, leading to resp[JM5] failure. In an interview on 10/29/25 at 3:45pm The DON stated Resident #1 does stay up very late sometimes watching TV. The APAP machine assists with oxygen levels and prevents episodes of sleep apnea (a pause in breathing while sleeping). Nursing staff had been trained in applying the mask and turning the machine on. The nurses on night shift were responsible for monitoring it. The DON stated negative effects for not wearing the mask with the machine on included a drop in oxygen levels. [JM6] In an interview on 10/29/25 at 4:00pm The Primary Physician stated Resident #1 used the APAP machine intermittently for sleep apnea. The Primary Physician stated Resident #1 had pneumonia several months ago and that is when the APAP machine was ordered. Not wearing the machine long term could affect the resident's cardiovascular system and just overall quality because he may be tired all the time. Record review of policy and procedure titled Respiratory Care - Prevention of Infection dated 09/2025 reflected The purpose of this policy is to guide the prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and associates. Documentation: The following information should be recorded in the resident's medical record: the resident refused the therapy, the reason(s) why and what was done as a result.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen and 3 of 3 satellite kitchens (second floor, third floor, fourth floor). The facility failed to ensure the cornmeal, sugar, breadcrumbs, salt, and parboiled rice packages were re-sealed in the dry pantry. The facility failed to ensure the walk-in cooler for produce in the main kitchen did not have food packages stored on the floor. The facility failed to ensure the walk-in freezer in the main kitchen did not have food packages stored on the floor. The facility failed to ensure the single door reach in cooler in the main kitchen was clean and free of food debris. The facility failed to ensure the small microwave in the main kitchen was clean. The facility failed to ensure the satellite kitchens were clean and free of dust. The facility failed to ensure DA A in the fourth floor satellite kitchen wore a hairnet over his beard. The facility failed to ensure DS C wore a hairnet in the main kitchen. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: 1.During observations and interviews on 02/24/25 of the main kitchen the following was noted: *at 10:25 AM in the Dry Pantry: 1-25 lb. [NAME] bag of Japanese panko breadcrumbs opened and not re-sealed. 1-50 lb. [NAME] bag of granulated sugar opened and not re-sealed. 1-25 lb. [NAME] bag of yellow cornmeal opened and not re-sealed. 1-25 lb. [NAME] bag of granulated plain salt opened and not re-sealed. 1-25 lb. box containing an opened bag of parboiled rice that was not re-sealed and also contained a plastic scoop inside the product. *at 10:30 AM in the walk-in cooler containing produce there were boxes stored on the floor that contained fresh carrots, fresh cucumbers, oranges, and lettuce. *at 10:41 AM in the walk-in freezer had these items stored on the floor: 2-three-gallon ice cream containers, 1 case (12- 16 oz packages) of whipped topping, 1 case biscuit dough, and 2 cases of chocolate ice cream cups. *at 10:45 AM in the single door cooler containing pickles, salad, and mayonnaise had food debris on the bottom of the cooler. *at 10:46 AM the small microwave had dried food splatters. During an interview on 02/24/2025 at 10:10 AM, the acting DM said plates, cups, bowls, glasses, and silverware were all done in a dish machine on each floor of the SNF. She said there were 2 dietary servers on each floor that came and got the food items from the main kitchen and took it the floor and placed the food pans on the steam tables and served. She said the dietary servers did the dish washing. During an interview on 02/24/2025 at 11:05 AM, the acting DM said another employee was responsible for the pantry, coolers and freezer. She said he was off today but had been on duty on Sunday. She said he was responsible for putting away, stacking and labeling all food items, mopping and sweeping the floors. The DM said he should not have opened the breadcrumbs because her storage bin was full. She took the opened bags of cornmeal and sugar out of the pantry and placed them in the main kitchen area. She said she would empty them into her bulk bins. She did not do anything with the salt bag or parboiled rice package. Review of a facility policy, revised 01/2024, on Food and Supply Storage indicated All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain safety and wholesomeness of the food for human consumption.store foods in their original packages. Foods that must be opened must be stored in approved containers that have tight-fitting lids.Store food items 6 inches above the floor, 2 inches from the walls, and 18 inches from the ceiling . Food and Drug Administration Code, Dated, 2013, indicated the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. .3-305.11 Food Storage Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to slash, dust or other contamination . 2. During observations on 02/24/2025 the following was noted: *11:55 AM- The Satellite Kitchen on the 2nd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:34 PM- The Satellite Kitchen on the 3rd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:43 PM- The Satellite Kitchen on the 4th floor had an air vent directly above the serving steam table. There was dust on the air vent grates. During observations on 02/25/25 the following was noted: *11:50 AM- The Satellite Kitchen on the 2nd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *11:54 AM- The Satellite Kitchen on the 3rd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:00 PM- The Satellite Kitchen on the 4th floor had an air vent directly above the serving steam table. There was dust on the air vent grates. During observations on 02/26/25 the following was noted: *12:14 PM- The Satellite Kitchen on the 2nd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:21 PM- The Satellite Kitchen on the 3rd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:30 PM- The Satellite Kitchen on the 4th floor had an air vent directly above the serving steam table. There was dust on the air vent grates. During an interview on 02/26/2025 at 2:05 PM, the Maintenance Director said his department was responsible for cleaning the air vents in the satellite kitchens located on the 2nd, 3rd and 4th floors. The Maintenance Director said he was not aware the air vents had dust on them and needed to be cleaned until yesterday when the LSC surveyor pointed it out to him. The Maintenance Director said he did not know when the satellite kitchen vents were last cleaned, and it was an oversight on his part they were not. The Maintenance Director said the vents should be cleaned monthly to prevent dust from falling into the food and contaminating it. Record review of the facility's Sanitation and Infection Prevention/Control policy revised 01/2021 indicated, Policies: .The facility/community's Maintenance Department is scheduled to clean equipment that requires special training and equipment, such as the ice maker, refrigeration coils and exhaust hood .Procedures: .Assigns daily cleaning responsibilities in each position workflow . The Texas Food Establishment Rules, dated October 2015, revealed: S228.114. Frequency of Cleaning. .(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues 3. During an observation in the fourth-floor satellite kitchen on 02/24/2025 at 1:06 PM, DA A was observed handling foods and making special food orders that were given to residents in the dining hall. DA A was not wearing a hairnet covering his beard. DA A said he was not wearing a hairnet covering his beard because they were out of hairnets. He said they did not have a DM, and supplies have not been consistent. During an observation and interview on 02/26/25 at 12:21 PM, DS C, was observed walking in the main kitchen of the facility without wearing a hairnet. C said he entered from the other door which was why he did not have on a hairnet. DS C said no, it does not mean he should not have on a hairnet when entering the kitchen from another door. DS C said an hairnet should be worn at all times and he forgot to put a hairnet on but he remembered he did not have one on when he saw this surveyor in the kitchen. During an interview on 02/26/2025 at 1:33 PM, the DON said a hairnet should be worn at all times when in the main kitchen and the satellite kitchens. He said when dietary staff are in the kitchen, a hairnet should be worn to cover hair on their head as well as beards. The DON said they are without a DM at the time, but DS C should have been more conscience of a hairnet, because hairnets were just discussed with the staff on 02/25/2025. Review of a policy titled: Orientation and Education, Subject: Dress Guidelines for Food Service Management and Clinical Nutrition Staff. Policy #E007 dated 5/95, revised 1/22. Procedure: Hair restraints are worn by all when in the kitchen. This includes department associates, associates from other facility departments and guests, such as vendors. 37495 41695 42190

Based on interview and record review the facility failed to ensure accurate assessments were completed for 2 of 30 residents (Residents #6 and #87) reviewed for accuracy of assessments. The facility failed to ensure Residents #6 and #87's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #6's face sheet for February 2025 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective bipolar disorder (mental health condition including schizophrenia and mood disorder), anxiety, and major depressive disorder. A review of Resident #6's PASRR Level 1 screening done 01/08/2021 indicated she was positive for mental illness. A review of Resident #6's PASRR Evaluation done 02/08/2021 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #6's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, schizophrenia, and schizoaffective bipolar disorder. Section N Medications indicated the resident received antipsychotic and antianxiety medications. 2. A review of Resident #87's face sheet for February 2025 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #87's PASRR Level 1 screening done 02/26/2022 indicated he was positive for MI. A review of Resident #87's PASRR Evaluation done 04/14/2022 indicated he was positive for MI. The resident was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #87's significant change MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, depression, and bipolar disorder. During an interview on 02/26/2025 at 9:15 AM, MDS Coordinator B said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said if she had any questions regarding the MDS assessment she went directly to the RAI manual. She said Section A 1500 indicated if the resident was positive for mental illness, intellectual disability or developmental disability. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said she had been taught if the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services and she was told to answer no because they were negative. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability or developmental disability even though they did not qualify for PASRR services. 37495

Based on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of (Resident #1) of three residents review for medication changes. The facility failed to obtain written consent from Resident #1's Representative (RP) before administering her Seroquel (for psychosis). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia, depression, anxiety, and delirium (a change in mental abilities). Review of Resident #1's quarterly MDS assessment, dated 09/09/24, reflected a BIMS of 1, indicating a severe cognitive impairment. Section M (Medications) reflected she was receiving an antipsychotic, antidepressant, and hypnotic. Review of Resident #1's quarterly care plan, dated 07/09/24, reflected she had a potential for drug-related complications associated with use of psychotropic medications related to depression, anxiety, and delirium with an intervention of consulting with the pharmacy and MD to consider a dosage reduction when clinically appropriate. Review of Resident #1's Consent for Antipsychotic Medication Treatment, dated 05/10/23, reflected an order for Seroquel - 75 mg/twice daily for amelioration (improvement) of psychosis. The consent form was not signed by her RP. Review of Resident #1's Consent for Antipsychotic Medication Treatment, dated 05/23/24, reflected an order for Seroquel - 100 mg/twice daily for amelioration (improvement) of psychosis. The consent form was not signed by her RP. During an interview on 09/10/24 at 12:52 PM, Resident #1's RP stated she was not notified nor did she give consent to Resident #1 being on Seroquel. She stated she would like to be informed of the medication changes so she was involved in the care of Resident #1. During an interview on 09/10/24 at 1:55 PM, the DON stated whenever an order for a psychotropic medication was given for a resident, he expected a consent to be signed by the resident or the resident's RP. He stated it was the SW who normally ensured they were signed. He stated the importance of obtaining a signed consent before administering any psychotropic medications was because it was part of the rules and regulations and it was important to inform family of possible side effects. He stated their policy did not address that a consent was needed, however, it did include the consent attached. He stated he would be addressing this on the corporate level. Review of the facility's Psychotropic Medication Policy, revised 11/2022, reflected the following: Psychotropic medications may be considered for residents but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5(Residents #3, #71, #83, #84 and #94) of 8 residents reviewed for infection control in that: MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #3, #71, #84 and #94. LVN B failed to disinfect the stethoscope prior to and after use during g-tube (feeding tube) medication administration for Residents #84. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #3's EHR on 01/24/24 revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertension, with diagnoses of CVA (Stroke), essential hypertension (increased blood pressure), hemiplegia (partial weakness on same side of the body) and hemiparesis (partial weakness on one side of the body) effecting the right side. Review of Resident #3's quarterly MDS assessment, dated 01/15/24, reflected a BIMs score of 01, indicating the resident was severely impaired, unable to make decisions. Her functional status indicate he needed one staff to complete his activities of daily living. Review of Resident #3's physician orders dated 01/15/24 reflected, Amiodarone HCL tabs 500 mg one time a day for arrhythmia and Digoxin 25mg two times a day for pulse control. Take Blood pressure every day. Review of Resident #71's EHR on 01/24/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertension (increased blood pressure) and Hypertensive chronic kidney disease (kidney affected by uncontrolled blood pressure). Review of Resident #71's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating she was alert and oriented not impaired for decision making. Her functional status indicated she needed assist of one staff with her activities of daily living. Review of Resident #71's physician orders dated 01/03/24 reflected, Amlodipine 5 mg tablet [generic] 5 mg by mouth one time a day for hypertension (increased blood pressure). Review of Resident #83's her on 01/24/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnosis including dementia, aphagia, dysphasia, cerebral infraction, and gastro-tube (feeding tube). Review of Resident #83's quarterly MDS, dated [DATE] revealed a BIMs score of 0, indicating she was severely impaired for decision making. Her functional status indicated she needed assist of two staff with her ADLs. Review of Resident #83's physician orders dated 01/11/24 reflected, all medications must be given per (by) G-tube (feeding tube). Auscultation ( to listen with stethoscope) for G-tube placement, in the stomach. Review of Resident #84's her on 01/24/24 revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including hypertension(elevated blood pressure), and atrial fibrillation (unusual heart beat). Review of Resident #84's quarterly MDS, dated [DATE] revealed a BIMs score of 12, indicating she was alert and oriented, not impaired for decision making. Her functional status indicated she needed assist of one staff with her ADLs. Review of Resident #84's physician orders dated 12/01/23 reflected, Lisinopril 2.5mg every day (blood pressure), Metoprolol ER 50mg every day(for increased blood pressure, and digoxin 25mg two times a day (increased pulse). Checking blood pressure prior to administration. Review of Resident #94's her on 01/24/24 revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including essential hypertension (elevated blood pressure), and heart disease. Review of Resident #94's quarterly MDS, dated [DATE] revealed a BIMs score of 8, indicating he was confused and impaired for decision making. His functional status indicated he needed assist of one staff with his ADLs. Review of Resident #94's physician orders dated reflected, Metoprolol 25mg by mouth two times a day (blood pressure) and Cardizem 180mg by mouth every day (blood pressure) . Checking blood pressure prior to administration. Observation on 01/23/24 at 10:01 a.m. revealed MA A performing morning medication pass, during which time she checked the blood pressure of Resident #3. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #3. Observation on 01/23/24 at 10:08 a.m. revealed MA A performing a medication pass, during which time she checked the blood pressure of Resident #71. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #71. Observation on 01/23/24 at 10:10 a.m. revealed MA A performing a medication pass, during which time she checked the blood pressure of Resident #84. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #8. Observation on 01/23/24 at 10:22 a.m. revealed MA A performing morning medication pass, during which time she checked the blood pressure of Resident #94. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #94. Observation on 01/23/24 at 01:27 p.m. revealed LVN B performing afternoon medication pass, during which time she checked the g-tube (feeding tube) for placement of Resident #83. LVN B failed to sanitize the stethoscope before or after using it on Resident #83. Interview on 01/23/24 at 10:30 a.m., MA A stated she always cleaned the blood pressure cuff with the purple top before and after each use. MA A stated she had used the purple top wipes that were on her medication cart to clean the blood pressure cuff before and after use She stated there had been in-services on infection control and cleaning equipment, but she could not recall when that had occurred. MA A stated that if the cuff was not cleaned appropriately, it could spread germs. Interview on 01/23/24 at 1:45 p.m., LVN B stated stethoscopes should be sanitized with purple top wipes between each resident use to prevent transmitting an infection from one resident to another. She stated she was supposed to cleanse the stethoscope in-between each usage. LVN B stated she had been nervous because she had never had to perform her medication pass in front of a state surveyor. LVN B stated that if the equipment that was used on the residents was not cleaned correctly it could cross contaminate causing a spread of infection. Interview on 01/25/24 at 11:45 a.m. with the DON, he stated that his expectation was that staff would sanitize all reusable equipment between each resident use. He stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. He stated there was plenty of supplies for the nursing staff to have the sanitization wipes that were EPA-registered disinfectant, on all the medication carts. He stated that should be basic nursing to understand you should practice appropriate infection control. Review of facility's Policies and Procedure titled: Infection Prevention and control Program, dated November 2023, reflected the following: The infection control prevention and control program is a facility -wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . The program will be carried out by the facility infection control preventionist Policies/Procedures 1. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the community . b. maintain a safe, sanitary , and comfortable environment for personnel, residents, visitors, and the general public .e. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment

Based on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 2 (Residents #17 and #120) of 9 residents reviewed for Residents Rights. The facility failed to ensure MA C logged out of her computer and protected Resident#17 and #120's's MAR's. This failure could place residents at risk of being vulnerable to exploitation of their insurance benefits resulting in fraud and possible embarrassment resulting in distress and loss of dignity and causing a decrease in their psychosocial well-being. Findings included: Observation on 01/25/24 at 9:02 am, approximately 10 feet from the elevators on the fourth floor, there was no staff at a medication cart parked in the middle of the hallway. There was a computer on top of it that was unlocked and displayed Residents #17 and #120's MAR which listed their medications, dosages, and diagnoses. Observation and interview 01/25/24 at 9:05 am MA C came from the elevator and walked up to the medication cart and started rolling it down the hallway and she stated she left the medication cart unattended because she saw her resident in the elevator leaving the facility for a doctor's appointment and she needed to make sure he had his pain medication before leaving. MA C stated she was gone for about 2 minutes and usually locked her computer and forgot. She stated leaving the computer screen displaying resident information was technically a HIPAA violation and stated she was gone for less than 2 minutes and if she had left the screen display for a much longer time was more of a HIPAA violation. She stated her last HIPAA training was last summer 2023 and added she was responsible for ensuring the computer was locked and Nurse Manager D was also responsible for ensuring the staff were compliant. Interview on 01/25/24 at 12:04 pm, Nurse Manager D stated there were no issues with locking their computers and the staff knew when they walked away from them, they needed to click on an icon to white the screen out. She stated the HIPAA trainings were yearly and added if staff left their screens up displaying resident information was a HIPAA violation which could result in fraud of the resident's medical records. She stated the resident's medical information could be stolen. She stated the residents and nurses should only know the resident's medical information. Interview on 01/25/24 at 12:24 pm, SW E stated leaving the computers unlocked could disclose the residents' medications and diagnoses and added she knew not to openly display the resident's info due to the increase in scammers and for others to know and have access about who took controlled medication. Interview on 01/25/24 at 1:12 pm, the HIM Director stated the facility did not have any issues with the staff leaving their computers unlocked which displayed the resident's information. She stated her expectations for this facility was to be 100% HIPAA compliant and added when the staff walked away from their computers, they were supposed to log off the program and log out of the actual computer. She stated not being HIPAA compliant could affect the residents if the wrong person saw the resident's information which was a breach of their privacy and took their social security, address, shared their diagnoses to family friends' staff. She stated if a HIPAA violation was to happen the staff should get written up and addressed about the non-compliance. She added the Nurse Managers were responsible for ensuring the computer screens were locked to secure the resident's privacy. She stated she was not aware of MA C leaving her medication cart computer unlocked. Interview on 01/25/24 at 1:28 pm, the DON stated HIPAA was the protection of the resident chart information and added there were no issues with the staff leaving the computers unlocked and disclosing resident information. He stated HIPAA trainings were done upon hire and annually and stated HIPAA violations could be used against the resident and allow people to get information about the residents they wanted private. He stated his expectations for HIPAA compliance was for the staff to always press the button for the screen saver before walking away. He stated he was not aware MA C left her medication cart computer unlocked today and would go talk to her about the matter. Record review of the facility's Resident Rights Policy last revised 07/2018 revealed, Policy Statement: It is the policy of [Facility] to promote and protect the rights of resident residing in our ministry .Policy interpretation: 1. Resident Rights are explained to the resident (or responsible party) at the time of move in. A copy is given to him/her, and an acknowledgement of receipt is signed by him/her. A. State specific residents' rights are provided, per state requirements .have community information about you maintained as confidential Record review of the facility's HIPAA policy revision date: June 1, 2023, revealed, Subject: [Facility] is committed to protecting the privacy rights of our patients and residents (Individuals). In compliance with the (HIPAA) Act of 1996, the health information technology for economic and clinical health act (HITECH) .procedure sets forth the HIPAA Privacy Program policies, procedures, and standards .General policy: [Facility] shall implement policy and procedures, and standards that are reasonably designed to ensure compliance with HIPAA rules .

Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning for one (Resident #111) of six residents reviewed for PASRR assessments. The facility failed to provide a specialized Customized Wheelchair to Resident #111, after her 11/22/23 IDT meeting, when a request for a CWC was made but the NFSS form was not submitted until 01/16/24. And as of 01/25/24 Resident #111 had not received her Customized wheelchair. SW E failed to notify MDS Coordinator Director H about Resident #111's need for a Specialized Customized Wheelchair. These failures could place PASRR positive residents at risk of not getting medical equipment they were eligible to receive which could cause a decline in their health, resulting in a loss of mobility, falls and decrease in their psycho-social well-being and quality of life. Findings included: Record review of Resident #111's MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted [DATE] with a BIMS score 04 (Severe cognitive impaired). The resident was coded as using a wheelchair. with no psychosis, no upper and lower extremity Impairment, independent and partial/moderate assist with ADL care. And independent and partial/moderate assist with wheelchair mobility. She was frequently incontinent of bladder and diagnoses of anemia (low iron), heart failure, renal insufficiency (kidney failure), hyperkalemia (high potassium level), depression (sadness) .Down Syndrome (developmental delay) .Major Depressive Disorder (persistent sadness) . Record review of Resident #111's Physician Orders dated 01/25/24 revealed orders for, Administer Medication and assist with ADLS at needed, Anti-depressant Behavior monitoring .anti-depressant side effect monitoring, Nortriptyline 50 mg every PM evening for depression . Record review of Resident #111's Care Plan with date start date 04/01/22 and revised 08/10/23 read, Provide habilitation coordination with HC, will hold quarterly SPT meetings at the nursing facility to review/monitor all PASRR services . Record review of Resident #111's PASARR level 1 form dated 03/23/22 revealed yes for Section C: Mental illness, Intellectual disability, and Developmental disability and date of entry 04/01/22 . Record review of Resident #111's PASARR Evaluation dated 05/02/22 revealed she was eligible and coded yes for Intellectual disability, developmental disability and intervention by law enforcement, protective services, or other housing officials in the last two years .recommended services: Habilitation Coordination .Specialized Occupational therapy, specialized physical therapy and Durable Medical Equipment .with mood disorder, sleep disturbance . Record review of Resident #111's Quarterly PASRR Comprehensive Service Plan Form dated 11/22/23 by HC revealed PASRR Evaluation: pending for a Customized Manual Wheelchair. Record review of Resident #111's Simple LTC PASRR Nursing Facility Specialized Services (NFSS) form revealed it was submitted 01/16/24 for a Customized Manual Wheelchair and 01/22/24 TMHP: A free form manual alert was created and submitted by HHSC. Check the LTC PASSAR Portal alerts page for details, Record review of Resident #111's Texas Medicaid Healthcare Partnership Form Activity revealed, On 12/17/2023 and 12/29/23: Conduct PASRR Evaluation - First Notification .An individual exhibiting signs of MI and/or IDD requires a PASRR Evaluation. A PASRR Evaluation must be successfully submitted on the TMHP LTC Online Portal within 7 calendar days of this notification . Record review of Resident #111's Texas Medicaid Healthcare Partnership Form Activity revealed, On 01/17/2024: Confirm IDT .The NF has submitted a New or Updated IDT meeting on the LTC Online Portal for an individual for which your LA - IDD/LA - MI is responsible. Please check the IDT Meeting information on the PCSP form for accuracy and confirm . Record review of Resident #111's Physical Therapy Plan of Care dated 11/27/23 by Physical Therapist K revealed, Treatment Diagnosis: Other Abnormalities of gait and mobility .the patient referred due to eligibility for habilitative services under PASRR .current level of function: The patient demonstrates muscle weakness causing ipsilateral (same sided) pelvic drop and step to gait pattern during ambulation with front wheeled walker and stand by assist. Close enough to reach patient if assist needed for 100 feet .The patient's Right lower extremity hip abduction muscle strength 3 -/5 .The patient's Right lower extremity knee extension/flexion muscle strength is 3-/5 . Observation on 01/23/24 at 12:30 pm revealed Resident #111 was in the dining room, sitting in a regular wheelchair (not customized). After eating she was able to unlock the brakes of her wheelchair, then she asked for assistance to leave. A female staff assisted with moving her out of the dining room. Interview on 1/23/24 at 11:13 am, the MDS Coordinator Director H stated they did not have any problems submitting the PASRR forms and added she was responsible for submitting them. She stated the only delay could be if she did not know when a service had been requested in a meeting for her to complete. She stated this happened with Resident #111, she had an IDT meeting on 11/23/23 and she had up until 12/23/23 to get the NFSS form submitted. She stated she just recently submitted the form and added she did not know Resident #111 had a request for a CWC until the HC told her. She stated filling out the NFSS form was all new to her and she did not know the therapist and resident measurements were needed. She stated constant communication with SW E and HC was needed in order to know when they had IDT meetings to start the referral process on specialized services. She stated she submitted Resident #111's NFSS form 01/16/24 and added usually the SW, HC and Nurse Manager were in the Quarterly PASARR meetings, and she was in the Annual ones. She stated she completed the PASARR trainings in the past but did not know how to complete the NFSS forms and had to ask one of the therapists to assist her with filling out Resident #111's NFSS form. She stated she spoke to SW E about informing her about the IDT meetings so that she did not miss what was discussed and referrals she needed to do. Interview on 01/24/24 at 1:10 pm, Nurse Manager D stated, Resident #111 had an IDT meeting last November 2023 and SW E, HC and herself was in the meeting with the resident and her RP and a CWC was requested. She stated SW E notified them about the IDT meetings and documented what was discussed in the meetings and added she was not aware of any issues or delays with submitting Resident #111's PASARR forms. She stated MDS Coordinator Director H was not always in their meetings, and she was not sure if SW E emailed the MDS Coordinator Director H about Resident #111's CWC referral. She stated although she was in Resident #111's IDT Meeting 11/23/23, she did not notify MDS Coordinator Director H of the CWC need because she believed the SW E notified MDS Coordinator Director H. She stated Resident #111 had a wheelchair, but she needed staff assistance to get around in it. She stated if a resident did not have the right type of wheelchair, it could limit their mobility and ability to get around independently. Interview on 1/24/24 at 4:16 pm, PT F stated she never attended the IDT meetings and was aware Resident #111 was in the process of getting a CWC because MDS Coordinator Director H had her fill out part of the NFSS. She stated she evaluated Resident #111 for therapy and noticed her wheelchair was too tall and she needed a shorter wheelchair for her to get around in independently. She stated the wheelchair vendor came out either last month (December 2023) or this month (January 2024) for her measurements for her wheelchair. She stated she would think SW E who coordinated the IDT Meetings would let MDS Coordinator Director H know about all specialized needs requested. She stated if a resident did not have a CWC they may not have appropriate mobile status and could get contractures, fall, and develop pressure ulcers. She stated Resident #111 was getting PT for a better gait pattern and to get her legs stronger by walking a little more smoothly. She stated she was able to walk short distances and could benefit from getting a CWC to strengthen her legs. Interview on 01/24/24 at 9:37 am, HC stated Resident #111 gained weight and it was decided in the Quarterly IDT meeting 11/22/23 for her to get a CWC. She stated Nurse Manager D, SW E and LVN I was at the meeting. She stated after Resident 111's IDT meeting 11/22/23, she emailed MDS Coordinator Director H and it showed she was on vacation on 11/27/23 and emailed her again 11/28/23 and MDS Coordinator Director H replied 11/28/23 that she was working on it and was not sure how to do it then she explained it was a benefit under PASSAR services. She stated on 12/08/23 she asked MDS Coordinator Director H for a status update with Resident #111's PASARR NFSS form, and she said she was working on it and was gathering pertinent information that OTA J assisted her with. She stated on 12/15/23 MDS Coordinator Director H said she was working on it, then on 12/19/23 therapy completed the wrong form and MDS Coordinator Director H gave the therapist the NFSS form and at that point advised MDS Coordinator Director H she was getting close to the deadline the 12/22/23 cutoff date and the form needed to be expedited. She stated MDS Coordinator Director H said she dropped the ball with getting the form submitted by the deadline, then on 1/16/23 it was filled out by the therapist, but it was not signed, she told her to re-submit it. She stated on 01/23/24 MDS Coordinator Director H said the CWC had been approved. She stated the facility had a lack of communication when it came to Resident #111's CWC need. Interview on 01/25/24 at 11:16 am, MDS Coordinator Director H stated MDS G filled in for her while she was out of town November 2023 and went to the IDT meetings and stated SW E nor MDS G told her about Resident #111's CWC referral. She stated either MDS G or SW E should have told her about the referral and said she found out about it on 11/27/23 when HC emailed her about the status of Resident #111's CWC request. She stated she went to therapy to assist with the form and had to get back with therapy for more information on the NFSS form. She stated then a wheelchair vendor came to measure Resident #111 and the time just caught up with her and she was not able to get the NFSS form submitted by 12/21/23. She stated Resident #111's current wheelchair sat up too high, and her feet did not touch the floor and needed a smaller and lower setting wheelchair. She stated today (01/25/24) they had a meeting with the therapy department, and they concluded the SW, Nurse Manager, Therapy Director and MDS Coordinator needed to be in all of their IDT meetings including the quarterly ones. She stated they needed better communication so that the referral process would move a lot faster . She stated if residents did not get specialized services, it could affect the resident's independence and they may not reach their full potential. She stated since 01/07/24 she started checking the PASARR LTC portal daily for any status changes to see what was going on with the resident's forms, instead of checking them weekly. She stated her goal was to follow the processes and policies needed for the PASARR positive residents. Interview on 01/25/24 at 11:50 am, MDS G stated she was the alternate MDS Nurse when her supervisor MDS Coordinator Director H was not at work and last November 2023 she covered for MDS Coordinator Director H but said she was not in Resident #111's IDT Meeting. She stated Unit Manager D said she did not have to attend the meeting and added she was unaware Resident #111 needed a CWC until MDS Coordinator Director H mentioned it to her. She stated she was not sure how the PASARR CWC process worked, and her understanding was that the MDS needed to fill out some paperwork to be approved for the CWC . She stated she had not had any PASARR training in the past. She stated SW E was usually good about taking notes in the IDT meetings and was not sure what happened in Resident #111's case. She stated they were all aware of the delay in getting Resident #111's CWC and was currently working on a plan to prevent this from happening again. She stated if a resident did not get PASARR specialized services timely could cause the residents to decline in health. She stated she was not sure how this got dropped and they were reviewing other PASRR positive residents' records to ensure this was not happening with any other residents. Interview on 01/25/24 at 12:04pm, Nurse Manager D stated, for Resident #111's IDT meeting on 11/22/23, MDS Coordinator Director H and MDS G was not in the meeting. She stated HC mentioned Resident #111 needed a CWC and thought SW E sent an email to therapy herself, and MDS Coordinator Director H. She stated after a PASARR referral, they needed to get therapy to evaluate the resident for the new medical equipment requested and they needed to follow up on the requests to make sure everyone involved did their part. Interview on 01/25/24 at 12:24 pm, SW E stated they had Resident #111's IDT meeting on 11/22/23 and HC put in a suggestion about the resident getting a CWC. She stated she spoke to the former Rehabilitation Director and MDS Coordinator Director H sometime in November 2023 and said she would get Resident# 111 assessed by the therapist. She stated Resident #111 currently had a regular wheelchair and said she did not know there was a deadline on when to submit the PASARR NFSS form. She stated today (01/25/24) she asked MDS Coordinator Director H what could be done differently and was told to put the referral requests in an email and also ensure the MDS Coordinator H was notified to attended the IDT Meetings. She stated she did not know this needed to be done and thought they were just considering getting Resident #111 a CWC. She stated she spoke to therapy today (01/25/24) about what processes could be put in place to get the referrals done timely and was told to just follow up with MDS and therapy. She stated she did not know the MDS, and therapy department had a part in doing the NFSS forms and timelines to submit the form. She stated there was definitely a breakdown in communication and now knew they had 30 days to get the NFSS form submitted for CWC specialized service requests. She stated not getting resident's DME timely could cause fall risks and skin breakdown. She stated she had a PASARR training last year online but now knew when they discussed things in the IDT meeting, she needed to email MDS Coordinator Director H and therapy about the requested DME if they were not in the meeting, Interview on 01/25/24 at 1:28 pm, the DON stated he was unaware of Resident 111's CWC referral was delayed and causing her a delay in getting her CWC. He stated the Nurse Managers attended the IDT meetings and MDS Coordination Director H had not informed him about any issues with submitting the PASARR forms. He stated they had PASARR meetings with HC and added he needed to be involved in the IDT meetings and he thought SW E forwarded the CWC requests to MDS and therapy. He stated residents not getting PASARR specialized services and equipment, could potentially affect the resident's mobility with how they moved around. He stated MDS Coordinator Director H was responsible for submitting the resident's PASARR documents. He stated his expectations for PASARR referrals was for them to be done timely and if not done timely, MDS needed to let him or another MDS Coordinator know to assist. He stated he was not sure why this issue was not brought to his attention about MDS Coordinator Director H not knowing how to complete and submit the PASARR NFSS form and with the communication issues amoung the Directors. Interview on 01/25/24 at 3:50 pm the DON stated they did not have a PASARR policy.

Based on interview and record review the facility failed to coordinate assessment with the preadmission screening and resident review (PASSR) program to the maximum extent practicable to avoid duplicative testing and effort which included incorporating the recommendation from the PASSR level II determination into the resident assessment, care planning and transition of care for one (Resident # 1) of one resident reviewed. The facility failed to provide specialized service to Resident # 1 due to the facility not submitting the Nursing Facility Specialized Services (NFSS) request form in the Simple LTC portal. This failure could place residents at risk of not receiving necessary care of specialized service which could diminish the residents' quality of life and highest level of functioning. Finding include: Review of Resident #1 face sheet dated 11/15/2023 revealed a [AGE] year old male admitted on [DATE] and discharged on [DATE] with diagnoses that included unspecified intellectual disabilities ( a developmental disorder, characterized by less than average intelligence and significant limitations in adaptive behavior with onset before the age of 18), Acute on Chronic systolic (congestive) heart failure ( active symptoms of heart problems or diseases can lead to heart failure which is a long -term condition ), . Cognitive Communication deficit (difficulty with thinking and how someone uses language) and Unsteadiness on feet (Gait and balance issues can cause unsteadiness and difficulty standing and walking). Review of Resident #1's Admission MDS dated [DATE] revealed a BIMS score of 9 (8 to 12 points suggest moderate cognitive impairment). Review of Resident # 1's PASSR level I screening dated 8/12/2023 shows positive for intellectual disorder. Review of Resident # 1's care plan shows indication dated 8/23/2023 show PASSR positive resident. Review of Resident # 1's medical records revealed physical, occupational, and speech therapy services under part B services from 9/4/2023 through 9/24/2023. Resident # 1 was discharged from Physical, occupational, and speech services on 9/23/2023. No physical, occupational, or speech therapy services were received from 09/24/2023 through discharge date of [DATE]. Review of Resident #1's IDT team meeting dated 08/25/2023 that included LIDDA representative, team determined individual would benefit from HAB coordination, PT, OT, ST, and independent living skills. Review of Policy completing the NFSS form for a Habilitative therapy assessment dated [DATE] revealed Once the assessment has been performed, the nursing facility must submit the request through the LTC online portal no more than 30 days from the date it was preformed by the therapist. Interview with the RN MDS nurse on 11/16/2023 1:30 pm, stated that she was present at the IDT meeting on 8/25/2023 where plan for Resident # 1 was discussed. Resident was admitted under Medicare part B and she did not submit a NFSS as she thought since he was receiving services it was not needed. When Resident # 1's medical conditions changed, and he could no longer participate in therapies under Medicare Part B, the resident transferred to the hospital, and did not return prior to completing the paperwork. She stated it is part of her job as MDS nurse to coordinate services with the local authority. She uses facility policy and state guidelines as reference. She stated she thought she had 30 days from the last day of service not from the determination from the need of services. Interview with the DON on 11/16/2023 2:00 PM, he stated he was not aware the forms were not submitted, nor was he aware that an attempt was made to contact the facility. He stated that the MDS nurse is responsible for coordinating with the local authority, but the IDT is responsible for the implementation and oversite. He stated his expectation was that all residents receive the services they need to improve their quality of life. He stated that if a resident did not receive these services a potential negative outcome would be not maintaining the current level of function. Interview with the ADM on 11/16/2023 2:30 pm, her expectation was that all the residents were assessed, and services needed be provided. She stated a resident who does not receive the needed services can have a potential in decreased quality of life

Based on observations, interviews, and record review the facility failed to ensure medications were stored in locked compartments to be accessed only by authorized personnel, and ensure medications were labeled in accordance with currently accepted professional principles, to include the appropriate accessory and cautionary instructions, and the expiration date in that: 148 residents medications were not properly labeled -Medications from pharmacy were not labeled with directions or expiration date. -Medication cart was left unlocked and unsupervised. This failure could place all 148 residents receiving medications in the facility at risk of unauthorized access to medication and medication administration error in administration which could lead to adverse reaction, potential harm. Findings Included: In a med pass observation on 11/8/22 at 8:12AM of the 2nd floor med cart revealed, medication packages from pharmacy. Packages for scheduled medications for all residents on this floor contained labels that did not contain expiration date of medication, the route of which medication was to be taken, and the directions on how often medication was to be taken. In an observation on 11/10/22 at 8:15AM revealed LVN C was walking out of resident room with insulin pen back to medication cart that was unlocked. She put the insulin pen back in the medication cart, left cart unlocked, and went back into the room to get hand sanitizer. In an observation on 11/10/22 at 8:27AM of the 4th floor med cart revealed, medication packages from Pharmacy. Packages for scheduled medications for all residents on this floor contained labels that did not contain expiration date of medication, the route of which medication was to be taken, and the directions on how often medication was to be taken. In an observation on 11/10/22 at 8:35AM of the 3rd floor med cart revealed, medication packages from Pharmacy. Packages for scheduled medications for all residents on this floor contained labels that did not contain expiration date of medication, the route of which medication was to be taken, and the directions on how often medication was to be taken. In an interview on 11/9/22 at 8:12AM with LVN H, she said she worked all floors in the facility passing medications and all medications in the building were labeled the same way. She said she was trained to verify labels against the medication administration record and a medication error could occur because the label did not include the directions of how a medication should be given or the expiration date. She said she had not told anyone about the label being incorrect because all medications were labeled the same way. In a phone interview with on 11/09/22 at 1:47PM with PHARMG , he stated a medication label legally must include: Patient name, facility name & address, physician name, pharmacy name & address, medication name, medication strength, medication directions, medication expiration date, date medication was filled. In a phone interview with on 11/09/22 at 1:55PM with PHARMF he stated a medication label legally must include: Patient name, facility name & address, physician name, pharmacy name & address, medication name, medication strength, medication directions, medication expiration date, date medication was filled. He said a prescription not labeled properly could potentially be dangerous to a patient. He said it was difficult to say what could happen as it would depend on the medication and issue. He said some medications could be dangerous if given the incorrect route because of absorption differences depending on route. In a phone interview with on 11/09/22 at 2:18PM with Pharmacist Consultant PHARME and Pharmacist and [NAME] President of Clinical Services PHARMD Consultant , they stated a medication label legally must include: Patient name, facility name & address, physician name, pharmacy name & address, medication name, medication strength, medication directions, medication expiration date, date medication was filled. PHARMD said a physician order, mar, and medication label should all match and be checked when passing medications. If these 3 things did not match there could be an increased risk for a medication error. In an interview on 11/10/22 at 8:15AM with LVN C, she stated she didn't lock the medication cart because she had to wash her hands and she didn't have hand sanitizer on the medication cart. She said it really was not a good excuse because she knew it was supposed to be locked and it could be dangerous if a resident were to take medication that was not prescribed to them. In an interview on 11/10/22 at 8:27AM with MA B said she works on all floors in the facility and all medications in the building were labeled the same way. She said she was trained to verify labels against the medication administration record and when the pharmacy started this new system a couple of years ago, she was nervous she was going to make a medication error because the label did not include the directions of how a medication should be given or the expiration date. She said since the prescription label did not have directions, she followed the medication administration record and assumed the pharmacy was correct. She said she had not told anyone about the label being incorrect because all medications were labeled the same way. In an interview on 11/10/22 at 8:35AM with LVN A said she passed medication for the entire third floor. She said she did not trust the prescription label to be correct since the directions were not written for each medication. She said she checks everything herself because she had found errors from the pharmacy in the past. She said the bag with the medication label on it was there to tell her what medications were supposed to be in the bag. She said prescription labels were supposed to have the directions and expiration date listed. She said she had been trained to check label against medication administration record and without the directions it could put a resident at an increased risk of medication error. In an interview on 11/10/22 at 1:28PM with the DON, he stated the people passing medications were trained to do a 3-check system comparing the prescription label to the medication administration record. He said the prescription label should include the route a medication should be taken, how often medication was to be taken, and the expiration date. He said he was not aware the medications labels throughout the building did not list these items. He said the pharmacy consultant company that comes in should have caught this error. He said there was a potential for a medication error to occur without these specific directions. He said they had been using for 2 years and had no complaints from staff about the labels being without needed information. He said if a nurse saw a prescription was not labeled correctly the pharmacy should be notified. He said this error was a concern for the entire facility because all of them could be at risk for a medication error despite an error not being made at this time. He said he was going to have pharmacy make this correction and it would be fixed by Saturday since all medications were delivered 2 days early. In an interview on 11/10/22 at 1:42PM with the ADM, she said she would not know how to give a medication based on the prescription label. She said the medication administration record should be used when passing medications. The DON explained to her the 3-step process of verifying medications were correct. She said in that case she understood this was a concern and could lead to a medication error. She said she would be placing phone calls to her corporate and the pharmacy to get labels corrected immediately. Record review of the email from to DON dated 11/10/22 stated the medication label at a minimum includes the medication name, prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration. Record review of the policy Administering Medications dated 12/2021 revealed the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of the policy Labeling of Medication Containers dated 08/2021 revealed E. labels for each single unit dose package shall include all necessary information, such as: 5. The expiration date when applicable and 9. Directions for use.

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for one of four kitchens reviewed for kitchen sanitation. A. The facility failed to properly store, label and cover food in the facility's walk-in refrigerator in the kitchen on 11/08/2022 from 8:30 AM -10:00 AM. B. The facility failed to ensure Dietary Baker I properly sanitized hands when placing food in bowls. C. Dietary Cook J failed to wear hair net when entering the main kitchen on first floor and Sous Chef K failed to wear a beard net when preparing food on the prep table in the main kitchen. These failures could place the residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings Included: A. Observation on 11/08/2022 from 8:30 AM -9:15 AM of walk-in refrigerator in the main kitchen on the first floor revealed the following: -slightly hardened left-over hoagie rolls not in the original bag was not labeled or dated. - leftover hamburger patties not in the original package that was not labeled or dated. - leftover fired mushrooms not labeled or dated. - bowls of shredded lettuce, prepared tuna salad, green bean salad, cheese, olives and orzo salad not labeled or dated. - container of strawberries with mold on approximately 6 strawberries not labeled or dated. - clear bag of shredded cabbage not in its original package with brownish color on the edges and in middle of the cabbage not labeled or dated. - two bags of shredded lettuce not in the original package had brownish color on the edges of the lettuce and some of the lettuce had brownish color on the entire lettuce not labeled or dated. - five half and half milk with best buy date of 10/22/22. - 13 tubes of hamburger meat on a silver tray not labeled or dated and not in the original container/box on the meal tray rack (approximately 8 -10 pounds each tube). B. Observation on 11/08/2022 at 9:00 AM reflected Dietary Baker I was placing bowls on the prep table. Dietary Baker I began to place red pureed beets into the bowls. She reached under the prep table and in a bucket of bubble liquid she grabbed a towel and began to wipe area of the prep table and returned the towel into the bucket. Dietary Baker I did not remove her gloves after touching the wet towel with yellowish/ brownish stains on the towel. She continued with the task of placing red pureed beets into the bowls with the same gloves on her hands and 3 of her fingers on the right hand touched inside of the bowls (middle finger, index finger and ring finger). In an interview on 11/08/2022 at 9:10 AM Dietary Baker I stated she was placing pureed beets into the bowls. She stated she did touch the towel that was in disinfectant water under the prep table. She stated she did not remember if she changed her gloves or sanitized her hands. She stated she had been in serviced on removing gloves in between tasks and to wash hands prior to placing new gloves on her hands. She stated if she did not change gloves and wore the same gloves, she touched the towel it was a possibility she could contaminate the beets and inside the bowls with whatever was on the towel, and it was possibly disinfectant. Dietary Baker I stated she didn't change her gloves after touching the towel. C. Observation on 11/09/2022 at 8:05 AM Dietary Baker I walked in the first-floor kitchen without wearing a hair net. Observation of a sign posted on the door the Dietary Baker I entered revealed Hairnets need to be worn past this point. In an interview on 11/09/2022 at 8:20 AM Dietary Baker I stated she was in a hurry and forgot to place hairnet over her hair. She stated all hair nets are to be worn when entering any part of the kitchen area. She stated she had been in serviced on wearing hair nets prior to entering the kitchen area. She stated she knew the sign was on the door as a reminder to wear a hair net. She stated if staff did not wear hair nets hair could fall into food, plates, or on anything in the kitchen. She stated if hair was on the food a resident could eat the hair and possibly could become sick. Observation on 11/09/2022 at 8:10 AM Sous Chef K failed to wear a beard net when near food on the prep table and oven. His beard was approximately 8 inches long. In an interview on 11/09/2022 at 8: 35 AM Sous Chef K stated he forgot to placed beard net over his beard. He stated he had been in serviced on wearing beard nets when in the kitchen. He stated he was checking the food on the oven and the prep table. He also stated it was possible for hair from his beard to fall into the food or anything in the kitchen. He stated hair could contaminate the food and possibly cause illness to residents. In an interview on 11/10/2022 at 7:36 AM Executive Chef L stated all foods whether left-over foods or foods wasn't in the original container was expected to be labeled and dated. The left-over foods were especially needed to be labeled and dated. If the food had passed the use by date, it was expected to be disposed of in the garbage. All foods prepped to be used was expected to be labeled and dated. If any food had mold on it or was turning brown was to be thrown in the garbage. There should be no food in the refrigerator with mold or had turned brown. Any food or drinks with use by date in October 2022 required to be discarded in the garbage or sent back to the company responsible for delivering the milk. She stated if food or drinks was served after the use by date it was possible a resident could get food poisoning. She stated Dietary Baker I was to change her gloves after she touched the wet towel from the disinfectant water before continuing her task of placing pureed beets in bowls. She stated not changing gloves or sanitizing hands had a potential of contaminating the food with whatever was on the towel that touched her gloves. She stated all staff had been in serviced on hand hygiene. She stated no matter where staff is in the kitchen area once you enter the double doors all staff was expected to place a hair net and beard net over their hair. She stated there were beard nets and hair nets beside all doors that enter the kitchen. She stated the hair nets was available for Dietary Baker I to place on her hair prior to entering the kitchen area. She stated the sign on the door was a reminder for all staff to wear hair net prior to entering any part of the kitchen. She stated Sous Chef K was expected to wear a beard net and all the males with facial hair had been in serviced on wearing beard nets. In an interview on 11/10/2022 at 8:13 AM ADFS M stated all foods that was past the used by date was expected to be discarded end of shift of the used by date. If it was not discarded an employee possibly pick could up the food and use it for a meal or give it to a resident as a snack without looking at the use by date and the resident had a potential of getting food poisoning. The half and half milk that was out of date was to be sent back to the company or discarded. There should have been a sign on the crate the milk was in stating not to be used. All foods are to be labeled and dated. If staff not wearing hair nets, beard guards or not changing gloves after touching an item that was possibly contaminated, was not sanitary and could cause illness with the residents. Hair is considered contaminated if it is in a resident's food or on their plates. She stated all staff was expected to wear hair nets prior to entering any section of the kitchen and to always wear beard nets when in the kitchen. In an interview on 11/10/2022 at 8:30 AM SDFS N stated all foods are to be labeled and dated including leftover foods. Foods should be discarded the day after the use by date or at the end of shift of the used by date. Staff was expected to change gloves when touching anything in the kitchen that was considered contaminated including wet towel. The chemical from the towel had potential of being on the staff gloves and could possibly contaminate the food. He stated any food with mold should be discarded. All staff was expected to wear hair nets and beard nets prior to entering any door leading into the kitchen area. The main kitchen on the first floor is large and there were several doors entering the kitchen areas. He stated there were hair nets and beard nets beside each door. He stated the door Dietary Baker I entered there was a sign on the door not to enter unless wearing hair net. He stated hair from beard and from any part of the head could fall into resident's food or dinnerware. He stated a resident could possibly become sick if served out of date food, contaminated food from staff not changing their gloves and/ or from hair falling into their food. He stated it was his responsibility and the ADFS responsibility of monitoring to ensure all staff was following guidelines. In an interview on 11/10/2022 at 12:14 PM the Administrator stated all foods especially left-over food was expected to be labeled and dated. She stated the half and half outdated milk, molded strawberries, lettuce and cabbage with brown color were to be discarded. She stated all staff was expected to always wear hair nets and beard nets prior to entering any section of the kitchen. She stated hair can fall into the food and cause contamination. Facility Policy on Food and Supply Storage reflected foods past the use by, sell by, best by or enjoy by date should be discarded. Products are good through the close of the business on the dated noted on the label. Gloves are changed between tasks and hands are washed after gloves are removed. Facility Policy on Labeling and Record Keeping dated 10/1/2022 reflected all foods opened, prepared and used in the unit must be dated and labeled. Date marks are important for all TCS foods because while growth of bacteria in refrigerated foods is largely controlled by temperature, it is not stopped altogether. Date marks indicate when foods have been in refrigeration too long and have reached unsafe levels of bacterial growth. Common name labeling is also important since certain foods can be difficulty to identify once they are processed or removed from their original package. Date all foods when they are prepared or when the original package is opened. Sandwiches, salads, yogurt and cut fruit salads must be marked with an easily identifiable date marking system. All foods, including prepared items, bulk foods, frozen foods and ingredients must be always labeled. Labeled with the common name, preparation date, discard date and associate initials.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed, in that: The facility failed to utilize a two-person transfer for Resident #1 when transferring her from her wheelchair to her bed, which resulted in the resident obtaining a laceration measuring 7cm x 2cm x 5cm and requiring 22 sutures. This failure placed could place residents that require two person transfers at risk for neglect, harm, pain, and injuries. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including spinal stenosis (compression of the spinal cord), cervical disc disorder, abnormal posture, weakness, and difficulty in walking. Review of Resident #1's MDS, dated [DATE], reflected a BIMS of 8, indicating a moderate cognitive impairment. It further reflected that she required extensive assistance with transfers (two person staff support). Review of Resident #1's care plan, revised 7/11/22, reflected she had an ADL self-care performance deficit with an intervention of utilizing two-person assistance during transfers. Review of a nursing progress note for Resident #1 written by LVN C, dated 5/22/22 at 3:48 PM, reflected the following: Deep laceration obtained to RLE when resident was being transferred from wheelchair to bed. Resident was sent to ER for sutures. Review of Resident #1's ER discharge paperwork reflected she obtained a 7cm x 2cm x 5cm laceration from skin tear on her right lower leg involving subcutaneous tissue. Twenty-two sutures were used to close the laceration. Review of an Incident Statement written by CNA A regarding Resident #1's transfer and injury, dated 5/22/22, reflected the following: On Sunday May 22, 2022, I [CNA A] was getting [Resident #1] ready for bed . [CNA A] removed the halo (safety grab bar) from her bed . [CNA A] asked [Resident #1] to bend her knees as much as she could because her legs are a little stiff and hard to bend . When we stood and turned, [CNA A] think the resident's leg had straightened back out and caught the bottom of the halo connector and cut the resident's leg . [Resident #1] looked at me and said, I think I hurt my leg. [CNA A] put her legs on the bed and that's when [CNA A] saw the blood on her pant leg . Review of an Incident Statement written by the ADM regarding Resident #1's transfer and injury, dated 5/23/22, reflected the following: The ADON and ADM spoke to [CNA A] in regards to what happened to Resident #1's leg on 5/22/22. [CNA A] reported she was transferring [Resident #1] from her wheelchair to bed . [CNA A] stated she transferred the resident by herself since she was a smaller resident . According to [CNA A] she left immediately to report the injury to [LVN C], who was in the breakroom . [ADON] asked [CNA A] what the transfer status was of [Resident #1] and she said a two person, but no one was available to assist her and I [CNA A]thought I [CNA A]could do it alone. [ADM] pointed out that [LVN C] was in the breakroom and she could have been asked to help with the transfer, and asked [CNA A] why she did not ask [LVN C] to help if the transfer could not wait, [CNA A] stated she didn't know why. During and observation and interview on 7/20/22 at 10:08 AM, with Resident #1, she was laying in her bed watching TV. She was clean, appropriately dressed, and there were no apparent foul odors. She stated she remembered the incident when she obtained a skin laceration and that it was just an accident. She stated it was only one person transferring her that day from her wheelchair to her bed when usually there are two that help transfer her. During a telephone interview on 7/20/22 at 11:26 AM with Resident #1's NP, she stated she was made aware of Resident #1's skin laceration to her right leg the same day it happened, 5/22/22. She stated she was not aware that it happened during a one-person transfer. She stated Resident #1 needed two people to transfer her due to her not being weight-bearing. She stated she was sorry to hear that and the one-person transfer was not appropriate. During an interview on 7/20/22 at 11:56 AM, with the DON, he stated if a resident was admitted for sub-acute care (therapy), their transfer status would be assessed by the therapy department. He stated if a resident was admitted for long-term care, normally the nursing team would conduct the transfer status assessments. He stated there were red circle stickers place on residents' name plates which indicated a two-person transfer. He stated CNA A knew better than to transfer Resident #1 by herself and she should have used better judgement. He stated he would not use the word 'neglect' to describe the incident, but rather, 'an accident'. He stated it was important for staff to follow the residents' transfer status to prevent falls or injuries. On 7/20/22 at 12:17 PM a phone call was made to CNA A. A voicemail was left requesting a call back. During an interview on 7/20/22 at 12:40 PM with LVN C, she stated she was the nurse working the day Resident #1 obtained a skin laceration. She stated Resident #1 was a two-person transfer because she was non-weight bearing and CNA A should have waited until she could find another staff member to assist her. She stated the staff were able to identify who was a two-person transfer by the red circle sticker on their nameplate of their door. She stated the importance of following the two-person transfer when a resident required one was to prevent injuries. During an observation and interview on 7/20/22 at 12:44 PM with LVN D, she stated staff were able to identify a resident's transfer status by the red sticker on their nameplate. She walked to Resident #1's room and showed Surveyor the red circle, which she indicated that it meant Resident #1 was a two-person transfer status. During an interview on 7/20/22 at 12:48 PM with CNA B, she stated residents' transfer status could be identified by a red sticker on their nameplate. She stated if they had a red sticker it meant they were a two-person transfer. She stated if there was a resident that required a two-person status and she could not find an aide to assist her, she would wait or even ask her nurse for assistance. Review of a facility in-service conducted by the DON, entitled Communicating Transfer Status, dated 5/23/22, reflected the staff were in-serviced on the facility's process for communicating residents' transfer status: On LTC units 'RED DOT' on a resident's door means a 'TWO PERSON TRANSFER' . Do not transfer a resident on your own if the resident is a two-person transfer. Get assistance. Review of a Written Reminder for CNA A, dated 5/22/22, reflected the following: Area of focus: Following policy and procedures put in place to maintain a safe environment for residents and staff. [CNA A] transferred [Resident #1] from chair to bed with resident hitting leg on bedrail requiring ER visit resulting in sutures. [CNA A] was re-educated on transfer status and patient safety. Review of CNA A's skills/competencies check off, dated April 2021, reflected the standards were met for transfers. Review of CNA A's skills/competencies check off, dated June 2022, reflected the standards were met for transfers. Review of the facility's Safe Lifting and Moving of Patients Policy, revised 12/2019, reflected the following: Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of the facility's Abuse Prevention Policy, revised 6/2020, reflected the following: Our residents have the right to be free from abuse, neglect . 'Neglect' means the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview, and record review, the facility failed to properly store, prepare, distribute and serve food in accordance with the professional standards for food service safety in the facility's only kitchen reviewed for safety requirements. 1. The facility failed to ensure food items in the dry pantry were labeled, dated, sealed, and free of dirt and sticky substance. 2. The facility failed to ensure food items in the refrigerator and freezer were sealed, labeled, and dated appropriately. 3.The facility failed to ensure staff wore hair restraints while in the kitchen. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: 1). Observation of the dry pantry on 08/17/21 at 8:27 AM revealed the following: -1 gallon of molasses with a brown sticky substance on the side, near the handle of the bottle. - A large clear plastic bag, which contained a powdery white substance that was not sealed or dated, exposing the contents to air. - White powdery substance on the floor in front of the shelf, which contained the large plastic white bag of a white powdery substance. - 24oz package of country gravy mix was sealed with plastic wrap but was not dated - 24oz package of labeled salt was open and contents was exposed to air. - 11oz package of Lawry's seasoning which had red dry powdered substance on top of the package. - 3 large packages of dry pasta not dated or sealed, which exposed the dry pasta to air. - 31oz package of mashed potatoes was sealed with plastic wrap but was not dated. - 24oz of lemon instant pudding not sealed or dated. Pudding was exposed to air. - 24oz of fruit punch mix package had a brown sticky substance covering the face of the package. 2). Observation of refrigerator one on 08/17/21 at 8:47 PM revealed the following: - 5 gallon of pickles in a large white container was not sealed properly. The lid to the container was not properly secured on container, exposing the pickles to air. - 1 large brown cardboard box, which contained 3 large bags of spring mix salad had dark brown liquid substance in each bag and was leaking through the bags and box onto the refrigerator floor. Each bag of spring mix reflected, Best By July 31st [2021], received July 14th [2021]. Observation of refrigerator two on 08//17/21 at 9:00 AM revealed the following: -20lbs parsnip was soft to the touch and was molded. - 1 large cardboard box of zucchini on the floor of the refrigerator which contained molded zucchinis. There were approximately 15 to 20 zucchinis in the box. - 18lbs of cherry filling had a red sticky substance around the rim of the white container. - 1 white plastic sack, which contained a hard to the touch, solid block of cheese and unlabeled meat. The cheese and meat were not sealed or labeled. - 1 large pan of approximately 20 sliced [MEDICATION(S)] pieces was sealed but not dated. - 3 individual cups of cubed pieces of [MEDICATION(S)] were sealed but not dated. - 5lbs of cheese slices not dated. - 5lbs of shredded cheese not dated. - 10lbs of okra not dated. Interview with Dietary Manager on 08/17/21 at 9:15 AM revealed all food items in the dry pantry, and refrigerator should be labeled, sealed and dated. She stated there should not be any molded food in the refrigerator. She stated she blamed her staff. She stated her staff was to ensure food is sealed and stored properly. Review of the facility's kitchen in-servicing of Associate Food Safety Training record revealed all kitchen staff were in-serviced on labeling and dating on 06/29/21 and 06/30/21. Review of the U.S. Public Health Service Food Code, 2017, reflected, Food Establishment and if the Food is held for more than 24 hours, to indicate the date or day by which the Food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and:(1) The day the original container is opened in the Food establishment shall be counted as Day 1; and (2) The day or date marked by the Food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on Food safety. 3) Marking the date or day the original container is opened in a Food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Regulatory Authority upon request. Review of the U.S. Public Health Service Code, 2017, reflected, Preventing Contamination from the Premises 3-305.11 Food Storage. Food shall be protected from contamination by storing the food: In a clean, dry location. Where it is not exposed to splash, dust, or other contamination; and at least 15 cm (6 inches) above the floor. 3). Observation on 8/18/21 at 4:15 PM, revealed four kitchen staff (Kitchen Supervisor, Dietician, Server E and Server F) were not wearing their hair restraint properly. The Kitchen Supervisor's hair restraint was partially on, exposing hair starting from her hairline to the middle or crown of her head. The Dietician's hair was in a ponytail under her hair restraint but hair on the sides of her face was not under her hairnet, causing her hair to be exposed. Server E and Server F had on hair restraints, but they were not on properly, exposing the hair on the sides of their face. During the observation Server E and F were near carts which contained food. Interview with Servers E and F on 08/18/21 at 4:20 PM revealed they did not know their hair was exposed. Each server stated their hair should always be covered while in the kitchen to prevent contamination and foodborne illness. Interview with the Dietician on 08/18/21 at 4:25 PM revealed there were times her hairnet would slip due to wearing her mask. She stated the straps to her mask caused her hairnet to slip. She stated the point of hairnets was to keep hair from getting into the food and to prevent contamination and foodborne illness. Interview with Supervisor D on 08/18/21 at 4:30 PM revealed hairnets should be appropriately worn, covering hair at all times while in the kitchen. She stated there should not be any hair left out of the hairnet. She stated, The kitchen staff is good about reminding each other of hairnets or letting others know if their hair is being exposed or outside of the hairnet. She stated hairnets was to prevent contamination. Review of the facility's kitchen in-service of Associate Food Safety Training record revealed all kitchen staff were in-serviced on hairnets on 06/29/21 and 06/30/21. Review of the facility's kitchen policy for hairnets, dated January 2021, revealed Associates working with food must wear the approved hair restraint when on duty . Hairnets and hats should be worn as appropriate. Review of the U.S. Public Health Service Code, 2017, reflected, Hair Restraints 2-402.11. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that as designed and work to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens, and unwrapped single-service and single-use articles.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for one (Resident #30) of seven residents reviewed for dignity. The facility failed to cover Resident #30's Foley catheter with a privacy bag. This failure could place residents at risk for decreased sense of dignity and quality of life. Findings included: Review of Resident #30's Annual MDS assessment, dated 08/09/21, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] from an acute hospital. His active diagnoses were [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], hypertension, [CONDITION(S)], [CONDITION(S)], diabetes mellitus, [CONDITION(S)], [CONDITION(S)]. The MDS reflected he had an indwelling catheter. Resident #30 had cognitive loss and dementia. Review of Resident #30's Care Plan, dated 08/05/21, revealed the resident had an indwelling catheter related to altered elimination. Interventions included the use of a urine bag to secure the drainage bag and protect privacy. An observation on 08/17/21 at 11:05 AM revealed Resident #30 was self-propelling in the hallway, with catheter bag uncovered and exposed without a privacy bag, underneath the seat of the resident's wheelchair, near the right wheel. An interview with Resident #30 on 08/17/21 at 11:08 AM revealed he was not aware of his catheter bag being exposed and continued to self-propel down the hallway. Interview with LVN A on 08/17//21 at 11:07 AM revealed the resident was supposed to have a privacy bag over his catheter. She stated, I guess the nurse that changed the resident's catheter bag did not put the cover bag over it. She stated she did not know the nurse, which provided care to Resident #30. She stated she would get him a privacy bag. Observation of Resident #30 on 08/17/21 at 12:00 PM revealed the Foley catheter bag was in a privacy bag. Interview with the DON on 08/17/21 at 1:00 PM revealed Resident #30's catheter bag should have never been exposed and without a privacy bag because it was a dignity issue. Review of the facility's Quality of Life- Dignity policy, dated December 2017, revealed, .A. Residents shall be treated with dignity and respect at all times .K. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by 1. Helping the resident to keep urinary catheter bags covered

Based on observation, interview and record review, it was determined the facility failed to ensure medications were stored in accordance with State and Federal laws, for one, 400 hall medication cart of eight medication carts reviewed. The facility failed to ensure 400 hall medication cart was secured while left unattended. This failure could place residents at risk for accessing drugs and items with potentially hazardous contents. Findings included: Observations made on 08/18/2021 at 11:07 a.m. revealed a medication cart with the lock face protruding approximately one inch from the cart, unlocked and was unattended. There were two residents near the cart. There were no staff within eyesight of the cart. In an interview on 8/18/21 at 11:09 a.m. with LVN B revealed she was aware she left the cart unlocked. She stated the risk that it posed to the residents was that it would be bad if they got a medication out of the cart and took it. She said she was supposed to lock the cart when she walked away. In an interview on 8/18/21 at 12:30 p.m. with DON revealed the nurses were supposed to lock their carts each time before walking away from them. He stated the risk it posed to the residents was that a resident could potentially ingest a medication that was not prescribed to them. Record review of the facility policy, dated January 2018, and titled Security of Medication Cart, reflected B. Medication carts should be securely locked when out of the medication administering associate's view. C. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (CNA C) of 12 staff members observed for infection control. The facility failed to ensure CNA C wore a gown, gloves and face shield prior to entering a resident's room of an unknown COVID-19 status. This failure placed residents at risk of exposure and infectious disease outbreak. Findings included: Review of Resident #117's Annual MDS assessment, dated 07/30/21, reflected she was an [AGE] year old female who admitted to the facility on [DATE] from an acute hospital. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #117 had cognitive loss. Review of Resident #117's Care Plan, dated 07/26/21, revealed the resident was being observed for COVID-19 related signs and symptoms, such as fever, cough, sneezing, sore throat, respiratory issues. Observation on 08/17/21 at 10:24 AM revealed Resident #117 had a transmission-based precaution sign on the wall to the left of her door, which led to the inside of her room. Below the transmission-based precaution sign was a 3-drawer medium storage cart, which contained PPE- blue gowns, a box of gloves and face shields. Observation on 08/17/21 at 10:26 AM revealed CNA C walked past the 3-drawer medium storage cart, which contained PPE and into Resident #117's room. CNA C was in the resident's room without a gown, gloves or face shield on while talking to the resident and her family member regarding the resident's upcoming [CONDITION(S)] appointment. CNA C was wearing a N-95 mask. Interview with CNA C on 08/17/21 at 10:30 AM revealed she forgot to put on the appropriate PPE prior to entering Resident #117's room. She stated she was not thinking and stated the resident was recently switched to transmission-based precaution that same day due to potential exposure from a staff member, which recently tested positive. She stated wearing the appropriate PPE was to prevent the potential outbreak of COVID-19. Review of the facility's Infection Prevention and Control Program, dated June 2020, reflected, The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the community; b. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors and the general public; c. Establish guidelines for implementing Standard and Transmission-Based Precautions .2. Important facets of infection prevention include: . c. Following established general and disease-specific guidelines such as those of the Centers for Disease control (CDC).

Based on interview, and record review, the facility failed to administer medication according to physician's orders to one of three residents (Resident #1) reviewed for medications. RN B gave Resident #1 medications belonging to another resident resulting in Resident #1 having a change of condition and being transferred to emergency department. This failure placed residents at risk of experiencing non-therapeutic side effect which could include injury and/or death. Findings include: Review of Resident #1's face sheet revealed a [AGE] year-old male DOB [DATE] with original admission date of [DATE] and current admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed BIMS score of 000. Staff assessment was done indicating memory problems. Review of Resident #1's Care Plan dated [DATE] revealed the resident has impaired decision-making skills and impaired ability to comprehend due to mental [MEDICAL CONDITION] and dementia; requires assist with ADL care. Review of Provider Investigation Report dated [DATE] revealed the following description error involving Resident #1: On [DATE] at 8:30 am, there was a medication error. LVN A drew up medications for two residents. LVN A entered Resident #1's room with both medications and left the room for an urgent matter. LVN A then requested assistance from RN B to administer the medication. RN B administered 3 medications that were not prescribed to Resident #1. The medication [MEDICATION NAME] 5mg (hypertensive), [MEDICATION NAME] 25mg (hypertensive) and [MEDICATION NAME] 100mg (anticonvulsent). The medication error was reported to the Weekend Supervisor and the MD. Resident #1's blood pressure was monitored and got as low as ,[DATE]. Intravenous fluids were ordered. When blood pressure did not return to normal, Resident#1 was ordered to be sent to the emergency room for treatment. Resident #1 returned to the facility on the same day. Review of Resident #1's interdisciplinary notes dated [DATE] at 10:12 am revealed the following: -at 8:30 am blood pressure of ,[DATE] -at 8:45 am blood pressure of ,[DATE] -at 9:00 am blood pressure of ,[DATE] -at 9:15 am blood pressure of ,[DATE] -at 9:30 am blood pressure of ,[DATE] -at 9:40 am MD was notified of blood pressure, order given to send Resident #1 to the emergency department for further evaluation. -at 10:00 am, EMS transported Resident #1 to the emergency department. Review of Resident #1's hospital records dated [DATE] revealed the following: Residen t#1 was treated with Sodium Chloride 0.9% bolus, 1000ml intervenous infusion. Final Impression as of [DATE] at 2:46 pm -Accidental overdose. Resident #1 was transferred back to facility from the hospital on [DATE] at 4:45pm. Review of Resident #1's physician orders reflected no order for antihypertensive (blood pressure medication). In an interview on [DATE] at 3:51 pm, LVN A stated on [DATE] at about 8:30 am, she had prepared Resident #1's medications and another resident's blood pressure medications ([MEDICATION NAME] 5mg and [MEDICATION NAME] 25mg and [MEDICATION NAME] 100mg) at the same time and took both medications in Resident #1's room. She also stated she got called out of Resident # 1's room due to an emergency with another resident and she left both resident's medications in Resident #1's room. She stated she asked RN B to administer Resident #1's medications. She stated RN B had notified her after administering the medications to Resident #1 and what his blood pressure was. She then stated, at about 9:30 am while documenting, she realized Resident #1 was given another resident's blood pressure medications. She stated she notified the Unit Manager who notified the Weekend Supervisor. Resident #1 was assessed, and his blood pressure was dropping. The MD was also notified, orders were given to infuse IV fluids, monitor blood pressure and if the Resident's blood pressure keeps dropping to send him to the emergency department for further evaluations. She ended by saying, I was not supposed to prepared more than one resident medication at the same time. I was not supposed to ask another nurse to give medication they did not prepare because they did not know what was prepared. I think Resident #1 was harmed because he was administered medications he was not supposed to receive if I had not noticed, he would have died . In an interview on [DATE] at 4:25 pm, RN B stated she was asked by LVN A to administer medication to Resident #1 which was already prepared by LVN A. She stated there was one cup with crushed medication in pudding and the other cup with crushed blood pressure medication (indicated on the cup) in Resident #1's room. She stated she took Resident #1's blood pressure, ,[DATE] which was normal base on standing orders for blood pressure medication parameters. She also stated, she went ahead and administered medications in both cups and notified LVN A of Resident #1's blood pressure reading. She stated she thought she was helping because LVN A was attending to an emergency. She said it is not ok to administer medication prepared by someone other than yourself because you do not know what was prepared. In an interview on [DATE] at 3:28 pm, the Unit Manager stated on [DATE] LVN A told him she thought the wrong medication was given to Resident #1. He also stated he asked LVN A what medications were given to Resident #1 that were wrong and she listed the following medications: [REDACTED]. He stated, he asked LVN A if Resident #1 usually gets blood pressure medications in the morning and she said no. He said he and LVN A went into Resident#1's room to check for the medication cups to verify if those medications were given to Resident #1 and noted the medication cups in the trash bag. He then stated he asked LVN A to assess and check Resident #1's blood pressure while he called the Weekend Supervisor. Unit Manager stated Resident #1's blood pressure kept dropping (he was not sure of the exact numbers, but it is documented) so he asked the staff to put Resident #1 in bed and elevate his legs while he contacted the MD. He stated the MD ordered: -Sodium Chloride 0.9% 1000ml intravenously, to bolus 500ml and the rest of the 500ml at 125ml per hour, -monitor Resident #1's vital signs every 15 minutes, if he becomes symptomatic to send Resident#1 to the local emergency department. Unit Manager stated Resident #1 complained of feeling dizzy and his blood pressure had dropped to about ,[DATE] and so EMS was notified and Resident #1 was sent out to the emergency room . He stated, it is not ok to prepare more than one resident medication at a time because it could be given to the wrong resident. He further stated, Me as a nurse will not administer a medication another nurse prepared, I don't know what is in the cup, or if it is the actual medication or not. In an interview on [DATE] at 3:00 pm, the Weekend Supervisor stated she was notified by the Unit Manager a medication error had occurred. She stated once she found out blood pressure medications were given to Resident #1 who has no blood pressure medication ordered, she asked about the blood pressure and was told it was about ,[DATE]. She stated it was then the MD was notified and orders were given. She stated Resident #1 said he felt dizzy and his eyes were feeling funny, blood pressure continued to drop to about ,[DATE]s and Resident #1 was sent to the emergency room . She further stated, RN B did not know what was in the medication cup, Myself, I will not administer medication I did not prepare. She also stated you do not walk away from a medication in a resident's room, it is against the nursing scope of practice, it is detrimental to the resident, you never do that, to prevent medication error. In an interview on [DATE] at 11:55 am, the DON stated staff are not supposed to administer medications they did not prepare. He also stated, staff are not supposed to pre-pour or pre-prepare medications because it gets mixed and the wrong person gets the wrong medication. This is to prevent medication errors, follow the medication rights (right patient, right medication). Review of facility's policy titled Adverse effect and Medication Error dated ,[DATE] reflected: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing service. ---unauthorized drugs-a drug is administered without a physician's order ---wrong drug ---Wrong dose/ dosage form