Every finding on record at The Arbour at Westminster Manor

Based on observation, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to seal the food in the freezer. The facility failed to ensure that items were labeled and dated in the freezer. These failures could place residents at risk for consuming contaminated food and developing foodborne illnesses. An observation made on 12/01/2025 at 9:00 AM, of the walk-in freezer revealed food boxes stored on top of crates, unlabeled unidentified food items, and there was food opened in a bag that was not sealed, and the food was exposed to the air. An observation made on 12/01/2025 at 1:30 PM, revealed a variety of packaged food was still on the crate inside the walk-in freezer. An observation made on 12/02/2025 at 10:40 AM, revealed new unidentified food boxes inside the walk-in refrigerator on the floor and walk in freezer on the floor. During the observation, the opened unlabeled food items were still opened inside the freezer. An interview conducted on 12/03/2025 at 11:57 AM, with the DM revealed that they had been employed at the facility for 7 years. The DM stated that the policy on food storage is food should be stored in a safe manner. The DM stated that food should be labeled and dated after opening. The DM stated that all the food should be in containers, if needed and covered. The DM stated that for food for shelving should be at least 6 inches from the ground. The DM stated that food should never be placed on the ground even if it is in the package. The DM stated that it could negatively affect residents by potentially causing food borne illnesses and contact with unclean surfaces. An interview made on 12/03/2025 at 1:15 PM, with CK A revealed that they had been employed at the facility for 1.5 years. CK A stated food should be closed and if food was opened in a bag, it should be closed because it is considered an open container. CK A stated that the food should be closed because the expiration date automatically starts when the item is open. CK A stated food staff should follow procedures.An interview made on 12/03/2025 at 2:00 PM, with SC revealed that they had been employed at the facility for 7 years. SC stated that after food deliveries that are done Monday through Friday, the food should be put away. SC stated that the food would come off the truck and put in the respective areas in the kitchen. SC stated that the policy for food receiving was to put the food away right when the facility received it. SC stated the staff do not store food on the floor. SC stated when food is inside of a bag, the bag should be wrapped back up before they close the box. SC stated not closing the bag could result in frost burn, flavor loss and color loss. SC stated it could negatively affect a resident by psychologically off putting. An interview made on 12/03/2025 at 4:24 PM, with the DON revealed that they had been DON at the facility for 3 months. The DON stated food that had been left uncovered and sealed may cause resident harm. The DON stated that the standard was for the staff to close the products that they used when they were done with it. An interview made on 12/03/2025 at 4:48 PM, with the ADM revealed that the ADM had been employed at the facility for 6 years. The ADM stated the policy for kitchen storage was when staff received the food delivery, the food should go straight to the fridge or freezer. The ADM stated food could be placed on the floor when it was delivered. The ADM stated that placing the food on the floor in its assembled box could not affect the quality of the food. The ADM said it would not affect residents. The ADM stated the policy for food exposure would be to discard the food that was left open. The ADM stated she does not know what type of harm could arise for residents if food was exposed to the air. The ADM stated the expectation for food bags is to ensure they are closed when staff are done using the food. The ADM stated that food should be labeled when they arrive to the facility and should follow facility policy regarding that. Record review of a document provided by the facility titled Policy & Procedure Manual Delivery Schedule dated 2023 revealed the following:1. Deliveries are accepted 7 days a week. Record review of a document provided by the facility titled Policy & Procedure Manual Food Storage dated 2023 revealed the following:1. All food items should be stored upon delivery and careful rotation procedures should be.followed.2. All foods should be stored off the floor.3. All foods should be covered, labeled, and dated. All foods will be checked to ensure that.foods will be consumed by their use by dates or discarded. 4. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident #25) reviewed for accuracy of assessments. The facility failed to ensure Resident #25's MDS assessments date 10/01/2025 reflected his contractures on both his hands. This failure could place residents at risk of inadequate care due to an inaccurate MDS assessment. Findings include:Record review of Resident #25's face sheet, dated 12/02/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #25 had a diagnoses including dementia (memory, thinking, difficulty), anxiety (feeling of uneasiness or worry), hypertension (high blood pressure), gout (swollen arthritis), hyperlipidemia (high cholesterol), and depression (persistent feeling of sadness). Record review of Resident #25's quarterly MDS dated [DATE], revealed Resident #25 had a BIMS of 99 indicated unable to complete the interview. The MDS also revealed that Resident #25 was substantial/maximal assist with eating. Resident #25 was dependent on staff for toileting, dressing, bed mobility, and transfers. The MDS revealed for functional limitation in range of motion for upper extremity no impairment. Record review of Resident #25's care plan, dated 09/30/2025, revealed Resident #25's hospice company managed his Bilateral hand rolls to hand contractures. Encourage participation to the extent the resident wishes to participate. Resident #25's care plan also revealed he was extensive assist/one-person physical assist with eating. Assist Bars are indicated and serve as an enabler to promote independence. Goal was that resident will feel more secure and independent in bed during ADL's and risks will be minimized. Interventions were resident will be using assist bars as enabler to promote independence. Record review of Resident #25's Restorative Nursing Screener/GG Evaluation dated 06/27/2025 revealed: Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury: Needed Some Help - Resident needed partial assistance from another person to complete any activities. Range of Motion: upper extremity (Shoulder, elbow, wrist, hand) impaired on both sides. lower extremity (hip, knee, ankle, foot) impairment on one side. During an interview with the MDSN on 12/03/2025 at 3:52 p.m., revealed that she had been trained on the MDS. She said she was responsible for completing the MDS. She said information on the MDS was about a resident's oxygen status, behaviors, medications, and any other information about the resident. She said if the resident had a contracture on his hands that affected the range of motion it would need to be put on the MDS. She said Resident #25's contractures did limit his range of motion, and his contractures should have been put on his MDS. She said she would do a new MDS if the resident had a change in condition, or quarterly. She said by the MDS not being accurate it would not affect the resident's care or payment. She said the MDS not being correct would just be an error. She said she was responsible for monitoring to ensure the MDS was correct. She said she monitored the MDS by doing an audit and pulling a report that will flag areas that are not correct. She said she did not know why Resident #25's hand contractures was not on his MDS. During an interview with the DON on 12/03/2025 at 4:18 p.m., said she had been trained on the MDS. She said the policy for the MDS was that the MDS had to be done within 14 days of admission. She said the MDS Nurse was responsible for completing the MDS. She said the MDS consisted of everything the resident does. She added the MDS covered the resident's cognitive level, and ADLs. She said a resident's contractures was also to be on the MDS. She said if a resident's contractures was not on the MDS then the facility would not capture the care and management for the resident. She said the MDS nurse would pull all the data from the nurses and the CNAs and making sure that information was correct. She said that she did not know why Resident #25's contractures was not on his MDS. During an interview with the ADM on 12/03/2025 at 4:40 p.m., said she had not been formally trained on the MDS. She said the MDS had to be done within 14 days of admission and quarterly there after depending on the resident's stay status. She said the MDS coordinator was responsible for completing the MDS. She said the MDS was a health assessment. She said the contractures should be on the MDS if the contracture affects a resident's range of motion. She said the if the contractures did not affect the resident's range of motion it did not have to be on the MDS. She said that MDS nurse monitors to ensure the MDS was correct. She said she monitored the MDS by using a tool on the computer to scan for errors. She said Resident #25's contractures did not need to be on the MDS because he was dependent on staff and Resident #25 did not complete any part of his ADLs. Record review of MDS 3.0 Completion policy not dated revealed According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. Residents are assessed by using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. Care Area Assessment (CAA's): i. The CAA process outlined in Chapter 4 of the RAI manual is designed to assist the assessor in systematically interpreting the information recorded on the MDS to facilitate decision making regarding the resident's plan of care. ii. There are 20 CAAs. The responsibility for completion of each CAA will be clearly assigned. See CAA and Care Plan Division of Responsibility - Expectation List supplemental document. iii. Written documentation of the CAA findings and decision-making process may appear anywhere in the resident's record. iv. The signature of the Person Completing Care Planning Decision can be any designated member of the care plan team or persons who facilitate the care planning decision-making process. Record review of the RAI [NAME] dated 10/2025 revealed You must determine whether the limited ROM has an impact on functional ability or places the resident at risk for injury. Coding Instructions for GG0115A: Functional Limitation in Range of Motion Upper Extremity (Shoulder, Elbow, Wrist, Hand); GG0115B, Lower Extremity (Hip, Knee, Ankle, Foot)Code 0, no impairment: if resident has full functional range of motion on the right and left side of upper/lower extremities. Code 1, impairment on one side: if resident has an upper- and/or lower-extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury. Code 2, impairment on both sides: if resident has an upper- and/or lower extremity impairment on both sides that interferes with daily functioning or places the resident at risk of injury.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be free from abuse for one resident (Resident #44) of six residents reviewed for freedom from abuse. The facility failed to protect Resident #44 from an aggressive family member with suspected history of abuse. On 08/03/2024 at about 6:30pm, during the dinner, the family member shouted at Resident #44 and forcefully fed her against her will by putting the spoon with food in her mouth, as witnessed by staff members. On 09/24/24 at 4:36 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/24, the facility remained out of compliance at a scope of isolated and a severity J level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed the residents at risk for mental and physical harm. Findings included: Review of Resident #44's face sheet dated 09/12/24 reflected, Resident #44 was admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with aftercare following joint replacement surgery, Cognitive communication deficit, Unsteadiness on feet, Muscle weakness, Pain in right shoulder and Dementia. Record review of Resident #44's quarterly MDS assessment dated [DATE] reflected the facility was unable to complete BIMS. MDS indicated Resident #44 had some difficulty to make decisions only in new situations. She did not have any symptoms of psychosis, and no unusual behaviors were indicated. Record review of Resident #44's care plan dated 09/09/24 revealed the plan of structured visits of her FM, developed in the IDT meeting conducted on 08/06/24, was not incorporated into the care plan . Record review of facility's investigation report dated 08/06/2024 on the incident of forceful feeding and shouting involving Resident #44 and her FM on 08/02/2024 at 6:30 pm in the dining hall, confirmed the occurrence of the abuse. Record review on 09/24/24 of the written statement of the incident by DA E dated 08/03/24 revealed Resident #44's FM insisted her to consume the food items she did not want. DA E stated she heard a scream from the dining room when only Resident #44 and FM were there, after everyone finished dinner and left. DA E stated she heard Resident #44's FM raising his voice at her. However, since DA E was far away, she could hear only Resident #44 telling him to hush. During an interview on 09/12/24 at 2:46 PM, the CADM stated Resident #44's POA reported to the facility, during the admission, that that there was abusive history with FM while Resident #44 was living with him in the community, with APS involvement. The CADM said she conducted a meeting on 08/06/24 with Resident #44's FM, Ombudsman, and the POA of Resident #44. In the meeting, it was decided to welcome Resident #44's FM to visit her during the restricted hours. As per this plan, the FM was allowed to visit daily from 2:00pm - 4:00pm or 3:00pm - 5:00pm in the common areas or participate in activities with Resident #44, to make every visit more enjoyable than stressful for Resident #44. She said Resident #44's FM could not visit her in her room due to his history of abusive behavior. The CADM stated Resident #44 had issues with dementia and might permit him to her room without remembering his abusive behaviors in the past. When the surveyor pointed out the absence of a care plan related to this arrangement for Resident #44's visits, for about a month after the decision being taken, the CADM stated she would add the plan to the care plan with immediate effect. She stated their plan for Resident #44's FM's visits were documented nowhere in the system. CADM said his visit was electronically monitored by her and explained that when the FM signed in at the facility, she would get an electronic notification on her mobile and then CADM would let the staff know about his arrival. When the surveyor asked what if CADM was away from her mobile phone when the FM arrived at the facility, she stated that there was a very rare chance for that. The CADM stated two other staff members from the administrative team had similar features on their mobile phone and they would be able to give directions to the staff Interview on 09/24/24 at 12:30 pm with the CADM and record review of Resident #44's care plan dated 09/12/24 revealed Resident #44's FM was allowed to visit daily from 2:00 pm - 4:00 pm or 3:00 pm - 5:00 pm in common areas or participate in activities with Resident #44, and he could not visit in her room. CADM stated this care plan was added on 09/12/24, after the HHSC surveyor pointed out the absence of a careplan related to the restricted visit of Resident #44's FM. During an interview on 08/11/24 at 10:00 am, Resident #44 stated she was married for [AGE] years and like to see FM every day. When asked about the incident that occurred in the dining room, she stated that was a month ago, and currently the visits occurred outside her room. She stated they spent time together with playing board games and chatting. She said there was no issues after the incident occurred in the dining hall and happy with the current arrangement. During a telephone interview on 08/12/24 at 11:30 am, the FM stated he wanted to see Resident #44 and have dinner with her every day. He stated the facility was unfair to him by putting restriction on his visits. He stated he was trying to make her eat the whole meal severed so that she would get well faster. The FM stated he did that many times in the past when she refused to eat. He said he was not abusive and did nothing wrong, however the facility was interpreting the incident differently. FM stated his intention was to improve her health. During an interview on 09/24/24/ at 11:30 am, the DM stated on 08/03/24 at about 6:30 pm she was at home after her shift and got a phone call from DA D stating Resident #44's FM was shouting at Resident #44 and forcefully feeding her by putting the spoon in her mouth. The DM stated Resident #44 was screaming as if she was in pain. The DM stated she managed to get the security with the help of the receptionist. She said Resident #44's FM was escorted out of the facility by the security without any further incidents. During a telephone interview on 09/24/24 at 1:00 pm, DA D stated she witnessed the incident that happened between Resident #44 and her FM on 08/03/24 at about 6:30 pm. She stated ,after the dinner time while cleaning the dining area and the kitchen in the back with DA E, she heard Resident #44 yelling that sounded as if she was hurt or was in pain. She stated she went up front and observed Resident #44 telling her FM to shut up and kept saying stop feeding. She said, at that time, FM kept telling Resident #44 she had to eat and then forced her to eat. She stated she saw him putting the fork into her mouth and she pushed it away. DA D stated Resident #44 asked for dessert, however FM told DA D not give the desert. DA D stated when she provided the dessert, the FM told Resident #44 that she could not have the desert before finishing all the meal left in the plate. DA D stated they kept arguing, and at one point, she saw Resident #44 drying her eyes with a paper towel. DA D added that wasn't the first time she had seen him trying to force feed her. When asked why she did not report it that time, she stated she thought things would get better. However, she now realized it was going bad. On 09/24/24 at 1:30 pm, an attempt to have a telephone interview with DA E was unsuccessful. During an interview on 09/13/24 at 11:30 am, Resident #44's POA stated she had a meeting with the CADM, Resident #44's FM, and the ombudsman at the facility on 08/06/24, and they decided to have a plan for restricted and supervised visits for Resident #44's FM. She stated she agreed with this arrangement as she was aware of the long history of physical and mental abuse by him while Resident #44 was living with him in the community. The POA stated there was APS involvement in the past due to domestic violence and abusive behavior of the FM. She stated she wanted to protect Resident #44 from incidents of abuse at the facility. The POA added , at the same time, she did not want to totally cut her off from FM and found the idea of supervised visits as a useful solution to the situation. During an interview on 09/12/24 at 2:46 PM, the MDSC stated it was his responsibility to make changes in the care plan based on the information passed on by SW worker, DON, CADM, or other responsible parties. He stated he heard about the incident that occurred in the dining hall and the meeting thereafter. However, no one reported to him about the outcome of the meeting for care planning. During interview on 09/12/24 at 4:00 pm, CNA A stated she worked on Resident #44's hall. She said she was not aware of any care plan related to Resident #44's FM's visit. She stated she knew him and would allow him to meet Resident #44 in her room if he wanted, as it was part of the resident's rights policy. During an interview on 09/12/24 at 4:10 PM, CNA B stated Resident #44's family member was a regular visitor and would encourage him to visit her anytime if they wanted to. She said she was not aware of any specific plan for his visit. During an interview on 09/12/24 at 4:45 pm, the RA stated she had seen Resident #44 and her family member almost every day in the recreational area, engaged in board games. RA said she did not know why they were there instead of her room. The RA stated she would guide him to her room if he requested, or would encourage them to have meals together. During an observation and interview on 09/24/24 at 10:55 am, MA C was administering medications to residents. She stated she generally worked on the 1st floor and occasionally works at 2nd floor where Resident #44 resides. She stated she heard from other staff members that there were restrictions on Resident #44's FM to visit her. She stated she did not know what the restricted hours and the exact plan was. During an interview on 09/24/24 at 11:10 am, CNA D stated she worked at the facility as PRN and was aware of some restrictions on Resident #44's FM to visit her. She stated she did not know the details about it. However, when he asked to see Resident #44 , she would redirect him to the nurse in charge. During an interview on 09/24/24 at 3:30 pm, DA F stated she worked at the facility part time since April 2024. She stated she knew Resident #44 and her FM, and saw them, many times, arguing . She stated she had an impression that FM was trying control Resident #44 . She stated she had seen Resident #44 trying to get away from FM during dinner times as FM took control on her and insisted her to eat the way he decided. She stated she never had seen any physical abuse from him so she thought they were not reportable. DA F stated she knew there were some restrictions on his visits, however, she did not know the visitation time or the plan for his restricted visits. During an interview on 09/24/24 at 3:45 pm, DA G stated she worked at the facility for about a year and knew the dynamics between Resident #44 and the FM. She stated serving food to them was always difficult as the FM demanded attention as if there were no other residents to attend to. She stated Resident #44's FM gave priority to him over Resident #44. DA G stated she had seen Resident #44 and the FM arguing while having dinner , mostly when the FM shouted at her. When the investigator asked DA G if there were any restrictions in place for Resident #44's FM's visits , she stated she was not aware of any and would serve them dinner if they wanted to eat together. She stated she had not seen the FM at dinner for while, however, she had seen them spending time together in the activity room. During an interview on 09/24/24 at 4:00 pm, the CADM stated Resident #44's FM visited her as per the plan without any deviation. She stated they remained in the open area so that staff could supervise. When the surveyor asked, since it was a supervised visit who was responsible for supervision during his visit, CADM stated there were no specific persons responsible as they sat in the open area and were visible to everybody. Record review of the in-services revealed on 08/11/24 in-services were conducted on Definition of caregiver, provider, and sitter to include staff responsibilities. Limitations of visit for [Resident #44's FM] and on 09/13/24 Visitation for [Resident #44] and [FM]. The attendance sheet reflected 8 staff members were in serviced and CNA A, CNA B , RA, MA C, DM, DA E, DA F and DA G were not participant in these in-services. Review of the facility's policy Reporting abuse to facility management revised February 2024 reflected: 1.Our facility does not condone resident abuse to anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided: a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. b. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents; regardless of their age, ability to comprehend, or disability. This was determined to be an Immediate Jeopardy (IJ) on 09/24/24 at 3:00 PM. The ADM was notified and provided with the IJ template on 09/24/24 at 4:36pm. The following Plan of Removal submitted by the facility was accepted on 09/25/24 at 12:40 PM and reflected the following: Immediate Jeopardy On 09/10/2024 an abbreviated survey was initiated at [facility]. On 09/24/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to protect Resident #44 from an aggressive family member with behaviors. Action: Referral made to, for Resident #44. Will be completed on 09/25/2024. Start Date: 9/25/24, Completion Date: 9/25/24, Responsible: Administrator. Action: Social Worker to interview Resident #44 for psychosocial well-being. Start Date: 9/25/24, Completion Date: 9/25/24, Responsible: Administrator Action: Executive Director in serviced Administrator and Director of Nursing on any allegation of resident abuse/neglect with findings, will have interventions care planned and will ensure all staff are educated on the interventions. Start Date: 9/24/2024, Completion Date: 9/24/2024, Responsible: Executive Director Action: All staff in-serviced on Resident #44's visiting instructions with Resident #44's husband. In-service includes visiting hours, husband's meal restriction while visiting, and if there are any concerns during visitation to immediately inform charge nurse, ADON, DON, or Administrator. Start Date: 9/24/2024. Completion Date: on-going until all staff (nursing department, dietary department, housekeeping department, activity department, front desk) who are employed by the facility are in serviced. Responsible: Administrator Action: All staff not present and new staff will be in-serviced on Resident #44's visiting instructions with Resident #44's husband prior to the start of their shift. Start Date: 9/24/2024,Completion Date: on-going, Responsible: Administrator Action: New staff, PRN and agency nursing staff will be in serviced prior to the start of their shift. Start Date: 9/24/2024,Completion Date: on-going, Responsible: Director of Nursing. Action: Resident #44's FM is allowed to have observed visits by staff during an agreeable time frame by Resident #44, her POA, and her husband. Start Date: 9/24/2024,Completion Date: 9/24/24,Responsible: Administrator. Action: Resident #44's POA agreed with the Resident #44's FM's visitation instructions. Start Date: 9/24/2024,Completion Date: 9/24/24,Responsible: Administrator. Action: Resident #44 agreed with her FM's visitation instructions. Start Date: 9/24/2024, Completion Date: 9/24/24,Responsible: Administrator. Action: Resident #44's FM visitation instructions have been care planned by the Director of Nursing ensuring Resident's rights are being met. Start Date: 9/24/2024,Completion Date: 9/24/24,Responsible: Administrator. Action: Resident #44's FM had agreed to the visitation instructions. Start Date: 9/24/2024,Completion Date: 9/24/24,Responsible: Administrator Monitoring of the Plan of Removal on 09/25/24 included the following: POA approved for a Referral for psychiatric assessment of Resident #44. During an interview on 09/25/24 at 12:00pm CADM reported that the team visited and assessed of Resident #44 was in progress on 09/25/24 at 12:45pm. During an interview on 09/25/24 at 12:00pm CADM stated the psychosocial wellbeing interview was completed by the social worker to asses her mood, on 09/25/24. CADM and the DON on any allegation of resident abuse/neglect with findings, will have interventions care planned and will ensure all staff are educated on the interventions. Record review of the employee list revealed that the facility employed about 100 staff members including PRN staff members. Review of in-service record revealed about 80 staff members were in serviced and the program was still going on. During an interview on 09/25/24 at 12:00pm CADM stated she texted all the PRN employees and instructed about the in service. She stated they would be able to complete the in-service sooner than later. During an interview on 09/25/24 at 2:00pm CADM explained the structure and plan of the visits. She stated on Monday - Friday, the activities director or assistant, would either observe or designate observation of visitation in the activity room. She stated Saturday - Sunday, the weekend ADON will either observe or designate observation of visitation in the activity room. During an interview on 09/24/24 at 4:50 pm, the POA stated she was happy with the current arrangement of the restricted visit. During an interview on 09/25/24, at 10:30am Resident#44 stated she wanted her FM to visit her every day and was okay with the plan. Review of Resident #44's updated careplan dated 09/12/24 revealed Resident #44's FM was allowed to visit daily from 2:00 pm - 4:00 pm or 3:00 pm - 5:00 pm in common areas or participate in activities with Resident #44, and he could not visit in her room. CADM stated this care plan was added on 09/12/24, after the HHSC surveyor pointed out the absence of a careplan related to the restricted visit of Resident #44's FM. Record review of the in-service record on 9/25/24 revealed Executive Director in serviced on 09/24/24 the CADM and DON on any allegation of resident abuse/neglect with findings, will have interventions care planned and will ensure all staff are educated on the interventions. The staff from morning and afternoon shift who were interviewed on 09/25/24 stated, they had attended the in-service on the restricted visit of Resident #44's FM and were able to explain the plan in place for the restricted visit. The CADM was informed the Immediate Jeopardy (IJ) was removed on 09/25/24 at 3:10pm. The facility remained out of compliance at a scope of isolated and a severity J level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 10 Residents (Resident #43 and Resident #44) reviewed for care plans. Resident #43 The facility failed to ensure: 1. Resident #43's legs were elevated while sitting or sleeping. 2. Resident #43 wore her compression stockings. 2. Resident #43's door remained open, except when receiving care. Resident #44 The facility failed to develop a comprehensive care plan that included interventions to ensure safety of Resident # 44 from the visitor's aggressive, physical, and verbal behaviors. This failure could place residents at risk of continued abuse, and not reaching their highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #43 Record review or Resident #43's AR, dated 9/10/2024, reflected an [AGE] year-old woman, born on 12/22/1936, who admitted to the facility on [DATE]. He She was diagnosed with Peripheral Vascular Disease (which was a progressive disorder of the blood vessels, having caused narrowing, spasms, or blockage of blood vessels,) Venous Insufficiency (which was a condition having caused problems with the body's ability to channel blood flow towards the heart,) Parkinson's Disease (which was progressive disorder that affected the nervous system and the parts of the body controlled by the nerves,) Repeated Falls (which was a medical code, utilized in diagnosing, which was used do designate numerous past falls and future risk of falls,) and Psychosis, Unspecified, (which was a classification of a non-specific disorder associated with the mind.) Record review of Resident #43's Quarterly MDS, dated [DATE], reflected the Staff's assessment of Resident #43's cognitive skills for daily decision indicated Resident #43 was severely impaired. Resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand;) Resident had no impairment in either lower extremity (hip, knee, ankle, and foot;) Resident utilized a wheelchair for mobility. Resident required substantial/maximum assistance for eating, oral hygiene, and personal hygiene, rolling left to right (which meant the helper provided more than half the effort while the resident completed the lesser portion of the activity.) Resident was dependent for toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off shoes, sitting to lying, lying to sitting on side of bed, sitting to standing, chair to bed/ bed to chair transfer, and tub/shower transfer (which meant the helper provided all the effort of the activity.) Resident was always incontinent of bladder. Resident was always incontinent of bowel. Record review of Resident #43's CCP reflected the following Problem areas: *Functional performance, initiated on 4/1/2021. The Goal, revised on 9/9/2024, reflected the resident would have maintained functional performance through the target date of 12/8/2024. The Intervention, initiated 4/1/2021, reflected staff would provide two-person assist for bed mobility, one-person assist for personal hygiene one-person assist for toileting, and two-person assist for transfer. * Assist bars, initiated 7/9/2024, evidenced by the need to enable and promote independence. The Goals, revised on 9/9/2024, reflected the resident was supposed to feel more secure and independent in bed during ADLs and to minimize associated risks. The Intervention, initiated on 7/9/2024, reflected the resident was supposed to have utilized the assist bars to promote independence. * Peripheral Vascular Disease (PVD) initiated 10/28/2020. The Goal, initiated on 10/28/2024, reflected the resident was supposed to have remained free of complications of PVD through the target date of 12/8/2024. The Interventions, initiated on 10/28/2020, reflected nursing home staff was supposed to have elevated Resident #43's legs while sitting or sleeping and encourage resident to change positions frequently. * Inability to have utilized the call light button, initiated 9/10/2024, evidenced by low cognition level. The Goal, initiated on 9/10/2024, reflected the resident was supposed to have maintained cognitive function through the target date of 12/8/2024. The Interventions, initiated on 9/10/2024, reflected nursing home staff was supposed to have left Resident #43's bedroom door open, unless having received care, and having provided frequent checks while resident was in the bedroom. * Skin integrity, initiated on 7/17/2020, R/T chronic stasis (poor blood flow) and fragile skin. The Goals revised on 10/28/2020 reflected the resident was supposed to maintain clean and intact skin; having had no complications R/T stasis through the review date of 12/8/2024. The Intervention, initiated on 7/17/2020, delegated nursing home staff to assist in having daily applied compression stockings (which were specialized socks that applied gentle pressure to improve blood flow from the legs to the heart.) According to the CCP, the date of the last CCP review was 9/9/2024. The print date of the CCP was 9/10/2024. Record review of a progress note entered by Social Services, dated 9/9/2024 at 9:36 AM, reflected Resident #43 temporarily changed rooms to 1118. Observations and interview on 09/10/24 at 3:32 PM at Residents #43's room revealed the door to the room was closed. When having entered the room, there was no staff present and care was not being provided. There was a strong odor of bowel. The bed was in the lowest position, with blue floor fall mats on both sides of the bed. Observations revealed Resident #43 sleeping in her bed. While having faced the bed from the footboard, the head rest portion of the bed, located at the 12 o'clock position, was elevated approximately 20 degrees. The resident was lying on her left side of her body, curved diagonally from left to right like the shape of a banana. Resident was lying perpendicular to the mattress. The left side of her face was resting against the mattress and pillow, facing away from the observer, at the spot where the mattress began to tilt upwards 20 degrees. Her head was at the 10 o'clock position of the bed on the far-left edge of the mattress close to the assist bar. Both of her legs, from the lower knees/upper shins area down, were hanging off the bed at the 4 o'clock position, uncovered. She was not wearing compression stockings. The positioning of her lower extremities was lower than the level of the rest of her body. There was a normal sized bed pillow under Resident #43's covers at the 5 o'clock position. Interview with RN N revealed the resident's legs had purposely been hung over the end of the of the bed to protect her heals from pressure ulcers; He was observed having knelt beside the resident and was observed having pointed to Resident #43's left and right heels with his finger. Initially, he stated the pillow was placed on the bed to keep the resident from bringing her legs back to the mattress, but later admitted he did not know why the pillow was there. RN M was observed having briefly exited the room to get assistance from LVN O to have helped reposition the resident. RN M and LVN O were observed having repositioned Resident #43 on her bed. Observations revealed the residents head placed at the 12 o'clock position and her feet at the 6 o'clock position with her feet elevated under the pillow that was already under her covers. Both RN M and LVN O admitted not knowing much about Resident #43's care because she just moved down from the 2nd floor, on 9/9/2024. LVN O stated Resident #43 was not positioned correctly at the time she entered the room. LVN O stated she checked on Resident #43 when she came on shift at 2:00 PM but did not know if she had been checked upon since 2:00 PM. Two CNAs had entered the room to provide resident with care. Interview on 9/11/2024 at 8:03 AM with CNA P revealed she had access to Resident #43's care instructions, which were found in the Kardex. The Kardex was a brief written description of Resident #43's needs, taken from her CCP. The Kardex was located on a medium sized touchscreen monitor, known as a Kiosk, located in the resident's hallway. She stated Resident #43's legs were supposed to be elevated to prevent swelling and discomfort. CNA P stated, she was unaware of the resident's need for compression stocking and did not put any on the resident. Interview, observation, and record review on 9/13/2024 at 10:20 AM with CNA M revealed Resident #43's care information was found on her Kardex. CNA M was observed logging into the Kiosk and having pulled up Resident #43's Kardex. The Kardex indicated Resident #43 was supposed to have her door open when not receiving care and was supposed to receive frequent checks. The Kardex did not have instructions to ensure Resident #43's legs were elevated while sitting or sleeping or to have compression stockings; however, CNA M did have access to viewing the resident's entire CCP. CNA M was observed viewing the CCP in its entirety, from the Kiosk where the elevation of legs and compression stockings were mentioned. CNA M stated she was instructed to check both the CCP and the Kardex to know the resident's needs. Interview on 9/13/2024 at 10:40 AM with NP T, who worked at a local geriatric care provider agency, revealed PVD was a medical condition that effected circulation of blood in the extremities. The intervention of elevating someone's legs, who was diagnosed PVD, would help reduce swelling and fluid collection in the lower extremities. Without elevation, the resident risked complications with skin integrity, accumulation of fluid, pain, and discomfort in the extremity. Interview on 9/13/2024 at 12:07 PM with the DON revealed interventions for a resident, with a diagnosis of PVD, would be to elevate their legs, if they were showing signs or symptoms. If a resident were unable to utilize their call light, interventions would be written in the CCP. The DON stated all nursing staff had access to the resident's Kardex's, and the CCPs. The expectation of staff was that they utilized both the Kardex, and the CCP, to have known the specifics of each resident's needs. Interview on 9/13/24 at 1:08 PM with the CADM revealed residents who were not able utilize their call lights received alternate interventions, which were found in the resident's Kardex and CCP. The relationship between a call light button, and a resident who was able to use it, was just as important as the interventions for the resident who could not use theirs. Having deferred responses to medical questions, the CADM stated CNA staff was not trained to make medical assessments of resident's medical conditions, so they were expected to follow the care plan. From time to time, residents will move from one area of the facility to another, and care givers may change; however, unfamiliar staff were expected to know the same information about the resident. The CADM expected her staff to follow the instructions and interventions in the Kardex, and the CCP. Record review of the facility's Comprehensive Person-Centered Care Plan, dated March 2022, reflected each resident's comprehensive person-centered care plan was consistent with the resident's rights to receive the services and/or items included in the care plan. The comprehensive person-centered care plan described the services that were supposed to be furnished to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being, including which professional services were responsible for each element of care. Services provided, or arranged by the facility, were outlined in the comprehensive person-centered care plan, and were provided by qualified persons, who were culturally competent, and trauma informed. Record review of the facility's ADL Policy, dated March 2018, reflected appropriate care would be provided for residents who were unable to conduct ADLs independently, such as hygiene, mobility, and toileting, and communication (speech, language, and any functional communication system.) Interventions to improve, or minimize, a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. Record review of the facility's Call Light Policy, dated October 2010, reflected some residents may not be able to use their call light. Be sure to check these residents frequently. Resident #44 Review of Resident #44's face sheet dated 09/12/24 reflected, Resident #44 was admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with aftercare following joint replacement surgery, Cognitive communication deficit, Unsteadiness on feet, Muscle weakness, Pain in right shoulder and Dementia. Record review of Resident #44's quarterly MDS dated [DATE] reflected the facility was unable to complete BIMS. MDS indicated Resident #44 had some difficulty to make decisions only in new situations. She did not have any symptoms of psychosis, also no unusual behaviors indicated. Record review of Resident #44's care plan dated 09/09/24 did not address structured visits of her family member per IDT meeting conducted on 08/06/24 During an interview on 08/11/24 at 10:00AM Resident#44 stated she was married for [AGE] years and like to see him every day. When asked about the incident occurred in the dining room, she stated that was a month ago and currently the visit occurred outside her room. She stated they spent time together with playing board games and chatting. She said there was no issues after the incident occurred in the dining hall and happy with the current arrangement. Interview on 09/12/24 at 2:46 PM, the CADM stated she was informed by the POA that there was history of abusive incidents in the past while Resident #44 and family member lived in the community . The CADM said she conducted a meeting on 08/06/24 with Resident #44's family member, Ombudsman and the POA of Resident #44. In the meeting it was decided to welcome Resident #44's family member to visit her in the restricted hours. As per this plan Resident#44's husband was allowed to visit daily from 2:00pm - 4:00pm or 3:00pm - 5:00pm in the common areas or participate in activities with Resident #44, to make every visit enjoyable than stressful for Resident #44. She said Resident #44's family member could not visit her in her Room due to his abusive behavior. The CADM stated Resident #44 has issue with dementia and might permits him to her room without remembering his abusive behaviors in the past. During an interview Resident #44's POA stated she had a meeting with the CADM, Resident #44's husband and ombudsman at the facility on 08/06/24 and decided to have a plan for restricted and supervised visits for Resident #44's family member. She stated she agreed with this arrangement as she was aware of the long history of physical and mental abuse by him while Resident #44 was living with him in the community. She stated she wanted to protect Resident #44 from incidents at the facility as Resident #44 would not be safe if they were left alone unsupervised. The POA stated there was APS involvement in the past due to domestic violence and abusive behavior. Interview on 09/12/24 at 2:46 PM, the MDSC stated it was his responsibility to make changes in the care plan based on the information passed on by social worker, DON, CADM, or other responsible parties. He stated he heard about the incident occurred in the dining hall and the meeting thereafter however no one reported to him about the outcome of the meeting for care planning. During interview on 09/12/24 at 4:00pm CNA A stated she worked on Resident #44's hall. She said she was not aware of any care plan related to Resident #44's family member's visit. She stated she knew him and would allow him to meet Resident #44 in her room if he wanted, as it was part of the resident's rights policy. During an interview on 09/12/24 at 4:10PM CNA B stated Resident #44's family member was a regular visitor and will encourage him to visit her anytime if they wanted to. She said she was not aware of any specific plan for his visit. During an interview on 09/12/24 at 4:45pm the RA stated she had seen Resident #44 and her family member almost every day in the recreational area, engaged in board games. RA said she did not know why they were there instead of her room. The RA stated she would guide him to her room if he requested or encourage to have meals together. During a second interview on 09/13/24 at 11:20AM, the CADM stated they should have incorporated the plan for Resident #44's family member's restricted visit in the care plan. She said his visit at the facility was going well as per the plan for the last month, without any issues however including the plan in the care plan was important for the effectiveness of the intervention. She stated it was unfortunate that staff did not know about the care plan for his visit. Record review of the in-services in August 2024 revealed on 08/11/24 an Inservice on Definition of caregiver, provider, and sitter to include staff responsibilities. Limitations of visit for [Resident #44's husband]. The attendance sheet reflected CNA A, CNA B and RA were not participant in this Inservice. Record review of facility policy Care plans, Comprehensive Person-Centered revised in March 2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of the resident's needs and preferences for 1 of 8 residents (Resident #59) reviewed for accommodation of needs. The facility failed to ensure Resident #59's call light button was within her reach to call for nursing assistance. This failure placed residents at risk of having their needs gone unmet. Findings included: Record review or Resident #59's AR, dated 9/10/2024, reflected a [AGE] year-old female, born on 03/05/1933, who admitted to the facility on [DATE]. She was diagnosed with Fracture of T-11-T12 Vertebra (which was a fracture in the lower spine,) Fracture of Sacrum (which was a fracture of the large triangle shaped bone at the bottom of the spine,) and Repeated Falls (which was a medical code, utilized in diagnosing, to describe numerous past falls and future risk of falls.) Record review of Resident #59's Admission MDS, dated [DATE], reflected the resident had a BIMS Score of 8. A BIMS Score of 8 indicated the resident had moderate cognitive impairment. Resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand;) Resident had no impairment in either lower extremity (hip, knee, ankle, and foot;) Resident utilized a wheelchair for mobility. Resident required supervision or touching assistance with eating, oral hygiene, and personal hygiene (which meant the helper provided verbal ques, touching, steadying, or contact guard assistance while the resident completed the activity.) Resident was dependent for toileting hygiene, showering/bathing self, upper body dressing, lower body dressing and putting on/taking off shoes (which meant the helper provided all the effort of the activity.) Resident required partial/moderate assistance to walk 10 feet (which meant the helper provided less than half the effort while the resident completed the greater portion of the activity.) Resident was frequently incontinent of bladder. Resident was always incontinent of bowel. Record review of Resident #59's CCP reflected the following problem areas: *Fall risk, initiated on 8/1/2024, and was evidenced by new admission, recent hospital stay, and a recent illness. The Goals, initiated on 8/1/2024, reflected the resident was supposed to be free from falls, and injury, over the next 90 days. The Intervention, initiated 8/1/2024, reflected nursing home staff was supposed to place call light within resident's reach. * Injuries of the back, initiated on 9/10/2024, and was evidenced by fracturs of the vertebra and sacrum. The Goals, initiated on 9/10/2024, reflected the resident was supposed to be free from injury, and complication, by the target date of 12/9/2024. The Intervention, initiated on 9/10/2024, reflected nursing home staff was supposed to anticipate the resident's needs and be sure the call light was within resident's reach and responded to promptly. Observations and interview on 09/10/24 at 3:16 PM in Resident #59's room reflected the resident sitting in her wheelchair watching television. She was facing the television, which was at her 12 o'clock position. Observation reflected the resident's bed, the footboard area, was next to her on her right side at the 3 o'clock position. Resident #59's call light button was wrapped around the bed's stability bar, on the opposite side of her bed, near the headboard, at her 5 o'clock position. Resident #59 stated when she needed help, she could use the call button, but she was unable reach or move herself close enough to grab it. She thought the call light should have been closer for her to use. She stated she used to button to call for help if she needed to use the toilet, or be changed; and, stated she would have felt undignified if she had a toileting accident and was left wet or soiled. If she were in pain, and could not call for help, she stated she would have felt isolated and ignored. Interview on 9/13/2024 at 10:07 AM with CNA M revealed residents had a call light in the room in case they needed to call for help, such as restroom visits, getting an item for them, or general care. When the resident was in the room, the call light was supposed to kept within arm's reach, or nearer, preferably clipped to their pillow, blanket, or chair. If a resident did not have access to their call light, they risked falls, being left soiled, skin breakdown, feeling helpless, or feeling isolated. Measures in place to ensure a resident had access to their call light were room rounds, every 1 to 2 hours, where call light placement was supposed to be confirmed, or corrected. The failure for the resident to have their call light in reach was staff duty oversight. Interview on 9/13/2024 at 11:53 PM with the DON revealed call lights were utilized in resident's rooms for residents to call for staff assistance. Staff was trained staff to make sure the call light was within a resident's reach. If a resident was not able reach the call light to call for assistance, that resident risked having their needs gone unmet. Interview on 9/13/24 at 1:08 PM with the CADM revealed her staff trained was trained on the call light button use, and placement, per facility policy. The CADM's expectation for staff was to have ensured each resident's call light button was within reach, for those who were capable to use it, as to call for assistance. Examples of instances when a resident may have used their call light button were to use the bathroom, ask for a snack, or a general need for care. If a resident was unable to reach their call light button, they risked having their needs gone unmet. Record review of the facility's Answering the call Light Policy, dated October 2010, reflected the resident's call light button was supposed to be within easy reach, whether the resident was in bed, or confined to a chair.

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 disease and infection for 1 of 2 wings (East wing) on the second floor of the facility reviewed for infection control, in that: 1. Laundry staff C did not cover Resident's cleaned clothing on the laundry cart while bringing the clothing back to the residents. Laundry staff C did not sanitize her hands between residents' room. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1 . Observation on 07/18/2023 at 1:12 p.m. revealed Laundry staff C, on the second Eastside wing was passing clean clothing to the residents' room. The cart carrying the clean clothing was uncovered letting the clothing exposed to particles of dust in the air. Laundry staff C was observed going to 3 different rooms, placing clothing in closets and drawers, without practicing hand hygiene. Interview with Laundry staff C, on 07/18/2023 at 1:18 p.m., revealed she confirmed her cart was uncovered and she did not sanitize her hands. She was never told she had to cover the clothing when she was delivering it. She received infection control and hand hygiene training. Interview with the DON, on 07/20/2023 on 2:34 p.m., revealed he confirmed the clothing should be covered to prevent contagion during transport and the laundry staff should practice hand hygiene between rooms and residents. Laundry staff was trained on infection control like the rest of the staff. Audit and spot check were done by the ADON during the week and the RN supervisor during the weekend to insure procedures were followed. Review of the facility policy titled, Personal laundry process, undated, revealed socks, under garment, t-shirts, pajamas, sweat pants place in clear bag with room number written. Review of the facility policy titled, Handwashing/hand hygiene, dated August 2019, revealed use an alcohol-based hand rub containing at least 62% alcohol [ .] for the following situations: [ .] after contact with objects in the immediate vicinity of the resident.

Based on interview and record review, the facility failed to complete an assessment which accurately reflected the resident's status for 1 of 18 (Resident #33) residents reviewed, in that: Resident #33's quarterly MDS assessment inaccurately documented 2 administrations of insulin which did not occur. This failure could result in inadequate care due to an inaccurate assessment of his medication administrations. The findings were: Record review of Resident #33's face sheet, dated 07/19/2023, revealed the male resident, aged [AGE] year, was admitted to the facility on [DATE] with diagnoses including: type 2 diabetes mellitus with hyperglycemia (a condition that occurs with elevated blood sugar levels), anxiety disorder unspecified (a condition in which feelings of worry and fear interfere with daily activities), and peripheral vascular disease unspecified (a condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #33's Quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #33's physician order summary dated 7/19/23 revealed an order, initiated 02/05/2021, for Trulicity Solution (an active substance which is not insulin and is used to lower blood sugar) Pen-injector .75mg, inject 0.5 ml subcutaneously once a week. The physician order summary revealed no orders for insulin for the time frame of 05/06/2023 or for a look back period of 7 days. Record review of Resident #33's quarterly MDS assessment dated [DATE] Section N revealed documentation of two insulin administrations. During an interview with the MDS Manager and the DON on 07/20/2023 at 08:15a.m. both staff stated that the MDS document dated 05/06/2023 for Resident #33 inaccurately noted that Resident #33 was given 2 insulin administrations during a 7 day look back period. The MDS Manager stated that the medication administrations were for the medication Trulicity and not for the medication insulin. She stated that Resident #33 does not take insulin. She stated that the MDS assessments need to accurately reflect what was going on with the resident. The DON stated the MDS assessment needs contain accurate information to be reported to the government. Record review of the facility policy for Comprehensive Assessments dated 02/2022 stated that the comprehensive assessments are to be conducted in accordance with the criteria and time frames established in the Resident Assessment Instrument User Manual.

Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 16 resident (Resident #61) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #61 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record review of Resident #61's face sheet dated 07/21/2023, revealed an admitted [DATE], Record review of Resident #61's medical record revealed that as of 07/18/2023, no Admission assessment MDS had been completed. Section A of the MDS assessment was still showing as incompleted. Interview with MDS Coordinator B on 07/21/23 at 11:40 a.m. revealed the time frame for an initial MDS to be completed was 14 days from admission. He stated he was not the only MDS nurse for the facility and had not done the assessment for Resident #61. He did no know why the other MDS had not completed the assessment on time. He revealed they used the RAI manual as reference and they had electronic access to the manual. He revealed an incomplete Admission assessment was putting the resident at risk for improper care. Interview with the Administrator on 07/21/2023 at 11:45 a.m. revealed the Administrator was not aware the assessment was late. Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the endn of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for one of one kitchen reviewed for dietary services. 1. The facility failed to ensure items in the refrigerator were properly stored dated and labeled. 2. The Dietary Manager failed to ensure the proper use of hair restraints by staff while in the kitchen. 3. The Dietary Manager failed to ensure the staff washed their hands when entering the kitchen and serving the residents. These failures could affect all residents who ate food from the facility's kitchen by placing them at risk of foodborne illness. The findings include: Observation of the facility kitchen conducted on [DATE] between 9:15 a.m. and 11:00 a.m., revealed several staff members entering from the independent living restaurant into the shared kitchen without hairnets and without washing their hands. Observations of the facility kitchen conducted on [DATE] at 9:21 a.m., revealed an open raw sausage pork patty in an open box in the refrigerator without a pan under the box. Further observations revealed that there was no label indicating the type of meat, date of when the sausage was pulled from the freezer to thaw, or the open and use by date label. Observation of the facility kitchen conducted on [DATE] at 9:28 a.m. revealed two open ice cream containers in the freezer without the open and used by date. Observation of the facility kitchen conducted on [DATE] at 9:28 a.m. revealed the dish washer walking around the kitchen without wearing a hair restraint. Observation of the facility kitchen conducted on [DATE] at 9:34 a.m., revealed DD A entering the kitchen without covering his beard with a hair restraint. Observation of the facility kitchen conducted on [DATE] at 10:03 a.m., revealed DD A entering the kitchen without washing his hands. Observation of the facility dining room on the first floor conducted on [DATE] at 12:07 p.m., revealed CNAs and LPN C not washing or using hand sanitizer between serving meals to the residents. Observation of the facility dining room on the first floor conducted on [DATE] at 12:23 p.m., revealed CNA B handing a resident a sandwich, goes back and grabs several meal tickets and gets food plates and hands them to the residents without washing her hands or using hand sanitizer between activities. Observation of the facility dining room on the second floor conducted on [DATE] at 10:30 a.m. revealed CNA D walked into the kitchen without washing hands or wearing a hair restraint. Observation of the facility dining room on the second floor conducted on [DATE] at 11:51 a.m. revealed CMA F walking into the kitchen with no hair restraint on and getting ice from water pitcher without first washing his hands. Observation of the facility dining room on the second floor conducted on [DATE] at 11:51 a.m. revealed DA A and DA B not washing their hands or sanitizing their hands in between each food plate that was served to the residents. Observation of the facility dining room on the second floor conducted on [DATE] at 11:51 a.m. revealed CNA C entering the kitchen without a hair restraint. Observation of the facility dining room on the second floor conducted on [DATE] at 11:51 a.m. revealed LPN A touching plates without washing hands in between. Observation of the facility dining room on the second floor conducted on [DATE] at 11:51 a.m. revealed LPN B touched her pocket, pulled out a walkie talkie and then went to feed resident without washing her hands. Observation of the facility kitchen conduct on [DATE] at 2:45 p.m. revealed five large packets of pork ribs in the sink being thawed at room temperature without running water. Observation of the facility kitchen conducted on [DATE] between 2:50 p.m. and 10:32 a.m. revealed the following: -an open lemon juice container in the refrigerator without the open date and use by date; -an open general Tso's container in the refrigerator without the open date and use by date; -an open red salsa, general Tso's, cocktail, horseradish, and tartar sauces containers in the refrigerator without the open date and use by date; -a expired packet of sliced provolone cheese and a container of French mozzarella cheese; -a partial covered plastic container with slices of potatoes with a past its use by date; -a packet of raw meat patties without a pan under the packet. Further observations revealed that there was no label indicating the type of meat, or date when the meat was pulled to thaw; -a pan with cooked rice uncovered in the refrigerator; -a cart of topping salads (veggies, eggs, meats, and dressings) uncovered; -a packet of cheese with a past its use by date in a second walk-in refrigerator Observation of the facility kitchen conducted on [DATE] at 3:10 p.m. revealed DS B entering facility restaurant's freezer and retrieving a packet of meat. During an interview with CNA D on [DATE] at 10:30 a.m. CNA D stated that the procedure for entering the kitchen was to put on your protective wear and washing your hands. During an interview with DA A on [DATE] at 2:30 p.m., DA A stated that they were supposed to wash their hands before handling food or going between residents, touching plates, or touch trays. DA A stated that when entering the kitchen, they are supposed to wash hands and wear hair restraints. During an observation and interview on [DATE] at 3:20 p.m., the DS C stated that he oversees all kitchen personnel including the independent living restaurant. During the interview, a staff member from the facility restaurant was observed entering the kitchen without washing her hands or wearing a hair restraint. DS C stated that the employee should be wearing a hair restraint and washing his hands before entering the kitchen. During an interview on [DATE] at 4:37 p.m., DS A stated that she expects that anyone that enters the kitchen should be wearing hairnets and washing their hands. She stated that if they run out of a product or food for the kitchen facility, they borrow and use items from the facility restaurant. She stated that they don't have any system in place to track every time they use a product from the facility restaurant. She stated that she expects that all the food and items that are in the kitchen should be labeled with the open date and disposal date. During an interview on [DATE] at 2:00 p.m., CNA A stated that she should wash her hands every time she goes from one resident plate to the next. She stated that they should wear hair restraint and wash her hands when entering the kitchen. During an interview on [DATE] at 2:21 with CNA B stated that they should wash their hands every time they are in contact with used utensils or meal tickets before passing residents plate. She stated that staff should wear hair restraints when entering the kitchen. During an interview on [DATE] at 2:21 p.m., DS A stated that her expectations of the kitchen staff was when products were thawing they should be under running water. She stated expired products should be disposed of. During an interview on [DATE] at 2:53 p.m., DD stated that DS B left the kitchen for 10 minutes and someone from the staff kitchen turned off the water when the pork ribs were thawing. Review of facility In-services dated [DATE], reflected an In-services of Infection control practices/ Employee Hygiene. Review of facility, preventing foodborne illness Employee Hygiene and Sanitary practices Policy dated [DATE] read in part: 1. all employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior of working with food or serving food to residents. 2. Employees must wash their hand: a. Whenever entering or re-entering the kitchen b. Before coming in contact with any food surfaces c. After handling soiled equipment or utensils d. After engaging in other activities that contaminate the hands 3. Hair net or caps and/or beard restraints must be worn in food preparation areas from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident# 29 and Resident #78) of two residents observed for incontinent care. CNA A failed to properly change gloves and wash hands or sanitize hands when moving from a dirty area to clean area when providing incontinent care to Resident #78. CNA D failed to properly change gloves and wash hands or sanitize hands when moving from a dirty area to clean area when providing incontinent care to Resident #29. This deficient practice placed all residents who receive care from CNA A and D at risk for cross contamination and/or spread of infections. Findings include: Review of Resident #78's face sheet, dated 10/28/19 reflected resident is a [AGE] year-old female who was originally admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of current Resident #78's Minimum Data Set (MDS) reflected Resident #78's BI[CONDITION] Score of 00 which indicates resident is cognitively severely impaired and section H0100 reflected resident is always incontinent. Review of Resident #78's Care plan revised 12/13/19 reflected Resident #78 has impaired cognitive function/dementia or impaired thought process rule out [MEDICAL CONDITION]. During an observation on 1/21/20 from 2:35pm through 3:00pm in Resident #78's room revealed CNA A providing incontinent care to Resident #78. After appropriately washing hands with soap and water, CNA A donned clean gloves. CNA A elevated head of Resident #78's bed with gloved hand touching the remote control. CNA A with same gloved hands pulled Resident #78's bed sheets back to Resident #78's abdomen and loosened the old brief and tucked the brief under Resident #78. CNA A failed to change gloves, wash hands or use sanitizer before reaching to her table of supplies to pick up clean wipes and preceded to wipe Resident #78's labia from front to back twice. CNA A then discarded the gloves and wipes into the trash bin and sanitized her hands with alcohol -based swabs. Review of Resident #29's face sheet, dated 1[DATE] reflected resident is a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of current Resident #29's Minimum Data Set (MDS) reflected Resident #29's BI[CONDITION] Score of 00 which indicates resident is cognitively severely impaired and section H0100 reflected resident is always incontinent. Review of Resident #29's Care plan revised 1/22/20 reflected Resident #29 had impaired cognitive function/dementia or impaired thought process. During an observation on [DATE] from 2:38pm through 3:03pm in Resident #29's room revealed CNA C and CNA D providing incontinent care to Resident #29. Resident #29 was lying in bed with sheet pulled to her mid chest area. Observation at 2:49pm revealed CNA C and D wash hands with soap and water and put on clean gloves. CNA D pulled Resident #29's overbed table containing clean wipes and brief to Resident' #29's left side to bring it closer to herself. CNA C & D then pulled Resident # 29's bed sheet down to her abdomen and loosened her old brief. CNA D with same gloved hands picked up clean wipes and handed it over to CNA C who preceded to clean Resident #29's labia wiping from front to back. At 2:53pm CNA D assisted CNA C to turn Resident #29 right side. CNA C failed to change gloves, wash hands or use hand sanitizer before picking up a couple of clean wipes again handing them over to CNA C who used these wipes to clean Resident #29 's perineal area. During an interview on [DATE] at 3:01pm CNA D stated she should have changed her gloves and wash her hands after moving the overhead table before handing over clean wipes to CNA C. She stated that there is risk for infection. During an interview on [DATE] at 3:03pm CNA D stated staff were taught to wash hands and change gloves when moving from dirty area to clean area during care. During an interview on 1/22/20 at 2:58pm CNA A stated that she should have changed gloves, apply hand sanitizer after she touched the bed remote and unclean bed sheets before getting clean wipes to do pericare. During an interview on 1/22/20 at 3:00pm CNA B stated we are supposed to wash hands, change gloves before touching clean wipes to avoid infection. During an interview on [DATE] at 3:06pm DON stated staff was supposed to wash hands, change gloves, before touching clean wipes for infection control and avoid cross contamination.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for four (Residents #68, 65, [AGE], and [AGE]) of 18 residents reviewed for facility comprehensive care, in that 1. Care Plan failed to reflect that Resident #68 received palliative services. 2. Care Plan failed to reflect that Resident #65 received palliative services. 3. Care plan failed to reflect that Resident #[AGE] received hospice services. 4. Care plan failed to reflect that Resident #[AGE] received hospice services. This failure could place residents who require palliative service or hospice services at risk for sustaining injuries that could affect residents by placing them at risk for choking, hospitalization , death and dehydration. Findings include: Review of the Face Sheet for Resident #68 reflected a [AGE] year-old male who was admitted on [DATE]. Initial admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS for Resident #68 dated 1[DATE]19 reflected a BI[CONDITION] of 11 indicating moderately impaired cognition. Review of Order Details dated 01/14/2020 for Resident #68 reflected order by: primary physician. Description: Palliative Care- no artificial feeding or hydration. Review of the Care Plan for Resident #68 last care plan review dated 01/21/2020 reflected no mention of palliative care in the electronic record. Review of the Face Sheet for Resident #65 reflected a [AGE] year-old male who was originally admitted on [DATE]. Current admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS for Resident #65 dated 12/18/2020 reflected a BI[CONDITION] of 8 indicating moderately impaired cognition. Review of Order Details dated 01/07/2020 for Resident #65 reflected order by: primary physician. Description: Palliative Care- no artificial feeding or hydration. Review of the Care Plan for Resident #65 last care plan review completed dated 01/21/2020 reflected no mention of palliative care in the electronic record. Review of the Face Sheet for Resident #[AGE] reflected an [AGE] year-old female who was originally admitted on [DATE]. Current admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Order Details dated 1[DATE] for Resident #[AGE] reflected order by: primary physician. Description: Admit to Hospice. Review of the Care Plan for Resident #[AGE] last care plan review completed dated [DATE]20 reflected Restorative care program revised 11/14/2019 however there is no mention of Hospice service in the electronic record. Review of the Face Sheet for Resident #[AGE] reflected an [AGE] year-old female who was originally admitted on [DATE]. Current admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS for Resident #[AGE] dated 12/08/2019 reflected no score for BI[CONDITION] however the Cognitive skills for daily decision making was scored a 3 indicating severely impaired- never/rarely made decisions. Review of Order Details dated 12/24/2018 for Resident #[AGE] reflected order by: primary physician. Description: Admit patient to Hospice. patient to keep taking current medications, maintain current activity level and diet. Review of the Care Plan for Resident #[AGE] last care plan review completed dated 12/11/2019 reflected no mention of hospice care in the electronic record. In an interview at 1:01 PM Administrator stated her expectation was that Hospice and Palliative care should be care planned and follow policy. In an interview at 1:15 PM MDS coordinator stated when I asked for a copy of the care plans she recognized the issue and fixed the care plans by adding the palliative and hospice services to everyone's care plan who was receiving the service and then provided the printed copy. She stated her expectations were all hospice and palliative care should be on the resident's care plan, Oh yes. Review of the facility policy on comprehensive care plans dated April 2010 revealed The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans revised as information about the resident and the resident's condition change. Each resident's comprehsnvie care plan is designed to: d. Reflect the resident's expressed wishes regarding care and treatment goals. Review of the facility policy on Hospice care dated revealed When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflet the resident's current status.

Based on observations, interview and record review, the facility failed to respect the residents' right to personal privacy during medical treatment for one of one resident (Resident #39) observed during wound care. RN 1 failed to close resident's private room door while performing treatment and dressing change on Resident #39. This failure could place residents at risk of personal information being exposed to unauthorized persons, loss of dignity, and low self-esteem. Findings include: Review of Resident #39's face sheet reflected a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #39's most recent quarterly minimum data set (MDS) assessment reflected a brief interview for mental status (BI[CONDITION]) score of 12 indicating no cognitive impairment. Observation on [DATE] at 11:06 AM revealed RN 1 knocked on Resident #39's door, waited for an answer before entering the room. RN 1 opened resident's door and left the door wide open, walked into resident room and introduced herself and this surveyor to Resident #39. RN 1 explained that she will change dressing on resident's left heel wound. Resident stated ok. RN 1 then went to the resident's bathroom washed her hands appropriately with soap and water. RN 1 walked outside the resident's room to the hallway where she had packed the nurses wound care cart and brought in her supplies. RN walked back to Resident #39's room and preceded with wound care. RN did not make any attempts to close resident's door or ask resident if he wanted his door open. At 11:11 AM RN sanitized her hands with alcohol-based sanitizer and donned clean gloves and propped up resident's left leg on a chair and took off his left leg socks and placed on the chair. RN 1 then took off old dressing from the left heel wound, exposing left heel wound. She explained to resident that the wound is healing well while other residents were passing by Resident #39's hallway with door wide open. Resident #39's room does not have privacy curtain as it is a private room. RN 1 discarded the old dressing in the trash bin. She cleaned the wound with normal saline using 4x4 gauze, discarded in the trash bin. Dried with 4x4, applied [MEDICATION NAME] oil, covered wound with foam dressing and secured with [MEDICATION NAME] tape. RN 1 completed the procedure with the resident's door open the entire procedure. During an interview on [DATE] at 11:23 AM RN 1 stated she was supposed to close the door before wound care but was nervous and forgot to close the door. Interview on 0[DATE] at 03:06 PM DON stated staff should make sure to knock on resident's door and get a response before entering the room. DON also stated staff should close the door before performing treatments or care unless the resident says, I don't want the door closed. Review of Quality of Life-Dignity policy revised October 2009 reflects each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. #10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview and record review, the facility failed to store and prepare food under sanitary conditions in two of three kitchens. Dietary Manager failed to wash hands when entering and reentering kitchen area Facility failed to label and date food properly Facility failed to maintain refrigerator temperatures at 41 degrees These deficient practices could contribute to forborne illness resulting in vomiting and dehydration for the 78 residents who receive meals from the facility kitchen. Findings include: Observation on [DATE] revealed: 9:12 am Main Freezer: bag of unlabeled raw meet with an open date of ,[DATE] and a use by date of ,[DATE] 9:17 am Main Walk-in Refrigerator: Two tubs of unlabeled raw chicken thawing with no pull date or use by date 9:20 am Small Refrigerator for Healthcare kitchen contained unlabeled raw chicken, no open date or use by date 9:38 am Refrigerator on first floor outside satellite kitchen had a temp of 43 degrees. 9:45 am dietary manager did not wash her hands before entering, exiting then reentering the second floor satellite kitchen 10:06 am the garage level walk in refrigerator revealed molded super sweet grape tomatoes in a container dated ,[DATE] During an Interview on [DATE] at 9:18am with Dietary Manager (DM), DM stated that she did not know when chicken was pulled or who was using it. Dietary manager stated that the healthcare and bistro kitchen both utilize the main walk in refrigerator. Dietary manager stated that the protocol for labeling food is to have a pulled date and use by date. During an Interview on [DATE] at 10:10am with Dietary Manager (DM), DM stated that the facility used the molded tomatoes the morning of the observation. DM states that the facility frequently uses tomatoes in their salads that are served in the nursing facility. Record review of the temperature log for the first floor satellite kitchen refrigerator at 9:38am, revealed the following recorded temperatures and dates for the refrigerator: [DATE] at 6:00 am - 43 degrees [DATE] at 6:00 am - 44 degrees [DATE] at 6:00 am - 44 degrees (This temp was checked on the [DATE] at 8:51 am) During an Interview on [DATE] at 9:38 am Interview with Dietary Manager (DM), DM stated that she has had previous problems with the temperatures on the first floor satellite refrigerator. DM stated that they've tried adjusting the temperatures to make the refrigerator colder. DM states that when they adjust/or lower the temperatures, the refrigerator then starts freezing the foods. DM states that maintenance is aware of the problems associated with the refrigerator. On [DATE] at 9:24 am observation of first floor refrigerator outside of satellite kitchen was place out of order. On [DATE] at 5:30 pm observation revealed dietary manager entered second floor satellite kitchen without washing hands then attempted to assist the kitchen staff in taking food temps. This surveyor stopped the dietary manager before handling the food. Dietary manger stated that staff should have a hairnet on at all times and to wash hands before entering. Record review of facility policy for preventing foodborne illness - Employee Hygiene and Sanitary Practices dated ([DATE]) on [DATE], revealed in section C. that employees must wash their hands whenever entering or reentering the kitchen. Record review of facility policy for refrigerators and freezers revised date of ([DATE]) on [DATE], revealed that acceptable temperatures should be 35F-40F degrees for refrigerators, the supervisor will take immediate action if temperatures are out of range, all food shall be appropriately dated to ensure proper rotation by expiration date. Received Dates (dates of delivery) will be marked on the cases and individual items removed from cases or storage. Use By dates will be completed with expiration dates on all prepared food in refrigerators, supervisors will be responsible for ensuring the food items in the pantry, refrigerators, and freezers are not expired or past perish date. Review of Texas Food Establishment Rules Field Inspection Manuel dated [DATE] (TFER) 228.38 section (D ) titled hands and arms revealed that Food employees shall clean their hands and exposed portions of their arms as specified under subsection (b) immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single- service and single-use articles. Review of Texas Food Establishment Rules Field Inspection Manuel dated [DATE] (TFER) 228.75 Temperature and time control revealed that (c) Thawing. Except as specified in paragraph (4) of this subsection, time/temperature controlled for safety (TCS) food shall be thawed: (1) under refrigeration that maintains the food temperature at 5 degrees Celsius (41 degrees Fahrenheit) or less; Per CMS 672 dated [DATE] reflected a census of 78 residents.

Based on observation, interview and record review, the facility failed to provide ADL care for one of five dependent residents (Resident #23). A. Certified Nurse Aides (CNAs) and nursing staff failed to accommodate Resident #23's request for showers. Shower logs revealed Resident #23 went nine days without a shower. This deficient practice could place 25 residents in second floor West Hallway who require assistance for showers at risk not receiving ADL care. Findings include: Record review of resident #23 quarterly MDS with effective date of 10/01/2017 revealed that resident is identified as an [AGE] year old woman with a [DIAGNOSES REDACTED]. Resident's long-term and short-term memory are documented as ok and memory/recall ability revealed resident was aware of current season, location of own room, staff name and faces, that she was in a nursing home/swing bed. The resident is not recorded as having behaviors and does not have evidence of an acute change in mental status. Resident is recorded as being totally dependent for bathing. Record review of resident #23 care with effective date of 2/23/2016 revealed the resident's [DIAGNOSES REDACTED]. Resident # 8 is actively care planned to have showers 3 times weekly with a goal date of 2/20/2018. Interview with resident #23 on 1/8/2018 at 11:55 AM Resident stated that she has not showered in a week due to staff shortages. Resident stated that she likes her showers. Resident states that she doesn't complain because she knows they are short staffed. Resident stated that they do change her and give her wipe downs but prefers to have her showers. Interview with resident # 23's privately hired caregiver on 01/9/2018 at 6:50pm revealed that the resident did not refuse her shower but that they make it seem like she did. The caregiver stated that the facility does not even offer a shower at times and it has been a problem in the past. The caregiver stated that she tries not to over step her boundaries since she does not work for the facility but that has been in conflict with the facility when voicing her concerns. Caregiver stated that she does not work for the facility and that she is privately hired by the family to be with the resident during the day. Interview with RN A on 01/9/2018 at 6:30 pm revealed that RN A marked resident #23 for refusing showers on 01/09/2018 and stated that they agreed that they will give her a shower tomorrow 01/10/2018. RN A stated that resident was unable to receive a shower because resident went to resident council meeting at 2:00pm and then to a facility initiated activities shortly thereafter. Interview with resident # 23 on 01/9/2018 at 6:45pm revealed that the resident #23 did not refuse her shower. Resident # 23 stated that she wanted her shower, but they (facility staff) told her that they will give her a shower tomorrow 01/10/2018. Record review of shower logs at 01/09/2018 at 2:00pm revealed that resident # 23 went nine days without a shower. Dates reflected in shower log are as follows: 01/1/2018 thru 01/09/2018. Record review of shower schedule on 01/9/2018 at 6:35pm, revealed that resident #23 was scheduled for two showers a week. Record review of resident # 23 active care plan on 1/10/2018 at 8:30am revealed that the resident is to receive three showers per week. Interview with ADON on 1/11/2018 at 11:00 am revealed that the facility makes accommodations when residents refuse showers. Interview with RN A on 1/11/2018 at 2:45 pm revealed that the protocol for tracking residents who refuse showers is for CNAs to inform RN A of who refused or who did not shower, then RN A will write a nurse note stating reason for refusal or reason for missed shower. RN A stated that resident # 23 seldom refuses showers but that it's hard to work with her because she is active in the day. RN A stated that resident #23 refused her shower on 1/9/2018. RN A stated that she could keep better notes to keep track of who showered. RN A stated that the shower schedule was reduced to two times a week for all residents a couple of months ago to try and keep the showers more consistent. RN A was informed that there were MDS care plans identified that show resident scheduled for showers three times a week. RN A stated that they provide showers twice a week and that the MDS has not been updated. Record review of facility shower/tub bath policy revealed that if the resident refused the shower/tub bath, the reason(s) why and the intervention taken and to notify the supervisor if the resident refuses the shower/tub bath. Facility Shower/Tub policy is dated October 2010. Per DON there are 25 residents that receive showers on the west hall.

Based on observation, interview and record review, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for one resident observed during catheter care (Resident #8). CNA A, failed to clean resident #8's penis during catheter care. This deficient practice could place 4 residents who received catheter care at risk for cross-contamination and the spread of infection. Findings Include: Review of Resident #8 face sheet reflected a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of MDS assessment dated [DATE] indicated Resident #8's BIMS Score is 14 and section H0100 reflected Indwelling Catheter. Review of the Care Plan dated 03/15/16 indicated Resident #8 requires total assist. Resident #8 has a Foley catheter and is on bowel program r /t [MEDICAL CONDITION] bowel/bladder secondary to [MEDICAL CONDITION]. Intervention: Catheter care per facility protocol. During an observation on 01/09/18 at 09:33 AM, CNA A and CNA B entered Resident #8's room, greet him and explained the catheter care procedure to Resident #8. CNA A and CNA B went to the restroom and washed their hands. CNA A put on gloves and emptied Resident #8's catheter bag while CNA B prepared the equipment for the catheter care. After CNA A emptied the catheter bag, CNA A threw dirty gloves to the trash can,sanitized her hands and put new gloves on. CNA A unfastened Resident #8 briefs and wiped Resident #8 scrotum, perineal area and catheter tube (from the insertion site to 4 inches outward) without cleaning Resident #8 penis. CNA A threw dirty gloves to the trash can, used hand sanitizer and put on new gloves. CNA A and CNA B turned Resident #8 to Resident #8's right side and CNA A cleaned Resident #8's back. After cleaning Resident 8#'s back, CNA A removed dirty briefs from Resident #8, removed her dirty gloves, sanitized her hands and donned new gloves. CNA A placed new briefs on Resident #8, turn Resident #8 onto his back and wiped catheter from the insertion area to outward. CNA A removed dirty gloves, hand sanitized and donned new gloves. CNA A fastened Resident #8 briefs. After catheter care procedure, Resident #8 was transferred to his wheelchair. Both, CNA A and CNA B, washed their hands before leaving room. During an interview on 01/09/18 at 10:04 AM, CNA A stated she was nervous and forgot to wipe Resident #8 penis during catheter care. CNA A added she usually sprays genitalia with pericare spray, clean the penis and then the catheter. During an interview on 01/09/18 at 02:41 PM, DON stated he would expect nurses and CNAs to include wiping male resident's penis during catheter care. DON added he would expect nurses and CNAs to wipe first the penis and then the catheter tube. Record Review of facility policy on Catheter Care revised on October 2010, tittle Catheter Care, Urinary reflected Steps in the Procedure .7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry.13 retract the foreskin of the uncircumcised male resident.15 . For the male: use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular [MEDICAL CONDITION] from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Review of the facility CMS 672 dated 1/9/18 reflected 4 residents had indwelling or external catheter

Based on observation, interview and record review, the facility failed to ensure nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for two of four residents reviewed for incontinent care (Residents #5 and #4). 1. CNA B failed to follow infection control practices during incontinent care on Resident #5 by not changing her gloves when moving from a dirty area to a clean area and allowing a clean area to touch a dirty area. 2. CNA C failed to follow infection control practices during incontinent care on Resident #4 by not changing her gloves when moving from a dirty area to a clean area and not washing or sanitizing her hands between glove changes. This failure could place four residents with indwelling or external catheters, 48 residents incontinent of bowel and 75 residents incontinent of bladder at risk for infection. Findings included: 1. Review of the Face Sheet dated on 03/15/16 indicated Resident #5 was a [AGE] year old male with [DIAGNOSES REDACTED]. Review of the most recent significant change MDS assessment dated [DATE] indicated Resident #5 ' s cognition was severely impaired; he demonstrated no [MEDICAL CONDITION] or other behaviors, including rejection of care. Resident #5 was frequently incontinent of bowel and bladder. Review of the Care Plan dated 03/15/16 indicated Resident #5 received palliative care. He required extensive assistance with toileting. During an observation on 03/16/16 at 9:00 a.m., CNA A and CNA B provided incontinent care to Resident #5. CNA A and CNA B washed their hands and put on gloves. CNA B cleaned Resident #5 ' s penis. She then allowed his penis, which was already clean, to lay on the soiled brief, that was still lying under the resident. CNA B did not re-clean Resident #5 ' s penis after it touched the soiled brief. During an interview on 03/16/16 at 9:15 a.m., CNA B stated she was unaware Resident #5 ' s penis, after cleaned, was allowed to touch the soiled brief. During an interview on 03/17/16 at 12:50 p.m., the DON stated if Resident #5's penis, which was already cleaned, touched the soiled brief, he expected the resident's penis to be re-cleaned. 2. Review of the Face Sheet dated 03/17/16 indicated Resident #4 was an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the most recent quarterly assessment indicated Resident #4 ' s cognition was severely impaired; she demonstrated no [MEDICAL CONDITION] or behaviors, including rejection of care. Resident #4 was always incontinent of bowel, but had an indwelling catheter due to a [MEDICAL CONDITION] bladder. Review of the Care Plan dated 03/15/16 indicated Resident #4 had a suprapubic catheter. Interventions included monitoring for signs and symptoms of infection and keeping the catheter bag below the level of the bladder. Resident #4 required incontinent care after each incontinent episode. During an observation on 03/16/16 at 2:40 p.m., CNA C and CNA D provided incontinent care to Resident #4. CNA C and CNA D washed their hands and put on gloves. CNA C held Resident #4 ' s suprapubic catheter about a half inch from the insertion site and cleaned in a downward movement, away from the insertion cite. CNA C then took a cloth and cleaned the area at the crease of Resident #4 ' s right and left thighs. She took a cloth and cleaned Resident #4 ' s vaginal opening in a front to back movement. CNA C changed her gloves without washing or sanitizing her hands prior to cleaning the vaginal area. CNA C and CNA D assisted Resident #4 to turn onto her right side. CNA C cleaned stool off Resident #4 ' s rectum and buttocks. She changed gloves, but did not wash or sanitize her hands between glove changes. CNA C again cleaned stool from Resident #4 ' s rectum. She then changed gloves, but did not wash or sanitize her hands between glove changes. During an interview on 03/16/16 at 2:55 p.m., CNA D stated she was supposed to sanitize her hands between glove changes. During an interview on 03/16/16 at 3:00 p.m., CNA C stated she was supposed to use sanitizer between glove changes and wash her hands after using the sanitizer three to four times. During an interview on 03/17/16 at 12:50 p.m., the DON stated he expected staff to change gloves and either wash or sanitize their hands after cleaning the tubing for an indwelling catheter and the area around the crease of Resident #4's thighs prior to cleaning the vaginal opening. Review of the Perineal Care policy dated October 2010 read in part, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident ' s skin condition .Steps in the Procedure: .2. Wash and dry your hands thoroughly .7. Put on gloves .9. For a female residents: .b. Wash perineal area, wiping from front to back. (1) Separate the labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Do not reuse the same wipe to clean the urethra or labia . Review of the Handwashing/Hand Hygiene policy dated May 2015 read in part, This policy considers hand hygiene the primary means to prevent the spread of infection .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .5. Employees must wash their hands for at least fifteen (15-20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .b. When hands are visibly soiled (hand washing with soap and water); c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); u. After removing gloves, post and mid-procedure, or aprons .6. In most situation, the optional method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for the following situations: .j. After removing gloves. The use of alcohol based cleanser occurs after removal and shall include: mid-procedure glove changes . Review of the facility ' s Infection Control Guidelines for All Nursing Procedures, revised 9/2012 reflected (3) Employees must wash their hands for twenty (20) to thirty (30) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .(d) after removing gloves; (e) after handling items potentially contaminated with blood, body fluids, or secretions . (4) In most situations, the preferred method of hand hygiene is with an alcohol-based had rub . (b) Before donning sterile gloves .(f) Before moving from a contaminated body site to a clean body site during resident care The CMS 672 dated 03/15/16 indicated four residents had indwelling or external catheters, 48 residents were incontinent of bowel and 75 residents were incontinent of bladder.

Based on observation, interview and record review, the facility failed to implement an effective infection control program to provide a safe and sanitary environment and to help prevent the development and transmission of infections for two of four residents reviewed for incontinent care (Residents #5 and #4). 1. CNA B failed to follow infection control practices during incontinent care on Resident #5 by not changing her gloves when moving from a dirty area to a clean area and allowing a clean area to touch a dirty area. 2. CNA C failed to follow infection control practices during incontinent care on Resident #4 by not changing her gloves when moving from a dirty area to a clean area and not washing or sanitizing her hands between glove changes. This failure could place four residents with indwelling or external catheters, 48 residents incontinent of bowel and 75 residents incontinent of bladder at risk for infection. Findings included: 1. Review of the Face Sheet dated on 03/15/16 indicated Resident #5 was a [AGE] year old male with [DIAGNOSES REDACTED]. Review of the most recent significant change MDS assessment dated [DATE] indicated Resident #5 ' s cognition was severely impaired; he demonstrated no delirium or other behaviors, including rejection of care. Resident #5 was frequently incontinent of bowel and bladder. Review of the Care Plan dated 03/15/16 indicated Resident #5 received palliative care. He required extensive assistance with toileting. During an observation on 03/16/16 at 9:00 a.m., CNA A and CNA B provided incontinent care to Resident #5. CNA A and CNA B washed their hands and put on gloves. CNA B cleaned Resident #5 ' s penis. She then allowed his penis, which was already clean, to lay on the soiled brief, that was still lying under the resident. CNA B did not re-clean Resident #5 ' s penis after it touched the soiled brief. During an interview on 03/16/16 at 9:15 a.m., CNA B stated she was unaware Resident #5 ' s penis, after cleaned, was allowed to touch the soiled brief. During an interview on 03/17/16 at 12:50 p.m., the DON stated if Resident #5's penis, which was already cleaned, touched the soiled brief, he expected the resident's penis to be re-cleaned. 2. Review of the Face Sheet dated 03/17/16 indicated Resident #4 was an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the most recent quarterly assessment indicated Resident #4 ' s cognition was severely impaired; she demonstrated no delirium or behaviors, including rejection of care. Resident #4 was always incontinent of bowel, but had an indwelling catheter due to a neurogenic bladder. Review of the Care Plan dated 03/15/16 indicated Resident #4 had a suprapubic catheter. Interventions included monitoring for signs and symptoms of infection and keeping the catheter bag below the level of the bladder. Resident #4 required incontinent care after each incontinent episode. During an observation on 03/16/16 at 2:40 p.m., CNA C and CNA D provided incontinent care to Resident #4. CNA C and CNA D washed their hands and put on gloves. CNA C held Resident #4 ' s suprapubic catheter about a half inch from the insertion site and cleaned in a downward movement, away from the insertion cite. CNA C then took a cloth and cleaned the area at the crease of Resident #4 ' s right and left thighs. She took a cloth and cleaned Resident #4 ' s vaginal opening in a front to back movement. CNA C changed her gloves without washing or sanitizing her hands prior to cleaning the vaginal area. CNA C and CNA D assisted Resident #4 to turn onto her right side. CNA C cleaned stool off Resident #4 ' s rectum and buttocks. She changed gloves, but did not wash or sanitize her hands between glove changes. CNA C again cleaned stool from Resident #4 ' s rectum. She then changed gloves, but did not wash or sanitize her hands between glove changes. During an interview on 03/16/16 at 2:55 p.m., CNA D stated she was supposed to sanitize her hands between glove changes. During an interview on 03/16/16 at 3:00 p.m., CNA C stated she was supposed to use sanitizer between glove changes and wash her hands after using the sanitizer three to four times. During an interview on 03/17/16 at 12:50 p.m., the DON stated he expected staff to change gloves and either wash or sanitize their hands after cleaning the tubing for an indwelling catheter and the area around the crease of Resident #4's thighs prior to cleaning the vaginal opening. Review of the Perineal Care policy dated October 2010 read in part, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident ' s skin condition .Steps in the Procedure: .2. Wash and dry your hands thoroughly .7. Put on gloves .9. For a female residents: .b. Wash perineal area, wiping from front to back. (1) Separate the labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same wipe to clean the urethra or labia . Review of the Handwashing/Hand Hygiene policy dated May 2015 read in part, This policy considers hand hygiene the primary means to prevent the spread of infection .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .5. Employees must wash their hands for at least fifteen (15-20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .b. When hands are visibly soiled (hand washing with soap and water); c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); u. After removing gloves, post and mid-procedure, or aprons .6. In most situation, the optional method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for the following situations: .j. After removing gloves. The use of alcohol based cleanser occurs after removal and shall include: mid-procedure glove changes . Review of the facility ' s Infection Control Guidelines for All Nursing Procedures, revised 9/2012 reflected (3) Employees must wash their hands for twenty (20) to thirty (30) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .(d) after removing gloves; (e) after handling items potentially contaminated with blood, body fluids, or secretions . (4) In most situations, the preferred method of hand hygiene is with an alcohol-based had rub . (b) Before donning sterile gloves .(f) Before moving from a contaminated body site to a clean body site during resident care The CMS 672 dated 03/15/16 indicated four residents had indwelling or external catheters, 48 residents were incontinent of bowel and 75 residents were incontinent of bladder.

The facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care when: Certified Nurses Aide (CNA) H did not wash or sanitize his hands between glove changes while providing perineal care (cleaning the perineum, the external genitalia, and the surrounding skin for residents who are incontinent) for Resident #24. This deficient practice could place 74 residents that are incontinent at risk of infection and disease. Findings included: An observation on 04/09/15 at 10:15 am revealed that Certified Nurses Aide (CNA) H did not wash or sanitize his hands between glove changes a total of eight (8) (of 25 total glove changes) times while providing perineal care (cleaning the perineum, the external genitalia, and the surrounding skin for residents who are incontinent) for Resident #24. CNA H did not sanitize or washing his hands after changing his gloves from cleaning Resident #24 ' s sacrum, buttocks, and lower back that was noticeably soiled with bowel movement before applying clean gloves to finish the process. During an interview on 4/9/15 after 10:54 am (after perineal care was provided), CNA H stated before care I wash my hands singing Happy Birthday. If I feel like a have to wash my hands between glove changes, I will but that ' s why I use sanitizer. Then after I wash my hands. Review of the facility ' s Handwashing/Hand Hygiene policy revised August 2012 reflected that: .When to Wash Hands 5. Employees must wash their hands for at least fifteen (15-20) seconds using antimicrobial or non-anti-microbial soap and water under the following conditions: . k. Before and after changing a dressing . u. After removing gloves . .When to Use Alcohol-Based Hand Rub 6. In most situations, the optional method of hand hygiene is with alcohol-based hand rub. If hands are not visibly soiled, use of alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for the following situations: . e. Before handling clean or soiled dressings, gauze pads, etc . h. After handling used dressings, contaminated equipment, etc . j. after removing gloves . .Use of Gloves 8. The use of gloves does not replace handwashing/hand hygiene. Review of the Centers for Disease Control and Prevention ' s Hand Hygiene Basics revised May 1, 2014 (website accessed on 4/16/15) reflected that Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact, after contact with blood. body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings. Review of the Centers for Disease Control and Prevention ' s Hand Hygiene Basics revised May 1, 2014 (website accessed on 4/16/15) reflected that Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact, after contact with blood. body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings. Review of the facility CMS 672 reflected 74 residents were incontinent and needed assistance.

Based on interview and record review, the facility failed to maintain an effective infection control program to ensure a safe, sanitary, and comfortable environment that prevents the development of transmission of disease and infection for one 1 of 3 (three) residents who ( Resident #23) require incontinent care and 1 of 1 residents who receive wound care (Resident #24). A. Licensed Vocational Nurse (LVN) E did not wash or sanitize her hands between glove changes when providing wound care on Resident #23. This deficient practice placed 1 resident that required wound care at risk for disease and infection. B.Certified Nurse ' s Aide (CNA) H did not wash or sanitize his hands between glove changes a total for eight while providing perineal care (cleaning the perineum, the external genitalia, and the surrounding skin for residents who are incontinent) for Resident #24. This deficient practice placed 74 residents who were incontinent at risk of exposure to disease and infection. Findings included: A. An observation on 04/09/15 at 9:41 am revealed that Licensed Vocational Nurse (LVN) E did not wash or sanitize her hands between glove changes when providing wound care on Resident #23. When LVN E removed the old dressing from a sacral wound, she changed her gloves without washing or sanitizing her hands before donning clean gloves to clean the wound and apply the new dressing. During an interview on 4/9/15 after 9:41 am (after wound care was provided), LVN E stated that I wash my hands before and change my gloves in between unless a brief or something is dirty. During an interview with the Director of Nurses (DON) on 4/9/15 at 9:52 am stated that they (staff) are expected to wash their hands before and after care and if they become soiled, but I will have to look up if they are required to sanitize between glove changes. Review of the facility' s Hand washing/Hand Hygiene policy revised August 2012 reflected that: .When to Wash Hands 5. Employees must wash their hands for at least fifteen (15-20) seconds using antimicrobial or non-anti-microbial soap and water under the following conditions: . k. Before and after changing a dressing . u. After removing gloves . .When to Use Alcohol-Based Hand Rub 6. In most situations, the optional method of hand hygiene is with alcohol-based hand rub. If hands are not visibly soiled, use of alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for the following situations: . e. Before handling clean or soiled dressings, gauze pads, etc . h. After handling used dressings, contaminated equipment, etc . j. after removing gloves . .Use of Gloves 8. The use of gloves does not replace hand washing/hand hygiene. Review of the Centers for Disease Control and Prevention ' s Hand Hygiene Basics revised May 1, 2014 (website accessed on 4/16/15) reflected that Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact, after contact with blood. body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings. B. An observation on 04/09/15 at 10:15 am revealed that Certified Nurse ' s Aide (CNA) H did not wash or sanitize his hands between glove changes for a total of eight (8) (of 25 total glove changes) times while providing perineal care (cleaning the perineum, the external genitalia, and the surrounding skin for residents who are incontinent) for Resident #24. LVN E assisted CNA H during perineal care for Resident #24 and neither sanitized or washed her hands for 1 of 1 glove changes. CNA H did not sanitize or washing his hands after changing his gloves from cleaning Resident #24 ' s sacrum, buttocks, and lower back that was noticeably soiled with bowel movement before applying clean gloves to finish the process. During an interview on 4/9/15 after 10:54 am (after perineal care was provided), CNA H stated before care I wash my hands singing Happy Birthday. If I feel like a have to wash my hands between glove changes, I will but that 's why I use sanitizer. Then after I wash my hands. During an interview with the DON on 4/9/15 at 11:21 am stated I don 't expect hand washing between glove changes unless their hands are soiled. It is not our policy to wash hands/sanitize in between. Review of the facility' s Hand washing/Hand Hygiene policy revised August 2012 reflected that: .When to Wash Hands 5. Employees must wash their hands for at least fifteen (15-20) seconds using antimicrobial or non-anti-microbial soap and water under the following conditions: . u. After removing gloves . .When to Use Alcohol-Based Hand Rub 6. In most situations, the optional method of hand hygiene is with alcohol-based hand rub. If hands are not visibly soiled, use of alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for the following situations: . .Use of Gloves 8. The use of gloves does not replace hand washing/hand hygiene. Review of the Centers for Disease Control and Prevention ' s Hand Hygiene Basics revised May 1, 2014 (website accessed on 4/16/15) reflected that Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact, after contact with blood. body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings. Review of the facility CMS 672 reflected that 1 resident required wound care and 74 residents were incontinent and needed assistance.

Based on observation, interview, and record review the facility failed to ensure that drugs were stored in accordance with currently accepted professional principles for one (1) of six (6) medication carts when: Medication Aide (MA) F left a lidocaine patch (medication patch that contains medication for pain) on top of the the medication cart unsecured when administering medications to Resident # 22 in her room. This deficient practice placed 83 Residents who receive medications administered by Facility staff at risk for hall at risk of potential drug diversion from unsecured medications which could lead to disease complications and death. Findings include: Observation on 4/9/15 at 7:40 am revealed that Medication Aide (MA) F left a lidocaine patch (medication patch that contains medication for pain) on top of the the medication cart unsecured when administering medications to Resident #22 during medication pass. The surveyor and MA F were in Resident' s room approximately five (5) minutes. When the surveyor and MA F returned to the medication cart, the lidocaine patch was still unsecured on top of the cart. During an interview on 4/9/15 after medication pass (at 7:40 am), MA F stated that I don' t usually leave them out; I thought I put it in my pocket. During an interview on 4/9/15 at 9:12 am with the Director of Nurses (DON) and Registered Nurse (RN) A stated that: RN A-They are supposed to lock up meds if they leave their cart, or take everything with them. DON-They are in serviced to our policies here, but medication pass itself is taught as a part of their CMA (certified medication aide) training. If we see that a mistake is made, we immediately correct it and in-service the entire staff. RN A-We will be conduct an in-service today to go over med (medication) pass. Review of the facility policy Storage of Medications revised April 2007 reflected that: .Maintaining Storage and Preparation 2. The nursing staff shall be responsible for maintaining medication storage . Locked Compartments 7.carts used to transport suck items shall not be left unattended .or otherwise potentially available to others . Orderly Storage and Dispensing 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts .Each resident ' s medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents . Access to Medications and Keys 10. Only persons authorized to prepare and administer medications shall have access to the medications. Resources: Facility Storage of Medications policy (revised April 2007)