SEABREEZE NURSING AND REHABILITATION

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment (boiler room equipment) in safe operating condition for 1 of 1 hot water heater heaters system in the facility in that -<BR/>The facility did not have hot water for resident's use in two weeks .<BR/>This failure could place the residents at risk of not having their ADL care in a timely manner and as needed.<BR/>Findings included:<BR/>Interview and observation on 09/23/24 at 1:28 p.m ., revealed the facility did not have hot water for resident's use. During an interview, Resident #12 said she did not want to take shower with cold water. She said the facility had no hot wat ER and she had not had her showers for about two to three weeks. She said she only have bed baths. <BR/>Observation on 09/23/24 at 1:30 PM revealed there are two shower rooms on hall 100. The water for the shower room was turned on for 5 minutes. The water was lukewarm at 84 degrees Fahrenheit-F). <BR/>During an interview on 09/23/24 at 1:45 PM, CNA K she said she had did not given resident showers today. She explained how showers are provided to residents. She said even rooms are Mondays, Wednesdays, and Fridays. She said morning CNA gives showers to A-beds and evening CNAs gives showers to the B beds on their shower days. She did not answer how long the hot water had been off. She said she did not know. She said she washed her hands with the luck luke warm water (not too cold).<BR/>During an interview with the ADON on 09/23/21 at 1:50 PM, she said the hot water had been called in by the facility Administrator. She said the hot water stop working last week 9/16/24 and she immediately told the Administrator. She did not give any date. She said the hot water had been on and off at different parts of the facility. She said it was her understanding that the Administrator had reported the incident to the state . <BR/>During an interview with the Maintenance Director on 09/23/24 at 2:10 PM, he said he had been trying to find out what the problem was for sometimes. He said he tried adjusting the thermostat thinking the thermostat was the problem. He said the hot water was on and off at different parts of the facility for almost a month. He said he found out last Friday the thermostat broke and that was when a local plumbing company was called in to detect the problem.<BR/>Observation with the Maintenance Director on 09/23/24 from 2:10 p.m. to 2:30 Pp.m., revealed the water temperature on randomly selected rooms ranged from 84-86-degrees Fahrenheit. <BR/>During an interview on 09/23/24 at 3:00PM, Resident # 27 said, she used wipes and face sheet to clean herself in the bathroom . <BR/>During an interview on 09/23/24 at 3:30 PM, with a group of unidentified residents in the smoking area, 5 of the residents said the hot water has not worked for over three weeks and 2 said for a month . They could not give date range.<BR/>During an interview with the facility Administrator on 09/23/24 at 4:00 PM, he said the facility was an old building. He said the hot water had been on and off at different parts of the building and he cannot put a timeline. He said he was out on vacation and came back August 26 . He said the Maintenance Director had worked on and off on the hot water for a sometimes. He said the maintenance Director adjusted the thermostat on and off and it makes the water either too hot on one side of the building and cold on the other side. He said it was brought to his attention on 09/16/24. He said he called a local plumbing company, and the facility was trying to get approval and eventually fall on the weekend . He said he called the incidents of the hot water to state on 09/20/24 expecting the plumbing company to start the work on Monday 09/24/24. <BR/>During an interview with CNA J in the secured unit on 09/24/24 at 10:50 AM, he said he had not given showers to residents for about two weeks but only provided bed baths because the hot water was off. He said he did not know how long because the hot water had been on and off at different times. He said he gave bed baths as needed .<BR/>During an interview with the facility Administrator on 09/26/24 at 2:30 p.m., he said the facility lack of hot water makes it harder for the staff to complete their job if they had to heat hot water for those who needed hot water to take a bath. He did not answer questions on how the lack of hot water affected residents .<BR/>Record review of facility's policy titled Supplies and Equipment; Environmental Services read in part, .Policy Statement <BR/>Housekeeping/laundry department supplies, and equipment shall be readily available so that department personnel can perform necessary tasks. <BR/>Policy Interpretation and Implementation <BR/>1. Equipment must be ready for use at all times of the day and night to serve the residents' needs. Care should be exercised in the handling and in the use of our equipment to prevent damage or breakage .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that Resident#1 medications were properly stored.<BR/>The facility staff failed to ensure that resident's medication was stored and secured in a secure manner. LVN-A did not secure her keys, nor did she ensure that the med room was secure. As a result, Norco drugs were unaccounted for.<BR/> This failure could place residents at risk of not having their prescribed medications given to them as directed according to physician orders. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included major depressive disorder, bipolar disorder, dementia, shortness of breath, and congestive heart failure.<BR/>Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 01/11/25, section C revealed a BIMS (Brief Interview for Mental Status) score of 14.<BR/>Record review of Resident #1's care plan dated 12/05/2024 revealed Resident#1 was care planned for falls and that his medication should be administered to him as prescribed by his physician.<BR/>Record review of Narcotic sheet for the CMA cart on 02/06/25 at 1:30pm reflected that on 02/05/25 that six pills were missing from Resident#1 Narcotic blister pack.<BR/>Record review of physician orders dated 12/26/24 on 02/24/25 for Resident#1 narcotic medication Hydrocodone 325mg tablet reflected that medication should be given by mouth 1 tablet every eight hours as needed. <BR/>- In an Interview with staffing coordinator on 02/06/25 at 12:18pm,. the staffing coordinator said that she received a call on 02/05/25 from LVN-B and LVN-B told her that LVN-A and CNA-A accused her of taking keys to the CMA medication cart. The staffing coordinator said that when she got to the facility, she got LVN-B's keys so that a count of LVN-B medication cart could be conducted. The staffing coordinator said that she and the DON counted LVN-B medication cart and the count was good. <BR/>In an interview with DON on 02/06/25 at 3:05pm the DON said that she received a call the morning of 02/05/25 at about 4:47am from LVN-A informing her that Norco medication was missing. The DON said that she immediately called the facility and told no one to leave until she arrives. The DON said that when she arrived, she had her staffing coordinator to get all nurses keys. The DON said at that point she and the staffing coordinator began to count meds and that all meds cleared except for LVN-A's. The DON said that a total of six hydrocodone pills were missing. The DON said she drug tested all staff and everyone passed. The DON said she called the local police and when they arrived, she informed them of the missing pills. <BR/>In an interview with LVN-A on 02/06/25 at 4:42pm LVN-A said that when she came on duty the day of 02/04/25 that her nursing cart medication count cleared. And that at 9:00pm her CMA medication count cleared. LVN-A said that at 12:00am she gave meds to Resident#1 out of the CMA medication cart. LVN-A said that she then put the keys to the CMA cart in the med room on top of the CMA cart in a binder. LVN-A said that the CMA box is locked but the med room where the cart was kept was not locked. LVN-A said that at 4:50am she went back to the med room to get meds out of the CMA cart and when she opened the cart, LVN-A noticed six pills missing. LVN-A said that she immediately called the DON, and the DON told her to tell all staff not to leave. LVN-A said that she along with other staff were given a drug test. LVN-A said the DON informed her that everyone had tested negative, and the DON asked for statements from staff. <BR/>In an interview with CMA-A on 02/06/25 at 5:32pm CMA-A said that at the end of her shift, that she and LVN-A counted the CMA medication cart at 9:15pm the night 0f 02/04/25 and that there were no missing medications. <BR/>Record review of the facilities' medication policy on 02/06/25 at 5:00pm dated 06/01/22 reflected that All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 11 residents (CR#4) reviewed for care plans, in that:<BR/>-CR#4 did not have a completed baseline care plan completed within 48 hours of admission. <BR/>-CR#4 did not have a baseline care plan to address her indwelling catheter. <BR/>These failures could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care.<BR/>Findings included:<BR/>Record review of CR #4's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included orthopedic aftercare and left leg femoral fracture. Her discharge date was 04/26/2023 to be transferred to another facility. <BR/>Record review of CR#4's admission Observation Report dated 04/10/2023, indicated CR#4 admitted with indwelling catheter. <BR/>Record review of CR #4's baseline care plan dated 04/14/2023 and completed by the CCM did not address focus, goals, or intervention for an indwelling catheter. <BR/>Record review of CR #4's MDS assessment dated [DATE] and completed by the CCM revealed CR #4 was cognitively intake with a BIMS score of 12 in section C. She was triggered for an indwelling catheter in section H for Bladder and Bowel.<BR/>In an interview on 05/05/2023 at 10:38pm with the CRN, she said that the admitting nurse is responsible for completing the baseline care plan for newly admitted residents within 48 hours. She said upon her review the admitting nurse, LVN D, did not complete the baseline care plan timely, it was completed on 04/14/2023 by the CCM, and the CCM did address that CR#4 had a catheter on the care plan. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT met meet regarding CR#4. She said that the IDT should consist of the CCM, DON, ADON, and DOR. She said that the DON is the oversite oversight and should ensure that all admission tasks are completed accurately. She stated that the risk to residents of not having systems in place could cause residents to not receive appropriate care, delay in diagnosis, delay in treatment, and infection to include UTI.<BR/>In an interview on 05/05/2023 at 11:01am with the CCM, she said that she is an LVN. She said that she has worked at the facility since 09/01/2022, she completes all MDS assessments for the facility. She said that the admitting nurse is responsible for completing baseline care plan for newly admitted residents within 48 hours. She said the ADON checks for accuracy of the admission process. She stated that the IDT consists of the DON, ADON, CCM, DOR, and SW, and the IDT meets Monday-Friday, and review admission process for newly admitted residents. She said that she helps the ADON audit baseline care plans, and the ADON and she will complete the care plan if had not been completed within 48 hours. She said that upon her review CR#4 admitted to the facility with catheter on 04/10/2023, the baseline care plan was not completed until 04/14/2023, and it did not address that the resident had a catheter. She said completed the baseline care plan while completing audits on 04/14/2023. She said that she could not remember if the IDT meet met regarding CR#4. She stated that the risk of not having the systems in place could cause a resident to not receive appropriate care. <BR/>In an interview on 05/05/2023 at 11:49am with the DON, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the ADON is the oversite oversight to ensure that admitting nurse completed the admission process with accuracy. She said that the CCM is the oversite oversight for to ensure that baseline care plans are completed timely and accurately within 48 hours. She said that she is the oversite oversight for the ADON and CCM. She stated that she completes an audit twice each week to ensure that the admitting nursing and ADON have completed the admission process accurately, she could not remember if she audited the records for CR#4, and she did not keep a record of her audits. She stated that IDT meets to discuss newly admitted residents a few days after admission. She said that she could not recall if the IDT reviewed the admission process for CR#4. She said that based on her review the baseline care plan was not completed timely and did not address the catheter for CR#4. She stated that the risk to the resident of not having systems in place is not receiving appropriate care. <BR/>In an interview on 05/04/2023 at 12:57pm with the ADON, she said that she is a LVN , and she has worked at the facility for 16 months. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the baseline care plan should be completed in 48 hours. She stated that she audits the admission process the next business day for accuracy and completion. She said that the CCM will help her audit the baseline care plans. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet regarding CR#4. She said that CR#4 was admitted on [DATE] with a catheter. She said she did not work on 04/11/2023-04/12/2023, and she worked the floor for the remaining days of the week. She said that the DON is the oversight oversite, and if she is not able to audit the DON is to complete the task. She said that upon her review the baseline care plan for CR#4 did not address her catheter and was not completed timely. She stated that the risk of not having the system in place is that a resident may not receive appropriate care. <BR/>Record review of the facility's policy titled Care Plans - Baseline dated 2001 Med-Pass, Inc. (Revised December 2016) read in part. <BR/>A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. <BR/>- Policy Interpretation and Implementation. <BR/>1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. <BR/>2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; .<BR/>Record review of the facility's policy titled, IDT Daily PPS meeting Agenda dated January 2023 read in part. <BR/>Purpose Statement: To provide on-going communication with the IDT members to discuss the plan of treatment and to assure required procedures are completed in a timely manner for all new admission. Frequency: Meets daily. Team Members: The Interdisciplinary team members (IDT) include but not limited to the following: CCM, Therapy representative, Business office Manager, DON or designee, and social services or designee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #5) out of 3 residents reviewed for wound care. In that,<BR/>The facility failed to ensure Resident #5's wound vac was applied on her wound as ordered by the physician.<BR/>This failure could expose residents to low quality of care, worsening of condition, hospitalization, and death.<BR/>Findings included:<BR/>Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), chronic pain, Essential (primary) hypertension (too high pressure in the blood vessel), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm.), cardiac arrhythmia (a disease process characterized by when electrical impulses in the heart don't work properly), congestive heart failure (occurs when the heart's capacity to pump blood cannot keep up with the body's need), constipation. <BR/>Record review of Resident #5's care plan dated 02/24/2024 revealed Resident #5 had surgical wounds with intervention to apply negative pressure at setting of (125) mm Hg continuous.<BR/>Record review of Resident #5's MDS (Minimum Data Set) dated 02/24/2024 revealed Resident #5 had surgical wounds. <BR/>Record review of Resident #5's order dated 02/01/2024 revealed order was given for wound treatment NPWT (KCI): Wound location (RUQ/ABD). Cleanse wound with wound cleanser, pat dry, apply foam to wound bed, cover with transparent dressing. Apply Negative Pressure at setting of (125) mm Hg (continuous). Change dressing/tubing/canister 2x weekly on M/F, once a day on Mon, Fri Resident #5 also had order for PRN (as needed) wound care dressing change for the wound to be cleansed with wound cleanser, and apply gauze soaked in Dakin's 0.25% solution to be applied on the wound and cover with dressing.<BR/>Record review of TAR (Treatment Administration Record) for the month of February 2024 revealed the wound vac was not applied on the following dates:<BR/>*02/11/2024 not administered: resident unavailable by Nurse D. <BR/>* 02/28/2024 not administered: drug/item unavailable comment: prn wet to dry dressing applied through applied. by the Wound Care Nurse.<BR/>Record review of Wound Care Doctor's note revealed the following wound measurement:<BR/>Site #1 surgical wound right abdomen full thickness<BR/>03/18/2024 = 19cm x 16cm x 2cm<BR/>03/11/2024 = 19.5cm x 16cm x 2cm<BR/>03/04/2024 = 28cm x 20cm x 3cm<BR/>02/29/2024 = 27cm x 20cm x 3cm<BR/>02/05/2024 = 27cm x 20cm x 3cm <BR/>Site #2 surgical wound left upper abdomen full thickness.<BR/>03/18/2024 = 2cm x 1.5cm x 1.5cm<BR/>03/11/2024 = 2cm x 2cm x 2cm<BR/>03/04/2024 = 5cm x 4cm x 2cm<BR/>02/29/2024 = 6cm x 4cm x 2cm<BR/>02/05/2024 = 6cm x 4cm x 2cm <BR/>Site #3 stage 3 pressure wound of the left buttock.<BR/>03/11/2024 = Resolved <BR/>03/04/2024 = 2cm x 2cm x 0.1cm<BR/>02/29/2024 = 2cm x 2cm x 0.1cm<BR/>02/05/2024 = 3cm x 3cm <BR/>On 02/23/2024 at 11:36am in an interview with Resident #5 stated they were not treating her wound very well, they were not helping her to apply the wound vac to her wound. She said every time she went to the hospital her wound would be very close to healing but when she comes back to the facility they did not do much for her wound. Resident #5 said she barely gets wound care in a day at the facility, she said if she was in hospital they could do her wound up to 3 three times sometime if needed, but at the facility, they did not do her wound regularly and they did not put the wound vac on her. She said they have Wound Care Nurse at the building who does her wound vac but if the wound care nurse was not in the building nobody does her wound vac. She said the wound care doctor only came one time and when he came he watched the wound care nurse do the wound vac. <BR/>On 02/23/2024 at 11:36am observation revealed the wound vac was not connected to Resident #5's wound. Resident #5 stated the floor nurse last night (02/22/2024) who took care of her could not fix the wound vac, she said the nurse told her that she did not know how to fix Resident #5's wound vac. She said the nurse came in to dress her wound when her wound was saturated but she was unable to put the wound vac back on her because she could not do it, the nurse (Nurse B) had to do wet to dry dressing. <BR/>On 02/23/2024 at 12:26pm in an interview with Nurse A, she stated said she never had the opportunity to do Resident #5's wound because the Resident #5 was on B-bed, and the B-beds were assigned to the night-shift nurses while the A-beds were assigned to the day-shift nurses. She stated the facility had a wound care nurse who was taking care of residents' wound, and if the wound care nurse was not in the building, the wound dressing change of patients were done by the nurses. Nurse A stated she was aware Resident #5 had wounds and a surgical wound where the wound vac was to be applied. Nurse A stated she did not know if the wound vac was to be applied weekly and she had to go look it up. She stated she had not done a wound vac before, even though as a nurse she had been trained to do wound vac, but she did not have any training at the facility to do wound vac. She stated the wound care nurse was not in the facility today. <BR/>On 03/04/2024 at 11:43am in an observation and interview with Resident #5, she stated she did not have any wound care yesterday Sunday 03/03/2024. She stated if the wound care nurse was not around, she would probably not get wound care. Surveyor observed the wound vac, and it was not connected to Resident #5's wound, the wound vac was on a table by the bedside. Resident stated she did not have the wound vac for many days when the wound care nurse was away. She stated the wound vac was placed by the Wound Care Nurse on the last weekend, the date on the canister revealed 2/29/2024. She said when the wound care nurse put the wound vac on her, it worked really well for about a day, but the wound vac canister was full and the wound vac stopped working and she believed that it was because the canister was full. She stated they disconnected the wound vac three days ago. She said all they needed to do was to empty it or change it and fix the wound vac back into her wound, but she did not know why they were not doing that.<BR/>On 03/04/2024 at 11:56am in a wound observation with the Wound Care Nurse, the surgical wound on the right abdomen was observed covered in clean dressing dated today (03/04/2024) the nurse removed the dressing and Surveyor observed the surgical wound at resident's right abdomen - it appeared red beefy about the size 28cm x 20cm the left buttock pressure wound appeared red beefy and round, about 4cm x 4cm in size. There was no concern with the process of the wound care and infection control. The wound care nurse stated she did not apply the wound vac today because Resident #5 was on her way to hospital for blood transfusion because resident's lab came back with low blood level.<BR/>On 03/04/2024 at 12:28pm in an interview with the Wound Care Nurse, she stated if she was not in the building, the nurses on the floor were responsible to do the wound, she was not aware that the nurses did not know how to operate the wound vac. The wound care nurse stated she was gone on vacation from Thursday 2/22/2024 till the Wednesday 2/28/2024. She did not know if they were doing the wound vac or placing the wet to dry on the resident. She said the wound vac keeps excess drainage from the wound because if the drainage was sitting in the wound dressing, it could grow bacteria and affect the wound the more, and could cause the wound to decline and the surrounding tissue could get damaged.<BR/>On 03/04/2024 at 12:51pm in an interview with Nurse A, she stated the floor nurses also did wound care for residents on weekends (Saturdays and Sundays) because the Wound Care Nurse' schedule was Monday to Friday and they did not have weekend wound care nurse. She stated if Resident #5's wound vac needed to be fixed or if anything happened she would not be able to apply the wound vac but she would do wet-to dry wound dressing. She stated she had not spoken with anyone in the past regarding her not able to apply wound vac, but she told the DON about the wound vac today 03/04/2024 and she (DON) said they would train the nurses and show them how to use it. She said generally, wound vac help to heal and control drainage so the wound can heal well. She stated they could do a wet-to-dry dressing if they were not able to do the wound vac. <BR/>On 03/04/2024 at 2:57pm in an interview with the Attending Physician, she stated she saw Resident #5 few weeks ago within the week of her admission, and she had been taking care of Resident #5 for about a month. She stated she saw Resident #5's wound and saw the Wound Care Nurse did the wound vac on that day. The Attending Physician stated the wounds were severe and large and Resident #5 was in pain when she saw her. She said she could not handle the wound alone, especially any wound with a wound vac. She said when it comes to wound vac, you need to know what you are doing she would have a wound specialist consulted to follow the resident, which was why the wound care Doctor followed Resident #5 to ensure proper management and monitoring of her wounds. She stated she was not aware that nurses were not able to apply wound vac on the resident. The Attending Physician stated wound care was not her specialist, but she knew the wound vac was an integral part of the resident's care and the Wound Care Doctor knew better why the wound vac had to be used. <BR/>On 3/5/2024 at 2:04pm in an interview with the Wound Care Doctor, he stated he had not been able to see the Resident #5 much, because the Resident #5 would go to dialysis Mondays Wednesdays and Fridays and sometimes she would be sent to hospital for non-wound related issue. The Wound Care Doctor said he came to the facility mostly on Mondays. He stated the wound vac was a very important as part of the care of Resident #5 because it was recommended by a specialist surgeon who did the surgery for her, and the wound vac would help residents wound to heal better. The Wound Care Doctor said compared to a wet to dry, the wound vac was recommended and more preferred by the specialist who recommended it, any he would not change that. He said there was order in place for wet to dry dressing change in case something happened to the wound vac. He said his expectation was that when orders were given, the order should be followed by the facility and the employees. He stated no one ever informed him that the floor nurses did not know how to apply wound vac for Resident #5. He said the order for wet-to-dry dressing change was given in case anything happened to the wound vac, there could be any accident, it could fall, it was a machine, and it could malfunction at any time, and that was why they gave the order for wet-to-dry dressing. The Wound Care Doctor stated but the main treatment for the wound was the wound vac according to the recommendation from the specialist surgeon.<BR/>On 03/05/2024 at 4:34pm in an interview with the ADON, she stated Resident #5 was always refusing her wound vac and she was told by the Wound Care Nurse that Resident #5 was refusing her wound vac, so the wound care nurse did wet to dry dressing. She stated she assisted in supervising and overseeing the duties of other nurses and to make sure their jobs and the documentation were done properly. She stated no nurse ever told her that they were not able to do wound vac. She said they did not have any training on wound vac or wound care, she said the nurses get the training in nursing school and they all should be able to apply wound vac. She stated the wound vac was to aide in the healing process of wounds and it was used to remove the drainage from the wound so it would not become infected.<BR/>On 03/05/2024 at 4:46pm in an interview with the Wound Care Nurse, she stated that Resident #5 did not refuse care or refuse wound vac for her. She stated she could not remember any day that the resident refused wound care or wound vac. She stated they would do wet to dry dressing for Resident #5's wound when going to dialysis on Mondays, Wednesdays, and Fridays. She was not sure if she selected the wrong reason for not doing the wound vac on 2/28/2024, that day was Wednesday and could be the resident was going for dialysis.<BR/>On 03/06/2024 at 9:37am in an interview with Nurse B, she stated she knew Resident #5 had abdominal wound, bottom wound, left abdominal wound and colostomy, she stated the facility Wound Care Nurse comes to the facility on Mondays to Fridays and the wound care nurse always did the wounds, while the floor nurses - dayshift nurses do A beds and the night shift do B beds whenever the Wound Care Nurse did not come to work. She said she had not been trained on the wound vac at the facility. Nurse B stated the resident did not have the wound vac functioning on the night of 2/22/24, the wound vac was attached but it was not working, and the dressing was due for the night. Nurse B stated she told the resident she did not know how to operate the wound vac and she would do the wet-to-dry dressing as in the order. She said the resident had never refused any care that she knew of. She stated the ADON was the supervisor who oversaw their work. She stated had not specifically told her supervisor she was not trained on wound vac but she was sure she must have mentioned it to them sometime. She said on 2/26/24 and 2/27/24 the wound vac was not on the resident at that time and she (Nurse B) did wet-to-dry dressing.<BR/>On 03/05/2024 at 3:48pmin an interview with Nurse C stated she did not regularly work with Resident #5's . Nurse C stated she may have assisted the resident with her wound once but the wound vac was malfunctioning at that time so she did wet- to-dry. She stated she was not confident on how to apply wound vac and she had not received any training to do wound vac at the facility but she had been trained somewhere else. She stated she had not mastered using the wound vac to the point that she would be able to do it confidently. She stated she had not told her supervisor to do wound vac training for her.<BR/>On 03/07/2024 at 2:22pm in an interview with Nurse D, she stated she worked night shift. She was usually the nurse taking care of Resident #5 every time she worked on that side of the facility hall. She stated she had not changed her wound vac before but have changed the canister for her wound vac in the past. She said she believe she was very competent to apply wound vac, she had done wound vac on another resident but had not applied wound vac on Resident #5 because Resident #5's wound vac was being done differently, and she was not able to do it. She stated on 2/23/2024 during the night shift she remembered she had to change Resident #5's wound dressing because it was saturated, and she changed the cannister but when she removed the dressing wound, she could not re-apply the wound vac, because she was not sure how to apply it properly, and she did not want to mess up anything. She stated she did wet to dry for that night on 2/23/2024. She stated Wound vac was useful for a wound with a lot of drainage because the wound vac removed body fluid drainage from the wound, she said if the drainage was not removed the wound would not heal and could be infected.<BR/>On 03/06/2024 in an interview with the DON, she stated none of the nurses informed her that they were not able to apply wound vac on Resident #5. The DON stated the wound vac promote healing of the wound and prevent infection by removing excess drainage from the wound. She stated they had started in servicing the nurses and they would also have the wound vac company come in to train the nurses on using the wound vac and have each nurse perform a return demonstration.<BR/>Facility policy titled 'Competency of Nursing Staff' dated May 2019 revealed in part . licensed nurses and nursing assistants employed or contracted by the facility will demonstrate specific competency and skill sets deemed necessary to care for the needs of residents as identified through resident assessments and described in the plans of care.<BR/>The facility did not have policy for quality of care or wound vac.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs for 1 (Residents #60) of 12 residents reviewed for pharmacy services. <BR/>The facility failed to ensure Resident #60 's GT medication order complete, with amount of water to give in between med administration, and before and after meds and water to dilute medication, to her GT. <BR/>The facility failed to ensure medication order was accurate, without an extended release (ER), a medication that should not be crushed, Metoprolol Succinate 12.5 mg BID to administer for Resident #60.<BR/>The facility failed to ensure Resident #60 's medication order was complete, with order to shake well anti-seizure meds Levetiracetam solution (Keppra) and Carbamazepine (Tegretol) suspension, before administration.<BR/>The facility failed to ensure Resident #60 's Levetiracetam solution (Keppra) and Metoprolol Succinate medication orders complete, with a diagnosis (dx) or indication for its use. <BR/>These failures could place all residents receiving medications at risk for receiving less than therapeutic benefits of their medication and worsening of medical condition.<BR/>Findings Include:<BR/>Record review of Resident # 60's face sheet revealed, a [AGE] year-old female admitted to facility on 3/30/21 with diagnoses which included, cerebral infarction due to embolism (blood clot), seizure disorder or epilepsy, difficulty swallowing (dysphagia), Lt hemiplegia (Lt side paralysis), gastro-esophageal reflux disease, HTN, chronic pain and polyneuropathy. <BR/>Record review of Resident #60's entry MDS revealed she had moderately impaired cognition with feeding tube for dysphagia. She required extensive-total assistance of 1-2 staff for most activities of daily living.<BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed Metoprolol Succinate ER 25 mg, give &frac12; tab=12. 5 mg via gastrostomy tube (GT) BID, start date 8/19/21. No dx or indication for its use. Carbamazepine 100 mg/5 ml suspension give 15 ml =300 mg via GT BID, for epilepsy. Levetiracetam 100 mg/ml solution, give 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered. <BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed give 50 cc water per GT every 6 hrs. for patency. No order with the amount of water to dilute medications. No order to give water in between med administration. No order to give water flush before and after meds administered to her GT. <BR/>Record review of MAR dated May 2022 - June 2022 revealed Resident #60 received Metoprolol Succinate ER 25 mg, crushed &frac12; tab=12. 5 mg via G-tube BID, start date 8/19/21. Carbamazepine 100 mg/5 ml suspension 15 ml =300 mg via GT BID. Levetiracetam 100 mg/ml solution, 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered.<BR/>Record review of Resident #60's MAR dated May 2022 - June 2022 revealed no order received with the amount of water to dilute medication, and in between med administration, and no water flush before and after the medications administered to her GT.<BR/>Interview on 6/09/22 at 12:15 p.m., the DON stated Resident #60's GT order was incomplete, and stated normally we give 30 ml water flush before and after meds and 10 ml water in between meds, and will call the MD. However, she stated LVN A should have also called the MD, since the Resident 's GT medication orders incomplete. The DON stated she was in-charge to reconcile monthly residents' physician orders along with the ADON. The DON stated moving forward she will ensure there are no missing medication orders, are accurate and irregularities were caught. The DON stated that Extended-Release (ER) Metoprolol Succinate should not be crushed, because by administering crushed ER Metoprolol, resident may not get a sufficient dose of the medication. The DON stated she will call the MD and instead use liquid form or dissolve Metoprolol tab. The DON stated she will call the MD to verify incomplete anti-seizure medication order for Carbamazepine (Tegretol) suspension and the Levetiracetam (Keppra) solution, to be shaken well before administered. The ADON was on training and unavailable for interview.<BR/>Interview on 6/09/22 at 2:00 p.m., LVN B stated she would not crush an extended-release medication, but she would clarify with physician if order was incomplete or missing order.<BR/>Interview on 06/09/22 at 1:15 p.m., the DON stated we verified with the MD and obtained water flush order for her GT meds, to give 5-10 ml water in between meds, and 5-10 ml water flush before and after meds given to her GT. The DON said moving forward the facility will conduct 100 % audit to ensure orders complete. The ADON was on training, unavailable for interview.<BR/>In an interview on 06/09/22 at 3:30 p.m., RN C stated she will follow-up and audit to ensure the residents' medication orders accurate and complete. She added new orders, will be reviewed the next day during daily AM meetings.<BR/>In an interview on 06/09/22 at 3:30 p.m. The Administrator stated that we will follow-up all the medication issues with QAPI. <BR/>Record review of the facility provided policy, Administering Medications through an Enteral Tube dated March 2015 read in part, . Verify that there is a physician 's medication order for this procedure .Do not crush enteric coated, sustained release meds .Place the MAR within easy viewing distance. If administering more than one medication, flush with 15 ml or prescribed amount, warm sterile or purified water.<BR/>Record review of the facility provided policy, Medication and Treatment Orders dated July 2016 read in part, .Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders for medication must include .Clinical condition or symptoms for which the medication is prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical record in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #8) reviewed for medical records, in that:<BR/>Facility failed to ensure Resident #8's list of medication during discharge was kept in the medical record with the facility.<BR/>This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication and delay in services. <BR/>Findings include:<BR/>Record review of facesheet revealed Resident #8 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), multiple sclerosis (immune-mediated disease that affects the nerve cells of the body), hemiplegia (paralysis that affects only one side of your body.), Parkinson's disease (progressive disease marked by tremor, muscle rigidity, slow imprecise movement, mostly affecting middle-aged and elderly people), pneumonia (an infection that occurs in the lungs when it is filled with fluid or pus). <BR/>On 03/22/2024 at 1:46pm in an interview with Nurse E who discharged Resident #8, she stated when she discharged Resident #8, she wrote the list of all the medication sent home and signed the list. She kept a copy of the record in the medical record box and kept the other copy on the nurses station at the north side of the building. Nurse E stated she could not find the medication list when surveyor requested for it. <BR/>On 03/22/2024 at 4:22pm in an interview with the Director of Nursing (DON) stated the medical record person quit some days ago and they had paperwork that was piling up and sometimes she (DON) tried to scan those documents whenever she came across them, but they were in the process of getting somebody into that position to continue to handle residents' records. She said it could be that somebody picked it and thought it was not an important document, and just put it somewhere. The DON said she started an in-service on Wednesday, 3/20/2024, about handling resident medical records, because she noticed some inconsistencies about how the resident information paperwork were being handled, and she wanted to put everything right because medical records are very important documents used for resident's care. The DON stated the MDS nurse was the one currently helping out with medical records.<BR/>On 3/25/2024 at 12:09pm in an interview with the MDS Nurse stated she saw the Resident #8's discharge medication list at the north nursing station on Monday (03/11/2024) but she did not take it. She stated at the time she saw it, she was looking for another resident's medical record.<BR/>The policy (Electronic Medical Records) provided did not address deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, leading to potential entrapment hazards for 1 (Resident #49) of 13 residents reviewed for safety in rooms.<BR/>The facility failed to conduct regular inspections of resident bed frames and mattresses to identify risks and problems. Resident #49's bed had a significant gap between the mattress and bedframe. The mattress was torn with mattress foam coming away from the mattress cover and was covered with stains and rips in the center of the mattress. <BR/>The finding Include:<BR/>Record review on 9/24/24 at 9:00 am of Resident #49 admission face sheet revealed she was a [AGE] year-old female with Parkinson's, osteomyelitis, and dementia.<BR/>Record review on 9/24/24 at 9:30am Resident #49's MDS dated [DATE], revealed a BIMS score of 9, which indicated cognitive impairment to make decision. Section GG (function abilities) revealed Resident#49 needed substantial assistance for bed mobility. Observation on 9/24/24 at 8:20 a.m., several resident beds were found with loose bed rails and gaps between the mattress and bed frame, torn and stained mattress.<BR/>Observation on 9/24/24 at 8:30 a.m., Resident #49's bed had a significant gap between the mattress and the bed frame. Resident #49 mattress was torn with mattress foam coming away from mattress cover. Resident #49's mattress was covered with stains and rips in the center of mattress. Resident #49 was on a low bed with fall mat that was torn around edges.<BR/>Interview on 9/24/24 at 10:30 a.m., a family member of Resident #49 stated they spoke with staff to have mattress replaced due to mattress looked worn out and was torn on the sides and foam was coming out. The FM stated Resident #49's mattress was still on bed despite asking for it to be replaced.<BR/>Interview on 9/24/24 at 11:00 a.m., the Administrator stated that residents will let the nursing staff know when they want a new mattress if the resident can speak for themselves and those that cannot it was the nursing staff and department head responsibility to bring it up when doing Angel rounds. The Administrator stated that the facility maintenance director does not have a schedule or plan to check all beds, but we have new beds in facility residents just have to ask. Adminstrator stated the facility did not have a policy on replacing beds or mattress for beds.<BR/>Interview on 9/24/24 at 11:30 a.m., the facility maintenance director stated the staff will have to tell my staff and will get the mattress replaced. He said he ordered new mattresses all the time but need the nursing staff to tell him who or what resident needed a new mattress. Facility manintenance directored stated he was not aware of any policies on replacing beds or mattress.<BR/>Interview on 9/24/24 at 12:15 p.m., the facility DON stated the nurses are required to inspect mattresses to ensure the mattresses are in good condition as well as the beds. <BR/>Interview on 9/24/24 at 12:45 p.m., CNA B, CNA C stated they mention some of the residents having torn mattress and needed new ones, but nothing was done.<BR/>Interview on 9/24/24 at 1:00, charge nurse, stated the aides will tell them if the resident needs a new mattress because they are the ones that make up the beds during ADL care and if a resident needs a new mattress or something was wrong with the bed we tell the Administrator or Maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (Resident #70) of 18 reviewed for abuse. <BR/>The facility failed to ensure Resident #70, who was cognitively impaired, had a history of aggressive behaviors, and resided in the facility's memory care unit, was free from abuse when she was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. The IJ template was provided to the facility on [DATE] at 5:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures placed cognitively impaired residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. <BR/>Findings include:<BR/>Record review of Resident #70's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Diffuse Lewy Body (protein deposits which develop in nerve cells in the brain), psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), muscle wasting and atrophy (muscles that lose their nerve supply can decrease in size and waste away), chronic skin ulcers (ulcers that do not heal well after 12 weeks), dysphagia- oropharyngeal phase (difficulty initiating a swallow and generally due to structural , anatomical or neuromuscular abnormalities), cognitive communication deficit (difficulty with thinking and how someone uses language), restlessness and agitation (a common symptom of anxiety that makes someone have an uncomfortable urge to move), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and chronic pain of the right hip joint. Resident #70 died on [DATE].<BR/>Record review of Resident #70's MDS dated [DATE] revealed she had a BIMS of 00 (severe cognitive impairment); she did not have hallucinations or delusions; she did not exhibit physical, verbal, or other behavioral symptoms towards others and she did not reject care. Resident #70 required extensive physical assistance from at least two staff for bed mobility, dressing, toilet use, and bathing; she required extensive physical assistance from one staff for transfers, walking, locomotion, eating, and personal hygiene; used a wheelchair for mobility and required substantial/maximum assistance; had an unsteady gait and was only able to stabilize with staff assistance; was always incontinent of bowel and bladder; had a history of falls; had skin tears; and was prescribed antianxiety and antidepressant medications. <BR/>Record review of Resident #70's care plan revised [DATE] revealed the following care areas:<BR/>*Resident #70 had pustules (a bulging patch of skin that is full of a yellowish fluid called pus) to the right ankle and left pinky toe. Goals included: Resident will not develop complications from foot problems as evidenced by not exhibiting infection or pain. Approach included: Apply dressing with topical medication.<BR/>*ADLs Functional Status/Rehabilitation Potential. Goals Included: Resident will achieve maximum functional mobility. Approach included: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Eating amount of assist: Extensive. Toileting amount of assist: Extensive. Consult PT, OT, ST as needed. Personal care as per facility protocol.<BR/>*Behavioral Symptoms. Resident did not adjust well to change. Resident was verbally and physically aggressive. At times, Resident crawled on the floor and over beds, and was not always easily redirected. Goals included: Resident will have fewer episodes of verbal and physical aggression. Approach included: Always ask for help if resident becomes abusive/resistive. Convey acceptance of acceptance during periods of inappropriate behavior. Encourage diversional activities. Keep environment calm and relaxed. Remove from public area when behavior is unacceptable. <BR/>*Cognitive Loss/Dementia. Goals included: Resident will be as alert and oriented as possible. Approach included: Anticipate needs and observe for non-verbal cues. Approach in calm manner. Explain what you intend to do while providing care. Introduce self. Orient PRN to person, place, and time. <BR/>*Communication. Goals included: Resident needs/wants will be met at all times. Approach included: Ask simple yes/no questions and allow adequate time to respond. Do not pretend to understand, request clarification when needed. Speak directly to resident in a clear voice facing him/her. <BR/>*Mood State. Goals included: Resident will express/exhibit satisfaction. Approach included: Assess, monitor, and document mood. Be reassuring and listen to concerns. Encourage group activities. Medications as ordered. Social Services to visit 1:1.<BR/>*Pressure Ulcer/Injury/Skin Care. Resident had thin and fragile skin. Resident got skin tears often and could not remember what caused the skin tears. Goals included: Prevent/heal pressure sores and skin breakdown. Approach included: Follow facility skin care protocol. Preventative Measures. Report to charge nurse any redness or skin breakdown immediately. Treatment as ordered. <BR/>*Psychotropic Drug Use. Alprazolam, Paxil, Trazodone, Depakote. Goals included: Benefit without side effects. Approach included: Anti-Anxiety Medication Use - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. Anti-Depressant Medication Use - Observe resident closely for significant side effects: Common - sedation, drowsiness, dry mouth, blurred vison, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain. Gradual dose reduction. Monitor for side effects per psychotropic flowsheet. Monitor target behaviors per psychotropic flowsheets. <BR/>*Behavioral Symptoms. Resident had socially inappropriate/disruptive behavioral symptoms as evidenced by: resident pinched, hit, scratched, and bit at staff. Goals included: Resident will not exhibit socially inappropriate/disruptive behavior. Approach included: Assess resident for placement in a specially designed therapeutic unit. Resident was on memory care unit for personal safety. Maintain a calm environment and approach to resident.<BR/>Observation and interview with Resident #70 on [DATE] at 10:30 a.m. revealed Resident #70 was in bed alert and yelling, Help, Help!. Resident #70 had bruises on her right leg, and she was observed scratching the bruises. There was an unidentified staff member sitting beside her. Interview with the unidentified staff member revealed Resident #70 was always restless after breakfast but fell asleep after some time. The unidentified staff member said she was watching Resident #70 to make sure she did not attempt to get up and fall. <BR/>Record review of facility document entitled Concern Form dated [DATE] and signed by the Administrator revealed, Date received: [DATE]. Concern initiated by: Staff. Individual's name: [Housekeeper C] Concern reported to: DON, NHA nursing home administrator . Employee report concerns of yelling and screaming back in memory care unit . Individuals designated to take action on this concern: NHA/DON. Date assigned: [DATE]. Date to be resolved by: [DATE]. Was a group meeting held: No . Results of action taken: Resident screaming identified, care plan and behaviors reviewed, verbal education of employee due to behaviors and memory care unit, dementia, Alzheimer's . Was concern resolved? Yes, describe resolution. Employee stated she understood that dementia/Alzheimer's residents have behaviors that may include yelling, screaming, panicking, confusion, agitation, etc. Identify method used to notify the complainant of resolution: One-to-one discussion. Date: [DATE]. Was complainant satisfied with the resolution? Yes. Employee stated she understood behaviors. This form was completed by: NHA (Administrator). <BR/>In an interview with the Administrator, DON, and ADON on [DATE] at 11:15 a.m., the Administrator said there was a recent incident involving a resident who passed away in the facility on the previous day, Resident #70, but the staff member, Housekeeper C, did not tell them everything that happened. The DON stated Housekeeper C said she had concerns regarding Resident #70 because she was screaming. The DON said she told Housekeeper C that screaming in the memory care unit was not unusual. The DON said regarding the incident that was reported, the aides (she did not name the aides) were trying to transfer Resident #70 to her bed and calm her down. The DON said Resident #70 was confused and combative. The DON said the staff member took it (the incident with Resident #70) personally, and thought it was abuse. The Administrator said they (administration) looked into the incident involving Resident #70 and they did not think it was abuse. The Administrator said all Housekeeper C said was that Resident #70 was yelling. The Administrator said Housekeeper C never said abuse, just that the resident was yelling. The DON said Housekeeper C quit earlier that morning ([DATE]). The ADON said Housekeeper C never mentioned that she saw or heard anybody drop Resident #70, or that she fell. The ADON said Housekeeper C said Resident #70 was yelling and she had concerns. The ADON said Housekeeper C did not name the staff, but she did try to describe the staff. The DON stated they (administration) never figured out which staff Housekeeper C was talking about. The DON said Housekeeper C came back a second time after she voiced concerns, and she still could not identify the staff involved. The ADON said Housekeeper C expressed her concerns to her supervisor, the Housekeeping Supervisor. The ADON said the Housekeeping Supervisor did not notify them (administration) until the next day, which was last week. The ADON could not recall the day administration was notified by the Housekeeping Supervisor. The Administrator said they had good continuity of care in the memory care unit, so they kept the same staff in there for each shift. The Administrator said no staff from the memory care unit had been reassigned to work another area of the building. <BR/>In an interview with the Housekeeping Supervisor on [DATE] at 1:00 p.m., she stated Housekeeper C expressed concerns about Resident #70 to her on [DATE]. The Housekeeping Supervisor stepped out of the room twice at the beginning of the interview and kept saying, they (administration) were watching the door and keeping track of who entered the conference room to speak to the state surveyor about the incident. The Housekeeping Supervisor said Housekeeper C said she heard Resident #70 yelling down the hallway on [DATE], and it was concerning to her. The Housekeeping Supervisor said she explained to Housekeeper C that it was Resident #2 who always yelled in memory care, not resident #70. The Housekeeping Supervisor said Housekeeper C was fairly new to the facility and did not know residents' names. The Housekeeping Supervisor said Resident #2 always yelled, Help me! all day. The Housekeeping Supervisor initially said Housekeeper C did not say she saw anything, just that she heard yelling, and it made her uncomfortable. She said Housekeeper C was not able to say who the staff members were, just that the resident was yelling. The Housekeeping Supervisor said Resident #70 always yelled out, Stop, leave me alone. I do not want to sit down! The Housekeeping Supervisor said Housekeeper C sent a text message on Thursday, [DATE], at 10:27 p.m. saying it had been a rough and emotional day. She said when she saw the text message the next day, [DATE], she texted Housekeeper C asking her what happened and then she called Housekeeper C. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON on the next day, [DATE]. <BR/>In an interview with the Staffing Coordinator on [DATE] at 2:00 p.m., she stated she heard a few rumors regarding the incident involving Resident #70, but she did not know anything about it personally. She stated other staff (she would not name the staff) told her the incident involved Resident #70 and 2-3 aides, but she did not know who those aides were. She said staff had concerns because there was an incident with Resident #70 last week ([DATE]) and then she died over the weekend. She said other staff told her two aides were taking care of Resident #70 and they were swinging her around and she fell. The Staffing Coordinator said the fall was not reported and over the weekend Resident #70 was sick and vomited blood. She said the same staff always worked in the memory care unit and the same staff worked on the same days (the same staff always worked together and were off on the same days). The Staffing Coordinator said there was a lady who wanted to talk to the state surveyors about the incident, but she was scared and feared retaliation from administration. The Staffing Coordinator said the lady who wanted to talk said she saw some things but did not want to lose her job. She said recently, both TNA A and TNA B had been calling in sick, which was unusual. The Staffing Coordinator said one (TNA A or TNA B) was pregnant (she could not say which one). She said she did not know if anybody mentioned or questioned them about the incident regarding Resident #70. The Staffing Coordinator stated Housekeeper C was the original source of the information, but the person who wanted to talk to the state surveyors was a different person. <BR/>In a telephone interview with TNA A on [DATE] at 2:22 p.m., she stated she often cared for Resident #70, who was confused. She said Resident #70 tried to walk but could not. She said Resident #70 was sweet some days, but some days, she did not want to be bothered. She said Resident #70 had her days when she did not want anybody to touch her. TNA A said Resident #70 had a witnessed fall in the dining room ([DATE]) and when she returned from the hospital, she was strong like super woman and tried to walk. She said she worked with Resident #70 last week (she could not recall the day) and after that, she was moved around to work on another hall. She said on that last day with Resident #70, she was really just being herself, talking and trying to get out of bed. TNA A said she sat in the room with Resident #70 on that night around 8:00 p.m. or 9:00 p.m. She said on that night, after Resident #70 got her medication, she was antsy (anxious) and she did not want Resident #70 to get out of bed, so she sat with her until she fell asleep for about 15 minutes. TNA A said Resident #70 was not aggressive or combative that night. She said Resident #70 was wheeled into her room and she was given her medications. She said she heard Resident #70 moving around on the baby monitor at nurse' station. She said it sounded like Resident #70 was talking and had a regular conversation with somebody. TNA A said Thursday, [DATE] was like a normal night and nothing unusual happened. <BR/>In a telephone interview with TNA B on [DATE] at 2:44 p.m., she stated she worked nights in the memory care unit. She said Resident #70 could not walk but she tried. She said Resident #70 sometimes got fussy when she tried to provide care. TNA B said she gave Resident #70 some time when she got fussy and then came back and Resident #70 would allow her to give care. She said she was off Friday thru Sunday ([DATE] - [DATE]). TNA B said on [DATE], nothing unusual happened. She said Resident #70 had a lot of sores and she scratched them a lot. She said sometimes, nurses had to give Resident #70 first aide because she scratched the sores until they bled. She said Resident #70 never had a fall during her shifts. She said she worked on the North part of the building (not memory care) yesterday ([DATE]). <BR/>Record review of facility sign-in sheets for [DATE] revealed the following:<BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A and TNA B, indicating TNA A and TNA B worked that shift. <BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A. TNA B's name was scratched out and listed under Call Ins, indicating TNA A worked the shift, but TNA B called in for that shift. <BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: Both TNA A and TNA B's names were crossed out. TNA B's name was listed under Call Ins. TNA A's name was written in under 6:00 p.m. - 6:00 a.m. North Nursing Station but it was crossed out and, and went home was written under her crossed out name. <BR/>In an interview with the DON and ADON on [DATE] at 3:25 p.m., the DON said there should not have been any housekeepers on night shift that she knew of (6:00 p.m. - 6:00 a.m.). The ADON said the Housekeeping Supervisor told them it was Resident #70 that Housekeeper C was talking about. The DON had a small stack of papers and stated they were complaints the facility's administration had submitted to their corporate office against the Housekeeping Supervisor. The DON said they had issues with the Housekeeping Supervisor's performance for some time and she was aware. <BR/>In a telephone interview with Housekeeper C on [DATE] at 3:45 p.m., she stated she worked as a housekeeper in the facility for approximately one month and a couple of weeks, so she was familiar with Resident #70, and she would not confuse her for Resident #2. She said she worked all over the building and her normal shift was 6:00 a.m. until 12:00 p.m., but she also worked nights sometimes from 3:00 p.m. - 8:00 p.m. She said she was cleaning in the memory care unit on [DATE] and she heard a lady, Resident #70, screaming. She said earlier that day, Resident #70 was perfectly fine. She said at 7:12 p.m. exactly, two of the night shift girls (TNA A and TNA B) had Resident #70 stripped naked with no brief, twirling her. She said Resident #70 was in her wheelchair and one of the staff was sitting in a regular chair behind the resident. She said the staff had her foot on the back of Resident #70's wheelchair like she was popping a wheelie with Resident #70's legs up in the air. She said the staff was moving Resident #70's wheelchair side to side and Resident #70 was screaming and hollering for her to stop. She said the screaming was what got her attention and she rolled her housekeeping cart to the very end of hall, where Resident #70's room was. She said another resident was walking by and told the staff to stop when she saw what the aides were doing to Resident #70. Housekeeper C said the aides were laughing during the incident. She said one of the aides was pregnant and the other was not. She said Resident #70 was bleeding, but she could not see where the blood was coming from. She said one of the aides wiped Resident #70's blood with her bed sheet. She said the pregnant aide saw her in the doorway and told her to get the bloody sheet. Housekeeper C said she picked up the bloody sheet, took it to laundry, then she went and clocked out. Housekeeper C said Resident #70's legs were still up in the air when she (Housekeeper C) walked out of the room with the bloody sheet. She said Resident #70 let out a very loud scream when she (Housekeeper C) was walking out of the room, but she did not know if that was when the staff let Resident #70's wheelchair down to the floor because she (Housekeeper C) did not turn around to look. She said she had a video of the incident that was only audio and no visual (she started recording with her phone when she heard Resident #70 screaming), but the DON made her delete it out of her phone when she was called in to report the incident. Housekeeper C said she initially reported the incident to her supervisor, the Housekeeping Supervisor, and then the DON told her to come into the office (the DON's office) and tell what her happened on Sunday, [DATE]. She said she had initially texted her supervisor the night of [DATE], but her (Housekeeping Supervisor) phone was off, and she did not see the message until the next day. She said the Administrator, DON, ADON, and the Housekeeping Supervisor were all present in the room when she reported what happened. She said there were six people in the room;, her, the Administrator, DON, ADON, Housekeeping Supervisor, and she could not name the last person. She said the video slipped her mind at first, so she did not mention it during the first meeting. She said the DON said sometimes they had to restrain residents when the residents tried to harm them. She said they told her she was too emotionally involved for that job. She said she told the DON and the Housekeeping Supervisor she thought Resident #70 was being abused because she was being abused. She said she also showed the video/audio to two other staff members (CNA K and TNA Y, but she did not say when this happened). Housekeeper C said CNA K and TNA Y asked her if she was going to report the incident to Resident #70's family member when she visited. She said CNA K told her Resident #70's leg was purple, and it looked like they (TNA A and TNA B) broke her leg. Housekeeper C said when Resident #70's family member visited her (she did not say what day this was), the family member said Resident #70 was perfectly fine when she ate lunch with her Tuesday ([DATE]). She said on her last day at the facility, Sunday, or Monday ([DATE] or [DATE]), Resident #70's family member was basically there saying her good-[NAME] to Resident #70. She said the DON called her into her office a second time on the same day and asked her who she had shown the video/audio to. She said she did not know how the DON found out about the video/audio, but after she played it for the DON, she made her air drop it to her (the DON) phone and then made her delete it from the phone and trash (in the phone). She said the DON said the voice in the audio was the lady who hollered all the time, Resident #2, but Housekeeper C said it was not Resident #2, it was Resident #70. She said they (administration) told her to think really hard about what she wanted to do at the facility and then they had her clock out. Housekeeper C said she quit when they told her to get out of the office and clock out. She said she tried to go to the facility and get paperwork to resume her state benefits earlier that morning ([DATE]) but they (administration) would not allow her into the building. She said she assumed it was because state was in the building, and they did not want her to talk. <BR/>In an interview with the DON on [DATE] at 4:15 p.m., she stated Housekeeper C never sent her a video or audio and she never heard one regarding the alleged incident with Resident #70. The DON said there was talk around the facility about a video or audio, but she never told Housekeeper C to delete it. <BR/>In a telephone interview with the Housekeeping Supervisor on [DATE] at 7:35 a.m. she said she was ready to tell the truth about what she knew regarding the incident with Resident #70. She said before she went to the conference room to speak with the state surveyor on [DATE], the DON texted her and told her to go to her (DON) office. She said the DON asked her what she was going to say to the state surveyor. She said she told the DON she was going to tell the state surveyor what Housekeeper C told her. She said the DON said please do not do that. She said the DON asked her to not tell the state surveyor everything. She said the DON told her to say Housekeeper C said she heard someone yelling down the hallway. The Housekeeping Supervisor said she was previously scared to talk to the state surveyor for fear of retaliation by administration. She said the Staffing Coordinator told her the DON called her into the office before she spoke to the state surveyor on [DATE] and told her the same thing, not to tell state the truth. She said Housekeeper C texted her on [DATE] at 10:27 p.m. and said she had an emotional day. She said she saw the text on Friday, [DATE] at 9:39 a.m. She said she called Housekeeper C on [DATE], after their 10:00 a.m. morning meeting. She said Housekeeper C told her that the pregnant girl at night and another one with her were involved. She said Housekeeper C said she was walking down the hall and saw Resident #70 naked in her wheelchair. She said Housekeeper C told her Resident #70 was trying to get up, but the staff were leaning the chair back and they started turning and twisting her in the air. She said Housekeeper C told her everybody kept coming up to her and asked who she reported the incident to and why she did not report it to them. She said Housekeeper C said she was scared to lose her job. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON after she spoke to Housekeeper C on [DATE]. She said the Administrator and DON had her call Housekeeper C into the DON's office on Sunday, [DATE] at 3:08 p.m. because they said they needed to talk to her. She said they all talked together, then the Administrator and DON asked the Housekeeping Supervisor to leave. She said they called Housekeeper C back into the office and the DON said there was a video. She said the DON found out about the video because Housekeeper C showed it to CNA K and TNA Y. She said Housekeeper C also told her that CNA K said Resident #70's ankle was broken. The Housekeeping Supervisor said she did not know about the video when they initially walked into the office. She said the DON asked her (Housekeeping Supervisor) to have Housekeeper C come back into the office. She said the Administrator and DON asked her (Housekeeping Supervisor) to leave out of the office. She said Housekeeper C came out crying and saying she was about to lose her job. She said she told Housekeeper C she was not supposed to be on the phone. She said she thought Housekeeper C recorded the video/audio because she was already on a video call while working that night. The Housekeeping Supervisor said they (administration) made her send Housekeeper C home because state was in the building. The Housekeeping Supervisor said she never saw the video/audio because the DON made Housekeeper C send the video/audio to her (DON) phone and then made Housekeeper C delete it. She said Housekeeper C said she thought Resident #70 was being mistreated to everyone in the DON's office. She said Housekeeper C told her the staff were spinning her around and that was not right. She said Housekeeper C said one resident in the hall told them to stop when she saw what they were doing to Resident #70. <BR/>Record review of a screenshot of a text message thread between the DON and the Housekeeping Supervisor's phone revealed, DON (Work) at the top of the text thread. On Wednesday, [DATE], at 12:39 p.m., the DON sent a text message that reflected, Need you to come to my office plz, and the Housekeeping Supervisor responded, On my way. <BR/>In an interview with the Administrator on [DATE] at 12:35 p.m., he stated there was no evidence Resident #70 was abused and employees denied it. He said the two people (Housekeeping Supervisor and Housekeeper C) who made the accusations did it in retaliation because he made them do their jobs. He said there was an ulterior motive to the allegations. He said the first they heard of the abuse was when the HHSC complaint came in ([DATE]). The Administrator said the only time Housekeeper C came to him about any concerns was on [DATE] when she had concerns about residents yelling in memory care. <BR/>In a follow up telephone interview with Housekeeper C on [DATE] at 1:00 p.m., she said on [DATE] at 7:12 p.m., she knew Resident #70 was being mistreated by the two staff (TNA A and TNA B) in the room, so she did not know what else to do but turn her video on her phone and put it (her phone) in her pocket. She said she went to the room so the video could pick up the audio of the resident yelling Stop It!, Help!. She said the resident was stripped naked, in a wheelchair with it propped back in a wheelie, and the staff members were laughing. She said another resident went by and told the staff members to stop and leave her alone, and the staff members told her to shut up and go to your room. Housekeeper C said she started to walk off and one of the staff members called her back and gave her a sheet with blood on it to take. She said she took it and walked away to put the sheet in the laundry, then she clocked out. She said when she was walking away, she heard a loud scream from the same resident that she had never heard before. She said she knew something was wrong but was too afraid to turn around at that point and she clocked out and left. She said she called the Housekeeping Supervisor as soon as she clocked out, but her phone was turned off. She said when she got to work the next day on [DATE], she told the Housekeeping Supervisor about what happened, and the Housekeeping Supervisor went to tell the Administrator and DON. She said she was called into the DON's office and told them that Resident #70 was being mistreated and what happened. She said they asked the Housekeeping Supervisor to leave the room and continued to talk to her (Housekeeper C). She said the DON said the staff could have been trying to use some kind of restraint with the resident. She said the Administrator asked her to send the video to him, but she was unable to, so the DON said to airdrop it to her. She said after she sent the video to the DON, she told her to delete it from her phone. She said her last day of work was on [DATE]. She said they (administration) told her she was too emotional and to think about what she really wanted to do. She said she went back up to the facility on [DATE] to try to get papers for her benefits and the ADON kicked her out of the facility and said she was not allowed back in the facility. She stated she never filled out a concern form or was even at the facility on [DATE]. She said she did not have a backup of the video and did not send it to anyone else besides CNA K and TNA Y. Housekeeper called back on [DATE] at 1:15 p.m. crying and said that her cellular phone maker told her if the video was deleted from the phone, there was nothing they could do.<BR/>In an interview with TNA Y on [DATE] at 1:23 p.m., he stated he did not see a video (regarding Resident #70), but he heard about it from Housekeeper C and other staff in the facility. He said he was never told to not say anything or hide anything. He said when he heard about what was on the recording, he thought it was horrible. <BR/>In an interview with the Staffing Coordinator on [DATE] at 3:05 p.m., she stated she received a call on [DATE] in the evening, after she was at home from the ADON. She said the ADON asked if TNA A and TNA B were on the schedule for [DATE], and she said no. She said when she came to work on [DATE], one of the aides (she did not say who) was really upset because Resident #70 had passed away. She said the anonymous aide stated, If it had anything to do with what I am hearing about, I am not comfortable. The Staffing Coordinator stated Housekeeper C was not the one who gave her the anonymous note to show the state surveyors (the Staffing Coordinator was given an anonymous note to show the state surveyors on [DATE], saying they had concerns about a resident who passed away. The anonymous person never approached the state surveyors in fear of retali[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 8 of 18 residents reviewed for ADL care (Residents # 4, #7, #20, #28, #44, #55, #60, #181).<BR/>--facility staff failed to provide personal hygiene care to Resident #4, #44, #55, #60 <BR/>--facility staff failed to turn and reposition Resident # 7 as ordered <BR/>--facility staff failed to provide timely incontinent care and transfer assistance to Resident #20<BR/>---facility staff failed to provide timely incontinent care to Resident # 28, #55, #60, #181 <BR/>Theis failurefailures placed residents who were unable to carry out ADLs at risk of not receiving necessary care and assistance when needed. <BR/>Findings include:<BR/>Resident #4<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted and readmitted to the facility 07/06/23. His diagnoses included Acute respiratory distress (inability to breath) sepsis (infection) Contractures, persistent vegetative state (a person who is unaware and unresponsive), muscle wasting, pneumonia, multiple site pressure ulcers and dysphasia.<BR/>Record review of Resident #4's significant change MDS assessment dated [DATE] revealed his cognitive level ( BIMS) score was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident # 4's care plan dated 10/08/20and edited 05/11/23 read in part -<BR/>ADLs Functional Status/Rehabilitation Potential. Resident #4 is dependent with all ADLs. Bed mobility with two to three person assist for Transfer: total assistance with 3 staff, Dressing: total assistance with 2 staff and personal hygiene: 2 staff assist.<BR/>Goal: Resident # 4 is dependent with all ADLs. Bed Mobility: total assistance. Resident #4's dignity will be maintained, and he will be clean, dry, well-groomed and odor free during the next 90 days.<BR/>Approach: dress resident according to season and climate. Provide oral care twice daily. Shower, shampoo hair, and give nail care per shower schedule and as needed.<BR/>Observation on 07/15/23 at 2:00PM, revealed Resident #4 was in bed, noncommunicative and in a semi fetal position. He was contracted with his two-hand clenched in a fix position, unkept facial hair, dirty long nails about 1\2 an inch, and there was dry white substance around his mouth. He had a dirty hospital gown on and a catheter with 300 ML of clear yellow urine.<BR/>Observation and interview on 07/16/23 at 10:00AM revealed Resident #4 was in the same position with the same hospital gown on, dirty long nails and unkept facial hair. In an interview with CNA Y, she looked at Resident #4 and said she would clean him.<BR/>In an interview with LVN L on 07/16/23 at 10:00am, she said Resident # 4 was on hospice and hospice usually cleaned him.<BR/>Record review of Physician's telephone orders dated 04/13/23 revealed Resident # 4 was admitted on hospice on 07/13/23. Hospice documentation was requested from ADON on 07/16/23 at 3:30pm but was not provided. <BR/>Resident #7<BR/>Record review of Resident #7's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood causing respiratory failure), vascular dementia (brain damage from impaired blood flow to brain), shortness of breath, cognitive communication deficit (difficulty with thinking and language), obstructive and reflux uropathy (urine unable to drain through urinary tract), muscle wasting and atrophy (decrease and thinning in muscle size), dysphagia (trouble swallowing), pneumonitis due to inhalation of food (inflammation of the lungs), schizophrenia (false beliefs, hallucinations, unusual behavior, and disorganized thinking and speech), and pressure ulcer of sacral region (pressure sore in the lower back and tailbone area). The face sheet also revealed the resident was a DNR.<BR/>Record review of Resident #7's Comprehensive MDS dated [DATE], revealed a BIMS score of 5 which indicated severely impaired cognition. The MDS revealed the resident had a serious mental illness of schizophrenia. He had unclear speech, sometimes could make himself understood, and sometimes understands others. Resident #7 required extensive assistance with personal hygiene, dressing, and bed mobility. He required physical help with bathing and one-person physical assistance. He used a wheelchair for mobility. The resident had an indwelling catheter for obstruction but was always incontinent of bowel. He had a stage 4 pressure ulcer to his sacrum, was on tube feeding, and on hospice.<BR/>Observations of Resident # 7 on 7/15/23 revealed: 10:22am: on his back, asleep in bed, 1:30pm: on his back in bed, no one had gone in the room to check on him. <BR/>Observations of Resident #7 on 7/16/23 revealed: 9am: on his back, asleep, 1:57pm: on his back, asleep in bed, no one had gone in the room to check on him. <BR/>Observation of Resident #7 on 7/17/23 revealed: 11am: on his back, asleep in bed.<BR/>Observations of Resident #7 on 7/18/23 revealed: 9:03am: on his back, asleep in bed, 12:40pm: on his back, asleep in bed, no one had gone in the room to check on him. <BR/>Record review of Resident #7's care plan, revised 7/3/23, revealed I have a stage 4 to my sacrum from admission-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Dental Care-Maintain oral hygiene/status: Oral Care BID. Bowel Incontinence-I will establish an individual bowel and bladder routine: Check for incontinence Q2hrs and PRN. ADL Function/Rehab Potential-I will achieve maximum functional mobility: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Toileting amount of assist: Extensive. Activities-I will attend/participate in 1 activity per week. The resident will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Mon, Wed, Fri: 6am-6pm. Nail Care Once a Day on Mon, Wed, Fri: 6am-6pm. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>Resident #20<BR/>Record review of Resident #20's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE] with diagnoses of demyelinating disease of central nervous system (multiple sclerosis which is an autoimmune attack on the coating of nerves and causes inflammation and damage to brain and/or spinal cord), muscle wasting and atrophy (decrease and thinning of muscle), dysphagia (trouble swallowing), contracture of muscle (muscles, tendons, joints, or other tissues tighten/shorten causing a deformity), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry about everyday issues and situations), pain, and repeated falls.<BR/>Record review of Resident # 20's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, which indicated normal cognition. The MDS also revealed she had a serious mental illness. Resident #20 indicated it was very important for her to choose what clothes to wear, to choose between a tub bath, shower, bed bath or sponge bath, and to do her favorite activities. She required extensive assistance with personal hygiene, dressing, transfer, and bed mobility, and total dependence with toilet use. She also required 1-2 people to assist her with the activities. She needed physical help with bathing and 1 person to physically help her. Resident #20 used a wheelchair for mobility. She was always incontinent of urine and bowel.<BR/>Observation and interview with Resident #20 on 7/15/23 revealed: 1:26pm: said they did not get her up for lunch. Food was observed on her chest and on her mouth. She said there was barely any staff, so she did not ask to get into her electric chair because she was afraid, she would not be able to get back into bed and would be in pain. Mon/Fri were supposed to be shower days, and Wed were lotion days, but that had not been happening. She had not been turned all day and she was unable to turn herself. So far, she had not had any skin breakdown. There was only 2 people in the whole building last night and she did not get changed the whole night until 6am this morning. She had not brushed her teeth all day.<BR/>Interview on 7/15/23 at 1:40pm with TNA CW revealed he comes in 6a to 6p and usually changes/brushes the resident's teeth between 6a-6:30am. He said he turns residents every 2hrs because he was a patient himself before. He said Resident #20 is definitely a resident that needs to be turned every 2hrs. When asked about Resident #20 not having her teeth brushed or being turned, he said he didn't know what happened. He said if she's not turned, a bedsore could happen because she can't turn herself. When asked about setting her up for lunch, he said he didn't pass her tray and that he was in the dining room. Whoever passed the tray should have set her up. He also said that he always takes a female with him when he goes in her room. Surveyor said she had food all over her chest, needed her teeth brushed, and needed to be turned. He said he would go in and take care of it. He said they usually have 4 aides during the day, and he didn't feel like they were short staffed today.<BR/>Observation and interviews with Resident # 20 on 7/16/23 revealed: 10am: said she was last changed last night and has not been changed this morning yet. Flat on her back in bed, 2:02pm: said she had not been in her chair in 2-3 weeks. She asked TNA CW to sit her up in bed for lunch and he didn't. She was flat on her back in bed, 2:05pm: TNA CW said he did not remember telling Resident #20 that he would sit her up in bed and he did not go into her room unless he had a female with him, 2:10pm: CMA M said Resident #20 was turned when she was changed. Resident said she was not.<BR/>Observations of Resident #20 on 7/17/23 revealed; 9am: flat on her back and not in her wheelchair. She stated she was afraid to ask to get in the wheelchair, 2:05pm: flat on her back and not in her wheelchair. She stated it was too late to ask to get into her wheelchair now.<BR/>Observation of resident #20 on 7/18/23 revealed: 9:08am: resident told CMA I and TNA C that she wanted to get up in her electric chair by 11am. She did not get her suppository yesterday at 3pm even though she asked for it. She told TNA C today, that she wanted it. She still had not had breakfast and was still waiting on it, 1:15am: not in her wheelchair yet. Staff was standing in the hall talking and laughing.<BR/>Interview on 7/18/23 at11:20am with DON and Clinical Resource Nurse about Resident #20 not being in her wheelchair by 11am: revealed DON did not know why someone had not helped her yet. Also informed them about Resident #20 not being in her wheelchair in the past 2-3 weeks and they said the resident overexaggerates and there was no way it had been 2-3 weeks since she had been in her wheelchair.<BR/>Observation on 7/18/23 at 12:36pm revealed: Resident #20 was put into her electric wheelchair. She had not had lunch yet.<BR/>Record review of Resident #20's care plan, revised 6/6/23, revealed I have thin and fragile skin-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Oral/Dental Status. I use a rechargeable toothbrush-Maintain oral hygiene/status: Oral Care BID. B/B Incontinence-I will establish an individual bowel and bladder routine: Briefs when out of bed. Toileting. Resident #20 has been identified as having DD PASRR positive status related to Demyelinating disease of central nervous system. I am currently receiving habilitation coordination and habilitative therapy (3/10/23-9/5/23)-Resident #20 will maintain highest level of practicable well-being for the next 90 days: I am recommended to receive PASRR habilitative services through PT and OT. Patient will exhibit improved fine motor coordination skills to facilitate patient's ability to grasp items during self-feeding with stand by assistance in order to improve functional use of upper extremity's during ADL's and perform ADL's w/ increased safety. Patient will increase activity tolerance for functional activities of choice in wheelchair 2 x week for 2 hours in order to help with implementation of compensatory strategies and with improved ROM and coordination and increase participation within environment. Patient will complete hygiene and grooming tasks while sitting in front of mirror with caregiver assistance with implementation of compensatory strategies in order to perform ADLs with increased safety. Patient will increase trunk strength to 2+ out of 5 in order to facilitate improved trunk balance, facilitate upright posture and increase core strength for functional activities. Patient will increase static sitting balance to poor using protective extension 70 percent of the time to right self in order to participate in edge of bed activities and decrease loss of balance during functional mobility. Patient will tolerate sitting up x 2hr for skin integrity: Therapy to treat once a day, 3 x week x 6 months. I prefer to have showers on Mon/Wed. On Wednesdays I prefer to have lotion applied with no shower: Showers including hair wash on Monday and Friday only Once a Day on Mon, Fri: 6pm-6am. Nail Care Once a Day on Mon, Wed, Fri: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>Interview with Administrator and DON on 7/16/23 at 11a.m. regarding where showers would be documented. They said it would be documented in the computer.<BR/>Record review on 7/16/23 at 12pm revealed the shower documentation on the computer was incorrect. It showed everyone had a shower, every day. The residents said they were not showered in days up to a week and looked dirty and greasy.<BR/>Record review 7/17/23 at 10am revealed shower sheets in a binder at the South nurse's station were all blank.<BR/>Interview with DON on 7/18/23 at 3pm about why she thought ADLs were not being done. She said she was not sure why the ADL's were not done, and did not have a reason why.<BR/>Resident #28<BR/>Record review of Resident # 28's face sheet revealed a [AGE] year-old female with admission date of 3/3/23 and diagnoses including atrial fibrillation, Diabetes, major depressive disorder, single episode, hypertension, osteoarthritis, systemic lupus (disease when immune system attacks its own tissues), chronic obstructive pulmonary disease (lung disease that blocks airflow), rheumatoid arthritis (inflammatory disorder that attacks joints). <BR/>Record review of Resident #28's care plan for ADL Functional Status/Rehab Potential dated 3/3/23 revealed extensive assistance by 1 staff required for bathing, hygiene, dressing, grooming, and toileting. <BR/>Record review of Resident # 28's admission MDS dated [DATE] revealed modified independence in cognitive skills, able to make herself understood and understands, always incontinent of bowel and bladder, and extensive assistance of 1-2 staff required for transfer, dressing, toileting, personal hygiene, and bathing. <BR/>Observation of Resident #28 on 7/15/23 at 10:00 AM revealed she was in bed. Interview at that time revealed she was waiting for someone to get her cleaned up and dressed. When asked if someone came to check on her or change her last night, she said no one came. She said she thought her call light was not working because no one came after she pushed it. She said it happens often that no one comes to check on her overnight. <BR/>Record review of Point of Care History, staff support for toileting dated 7/15/23 revealed documentation of Resident #28 receiving assistance with toileting at 2:19 AM and 10:37 PM. <BR/>Resident # 44 <BR/> <BR/> <BR/>Record review of Resident #44's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia, behavior disturbance, upper respiratory infection, muscle wasting, lack of coordination, essential hypertension, Kidney complication and human immune deficiency, and diabetes.<BR/>Record review of Resident #44's admission MDS assessment dated [DATE] revealed his BIMS score 9 out of 15 reflected he was moderately impaired on cognition. <BR/>Record review of his annual MDS assessment section on ADLs assessment indicated physical help in part bathing activities was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident #44's care plan dated his 11/14/22 and edited 05/04/23 revealed -<BR/>-ADLs Functional Status/Rehabilitation I am limited in ability to toilet self R/T cognitive<BR/>deficits. <BR/>-I require supervision to ensure I turn and reposition while in bed.<BR/>- ADLs Functional Status/Rehabilitation Potential, I am limited in ability to bathe self R/T cognitive deficits r/t dementia .<BR/>Goals: <BR/>I will dress/undress self independently with supervision; I will bathe with assistance <BR/>Allow sufficient time to complete bathing.<BR/>Observation and interview on 07/15/23 at 11:00AM, revealed Resident #44 was in bed with dirty personal clothes on. He shirt had food stained on it. He had unkept facial hair and dirty long fingernails. <BR/>Observation on 07/16/23 at 8:30AM, revealed resident #44 was in the dining room he had just finished his breakfast with the same dirty shirt on. During an interview, he said he had stroke and need assistance in caring for himself. He said he does not remember the last time he had a bath\shower. He said he would like to be shaved and cleaned up. He said nothing when asked if he had asked for any assistant.<BR/>During an interview with TNA S acknowledged that Resident #4 needed to be cleaned. She said the facility need need more staff. <BR/>During an interview with LVN F asked Resident #44 if he would like to have a bath, be shaved and have his fingernails trimmed. He said yes. She said she would make sure that he was cleaned.<BR/>Resident #55<BR/>Record review of Resident #55's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of myocardial infarction (heart attack), muscle wasting and atrophy (decrease in size and thinning of muscle), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness and paralysis after a stroke), protein-calorie malnutrition (lack of protein and calories in the diet), major depressive disorder (persistent feeling of sadness and loss of interest), heart failure (heart is not pumping as strong as it should), and dysarthria and anarthria (trouble speaking).<BR/>Record review of Resident #55's Comprehensive MDS dated [DATE], revealed a BIMS score of 9, which indicated moderately impaired cognition. Resident #55's MDS also revealed he had a serious mental illness. The resident had unclear speech and impaired vision. He felt it was very important to chose what clothes to wear, to choose between a tub bath, shower, bed bath, or sponge bath, and to go outside to get fresh air when the weather was good. Resident #55 required extensive assistance with personal hygiene, dressing, transfer, and bed mobility. He required physical help with bathing and two+ persons physical assist. He used a wheelchair for mobility. The resident was always incontinent of urine and bowel.<BR/>Observations of resident #55 on 7/15/23 revealed: 9:22am: greasy looking hair, long facial hair, long nails, and had a patient gown on. He said there was never enough staff, and they never had enough supplies. He had to wait long periods of time to be changed.<BR/>Observations of resident #55 on 7/16/23 revealed: 9:49am: said he had not had a shower in over a week. He was last changed at 5am. He had not had his teeth brushed today or yesterday. He was still in a patient gown, would like his nails trimmed, and would like to be shaved. He also needed to be changed.<BR/>Observation on 7/16/23 10:15am revealed: Restorative CNA went into the room to shave the resident. Surveyor asked why she was just now shaving him, and she said she just became Restorative on Saturday and before that she worked in HR. She said the CNAs should have been shaving and brushing his teeth for him.<BR/>Observation on 7/18/23 at 3:00pm: Resident was not out of bed for the 4 days of the survey.<BR/>Record review of Resident #55's care plan, revised 5/24/23, revealed I am at risk for pressure ulcers r/t left sided hemiplegia-My skin will remain intact: Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry, and wrinkle free. I have urinary incontinence; I have limited mobility due to left sided CVA-I will not develop skin breakdown related to incontinence: Check for incontinent episodes at least every 2 hours. I am limited in ability to transfer self r/t left side hemiplegia- I will transfer self with extensive assistance. I am limited in ability to toilet self r/t left sided hemiplegia-I will toilet with extensive assistance of one staff: Provide incontinence care as needed. I am limited in ability to dress/undress self r/t left sided hemiplegia-I will dress/undress self with extensive assistance: Allow me to choose own clothing, dress affected side first. I am limited in ability to maintain grooming/personal hygiene r/t CVA-I will groom self with limited assistance. I am limited in wheelchair mobility r/t left sided hemiplegia-I will achieve highest level of wheelchair mobility as evidenced by increased mobility. Resident #55 will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Tue, Thu, Sat: 6pm-6am. Nail Care Once a Day on Tue, Thu, Sat: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am. Resident experiences bladder incontinence-Resident will maintain current level of bladder continence: Provide incontinence care after each incontinence episode.<BR/>Resident #60<BR/>Record review of Resident #60's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of end stage renal disease (kidneys stopped working), Type 1 diabetes with diabetic neuropathy (autoimmune disorder where pancreas stops making insulin with pain caused by nerve damage) , other disorders of electrolyte and fluid balance (when a large amount of body fluid is lost), chronic pain syndrome (symptoms beyond pain alone like depression and anxiety that interfere with life), major depressive disorder (persistent feeling of sadness and loss of interest), Type 2 diabetes with diabetic retinopathy (body doesn't produce insulin and a complication of diabetes causing blindness), muscle wasting and atrophy (decrease in size and thinning of muscle), and neuromuscular dysfunction of the bladder (nerves and muscles do not work in the bladder).<BR/>Record review of Resident #60's Comprehensive MDS dated [DATE], revealed a BIMS score of 13, which indicated normal cognition. The MDS also revealed the resident had impaired vision. According to the resident's preferences, it was very important for him to choose what clothes he wore, and it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The resident required extensive assistance with personal hygiene, dressing, transfer, and mobility. He required physical help with bathing and needed one-person physical assist. He used a wheelchair for mobility. Resident #60 had an indwelling catheter for a neurogenic bladder but was always incontinent of bowel.<BR/>Observation of Resident #60 on 7/15/23 9:29am: had long nails and was wearing a patient gown. He stated he had to use a Hoyer lift to get out of bed and into his wheelchair, but he was scared when he got into his wheelchair because there was never anyone around to get him back into bed. He had to get into his wheelchair on M/W/F for dialysis and it took a long time for them to get him up and then for them to get him back in bed. His sheets had a yellow, urine stain on them. Resident had been vomiting and had an emesis bucket under his chin. He was laying supine in bed.<BR/>Observation of Resident #60 on 7/16/23 9:45am revealed: said staff told him yesterday that only CNAs could change him and not TNAs, so he had to wait a really long time to be changed. He still had not had his teeth brushed yet today. He had not had his sheets changed since Wednesday. He still had a yellow, urine stain on his sheets. He still had not had a bath since Monday and still had long nails. He also was still laying supine in bed, 2:15pm: said he had not been changed since 9am. He told TNA C and he just picked up his lunch tray and left. <BR/>Interview with ADON on 7/16/23 at 2:19pm: she did not know why someone did not go change him and why he had been waiting since 9am. She said she would go change him.<BR/>Observations of Resident # 60 on 7/17/23 revealed: 9:39am: stated he waited over 8hrs to be changed yesterday afternoon due to having so many TNAs and only 1 or 2 CNAs. He was last checked at 4-5am today. He still had not been bathed or had his teeth brushed, nails trimmed, or been shaved, 9:45 am-10:15am: ringing his bell (call bell was not working) to be changed and the Restorative Nurse finally went into the room. Surveyor went in and saw the Restorative Nurse was shaving the roommate. She did not change Resident #60. Resident #60 said he told TNA C that he needed to be changed, but he never went back, 10;15 am: Surveyor asked TNA C about changing Resident #60. He said that he did tell him he was going to go back and change him, but he got caught up doing other things and had been busy and had not had a chance to go back yet. He also said that was not his side of the hall, that it was CNA A's, but they call him to go over there because he had all the muscle. He said the facility needs more staff.<BR/>Observation on 7/18/23 at 3:00pm revealed Resident #60 was never out of bed except to go to dialysis.<BR/>Record review of Resident #60's care plan, revised 7/16/23, revealed the resident will perform the following tasks at their highest practicable level: Nail Care Once a Day on Mon, Wed, Fri 6pm-6am, Oral Care Twice a Day 6am-6pm and 6pm-6am. I am at risk for pressure ulcers r/t decreased physical abilities-Resident's skin will remain intact: Keep linens clean, dry, and wrinkle free. I am limited in ability to transfer self r/t physical deficits-I will transfer self with extensive assistance: Remind me to not transfer without assistance. I am limited in ability to toilet self r/t physical deficits-I will toilet self with use of extensive assist x 1 staff: Provide extensive assistance for toileting. I am limited in ability to eat and drink r/t vision and cognitive deficits-I will be hydrated and well-nourished as evidenced by stable weight. I am limited in ability to dress/undress self r/t physical and cognitive deficits-I will dress/undress self with extensive assistance. I am unable to independently change position while in bed as evidenced by requiring assistance with bed mobility-I will reposition self with bed rails and the assistance of one: Provide hands assistance for repositioning/transferring in and out of bed. Turn and reposition every 2 hours. I am limited in ability to maintain grooming/personal hygiene r/t cognitive and physical deficits-I will groom self with extensive assistance. I am limited in wheelchair mobility r/t physical deficits-Resident will achieve highest level of wheelchair mobility: Provide assistance for wheelchair mobility.<BR/>Resident #181<BR/>Record review of Resident # 181's face sheet revealed a [AGE] year-old male with admission date 2/14/23 and diagnoses including cerebral infarction (disruption of blood flow to the brain due to blood vessel problems), cognitive communication deficit, cellulitis (bacterial skin infection), pain in right shoulder, contracture (shortening and hardening of muscles), restlessness and agitation.<BR/>Record review of Resident #181's Urinary Incontinence care plan dated 2/20/23 revealed bowel and bladder incontinence. Approaches included: check for incontinence every 2 hours and PRN, and toileting every 2 hours and PRN. <BR/>Record review of Resident #181's ADL Functional Status care plan dated 2/20/23 revealed assistance with activities of daily living was needed, and approaches were for maximum amount of assistance for toileting, bathing, hygiene, dressing, and grooming.<BR/>Record review of Resident #181's admission MDS dated [DATE] revealed severely impaired cognitive skills and never or rarely made decisions, rarely or never understood by others and rarely or never understands others, always incontinent of bowel and bladder, and extensive 2-person staff assistance required for transfer, dressing, toileting, personal hygiene, and total assistance required for eating and bathing. <BR/>Observation of Resident #181 on 7/15/23 at 10:00 a.m. revealed he was in bed, and family member was in the room changing his brief. Family member had placed the soiled brief and under pad on the floor, which were saturated with urine and had a visible dark circle on the outer edges of the brief and under pad. Interview with Resident #181's family member at that time revealed she comes in the morning and always changes his brief because it is soaked with urine, and when she asks him if anyone came to change him the night before, he says no. Interview with Resident #181 on 7/15/23 at 10:30 a.m. revealed, when asked if anyone came to change him last night, he shook his head and said no. <BR/>Record review of Point of Care History, staff support provided for toileting dated 7/15/23 revealed documentation Resident #181 received staff assistance with toileting at 2:40 AM and 7:40 PM. There was no documentation of staff assistance with toileting on 7/16/23. <BR/>In an interview with an advocate for a resident in the facility on 7/15/23 at 1:10 p.m., she said they need more help here, they are short staffed, and residents wait up to an hour to be changed after they push the call light. <BR/>In a confidential interview with Resident #181's family member on 7/16/23 at 11:34 a.m. revealed Resident #181 has been here since January 2023, and she comes every day. She said there are problems with him being changed, especially overnight. She said she changes him when she gets here, and his brief is always soaked. Two pillows were soaked with urine today. She asked him if anyone came to change him overnight, and he said no. <BR/>Interview with the interim DON on 7/15/23 at 1:50 p.m. revealed she has been here 8 days as interim DON and has seen the staff really trying to care for all residents timely, but it's a problem because there are not enough staff working at a given time. She said if someone calls in, there is not always someone who can work in their place, but management staff can help if needed. <BR/>Record review of facility policy Activities of Daily Living (ADL's) Supporting, revised March 2018, revealed, in part: . appropriate care and services will be provided for residents who are unable to carry out ADL's independently .including appropriate support and assistance with hygiene (bathing, dressing, grooming, oral care) and elimination (toileting) . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to obtain laboratory services when ordered by a physician in accordance with the State law, including scope of practice laws for 1 of 12 residents (CR #1) reviewed for laboratory services. <BR/>1. <BR/>LVN A failed to document physician's orders and obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by CR #1's infectious disease physician when she was discharged from an acute care hospital on [DATE] and resulted in re-hospitalization on 04/16/2024 with elevated WBC values, which indicated infection. <BR/>2. <BR/>LVN A failed to document physician's orders and obtain weekly laboratory services (BMP and CBC) as ordered by CR #1's NP when she reconciled (the process of comparing a patient's medication orders) medication orders on 03/29/2024 and resulted in re-hospitalization on 04/16/2024. She was diagnosed with polymicrobial (multiple bacteria) skin and soft tissue infections and multifocal (having more than one location) osteomyelitis of the pelvis. <BR/>On 04/25/2024 at 3:20 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/27/2024, the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan or Removal. <BR/>These findings placed residents at risk of experiencing pain, worsening of symptoms/condition, and possible death from not having vital laboratory tests completed to monitor/diagnose infection, disease, and other health conditions. <BR/>Findings included:<BR/>Record review of CR #1's face sheet dated 04/24/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with metabolic encephalopathy (a series of neurological disorders caused by systemic illness), quadriplegia (paralysis that affects all of a person's limbs and body from the neck down), local infection of the skin and subcutaneous (under the skin) tissue, acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), acute respiratory failure (sudden inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient), sepsis (life-threatening complication of an infection; when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body) due to staphylococcus, osteomyelitis (inflammation of bone or bone marrow, usually due to infection) - multiple sites, chronic pain (persistent pain that lasts weeks to years), hypotension (low blood pressure), anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), stage 4 pressure ulcer (full thickness skin loss extends through the fascia with considerable tissue loss), and muscle wasting and atrophy (a decrease in size of muscle tissue). She was discharged from the facility to an acute care hospital on [DATE] at 3:12 a.m. <BR/>Record review of CR #1's quarterly MDS, dated [DATE] revealed she had a BIMS score of 15 (cognitively intact). CR #1 did not experience hallucinations or delusions. CR #1 did not exhibit behaviors which indicated rejection of care (bloodwork, taking medications, or ADL assistance). CR #1 had functional limitations in range of motion in both upper extremities and both lower extremities. CR #1 used a motorized wheelchair for ambulation. CR #1 required substantial/maximal assistance from staff for oral hygiene, toileting, showers, upper body dressing, personal hygiene, sitting, transfers, and rolling left and right. CR #1 received pain medications. CR #1 had six unhealed stage 4 pressure ulcers upon admission and was prescribed antibiotic medications.<BR/>Record review of CR #1's care plan, revised on 04/22/2024 revealed the following care areas:<BR/>* <BR/>CR #1 refused wound treatments and labs at times. Goals included: Resident will allow wound treatments and labs to be complete as scheduled. Approach included: Staff will encourage wound treatments and labs as scheduled.<BR/>* <BR/>CR #1 was at risk for pressure sore infections. CR #1 was admitted with infected pressure injuries. CR #1 had osteomyelitis with recurring infections. Goals included: CR #1's pressure ulcer will not exhibit purulent discharge, foul odor, or peri ulcer inflammation (inflammation around the ulcer). Approach included: Enhanced barrier precautions, central line care per facility policy and MD orders, and administer antibiotics as ordered. Evaluate/record/report effectiveness/adverse side effects, observe and report signs of purulent discharge, foul odor, or peri ulcer inflammation. Report signs of cellulitis (bacterial skin infection), sepsis, tachycardia (increased heart rate), and osteomyelitis. On low air-loss alternating mattress for the treatment of pressure injuries.<BR/>Record review of CR #1's progress notes for March 2024 and April 2024 revealed the following:<BR/>On 03/22/2024 at 6:53 p.m., LVN D wrote, Resident stated she wants to go to the hospital because she feels her wounds are infected. Writer noted yellow discharge to wound during wound care. Resident refused protein supplement because she said it is nasty. New order per NP to send resident to ED for evaluation .<BR/>On 03/23/2024 at 7:41 a.m. (recorded as late entry from 03/22/2024), LVN C wrote, Received order from medical provider to transfer resident to hospital ER. Transfer order obtained from physician . Primary reason for transfer: Foul odor from wounds . Resident left the facility at 8:45 p.m. <BR/>On 03/30/2024 at 1:59 p.m. (recorded as late entry from 03/29/2024), Treatment LVN B wrote, Resident arrived at facility on 03/29/2024 at 5:00 p.m. Primary admitting diagnosis: Osteomyelitis . admission orders entered into system and medication orders sent to pharmacy: 5:20 p.m. Referrals made for the following: No referrals at time of admission . Additional Notes: Resident returned to facility with new orders for IV ABT's and with IJ tunnel catheter with CVC double lumen to right chest, dressing is clean, dry, and intact, with no signs and symptoms of infection observed at this time . <BR/>On 04/04/2024 at 5:15 p.m., Treatment LVN B wrote, . Transmission based precautions in place: Type: Skin/Soft Tissue Infection: osteomyelitis/wound. Resident is receiving antibiotic: Daptomycin reconstituted (recomposed) solution (500 mg) and Ceftriaxone, IV administration. Resident has received treatment for 4 days . Resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . <BR/>On 04/05/2024 at 2:26 p.m., Agency LVN E wrote, IV ABT therapy in progress due to osteomyelitis. Resident afebrile (no fever) with no adverse reactions noted . Resident has received treatment for 5 days . Resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound .<BR/>On 04/09/2024 at 12:57 a.m., LVN F wrote, Resident is being monitored for an active infection . Resident has received treatment for 8 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . <BR/>On 04/09/2024 at 9:48 p.m., LVN F wrote, Resident is being monitored for an active infection . Resident has received treatment for 9 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . <BR/>On 04/11/2024 at 4:32 p.m., LVN G wrote, Resident is being monitored for an active infection . Resident has received treatment for 10 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . <BR/>On 04/13/2024 at 5:16 p.m., Treatment LVN B wrote, Resident is being monitored for an active infection . Resident has received treatment for 14 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . <BR/>On 04/15/2024 at 1:12 a.m., LVN F wrote, Resident is being monitored for an active infection . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . <BR/>On 04/15/2024 at 5:13 p.m., LVN G wrote, Resident noted sweating and complained of not feeling well. Resident's vitals are 100.4 temperature, pulse 84, blood pressure 145/86, O2 saturation 98% on room air, respirations 18. Placed call to NP. She instructed this writer to give 500 ml of normal saline per IV. Fluids were given as ordered.<BR/>On 04/16/2024 at 3:37 p.m., Treatment LVN B wrote, Weekly Skin Assessment: 04/16/2024 at 12:30 p.m. Transmission Based Precautions in place: osteomyelitis/wounds . Resident has received treatment for more than 14 days . The resident has experienced the following signs/symptoms of infection during this shift: Fever . 500 ml of normal saline per IV. Laboratory/Diagnostic: wound culture was done. Spoke to medical provider at: 04/15/2024 at 1:30 p.m.<BR/>Record review of CR #1's laboratory orders, dated 04/16/2024 revealed, CR #1; Start Date: 04/16/2024; Order Choices: CBC with Auto Differential, Basic Metabolic Panel; Recurrence Schedule: Starting on Tuesday, 04/16/2024, repeat every 1 week, on Tuesday, until 05/21/2024 .<BR/>Record review of CR #1's wound culture laboratory results dated [DATE] revealed, Collected: 04/15/2024 at 10:35 a.m. Received: 04/16/2024 at 3:44 p.m. Reported: 04/19/2024 at 11:55 a.m. Pathogens Detected: Acinetobacter Baumannii complex (Heavy Growth); Escherichia coli (Heavy Growth) .<BR/>Record review of CR #1's laboratory results (collected at the facility) dated 04/16/2024 revealed, Collection date/Time: 04/16/2024 at 10:55 a.m. Received Date/Time: 04/16/2024 at 2:44 p.m. Reported Date/Time: 04/16/2024 at 3:57 p.m. CBC with differential - WBC: 10.6 (high; range: 4.0 - 10.0) . <BR/>Record review of CR #1's Observation Details, created by LVN C, dated 04/17/2024 revealed CR #1 was transferred to an acute care hospital on [DATE] at 7:44 p.m. The document read in part, This resident was transferred to an acute care hospital. She was having severe pain, low O2 saturation, and severe shivers. She requested to go to the hospital . No vitals have been recorded for this observation . There are no associated progress notes. <BR/>Record review of CR #1's hospital Nursing Note, dated 03/29/2024 revealed, Date of Service: 03/29/2024 at 4:04 p.m. Gave report to LVN A at the facility about the patient current vitals and discharge information . <BR/>Record review of CR #1's hospital After Visit Summary dated 03/29/2024 (provided by facility) revealed CR #1 was admitted to the acute care hospital on [DATE] and discharged on 03/29/2024. The electronic orders listed each medication CR #1 was discharged from the hospital with. Some of the listed medications had hand-written notes beside them, indicating they were new medications from the hospital which CR #1 did not take at the facility before she was discharged to the hospital. The document read in part, Sodium Chloride 100 ml with Daptomycin 500 mg Solution 500 mg . Last dose taken: 03/29/2024 at 2:25 p.m. New. CBC/BMP Once (per) week was hand-written in the box next to the listed medication. <BR/>Record review of CR #1's hospital discharge records sent to the facility from the hospital (provided by facility) dated 03/29/2024 revealed, . [AGE] year-old female with past medical history significant for gunshot wound complicated by quadriplegia complicated by sacral and lateral left buttock decubitus ulcers now complicated by polymicrobial (multiple bacteria) skin and soft tissue infections and multifocal (having more than one location) osteomyelitis of the pelvis . Will treat for 6 weeks with empiric Ceftriaxone and Daptomycin to minimize dosing complications and monitoring. Patient has historic venous access difficulty due to anatomic reasons and requires tunneled CVC catheter for IV antibiotic administration outpatient. She will need a SNF committed to turning her, aggressive wound care, and appropriate administration of IV antibiotics and lab monitoring as ordered . Overall plan will be . 2. 6 weeks IV abx and smoking cessation with monitoring of labs, ESR, CRP . quadriplegia secondary to gunshot wound, complicated by sepsis secondary to acute on chronic, multifocal polymicrobial osteomyelitis of the pelvis . [NAME] Instructions: . Obtain weekly CMP, CBC with differential and Creatine Kinase. Fax lab results to hospital: Attention Infectious Disease Doctor . Recommendations Summary: . When preparing for discharge, [NAME] instructions below: . Obtain weekly CMP, CBC with differential and Creatine Kinase. Fax lab results to hospital: Attention Infectious Disease Doctor . Labs: CBC with differential - Collection time: 03/28/2024 at 6:17 a.m. Result: WBC - 8.90 (normal range) . CBC with differential - Collection time: 03/29/2024 at 5:12 a.m. Result WBC - 7.95 (normal range) . admission Date: 03/22/2024. discharge date : [DATE] .<BR/>Record review of CR #1's hospital records dated 04/24/2024 revealed, Date of Service: 04/16/2024 at 8:34 p.m. Emergency Department Note: . History of Present Illness: Resident is a [AGE] year-old female presents today with a chief complaint of weakness and wound (multiple sacral). Patient endorses that she has a fever taken yesterday temporarily of 100 degrees Fahrenheit. Has had nausea without emesis (vomiting) yesterday as well. Today has been having shaking chills . Physical Exam: Blood Pressure - 137/97 . Temperature - 99 degrees Fahrenheit . Skin: Skin is pale . Lab Results: CBC with differential - Abnormal. WBC - 12.32 (high) . Diagnosis/Impression: Chills, pain associated with wound, sepsis due to unspecified organism . Laboratory Results - . Erythrocyte sedimentation rate (monitored for the detection of inflammation in the body): 03/24/2024 - 127 (elevated); 04/16/2024 - 127 (elevated) .<BR/>Record review of CR #1's physician's orders for March 2024 and April 2024 revealed the following order: <BR/>* <BR/>RN may access Central Line and perform blood draw as needed. Start Date: 03/29/2024. End Date: Open Ended.<BR/>Further review of CR #1's physician's orders for March 2024 and April 2024 revealed no documentation of any routine laboratory orders. <BR/>In an interview with Treatment LVN B on 04/24/2024 at 10:45 a.m., she stated CR #1 was not compliant with care and she liked to stay in her wheelchair all the time. She said if she was not able to get to CR #1's wounds right when she wanted them done, CR #1 would tell her to come back, or she said she would get them done on the night shift (the staff worked 12-hour shifts, 7:00 a.m. - 7:00 p.m. and 7:00 p.m. - 7:00 a.m.). She said sometimes, the night shift nurse did not get a chance to do CR #1's wound care because she stayed in her wheelchair until 2:00 a.m. She said CR #1 complained of pain in her joints, so sometimes, she did not want to be turned or bothered. She said she sometimes talked to CR #1 about staying in the same position all the time, but she said her joints felt better in that position. She said on 04/15/2024, CR #1 was in the bed and the wound doctor did a culture on her wounds himself because they were milky and opaque. She said the wound doctor cleaned the wounds out. She said CR #1's wounds did not have an odor, but CR #1 always complained they did have an odor. She said the wounds did not smell foul, but they smelled like it would if a female left a menstrual pad on too long, like old blood, but not an infected smell. She said CR #1 was already on two oral antibiotics at that time and the wound doctor said maybe those were not the right antibiotics for CR #1's wounds. She said CR #1 was on antibiotics for her wounds since she was admitted to the facility in September 2024. She said the wound culture results came back after CR #1 was already gone. She said the only weekly lab orders she knew about were the CBC and CMP the NP ordered for every Tuesday. She said she was the nurse who put the orders into the computer system for the weekly draws on 04/15/2024 (to be drawn on 04/16/2024). Treatment LVN B looked through CR #1's MAR and said she did not see the order for the weekly labs. She said she did not know why it was not there. She said on 04/15/2024, LVN G called CR #1's NP and said she was not feeling well. She said the NP asked LVN G to put in orders for a CBC and BMP. <BR/>Observation and interview with CR #1 at a local acute care hospital on [DATE] at 3:30 p.m. revealed she was alert and oriented. CR #1 was on contact isolation. CR #1's hands were contracted but she could move her arms enough to operate her cellular phone. She said her wounds had an odor at the facility, but they did not stink at the hospital. She said she knew she was supposed to get weekly labs done after she left the hospital in March (03/29/2024) but she never had any labs drawn until right before she left. <BR/>In a telephone interview with the hospital's infectious disease doctor on 04/24/2024 at 7:10 p.m., he stated whenever he sent a patient out (discharge from the hospital to a SNF) for IV antibiotic therapy, he always put all the details in the patient's orders. He stated all instructions for CR #1's weekly lab orders were in his notes. He said he went to the hospital's case manager and asked her what they needed to send to the facility to make sure they got the instructions. He said the case manager told him she was sending everything to the facility. He said a hospital nurse always called the facility before discharge, so CR #1's orders should have been communicated very well. He said the type of antibiotics he prescribed for CR #1 could have caused Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), so CR #1's Creatine Kinase levels needed to be monitored for this. He said failure to monitor CR #1's blood chemistry could have resulted in renal failure, Rhabdomyolysis, sludge in the gallbladder, and increased liver enzymes, which were adverse effects of the antibiotics. He said CR #1 was oriented and she told him the facility did not check any of her labs. He said CR #1's pressure ulcers developed infections that went into her bone. He said he was surprised to see her back at the hospital on [DATE] and her wounds were smelly with pus. He said CR #1's inflammatory markers (erythrocyte sedimentation rate), which tracked the bone infection were exactly the same when she returned to the hospital on [DATE] as when she discharged on 03/29/2024. He said he expected at least a small decrease based on the amount of time she was on the antibiotics. <BR/>In an interview with the DON on 04/25/2024 at 9:00 a.m., she said the facility did not usually get a resident's discharge summary from the hospital which documented everything that happened in the hospital. She said the hospital usually sent clinical updates and progress notes, which were very seldom completed by the actual doctor. She said she did not see any orders for labs on CR #1's discharge paperwork. She said the lab orders were not listed on the signed electronic orders. She said normally, the hospital called in report before the resident was discharged from the hospital. After review of the handwritten notes on the electronic hospital orders the facility received from the hospital, which read, New. CBC/BMP once (per) week, the DON said she assumed the handwritten notes were written by one of their (facility) nurses. She said she could not say the facility nurse who wrote the notes on the electronic orders was aware CR #1 was supposed to have weekly labs. She said she could not speak on what the nurse's handwriting meant or what she knew, but she would find out which nurse completed CR #1's admission on [DATE]. <BR/>In a telephone interview with CR #1's physician (who was also the facility's medical director) on 04/25/2024 at 10:49 a.m., he stated he was familiar with CR #1 because she had very bad wounds and to his understanding, she was non-compliant with treatments. He said facility staff usually reconciled medications for residents who discharged from the hospital, but he did not reconcile CR #1's medications. He said the NP reconciled CR #1's medications and he was aware of CR #1's order for weekly labs (the labs ordered by the NP), either through conversations with the NP or reading her notes. He said he thought the labs were supposed to be done because he was concerned about the infection getting worse. He said part of it was to see if the infection got better or if it was the same or worse. He said it was usual protocol for them (him or his NP's) to request weekly labs on all residents on IV antibiotics. He said he was not aware the weekly labs were not being done. He said he assumed the labs were being done but never saw any results. He said some infectious disease doctors do not care to see the lab results, but they request the labs.<BR/>In a telephone interview with the NP on 04/25/2024 at 11:00 a.m., she stated a facility nurse (she could not recall which nurse) reconciled CR #1's medications with her on 03/29/2024. The NP said she ordered weekly labs (CBC and BMP) for CR #1 on 03/29/2024 based on the antibiotics she was prescribed at the hospital. She said the weekly labs she ordered would have showed her if CR #1's infection was getting better and her kidney function. The NP said she asked for CR #1's lab results each time she visited the facility (she visited weekly), but she thought the facility nurses said CR #1 refused the labs. The NP said she did not think it was unusual because refusals were not uncommon for CR #1. She said she did not recall the nurse telling her that the hospital doctor requested weekly labs. She said it was normal to order weekly labs for residents on IV antibiotics like the ones CR #1 was prescribed, to make sure the kidneys functioned properly and to track the infection. She said she requested weekly labs on 03/29/2024 and on 04/15/2024 or 04/16/2024. <BR/>In an interview with LVN A on 04/27/2024 at 11:45 a.m., she stated she normally worked the 7:00 a.m. - 7:00 p.m. shift. She said CR #1 was admitted to the hospital on [DATE] for infection symptoms. She said she was on shift when CR #1 returned to the facility on [DATE]. LVN A said she did not receive report from the hospital on [DATE]. She said CR #1 returned to the facility an hour before her shift ended. She said nobody from the hospital called her ahead of CR #1's return. She said CR #1 just showed up at the facility and she (LVN A) did not talk to anybody from the hospital at all that day. She said if the hospital had her name listed as the person, they gave report to, then it had been a while since that day, and she could not recall if she got report or not. She stated report sheets were handwritten and if she did not have a form, she wrote on a blank sheet of paper. She said the report sheet should go into the resident's admission packet and sent to medical records. She said eventually the report sheet would be scanned and put in the computer system for that resident. She said she did not recall if she did or did not do a report sheet for CR #1. She said she could have done a sheet for CR #1, but she did not recall. She said she recalled calling the NP to reconcile CR #1's medication. She said she got CR #1's discharge medications (from the hospital) from the packet the resident brought with her from the hospital. She said when she reconciled medications for readmitting residents from the hospital, she let the doctors know if anything was new, and they either approve the new medication or discontinue it. She said she also asked the doctors if they wanted to continue the medications the resident was on before they left the facility. She said she usually tried to read every page of the discharge packet sent from the hospital. She said she usually looked for the diagnosis to determine why the resident went to the hospital and if they started anything new at the hospital. She said usually, recurrent orders for labs were not on the electronic orders from the hospital. She said when she called the doctor to reconcile medications, they would usually add recurrent orders then. She said it was unusual for the hospital doctors to order recurring labs. She said she called the NP to reconcile CR #1's medication when she returned from the hospital on [DATE]. She said she informed the NP that CR #1 had two new IV antibiotics and the NP ordered a weekly CBC and BMP. She said she thought she wrote the requested labs on a piece of paper. She said after she got off the phone with the NP, she started reconciling the medications and entered the new medication orders into the computer system. She said she wrote the requested labs on the hospital discharge paperwork and on a little piece of paper. She said the little piece of paper probably got lost in the shuffle (possibly lost in a stack of paperwork). She said she forgot to enter the NP's requested orders for weekly labs. She said she was the admitting nurse, and it was her responsibility to enter the orders into the computer system. She said she guessed the requested labs were to determine if CR #1 still had infection, or something like that because the NP really did not say why she wanted the orders. She said it was important to get the labs done because the labs told you everything going on in the body and if something was off, it would tell you. She said it was easy to get distracted while admitting residents because she still had residents asking for PRN medications and other things. <BR/>In an interview with an RN at a local acute care hospital on [DATE] at 10:30 a.m., she stated she was the hospital nurse who called to give report to the facility when CR #1 was discharged on 03/29/2024. She said she wrote the nurse's name on the discharge paperwork (LVN A), and she specifically gave thorough instructions regarding CR #1's wounds. She said she could not recall if they talked about the labs the infectious disease doctor requested, but she knew about the labs because the infectious disease doctor always requested labs in CR #1's circumstances. <BR/>In an interview with the DON on 04/30/2024 at 11:45 a.m., she stated she was the facility's interim DON and had only been working at the facility for a few days. She said she did not know if the facility's previous DON or the ADON (the facility recently hired a new ADON who had not started working at the facility yet) completed quarterly audits of physician's orders as referenced in the facility's Laboratory Tracking System policy (see below). She stated she did not find any documentation, as of 04/30/2024 to verify the audits were being done. She said it was important to carry out all physician's orders for the safety and well being of the residents. She said the nurses were supposed to read each page of the hospital discharge record if it was available. <BR/>In an interview with the Administrator on 04/30/2024 at 1:19 p.m., he stated it was important to make sure physician's orders were carried out because following orders was how they cared for their residents. <BR/>Record review of the facility's undated policy titled, Laboratory, Radiology, and Diagnostic Testing Services revealed, Policy Statement: This facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. Policy Interpretation and Implementation: 1. The facility must provide or obtain laboratory, radiology, and other diagnostic services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. 3. The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. No diagnostic tests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist orders in accordance with State law to include scope of practice laws .<BR/>Record review of the facility's policy titled, Medication Orders revised November 2014 revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication order. Supervision by a Physician: . 2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order . 5. Intravenous Orders - When recording orders for IV solutions, specify the type of solution, rate of flow and volume to be infused. 6. Treatment Orders - When recording treatment orders, specify the treatment, frequency, and duration of the treatment .<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/25/2024 at 3:20 p.m. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/25/2024 at 3:20 p.m. <BR/>The following Plan of Removal submitted by the facility was accepted on 04/25/2024 at 8:56 p.m.:<BR/>PLAN OF REMOVAL:<BR/>Laboratory Services, F-773<BR/>Name of Facility <BR/>Date: 4/25/2024<BR/>The facility failed to obtain laboratory services as ordered by a physician in accordance with the State law, including scope of practice laws. <BR/>The facility failed to obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by a hospital infectious disease doctor for CR #1, who was diagnosed with sepsis secondary to acute on chronic multifocal polymicrobial osteomyelitis of the pelvis, when she was discharged from an acute care hospital on [DATE]. <BR/>The facility failed to obtain weekly laboratory services (CMP and CBA) as ordered by CR #1's NP when LVN A reconciled medication orders on 03/29/2024.<BR/>Immediate Action:<BR/>Action: CR#1 is currently in the hospital and is not returning to the facility<BR/>Person(s) Responsible: Charge Nurse<BR/>Date/Time: 4/16/2024 at 7:44 p.m.<BR/>Facilities Plan to Ensure Compliance Quickly:<BR/>Action: Lab audit performed facility wide to ensure no other labs were missed. If any other labs are identified the physician will be notified and the facility will follow orders. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee <BR/>Date/Time: 4/25/2024 by 10:00 p.m. <BR/>Action: Residents who have been admitted /readmitted in the past 30 days will have their admission/readmission orders reviewed to ensure lab orders, if present, were transcribed appropriately into the orders, we have the lab results, the MD has been notified, and new orders, if any, have been followed. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee <BR/>Date/Time: 4/25/2024 by 10:00 p.m. <BR/>Action: Laboratory, Radiology, and Diagnostic Testing Service Policy reviewed by Director of Clinical Operations and no changes are identified as needed at this time. <BR/>Person(s) Responsible: Director of Clinical Operations<BR/>Date/Time: 4/25/2024 by 10:00 p.m.<BR/>Action: Director of Nursing and Assistant Director of Nursing have been educated regarding reviewing admission/readmission paperwork, transcribing orders (such as labs), lab communication to the MD and/or their extender

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #5) out of 3 residents reviewed for wound care. In that,<BR/>The facility failed to ensure Resident #5's wound vac was applied on her wound as ordered by the physician.<BR/>This failure could expose residents to low quality of care, worsening of condition, hospitalization, and death.<BR/>Findings included:<BR/>Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), chronic pain, Essential (primary) hypertension (too high pressure in the blood vessel), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm.), cardiac arrhythmia (a disease process characterized by when electrical impulses in the heart don't work properly), congestive heart failure (occurs when the heart's capacity to pump blood cannot keep up with the body's need), constipation. <BR/>Record review of Resident #5's care plan dated 02/24/2024 revealed Resident #5 had surgical wounds with intervention to apply negative pressure at setting of (125) mm Hg continuous.<BR/>Record review of Resident #5's MDS (Minimum Data Set) dated 02/24/2024 revealed Resident #5 had surgical wounds. <BR/>Record review of Resident #5's order dated 02/01/2024 revealed order was given for wound treatment NPWT (KCI): Wound location (RUQ/ABD). Cleanse wound with wound cleanser, pat dry, apply foam to wound bed, cover with transparent dressing. Apply Negative Pressure at setting of (125) mm Hg (continuous). Change dressing/tubing/canister 2x weekly on M/F, once a day on Mon, Fri Resident #5 also had order for PRN (as needed) wound care dressing change for the wound to be cleansed with wound cleanser, and apply gauze soaked in Dakin's 0.25% solution to be applied on the wound and cover with dressing.<BR/>Record review of TAR (Treatment Administration Record) for the month of February 2024 revealed the wound vac was not applied on the following dates:<BR/>*02/11/2024 not administered: resident unavailable by Nurse D. <BR/>* 02/28/2024 not administered: drug/item unavailable comment: prn wet to dry dressing applied through applied. by the Wound Care Nurse.<BR/>Record review of Wound Care Doctor's note revealed the following wound measurement:<BR/>Site #1 surgical wound right abdomen full thickness<BR/>03/18/2024 = 19cm x 16cm x 2cm<BR/>03/11/2024 = 19.5cm x 16cm x 2cm<BR/>03/04/2024 = 28cm x 20cm x 3cm<BR/>02/29/2024 = 27cm x 20cm x 3cm<BR/>02/05/2024 = 27cm x 20cm x 3cm <BR/>Site #2 surgical wound left upper abdomen full thickness.<BR/>03/18/2024 = 2cm x 1.5cm x 1.5cm<BR/>03/11/2024 = 2cm x 2cm x 2cm<BR/>03/04/2024 = 5cm x 4cm x 2cm<BR/>02/29/2024 = 6cm x 4cm x 2cm<BR/>02/05/2024 = 6cm x 4cm x 2cm <BR/>Site #3 stage 3 pressure wound of the left buttock.<BR/>03/11/2024 = Resolved <BR/>03/04/2024 = 2cm x 2cm x 0.1cm<BR/>02/29/2024 = 2cm x 2cm x 0.1cm<BR/>02/05/2024 = 3cm x 3cm <BR/>On 02/23/2024 at 11:36am in an interview with Resident #5 stated they were not treating her wound very well, they were not helping her to apply the wound vac to her wound. She said every time she went to the hospital her wound would be very close to healing but when she comes back to the facility they did not do much for her wound. Resident #5 said she barely gets wound care in a day at the facility, she said if she was in hospital they could do her wound up to 3 three times sometime if needed, but at the facility, they did not do her wound regularly and they did not put the wound vac on her. She said they have Wound Care Nurse at the building who does her wound vac but if the wound care nurse was not in the building nobody does her wound vac. She said the wound care doctor only came one time and when he came he watched the wound care nurse do the wound vac. <BR/>On 02/23/2024 at 11:36am observation revealed the wound vac was not connected to Resident #5's wound. Resident #5 stated the floor nurse last night (02/22/2024) who took care of her could not fix the wound vac, she said the nurse told her that she did not know how to fix Resident #5's wound vac. She said the nurse came in to dress her wound when her wound was saturated but she was unable to put the wound vac back on her because she could not do it, the nurse (Nurse B) had to do wet to dry dressing. <BR/>On 02/23/2024 at 12:26pm in an interview with Nurse A, she stated said she never had the opportunity to do Resident #5's wound because the Resident #5 was on B-bed, and the B-beds were assigned to the night-shift nurses while the A-beds were assigned to the day-shift nurses. She stated the facility had a wound care nurse who was taking care of residents' wound, and if the wound care nurse was not in the building, the wound dressing change of patients were done by the nurses. Nurse A stated she was aware Resident #5 had wounds and a surgical wound where the wound vac was to be applied. Nurse A stated she did not know if the wound vac was to be applied weekly and she had to go look it up. She stated she had not done a wound vac before, even though as a nurse she had been trained to do wound vac, but she did not have any training at the facility to do wound vac. She stated the wound care nurse was not in the facility today. <BR/>On 03/04/2024 at 11:43am in an observation and interview with Resident #5, she stated she did not have any wound care yesterday Sunday 03/03/2024. She stated if the wound care nurse was not around, she would probably not get wound care. Surveyor observed the wound vac, and it was not connected to Resident #5's wound, the wound vac was on a table by the bedside. Resident stated she did not have the wound vac for many days when the wound care nurse was away. She stated the wound vac was placed by the Wound Care Nurse on the last weekend, the date on the canister revealed 2/29/2024. She said when the wound care nurse put the wound vac on her, it worked really well for about a day, but the wound vac canister was full and the wound vac stopped working and she believed that it was because the canister was full. She stated they disconnected the wound vac three days ago. She said all they needed to do was to empty it or change it and fix the wound vac back into her wound, but she did not know why they were not doing that.<BR/>On 03/04/2024 at 11:56am in a wound observation with the Wound Care Nurse, the surgical wound on the right abdomen was observed covered in clean dressing dated today (03/04/2024) the nurse removed the dressing and Surveyor observed the surgical wound at resident's right abdomen - it appeared red beefy about the size 28cm x 20cm the left buttock pressure wound appeared red beefy and round, about 4cm x 4cm in size. There was no concern with the process of the wound care and infection control. The wound care nurse stated she did not apply the wound vac today because Resident #5 was on her way to hospital for blood transfusion because resident's lab came back with low blood level.<BR/>On 03/04/2024 at 12:28pm in an interview with the Wound Care Nurse, she stated if she was not in the building, the nurses on the floor were responsible to do the wound, she was not aware that the nurses did not know how to operate the wound vac. The wound care nurse stated she was gone on vacation from Thursday 2/22/2024 till the Wednesday 2/28/2024. She did not know if they were doing the wound vac or placing the wet to dry on the resident. She said the wound vac keeps excess drainage from the wound because if the drainage was sitting in the wound dressing, it could grow bacteria and affect the wound the more, and could cause the wound to decline and the surrounding tissue could get damaged.<BR/>On 03/04/2024 at 12:51pm in an interview with Nurse A, she stated the floor nurses also did wound care for residents on weekends (Saturdays and Sundays) because the Wound Care Nurse' schedule was Monday to Friday and they did not have weekend wound care nurse. She stated if Resident #5's wound vac needed to be fixed or if anything happened she would not be able to apply the wound vac but she would do wet-to dry wound dressing. She stated she had not spoken with anyone in the past regarding her not able to apply wound vac, but she told the DON about the wound vac today 03/04/2024 and she (DON) said they would train the nurses and show them how to use it. She said generally, wound vac help to heal and control drainage so the wound can heal well. She stated they could do a wet-to-dry dressing if they were not able to do the wound vac. <BR/>On 03/04/2024 at 2:57pm in an interview with the Attending Physician, she stated she saw Resident #5 few weeks ago within the week of her admission, and she had been taking care of Resident #5 for about a month. She stated she saw Resident #5's wound and saw the Wound Care Nurse did the wound vac on that day. The Attending Physician stated the wounds were severe and large and Resident #5 was in pain when she saw her. She said she could not handle the wound alone, especially any wound with a wound vac. She said when it comes to wound vac, you need to know what you are doing she would have a wound specialist consulted to follow the resident, which was why the wound care Doctor followed Resident #5 to ensure proper management and monitoring of her wounds. She stated she was not aware that nurses were not able to apply wound vac on the resident. The Attending Physician stated wound care was not her specialist, but she knew the wound vac was an integral part of the resident's care and the Wound Care Doctor knew better why the wound vac had to be used. <BR/>On 3/5/2024 at 2:04pm in an interview with the Wound Care Doctor, he stated he had not been able to see the Resident #5 much, because the Resident #5 would go to dialysis Mondays Wednesdays and Fridays and sometimes she would be sent to hospital for non-wound related issue. The Wound Care Doctor said he came to the facility mostly on Mondays. He stated the wound vac was a very important as part of the care of Resident #5 because it was recommended by a specialist surgeon who did the surgery for her, and the wound vac would help residents wound to heal better. The Wound Care Doctor said compared to a wet to dry, the wound vac was recommended and more preferred by the specialist who recommended it, any he would not change that. He said there was order in place for wet to dry dressing change in case something happened to the wound vac. He said his expectation was that when orders were given, the order should be followed by the facility and the employees. He stated no one ever informed him that the floor nurses did not know how to apply wound vac for Resident #5. He said the order for wet-to-dry dressing change was given in case anything happened to the wound vac, there could be any accident, it could fall, it was a machine, and it could malfunction at any time, and that was why they gave the order for wet-to-dry dressing. The Wound Care Doctor stated but the main treatment for the wound was the wound vac according to the recommendation from the specialist surgeon.<BR/>On 03/05/2024 at 4:34pm in an interview with the ADON, she stated Resident #5 was always refusing her wound vac and she was told by the Wound Care Nurse that Resident #5 was refusing her wound vac, so the wound care nurse did wet to dry dressing. She stated she assisted in supervising and overseeing the duties of other nurses and to make sure their jobs and the documentation were done properly. She stated no nurse ever told her that they were not able to do wound vac. She said they did not have any training on wound vac or wound care, she said the nurses get the training in nursing school and they all should be able to apply wound vac. She stated the wound vac was to aide in the healing process of wounds and it was used to remove the drainage from the wound so it would not become infected.<BR/>On 03/05/2024 at 4:46pm in an interview with the Wound Care Nurse, she stated that Resident #5 did not refuse care or refuse wound vac for her. She stated she could not remember any day that the resident refused wound care or wound vac. She stated they would do wet to dry dressing for Resident #5's wound when going to dialysis on Mondays, Wednesdays, and Fridays. She was not sure if she selected the wrong reason for not doing the wound vac on 2/28/2024, that day was Wednesday and could be the resident was going for dialysis.<BR/>On 03/06/2024 at 9:37am in an interview with Nurse B, she stated she knew Resident #5 had abdominal wound, bottom wound, left abdominal wound and colostomy, she stated the facility Wound Care Nurse comes to the facility on Mondays to Fridays and the wound care nurse always did the wounds, while the floor nurses - dayshift nurses do A beds and the night shift do B beds whenever the Wound Care Nurse did not come to work. She said she had not been trained on the wound vac at the facility. Nurse B stated the resident did not have the wound vac functioning on the night of 2/22/24, the wound vac was attached but it was not working, and the dressing was due for the night. Nurse B stated she told the resident she did not know how to operate the wound vac and she would do the wet-to-dry dressing as in the order. She said the resident had never refused any care that she knew of. She stated the ADON was the supervisor who oversaw their work. She stated had not specifically told her supervisor she was not trained on wound vac but she was sure she must have mentioned it to them sometime. She said on 2/26/24 and 2/27/24 the wound vac was not on the resident at that time and she (Nurse B) did wet-to-dry dressing.<BR/>On 03/05/2024 at 3:48pmin an interview with Nurse C stated she did not regularly work with Resident #5's . Nurse C stated she may have assisted the resident with her wound once but the wound vac was malfunctioning at that time so she did wet- to-dry. She stated she was not confident on how to apply wound vac and she had not received any training to do wound vac at the facility but she had been trained somewhere else. She stated she had not mastered using the wound vac to the point that she would be able to do it confidently. She stated she had not told her supervisor to do wound vac training for her.<BR/>On 03/07/2024 at 2:22pm in an interview with Nurse D, she stated she worked night shift. She was usually the nurse taking care of Resident #5 every time she worked on that side of the facility hall. She stated she had not changed her wound vac before but have changed the canister for her wound vac in the past. She said she believe she was very competent to apply wound vac, she had done wound vac on another resident but had not applied wound vac on Resident #5 because Resident #5's wound vac was being done differently, and she was not able to do it. She stated on 2/23/2024 during the night shift she remembered she had to change Resident #5's wound dressing because it was saturated, and she changed the cannister but when she removed the dressing wound, she could not re-apply the wound vac, because she was not sure how to apply it properly, and she did not want to mess up anything. She stated she did wet to dry for that night on 2/23/2024. She stated Wound vac was useful for a wound with a lot of drainage because the wound vac removed body fluid drainage from the wound, she said if the drainage was not removed the wound would not heal and could be infected.<BR/>On 03/06/2024 in an interview with the DON, she stated none of the nurses informed her that they were not able to apply wound vac on Resident #5. The DON stated the wound vac promote healing of the wound and prevent infection by removing excess drainage from the wound. She stated they had started in servicing the nurses and they would also have the wound vac company come in to train the nurses on using the wound vac and have each nurse perform a return demonstration.<BR/>Facility policy titled 'Competency of Nursing Staff' dated May 2019 revealed in part . licensed nurses and nursing assistants employed or contracted by the facility will demonstrate specific competency and skill sets deemed necessary to care for the needs of residents as identified through resident assessments and described in the plans of care.<BR/>The facility did not have policy for quality of care or wound vac.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical record in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #8) reviewed for medical records, in that:<BR/>Facility failed to ensure Resident #8's list of medication during discharge was kept in the medical record with the facility.<BR/>This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication and delay in services. <BR/>Findings include:<BR/>Record review of facesheet revealed Resident #8 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), multiple sclerosis (immune-mediated disease that affects the nerve cells of the body), hemiplegia (paralysis that affects only one side of your body.), Parkinson's disease (progressive disease marked by tremor, muscle rigidity, slow imprecise movement, mostly affecting middle-aged and elderly people), pneumonia (an infection that occurs in the lungs when it is filled with fluid or pus). <BR/>On 03/22/2024 at 1:46pm in an interview with Nurse E who discharged Resident #8, she stated when she discharged Resident #8, she wrote the list of all the medication sent home and signed the list. She kept a copy of the record in the medical record box and kept the other copy on the nurses station at the north side of the building. Nurse E stated she could not find the medication list when surveyor requested for it. <BR/>On 03/22/2024 at 4:22pm in an interview with the Director of Nursing (DON) stated the medical record person quit some days ago and they had paperwork that was piling up and sometimes she (DON) tried to scan those documents whenever she came across them, but they were in the process of getting somebody into that position to continue to handle residents' records. She said it could be that somebody picked it and thought it was not an important document, and just put it somewhere. The DON said she started an in-service on Wednesday, 3/20/2024, about handling resident medical records, because she noticed some inconsistencies about how the resident information paperwork were being handled, and she wanted to put everything right because medical records are very important documents used for resident's care. The DON stated the MDS nurse was the one currently helping out with medical records.<BR/>On 3/25/2024 at 12:09pm in an interview with the MDS Nurse stated she saw the Resident #8's discharge medication list at the north nursing station on Monday (03/11/2024) but she did not take it. She stated at the time she saw it, she was looking for another resident's medical record.<BR/>The policy (Electronic Medical Records) provided did not address deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 21 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance.<BR/>1. <BR/>The facility failed to effectively intervene or follow their own smoking policy when Resident #1 was known to drop cigarette ashes on herself.<BR/>2. <BR/>The facility failed to implement their own policy when resident #2, a memory care resident had smoked in his room. <BR/>3. <BR/>The facility failed to implement their own policy when Resident #3 was known to be non-compliant and placed a half-smoked cigarette that she had just extinguished into a paper bag.<BR/>These failures placed smoking residents at risk for injury from burns and fires caused by hazardous smoking behaviors.<BR/>Findings Included:<BR/>Record review of Resident #1's face sheet dated 2/28/2024 revealed she was a [AGE] year-old female who was admitted on [DATE]. She was diagnosed with anoxic brain damage(a brain injury due to restriction on the oxygen supplied to the brain), acute respiratory disease(a life-threatening lung injury that allows fluid to leak into lungs), muscle wasting and atrophy(is the decrease in size and wasting of muscle tissue), multiple sites; hereditary and idiopathic neuropathy(an illness where sensory and motor nerves of the peripheral nervous system are affected), unspecified; other lack of coordination, dysphagia oropharyngeal phase(problems with chewing and preparing food to be swallowed), bipolar disorder (mental disorder marked by extreme changes in mood, thought or behavior) and major depressive disorder .<BR/>Record review of Resident 1's quarterly MDS dated [DATE] revealed C0500- BIM summary score was 04, which represented severe cognitive impairment. Section GG Functional abilities and goals had upper extremities such as shoulder, elbow, wrist, and hand were coded (1)- which meant Impairment on one side. <BR/>Record review of smoking assessment dated [DATE] revealed she was careless with smoking materials-Drop cigarette butts/matches on the floor, furniture, self or others; smoked near oxygen. Coded at (3)- severe problem. However, smoking risk at bottom of form stated she was scored at 6- follow facility policy. Scores of 0-9 was deemed safe to smoke.<BR/>Record review of smoking assessment dated [DATE] revealed she was to use a smoke apron for safety & extender provided to help promote functional ability when smoking with supervision.<BR/>Record review of care plan dated 1/10/2024 and updated 2/28/2024 stated Resident #1 has smoking extender provided during smoking to hold and ash cigarettes.<BR/> Observation of Resident #1 on 2/28/2024 at 9:52 a.m. revealed she was smoking a cigarette in the smoking area with Resident #2, Resident #3 and Resident #4 without staff supervision or an assistive device to catch the cigarette ashes. <BR/>Resident #2<BR/>Record review of Resident #2's face sheet dated 2/28/2024 revealed he was a [AGE] year-old male who was admitted on [DATE]. He was diagnosed with unspecified intercranial injury without loss of consciousness, need for assistance with personal care, unspecified injury at C6 level of cervical spinal cord, conversion disorder with seizures or convulsion, schizoaffective disorder, dementia, shortness of breath and peripheral vascular disease and cognitive communication deficit.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed C0500 was scored at 09 represented moderately impaired.<BR/>Record review of Resident #2's smoke assessment dated [DATE] revealed it was safe for him to smoke. His smoking risk was 0. A score of 0-9 was deemed a safe smoker. No supervision was deemed necessary.<BR/>Record review of Resident #2's care plan dated 2/14/2024 read in part: Problem: I am a smoker; I must be supervised. I have smoked in my room. Intervention: Smoking paraphernalia will be kept by nursing and activity department. <BR/>Observation of Resident #2 on 2/28/2024 at 9:52am revealed he was smoking a brown cigarette without staff supervision. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 2/28/2024 revealed she was a 62- year-old female that was admitted to the facility on [DATE]. She had diagnosed with unspecified dementia, paranoid schizophrenia, Type 2 diabetes, cognitive communication deficit, dysphagia, presence of a cardiac pacemaker and atherosclerotic heart disease.<BR/>Record review of Resident #3's smoke assessment dated [DATE] revealed it was safe for her to smoke. She had a score of 0. A score of 0-9 were deemed a safe smoker.<BR/>Record review of Resident #3's care plan dated 5/26/2023 and edited on 12/19/2023 read in part: Problem: I am not compliant with smoking policy. Goal: I will smoke only during smoke times. Approach: I will be monitored to only smoke in designated smoking areas and times or might lose my privileges. <BR/>Observation of Resident #3 on 2/28/2024 at 9:52 a.m., revealed she was smoking a cigarette without staff supervision. Further observation revealed Resident #3 left the smoke area and went inside to the lobby area. She had placed her half-smoked cigarette and a lighter inside a brown paper bag. <BR/>An interview with the ADON on 2/28/2024 at 10:01a.m., she stated the residents are independent smokers. She said they are allowed to keep cigarettes and lighters on their person as this is their home. She stated Resident #2 is the only resident must have supervision. She stated he only smokes when his RP is there to supervise him. She stated that their policy would soon be changed, and all smokers would be supervised. <BR/>An interview with the traveling DON on 2/28/2024 at 10:06 a.m., revealed she had been working at the facility for about 5-6 weeks She said the company smoke policy is in the process of being changed. All of the residents' paraphernalia would be kept in locked boxes and would be kept at the nursing station. She said trying to change this procedure/policy has been met with a lot of pushbacks from the residents as they have rights. She said they are waiting for lockboxes to be delivered and all residents cigarettes and smoke devices will be locked. She said unsafe smoking habits of one resident could cause a disaster for the entire facility. <BR/>An interview with the Administrator on 2/28/2024 at 10:17a.m., revealed him to state for clarity, residents are allowed to smoke safely without supervision. They can have cigarettes and lighters in their rooms. However, they are transitioning to lockboxes to store cigarettes mostly due to complaints about cigarettes being stolen. He denied any unsafe smoking habits by the four residents observed outside smoking without supervision. He said the facility would be changing their policy to all smokers having supervision. He provided the facility smoking policy, smoke times and a census of all smokers.<BR/>Record review of the facility's smoking census revealed there were 17 residents listed.<BR/>Record review of the facility's smoke schedule updated on 2/1/2024 were as follow:<BR/>8:30 am- Maintenance Director<BR/>11am- Laundry/Housekeeping<BR/>1:00pm- North Hall nurse or designee<BR/>3:00pm- South Hall Nurse or designee<BR/>6:30pm- North Hall nurse or designee<BR/>8:00pm- South Hall nurse or designee<BR/>At the bottom of smoking schedule, it stated smokers are to be observed for safety and until the last cigarette is extinguished and smoking materials are all locked up. No residents are allowed to keep smoking materials or have keys to lock boxes. Violations of policies will result in suspension & potential termination of smoking privileges.<BR/>Record review of the facility's smoking policy dated April 2023 read in part: This facility shall establish and maintain safe resident smoking practices. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a safe smoker or non-smoker. If a smoker, the evaluation will include current level, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. 11. Any residents with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possessions. Only disposable safety lighters are permitted. All other forms of lighters and matches are prohibited. <BR/>Record review of an undated facility admission packet Attachment K-Smoking read in part: Our facility provides our residents and our employees with a smoke-free environment. While we recognize the need of many of our residents and employees to work and live in a smoke-free environment, we must also respect the rights if those residents and employees who choose to smoke. 2. Residents and Visitors -Certain smoking restrictions apply to our residents and visitors. 19.7.4 (2). This facility will supervise all resident smoking for the safety of all residents and employees. Supervised smoking times for residents are scheduled and limited to 15-minute increments. All resident smoking paraphernalia must be checked in with the nurse. Resident smoking paraphernalia will be secured at the nurse's station and provided to the resident at specified smoking times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment for 3 of 18 (Residents #2 #4, #56,) residents reviewed for resident assessments in that:<BR/>1 <BR/>Resident #2 Resident most recent comprehensive annual assessment did not accurately reflect her hearing deficit and oral dental status.<BR/>2 <BR/>Resident #4's most recent comprehensive assessment did not include his cognitive level, mood, oral dental status, and his dysphasia status (swallowing disorder).<BR/>3 <BR/>Resident #56's most recent comprehensive assessment did not include his diagnoses of dental root caries, Quadriplegia, Anxiety disorder <BR/>These failures could place residents at risk of not receiving care and services needed to attain/maintain their highest practicable quality of life.<BR/> Findings included:<BR/>1. <BR/>Resident # 2 <BR/>Record review of Resident #2's undated, face sheet, revealed she was a [AGE] year-old female with most recent admission date of 09/27/21, Her diagnoses included Alzheimer's diseases, fracture of second lumber vertebrate, muscle wasting, dysphagia (swallowing problems), and end stage renal failure(kidney disease). <BR/>Record review of Resident #2's care plan dated 08/03/2020 revised on 06/02/2023 revealed no care plan for her oral cavity.<BR/>Record review of Resident #2's care plan dated 08/03/20 updated 06/02/23 revealed she was care plan for hearing deficit as evidence by resident only hears in special setting. Speaker has to adjust tone and volume<BR/>Goal Dignity will be maintained, and residents need will be met .<BR/>Intervention: face resident when speaking use calm tones, allow ample time to respond .<BR/>Use communication boad, writing tablet as indicated .<BR/>Observation on 07/15/23 at 10:40 AM revealed Resident #2 was in her room on a low bed talking to herself and occasionally yelling out help. Observation indicated she would answer to her name when called out loudly. The Observation indicated she had missing teeth on her upper and lower oral cavity. <BR/>1 Resident #4<BR/>Record review of Resident #4's undated, face sheet, revealed he was a [AGE] year-old male with an admission date of 06/25/23, and re-admission date of 07/06/23. His diagnoses included sepsis (infection), contractures, oropharyngeal dysphagia (swallowing problems), Aphasia,(lack of communication) and intracranial hemorrhage,(bleeding within the skull).<BR/>Record review of Resident #4's care plan dated 10/11/20 edited 05/11/23 revealed Resident #4 was care planned for enteral feeding related to dysphagia intracranial hemorrhage.<BR/>Goal -Resident will exhibit no complication associated with tube feeding. <BR/>Resident #4 will not aspirate or experience shortness of breath, chest congestion .<BR/>Intervention -Administered tube feeding formula as ordered by physician.<BR/>Record review of Resident #4's admission MDS date of 07/12/23, revealed the following section were not assessed- cognitive pattern (BIMs), mood\behavior, neurological condition and were left blank. <BR/>Record review of Resident #4's care plan dated 08/03/2020 revised 05/11/23 indicated he was care planned for at risk for increase pain and infection related to need for dental \oral care.<BR/>Goal: resident will have no signs and symptoms of oral infection<BR/>Intervention-encourage \provide care in AM and PM. Monitor for oral pain .<BR/>Observation on 07/15/23 at 1:00 PM, revealed Resident #4 was in bed in fetal position, unable to communicate. He was contracted on his upper and lower extremities. He had a tube feeding on at 30cc per hour with 140 water flush every 4 hours.<BR/>Observation and interview on 07/16/23, TNA X looked at Resident#4's oral cavity and said resident #4 had some decayed missing teeth on his upper and lower oral cavity. <BR/> Resident # 56<BR/>Record review of Resident #56's undated, face sheet, revealed he was a [AGE] year-old male with an admission date of 07/6/22, and re-admission date of 06/16/23. His diagnoses included Quadriplegia, dental root caries (lesion which occurs on the root surface of the tooth) major depressive disorder, anxiety, and muscle spasm <BR/>Record review of Resident #56's annual MDS date of 06/15/23, indicated a BIMs score if 15 out of 15 indicated he was cognitively intact. Further review revealed the following section were not assessed- Neurological condition of quadriplegia was left blank, section on psychiatric\mood disorder was left blank. He was assessed as no issue section L oral dental status. <BR/>Record review of Resident #56's physician orders dated 06/22/23 revealed an order to refer resident #56 to a local hospital for oral surgery to evaluate and treat for the diagnosis of dental root caries.<BR/>Record review of Resident # 56's care plan dated 01/01/23 revealed no care plan for his dental caries.<BR/>Record review of his care plan dated 07/06/22 with a revision date of 07/13/23 revealed he was care planed for- ADLs Functional Status/Rehabilitation Potential I am limited in ability to transfer self R/T Quadriplegia. I choose to stay in bed all or most of the time. <BR/>Goal: Goal Target Date: 10/13/2023 Approach I will transfer self with total assistance and 2 staff.<BR/>ADLs Functional Status/Rehabilitation Potential Resident is limited in physical mobility, bedfast all or most of the time R/T Quadriplegia .<BR/>Goal-Resident will not exhibit complications of prolonged immobility .<BR/>Record review of the facility's social worker's notes dated 06/26/2023 11:38 AM <BR/>indicated SW asked res if he needed to see the dental group and said yes but did not want to wait any longer to see them since they cancelled 3x. Asked if it was ok to make referral with another oral surgery & res said yes. Called local clinic for appt but said physician order is needed . SW faxed physician order 6-22-23. Called today to see if they rec'd it and said that was not the right fax #. Then she said let her check some things out before faxing to the last number given and she would call me back. Awaiting a call. <BR/>Attempt was made to have an interview with social worker, but she was out on leave.<BR/>Observation on 07/16/23 revealed Resident # 56 was in bed his head was covered.<BR/>Observation and attempted interview on 07/17/23 at 10:45AM, indicated Resident # 56 was in bed, attempt was made to have an interview with him. He said he was in pain and needed to go to the hospital and covered his head back. In an interview with ADON, she said she had called for an ambulance to take Resident #56 out to the hospital for evaluation. She said Resident # 56 was having some stomach problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 6 of 18 residents reviewed for care plan accuracy (Residents #7, 20, 28, 32, 49, 60). <BR/>--Resident #7 was not care planned for Dialysis <BR/>--Resident #28 did not have a care plan for incontinence <BR/>--Resident # 20, #28 and Resident # 49's care plans did not specify level of assistance needed for ADL care<BR/>--Resident #32's care plan was not updated for room placement<BR/>--Resident # 49 did not have a care plan for Hospice <BR/>--Resident #60 was not care planned for Dialysis<BR/>These failures placed residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. <BR/>Findings include:<BR/>Resident #7<BR/>Record review of Resident #7's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood causing respiratory failure), vascular dementia (brain damage from impaired blood flow to brain), shortness of breath, cognitive communication deficit (difficulty with thinking and language), obstructive and reflux uropathy (urine unable to drain through urinary tract), muscle wasting and atrophy (decrease and thinning in muscle size), dysphagia (trouble swallowing), pneumonitis due to inhalation of food (inflammation of the lungs), schizophrenia (false beliefs, hallucinations, unusual behavior, and disorganized thinking and speech), and pressure ulcer of sacral region (pressure sore in the lower back and tailbone area). The face sheet also revealed the resident was a DNR.<BR/>Record review of Resident #7's Comprehensive MDS dated [DATE], revealed a BIMS score of 5 which indicated severely impaired cognition. <BR/>Record review of Resident #7's medical record revealed a DNR from Dr. RA on 6/9/23 at 1:49pm. There's also an order for hospice written on 6/11/23 at 2:22am that says, Admit to ABC Hospice, (xxx-xxx-xxxx) Primary Hospice Diagnosis: Senile Degeneration of the Brain. There was an order for a pressure reducing mattress for the bed ordered on 4/7/23. Also an order for oxygen at 2-4 liters via nasal cannula, PRN was created on 6/11/23. The medical record also revealed an order for Glucerna 1.5 (Diabetisource) to run at 60ml/hr ordered on 7/17/23, or Jevity 1.5 to run at 55ml/hr for when Glucerna was not available, ordered on 7/14/23. <BR/>Record review for Resident #7's care plan, revised 7/3/23, revealed the resident was listed as full code and not DNR. The care plan had Diabetisource (Glucerna) @ 50ml/hr on it, instead of 60ml/hr and did not have the order for Jevity 1.5 at 55ml/hr. The care plan also did not have hospice, the pressure reducing mattress, or oxygen listed on it. <BR/>7/15/23 10:22am: Resident #7 had Glucerna at 55ml/hr running on a feeding pump. The resident was on a pressure relieving mattress.<BR/>Resident #20<BR/>Record review of Resident #20's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE] with diagnoses of demyelinating disease of central nervous system (multiple sclerosis which is an autoimmune attack on the coating of nerves and causes inflammation and damage to brain and/or spinal cord), muscle wasting and atrophy (decrease and thinning of muscle), dysphagia (trouble swallowing), contracture of muscle (muscles, tendons, joints, or other tissues tighten/shorten causing a deformity), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry about everyday issues and situations), pain, and repeated falls.<BR/>Record review of Resident # 20's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, which indicated normal cognition. The MDS also revealed she had a serious mental illness. Resident #20 indicated it was very important for her to choose what clothes to wear, to choose between a tub bath, shower, bed bath or sponge bath, and to do her favorite activities. She required extensive assistance with personal hygiene, dressing, transfer, and bed mobility, and total dependence with toilet use. She also required 1-2 people to assist her with the activities. She needed physical help with bathing and 1 person to physically help her. Resident #20 used a wheelchair for mobility. She was always incontinent of urine and bowel.<BR/>Interview and observation on 7/15/23 at 1:26pm revealed she needed assistance with being sat up to eat, needed assistance turning, needed assistance getting out of bed into her electric chair, needed assistance with personal hygiene, needed assistance with toileting, and needed assistance with dressing. Resident had a trapeze bar above her to help sit up, but she still required the assistance of staff.<BR/>Record review of Resident #20's care plan, revised 6/6/23, revealed missing information under ADL Function/Rehab Potential. There was no information for the amount of assist needed for ambulation/transfers, bathing/hygiene, dressing/grooming, eating, or toileting.<BR/>Resident #28<BR/>Record review of Resident # 28's face sheet revealed a [AGE] year-old female with admission date of 3/3/23 and diagnoses including atrial fibrillation (irregular heart rate), Diabetes (chronic condition that affects production of insulin), major depressive disorder, single episode, hypertension (high blood pressure), osteoarthritis degenerative joint disease), systemic lupus (disease when immune system attacks its own tissues), cerebral infarction (stroke), chronic obstructive pulmonary disease (lung disease that blocks airflow), rheumatoid arthritis (chronic inflammatory disorder affecting joints).<BR/>Record review of Resident # 28's ADL Functional status care plan dated 3/3/23 revealed amount of assist for ADL's was left blank. There was no care plan for incontinence. <BR/>Record review of Resident # 28's admission MDS dated [DATE] revealed modified independence for cognitive ability, always incontinent of bowel and bladder, extensive staff assistance required for ADL's, with exception of supervision for eating. <BR/>Observation of Resident #28 on 7/15/23 at 10:00 AM revealed she was in bed. Interview at that time, she said she needed help to get cleaned up, change her brief and to dress, and she was waiting for someone to come help her, but she had not seen anyone yet. <BR/>Resident #32<BR/>Record review of Resident #32's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE] with diagnoses of pneumonia (lung infection), chronic obstructive pulmonary disease (airflow blockage and breathing related problems), protein calorie malnutrition (lack of protein and calories in the diet), muscle wasting and atrophy (decrease and thinning of muscle), major depressive disorder (persistent feeling of sadness and loss of interest), stage 4 pressure ulcer of left heel (deepest pressure ulcer that can cause extensive destruction with exposed bone, tendon, or muscle), stage 3 pressure ulcer of right heel (extends through skin into deeper tissue and fat but not into muscle, tendon, or bone), dementia (impaired ability to remember, think, or make decisions), and right artificial hip joint (right hip replacement).<BR/>Record review of Resident #32's Comprehensive MDS dated [DATE] revealed a BIMS score of 5, which indicated severely impaired cognition. It also revealed the resident had no hallucinations or delusions. He also had no presence of wandering. The MDS stated Resident #32 required a mechanically altered diet (he required a change in the texture of food or liquids).<BR/>Record review of Resident #32's medical record revealed an order for a regular diet with fortified foods, with nectar fluid consistency, ordered on 3/16/23. There was not an order for the resident to be in the secured unit.<BR/>7/15/23 9:50am: Resident was in a regular room on the long-term care side, and not in the secured unit.<BR/>Record review of Resident #32's care plan, revised 6/16/23, revealed under the nutritional status that the fluid consistency was thin, when it was supposed to be nectar. The care plan also said he was at risk for elopement and needed to be provided with a room on the secured unit for safety. The resident was in a regular room, not on the secured unit<BR/>Resident #49<BR/>Record review of Resident # 49's face sheet revealed an [AGE] year-old male with admission date of 10/22/22 and diagnoses including heart disease, dementia without behavioral disturbance, atherosclerosis (hardening) of arteries of right and left leg, Diabetes, mood disorder, hypertension (high blood pressure), atrial fibrillation (irregular heart rate). <BR/>Record review of Resident #49's physician's order dated 1/10/23 revealed Admit to Vantage Hospice with a primary diagnosis of generalized atherosclerosis with comorbidities of dysphagia, dementia, Diabetes, atrial fibrillation and depression. <BR/>Record review of Resident #49's ADL Functional Status care plan dated 2/23/22 revealed ADL amount of assist was left blank. There was no care plan for Hospice. <BR/>Record review of Resident #49's Significant Change MDS dated [DATE] revealed BIMS score of 7, indicating severely impaired cognitive ability, always incontinent of bowel and bladder, and Hospice care. <BR/>Observation of Resident #49 on 7/15/23 at 9:45 AM revealed he was in bed, covered up with blanket and stocking cap pulled over his eyes. When surveyor entered the room, resident moved the stocking cap from his eyes and said he just woke up and he's ok for now, just waiting for someone to come get him up since he needed help to get cleaned up and to get dressed. <BR/>Resident #60<BR/>Record review of Resident #60's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of end stage renal disease (kidneys stopped working), Type 1 diabetes with diabetic neuropathy (autoimmune disorder where pancreas stops making insulin with pain caused by nerve damage) , other disorders of electrolyte and fluid balance (when a large amount of body fluid is lost), chronic pain syndrome (symptoms beyond pain alone like depression and anxiety that interfere with life), major depressive disorder (persistent feeling of sadness and loss of interest), Type 2 diabetes with diabetic retinopathy (body doesn't produce insulin and a complication of diabetes causing blindness), muscle wasting and atrophy (decrease in size and thinning of muscle), and neuromuscular dysfunction of the bladder (nerves and muscles do not work in the bladder).<BR/>Record review of Resident #60's Comprehensive MDS dated [DATE], revealed a BIMS score of 13, which indicated normal cognition. The MDS revealed under section O, that the resident received dialysis while a resident.<BR/>Record review of Resident #60's medical record revealed a dialysis order from Dr. CL on 3/27/23 at 2:10pm. The order stated, Hemodialysis performed on M/W/F at 11am. Dialysis Center: ABC Dialysis Center, with the address, nephrologist information, and transportation information.<BR/>Record review of Resident #60's care plan with revision date of 7/16/23, does not have dialysis on it.<BR/>7/15/23 9:29am: Resident stated he goes to dialysis on M/W/F and uses a Hoyer lift to get out of bed, into a wheelchair. Then he got into a wheelchair van to be transported to the dialysis center.<BR/>Interview on 7/18/23 at11am with MDS Coordinator revealed: care plans are a team effort. She must have just missed the items on the care plans. When asked about Resident #32 needing to be on a secured unit, she said no the resident did not need to be in a secure unit and that the information was wrong. She gets the information from nurses, and from meetings. If care plans are wrong residents could receive incorrect care. She started September 2022. <BR/>In an interview on 7/18/23 at 11:45 AM, MDS nurse said she updates the care plans and keeps a running tab and checks for changes every morning, she goes to clinical meetings and nurses tell her of any changes with residents. She said there have been a lot of personnel changes and some things might have been missed but she is trying to correct them. She said the risk of not having accurate care plans would be the resident would not get the care they needed. <BR/>In an interview with the DON on 7/18/23 at 12:10 PM, she said she has been here 8 days as interim DON and the staff are working on correcting things from previous staff. She said the risk of not having updated care plans would be the residents would not get proper care. <BR/>Record review of facility policy Care Plans, Comprehensive Person-Centered, revised December 2020, revealed, in part .Interdisciplinary Team must review and update the care plan .at least quarterly, in conjunction with the required quarterly MDS assessment .when there has been a significant change in the resident's condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of eternal feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormality for 1 (Resident #60) of 2 residents reviewed for g-tubes. <BR/>LVN A failed to administer Resident #60's water flush and medication to flow by gravity and instead LVN A pushed the water and medication through the g-tube (GT) using enteral feeding 60 ml syringe. <BR/>The facility failed to clarify GT medication order for Resident #60, with no amount of water to give before and after meds, and in between med administration, and dilute medication via GT.<BR/>LVN A did not follow the facility policy to verify that there was a physician order for GT med administration procedure.<BR/>These failures could place residents who receive g-tube medications at risk of aspiration pneumonia, diarrhea, vomiting, dehydration or over-hydration and metabolic abnormalities.<BR/>Findings Included:<BR/>Record review of Resident # 60's face sheet revealed, a [AGE] year-old female admitted to facility on 3/30/21 with diagnoses which included, difficulty swallowing (dysphagia and gastro-esophageal reflux disease. <BR/>Record review of Resident #60's entry MDS revealed she had moderately impaired cognition and had a feeding tube for dysphagia. She required extensive-total assist of 1-2 staff for most activities of daily living.<BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed the following orders:<BR/>-Metoprolol Succinate ER 25 mg, give &frac12; tab=12. 5 mg via gastrostomy tube (GT) BID, start date 8/19/21. No dx or indication for its use.<BR/>-Carbamazepine 100 mg/5 ml suspension give 15 ml =300 mg via GT BID, for epilepsy. No order to shake well before administered. <BR/>-Levetiracetam 100 mg/ml solution, give 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered. <BR/>- Give 50 cc water per GT every 6 hrs. for patency.<BR/>There were no orders that indicated the amount of water to dilute medication, the amount of water to give in between medication administration; and the amount of water flush before and after the medications administered to her GT. <BR/>Record review of Resident #60's MAR dated May 2022 - June 2022 revealed there was no order for the amount of water to dilute the medication, and in between medication administration, and no water flush before and after the meds administered to her GT.<BR/>Observation and interview on 06/07/22 at 4:15 p.m., revealed LVN A prepared medication for administration to Resident #60, there was no computer MAR use She entered into the resident's room and checked her blood pressure. LVN A retrieved 1/2 tablet of 25 mg Extended-Release (ER) Metoprolol Succinate, and one other tablet and 1 capsule opened and placed them in individual medication cups diluted with 10 ml of water. She crushed all 2 tablets including the Metoprolol Succinate ER. LVN A did not shake the Levetiracetam solution, and Carbamazepine suspension and administered all crushed tabs. She poured 30 ml water directly into the 60 ml syringe in between medication but the water did not flow, and again plunge the water down the tube. LVN A used the 60 ml syringe and pulled last dissolved crushed tab metoprolol 12.5 mg from the med cup and plunged the medication through the GT. LVN A said, I still have some residual in those cups. Before leaving the room, she was shown the medicine cups had medication residual. <BR/>Interview on 06/07/22 at 4:25 p.m., LVN A stated her computer was borrowed from the med cart, but she knew the dosage and time to administer Resident #60's scheduled meds. LVN A said she should have administered the medication and water by gravity, but GT was clogged. Further interview revealed she poured water directly into the 60 ml syringe in between medication instead of using a measuring medication cup to accurately measure water. <BR/>Interview on 6/07/22 at 5:00 p.m., RN C stated LVN A was in-serviced 1:1, and suspended due to LVN A administered medications without the computer MAR in eyesight, and did not allow meds to flow by gravity via GT. RN C said we give only 10 ml amount water in between med administration, and LVN A should use a measuring medication cup to measure 10 ml water accurately, instead of pouring directly to a syringe. RN C stated that LVN A to provide a return demonstration before she could return to work.<BR/>Interview on 6/09/22 at 12:15 p.m., the DON stated she expected nurses to administer medications and water to flow down the GT by gravity. She further stated Resident #60's GT medication order was incomplete, and the water flush order was missing. However, she stated LVN A should have called the MD to verify regarding Resident's incomplete order. The DON stated prior to giving meds, the orders must be verified using the MAR and nurse to clarify with the MD if the order was incomplete.<BR/>Interview on 6/09/22 at 1:15 p.m., the DON stated in-service was just conducted and reinforced to nurses to administer meds accurately, allow meds to flow by gravity, and use a measuring medication cup to accurately measure water. The DON stated we called the MD and obtained order, to give=10 ml water flush before and after meds and give 5-10 ml water in between meds for Resident #60. <BR/>Interview on 6/09/22 at 2:00 p.m., LVN B stated she would use a measuring medication cup to accurately measure amount of water and allow the medication to flow by gravity via GT. <BR/>In an interview on 06/09/22 at 3:30 p.m., RN C stated moving forward she will continue to in-service staff, to ensure GT orders and meds administered accurately and orders verified using the MAR. RN C stated new orders will be reviewed next day during daily AM meetings.<BR/>In an interview on 06/09/22 at 3:30 p.m., the Administrator stated that will follow-up all the medication issues with QAPI. <BR/>Record review of the facility's policy, Medication and Treatment Orders dated July 2016 read in part, .Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders for medication must include .Clinical condition or symptoms for which the medication is prescribed.<BR/>Record review of the facility's policy, Administering Medications through an Enteral Tube dated March 2015 read in part, .Verify that there is a physician 's medication order for this procedure. Check gastric residual (GRV) to assess for tolerance of enteral feeding .Do not crush enteric coated, sustained release meds .Place the MAR within easy viewing distance. If administering more than one medication, flush with 15 ml or prescribed amount, warm sterile or purified water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #72) of 3 residents sampled for respiratory care.<BR/>The facility failed to get an order for Resident #72's oxygen and he was using it without an MD's prescription. <BR/>This failure could place residents at harm of receiving unnecessary treatments.<BR/>Findings include:<BR/>Record review of resident #72's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (airflow blockage and breathing related problems), pneumonia (infection in the lung), osteoarthritis (break down of cartilage within a joint), muscle wasting and atrophy (decrease in size and thinning of muscle), stage 4 pressure ulcer of back (deepest pressure ulcer that can cause extensive destruction with exposed bone, tendon, or muscle), chronic pain (symptoms beyond pain alone like depression and anxiety that interfere with life), severe protein calorie malnutrition (lack of protein and calories), and dyspnea (trouble breathing).<BR/>Record review of Resident #72's Comprehensive MDS dated [DATE], revealed a BIMS score of 11, which indicated moderately impaired cognition. The resident had oxygen therapy checked as being used while not a resident, in the past 14 days.<BR/>Record review of Resident #72's medical record on 7/18/23, revealed no order for oxygen.<BR/>Record review of Resident #72's care plan on 7/18/23, revealed no information about oxygen.<BR/>In an interview and observation on 7/15/23 at 10:27am, Resident #72 revealed his nose had been burning from the oxygen, for several days. He was on 5L via NC and the humidification bottle was completely dry. The resident stated he used oxygen continuously.<BR/>In an interview and observation on 7/16/23 at 1:55pm, Resident #72 said he had been on the oxygen since he came back from the hospital in June 2023. The resident was on 5L via NC and the humidifier was completely out.<BR/>In an observation on 7/18/23 at 9:05am, Resident #72 was using the oxygen at 5L and he had not had his humidifier refilled.<BR/>In an interview with the DON on 7/18/23 at 9:44am, she confirmed there was not an order for Resident #72's oxygen in the computer and she did not know he had been on oxygen. She stated she did not think anything could happen if he was on oxygen and did not require it. She stated that she would in-service staff, notify the MD to get an order, get the resident's oxygen saturation levels, and try to titrate his oxygen levels down.<BR/>Record review of the facility's policy and procedure on Oxygen Administration (Revised October 2010) read in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing) .Periodically re-check water level in humidifying jar .After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for prn administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure.<BR/>Record review of the facility's policy and procedure for Medication Orders (Revised November 2014) read in part: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .When recording order for oxygen, specify rate of flow, route and rationale.<BR/>Record review of the facility's policy and procedure for Administering Medications (Revised April 2019) read in part: Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions . Medications are administered in accordance with prescriber orders .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure that there were sufficient qualified nursing staff available to provide nursing and related services to meet the residents' needs and safely in a manner that promotes physical, mental, and psychosocial well-being for 6 of 18 residents ( Resident #4, #7,#20,#44, #55, #60), reviewed for Quality of care. <BR/>--The facility failed to provide Resident #4 with ADL care scheduled.<BR/>--The facility failed to provide Resident #44 with ADL care scheduled.<BR/>--The facility failed to provide Resident #7 with ADL care scheduled.<BR/>--The facility failed to provide Resident #20 with ADL care scheduled.<BR/>-The facility failed to provide Resident #55 with ADL care scheduled.<BR/>-Resident # 60 was not provided timely incontinent care and ADL care as scheduled<BR/>These failures could place residents at risk of not receiving appropriate care and services to improve their quality of life.<BR/>Findings included: <BR/>Observation and interview on 07/15/23 at 9:00 AM revealed the facility census was 75. Tthere were two nurse's present at the facility. One on the north side and one on the south side, 4 TNAs and one medication aide. In an interview, RN B said she was the weekend supervisor and the nurse on the floor. She was observed passing medication. She said there were two TNAs in the secured unit. <BR/>Observation and interview on 07/15/23 at 9:05 AM revealed the nurse on the North side, was passing medication. She said there were two TNAs and are in the secured unit.<BR/>Observation and interview on 07/15/23 at 9:15 AM revealed the nurse on the south side, was passing medication. She said there were two TNAs but not sure where they are. <BR/>Record review of the facility signed in sheet indicated there were two TNAs on the South side with one LVN and on the south side there was one nurse, the weekend supervisor, and two TNAs in the secured unit with 19 residents. <BR/>Resident #4 <BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted and readmitted to the facility 07/06/23. His diagnoses included Acute respiratory distress ( inability to breath) sepsis (infection) Contractures, persistent vegetative state (a person who is unaware and unresponsive), muscle wasting, pneumonia, multiple site Pressure ulcers and dysphasia.<BR/>Record review of Resident #4's SG MDS assessment dated [DATE] revealed his BIMS score was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident # 4's care plan revealed-10/08/20 edited 05/11/23 read in part -<BR/>ADLs Functional Status/Rehabilitation Potential. Resident #4 is dependent with all ADLs. Bed mobility x4, Transfer:4 with 3 assists, Dressing:4 assist 2 and personal hygin:2 assist.<BR/>Goal : Resident # 4 is dependent with all ADLs. Bed Mobility:4 Resident #4's dignity will be maintained, and he will be clean, dry, well-groomed and odor free during the next 90 days.<BR/>Approach : dress resident according to season and climate. Provide oral care twice daily. Shower, shampoo hair, and give nail care per shower schedule and as needed.<BR/>Observation on 07/15/23 at 2:00PM, revealed Resident #4 was in bed, noncommunicative in a semi fetal position. He was contracted with his two-hand clenched in a fix position, unkept facial hair, dirty long nails, and there was dry white substance around his mouth. He had a dirty hospital gown on and a catheter with 300 ML of clear yellow urine.<BR/>Observation and interview on 07/16/23 at 10:00am revealed Resident #4 were in the same position with the same hospital gown on, dirty long nails and unkept facial hair. In an interview with CAN Y looked at Resident #4's and said she would clean him.<BR/>In an interview with LVN--- on 07/16/23 at 10:00am, she said Resident # 4 was on hospice and hospice usually clean him up.<BR/>Record review of Physician's telephone orders dated 04/13/23 revealed Resident # 4 was admitted on hospice on 07/13/23. Hospice documentation was requested from ADON on 07/16/23 at 3:30pm but was not provided. <BR/>Resident #7 <BR/>Record review of Resident #7's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood causing respiratory failure), vascular dementia (brain damage from impaired blood flow to brain), shortness of breath, cognitive communication deficit (difficulty with thinking and language), obstructive and reflux uropathy (urine unable to drain through urinary tract), muscle wasting and atrophy (decrease and thinning in muscle size), dysphagia (trouble swallowing), pneumonitis due to inhalation of food (inflammation of the lungs), schizophrenia (false beliefs, hallucinations, unusual behavior, and disorganized thinking and speech), and pressure ulcer of sacral region (pressure sore in the lower back and tailbone area). The face sheet also revealed the resident was a DNR.<BR/>Record review of Resident #7's Comprehensive MDS dated [DATE], revealed a BIMS score of 5 which indicated severely impaired cognition. The MDS revealed the resident had a serious mental illness of schizophrenia. He had unclear speech, sometimes could make himself understood, and sometimes understands others. Resident #7 required extensive assistance with personal hygiene, dressing, and bed mobility. He required physical help with bathing and one-person physical assistance. He used a wheelchair for mobility. The resident had an indwelling catheter for obstruction but was always incontinent of bowel. He had a stage 4 pressure ulcer to his sacrum, was on tube feeding, and on hospice.<BR/>7/15/23 10:22am: Resident #7 was on his back, asleep in bed.<BR/>7/15/23 1:30pm: Resident #7 was still on his back. Have not seen anyone go in the room.<BR/>7/16/23 9am: Resident #7 was still on his back, asleep.<BR/>7/16/23 1:57pm: Resident #7 was on his back, asleep in bed. Have not seen anyone go in the room.<BR/>7/17/23 11am: Resident #7 was on his back, asleep in bed.<BR/>7/18/23 9:03am: Resident #7 was still on his back, asleep in bed.<BR/>7/18/23 12:40pm: Resident #7 was on his back, asleep in bed. Have not seen anyone go in room.<BR/>Record review of Resident #7's care plan, revised 7/3/23, revealed I have a stage 4 to my sacrum from admission-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Dental Care-Maintain oral hygiene/status: Oral Care BID. Bowel Incontinence-I will establish an individual bowel and bladder routine: Check for incontinence Q2hrs and PRN. ADL Function/Rehab Potential-I will achieve maximum functional mobility: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Toileting amount of assist: Extensive. Activities-I will attend/participate in 1 activity per week. The resident will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Mon, Wed, Fri: 6am-6pm. Nail Care Once a Day on Mon, Wed, Fri: 6am-6pm. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>Resident #20 <BR/>Record review of Resident #20's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE] with diagnoses of demyelinating disease of central nervous system (multiple sclerosis which is an autoimmune attack on the coating of nerves and causes inflammation and damage to brain and/or spinal cord), muscle wasting and atrophy (decrease and thinning of muscle), dysphagia (trouble swallowing), contracture of muscle (muscles, tendons, joints, or other tissues tighten/shorten causing a deformity), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry about everyday issues and situations), pain, and repeated falls.<BR/>Record review of Resident # 20's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, which indicated normal cognition. The MDS also revealed she had a serious mental illness. Resident #20 indicated it was very important for her to choose what clothes to wear, to choose between a tub bath, shower, bed bath or sponge bath, and to do her favorite activities. She required extensive assistance with personal hygiene, dressing, transfer, and bed mobility, and total dependence with toilet use. She also required 1-2 people to assist her with the activities. She needed physical help with bathing and 1 person to physically help her. Resident #20 used a wheelchair for mobility. She was always incontinent of urine and bowel.<BR/>In an interview and observation on 7/15/23 at 1:26pm Resident #20 said they did not get her up for lunch. Resident was lying flat on her back in bed, and food was observed on her chest and on her mouth. She said there was barely any staff, so she did not ask to get into her electric chair because she was afraid, she would not be able to get back into bed and would be in pain. She stated Mon/Fri were supposed to be shower days, and Wed were lotion days, but that had not been happening. She said she had not been turned all day and she was unable to turn herself. She said she had not had any skin breakdown so far. She also stated there were only 2 people in the whole building last night (7/14/23), and she did not get changed the whole night until 6am the next morning (7/15/23). She also had not brushed her teeth or had any personal hygiene care performed all day.<BR/>In an interview on 7/15/23 at 1:40pm TNA W said he came in from 6am to 6pm and usually changed/brushed the resident's teeth between 6am-6:30am. He said he turned residents every 2hrs because he was a patient himself before. He said Resident #20 was definitely a resident that needed to be turned every 2hrs. He said he did not know what happened and why Resident #20 had not been turned or had her teeth brushed. He said if she was not turned, a bedsore could happen because she could not turn herself. He stated he did not set her up for lunch because he was in the dining room, and whoever passed out the lunch tray should have set her up for lunch. He also said that he always took a female with him when he went in her room. He said he would go in and take care of the food all over her and get her teeth brushed. He said they usually have 4 aides during the day.<BR/>In an interview and observation on 7/16/23 at 10am Resident #20 said she was last changed last night (7/15/23) and had not been changed this morning yet. Resident was lying flat on her back in bed.<BR/>In an observation and interview on 7/16/23 at 2:02pm Resident #20 said she had not been in her electric wheelchair for 2-3 weeks. She asked TNA W to sit her up in bed for lunch today and he never came back to do so. Resident was lying flat on her back in bed.<BR/>In an interview on 7/16/23 at 2:05pm TNA W said he did not remember telling Resident #20 that he would sit her up in bed and he did not go into her room unless he had a female with him, then he promptly walked off.<BR/>In an interview on 7/16/23 at 2:10pm CMA B said Resident #20 was turned when she was changed, earlier in the day. Resident said she was not changed or turned.<BR/>In an observation and interview on 7/17/23 at 9am Resident #20 was still flat on her back and not in her wheelchair. She stated she was afraid to ask to get in the wheelchair because she did not want to be left in her wheelchair for many hours when she was ready to get back into bed. <BR/>In an observation and interview on 7/17/23 at 2:05pm Resident #20 was still flat on her back and not in her wheelchair. She stated it was too late to ask to get into her wheelchair now because it would take staff a couple hours to get her into the wheelchair and then it would take them several hours to get her back into bed.<BR/>In an interview on 7/18/23 at 9:08am Resident #20 said she told CNA A and TNA Y that she wanted to get up in her electric chair by 11am today (7/18/23). She stated did not get her suppository yesterday (7/17/23) at 3pm even though she asked for it. She said she told TNA Y today, that she wanted it. She still had not had breakfast and was still waiting on it.<BR/>In an observation on 7/18/23 at 11:15am Resident #20 was not in her wheelchair. Staff were standing in the hall talking and laughing.<BR/>In an interview on 7/18/23 at 11:20am: The DON and Clinical Resource Nurse did not know why someone had not helped Resident #20 get into her wheelchair yet. They said the resident overexaggerated and there was no way it had been 2-3 weeks since she had been in her wheelchair.<BR/>In an observation and interview on 7/18/23 at 12:36pm Resident #20 was put into her electric wheelchair. She stated she had not had lunch yet.<BR/>Record review of Resident #20's care plan, revised 6/6/23, revealed I have thin and fragile skin-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Oral/Dental Status. I use a rechargeable toothbrush-Maintain oral hygiene/status: Oral Care BID. B/B Incontinence-I will establish an individual bowel and bladder routine: Briefs when out of bed. Toileting. Resident #20 has been identified as having DD PASRR positive status related to Demyelinating disease of central nervous system. I am currently receiving habilitation coordination and habilitative therapy (3/10/23-9/5/23)-Resident #20 will maintain highest level of practicable well-being for the next 90 days: I am recommended to receive PASRR habilitative services through PT and OT. Patient will exhibit improved fine motor coordination skills to facilitate patient's ability to grasp items during self-feeding with stand by assistance in order to improve functional use of upper extremity's during ADL's and perform ADL's w/ increased safety. Patient will increase activity tolerance for functional activities of choice in wheelchair 2 x week for 2 hours in order to help with implementation of compensatory strategies and with improved ROM and coordination and increase participation within environment. Patient will complete hygiene and grooming tasks while sitting in front of mirror with caregiver assistance with implementation of compensatory strategies in order to perform ADLs with increased safety. Patient will increase trunk strength to 2+ out of 5 in order to facilitate improved trunk balance, facilitate upright posture and increase core strength for functional activities. Patient will increase static sitting balance to poor using protective extension 70 percent of the time to right self in order to participate in edge of bed activities and decrease loss of balance during functional mobility. Patient will tolerate sitting up x 2hr for skin integrity: Therapy to treat once a day, 3 x week x 6 months. I prefer to have showers on Mon/Wed. On Wednesdays I prefer to have lotion applied with no shower: Showers including hair wash on Monday and Friday only Once a Day on Mon, Fri: 6pm-6am. Nail Care Once a Day on Mon, Wed, Fri: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>In an interview on 7/16/23 at 11am The Administrator and DON stated showers would be documented in the computer.<BR/>Record review on 7/16/23 at 12pm revealed the shower documentation on the computer was incorrect. It showed everyone had a shower, every day. The residents said they were not showered, the shower days were not every day, and the residents looked dirty and greasy.<BR/>In an observation on 7/17/23 at 10am The shower sheets in a binder at the South nurse's station were all blank.<BR/>In an interview on 7/18/23 at 3pm the DON said she was not sure and did not have a reason why the ADLs were not being done.<BR/>Resident # 44 <BR/>Record review of Resident #44's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia, behavior disturbance, upper respiratory infection, muscle wasting, lack of coordination, essential hypertension, Kidney complication and human immune deficiency, and diabetes.<BR/>Record review of Resident #44's admission MDS assessment dated [DATE] revealed his BIMS score 9 out of 15 reflected he was moderately intact on cognition. <BR/>Record review of ADL section on ADLs assessment indicated physical help in part bathing activities was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident #44's care plan dated his 11/14/22 edited 05/04/23 revealed -<BR/>-ADLs Functional Status/Rehabilitation I am limited in ability to toilet self R/T cognitive deficits.<BR/>-I require supervision to ensure I turn and reposition while in bed.<BR/>- ADLs Functional Status/Rehabilitation Potential, I am limited in ability to bathe self R/T cognitive deficits r/t dementia .<BR/>Goals: I will dress/undress self independently with supervision; I will bathe with assistance <BR/>Allow sufficient time to complete bathing.<BR/>Observation on 07/15/23 at 11:00am, revealed Resident #44 was in bed with dirty personal clothes on. He shirt had food stained on it. He had unkept facial hair and dirty long fingernails. <BR/>Observation and on 07/16/23 at 8:30AM, revealed resident #44 were in the dining room he had just finished his breakfast with the same dirty shirt on. During an interview, he said he had stroke and need assistance in caring for himself. He said he does not remember the last time he had a bath\shower. He said he would like to be shaved and cleaned up. He said nothing when asked if he had asked for any assistant.<BR/>During an interview with TNA S acknowledged that he needed to be cleaned up. She said we need more staff. <BR/>During an interview with LVN F asked Resident #44 if he would like to have a bath, shaved, and had his fingernails trimmed. He said yes. She said she would make sure that he was cleaned.<BR/>Resident #60 <BR/>Record review of Resident #60's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of end stage renal disease (kidneys stopped working), Type 1 diabetes with diabetic neuropathy (autoimmune disorder where pancreas stops making insulin with pain caused by nerve damage) , other disorders of electrolyte and fluid balance (when a large amount of body fluid is lost), chronic pain syndrome (symptoms beyond pain alone like depression and anxiety that interfere with life), major depressive disorder (persistent feeling of sadness and loss of interest), Type 2 diabetes with diabetic retinopathy (body doesn't produce insulin and a complication of diabetes causing blindness), muscle wasting and atrophy (decrease in size and thinning of muscle), and neuromuscular dysfunction of the bladder (nerves and muscles do not work in the bladder).<BR/>Record review of Resident #60's Comprehensive MDS dated [DATE], revealed a BIMS score of 13, which indicated normal cognition. The MDS also revealed the resident had impaired vision. According to the resident's preferences, it was very important for him to choose what clothes he wore, and it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The resident required extensive assistance with personal hygiene, dressing, transfer, and mobility. He required physical help with bathing and needed one-person physical assist. He used a wheelchair for mobility. Resident #60 had an indwelling catheter for a neurogenic bladder but was always incontinent of bowel.<BR/>In an interview and observation on 7/15/23 at 9:29am Resident #60 had long nails and was wearing a patient gown. He stated he had to use a Hoyer lift to get out of bed and into his wheelchair, but he was scared when he got into his wheelchair because there was never anyone around to get him back into bed. He had to get into his wheelchair on M/W/F for dialysis and it took a really long time for them to get him up and then for them to get him back in bed. His sheets had a yellow, urine stain on them. Resident had been vomiting for several days and had an emesis bucket under his chin. Resident was lying on his back in bed.<BR/>In an interview and observation on 7/16/23 at 9:45am Resident #60 said staff told him yesterday (7/15/23) that only CNAs could change him and not TNA's, so he had to wait a really long time to be changed. He stated he still had not had his teeth brushed yet today and had not had his sheets changed since Wednesday (7/12/23). A yellow, urine stain on his sheets was still observed. He also said had not had a bath since Monday (7/10/23) and he was observed with long nails. The resident was still laying supine in bed.<BR/>In an interview on 7/16/23 at 2:15pm Resident #60 said he had not been changed since 9am. He said he told TNA W at lunch time, and he just picked up his lunch tray and left and never came back.<BR/>In an interview on 7/16/23 at 2:19pm: The ADON did not know why someone had not changed Resident #60 and why he had been waiting since 9am. She stated she would go change him.<BR/>In an interview on 7/17/23 at 9:39am Resident #60 stated he waited over 8hrs to be changed yesterday (7/16/23) afternoon due to having so many TNAs and only 1 or 2 CNAs. He stated he was last checked at 4-5am today. He said he still had not been bathed, had his teeth brushed, nails trimmed, or been shaved.<BR/>In an interview and observation on 7/17/23 from 9:45am-10:15am Resident #60 was ringing his hand held, manual bell (call bell was not working), to be changed and the Restorative Nurse went into the room. The Restorative Nurse was observed shaving the roommate and not changing Resident #60. The Restorative Nurse did not change Resident #60. Resident #60 said he told TNA Y that he needed to be changed, but he never went back.<BR/>In an interview on 7/17/23 at 10:25am TNA Y said that he did tell Resident #20 that he was going to go back and change him, but he had been busy and had not had a chance to go back yet. He also said that was not assigned to Resident #60's side of the hall, that it was TNA C, but he always got called over there because he had all the muscle. He said the facility needs more staff because he was constantly running around.<BR/>In an observation on 7/18/23 at 3:00pm Resident #60 was never out of bed except to go to dialysis.<BR/>Record review of Resident #60's care plan, revised 7/16/23, revealed the resident will perform the following tasks at their highest practicable level: Nail Care Once a Day on Mon, Wed, Fri 6pm-6am, Oral Care Twice a Day 6am-6pm and 6pm-6am. I am at risk for pressure ulcers r/t decreased physical abilities-Resident's skin will remain intact: Keep linens clean, dry, and wrinkle free. I am limited in ability to transfer self r/t physical deficits-I will transfer self with extensive assistance: Remind me to not transfer without assistance. I am limited in ability to toilet self r/t physical deficits-I will toilet self with use of extensive assist x 1 staff: Provide extensive assistance for toileting. I am limited in ability to eat and drink r/t vision and cognitive deficits-I will be hydrated and well nourished as evidenced by stable weight. I am limited in ability to dress/undress self r/t physical and cognitive deficits-I will dress/undress self with extensive assistance. I am unable to independently change position while in bed as evidenced by requiring assistance with bed mobility-I will reposition self with bed rails and the assistance of one: Provide hands assistance for repositioning/transferring in and out of bed. Turn and reposition every 2 hours. I am limited in ability to maintain grooming/personal hygiene r/t cognitive and physical deficits-I will groom self with extensive assistance. I am limited in wheelchair mobility r/t physical deficits-Resident will achieve highest level of wheelchair mobility: Provide assistance for wheelchair mobility.<BR/>Resident #55 <BR/>Record review of Resident #55's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of myocardial infarction (heart attack), muscle wasting and atrophy (decrease in size and thinning of muscle), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness and paralysis after a stroke), protein-calorie malnutrition (lack of protein and calories in the diet), major depressive disorder (persistent feeling of sadness and loss of interest), heart failure (heart is not pumping as strong as it should), and dysarthria and anarthria (trouble speaking).<BR/>Record review of Resident #55's Comprehensive MDS dated [DATE], revealed a BIMS score of 9, which indicated moderately impaired cognition. Resident #55's MDS also revealed he had a serious mental illness. The resident had unclear speech and impaired vision. He felt it was very important to chose what clothes to wear, to choose between a tub bath, shower, bed bath, or sponge bath, and to go outside to get fresh air when the weather was good. Resident #55 required extensive assistance with personal hygiene, dressing, transfer, and bed mobility. He required physical help with bathing and two+ persons physical assist. He used a wheelchair for mobility. The resident was always incontinent of urine and bowel.<BR/>In an observation and interview on 7/15/23 at 9:22am Resident #55 had greasy looking hair, long facial hair, long nails, and had a patient gown on. He said there was never enough staff, and they never had enough supplies. He also said he had to wait long periods of time to be changed.<BR/>In an observation and interview on 7/16/23 at 9:49am Resident #55 said he had not had a shower in over a week. He said he was last changed at 5am. He stated he had not had his teeth brushed today or yesterday (7/15/23). He was observed still in a patient gown. He stated he would like his nails trimmed and would like to be shaved.<BR/>In an observation and interview on 7/16/23 at 9:39am Resident #55 said he still had not had his teeth brushed, had a shower, been shaved, or had his nails trimmed. He said he also needed to be changed. Resident's nails observed to be long and yellow. Resident's hair looked greasy, and he had not been shaved.<BR/>In an interview with the Restorative CNA on 7/16/23 at 10:15am The Restorative CNA said she just became Restorative on Saturday (7/15/23) and before that she worked in HR. She did not know why the resident was not shaved or had his nails trimmed sooner. She said the CNAs should have been shaving and brushing his teeth for him.<BR/>In an observation on 7/18/23 at 3:00pm The Resident had not been out of bed for the whole 4 days we were there.<BR/>Record review of Resident #55's care plan, revised 5/24/23, revealed I am at risk for pressure ulcers r/t left sided hemiplegia-My skin will remain intact: Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry, and wrinkle free. I have urinary incontinence; I have limited mobility due to left sided CVA-I will not develop skin breakdown related to incontinence: Check for incontinent episodes at least every 2 hours. I am limited in ability to transfer self r/t left side hemiplegia- I will transfer self with extensive assistance. I am limited in ability to toilet self r/t left sided hemiplegia-I will toilet with extensive assistance of one staff: Provide incontinence care as needed. I am limited in ability to dress/undress self r/t left sided hemiplegia-I will dress/undress self with extensive assistance: Allow me to choose own clothing, dress affected side first. I am limited in ability to maintain grooming/personal hygiene r/t CVA-I will groom self with limited assistance. I am limited in wheelchair mobility r/t left sided hemiplegia-I will achieve highest level of wheelchair mobility as evidenced by increased mobility. Resident #55 will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Tue, Thu, Sat: 6pm-6am. Nail Care Once a Day on Tue, Thu, Sat: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am. Resident experiences bladder incontinence-Resident will maintain current level of bladder continence: Provide incontinence care after each incontinence episode.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that:<BR/> The walk-in refrigerator had Sliced American Cheese in a plastic bag container dated 5/30/22<BR/>The facility failed to maintain proper holding temperature for the following food<BR/>Mixed Vegetable 86 degrees Fahrenheit<BR/>Cooked [NAME] 74 degrees Fahrenheit<BR/>Mexicali Corn 94 degrees Fahrenheit<BR/>Baked Chicken 67 degrees Fahrenheit<BR/>This failure could place residents at risk of foodborne illness and disease.<BR/>Findings included:<BR/>Observation of the facility's kitchen on 6/08/22 between 9:00 am and 9:45 am revealed:<BR/>Sliced American Cheese in a plastic container dated 05/30/22 stored in the walk-in refrigerator<BR/>Interview with the Food Service Director on 6/08/22 at 9:30 AM revealed that items / food stored in the refrigerator should be discarded after seven days. She stated she was responsible for training staff on proper storage /temperature for potentially hazardous /time control for safety to prevent residents at risk of foodborne illness and disease. She discarded the sliced American Cheese dated 5/30/22. <BR/>Observation of the kitchen worktable on 6/08/22 from 12:35 to 3:35PM the following food temperature <BR/>taken by the Food Service Director revealed the following:<BR/>A plastic container of Mixed Vegetables on ice bed bath had a temperature of 86 degrees Fahrenheit<BR/>A plastic container of cooked [NAME] on ice bed bath had a temperature of 74 degrees Fahrenheit<BR/>A plastic container of Mexicali Corn on ice bed bath had a temperature of 94 degrees Fahrenheit.<BR/>A Plastic container of Baked Chicken on ice bed bath had a temperature of 67 degrees Fahrenheit.<BR/>Interview with the Food Service Director on 06/08/22 at 3:35 PM revealed that leftover food saved for later used should be cooled in an ice bath. She indicated that the staff were cooling the food since 12:35 after Lunch Service properly. The facility failed to chill leftover food properly by placing food in 4-inch to 6-inch-deep pans. Chill from 140 degrees Fahrenheit to 70 degrees Fahrenheit in 2 hours. Food was chilling since 12:30 to 3:30 PM therefore; not using the HACCP Chill Method. I requested to see the temperatures taken as the food is cooling. No documentation was done. She stated that she was responsible for training staff on proper cooling foods. <BR/>Record review of facility's Food and Nutrition Services Policy and Procedure Manual on Food Storage dated 06/01, 2019 read in part' .Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the State, Federal and US Food Codes and Hazard Analysis Critical Control Point Plan (HACCP). Procedure: 2. Refrigerators. E. Use all leftovers within 72 hours. Discard items that are over 72hours old.<BR/>Record review of facility's Food and Nutrition Services Policy and Procedure Manual on Cooling and Reheating Foods dated 10/01, 2018 read in part' .Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be cooled and reheated according to the state, US Food Codes and Hazard Analysis Critical Control Point Plan (HACCP). Procedure: 1. Cooling Foods. a. Rapidly cool all potentially hazardous food requiring refrigeration after preparation to an internal temperature of 41 degrees Fahrenheit or below with in six hours or less. The total cooling time may not exceed six hours. b. Use the HACCP Chill Methods: I. place food in 2-inch-deep pans ii. Chill from 140 degrees Fahrenheit to 70 degrees Fahrenheit in first two hours iii. Chill from 70 degrees AA to 41 degrees Fahrenheit or below in next four hours iv. Take and record temperatures every 30 minutes to assure temperatures are decreasing according to the above schedule.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #12, #42, and #4) of 18 residents observed for infection control, in that:<BR/>1. Resident #12 had a foley catheter bag (a bag that contains urine) dragging on the floor throughout the facility while he was in his wheelchair and was leaking along the way.<BR/>2. Resident #42 was given oral medications by LVN D without washing her hands beforehand, and with bare hands.<BR/>3. Resident #4 had wound care performed by Dr. B without gloves being changed between the dirty dressing removal and a clean dressing applied.<BR/>These failures could place residents at risk for cross contamination and infection.<BR/>The findings include:<BR/>1. Record review of Resident #12's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE] with diagnoses of chronic diastolic heart failure, acute cystitis without hematuria, extended spectrum beta lactamase (ESBL) resistance, chronic kidney disease, gastrointestinal hemorrhage, muscle wasting and atrophy, unspecified dementia, dysphagia, restlessness and agitation-anxiety, depression, retention or urine, diabetes mellitus with diabetic neuropathy, and hypertension.<BR/>Record review of Resident #12's Quarterly MDS, dated [DATE], revealed he had a BIMS of 8 which indicated moderately impaired cognition. The MDS also revealed he had an indwelling catheter due to obstructive uropathy.<BR/>In an interview and observation on 7/15/23 at 3:12pm Resident #12 was observed rolling down the North Hall in his wheelchair with his foley bag dragging on the floor. The urine in the foley bag had a foul smell to it. He passed the nurse's station where the nurse engaged in conversation with him but did not do anything about the bag and continued through the lobby and out to the smoking area. Along the way the resident had urine leaking from his foley bag. The Surveyor went in to the ADON's office and asked for someone to come assist with the resident. The Restorative CNA came out to help. The Restorative CNA went out to the smoking area and brought Resident #12 back inside and said she needed to change his foley bag because it was leaking and said she was going to call housekeeping to clean the floor. The Restorative CNA sounded surprised that Resident #12 had made it all the way through the building without being stopped by saying, Oh my God. Really? Let me go get him. When she came back in the building with the Resident, the Restorative CNA called out loudly, Someone help me. I need some gloves. His foley is leaking.<BR/>Record review of Resident #12's care plan, revised 5/27/23, revealed: UTI, I am at risk for recurring UTI's: Antibiotics as ordered, Encourage fluids, I&Os, Monitor urine color, frequency, and burning. I require an indwelling catheter, I have BPH. I do not always understand and attempt to remove my catheter and I removed the drainage bag from the dignity bag and place it in the wheelchair seat beside me and above the level of my bladder-I will not exhibit signs of urinary tract infection or urethral trauma: Position bag below level of bladder, Relocate bag and remind resident when observed above bladder level. Provide catheter care every shift and PRN. Report symptoms of UTI. Use a catheter strap. Position bag below level of bladder. Store collection bag inside a protective, dignity pouch, relocate bag back to dignity bag and remind resident of need to keep below level of bladder when observed in seat. I am limited in ability to transfer self r/t weakness-I will transfer self with assistance of one staff. I am limited in ability to manage catheter r/t cognitive decline-I will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or trauma.<BR/>2. Record review of Resident #42's undated face, sheet revealed he was a [AGE] year-old male readmitted on [DATE] with diagnoses of ankylosing spondylitis of the spine, anxiety, schizoaffective disorder, idiopathic progressive neuropathy, chronic pain, neurogenic arthritis, muscle wasting and atrophy, and depression.<BR/>Record review of Resident #42's Comprehensive MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderately impaired cognition. The MDS also revealed he had unclear speech, he had difficulty communicating some words or finishing thoughts, and missed some part/intent of the message but comprehended most conversation. According to the MDS, Resident #42 required extensive assistance with personal hygiene, eating, dressing, and bed mobility and required 2 people to physically assist him. Resident #42 was on a mechanically altered diet, which required a change in texture of food or liquids.<BR/>In an interview and observation on 7/16/23 at 1:34pm LVN D was observed using hand sanitizer and then quickly using a tissue to wipe it off. She then proceeded to put Resident #42's medication in a medication cup without putting any gloves on. She entered the room and picked up the medication tablets with her bare hands and placed them in Resident #42's mouth. During the process she went and grabbed the resident's water pitcher and touched his bed remote and kept giving the medications without cleaning her hands or applying gloves. LVN D said she did not wear gloves because her hands were clean. She stated she did not touch the water pitcher and the bed remote with the same hand she used to pick up the medication and place in Resident #42's mouth. She understood because of infection control issues, she should have worn gloves.<BR/>Record review of Resident #42's care plan, revised 6/19/23, revealed: ADL Function/Rehab Potential-I will achieve maximum functional mobility: Ambulation/Transfers amount of assist-Extensive, Bathing/hygiene amount of assist-Extensive, Consult PT/OT/ST as needed, Dressing/Grooming amount of assist-Extensive, Eating amount of assist-Limited, Toileting amount of assist-Extensive.<BR/>3. Record review of Resident #4's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE] with diagnoses of acute respiratory distress syndrome, contracture on the elbow and hand, persistent vegetative state, depression, muscle wasting and atrophy, dysphagia, stage 4 pressure ulcer of the left heel, stage 3 pressure ulcer of other site, stage 2 pressure ulcer of unspecified site, anoxic brain injury, pneumonia, gastrostomy, and sepsis.<BR/>Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS was not performed because the resident was in a persistent vegetative state. The resident required extensive assistance with personal hygiene, dressing, and bed mobility, and required 2 people physical assistance. According to the MDS Resident #4 had 2 stage 3 pressure ulcers and 1 stage 4 pressure ulcer.<BR/>Record review of Resident #4's wound management detail report from 7/18/23 at 11:56am revealed, the size of the pressure ulcer on the resident's right buttock was 5cm x 6cm. There was moderate exudate that was clear, no odor, and it was a stage 4 with necrotic tissue. According to the Wound Care nurse, the wound was stable.<BR/>Record review of Resident #4's wound care order from 7/11/23 by MD PB stated: Wound Treatment Order: Location: (R Buttock Full Thickness) Clean with Wound Cleanser, Pat dry Apply: Pack with Dakins 0.25% Soaked roll gauze secure with (Island Drsg of choice), Once a Day from 7am-3pm. Another wound care order from 7/11/23 by MD PB stated: Wound Treatment Order: Location: (R Medial Buttock) Clean with Wound Cleanser, Pat Dry Apply: (Collagen Powder then CA Alginate) Cover with Primary Dressing: (Island Drsg), Once a Day from 7am-3pm.<BR/>Record review of Resident #4's care plan, revised 6/7/23, revealed: Resident #4 is currently taking antibiotic/Keflex 500mg r/t GT wound infection-Resident infection to GT site will be resolved thru resolve date: Wound care Tx to GT site as ordered. Indwelling foley catheter at risk for infection-Resident will be free of complications related to indwelling catheter: Change catheter per MD order. Keep catheter system a closed system as much as possible. Provide catheter care every shift and as needed. Report UTI. Use catheter strap, assure enough slack is left in the catheter between the meatus and the strap. Stage 4 pressure wound r/t immobility. Full thickness wounds to right buttock-Heal pressure sores and skin breakdown within 90 days: Monitor site and notify MD for worsening symptoms. Wound care treatment as ordered per Hospice services. Alert-Elevated WBC's-Leukocytosis-Resolve Infection: Infection control per protocol. Meds as ordered. Monitor for s/s of infection. Resident #4 is at risk for skin breakdown due to decreased mobility, and incontinence-Resident #4 will have no skin breakdown during the next 90 days: I will need to have peri-care after each incontinent episode.<BR/>In an interview and observation on 7/17/23 at 10:17am Dr. B performed wound care on Resident #4's right hip and sacrum. Dr. B used hand sanitizer and applied gloves, then took off the resident's dirty wound dressing. Dr. B did not change gloves and then performed wound debridement. After wound debridement Dr. B wiped his dirty gloves on Resident #4's pillow that was at the foot of the bed. Dr. B did not change his gloves and then applied the resident's sterile wound care treatment followed by the sterile dressing. Dr. B said he must have forgotten to change his gloves. He said nothing will happen because the wound was already infected. He also said that he had 4 years of medical school and knew what he was doing.<BR/>Record review of the facility's policy and procedures on Infection Preventionist (Revised July 2016) read in part: The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control polices and practices. 1. The Infection Preventionist (or designee) shall coordinate the development and monitoring of our facility's established infection prevention and control policies and practices. 2. The Infection Preventionist shall report information related to compliance with our facility's established infection prevention and control policies and practices to the Administrator and Quality Assurance and Performance Improvement Committee .5. The Infection Preventionist .consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidenced-based infection prevention and control practices.<BR/>Record review of the facility's policy and procedures on Administering Medications (Revised April 2019) read in part: Medications are administered in a safe and timely manner, and as prescribed .2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions .21. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.<BR/>Record review of the facility's policy and procedures on Wound Care (Revised June 2022) read in part: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on clean gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. 6. Put on clean gloves .7. Use no touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wash wound in a circular motion from the inside out with ordered wound cleanse. 10. Apply treatments and dress wound as ordered by physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 13 (Resident rooms 100, 101, 102, 103, 105, 107, 109, 111, 115, 117, 119, 121, and 215) out of 27 resident rooms reviewed for environment.<BR/>The facility failed to have a working light on the outside of the room that would light up when the resident pushed the call bell for Resident rooms 100, 101, 102, 103, 105, 107, 109, 111, 115, 117, 119, 121, and 215.<BR/>This failure could place residents at risk of not being able to get staff assistance when needed.<BR/>The findings include:<BR/>1. Record review of the resident roster from 7/15/23, revealed Resident #60 was in room [ROOM NUMBER]A. <BR/>Record review of Resident #60's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of end stage renal disease (kidneys stopped working), Type 1 diabetes with diabetic neuropathy (autoimmune disorder where pancreas stops making insulin with pain caused by nerve damage, other disorders of electrolyte and fluid balance (when a large amount of body fluid is lost), chronic pain syndrome (symptoms beyond pain alone like depression and anxiety that interfere with life), major depressive disorder (persistent feeling of sadness and loss of interest), Type 2 diabetes with diabetic retinopathy (body doesn't produce insulin and a complication of diabetes causing blindness), muscle wasting and atrophy (decrease in size and thinning of muscle), and neuromuscular dysfunction of the bladder (nerves and muscles do not work in the bladder).<BR/>Record review of Resident #60's Comprehensive MDS dated [DATE], revealed a BIMS score of 13, which indicated normal cognition. The MDS also revealed the resident had impaired vision. According to the resident's preferences, it was very important for him to choose what clothes he wore, and it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The resident required extensive assistance with personal hygiene, dressing, transfer, and mobility. He required physical help with bathing and needed one-person physical assist. He used a wheelchair for mobility. Resident #60 had an indwelling catheter for a neurogenic bladder but was always incontinent of bowel.<BR/>Record review of Resident #60's care plan, revised 7/16/23, revealed: I am at risk for falling r/t physical and vision deficits-I will remain free from injury: Give me verbal reminders not to ambulate/transfer without assistance. Observe frequently. I am limited in ability to transfer self r/t physical deficits-I will transfer self with extensive assistance: Keep call light within reach. Remind me to not transfer without assistance. I am limited in ability to toilet self r/t physical deficits-I will toilet self with use of extensive x 1 staff: Provide extensive assistance for toileting. Remind me to not transfer without assistance. I have severely impaired vision r/t DM and ESRD-I will not experience negative consequences of vision loss as evidenced by remaining physically safe and participating in social and self-care activities: Assess effect of vision loss on functional status. Provide an environment free of clutter.<BR/>In an interview and observation on 7/15/23 at 9:29am Resident #60 stated the call bell had not worked in several months. He said that he had told the nurses, CNAs, and maintenance. He also said that maintenance told him that they would have to call an electrician, but nothing had been done so far. He stated if he needed anything, he had to yell out. Resident #60 pushed the call bell and the light outside his door did not light up, even though the red light on the wall was lit up.<BR/>2. Record review of the resident roster from 7/15/23, revealed Resident #55 was in room [ROOM NUMBER]B.<BR/>Record review of Resident #55's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of myocardial infarction (heart attack), muscle wasting and atrophy (decrease in size and thinning of muscle), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness and paralysis after a stroke), protein-calorie malnutrition (lack of protein and calories in the diet), major depressive disorder (persistent feeling of sadness and loss of interest), heart failure (heart is not pumping as strong as it should), and dysarthria and anarthria (trouble speaking).<BR/>Record review of Resident #55's Comprehensive MDS dated [DATE], revealed a BIMS score of 9, which indicated moderately impaired cognition. Resident #55's MDS also revealed he had a serious mental illness. The resident had unclear speech and impaired vision. He felt it was very important to choose what clothes to wear, to choose between a tub bath, shower, bed bath, or sponge bath, and to go outside to get fresh air when the weather was good. Resident #55 required extensive assistance with personal hygiene, dressing, transfer, and bed mobility. He required physical help with bathing and two+ person's physical assist. He used a wheelchair for mobility. The resident was always incontinent of urine and bowel.<BR/>Record review of Resident #55's care plan, revised 7/16/23, revealed: I am at risk for falling r/t left sided hemiparesis-I will remain free from injury: Keep bed in lowest position with brakes locked. Keep call light in reach at all times. I am limited in ability to transfer self r/t left side hemiplegia-I will transfer self with extensive assistance: Keep call light within reach. Remind me to not transfer without assistance. I am limited in ability to eat and drink r/t left sided hemiplegia-I will be well hydrated and well-nourished as evidenced by stable body weight: Observe me closely for signs of choking. I have impaired vision. I can only read large print-I will not experience negative consequences of vision loss as evidenced by remaining physically safe and participating in social and self-care activities: Keep call light in reach at all times. Provide an environment free of clutter. Resident experiences bladder incontinence-Resident will maintain current level of bladder continence: Keep call light in reach. Provide incontinence care after each incontinent episode.<BR/>In an interview and observation on 7/15/23 at 9:22am Resident #55 stated the call bell had not worked in several months, even though nursing, CNAs, and maintenance had been told. He stated that he was bedbound and would have to yell out if he needed help. The call bell was pushed, and the call light did not light up outside of the room, even though the red button was lit up on the wall.<BR/>In an observation on 7/15/23 at 9:15am it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room.<BR/>In an observation on 7/15/23 at 9:17am it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room.<BR/>In an observation on 7/15/23 at 9:20am it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room.<BR/>In an observation on 7/15/23 at 9:22am it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room.<BR/>In an observation on 7/15/23 at 9:25am it was revealed the call light in resident room [ROOM NUMBER] was not working. There was 1 resident assigned to the room.<BR/>In an observation on 7/15/23 at 9:28am it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room.<BR/>In an observation on 7/15/23 at 9:30am it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room.<BR/>In an observation on 7/15/23 at 9:32am it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room.<BR/>In an observation on 7/15/23 at 10:00am it was revealed the call light for resident room [ROOM NUMBER] on the Secure Unit, was not working. There were 2 residents in the room, but they were not able to be interviewed. <BR/>In an observation and interview on 7/15/23 at 12:30pm it was revealed resident room [ROOM NUMBER] was not working. There were 2 residents that stayed in the room. Resident #4 was not able to be interviewed and bed Resident #77 was not in his room. CNA W stated Resident #4 was unable to use the call light, but he would report it to the Maintenance Director.<BR/>In an observation on 7/15/23 at 1:20pm it was revealed the call light in resident room [ROOM NUMBER] was not working. There were 2 residents assigned to the room. Resident #45 was lying in bed and Resident #32 was not in the room.<BR/>In an observation on 7/15/23 at 3:00pm it was revealed the call light was not working in resident room [ROOM NUMBER].<BR/>In an observation on 7/16/23 at 8:54am it was revealed the call light was not working on the outside of the room for Resident #60 and #55, but it was ringing at the nurse's station.<BR/>In an interview with the Director of Maintenance on 7/15/23 at 3:00pm he stated he had to buy a part for the call light on the outside of the room for room [ROOM NUMBER]. He stated he was going to replace it on 7/17/23, but he would do it on 7/16/23 instead. The Director of Maintenance did not know about the other call lights not working. He said he would look at them on 7/17/23.<BR/>In an interview with the Maintenance Director on 7/16/23 at 10:47am, he stated he was still working on the call light outside of the room for room [ROOM NUMBER], because the call light was not getting power.<BR/>In an observation and interview on 7/16/23 at 2:15pm, Residents #60 and #55 in room [ROOM NUMBER], revealed their call light was still not working.<BR/>In an interview and observation on 7/17/23 at 9:39am Residents #60 and #55 in room [ROOM NUMBER], revealed their call light was not working. They were given a bell to ring since their call light did not light up.<BR/>In an interview with the Administrator on 7/17/23 at 4:00pm regarding the call bells not working, he stated staff checked the call bells every few days to ensure they were functioning. He also stated the facility had a backup plan if they were not working, so it was not a big deal if there were some call bells out because they found them and fixed them quickly. The Administrator did not agree that the call light had been out for several months for Residents #60 and #55. He stated the backup plan was that residents were given bells if their call lights were not working, and Resident #60 and Resident #55 would have had a bell because they had enough for the whole facility. The Administrator was informed that Residents #60 and #55 were not given a bell until today (7/17/23).<BR/>In an interview and observation on 7/18/23 at 9:10am Residents #60 and #55 in room [ROOM NUMBER], stated their call light was working.<BR/>Record review of the facility's policy and procedures on Answering the Call Light (Revised March 2021) read in part: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. 1. Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. 2. Ask the resident to return the demonstration .4. Be sure that the call light is plugged in and functioning at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 6. Some residents may not be able to use their call light. Be sure you check these residents frequently. 7. Report all defective call lights to the nurse supervisor promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (Resident #70) of 18 reviewed for abuse. <BR/>The facility failed to ensure Resident #70, who was cognitively impaired, had a history of aggressive behaviors, and resided in the facility's memory care unit, was free from abuse when she was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. The IJ template was provided to the facility on [DATE] at 5:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures placed cognitively impaired residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. <BR/>Findings include:<BR/>Record review of Resident #70's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Diffuse Lewy Body (protein deposits which develop in nerve cells in the brain), psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), muscle wasting and atrophy (muscles that lose their nerve supply can decrease in size and waste away), chronic skin ulcers (ulcers that do not heal well after 12 weeks), dysphagia- oropharyngeal phase (difficulty initiating a swallow and generally due to structural , anatomical or neuromuscular abnormalities), cognitive communication deficit (difficulty with thinking and how someone uses language), restlessness and agitation (a common symptom of anxiety that makes someone have an uncomfortable urge to move), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and chronic pain of the right hip joint. Resident #70 died on [DATE].<BR/>Record review of Resident #70's MDS dated [DATE] revealed she had a BIMS of 00 (severe cognitive impairment); she did not have hallucinations or delusions; she did not exhibit physical, verbal, or other behavioral symptoms towards others and she did not reject care. Resident #70 required extensive physical assistance from at least two staff for bed mobility, dressing, toilet use, and bathing; she required extensive physical assistance from one staff for transfers, walking, locomotion, eating, and personal hygiene; used a wheelchair for mobility and required substantial/maximum assistance; had an unsteady gait and was only able to stabilize with staff assistance; was always incontinent of bowel and bladder; had a history of falls; had skin tears; and was prescribed antianxiety and antidepressant medications. <BR/>Record review of Resident #70's care plan revised [DATE] revealed the following care areas:<BR/>*Resident #70 had pustules (a bulging patch of skin that is full of a yellowish fluid called pus) to the right ankle and left pinky toe. Goals included: Resident will not develop complications from foot problems as evidenced by not exhibiting infection or pain. Approach included: Apply dressing with topical medication.<BR/>*ADLs Functional Status/Rehabilitation Potential. Goals Included: Resident will achieve maximum functional mobility. Approach included: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Eating amount of assist: Extensive. Toileting amount of assist: Extensive. Consult PT, OT, ST as needed. Personal care as per facility protocol.<BR/>*Behavioral Symptoms. Resident did not adjust well to change. Resident was verbally and physically aggressive. At times, Resident crawled on the floor and over beds, and was not always easily redirected. Goals included: Resident will have fewer episodes of verbal and physical aggression. Approach included: Always ask for help if resident becomes abusive/resistive. Convey acceptance of acceptance during periods of inappropriate behavior. Encourage diversional activities. Keep environment calm and relaxed. Remove from public area when behavior is unacceptable. <BR/>*Cognitive Loss/Dementia. Goals included: Resident will be as alert and oriented as possible. Approach included: Anticipate needs and observe for non-verbal cues. Approach in calm manner. Explain what you intend to do while providing care. Introduce self. Orient PRN to person, place, and time. <BR/>*Communication. Goals included: Resident needs/wants will be met at all times. Approach included: Ask simple yes/no questions and allow adequate time to respond. Do not pretend to understand, request clarification when needed. Speak directly to resident in a clear voice facing him/her. <BR/>*Mood State. Goals included: Resident will express/exhibit satisfaction. Approach included: Assess, monitor, and document mood. Be reassuring and listen to concerns. Encourage group activities. Medications as ordered. Social Services to visit 1:1.<BR/>*Pressure Ulcer/Injury/Skin Care. Resident had thin and fragile skin. Resident got skin tears often and could not remember what caused the skin tears. Goals included: Prevent/heal pressure sores and skin breakdown. Approach included: Follow facility skin care protocol. Preventative Measures. Report to charge nurse any redness or skin breakdown immediately. Treatment as ordered. <BR/>*Psychotropic Drug Use. Alprazolam, Paxil, Trazodone, Depakote. Goals included: Benefit without side effects. Approach included: Anti-Anxiety Medication Use - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. Anti-Depressant Medication Use - Observe resident closely for significant side effects: Common - sedation, drowsiness, dry mouth, blurred vison, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain. Gradual dose reduction. Monitor for side effects per psychotropic flowsheet. Monitor target behaviors per psychotropic flowsheets. <BR/>*Behavioral Symptoms. Resident had socially inappropriate/disruptive behavioral symptoms as evidenced by: resident pinched, hit, scratched, and bit at staff. Goals included: Resident will not exhibit socially inappropriate/disruptive behavior. Approach included: Assess resident for placement in a specially designed therapeutic unit. Resident was on memory care unit for personal safety. Maintain a calm environment and approach to resident.<BR/>Observation and interview with Resident #70 on [DATE] at 10:30 a.m. revealed Resident #70 was in bed alert and yelling, Help, Help!. Resident #70 had bruises on her right leg, and she was observed scratching the bruises. There was an unidentified staff member sitting beside her. Interview with the unidentified staff member revealed Resident #70 was always restless after breakfast but fell asleep after some time. The unidentified staff member said she was watching Resident #70 to make sure she did not attempt to get up and fall. <BR/>Record review of facility document entitled Concern Form dated [DATE] and signed by the Administrator revealed, Date received: [DATE]. Concern initiated by: Staff. Individual's name: [Housekeeper C] Concern reported to: DON, NHA nursing home administrator . Employee report concerns of yelling and screaming back in memory care unit . Individuals designated to take action on this concern: NHA/DON. Date assigned: [DATE]. Date to be resolved by: [DATE]. Was a group meeting held: No . Results of action taken: Resident screaming identified, care plan and behaviors reviewed, verbal education of employee due to behaviors and memory care unit, dementia, Alzheimer's . Was concern resolved? Yes, describe resolution. Employee stated she understood that dementia/Alzheimer's residents have behaviors that may include yelling, screaming, panicking, confusion, agitation, etc. Identify method used to notify the complainant of resolution: One-to-one discussion. Date: [DATE]. Was complainant satisfied with the resolution? Yes. Employee stated she understood behaviors. This form was completed by: NHA (Administrator). <BR/>In an interview with the Administrator, DON, and ADON on [DATE] at 11:15 a.m., the Administrator said there was a recent incident involving a resident who passed away in the facility on the previous day, Resident #70, but the staff member, Housekeeper C, did not tell them everything that happened. The DON stated Housekeeper C said she had concerns regarding Resident #70 because she was screaming. The DON said she told Housekeeper C that screaming in the memory care unit was not unusual. The DON said regarding the incident that was reported, the aides (she did not name the aides) were trying to transfer Resident #70 to her bed and calm her down. The DON said Resident #70 was confused and combative. The DON said the staff member took it (the incident with Resident #70) personally, and thought it was abuse. The Administrator said they (administration) looked into the incident involving Resident #70 and they did not think it was abuse. The Administrator said all Housekeeper C said was that Resident #70 was yelling. The Administrator said Housekeeper C never said abuse, just that the resident was yelling. The DON said Housekeeper C quit earlier that morning ([DATE]). The ADON said Housekeeper C never mentioned that she saw or heard anybody drop Resident #70, or that she fell. The ADON said Housekeeper C said Resident #70 was yelling and she had concerns. The ADON said Housekeeper C did not name the staff, but she did try to describe the staff. The DON stated they (administration) never figured out which staff Housekeeper C was talking about. The DON said Housekeeper C came back a second time after she voiced concerns, and she still could not identify the staff involved. The ADON said Housekeeper C expressed her concerns to her supervisor, the Housekeeping Supervisor. The ADON said the Housekeeping Supervisor did not notify them (administration) until the next day, which was last week. The ADON could not recall the day administration was notified by the Housekeeping Supervisor. The Administrator said they had good continuity of care in the memory care unit, so they kept the same staff in there for each shift. The Administrator said no staff from the memory care unit had been reassigned to work another area of the building. <BR/>In an interview with the Housekeeping Supervisor on [DATE] at 1:00 p.m., she stated Housekeeper C expressed concerns about Resident #70 to her on [DATE]. The Housekeeping Supervisor stepped out of the room twice at the beginning of the interview and kept saying, they (administration) were watching the door and keeping track of who entered the conference room to speak to the state surveyor about the incident. The Housekeeping Supervisor said Housekeeper C said she heard Resident #70 yelling down the hallway on [DATE], and it was concerning to her. The Housekeeping Supervisor said she explained to Housekeeper C that it was Resident #2 who always yelled in memory care, not resident #70. The Housekeeping Supervisor said Housekeeper C was fairly new to the facility and did not know residents' names. The Housekeeping Supervisor said Resident #2 always yelled, Help me! all day. The Housekeeping Supervisor initially said Housekeeper C did not say she saw anything, just that she heard yelling, and it made her uncomfortable. She said Housekeeper C was not able to say who the staff members were, just that the resident was yelling. The Housekeeping Supervisor said Resident #70 always yelled out, Stop, leave me alone. I do not want to sit down! The Housekeeping Supervisor said Housekeeper C sent a text message on Thursday, [DATE], at 10:27 p.m. saying it had been a rough and emotional day. She said when she saw the text message the next day, [DATE], she texted Housekeeper C asking her what happened and then she called Housekeeper C. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON on the next day, [DATE]. <BR/>In an interview with the Staffing Coordinator on [DATE] at 2:00 p.m., she stated she heard a few rumors regarding the incident involving Resident #70, but she did not know anything about it personally. She stated other staff (she would not name the staff) told her the incident involved Resident #70 and 2-3 aides, but she did not know who those aides were. She said staff had concerns because there was an incident with Resident #70 last week ([DATE]) and then she died over the weekend. She said other staff told her two aides were taking care of Resident #70 and they were swinging her around and she fell. The Staffing Coordinator said the fall was not reported and over the weekend Resident #70 was sick and vomited blood. She said the same staff always worked in the memory care unit and the same staff worked on the same days (the same staff always worked together and were off on the same days). The Staffing Coordinator said there was a lady who wanted to talk to the state surveyors about the incident, but she was scared and feared retaliation from administration. The Staffing Coordinator said the lady who wanted to talk said she saw some things but did not want to lose her job. She said recently, both TNA A and TNA B had been calling in sick, which was unusual. The Staffing Coordinator said one (TNA A or TNA B) was pregnant (she could not say which one). She said she did not know if anybody mentioned or questioned them about the incident regarding Resident #70. The Staffing Coordinator stated Housekeeper C was the original source of the information, but the person who wanted to talk to the state surveyors was a different person. <BR/>In a telephone interview with TNA A on [DATE] at 2:22 p.m., she stated she often cared for Resident #70, who was confused. She said Resident #70 tried to walk but could not. She said Resident #70 was sweet some days, but some days, she did not want to be bothered. She said Resident #70 had her days when she did not want anybody to touch her. TNA A said Resident #70 had a witnessed fall in the dining room ([DATE]) and when she returned from the hospital, she was strong like super woman and tried to walk. She said she worked with Resident #70 last week (she could not recall the day) and after that, she was moved around to work on another hall. She said on that last day with Resident #70, she was really just being herself, talking and trying to get out of bed. TNA A said she sat in the room with Resident #70 on that night around 8:00 p.m. or 9:00 p.m. She said on that night, after Resident #70 got her medication, she was antsy (anxious) and she did not want Resident #70 to get out of bed, so she sat with her until she fell asleep for about 15 minutes. TNA A said Resident #70 was not aggressive or combative that night. She said Resident #70 was wheeled into her room and she was given her medications. She said she heard Resident #70 moving around on the baby monitor at nurse' station. She said it sounded like Resident #70 was talking and had a regular conversation with somebody. TNA A said Thursday, [DATE] was like a normal night and nothing unusual happened. <BR/>In a telephone interview with TNA B on [DATE] at 2:44 p.m., she stated she worked nights in the memory care unit. She said Resident #70 could not walk but she tried. She said Resident #70 sometimes got fussy when she tried to provide care. TNA B said she gave Resident #70 some time when she got fussy and then came back and Resident #70 would allow her to give care. She said she was off Friday thru Sunday ([DATE] - [DATE]). TNA B said on [DATE], nothing unusual happened. She said Resident #70 had a lot of sores and she scratched them a lot. She said sometimes, nurses had to give Resident #70 first aide because she scratched the sores until they bled. She said Resident #70 never had a fall during her shifts. She said she worked on the North part of the building (not memory care) yesterday ([DATE]). <BR/>Record review of facility sign-in sheets for [DATE] revealed the following:<BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A and TNA B, indicating TNA A and TNA B worked that shift. <BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A. TNA B's name was scratched out and listed under Call Ins, indicating TNA A worked the shift, but TNA B called in for that shift. <BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: Both TNA A and TNA B's names were crossed out. TNA B's name was listed under Call Ins. TNA A's name was written in under 6:00 p.m. - 6:00 a.m. North Nursing Station but it was crossed out and, and went home was written under her crossed out name. <BR/>In an interview with the DON and ADON on [DATE] at 3:25 p.m., the DON said there should not have been any housekeepers on night shift that she knew of (6:00 p.m. - 6:00 a.m.). The ADON said the Housekeeping Supervisor told them it was Resident #70 that Housekeeper C was talking about. The DON had a small stack of papers and stated they were complaints the facility's administration had submitted to their corporate office against the Housekeeping Supervisor. The DON said they had issues with the Housekeeping Supervisor's performance for some time and she was aware. <BR/>In a telephone interview with Housekeeper C on [DATE] at 3:45 p.m., she stated she worked as a housekeeper in the facility for approximately one month and a couple of weeks, so she was familiar with Resident #70, and she would not confuse her for Resident #2. She said she worked all over the building and her normal shift was 6:00 a.m. until 12:00 p.m., but she also worked nights sometimes from 3:00 p.m. - 8:00 p.m. She said she was cleaning in the memory care unit on [DATE] and she heard a lady, Resident #70, screaming. She said earlier that day, Resident #70 was perfectly fine. She said at 7:12 p.m. exactly, two of the night shift girls (TNA A and TNA B) had Resident #70 stripped naked with no brief, twirling her. She said Resident #70 was in her wheelchair and one of the staff was sitting in a regular chair behind the resident. She said the staff had her foot on the back of Resident #70's wheelchair like she was popping a wheelie with Resident #70's legs up in the air. She said the staff was moving Resident #70's wheelchair side to side and Resident #70 was screaming and hollering for her to stop. She said the screaming was what got her attention and she rolled her housekeeping cart to the very end of hall, where Resident #70's room was. She said another resident was walking by and told the staff to stop when she saw what the aides were doing to Resident #70. Housekeeper C said the aides were laughing during the incident. She said one of the aides was pregnant and the other was not. She said Resident #70 was bleeding, but she could not see where the blood was coming from. She said one of the aides wiped Resident #70's blood with her bed sheet. She said the pregnant aide saw her in the doorway and told her to get the bloody sheet. Housekeeper C said she picked up the bloody sheet, took it to laundry, then she went and clocked out. Housekeeper C said Resident #70's legs were still up in the air when she (Housekeeper C) walked out of the room with the bloody sheet. She said Resident #70 let out a very loud scream when she (Housekeeper C) was walking out of the room, but she did not know if that was when the staff let Resident #70's wheelchair down to the floor because she (Housekeeper C) did not turn around to look. She said she had a video of the incident that was only audio and no visual (she started recording with her phone when she heard Resident #70 screaming), but the DON made her delete it out of her phone when she was called in to report the incident. Housekeeper C said she initially reported the incident to her supervisor, the Housekeeping Supervisor, and then the DON told her to come into the office (the DON's office) and tell what her happened on Sunday, [DATE]. She said she had initially texted her supervisor the night of [DATE], but her (Housekeeping Supervisor) phone was off, and she did not see the message until the next day. She said the Administrator, DON, ADON, and the Housekeeping Supervisor were all present in the room when she reported what happened. She said there were six people in the room;, her, the Administrator, DON, ADON, Housekeeping Supervisor, and she could not name the last person. She said the video slipped her mind at first, so she did not mention it during the first meeting. She said the DON said sometimes they had to restrain residents when the residents tried to harm them. She said they told her she was too emotionally involved for that job. She said she told the DON and the Housekeeping Supervisor she thought Resident #70 was being abused because she was being abused. She said she also showed the video/audio to two other staff members (CNA K and TNA Y, but she did not say when this happened). Housekeeper C said CNA K and TNA Y asked her if she was going to report the incident to Resident #70's family member when she visited. She said CNA K told her Resident #70's leg was purple, and it looked like they (TNA A and TNA B) broke her leg. Housekeeper C said when Resident #70's family member visited her (she did not say what day this was), the family member said Resident #70 was perfectly fine when she ate lunch with her Tuesday ([DATE]). She said on her last day at the facility, Sunday, or Monday ([DATE] or [DATE]), Resident #70's family member was basically there saying her good-[NAME] to Resident #70. She said the DON called her into her office a second time on the same day and asked her who she had shown the video/audio to. She said she did not know how the DON found out about the video/audio, but after she played it for the DON, she made her air drop it to her (the DON) phone and then made her delete it from the phone and trash (in the phone). She said the DON said the voice in the audio was the lady who hollered all the time, Resident #2, but Housekeeper C said it was not Resident #2, it was Resident #70. She said they (administration) told her to think really hard about what she wanted to do at the facility and then they had her clock out. Housekeeper C said she quit when they told her to get out of the office and clock out. She said she tried to go to the facility and get paperwork to resume her state benefits earlier that morning ([DATE]) but they (administration) would not allow her into the building. She said she assumed it was because state was in the building, and they did not want her to talk. <BR/>In an interview with the DON on [DATE] at 4:15 p.m., she stated Housekeeper C never sent her a video or audio and she never heard one regarding the alleged incident with Resident #70. The DON said there was talk around the facility about a video or audio, but she never told Housekeeper C to delete it. <BR/>In a telephone interview with the Housekeeping Supervisor on [DATE] at 7:35 a.m. she said she was ready to tell the truth about what she knew regarding the incident with Resident #70. She said before she went to the conference room to speak with the state surveyor on [DATE], the DON texted her and told her to go to her (DON) office. She said the DON asked her what she was going to say to the state surveyor. She said she told the DON she was going to tell the state surveyor what Housekeeper C told her. She said the DON said please do not do that. She said the DON asked her to not tell the state surveyor everything. She said the DON told her to say Housekeeper C said she heard someone yelling down the hallway. The Housekeeping Supervisor said she was previously scared to talk to the state surveyor for fear of retaliation by administration. She said the Staffing Coordinator told her the DON called her into the office before she spoke to the state surveyor on [DATE] and told her the same thing, not to tell state the truth. She said Housekeeper C texted her on [DATE] at 10:27 p.m. and said she had an emotional day. She said she saw the text on Friday, [DATE] at 9:39 a.m. She said she called Housekeeper C on [DATE], after their 10:00 a.m. morning meeting. She said Housekeeper C told her that the pregnant girl at night and another one with her were involved. She said Housekeeper C said she was walking down the hall and saw Resident #70 naked in her wheelchair. She said Housekeeper C told her Resident #70 was trying to get up, but the staff were leaning the chair back and they started turning and twisting her in the air. She said Housekeeper C told her everybody kept coming up to her and asked who she reported the incident to and why she did not report it to them. She said Housekeeper C said she was scared to lose her job. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON after she spoke to Housekeeper C on [DATE]. She said the Administrator and DON had her call Housekeeper C into the DON's office on Sunday, [DATE] at 3:08 p.m. because they said they needed to talk to her. She said they all talked together, then the Administrator and DON asked the Housekeeping Supervisor to leave. She said they called Housekeeper C back into the office and the DON said there was a video. She said the DON found out about the video because Housekeeper C showed it to CNA K and TNA Y. She said Housekeeper C also told her that CNA K said Resident #70's ankle was broken. The Housekeeping Supervisor said she did not know about the video when they initially walked into the office. She said the DON asked her (Housekeeping Supervisor) to have Housekeeper C come back into the office. She said the Administrator and DON asked her (Housekeeping Supervisor) to leave out of the office. She said Housekeeper C came out crying and saying she was about to lose her job. She said she told Housekeeper C she was not supposed to be on the phone. She said she thought Housekeeper C recorded the video/audio because she was already on a video call while working that night. The Housekeeping Supervisor said they (administration) made her send Housekeeper C home because state was in the building. The Housekeeping Supervisor said she never saw the video/audio because the DON made Housekeeper C send the video/audio to her (DON) phone and then made Housekeeper C delete it. She said Housekeeper C said she thought Resident #70 was being mistreated to everyone in the DON's office. She said Housekeeper C told her the staff were spinning her around and that was not right. She said Housekeeper C said one resident in the hall told them to stop when she saw what they were doing to Resident #70. <BR/>Record review of a screenshot of a text message thread between the DON and the Housekeeping Supervisor's phone revealed, DON (Work) at the top of the text thread. On Wednesday, [DATE], at 12:39 p.m., the DON sent a text message that reflected, Need you to come to my office plz, and the Housekeeping Supervisor responded, On my way. <BR/>In an interview with the Administrator on [DATE] at 12:35 p.m., he stated there was no evidence Resident #70 was abused and employees denied it. He said the two people (Housekeeping Supervisor and Housekeeper C) who made the accusations did it in retaliation because he made them do their jobs. He said there was an ulterior motive to the allegations. He said the first they heard of the abuse was when the HHSC complaint came in ([DATE]). The Administrator said the only time Housekeeper C came to him about any concerns was on [DATE] when she had concerns about residents yelling in memory care. <BR/>In a follow up telephone interview with Housekeeper C on [DATE] at 1:00 p.m., she said on [DATE] at 7:12 p.m., she knew Resident #70 was being mistreated by the two staff (TNA A and TNA B) in the room, so she did not know what else to do but turn her video on her phone and put it (her phone) in her pocket. She said she went to the room so the video could pick up the audio of the resident yelling Stop It!, Help!. She said the resident was stripped naked, in a wheelchair with it propped back in a wheelie, and the staff members were laughing. She said another resident went by and told the staff members to stop and leave her alone, and the staff members told her to shut up and go to your room. Housekeeper C said she started to walk off and one of the staff members called her back and gave her a sheet with blood on it to take. She said she took it and walked away to put the sheet in the laundry, then she clocked out. She said when she was walking away, she heard a loud scream from the same resident that she had never heard before. She said she knew something was wrong but was too afraid to turn around at that point and she clocked out and left. She said she called the Housekeeping Supervisor as soon as she clocked out, but her phone was turned off. She said when she got to work the next day on [DATE], she told the Housekeeping Supervisor about what happened, and the Housekeeping Supervisor went to tell the Administrator and DON. She said she was called into the DON's office and told them that Resident #70 was being mistreated and what happened. She said they asked the Housekeeping Supervisor to leave the room and continued to talk to her (Housekeeper C). She said the DON said the staff could have been trying to use some kind of restraint with the resident. She said the Administrator asked her to send the video to him, but she was unable to, so the DON said to airdrop it to her. She said after she sent the video to the DON, she told her to delete it from her phone. She said her last day of work was on [DATE]. She said they (administration) told her she was too emotional and to think about what she really wanted to do. She said she went back up to the facility on [DATE] to try to get papers for her benefits and the ADON kicked her out of the facility and said she was not allowed back in the facility. She stated she never filled out a concern form or was even at the facility on [DATE]. She said she did not have a backup of the video and did not send it to anyone else besides CNA K and TNA Y. Housekeeper called back on [DATE] at 1:15 p.m. crying and said that her cellular phone maker told her if the video was deleted from the phone, there was nothing they could do.<BR/>In an interview with TNA Y on [DATE] at 1:23 p.m., he stated he did not see a video (regarding Resident #70), but he heard about it from Housekeeper C and other staff in the facility. He said he was never told to not say anything or hide anything. He said when he heard about what was on the recording, he thought it was horrible. <BR/>In an interview with the Staffing Coordinator on [DATE] at 3:05 p.m., she stated she received a call on [DATE] in the evening, after she was at home from the ADON. She said the ADON asked if TNA A and TNA B were on the schedule for [DATE], and she said no. She said when she came to work on [DATE], one of the aides (she did not say who) was really upset because Resident #70 had passed away. She said the anonymous aide stated, If it had anything to do with what I am hearing about, I am not comfortable. The Staffing Coordinator stated Housekeeper C was not the one who gave her the anonymous note to show the state surveyors (the Staffing Coordinator was given an anonymous note to show the state surveyors on [DATE], saying they had concerns about a resident who passed away. The anonymous person never approached the state surveyors in fear of retali[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and the facility failed to ensure the results of all investigations were reported to the administrator or his or her designated representative and to other officials in accordance with State law, which included the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action was taken for 2 of 11 residents (CR#1 and Resident#2) reviewed for abuse and neglect.<BR/>-The facility failed to report the results of a completed investigation to the State Survey Agency (SSA) within 5 working days involving the alleged abuse of Resident #2 by CR #1 that occurred on 04/12/2023. <BR/>This failure could place residents at risk if interventions are not put in place to prevent further abuse.<BR/>Findings include:<BR/>Resident #2:<BR/>Record review of the, undated, face sheet for Resident#2 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His primary diagnosis included cerebrovascular disease.<BR/>Record review of Resident#2 Quarterly MDS assessment, dated 05/03/2023, revealed the BIMS score of 6, which indicated severely impaired cognitive skills. <BR/>CR#1:<BR/>Record review of the, undated, face sheet for CR#1 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 04/12/2023. Her primary diagnosis included altered mental status. <BR/>Record review of CR#1 admission MDS assessment, dated 04/12/2023, revealed the BIMS score of 99, as the resident was unable to complete the interview, an indicated severely impaired cognitive skills.<BR/>Record review of SSA reporting database revealed that the completed PIR was submitted on 05/02/2023with allegations of Resident/Patient/Client Abuse, that were unfounded.<BR/>Record review of completed PIR for was signed by the DON on 4/19/2023. <BR/>In an interview on 05/03/2023 at 9:57am with the CRN, she said that she was a RN and had work for the corporate office in her current position for two years. She said that she discovered that the completed PIR for the incident involving Resident #2 and CR #1 was not submitted to the SSA timely while going through a stack of documents, and she had the DON submit it on 05/02/2023. She said that the PIR should have been submitted within 5 days on 04/19/2023 as indicated in the policy for Abuse and Neglect. She said that the oversight for completing the task belonged to the Administrator who is the Abuse Neglect Coordinator. She said the facility was without an Administrator from 03/31/2023-04/16/2023. She said that Admin #1 was at the facility from 4/10/2023-4/14/2023, she completed the investigation, and she left instructions for the DON to submit the PIR to the SSA in her absence. She said that Admin #2 started his position on 04/17/2023, and he claimed that he was not made aware of an outstanding PIR that needed to be submitted to the SSA. She said that the risk of not completing or submitting investigation to the SSA timely is the abuse or neglect could continue. <BR/>In an interview on 05/03/2023 at 11:04am with the DON, she said that she is an RN and she started her current position on 03/31/2023. She said that Interim Admin was the abuse coordinator at the time the incident was investigated, and it was the responsibility of Interim Admin to submit the completed PIR to the SSA. She said she was not aware that the PIR was not submitted until 05/02/2023, when the CRN told her to submit it to the SSA. She said that a completed PIR should be submitted to SSA within 5 days according to facility policy. She said the PIR for the incident involving Resident #2 and CR #1 was not submitted timely, and she was never made aware that she needed to submit it to SSA. She said that that risk of not completing investigations and not having the completed PIR submitted to the SSA is that the alleged abuse could continue and happen to other residents. <BR/>In an interview on 05/03/2023 at 11:37am with Admin#2, he said that he started his current position on 04/17/2023, and he was not told about any outstanding PIR that needed to be submitted to the SSA. He said that a completed PIR should be submitted to the SSA in 5 days. He said that the Administrator or designee (DON) should submit completed PIR to the SSA. He said that the risk is resident safety because interventions to prevent further abuse may not be put in place. <BR/>In a phone interview on 05/03/2023 at 3:35pm with the Interim Admin, she said that she works for the facility's corporate office as a traveling Administrator when there is a vacancy. She said that she was at the facility for a number of days at the beginning of April of 2023, and she believed that her last day was on 04/13/2023. She stated that while she was at the facility, she completed two PIR's, was unsure of the intake numbers, but she was only able to submit one to the SSA. She stated that she left instructions for Admin #2 to submit the second PIR to the SSA. She said that she did not talk to Admin #2, but she left detailed instructions for a number of things that he would need to complete on his start date, and she did not thing think he would have problems being an experienced Administrator. She said that the PIR was not due to the SSA until 4/18/2023 or 4/19/2023. She said the DON was in charge from her last day on 4/13/2023 until 4/17/2023 when Admin #2 started. She said that a completed PIR should be submitted to the SSA in 5 days, and the risk to residents by not doing so is that abuse or neglect could continue. <BR/>Record review of the facility's undated policy titled Abuse and Neglect Policy and Procedure, read in part: . Report/Respond 1. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source or abuse is reported, the facility Administrator, or his/her designee, will notify the Department of Aging and Disabilities Services (immediately upon learning of the incident and a written investigation no later than the fifth working day after the oral report . ).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 18 residents (Resident #70) reviewed for abuse. <BR/>The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and report an allegation of abuse in the facility's locked memory care unit when Resident #70, who was cognitively impaired and had a history of aggressive behaviors, was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE].<BR/>The facility's administration failed to initiate protective interventions and continued to allow TNA A to provide care for Resident #70 ([DATE]) after the abuse incident. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. The IJ template was provided to the facility on [DATE] at 5:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and emotional distress. <BR/>Findings included:<BR/>Record review of Resident #70's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Diffuse Lewy Body (protein deposits which develop in nerve cells in the brain), psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), muscle wasting and atrophy (muscles that lose their nerve supply can decrease in size and waste away), chronic skin ulcer (ulcers that do not heal well after 12 weeks), dysphagia- oropharyngeal phase (difficulty initiating a swallow and generally due to structural , anatomical or neuromuscular abnormalities), cognitive communication deficit (difficulty with thinking and how someone uses language), restlessness and agitation (a common symptom of anxiety that makes someone have an uncomfortable urge to move), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and chronic pain of the right hip joint. Resident #70 died on [DATE].<BR/>Record review of Resident #70's MDS dated [DATE] revealed she had a BIMS of 00 (severe cognitive impairment); did not have hallucinations or delusions; did not exhibit physical, verbal, or other behavioral symptoms towards other; did not reject care; required extensive physical assistance from at least two staff for bed mobility, dressing, toilet use, and bathing; she required extensive physical assistance from one staff for transfers, walking, locomotion, eating, and personal hygiene; used a wheelchair for mobility and required substantial/maximum assistance; had an unsteady gait and was only able to stabilize with staff assistance; was always incontinent of bowel and bladder; had a history of falls; had skin tears; and she was prescribed antianxiety and antidepressant medications. <BR/>Record review of Resident #70's care plan revised [DATE] revealed the following care areas:<BR/>*Resident #70 had pustules (a bulging patch of skin that is full of a yellowish fluid called pus) to the right ankle and left pinky toe. Goals included: Resident will not develop complications from foot problems as evidenced by not exhibiting infection or pain. Approach included: Apply dressing with topical medication.<BR/>*ADLs Functional Status/Rehabilitation Potential. Goals Included: Resident will achieve maximum functional mobility. Approach included: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Eating amount of assist: Extensive. Toileting amount of assist: Extensive. Consult PT, OT, ST as needed. Personal care as per facility protocol.<BR/>*Behavioral Symptoms. Resident did not adjust well to change. Resident was verbally and physically aggressive. At times, Resident crawled on the floor and over beds, and was not always easily redirected. Goals included: Resident will have fewer episodes of verbal and physical aggression. Approach included: Always ask for help if resident becomes abusive/resistive. Convey acceptance of acceptance during periods of inappropriate behavior. Encourage diversional activities. Keep environment calm and relaxed. Remove from public area when behavior is unacceptable. <BR/>*Cognitive Loss/Dementia. Goals included: Resident will be as alert and oriented as possible. Approach included: Anticipate needs and observe for non-verbal cues. Approach in calm manner. Explain what you intend to do while providing care. Introduce self. Orient PRN to person, place, and time. <BR/>*Communication. Goals included: Resident needs/wants will be met at all times. Approach included: Ask simple yes/no questions and allow adequate time to respond. Do not pretend to understand, request clarification when needed. Speak directly to resident in a clear voice facing him/her. <BR/>*Mood State. Goals included: Resident will express/exhibit satisfaction. Approach included: Assess, monitor, and document mood. Be reassuring and listen to concerns. Encourage group activities. Medications as ordered. Social Services to visit 1:1.<BR/>*Pressure Ulcer/Injury/Skin Care. Resident had thin and fragile skin. Resident got skin tears often and could not remember what caused the skin tears. Goals included: Prevent/heal pressure sores and skin breakdown. Approach included: Follow facility skin care protocol. Preventative Measures. Report to charge nurse any redness or skin breakdown immediately. Treatment as ordered. <BR/>*Psychotropic Drug Use. Alprazolam, Paxil, Trazodone, Depakote. Goals included: Benefit without side effects. Approach included: Anti-Anxiety Medication Use - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. Anti-Depressant Medication Use - Observe resident closely for significant side effects: Common - sedation, drowsiness, dry mouth, blurred vison, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain. Gradual dose reduction. Monitor for side effects per psychotropic flowsheet. Monitor target behaviors per psychotropic flowsheets. <BR/>*Behavioral Symptoms. Resident had socially inappropriate/disruptive behavioral symptoms as evidenced by: resident pinched, hit, scratched, and bit at staff. Goals included: Resident will not exhibit socially inappropriate/disruptive behavior. Approach included: Assess resident for placement in a specially designed therapeutic unit. Resident was on memory care unit for personal safety. Maintain a calm environment and approach to resident.<BR/>Observation and interview with Resident #70 on [DATE] at 10:30 a.m. revealed Resident #70 was in bed alert and yelling, Help, Help!. Resident #70 had bruises on her right leg, and she was observed scratching the bruises. There was an unidentified staff member sitting beside her. Interview with the unidentified staff member revealed Resident #70 was always restless after breakfast but fell asleep after some time. The unidentified staff member said she was watching Resident #70 to make sure she did not attempt to get up and fall. <BR/>Record review of facility document entitled Concern Form dated [DATE] and signed by the Administrator revealed, Date received: [DATE]. Concern initiated by: Staff. Individual's name: [Housekeeper C]. Concern reported to: DON, NHA . Employee report concerns of yelling and screaming back in memory care unit . Individuals designated to take action on this concern: NHA/DON. Date assigned: [DATE]. Date to be resolved by: [DATE]. Was a group meeting held: No . Results of action taken: Resident screaming identified, care plan and behaviors reviewed, verbal education of employee due to behaviors and memory care unit, dementia, Alzheimer's . Was concern resolved? Yes, describe resolution. Employee stated she understood that dementia/Alzheimer's residents have behaviors that may include yelling, screaming, panicking, confusion, agitation, etc. Identify method used to notify the complainant of resolution: One-to-one discussion. Date: [DATE]. Was complainant satisfied with the resolution? Yes. Employee stated she understood behaviors. This form was completed by: NHA (Administrator). <BR/>Record review of facility sign-in sheets for [DATE] revealed the following:<BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A and TNA B, indicating TNA A and TNA B worked that shift. <BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A. TNA B's name is scratched out and listed under Call Ins, indicating TNA A worked the shift, but TNA B called in for that shift. <BR/>[DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: Both TNA A and TNA B's names were crossed out. TNA B's name was listed under Call Ins. TNA A's name was written in under 6:00 p.m. - 6:00 a.m. North Nursing Station but it was crossed out and, went home was written under her crossed out name. <BR/>In an interview with the Administrator, DON, and ADON on [DATE] at 11:15 a.m., the Administrator said there was a recent incident involving a resident who passed away in the facility on the previous day (Resident #70 died on [DATE]), but the staff member (Housekeeper C) did not tell them everything that happened. The DON stated Housekeeper C said she had concerns regarding Resident #70 because she was screaming. The DON said she told Housekeeper C that screaming in the memory care unit was not unusual. The DON said Resident #70 had recently declined and she had a history of falls prior to admission. The DON said regarding the incident that was reported, the aides were trying to transfer her (Resident #70) to her bed and calm her down. The DON said Resident #70 was confused and combative. The DON said the staff member probably took it (the incident with Resident #70) personally, and thought it was abuse. The Administrator said they (administration) looked into it (the incident with Resident #70) and they did not think it was abuse and was not reported to HHSC. The Administrator said all Housekeeper C said was that the resident (Resident #70) was yelling. The Administrator said Housekeeper C never said abuse, just that the resident was yelling. The DON said Housekeeper C quit earlier that morning ([DATE]). The ADON said Housekeeper C never mentioned that she saw or heard anybody drop Resident #70, or that she fell. The ADON said Housekeeper C said Resident #70 was yelling and she had concerns. The ADON said Housekeeper C did not name the staff, but she did try to describe the staff. The DON stated they (administration) never figured out which staff Housekeeper C was talking about. The DON said Housekeeper C came back a second time after she voiced concerns, and she still could not identify the staff involved. The ADON said Housekeeper C expressed her concerns to her supervisor, Housekeeping Supervisor. The ADON said the Housekeeping Supervisor did not notify them (administration) until the next day, which was last week (she could not recall the day administration was notified by the Housekeeping Supervisor). The Administrator said they have had really good continuity of care in the memory care unit, so they kept the same staff in there for each shift. The Administrator said no staff from the memory care unit had been reassigned to work another area of the building. <BR/>In an interview with the Housekeeping Supervisor on [DATE] at 1:00 p.m., she stated Housekeeper C expressed concerns about Resident #70 to her on [DATE]. The Housekeeping Supervisor stepped out of the room twice at the beginning of the interview and kept saying, they (administration) were watching the door and keeping track of who entered the conference room to speak to the state surveyor about the incident. The Housekeeping Supervisor said Housekeeper C said she heard Resident #70 yelling down the hallway, and it was concerning to her. The Housekeeping Supervisor said she explained to Housekeeper C that Resident #2 always yelled in memory care, not Resident #70. The Housekeeping Supervisor said Housekeeper C was fairly new to the facility and did not know residents' names. The Housekeeping Supervisor said Resident #2 always yelled, Help me! all day. The Housekeeping Supervisor initially said Housekeeper C did not say she saw anything, just that she heard yelling, and it made her uncomfortable. She said Housekeeper C was not able to say who the staff members were, just that the resident was yelling. The Housekeeping Supervisor said Resident #70 always yelled out, Stop, leave me alone, I do not want to sit down! The Housekeeping Supervisor said Housekeeper C sent a text message on Thursday, [DATE], at 10:27 p.m. saying it had been a rough and emotional day. She said when she saw the text message the next day, [DATE], she texted Housekeeper C, asking her what happened and then she called Housekeeper C. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON on the next day, [DATE]. <BR/>In an interview with the Staffing Coordinator on [DATE] at 2:00 p.m., she stated she heard a few rumors regarding the incident with Resident #70, but she did not know anything about it personally. She stated other staff (she would not name the staff) told her the incident involved Resident #70 and 2-3 aides, but she did not know who those aides were. She said staff had concerns because there was an incident with Resident #70 last week ([DATE]) and then she died over the weekend. She said other staff told her two aides were taking care of Resident #70 and they were swinging her around and she fell. The Staffing Coordinator said the fall was not reported and over the weekend Resident #70 was sick and vomited blood. She said the same staff always worked in the memory care unit and the same staff worked on the same days (the same staff always worked together and were off on the same days). The Staffing Coordinator said there was a lady who wanted to talk to the state surveyors about the incident, but she was scared and feared retaliation from administration. The Staffing Coordinator said the lady who wanted to talk said she saw some things but did not want to lose her job. She said recently, both TNA A and TNA B had been calling in sick, which was unusual. The Staffing Coordinator said one (TNA A or TNA B) was pregnant (she could not say which one). She said she did not know if anybody mentioned or questioned them about the incident with Resident #70. The Staffing Coordinator stated Housekeeper C was the original source of the information, but the person who wanted to talk to the state surveyors was a different person. <BR/>In a telephone interview with TNA A on [DATE] at 2:22 p.m., she stated she often cared for Resident #70, who was confused. She said Resident #70 tried to walk but could not. She said Resident #70 was sweet some days, but some days, she did not want to be bothered. She said Resident #70 had her days when she did not want anybody to touch her. TNA A said Resident #70 had a witnessed fall in the dining room ([DATE]) and when she returned from the hospital, she was strong like super woman and tried to walk. She said she worked with Resident #70 last week (she could not recall the day) and after that, she was moved around to work on another hall. She said on that last day with Resident #70, she was really just being herself, talking and trying to get out of bed. TNA A said she sat in the room with Resident #70 on that night around 8:00 p.m. or 9:00 p.m. She said on that night, after Resident #70 got her medication, she was antsy (anxious) and she did not want Resident #70 to get out of bed, so she sat with her until she fell asleep for about 15 minutes. TNA A said Resident #70 was not aggressive or combative that night. She said Resident #70 was wheeled into her room and she was given her medications. She said she heard Resident #70 moving around on the baby monitor at nurse' station. She said it sounded like Resident #70 was talking and had a regular conversation with somebody. TNA A said Thursday, [DATE] was like a normal night and nothing unusual happened. <BR/>In a telephone interview with TNA B on [DATE] at 2:44 p.m., she stated she worked nights in the memory care unit. She said Resident #70 could not walk but she tried. She said Resident #70 sometimes got fussy when she tried to provide care. TNA B said she gave Resident #70 some time when she got fussy and then came back and Resident #70 would allow her to give care. She said she was off Friday thru Sunday ([DATE] - [DATE], which was confirmed by the sign-in sheets). TNA B said on [DATE], nothing unusual happened. She said Resident #70 had a lot of sores and she scratched them a lot. She said sometimes, nurses had to give Resident #70 first aide because she scratched the sores until they bled. She said Resident #70 never had a fall during her shifts. She said she worked on the North part of the building (not memory care) yesterday ([DATE]). <BR/>In an interview with the DON and ADON on [DATE] at 3:25 p.m., the DON said there should not have been any housekeepers on night shift that she knew of (6:00 p.m. - 6:00 a.m.). The ADON said the Housekeeping Supervisor told them it was Resident #70 that Housekeeper C was talking about. The DON had a small stack of papers and stated they were complaints the facility's administration had submitted to their corporate office against the Housekeeping Supervisor. The DON said they had issues with the Housekeeping Supervisor's performance for some time and she was aware. The DON said the facility used the state provider letter (Long-Term Care Regulatory Provider Letter 19-17 dated [DATE]) to let them know which incidents to report to HHSC. <BR/>In a telephone interview with Housekeeper C on [DATE] at 3:45 p.m., she stated she worked as a housekeeper in the facility for approximately one month and a couple of weeks, so she was familiar with Resident #70, and she would not confuse her for Resident #2. She said she worked all over the building and her normal shift was 6:00 a.m. until 12:00 p.m., but she also worked nights sometimes from 3:00 p.m. - 8:00 p.m. She said she was cleaning in the memory care unit on [DATE] and she heard a lady, Resident #70, screaming. She said earlier that day, Resident #70 was perfectly fine. She said at 7:12 p.m. exactly, two of the night shift girls (TNA A and TNA B but she did not know their names) had Resident #70 stripped naked with no brief, twirling her. She said Resident #70 was in her wheelchair and one of the staff was sitting in a regular chair behind the resident. She said the staff had her foot on the back of Resident #70's wheelchair like she was popping a wheelie with Resident #70's legs up in the air. She said the staff was moving Resident #70's wheelchair side to side and Resident #70 was screaming and hollering for her to stop. She said the screaming is what got her attention and she rolled her housekeeping cart to the very end of hall, where Resident #70's room was. She said another resident was walking by and told the staff to stop when she saw what the aides were doing to Resident #70. Housekeeper C said the aides were laughing during the incident. She said one of the aides was pregnant and the other was not. She said Resident #70 was bleeding, but she could not see where the blood was coming from. She said one of the aides wiped Resident #70's blood with her bed sheet. She said the pregnant aide saw her in the doorway and told her to get the bloody sheet. Housekeeper C said she picked up the bloody sheet, took it to laundry, then she went and clocked out. Housekeeper C said Resident #70's legs were still up in the air when she (Housekeeper C) walked out of the room with the bloody sheet. She said Resident #70 let out a very loud scream when she (Housekeeper C) was walking out of the room, but she did not know if that was when the staff let Resident #70's wheelchair down to the floor because she (Housekeeper C) did not turn around to look. She said she had a video of the incident that was only audio and no visual (she started recording with her phone when she heard Resident #70 screaming), but the DON made her delete it out of her phone when she (Housekeeper C) was called in to report the incident. Housekeeper C said she initially reported the incident to her supervisor, Housekeeping Supervisor, and then the DON told her to come into the office (the DON's office) and tell what happened. She said she had initially texted her supervisor the night of [DATE], but her (Housekeeping Supervisor) phone was off, and she did not see the message until the next day. She said the Administrator, DON, ADON, and the Housekeeping Supervisor were all present in the room when she reported what happened. She said there were six people in the room, her, the Administrator, DON, ADON, Housekeeping Supervisor, and she could not name the last person. She said the video slipped her mind at first, so she did not mention it during the first meeting. She said the DON said sometimes they had to restrain residents when the residents tried to harm them. She said they told her she was too emotionally involved for that job. She said she told the DON and the Housekeeping Supervisor she thought Resident #70 was being abused because she was being abused. She said she also showed the video/audio to two other staff members, (CNA K and TNA Y). Housekeeper C said CNA K and TNA Y asked her if she was going to report the incident to Resident #70's family member when she visited. She said CNA K told her Resident #70's leg was purple, and it looked like they (TNA A and TNA B) broke her leg. Housekeeper C said when Resident #70's family member visited her (she did not say what day this was), the family member said Resident #70 was perfectly fine when she ate lunch with her Tuesday ([DATE]). She said on her last day at the facility, Sunday, or Monday ([DATE] or [DATE]), Resident #70's family member was basically there saying her good-[NAME] to Resident #70. She said the DON called her into her office a second time on the same day and asked her who she had shown the video/audio to. She said she did not know how the DON found out about the video/audio, but after she played it for the DON, she made her air drop it to her (the DON) phone and then made her delete it from the phone and trash (in the phone). The DON said the voice in the audio was the lady who hollered all the time, Resident #2. Housekeeper C said it was not Resident #2, it was Resident #70. She said they (administration) told her to think really hard about what she wanted to do at the facility and then they had her clock out. Housekeeper C said she quit when they told her to get out of the office and clock out. She said she tried to go to the facility and get paperwork to resume her state benefits earlier that morning ([DATE]) but they (administration) would not allow her into the building. She said she assumed it was because state was in the building, and they did not want her to talk. <BR/>In an interview with the DON on [DATE] at 4:15 p.m., she stated Housekeeper C never sent her a video or audio and she never heard one regarding the alleged incident with Resident #70. The DON said there was talk around the facility about a video or audio, but she never told Housekeeper C to delete it. <BR/>In a telephone interview with the Housekeeping Supervisor on [DATE] at 7:35 am., she said she was ready to tell the truth about what she knew regarding the incident with Resident #70. She said before she went to the conference room to speak with the state surveyor on [DATE], the DON texted her and told her to go to her (DON) office. She said the DON asked her what she was going to say to the state surveyor. She said she told the DON she was going to tell the state surveyor what her staff (Housekeeper C) told her. She said the DON said please do not do that. She said the DON asked her to not tell the state surveyor everything. She said the DON told her to say Housekeeper C said she heard someone yelling down the hallway. The Housekeeping Supervisor said she was previously scared to talk to the state surveyor for fear of retaliation by administration. She said the Staffing Coordinator told her the DON called her into the office before she spoke to the state surveyor on [DATE] and told her the same thing, not to tell state the truth. She said Housekeeper C texted her on [DATE] at 10:27 p.m. and said she had an emotional day. She said she saw the text on Friday, [DATE] at 9:39 a.m. She said she called Housekeeper C on [DATE], after their 10:00 a.m. morning meeting. She said Housekeeper C told her that the pregnant girl at night and another one with her were involved. She said Housekeeper C said she was walking down the hall and saw Resident #70 naked in her wheelchair. She said Housekeeper C told her Resident #70 was trying to get up, but the staff were leaning the chair back and they started turning and twisting her in the air. She said Housekeeper C told her everybody kept coming up to her and asked who she reported the incident to and why she did not report it to them. She said Housekeeper C said she was scared to lose her job. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON after she spoke to Housekeeper C on [DATE]. She said the Administrator and DON had her call Housekeeper C into the DON's office on Sunday, [DATE] at 3:08 p.m. because they said they needed to talk to her. She said they all talked together, then the Administrator and DON asked the Housekeeping Supervisor to leave. She said they called Housekeeper C back into the office and the DON said there was a video. She said the DON found out about the video because Housekeeper C showed it to CNA K and TNA Y. She said Housekeeper C also told her that CNA K said Resident #70's ankle was broken. The Housekeeping Supervisor said she did not know about the video when they initially walked into the office. She said the DON asked her (Housekeeping Supervisor) to have Housekeeper C come back into the office. She said the Administrator and DON asked her (Housekeeping Supervisor) to leave out of the office. She said Housekeeper C came out crying and saying she was about to lose her job. She said she told Housekeeper C she was not supposed to be on the phone (she thought Housekeeper C recorded the video/audio because she was already on a video call while working that night). The Housekeeping Supervisor said they (administration) made her send Housekeeper C home because state was in the building. The Housekeeping Supervisor said she never saw the video/audio because the DON made Housekeeper C send the video/audio to her (DON) phone and then made Housekeeper C delete it. She said Housekeeper C said she thought Resident #70 was being mistreated to everyone in the DON's office. She said Housekeeper C told her the staff were spinning her around and that was not right. She said Housekeeper C said one resident in the hall told them to stop when she saw what they were doing to Resident #70. <BR/>Record review of a screenshot of a text message thread between the DON and the Housekeeping Supervisor's phone revealed, DON (Work) at the top of the text thread. On Wednesday, [DATE], at 12:39 p.m., the DON sent text message, Need you to come to my office plz, and the Housekeeping Supervisor responded, On my way. <BR/>In a follow up telephone interview with the Housekeeping Supervisor on [DATE] at 12:00 p.m., she stated on [DATE], she, Housekeeper C, the DON, ADON, and the Administrator were in the DON's office when Housekeeper C told them about the mistreatment she saw. She said the administration told her (The Housekeeping Supervisor step out. She said after the meeting they told Housekeeper C to go home because she was too emotional to work. She said the DON and ADON called her into the office on [DATE], before she spoke to the state surveyor. She said the DON asked her what she was going to say to state. The Housekeeping Supervisor said she did not want to tell the state anything because she was afraid she would get in trouble if she said the correct thing and afraid she would get in trouble if she said the wrong thing. She said she told the DON she was going to say the staff were swinging the resident around. She said the DON said no, no, no do not say that. She said the DON told her to say the resident was yelling and to not say the resident was being swung around. The Housekeeping Supervisor said they (administration) did not want her to go talk to the second state surveyor on [DATE]. Later on, [DATE], the DON called her into the office and the DON said, You got me an IJ and it is your fault! She said the DON, ADON, and Administrator were in the room and they all followed her out of the office. She said the DON cursed her out in front of residents, families, and other staff, calling her A stupid bitch! She said they followed her outside, calling her names and cursing and the Administrator slammed the door in her face. She said the ADON followed her outside cursing at her. The Housekeeping Supervisor said she was in fear for her own safety. She said the DON told her she was not fired, but she could not go to work. She said she was removed from of the facility's text message thread. <BR/>In an interview with the Administrator on [DATE] at 12:35 p.m., he stated there was no evidence Resident #70 was abused and employees denied it. He said the two people (Housekeeping Supervisor and Housekeeper C) who made the accusations did it in retaliation because he made them do their jobs. He said there was an ulterior motive to the allegations. He said the first they heard of the abuse was when the HHSC complaint came in ([DATE]). The Administrator said the only time Housekeeper C came to him about any concerns was on [DATE] when she had concerns about residents yelling in memory care. <BR/>In a follow up telephone interview with Housekeeper C on [DATE] at 1:00 p.m., she said on [DATE] at 7:12 p.m., she knew Resident #70 was being mistreated by the two staff (TNA A and TNA B) in the room, so she did not know what else to do but turn her video on her phone and put it (her phone) in her pocket. She said she went to the room so the video could pick up the audio of the resident yelling Stop It!, Help! She said the resident was stripped naked, in a wheelchair with it propped back in a wheelie, and the staff members were laughing. She said another resident went by and told the staff members to stop and leave her alone, and the staff members told her to shut up and go to your room. Housekeeper C said she started to walk off and one of the staff members called her back and gave her a sheet with blood on it to take. She said she took it and walked away to put the sheet in the laundry, then she clocked out. She said when she was walking away, she heard a loud scream from the same resident that she had never heard before. She said she knew something was wrong but was too afraid to turn around at this point and she clocked out and left. She said she called the Housekeeping Supervisor as soon as she clocked out, but her phone was turned off. She said when she got to work[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 8 of 18 residents reviewed for ADL care (Residents # 4, #7, #20, #28, #44, #55, #60, #181).<BR/>--facility staff failed to provide personal hygiene care to Resident #4, #44, #55, #60 <BR/>--facility staff failed to turn and reposition Resident # 7 as ordered <BR/>--facility staff failed to provide timely incontinent care and transfer assistance to Resident #20<BR/>---facility staff failed to provide timely incontinent care to Resident # 28, #55, #60, #181 <BR/>Theis failurefailures placed residents who were unable to carry out ADLs at risk of not receiving necessary care and assistance when needed. <BR/>Findings include:<BR/>Resident #4<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted and readmitted to the facility 07/06/23. His diagnoses included Acute respiratory distress (inability to breath) sepsis (infection) Contractures, persistent vegetative state (a person who is unaware and unresponsive), muscle wasting, pneumonia, multiple site pressure ulcers and dysphasia.<BR/>Record review of Resident #4's significant change MDS assessment dated [DATE] revealed his cognitive level ( BIMS) score was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident # 4's care plan dated 10/08/20and edited 05/11/23 read in part -<BR/>ADLs Functional Status/Rehabilitation Potential. Resident #4 is dependent with all ADLs. Bed mobility with two to three person assist for Transfer: total assistance with 3 staff, Dressing: total assistance with 2 staff and personal hygiene: 2 staff assist.<BR/>Goal: Resident # 4 is dependent with all ADLs. Bed Mobility: total assistance. Resident #4's dignity will be maintained, and he will be clean, dry, well-groomed and odor free during the next 90 days.<BR/>Approach: dress resident according to season and climate. Provide oral care twice daily. Shower, shampoo hair, and give nail care per shower schedule and as needed.<BR/>Observation on 07/15/23 at 2:00PM, revealed Resident #4 was in bed, noncommunicative and in a semi fetal position. He was contracted with his two-hand clenched in a fix position, unkept facial hair, dirty long nails about 1\2 an inch, and there was dry white substance around his mouth. He had a dirty hospital gown on and a catheter with 300 ML of clear yellow urine.<BR/>Observation and interview on 07/16/23 at 10:00AM revealed Resident #4 was in the same position with the same hospital gown on, dirty long nails and unkept facial hair. In an interview with CNA Y, she looked at Resident #4 and said she would clean him.<BR/>In an interview with LVN L on 07/16/23 at 10:00am, she said Resident # 4 was on hospice and hospice usually cleaned him.<BR/>Record review of Physician's telephone orders dated 04/13/23 revealed Resident # 4 was admitted on hospice on 07/13/23. Hospice documentation was requested from ADON on 07/16/23 at 3:30pm but was not provided. <BR/>Resident #7<BR/>Record review of Resident #7's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood causing respiratory failure), vascular dementia (brain damage from impaired blood flow to brain), shortness of breath, cognitive communication deficit (difficulty with thinking and language), obstructive and reflux uropathy (urine unable to drain through urinary tract), muscle wasting and atrophy (decrease and thinning in muscle size), dysphagia (trouble swallowing), pneumonitis due to inhalation of food (inflammation of the lungs), schizophrenia (false beliefs, hallucinations, unusual behavior, and disorganized thinking and speech), and pressure ulcer of sacral region (pressure sore in the lower back and tailbone area). The face sheet also revealed the resident was a DNR.<BR/>Record review of Resident #7's Comprehensive MDS dated [DATE], revealed a BIMS score of 5 which indicated severely impaired cognition. The MDS revealed the resident had a serious mental illness of schizophrenia. He had unclear speech, sometimes could make himself understood, and sometimes understands others. Resident #7 required extensive assistance with personal hygiene, dressing, and bed mobility. He required physical help with bathing and one-person physical assistance. He used a wheelchair for mobility. The resident had an indwelling catheter for obstruction but was always incontinent of bowel. He had a stage 4 pressure ulcer to his sacrum, was on tube feeding, and on hospice.<BR/>Observations of Resident # 7 on 7/15/23 revealed: 10:22am: on his back, asleep in bed, 1:30pm: on his back in bed, no one had gone in the room to check on him. <BR/>Observations of Resident #7 on 7/16/23 revealed: 9am: on his back, asleep, 1:57pm: on his back, asleep in bed, no one had gone in the room to check on him. <BR/>Observation of Resident #7 on 7/17/23 revealed: 11am: on his back, asleep in bed.<BR/>Observations of Resident #7 on 7/18/23 revealed: 9:03am: on his back, asleep in bed, 12:40pm: on his back, asleep in bed, no one had gone in the room to check on him. <BR/>Record review of Resident #7's care plan, revised 7/3/23, revealed I have a stage 4 to my sacrum from admission-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Dental Care-Maintain oral hygiene/status: Oral Care BID. Bowel Incontinence-I will establish an individual bowel and bladder routine: Check for incontinence Q2hrs and PRN. ADL Function/Rehab Potential-I will achieve maximum functional mobility: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Toileting amount of assist: Extensive. Activities-I will attend/participate in 1 activity per week. The resident will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Mon, Wed, Fri: 6am-6pm. Nail Care Once a Day on Mon, Wed, Fri: 6am-6pm. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>Resident #20<BR/>Record review of Resident #20's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE] with diagnoses of demyelinating disease of central nervous system (multiple sclerosis which is an autoimmune attack on the coating of nerves and causes inflammation and damage to brain and/or spinal cord), muscle wasting and atrophy (decrease and thinning of muscle), dysphagia (trouble swallowing), contracture of muscle (muscles, tendons, joints, or other tissues tighten/shorten causing a deformity), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry about everyday issues and situations), pain, and repeated falls.<BR/>Record review of Resident # 20's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, which indicated normal cognition. The MDS also revealed she had a serious mental illness. Resident #20 indicated it was very important for her to choose what clothes to wear, to choose between a tub bath, shower, bed bath or sponge bath, and to do her favorite activities. She required extensive assistance with personal hygiene, dressing, transfer, and bed mobility, and total dependence with toilet use. She also required 1-2 people to assist her with the activities. She needed physical help with bathing and 1 person to physically help her. Resident #20 used a wheelchair for mobility. She was always incontinent of urine and bowel.<BR/>Observation and interview with Resident #20 on 7/15/23 revealed: 1:26pm: said they did not get her up for lunch. Food was observed on her chest and on her mouth. She said there was barely any staff, so she did not ask to get into her electric chair because she was afraid, she would not be able to get back into bed and would be in pain. Mon/Fri were supposed to be shower days, and Wed were lotion days, but that had not been happening. She had not been turned all day and she was unable to turn herself. So far, she had not had any skin breakdown. There was only 2 people in the whole building last night and she did not get changed the whole night until 6am this morning. She had not brushed her teeth all day.<BR/>Interview on 7/15/23 at 1:40pm with TNA CW revealed he comes in 6a to 6p and usually changes/brushes the resident's teeth between 6a-6:30am. He said he turns residents every 2hrs because he was a patient himself before. He said Resident #20 is definitely a resident that needs to be turned every 2hrs. When asked about Resident #20 not having her teeth brushed or being turned, he said he didn't know what happened. He said if she's not turned, a bedsore could happen because she can't turn herself. When asked about setting her up for lunch, he said he didn't pass her tray and that he was in the dining room. Whoever passed the tray should have set her up. He also said that he always takes a female with him when he goes in her room. Surveyor said she had food all over her chest, needed her teeth brushed, and needed to be turned. He said he would go in and take care of it. He said they usually have 4 aides during the day, and he didn't feel like they were short staffed today.<BR/>Observation and interviews with Resident # 20 on 7/16/23 revealed: 10am: said she was last changed last night and has not been changed this morning yet. Flat on her back in bed, 2:02pm: said she had not been in her chair in 2-3 weeks. She asked TNA CW to sit her up in bed for lunch and he didn't. She was flat on her back in bed, 2:05pm: TNA CW said he did not remember telling Resident #20 that he would sit her up in bed and he did not go into her room unless he had a female with him, 2:10pm: CMA M said Resident #20 was turned when she was changed. Resident said she was not.<BR/>Observations of Resident #20 on 7/17/23 revealed; 9am: flat on her back and not in her wheelchair. She stated she was afraid to ask to get in the wheelchair, 2:05pm: flat on her back and not in her wheelchair. She stated it was too late to ask to get into her wheelchair now.<BR/>Observation of resident #20 on 7/18/23 revealed: 9:08am: resident told CMA I and TNA C that she wanted to get up in her electric chair by 11am. She did not get her suppository yesterday at 3pm even though she asked for it. She told TNA C today, that she wanted it. She still had not had breakfast and was still waiting on it, 1:15am: not in her wheelchair yet. Staff was standing in the hall talking and laughing.<BR/>Interview on 7/18/23 at11:20am with DON and Clinical Resource Nurse about Resident #20 not being in her wheelchair by 11am: revealed DON did not know why someone had not helped her yet. Also informed them about Resident #20 not being in her wheelchair in the past 2-3 weeks and they said the resident overexaggerates and there was no way it had been 2-3 weeks since she had been in her wheelchair.<BR/>Observation on 7/18/23 at 12:36pm revealed: Resident #20 was put into her electric wheelchair. She had not had lunch yet.<BR/>Record review of Resident #20's care plan, revised 6/6/23, revealed I have thin and fragile skin-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Oral/Dental Status. I use a rechargeable toothbrush-Maintain oral hygiene/status: Oral Care BID. B/B Incontinence-I will establish an individual bowel and bladder routine: Briefs when out of bed. Toileting. Resident #20 has been identified as having DD PASRR positive status related to Demyelinating disease of central nervous system. I am currently receiving habilitation coordination and habilitative therapy (3/10/23-9/5/23)-Resident #20 will maintain highest level of practicable well-being for the next 90 days: I am recommended to receive PASRR habilitative services through PT and OT. Patient will exhibit improved fine motor coordination skills to facilitate patient's ability to grasp items during self-feeding with stand by assistance in order to improve functional use of upper extremity's during ADL's and perform ADL's w/ increased safety. Patient will increase activity tolerance for functional activities of choice in wheelchair 2 x week for 2 hours in order to help with implementation of compensatory strategies and with improved ROM and coordination and increase participation within environment. Patient will complete hygiene and grooming tasks while sitting in front of mirror with caregiver assistance with implementation of compensatory strategies in order to perform ADLs with increased safety. Patient will increase trunk strength to 2+ out of 5 in order to facilitate improved trunk balance, facilitate upright posture and increase core strength for functional activities. Patient will increase static sitting balance to poor using protective extension 70 percent of the time to right self in order to participate in edge of bed activities and decrease loss of balance during functional mobility. Patient will tolerate sitting up x 2hr for skin integrity: Therapy to treat once a day, 3 x week x 6 months. I prefer to have showers on Mon/Wed. On Wednesdays I prefer to have lotion applied with no shower: Showers including hair wash on Monday and Friday only Once a Day on Mon, Fri: 6pm-6am. Nail Care Once a Day on Mon, Wed, Fri: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>Interview with Administrator and DON on 7/16/23 at 11a.m. regarding where showers would be documented. They said it would be documented in the computer.<BR/>Record review on 7/16/23 at 12pm revealed the shower documentation on the computer was incorrect. It showed everyone had a shower, every day. The residents said they were not showered in days up to a week and looked dirty and greasy.<BR/>Record review 7/17/23 at 10am revealed shower sheets in a binder at the South nurse's station were all blank.<BR/>Interview with DON on 7/18/23 at 3pm about why she thought ADLs were not being done. She said she was not sure why the ADL's were not done, and did not have a reason why.<BR/>Resident #28<BR/>Record review of Resident # 28's face sheet revealed a [AGE] year-old female with admission date of 3/3/23 and diagnoses including atrial fibrillation, Diabetes, major depressive disorder, single episode, hypertension, osteoarthritis, systemic lupus (disease when immune system attacks its own tissues), chronic obstructive pulmonary disease (lung disease that blocks airflow), rheumatoid arthritis (inflammatory disorder that attacks joints). <BR/>Record review of Resident #28's care plan for ADL Functional Status/Rehab Potential dated 3/3/23 revealed extensive assistance by 1 staff required for bathing, hygiene, dressing, grooming, and toileting. <BR/>Record review of Resident # 28's admission MDS dated [DATE] revealed modified independence in cognitive skills, able to make herself understood and understands, always incontinent of bowel and bladder, and extensive assistance of 1-2 staff required for transfer, dressing, toileting, personal hygiene, and bathing. <BR/>Observation of Resident #28 on 7/15/23 at 10:00 AM revealed she was in bed. Interview at that time revealed she was waiting for someone to get her cleaned up and dressed. When asked if someone came to check on her or change her last night, she said no one came. She said she thought her call light was not working because no one came after she pushed it. She said it happens often that no one comes to check on her overnight. <BR/>Record review of Point of Care History, staff support for toileting dated 7/15/23 revealed documentation of Resident #28 receiving assistance with toileting at 2:19 AM and 10:37 PM. <BR/>Resident # 44 <BR/> <BR/> <BR/>Record review of Resident #44's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia, behavior disturbance, upper respiratory infection, muscle wasting, lack of coordination, essential hypertension, Kidney complication and human immune deficiency, and diabetes.<BR/>Record review of Resident #44's admission MDS assessment dated [DATE] revealed his BIMS score 9 out of 15 reflected he was moderately impaired on cognition. <BR/>Record review of his annual MDS assessment section on ADLs assessment indicated physical help in part bathing activities was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident #44's care plan dated his 11/14/22 and edited 05/04/23 revealed -<BR/>-ADLs Functional Status/Rehabilitation I am limited in ability to toilet self R/T cognitive<BR/>deficits. <BR/>-I require supervision to ensure I turn and reposition while in bed.<BR/>- ADLs Functional Status/Rehabilitation Potential, I am limited in ability to bathe self R/T cognitive deficits r/t dementia .<BR/>Goals: <BR/>I will dress/undress self independently with supervision; I will bathe with assistance <BR/>Allow sufficient time to complete bathing.<BR/>Observation and interview on 07/15/23 at 11:00AM, revealed Resident #44 was in bed with dirty personal clothes on. He shirt had food stained on it. He had unkept facial hair and dirty long fingernails. <BR/>Observation on 07/16/23 at 8:30AM, revealed resident #44 was in the dining room he had just finished his breakfast with the same dirty shirt on. During an interview, he said he had stroke and need assistance in caring for himself. He said he does not remember the last time he had a bath\shower. He said he would like to be shaved and cleaned up. He said nothing when asked if he had asked for any assistant.<BR/>During an interview with TNA S acknowledged that Resident #4 needed to be cleaned. She said the facility need need more staff. <BR/>During an interview with LVN F asked Resident #44 if he would like to have a bath, be shaved and have his fingernails trimmed. He said yes. She said she would make sure that he was cleaned.<BR/>Resident #55<BR/>Record review of Resident #55's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of myocardial infarction (heart attack), muscle wasting and atrophy (decrease in size and thinning of muscle), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness and paralysis after a stroke), protein-calorie malnutrition (lack of protein and calories in the diet), major depressive disorder (persistent feeling of sadness and loss of interest), heart failure (heart is not pumping as strong as it should), and dysarthria and anarthria (trouble speaking).<BR/>Record review of Resident #55's Comprehensive MDS dated [DATE], revealed a BIMS score of 9, which indicated moderately impaired cognition. Resident #55's MDS also revealed he had a serious mental illness. The resident had unclear speech and impaired vision. He felt it was very important to chose what clothes to wear, to choose between a tub bath, shower, bed bath, or sponge bath, and to go outside to get fresh air when the weather was good. Resident #55 required extensive assistance with personal hygiene, dressing, transfer, and bed mobility. He required physical help with bathing and two+ persons physical assist. He used a wheelchair for mobility. The resident was always incontinent of urine and bowel.<BR/>Observations of resident #55 on 7/15/23 revealed: 9:22am: greasy looking hair, long facial hair, long nails, and had a patient gown on. He said there was never enough staff, and they never had enough supplies. He had to wait long periods of time to be changed.<BR/>Observations of resident #55 on 7/16/23 revealed: 9:49am: said he had not had a shower in over a week. He was last changed at 5am. He had not had his teeth brushed today or yesterday. He was still in a patient gown, would like his nails trimmed, and would like to be shaved. He also needed to be changed.<BR/>Observation on 7/16/23 10:15am revealed: Restorative CNA went into the room to shave the resident. Surveyor asked why she was just now shaving him, and she said she just became Restorative on Saturday and before that she worked in HR. She said the CNAs should have been shaving and brushing his teeth for him.<BR/>Observation on 7/18/23 at 3:00pm: Resident was not out of bed for the 4 days of the survey.<BR/>Record review of Resident #55's care plan, revised 5/24/23, revealed I am at risk for pressure ulcers r/t left sided hemiplegia-My skin will remain intact: Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry, and wrinkle free. I have urinary incontinence; I have limited mobility due to left sided CVA-I will not develop skin breakdown related to incontinence: Check for incontinent episodes at least every 2 hours. I am limited in ability to transfer self r/t left side hemiplegia- I will transfer self with extensive assistance. I am limited in ability to toilet self r/t left sided hemiplegia-I will toilet with extensive assistance of one staff: Provide incontinence care as needed. I am limited in ability to dress/undress self r/t left sided hemiplegia-I will dress/undress self with extensive assistance: Allow me to choose own clothing, dress affected side first. I am limited in ability to maintain grooming/personal hygiene r/t CVA-I will groom self with limited assistance. I am limited in wheelchair mobility r/t left sided hemiplegia-I will achieve highest level of wheelchair mobility as evidenced by increased mobility. Resident #55 will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Tue, Thu, Sat: 6pm-6am. Nail Care Once a Day on Tue, Thu, Sat: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am. Resident experiences bladder incontinence-Resident will maintain current level of bladder continence: Provide incontinence care after each incontinence episode.<BR/>Resident #60<BR/>Record review of Resident #60's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of end stage renal disease (kidneys stopped working), Type 1 diabetes with diabetic neuropathy (autoimmune disorder where pancreas stops making insulin with pain caused by nerve damage) , other disorders of electrolyte and fluid balance (when a large amount of body fluid is lost), chronic pain syndrome (symptoms beyond pain alone like depression and anxiety that interfere with life), major depressive disorder (persistent feeling of sadness and loss of interest), Type 2 diabetes with diabetic retinopathy (body doesn't produce insulin and a complication of diabetes causing blindness), muscle wasting and atrophy (decrease in size and thinning of muscle), and neuromuscular dysfunction of the bladder (nerves and muscles do not work in the bladder).<BR/>Record review of Resident #60's Comprehensive MDS dated [DATE], revealed a BIMS score of 13, which indicated normal cognition. The MDS also revealed the resident had impaired vision. According to the resident's preferences, it was very important for him to choose what clothes he wore, and it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The resident required extensive assistance with personal hygiene, dressing, transfer, and mobility. He required physical help with bathing and needed one-person physical assist. He used a wheelchair for mobility. Resident #60 had an indwelling catheter for a neurogenic bladder but was always incontinent of bowel.<BR/>Observation of Resident #60 on 7/15/23 9:29am: had long nails and was wearing a patient gown. He stated he had to use a Hoyer lift to get out of bed and into his wheelchair, but he was scared when he got into his wheelchair because there was never anyone around to get him back into bed. He had to get into his wheelchair on M/W/F for dialysis and it took a long time for them to get him up and then for them to get him back in bed. His sheets had a yellow, urine stain on them. Resident had been vomiting and had an emesis bucket under his chin. He was laying supine in bed.<BR/>Observation of Resident #60 on 7/16/23 9:45am revealed: said staff told him yesterday that only CNAs could change him and not TNAs, so he had to wait a really long time to be changed. He still had not had his teeth brushed yet today. He had not had his sheets changed since Wednesday. He still had a yellow, urine stain on his sheets. He still had not had a bath since Monday and still had long nails. He also was still laying supine in bed, 2:15pm: said he had not been changed since 9am. He told TNA C and he just picked up his lunch tray and left. <BR/>Interview with ADON on 7/16/23 at 2:19pm: she did not know why someone did not go change him and why he had been waiting since 9am. She said she would go change him.<BR/>Observations of Resident # 60 on 7/17/23 revealed: 9:39am: stated he waited over 8hrs to be changed yesterday afternoon due to having so many TNAs and only 1 or 2 CNAs. He was last checked at 4-5am today. He still had not been bathed or had his teeth brushed, nails trimmed, or been shaved, 9:45 am-10:15am: ringing his bell (call bell was not working) to be changed and the Restorative Nurse finally went into the room. Surveyor went in and saw the Restorative Nurse was shaving the roommate. She did not change Resident #60. Resident #60 said he told TNA C that he needed to be changed, but he never went back, 10;15 am: Surveyor asked TNA C about changing Resident #60. He said that he did tell him he was going to go back and change him, but he got caught up doing other things and had been busy and had not had a chance to go back yet. He also said that was not his side of the hall, that it was CNA A's, but they call him to go over there because he had all the muscle. He said the facility needs more staff.<BR/>Observation on 7/18/23 at 3:00pm revealed Resident #60 was never out of bed except to go to dialysis.<BR/>Record review of Resident #60's care plan, revised 7/16/23, revealed the resident will perform the following tasks at their highest practicable level: Nail Care Once a Day on Mon, Wed, Fri 6pm-6am, Oral Care Twice a Day 6am-6pm and 6pm-6am. I am at risk for pressure ulcers r/t decreased physical abilities-Resident's skin will remain intact: Keep linens clean, dry, and wrinkle free. I am limited in ability to transfer self r/t physical deficits-I will transfer self with extensive assistance: Remind me to not transfer without assistance. I am limited in ability to toilet self r/t physical deficits-I will toilet self with use of extensive assist x 1 staff: Provide extensive assistance for toileting. I am limited in ability to eat and drink r/t vision and cognitive deficits-I will be hydrated and well-nourished as evidenced by stable weight. I am limited in ability to dress/undress self r/t physical and cognitive deficits-I will dress/undress self with extensive assistance. I am unable to independently change position while in bed as evidenced by requiring assistance with bed mobility-I will reposition self with bed rails and the assistance of one: Provide hands assistance for repositioning/transferring in and out of bed. Turn and reposition every 2 hours. I am limited in ability to maintain grooming/personal hygiene r/t cognitive and physical deficits-I will groom self with extensive assistance. I am limited in wheelchair mobility r/t physical deficits-Resident will achieve highest level of wheelchair mobility: Provide assistance for wheelchair mobility.<BR/>Resident #181<BR/>Record review of Resident # 181's face sheet revealed a [AGE] year-old male with admission date 2/14/23 and diagnoses including cerebral infarction (disruption of blood flow to the brain due to blood vessel problems), cognitive communication deficit, cellulitis (bacterial skin infection), pain in right shoulder, contracture (shortening and hardening of muscles), restlessness and agitation.<BR/>Record review of Resident #181's Urinary Incontinence care plan dated 2/20/23 revealed bowel and bladder incontinence. Approaches included: check for incontinence every 2 hours and PRN, and toileting every 2 hours and PRN. <BR/>Record review of Resident #181's ADL Functional Status care plan dated 2/20/23 revealed assistance with activities of daily living was needed, and approaches were for maximum amount of assistance for toileting, bathing, hygiene, dressing, and grooming.<BR/>Record review of Resident #181's admission MDS dated [DATE] revealed severely impaired cognitive skills and never or rarely made decisions, rarely or never understood by others and rarely or never understands others, always incontinent of bowel and bladder, and extensive 2-person staff assistance required for transfer, dressing, toileting, personal hygiene, and total assistance required for eating and bathing. <BR/>Observation of Resident #181 on 7/15/23 at 10:00 a.m. revealed he was in bed, and family member was in the room changing his brief. Family member had placed the soiled brief and under pad on the floor, which were saturated with urine and had a visible dark circle on the outer edges of the brief and under pad. Interview with Resident #181's family member at that time revealed she comes in the morning and always changes his brief because it is soaked with urine, and when she asks him if anyone came to change him the night before, he says no. Interview with Resident #181 on 7/15/23 at 10:30 a.m. revealed, when asked if anyone came to change him last night, he shook his head and said no. <BR/>Record review of Point of Care History, staff support provided for toileting dated 7/15/23 revealed documentation Resident #181 received staff assistance with toileting at 2:40 AM and 7:40 PM. There was no documentation of staff assistance with toileting on 7/16/23. <BR/>In an interview with an advocate for a resident in the facility on 7/15/23 at 1:10 p.m., she said they need more help here, they are short staffed, and residents wait up to an hour to be changed after they push the call light. <BR/>In a confidential interview with Resident #181's family member on 7/16/23 at 11:34 a.m. revealed Resident #181 has been here since January 2023, and she comes every day. She said there are problems with him being changed, especially overnight. She said she changes him when she gets here, and his brief is always soaked. Two pillows were soaked with urine today. She asked him if anyone came to change him overnight, and he said no. <BR/>Interview with the interim DON on 7/15/23 at 1:50 p.m. revealed she has been here 8 days as interim DON and has seen the staff really trying to care for all residents timely, but it's a problem because there are not enough staff working at a given time. She said if someone calls in, there is not always someone who can work in their place, but management staff can help if needed. <BR/>Record review of facility policy Activities of Daily Living (ADL's) Supporting, revised March 2018, revealed, in part: . appropriate care and services will be provided for residents who are unable to carry out ADL's independently .including appropriate support and assistance with hygiene (bathing, dressing, grooming, oral care) and elimination (toileting) . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs for 1 (Residents #60) of 12 residents reviewed for pharmacy services. <BR/>The facility failed to ensure Resident #60 's GT medication order complete, with amount of water to give in between med administration, and before and after meds and water to dilute medication, to her GT. <BR/>The facility failed to ensure medication order was accurate, without an extended release (ER), a medication that should not be crushed, Metoprolol Succinate 12.5 mg BID to administer for Resident #60.<BR/>The facility failed to ensure Resident #60 's medication order was complete, with order to shake well anti-seizure meds Levetiracetam solution (Keppra) and Carbamazepine (Tegretol) suspension, before administration.<BR/>The facility failed to ensure Resident #60 's Levetiracetam solution (Keppra) and Metoprolol Succinate medication orders complete, with a diagnosis (dx) or indication for its use. <BR/>These failures could place all residents receiving medications at risk for receiving less than therapeutic benefits of their medication and worsening of medical condition.<BR/>Findings Include:<BR/>Record review of Resident # 60's face sheet revealed, a [AGE] year-old female admitted to facility on 3/30/21 with diagnoses which included, cerebral infarction due to embolism (blood clot), seizure disorder or epilepsy, difficulty swallowing (dysphagia), Lt hemiplegia (Lt side paralysis), gastro-esophageal reflux disease, HTN, chronic pain and polyneuropathy. <BR/>Record review of Resident #60's entry MDS revealed she had moderately impaired cognition with feeding tube for dysphagia. She required extensive-total assistance of 1-2 staff for most activities of daily living.<BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed Metoprolol Succinate ER 25 mg, give &frac12; tab=12. 5 mg via gastrostomy tube (GT) BID, start date 8/19/21. No dx or indication for its use. Carbamazepine 100 mg/5 ml suspension give 15 ml =300 mg via GT BID, for epilepsy. Levetiracetam 100 mg/ml solution, give 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered. <BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed give 50 cc water per GT every 6 hrs. for patency. No order with the amount of water to dilute medications. No order to give water in between med administration. No order to give water flush before and after meds administered to her GT. <BR/>Record review of MAR dated May 2022 - June 2022 revealed Resident #60 received Metoprolol Succinate ER 25 mg, crushed &frac12; tab=12. 5 mg via G-tube BID, start date 8/19/21. Carbamazepine 100 mg/5 ml suspension 15 ml =300 mg via GT BID. Levetiracetam 100 mg/ml solution, 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered.<BR/>Record review of Resident #60's MAR dated May 2022 - June 2022 revealed no order received with the amount of water to dilute medication, and in between med administration, and no water flush before and after the medications administered to her GT.<BR/>Interview on 6/09/22 at 12:15 p.m., the DON stated Resident #60's GT order was incomplete, and stated normally we give 30 ml water flush before and after meds and 10 ml water in between meds, and will call the MD. However, she stated LVN A should have also called the MD, since the Resident 's GT medication orders incomplete. The DON stated she was in-charge to reconcile monthly residents' physician orders along with the ADON. The DON stated moving forward she will ensure there are no missing medication orders, are accurate and irregularities were caught. The DON stated that Extended-Release (ER) Metoprolol Succinate should not be crushed, because by administering crushed ER Metoprolol, resident may not get a sufficient dose of the medication. The DON stated she will call the MD and instead use liquid form or dissolve Metoprolol tab. The DON stated she will call the MD to verify incomplete anti-seizure medication order for Carbamazepine (Tegretol) suspension and the Levetiracetam (Keppra) solution, to be shaken well before administered. The ADON was on training and unavailable for interview.<BR/>Interview on 6/09/22 at 2:00 p.m., LVN B stated she would not crush an extended-release medication, but she would clarify with physician if order was incomplete or missing order.<BR/>Interview on 06/09/22 at 1:15 p.m., the DON stated we verified with the MD and obtained water flush order for her GT meds, to give 5-10 ml water in between meds, and 5-10 ml water flush before and after meds given to her GT. The DON said moving forward the facility will conduct 100 % audit to ensure orders complete. The ADON was on training, unavailable for interview.<BR/>In an interview on 06/09/22 at 3:30 p.m., RN C stated she will follow-up and audit to ensure the residents' medication orders accurate and complete. She added new orders, will be reviewed the next day during daily AM meetings.<BR/>In an interview on 06/09/22 at 3:30 p.m. The Administrator stated that we will follow-up all the medication issues with QAPI. <BR/>Record review of the facility provided policy, Administering Medications through an Enteral Tube dated March 2015 read in part, . Verify that there is a physician 's medication order for this procedure .Do not crush enteric coated, sustained release meds .Place the MAR within easy viewing distance. If administering more than one medication, flush with 15 ml or prescribed amount, warm sterile or purified water.<BR/>Record review of the facility provided policy, Medication and Treatment Orders dated July 2016 read in part, .Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders for medication must include .Clinical condition or symptoms for which the medication is prescribed.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, comfortable environment for residents, staff, and the public in interior of the facility, and in 4 resident rooms (rooms 100, 120, 122, 124).<BR/>--Resident rooms 100, 122, 124 were hot and did not have operating air conditioners<BR/>--bathroom sink in room [ROOM NUMBER] had water gushing onto the floor when it was turned on<BR/>--scrapes on the wall with damage to paint and sheetrock in room [ROOM NUMBER]<BR/>--broken, missing tiles in laundry room<BR/>These failures could place residents, staff, and visitors at risk of living and working in an unsafe uncomfortable environment, exposure to infection or disease and decreased quality of life.<BR/>Findings include:<BR/>Observation on 7/15/23 at 10:30 a.m. in room [ROOM NUMBER], revealed the wall had large gouges on the wall by the resident's bed, and paint was peeling, and sheetrock was damaged. Interview with Resident #28 at that time revealed the wall has been damaged like that for a long time and no one had done anything about it. <BR/> Record review of Resident # 28's face sheet revealed a [AGE] year-old female with admission date of 3/3/23 and diagnoses including atrial fibrillation (irregular heart rate), Diabetes (chronic condition that affects production of insulin), major depressive disorder, single episode, hypertension (high blood pressure), osteoarthritis degenerative joint disease), systemic lupus (disease when immune system attacks its own tissues), cerebral infarction (stroke), chronic obstructive pulmonary disease (lung disease that blocks airflow), rheumatoid arthritis (chronic inflammatory disorder affecting joints).<BR/>Record review of Resident # 28's ADL Functional status care plan dated 3/3/23 revealed amount of assist for ADL's was left blank. There was no care plan for incontinence. <BR/>Record review of Resident # 28's admission MDS dated [DATE] revealed modified independence for cognitive ability, always incontinent of bowel and bladder, extensive staff assistance required for ADL's, with exception of supervision for eating. <BR/>Record review of Resident # 28's admission MDS dated [DATE] revealed modified independence for cognitive ability, always incontinent of bowel and bladder, extensive staff assistance required for ADL's, with exception of supervision for eating. <BR/>. <BR/>Observation in the laundry room, with Laundry Supervisor, on 7/18/23 at 10:30 a.m. revealed a large section of floor tiles on the clean side of the laundry were missing. Interview with Laundry Supervisor at that time revealed they roll the carts with the dirty clothes to the washers in that spot, so tiles were probably worn off from the repeated rolling of carts. <BR/>Record review of Resident #60's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of end stage renal disease (kidneys stopped working), Type 1 diabetes with diabetic neuropathy (autoimmune disorder where pancreas stops making insulin with pain caused by nerve damage) , other disorders of electrolyte and fluid balance (when a large amount of body fluid is lost), chronic pain syndrome (symptoms beyond pain alone like depression and anxiety that interfere with life), major depressive disorder (persistent feeling of sadness and loss of interest), Type 2 diabetes with diabetic retinopathy (body doesn't produce insulin and a complication of diabetes causing blindness), muscle wasting and atrophy (decrease in size and thinning of muscle), and neuromuscular dysfunction of the bladder (nerves and muscles do not work in the bladder).<BR/>Record review of Resident #60's Comprehensive MDS dated [DATE], revealed a BIMS score of 13, which indicated normal cognition. <BR/>Interview with Resident # 60 in room [ROOM NUMBER] on 7/15/23 at 9:29am revealed: Resident #60 said it was hot in the room and he told the nurse's and DON. Nothing had been done. They did not have any fans or anything. They close the door when he requested it to be cracked open.<BR/>Record review of Resident #55's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of myocardial infarction (heart attack), muscle wasting and atrophy (decrease in size and thinning of muscle), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness and paralysis after a stroke), protein-calorie malnutrition (lack of protein and calories in the diet), major depressive disorder (persistent feeling of sadness and loss of interest), heart failure (heart is not pumping as strong as it should), and dysarthria and anarthria (trouble speaking).<BR/>Record review of Resident #55's Comprehensive MDS dated [DATE], revealed a BIMS score of 9, which indicated moderately impaired cognition.<BR/>Interview with Resident #55 in room [ROOM NUMBER] on 7/15/23 9:22am revealed: Resident #55 says it was hot in the room and it had been like that for a while. Maintenance already knew about it. It felt better when the door was open, but a lot of times staff closed the door on purpose when they knew he wanted it open. Surveyor took temp in the room, and it was 76 degrees.<BR/>Record review of Resident #72's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (airflow blockage and breathing related problems), pneumonia (infection in the lung), osteoarthritis (break down of cartilage within a joint), muscle wasting and atrophy (decrease in size and thinning of muscle), stage 4 pressure ulcer of back (deepest pressure ulcer that can cause extensive destruction with exposed bone, tendon, or muscle), chronic pain (symptoms beyond pain alone like depression and anxiety that interfere with life), severe protein calorie malnutrition (lack of protein and calories), and dyspnea (trouble breathing).<BR/>Record review of Resident #72's Comprehensive MDS dated [DATE], revealed a BIMS score of 11, which indicated moderately impaired cognition.<BR/>Interview with Resident #72 in room [ROOM NUMBER]on 7/15/23 at 10:27am revealed: Resident #72 said it was hot in room. Resident stated they would constantly close the door when he requested it to be cracked open to help with the heat. Surveyor took temp in room, and it was 77 degrees.<BR/>Interview with Resident #10 in room [ROOM NUMBER] on 7/15/23 10:31am revealed: Resident #10 said it was hot in his room. He had a fan. He told everyone about the heat, but they did not do anything. Surveyor took temp in room, and it was 78 degrees.<BR/>Observation of shower rooms, with Restorative CNA, on 7/15/23 at 2:12pm revealed: Checked for hot water in the showers. Of 3 showers on the South side, 2 showers were out of order and 1 was working and water got hot. 1 shower in Memory Care, and water got hot. Of 2 showers on the North side, 1 shower was out of order and 1 was working. Water got warm, but not hot. <BR/>Interview with Director of Maintenance on 7/15/23 at 2:40 pm revealed: he switched out the circulation pump for the hot water to the North side. It had warm water now, but it was not hot, so he was looking into what was wrong. He said the a/c was old on the South side and it was having trouble keeping up and that was why it was warmer on that side. He provided fans as he could, but they did not have anymore. They were getting prices together to see about getting a new one. He also said the staff turned the a/c down to 68 to try to cool and it shut down the system. They cannot turn it below 72. He said no one had any heat problems from it being too warm.<BR/>Interview with Maintenance Director on 7/16/23 at 10:47am revealed: he said the bathrooms had been out of order since February. They had black stuff coming out of the drain. They had tried using plumbers to clean the pipes out, but it didn't work. As of right now there is no plan to fix them because they will need all new pipes.<BR/>Observation in room [ROOM NUMBER] on 7/17/23 at11:00am revealed: Bathroom sink, when turned on, had water gushing out of the pipes below. There was a trashcan to help catch some of the water, but there was still water all over the floor.<BR/>Interview with ADON 7/17/23 at 11:11am revealed: she was Informed of leaking pipes in room [ROOM NUMBER]'s bathroom and she did not say anything.<BR/>Interview with Wound Care Nurse on 7/17/23 at 1:15pm revealed the facility was aware of the leaking pipes in room [ROOM NUMBER] and it had been like that for at least 2 weeks. <BR/>Observations on 7/15/23 at 7/15/23 at 8:30 am, 7/16/23 at 8:30 am, 7/17/23 at 9:35 am and 7/18/23 9am revealed: Doors to smoking area were wide open and had been left open continuously during the survey. <BR/>In an interview with Maintenance Worker on 7/18/23 at 12:10 p.m., he said he was aware of the scraped walls, and it would be repaired, and the broken lock and missing tiles. He said the scraped wall and missing tiles could be dangerous like that because residents or staff could get cut on the jagged edges. He said there have been a lot of staff changes recently, and they are trying to stay caught up on all the maintenance issues. <BR/>Record review of facility policy Maintenance Service revised November 2021 revealed, in part: .maintenance department is responsible for maintaining building .in safe operable manner at all times .maintenance personnel maintain the building in good repair and free from hazards . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 8 of 18 residents reviewed for ADL care (Residents # 4, #7, #20, #28, #44, #55, #60, #181).<BR/>--facility staff failed to provide personal hygiene care to Resident #4, #44, #55, #60 <BR/>--facility staff failed to turn and reposition Resident # 7 as ordered <BR/>--facility staff failed to provide timely incontinent care and transfer assistance to Resident #20<BR/>---facility staff failed to provide timely incontinent care to Resident # 28, #55, #60, #181 <BR/>Theis failurefailures placed residents who were unable to carry out ADLs at risk of not receiving necessary care and assistance when needed. <BR/>Findings include:<BR/>Resident #4<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted and readmitted to the facility 07/06/23. His diagnoses included Acute respiratory distress (inability to breath) sepsis (infection) Contractures, persistent vegetative state (a person who is unaware and unresponsive), muscle wasting, pneumonia, multiple site pressure ulcers and dysphasia.<BR/>Record review of Resident #4's significant change MDS assessment dated [DATE] revealed his cognitive level ( BIMS) score was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident # 4's care plan dated 10/08/20and edited 05/11/23 read in part -<BR/>ADLs Functional Status/Rehabilitation Potential. Resident #4 is dependent with all ADLs. Bed mobility with two to three person assist for Transfer: total assistance with 3 staff, Dressing: total assistance with 2 staff and personal hygiene: 2 staff assist.<BR/>Goal: Resident # 4 is dependent with all ADLs. Bed Mobility: total assistance. Resident #4's dignity will be maintained, and he will be clean, dry, well-groomed and odor free during the next 90 days.<BR/>Approach: dress resident according to season and climate. Provide oral care twice daily. Shower, shampoo hair, and give nail care per shower schedule and as needed.<BR/>Observation on 07/15/23 at 2:00PM, revealed Resident #4 was in bed, noncommunicative and in a semi fetal position. He was contracted with his two-hand clenched in a fix position, unkept facial hair, dirty long nails about 1\2 an inch, and there was dry white substance around his mouth. He had a dirty hospital gown on and a catheter with 300 ML of clear yellow urine.<BR/>Observation and interview on 07/16/23 at 10:00AM revealed Resident #4 was in the same position with the same hospital gown on, dirty long nails and unkept facial hair. In an interview with CNA Y, she looked at Resident #4 and said she would clean him.<BR/>In an interview with LVN L on 07/16/23 at 10:00am, she said Resident # 4 was on hospice and hospice usually cleaned him.<BR/>Record review of Physician's telephone orders dated 04/13/23 revealed Resident # 4 was admitted on hospice on 07/13/23. Hospice documentation was requested from ADON on 07/16/23 at 3:30pm but was not provided. <BR/>Resident #7<BR/>Record review of Resident #7's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood causing respiratory failure), vascular dementia (brain damage from impaired blood flow to brain), shortness of breath, cognitive communication deficit (difficulty with thinking and language), obstructive and reflux uropathy (urine unable to drain through urinary tract), muscle wasting and atrophy (decrease and thinning in muscle size), dysphagia (trouble swallowing), pneumonitis due to inhalation of food (inflammation of the lungs), schizophrenia (false beliefs, hallucinations, unusual behavior, and disorganized thinking and speech), and pressure ulcer of sacral region (pressure sore in the lower back and tailbone area). The face sheet also revealed the resident was a DNR.<BR/>Record review of Resident #7's Comprehensive MDS dated [DATE], revealed a BIMS score of 5 which indicated severely impaired cognition. The MDS revealed the resident had a serious mental illness of schizophrenia. He had unclear speech, sometimes could make himself understood, and sometimes understands others. Resident #7 required extensive assistance with personal hygiene, dressing, and bed mobility. He required physical help with bathing and one-person physical assistance. He used a wheelchair for mobility. The resident had an indwelling catheter for obstruction but was always incontinent of bowel. He had a stage 4 pressure ulcer to his sacrum, was on tube feeding, and on hospice.<BR/>Observations of Resident # 7 on 7/15/23 revealed: 10:22am: on his back, asleep in bed, 1:30pm: on his back in bed, no one had gone in the room to check on him. <BR/>Observations of Resident #7 on 7/16/23 revealed: 9am: on his back, asleep, 1:57pm: on his back, asleep in bed, no one had gone in the room to check on him. <BR/>Observation of Resident #7 on 7/17/23 revealed: 11am: on his back, asleep in bed.<BR/>Observations of Resident #7 on 7/18/23 revealed: 9:03am: on his back, asleep in bed, 12:40pm: on his back, asleep in bed, no one had gone in the room to check on him. <BR/>Record review of Resident #7's care plan, revised 7/3/23, revealed I have a stage 4 to my sacrum from admission-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Dental Care-Maintain oral hygiene/status: Oral Care BID. Bowel Incontinence-I will establish an individual bowel and bladder routine: Check for incontinence Q2hrs and PRN. ADL Function/Rehab Potential-I will achieve maximum functional mobility: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Toileting amount of assist: Extensive. Activities-I will attend/participate in 1 activity per week. The resident will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Mon, Wed, Fri: 6am-6pm. Nail Care Once a Day on Mon, Wed, Fri: 6am-6pm. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>Resident #20<BR/>Record review of Resident #20's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE] with diagnoses of demyelinating disease of central nervous system (multiple sclerosis which is an autoimmune attack on the coating of nerves and causes inflammation and damage to brain and/or spinal cord), muscle wasting and atrophy (decrease and thinning of muscle), dysphagia (trouble swallowing), contracture of muscle (muscles, tendons, joints, or other tissues tighten/shorten causing a deformity), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry about everyday issues and situations), pain, and repeated falls.<BR/>Record review of Resident # 20's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, which indicated normal cognition. The MDS also revealed she had a serious mental illness. Resident #20 indicated it was very important for her to choose what clothes to wear, to choose between a tub bath, shower, bed bath or sponge bath, and to do her favorite activities. She required extensive assistance with personal hygiene, dressing, transfer, and bed mobility, and total dependence with toilet use. She also required 1-2 people to assist her with the activities. She needed physical help with bathing and 1 person to physically help her. Resident #20 used a wheelchair for mobility. She was always incontinent of urine and bowel.<BR/>Observation and interview with Resident #20 on 7/15/23 revealed: 1:26pm: said they did not get her up for lunch. Food was observed on her chest and on her mouth. She said there was barely any staff, so she did not ask to get into her electric chair because she was afraid, she would not be able to get back into bed and would be in pain. Mon/Fri were supposed to be shower days, and Wed were lotion days, but that had not been happening. She had not been turned all day and she was unable to turn herself. So far, she had not had any skin breakdown. There was only 2 people in the whole building last night and she did not get changed the whole night until 6am this morning. She had not brushed her teeth all day.<BR/>Interview on 7/15/23 at 1:40pm with TNA CW revealed he comes in 6a to 6p and usually changes/brushes the resident's teeth between 6a-6:30am. He said he turns residents every 2hrs because he was a patient himself before. He said Resident #20 is definitely a resident that needs to be turned every 2hrs. When asked about Resident #20 not having her teeth brushed or being turned, he said he didn't know what happened. He said if she's not turned, a bedsore could happen because she can't turn herself. When asked about setting her up for lunch, he said he didn't pass her tray and that he was in the dining room. Whoever passed the tray should have set her up. He also said that he always takes a female with him when he goes in her room. Surveyor said she had food all over her chest, needed her teeth brushed, and needed to be turned. He said he would go in and take care of it. He said they usually have 4 aides during the day, and he didn't feel like they were short staffed today.<BR/>Observation and interviews with Resident # 20 on 7/16/23 revealed: 10am: said she was last changed last night and has not been changed this morning yet. Flat on her back in bed, 2:02pm: said she had not been in her chair in 2-3 weeks. She asked TNA CW to sit her up in bed for lunch and he didn't. She was flat on her back in bed, 2:05pm: TNA CW said he did not remember telling Resident #20 that he would sit her up in bed and he did not go into her room unless he had a female with him, 2:10pm: CMA M said Resident #20 was turned when she was changed. Resident said she was not.<BR/>Observations of Resident #20 on 7/17/23 revealed; 9am: flat on her back and not in her wheelchair. She stated she was afraid to ask to get in the wheelchair, 2:05pm: flat on her back and not in her wheelchair. She stated it was too late to ask to get into her wheelchair now.<BR/>Observation of resident #20 on 7/18/23 revealed: 9:08am: resident told CMA I and TNA C that she wanted to get up in her electric chair by 11am. She did not get her suppository yesterday at 3pm even though she asked for it. She told TNA C today, that she wanted it. She still had not had breakfast and was still waiting on it, 1:15am: not in her wheelchair yet. Staff was standing in the hall talking and laughing.<BR/>Interview on 7/18/23 at11:20am with DON and Clinical Resource Nurse about Resident #20 not being in her wheelchair by 11am: revealed DON did not know why someone had not helped her yet. Also informed them about Resident #20 not being in her wheelchair in the past 2-3 weeks and they said the resident overexaggerates and there was no way it had been 2-3 weeks since she had been in her wheelchair.<BR/>Observation on 7/18/23 at 12:36pm revealed: Resident #20 was put into her electric wheelchair. She had not had lunch yet.<BR/>Record review of Resident #20's care plan, revised 6/6/23, revealed I have thin and fragile skin-Prevent/heal pressure sores and skin breakdown: Turn and reposition every 2 hours and PRN. Oral/Dental Status. I use a rechargeable toothbrush-Maintain oral hygiene/status: Oral Care BID. B/B Incontinence-I will establish an individual bowel and bladder routine: Briefs when out of bed. Toileting. Resident #20 has been identified as having DD PASRR positive status related to Demyelinating disease of central nervous system. I am currently receiving habilitation coordination and habilitative therapy (3/10/23-9/5/23)-Resident #20 will maintain highest level of practicable well-being for the next 90 days: I am recommended to receive PASRR habilitative services through PT and OT. Patient will exhibit improved fine motor coordination skills to facilitate patient's ability to grasp items during self-feeding with stand by assistance in order to improve functional use of upper extremity's during ADL's and perform ADL's w/ increased safety. Patient will increase activity tolerance for functional activities of choice in wheelchair 2 x week for 2 hours in order to help with implementation of compensatory strategies and with improved ROM and coordination and increase participation within environment. Patient will complete hygiene and grooming tasks while sitting in front of mirror with caregiver assistance with implementation of compensatory strategies in order to perform ADLs with increased safety. Patient will increase trunk strength to 2+ out of 5 in order to facilitate improved trunk balance, facilitate upright posture and increase core strength for functional activities. Patient will increase static sitting balance to poor using protective extension 70 percent of the time to right self in order to participate in edge of bed activities and decrease loss of balance during functional mobility. Patient will tolerate sitting up x 2hr for skin integrity: Therapy to treat once a day, 3 x week x 6 months. I prefer to have showers on Mon/Wed. On Wednesdays I prefer to have lotion applied with no shower: Showers including hair wash on Monday and Friday only Once a Day on Mon, Fri: 6pm-6am. Nail Care Once a Day on Mon, Wed, Fri: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am.<BR/>Interview with Administrator and DON on 7/16/23 at 11a.m. regarding where showers would be documented. They said it would be documented in the computer.<BR/>Record review on 7/16/23 at 12pm revealed the shower documentation on the computer was incorrect. It showed everyone had a shower, every day. The residents said they were not showered in days up to a week and looked dirty and greasy.<BR/>Record review 7/17/23 at 10am revealed shower sheets in a binder at the South nurse's station were all blank.<BR/>Interview with DON on 7/18/23 at 3pm about why she thought ADLs were not being done. She said she was not sure why the ADL's were not done, and did not have a reason why.<BR/>Resident #28<BR/>Record review of Resident # 28's face sheet revealed a [AGE] year-old female with admission date of 3/3/23 and diagnoses including atrial fibrillation, Diabetes, major depressive disorder, single episode, hypertension, osteoarthritis, systemic lupus (disease when immune system attacks its own tissues), chronic obstructive pulmonary disease (lung disease that blocks airflow), rheumatoid arthritis (inflammatory disorder that attacks joints). <BR/>Record review of Resident #28's care plan for ADL Functional Status/Rehab Potential dated 3/3/23 revealed extensive assistance by 1 staff required for bathing, hygiene, dressing, grooming, and toileting. <BR/>Record review of Resident # 28's admission MDS dated [DATE] revealed modified independence in cognitive skills, able to make herself understood and understands, always incontinent of bowel and bladder, and extensive assistance of 1-2 staff required for transfer, dressing, toileting, personal hygiene, and bathing. <BR/>Observation of Resident #28 on 7/15/23 at 10:00 AM revealed she was in bed. Interview at that time revealed she was waiting for someone to get her cleaned up and dressed. When asked if someone came to check on her or change her last night, she said no one came. She said she thought her call light was not working because no one came after she pushed it. She said it happens often that no one comes to check on her overnight. <BR/>Record review of Point of Care History, staff support for toileting dated 7/15/23 revealed documentation of Resident #28 receiving assistance with toileting at 2:19 AM and 10:37 PM. <BR/>Resident # 44 <BR/> <BR/> <BR/>Record review of Resident #44's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia, behavior disturbance, upper respiratory infection, muscle wasting, lack of coordination, essential hypertension, Kidney complication and human immune deficiency, and diabetes.<BR/>Record review of Resident #44's admission MDS assessment dated [DATE] revealed his BIMS score 9 out of 15 reflected he was moderately impaired on cognition. <BR/>Record review of his annual MDS assessment section on ADLs assessment indicated physical help in part bathing activities was left blank. On ADL, he was assessed as extensive assistance for all areas.<BR/>Record review of Resident #44's care plan dated his 11/14/22 and edited 05/04/23 revealed -<BR/>-ADLs Functional Status/Rehabilitation I am limited in ability to toilet self R/T cognitive<BR/>deficits. <BR/>-I require supervision to ensure I turn and reposition while in bed.<BR/>- ADLs Functional Status/Rehabilitation Potential, I am limited in ability to bathe self R/T cognitive deficits r/t dementia .<BR/>Goals: <BR/>I will dress/undress self independently with supervision; I will bathe with assistance <BR/>Allow sufficient time to complete bathing.<BR/>Observation and interview on 07/15/23 at 11:00AM, revealed Resident #44 was in bed with dirty personal clothes on. He shirt had food stained on it. He had unkept facial hair and dirty long fingernails. <BR/>Observation on 07/16/23 at 8:30AM, revealed resident #44 was in the dining room he had just finished his breakfast with the same dirty shirt on. During an interview, he said he had stroke and need assistance in caring for himself. He said he does not remember the last time he had a bath\shower. He said he would like to be shaved and cleaned up. He said nothing when asked if he had asked for any assistant.<BR/>During an interview with TNA S acknowledged that Resident #4 needed to be cleaned. She said the facility need need more staff. <BR/>During an interview with LVN F asked Resident #44 if he would like to have a bath, be shaved and have his fingernails trimmed. He said yes. She said she would make sure that he was cleaned.<BR/>Resident #55<BR/>Record review of Resident #55's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of myocardial infarction (heart attack), muscle wasting and atrophy (decrease in size and thinning of muscle), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness and paralysis after a stroke), protein-calorie malnutrition (lack of protein and calories in the diet), major depressive disorder (persistent feeling of sadness and loss of interest), heart failure (heart is not pumping as strong as it should), and dysarthria and anarthria (trouble speaking).<BR/>Record review of Resident #55's Comprehensive MDS dated [DATE], revealed a BIMS score of 9, which indicated moderately impaired cognition. Resident #55's MDS also revealed he had a serious mental illness. The resident had unclear speech and impaired vision. He felt it was very important to chose what clothes to wear, to choose between a tub bath, shower, bed bath, or sponge bath, and to go outside to get fresh air when the weather was good. Resident #55 required extensive assistance with personal hygiene, dressing, transfer, and bed mobility. He required physical help with bathing and two+ persons physical assist. He used a wheelchair for mobility. The resident was always incontinent of urine and bowel.<BR/>Observations of resident #55 on 7/15/23 revealed: 9:22am: greasy looking hair, long facial hair, long nails, and had a patient gown on. He said there was never enough staff, and they never had enough supplies. He had to wait long periods of time to be changed.<BR/>Observations of resident #55 on 7/16/23 revealed: 9:49am: said he had not had a shower in over a week. He was last changed at 5am. He had not had his teeth brushed today or yesterday. He was still in a patient gown, would like his nails trimmed, and would like to be shaved. He also needed to be changed.<BR/>Observation on 7/16/23 10:15am revealed: Restorative CNA went into the room to shave the resident. Surveyor asked why she was just now shaving him, and she said she just became Restorative on Saturday and before that she worked in HR. She said the CNAs should have been shaving and brushing his teeth for him.<BR/>Observation on 7/18/23 at 3:00pm: Resident was not out of bed for the 4 days of the survey.<BR/>Record review of Resident #55's care plan, revised 5/24/23, revealed I am at risk for pressure ulcers r/t left sided hemiplegia-My skin will remain intact: Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry, and wrinkle free. I have urinary incontinence; I have limited mobility due to left sided CVA-I will not develop skin breakdown related to incontinence: Check for incontinent episodes at least every 2 hours. I am limited in ability to transfer self r/t left side hemiplegia- I will transfer self with extensive assistance. I am limited in ability to toilet self r/t left sided hemiplegia-I will toilet with extensive assistance of one staff: Provide incontinence care as needed. I am limited in ability to dress/undress self r/t left sided hemiplegia-I will dress/undress self with extensive assistance: Allow me to choose own clothing, dress affected side first. I am limited in ability to maintain grooming/personal hygiene r/t CVA-I will groom self with limited assistance. I am limited in wheelchair mobility r/t left sided hemiplegia-I will achieve highest level of wheelchair mobility as evidenced by increased mobility. Resident #55 will perform the following tasks at their highest practicable level: I prefer to take my Bath/Shower Once a Day on Tue, Thu, Sat: 6pm-6am. Nail Care Once a Day on Tue, Thu, Sat: 6pm-6am. Oral Care Twice a Day: 6am-6pm and 6pm-6am. Resident experiences bladder incontinence-Resident will maintain current level of bladder continence: Provide incontinence care after each incontinence episode.<BR/>Resident #60<BR/>Record review of Resident #60's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of end stage renal disease (kidneys stopped working), Type 1 diabetes with diabetic neuropathy (autoimmune disorder where pancreas stops making insulin with pain caused by nerve damage) , other disorders of electrolyte and fluid balance (when a large amount of body fluid is lost), chronic pain syndrome (symptoms beyond pain alone like depression and anxiety that interfere with life), major depressive disorder (persistent feeling of sadness and loss of interest), Type 2 diabetes with diabetic retinopathy (body doesn't produce insulin and a complication of diabetes causing blindness), muscle wasting and atrophy (decrease in size and thinning of muscle), and neuromuscular dysfunction of the bladder (nerves and muscles do not work in the bladder).<BR/>Record review of Resident #60's Comprehensive MDS dated [DATE], revealed a BIMS score of 13, which indicated normal cognition. The MDS also revealed the resident had impaired vision. According to the resident's preferences, it was very important for him to choose what clothes he wore, and it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The resident required extensive assistance with personal hygiene, dressing, transfer, and mobility. He required physical help with bathing and needed one-person physical assist. He used a wheelchair for mobility. Resident #60 had an indwelling catheter for a neurogenic bladder but was always incontinent of bowel.<BR/>Observation of Resident #60 on 7/15/23 9:29am: had long nails and was wearing a patient gown. He stated he had to use a Hoyer lift to get out of bed and into his wheelchair, but he was scared when he got into his wheelchair because there was never anyone around to get him back into bed. He had to get into his wheelchair on M/W/F for dialysis and it took a long time for them to get him up and then for them to get him back in bed. His sheets had a yellow, urine stain on them. Resident had been vomiting and had an emesis bucket under his chin. He was laying supine in bed.<BR/>Observation of Resident #60 on 7/16/23 9:45am revealed: said staff told him yesterday that only CNAs could change him and not TNAs, so he had to wait a really long time to be changed. He still had not had his teeth brushed yet today. He had not had his sheets changed since Wednesday. He still had a yellow, urine stain on his sheets. He still had not had a bath since Monday and still had long nails. He also was still laying supine in bed, 2:15pm: said he had not been changed since 9am. He told TNA C and he just picked up his lunch tray and left. <BR/>Interview with ADON on 7/16/23 at 2:19pm: she did not know why someone did not go change him and why he had been waiting since 9am. She said she would go change him.<BR/>Observations of Resident # 60 on 7/17/23 revealed: 9:39am: stated he waited over 8hrs to be changed yesterday afternoon due to having so many TNAs and only 1 or 2 CNAs. He was last checked at 4-5am today. He still had not been bathed or had his teeth brushed, nails trimmed, or been shaved, 9:45 am-10:15am: ringing his bell (call bell was not working) to be changed and the Restorative Nurse finally went into the room. Surveyor went in and saw the Restorative Nurse was shaving the roommate. She did not change Resident #60. Resident #60 said he told TNA C that he needed to be changed, but he never went back, 10;15 am: Surveyor asked TNA C about changing Resident #60. He said that he did tell him he was going to go back and change him, but he got caught up doing other things and had been busy and had not had a chance to go back yet. He also said that was not his side of the hall, that it was CNA A's, but they call him to go over there because he had all the muscle. He said the facility needs more staff.<BR/>Observation on 7/18/23 at 3:00pm revealed Resident #60 was never out of bed except to go to dialysis.<BR/>Record review of Resident #60's care plan, revised 7/16/23, revealed the resident will perform the following tasks at their highest practicable level: Nail Care Once a Day on Mon, Wed, Fri 6pm-6am, Oral Care Twice a Day 6am-6pm and 6pm-6am. I am at risk for pressure ulcers r/t decreased physical abilities-Resident's skin will remain intact: Keep linens clean, dry, and wrinkle free. I am limited in ability to transfer self r/t physical deficits-I will transfer self with extensive assistance: Remind me to not transfer without assistance. I am limited in ability to toilet self r/t physical deficits-I will toilet self with use of extensive assist x 1 staff: Provide extensive assistance for toileting. I am limited in ability to eat and drink r/t vision and cognitive deficits-I will be hydrated and well-nourished as evidenced by stable weight. I am limited in ability to dress/undress self r/t physical and cognitive deficits-I will dress/undress self with extensive assistance. I am unable to independently change position while in bed as evidenced by requiring assistance with bed mobility-I will reposition self with bed rails and the assistance of one: Provide hands assistance for repositioning/transferring in and out of bed. Turn and reposition every 2 hours. I am limited in ability to maintain grooming/personal hygiene r/t cognitive and physical deficits-I will groom self with extensive assistance. I am limited in wheelchair mobility r/t physical deficits-Resident will achieve highest level of wheelchair mobility: Provide assistance for wheelchair mobility.<BR/>Resident #181<BR/>Record review of Resident # 181's face sheet revealed a [AGE] year-old male with admission date 2/14/23 and diagnoses including cerebral infarction (disruption of blood flow to the brain due to blood vessel problems), cognitive communication deficit, cellulitis (bacterial skin infection), pain in right shoulder, contracture (shortening and hardening of muscles), restlessness and agitation.<BR/>Record review of Resident #181's Urinary Incontinence care plan dated 2/20/23 revealed bowel and bladder incontinence. Approaches included: check for incontinence every 2 hours and PRN, and toileting every 2 hours and PRN. <BR/>Record review of Resident #181's ADL Functional Status care plan dated 2/20/23 revealed assistance with activities of daily living was needed, and approaches were for maximum amount of assistance for toileting, bathing, hygiene, dressing, and grooming.<BR/>Record review of Resident #181's admission MDS dated [DATE] revealed severely impaired cognitive skills and never or rarely made decisions, rarely or never understood by others and rarely or never understands others, always incontinent of bowel and bladder, and extensive 2-person staff assistance required for transfer, dressing, toileting, personal hygiene, and total assistance required for eating and bathing. <BR/>Observation of Resident #181 on 7/15/23 at 10:00 a.m. revealed he was in bed, and family member was in the room changing his brief. Family member had placed the soiled brief and under pad on the floor, which were saturated with urine and had a visible dark circle on the outer edges of the brief and under pad. Interview with Resident #181's family member at that time revealed she comes in the morning and always changes his brief because it is soaked with urine, and when she asks him if anyone came to change him the night before, he says no. Interview with Resident #181 on 7/15/23 at 10:30 a.m. revealed, when asked if anyone came to change him last night, he shook his head and said no. <BR/>Record review of Point of Care History, staff support provided for toileting dated 7/15/23 revealed documentation Resident #181 received staff assistance with toileting at 2:40 AM and 7:40 PM. There was no documentation of staff assistance with toileting on 7/16/23. <BR/>In an interview with an advocate for a resident in the facility on 7/15/23 at 1:10 p.m., she said they need more help here, they are short staffed, and residents wait up to an hour to be changed after they push the call light. <BR/>In a confidential interview with Resident #181's family member on 7/16/23 at 11:34 a.m. revealed Resident #181 has been here since January 2023, and she comes every day. She said there are problems with him being changed, especially overnight. She said she changes him when she gets here, and his brief is always soaked. Two pillows were soaked with urine today. She asked him if anyone came to change him overnight, and he said no. <BR/>Interview with the interim DON on 7/15/23 at 1:50 p.m. revealed she has been here 8 days as interim DON and has seen the staff really trying to care for all residents timely, but it's a problem because there are not enough staff working at a given time. She said if someone calls in, there is not always someone who can work in their place, but management staff can help if needed. <BR/>Record review of facility policy Activities of Daily Living (ADL's) Supporting, revised March 2018, revealed, in part: . appropriate care and services will be provided for residents who are unable to carry out ADL's independently .including appropriate support and assistance with hygiene (bathing, dressing, grooming, oral care) and elimination (toileting) . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and the facility failed to ensure the results of all investigations were reported to the administrator or his or her designated representative and to other officials in accordance with State law, which included the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action was taken for 2 of 11 residents (CR#1 and Resident#2) reviewed for abuse and neglect.<BR/>-The facility failed to report the results of a completed investigation to the State Survey Agency (SSA) within 5 working days involving the alleged abuse of Resident #2 by CR #1 that occurred on 04/12/2023. <BR/>This failure could place residents at risk if interventions are not put in place to prevent further abuse.<BR/>Findings include:<BR/>Resident #2:<BR/>Record review of the, undated, face sheet for Resident#2 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His primary diagnosis included cerebrovascular disease.<BR/>Record review of Resident#2 Quarterly MDS assessment, dated 05/03/2023, revealed the BIMS score of 6, which indicated severely impaired cognitive skills. <BR/>CR#1:<BR/>Record review of the, undated, face sheet for CR#1 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 04/12/2023. Her primary diagnosis included altered mental status. <BR/>Record review of CR#1 admission MDS assessment, dated 04/12/2023, revealed the BIMS score of 99, as the resident was unable to complete the interview, an indicated severely impaired cognitive skills.<BR/>Record review of SSA reporting database revealed that the completed PIR was submitted on 05/02/2023with allegations of Resident/Patient/Client Abuse, that were unfounded.<BR/>Record review of completed PIR for was signed by the DON on 4/19/2023. <BR/>In an interview on 05/03/2023 at 9:57am with the CRN, she said that she was a RN and had work for the corporate office in her current position for two years. She said that she discovered that the completed PIR for the incident involving Resident #2 and CR #1 was not submitted to the SSA timely while going through a stack of documents, and she had the DON submit it on 05/02/2023. She said that the PIR should have been submitted within 5 days on 04/19/2023 as indicated in the policy for Abuse and Neglect. She said that the oversight for completing the task belonged to the Administrator who is the Abuse Neglect Coordinator. She said the facility was without an Administrator from 03/31/2023-04/16/2023. She said that Admin #1 was at the facility from 4/10/2023-4/14/2023, she completed the investigation, and she left instructions for the DON to submit the PIR to the SSA in her absence. She said that Admin #2 started his position on 04/17/2023, and he claimed that he was not made aware of an outstanding PIR that needed to be submitted to the SSA. She said that the risk of not completing or submitting investigation to the SSA timely is the abuse or neglect could continue. <BR/>In an interview on 05/03/2023 at 11:04am with the DON, she said that she is an RN and she started her current position on 03/31/2023. She said that Interim Admin was the abuse coordinator at the time the incident was investigated, and it was the responsibility of Interim Admin to submit the completed PIR to the SSA. She said she was not aware that the PIR was not submitted until 05/02/2023, when the CRN told her to submit it to the SSA. She said that a completed PIR should be submitted to SSA within 5 days according to facility policy. She said the PIR for the incident involving Resident #2 and CR #1 was not submitted timely, and she was never made aware that she needed to submit it to SSA. She said that that risk of not completing investigations and not having the completed PIR submitted to the SSA is that the alleged abuse could continue and happen to other residents. <BR/>In an interview on 05/03/2023 at 11:37am with Admin#2, he said that he started his current position on 04/17/2023, and he was not told about any outstanding PIR that needed to be submitted to the SSA. He said that a completed PIR should be submitted to the SSA in 5 days. He said that the Administrator or designee (DON) should submit completed PIR to the SSA. He said that the risk is resident safety because interventions to prevent further abuse may not be put in place. <BR/>In a phone interview on 05/03/2023 at 3:35pm with the Interim Admin, she said that she works for the facility's corporate office as a traveling Administrator when there is a vacancy. She said that she was at the facility for a number of days at the beginning of April of 2023, and she believed that her last day was on 04/13/2023. She stated that while she was at the facility, she completed two PIR's, was unsure of the intake numbers, but she was only able to submit one to the SSA. She stated that she left instructions for Admin #2 to submit the second PIR to the SSA. She said that she did not talk to Admin #2, but she left detailed instructions for a number of things that he would need to complete on his start date, and she did not thing think he would have problems being an experienced Administrator. She said that the PIR was not due to the SSA until 4/18/2023 or 4/19/2023. She said the DON was in charge from her last day on 4/13/2023 until 4/17/2023 when Admin #2 started. She said that a completed PIR should be submitted to the SSA in 5 days, and the risk to residents by not doing so is that abuse or neglect could continue. <BR/>Record review of the facility's undated policy titled Abuse and Neglect Policy and Procedure, read in part: . Report/Respond 1. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source or abuse is reported, the facility Administrator, or his/her designee, will notify the Department of Aging and Disabilities Services (immediately upon learning of the incident and a written investigation no later than the fifth working day after the oral report . ).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that assessments accurately reflected the resident's status for 1 of 11 residents (Resident#3) whose assessments were reviewed in that:<BR/>-Resident#3's MDS did not reflect his indwelling catheter. <BR/>This failure could affect residents at the facility who had been assessed and could contribute to inadequate care.<BR/>The findings included: <BR/>Record review of Resident #3's undated face sheet revealed he was [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of end stage renal disease (condition in which kidneys cease functioning). <BR/>Record review of facility report of current residents with catheters to included Resident#3. <BR/>Record review of Resident #3's comprehensive care plan with start date 10/25/2022 and revisions on 04/20/2023 revealed:<BR/>Focus: I require an indwelling urinary catheter R/T Neurogenic Bladder & Chronic H/O Urinary Retention.<BR/>Goal: I will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma.<BR/>Intervention: Change catheter per MD order. Provide catheter care per MD orders and as needed.<BR/>Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed Resident#3 was cognitively intact with a BIMS score of 11 in section C. He was not triggered for an indwelling catheter in section H for Bladder and Bowel. <BR/>In an interview on 05/05/2023 at 10:38pm with the CRN, she said that the CCM completes all MDS assessments, with the DON as oversight oversite. She said that the risk to residents of an inaccurate MDS is that appropriate care may not be received. She said that the facilities used the RAI when completing MDS assessments. <BR/>In an interview on 05/05/2023 at 11:49am with the DON, she said that the CCM completes all MDS assessments, with her as oversight. She said that the risk of an inaccurate MDS is that residents may not receive appropriate care. She said that she was not sure if the facility used the RAI manual when completing MDS assessments, and she was not familiar with MDS assessments. <BR/>In an interview and observation on 05/05/2023 at 5:15pm with Resident#3, he was observed in his room with indwelling catheter with a privacy cover. He said that he has had a catheter since admission. <BR/>In a follow up interview and observation on 05/08/2023 at 1:40pm with the CCM, she reviewed Resident #3's Quarterly MDS assessment dated [DATE]. She said that Resident#3 was not triggered for an indwelling catheter in section H for Bladder and Bowel, and said it was an oversite as the resident was admitted with a catheter. She said that she did not know how she missed it. She stated that the risk of not having an accurate assessment is the resident may not receive appropriate care needed. <BR/>Record review of policy entitled MDS Completion and Submission Timeframes dated July 2017 read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .<BR/>Record review of CMS RAI 3.0 User's Manual dated October 2019 read in part Section H: Bladder and Bowel Planning for Care <BR/>o Care planning should include interventions that are consistent with the resident's goals and minimize complications associated with appliance use <BR/>o Care planning should be based on an assessment and evaluation of the resident's history, physical examination, physician orders, progress notes, nurses' notes and flow sheets, pharmacy and lab reports, voiding history, resident's overall condition, risk factors and information about the resident's continence status, catheter status, environmental factors related to continence programs, and the resident's response to catheter/continence services. <BR/>Steps for Assessment <BR/>1. Examine the resident to note the presence of any urinary or bowel appliances. <BR/>2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 11 residents (CR#4) reviewed for care plans, in that:<BR/>-CR#4 did not have a completed baseline care plan completed within 48 hours of admission. <BR/>-CR#4 did not have a baseline care plan to address her indwelling catheter. <BR/>These failures could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care.<BR/>Findings included:<BR/>Record review of CR #4's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included orthopedic aftercare and left leg femoral fracture. Her discharge date was 04/26/2023 to be transferred to another facility. <BR/>Record review of CR#4's admission Observation Report dated 04/10/2023, indicated CR#4 admitted with indwelling catheter. <BR/>Record review of CR #4's baseline care plan dated 04/14/2023 and completed by the CCM did not address focus, goals, or intervention for an indwelling catheter. <BR/>Record review of CR #4's MDS assessment dated [DATE] and completed by the CCM revealed CR #4 was cognitively intake with a BIMS score of 12 in section C. She was triggered for an indwelling catheter in section H for Bladder and Bowel.<BR/>In an interview on 05/05/2023 at 10:38pm with the CRN, she said that the admitting nurse is responsible for completing the baseline care plan for newly admitted residents within 48 hours. She said upon her review the admitting nurse, LVN D, did not complete the baseline care plan timely, it was completed on 04/14/2023 by the CCM, and the CCM did address that CR#4 had a catheter on the care plan. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT met meet regarding CR#4. She said that the IDT should consist of the CCM, DON, ADON, and DOR. She said that the DON is the oversite oversight and should ensure that all admission tasks are completed accurately. She stated that the risk to residents of not having systems in place could cause residents to not receive appropriate care, delay in diagnosis, delay in treatment, and infection to include UTI.<BR/>In an interview on 05/05/2023 at 11:01am with the CCM, she said that she is an LVN. She said that she has worked at the facility since 09/01/2022, she completes all MDS assessments for the facility. She said that the admitting nurse is responsible for completing baseline care plan for newly admitted residents within 48 hours. She said the ADON checks for accuracy of the admission process. She stated that the IDT consists of the DON, ADON, CCM, DOR, and SW, and the IDT meets Monday-Friday, and review admission process for newly admitted residents. She said that she helps the ADON audit baseline care plans, and the ADON and she will complete the care plan if had not been completed within 48 hours. She said that upon her review CR#4 admitted to the facility with catheter on 04/10/2023, the baseline care plan was not completed until 04/14/2023, and it did not address that the resident had a catheter. She said completed the baseline care plan while completing audits on 04/14/2023. She said that she could not remember if the IDT meet met regarding CR#4. She stated that the risk of not having the systems in place could cause a resident to not receive appropriate care. <BR/>In an interview on 05/05/2023 at 11:49am with the DON, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the ADON is the oversite oversight to ensure that admitting nurse completed the admission process with accuracy. She said that the CCM is the oversite oversight for to ensure that baseline care plans are completed timely and accurately within 48 hours. She said that she is the oversite oversight for the ADON and CCM. She stated that she completes an audit twice each week to ensure that the admitting nursing and ADON have completed the admission process accurately, she could not remember if she audited the records for CR#4, and she did not keep a record of her audits. She stated that IDT meets to discuss newly admitted residents a few days after admission. She said that she could not recall if the IDT reviewed the admission process for CR#4. She said that based on her review the baseline care plan was not completed timely and did not address the catheter for CR#4. She stated that the risk to the resident of not having systems in place is not receiving appropriate care. <BR/>In an interview on 05/04/2023 at 12:57pm with the ADON, she said that she is a LVN , and she has worked at the facility for 16 months. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the baseline care plan should be completed in 48 hours. She stated that she audits the admission process the next business day for accuracy and completion. She said that the CCM will help her audit the baseline care plans. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet regarding CR#4. She said that CR#4 was admitted on [DATE] with a catheter. She said she did not work on 04/11/2023-04/12/2023, and she worked the floor for the remaining days of the week. She said that the DON is the oversight oversite, and if she is not able to audit the DON is to complete the task. She said that upon her review the baseline care plan for CR#4 did not address her catheter and was not completed timely. She stated that the risk of not having the system in place is that a resident may not receive appropriate care. <BR/>Record review of the facility's policy titled Care Plans - Baseline dated 2001 Med-Pass, Inc. (Revised December 2016) read in part. <BR/>A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. <BR/>- Policy Interpretation and Implementation. <BR/>1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. <BR/>2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; .<BR/>Record review of the facility's policy titled, IDT Daily PPS meeting Agenda dated January 2023 read in part. <BR/>Purpose Statement: To provide on-going communication with the IDT members to discuss the plan of treatment and to assure required procedures are completed in a timely manner for all new admission. Frequency: Meets daily. Team Members: The Interdisciplinary team members (IDT) include but not limited to the following: CCM, Therapy representative, Business office Manager, DON or designee, and social services or designee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (CR#4) reviewed for incontinent care in that:<BR/>-The facility failed to document treatment orders and collect the urine sample for CR #4 for three days after order was given on [DATE] after experiencing altered mental status, the resident was transferred to another facility on [DATE], and confirmed to have an UTI. <BR/>This failure could place residents with urinary catheters at risk for discomfort, trauma, and possibly urinary tract infections. <BR/>The findings included:<BR/>Record review of CR #4's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included orthopedic aftercare and left leg femoral fracture. Her discharge date was [DATE] to be transferred to another facility. <BR/>Record review of CR#4's admission Observation Report dated [DATE] and completed by LVN D, indicated CR#4 admitted with indwelling catheter. <BR/>Record review of CR #4's physician order summary report dated [DATE]-[DATE] revealed that there were no orders entered addressing residents' treatment for a catheter.<BR/>Record review of CR #4's MAR dated from [DATE] revealed no information addressing residents' treatment for a catheter. <BR/>Record review of CR #4's baseline care plan dated [DATE] and completed by the CCM did not address focus, goals, or intervention for an indwelling catheter. <BR/>Record review of CR #4's MDS assessment dated [DATE] revealed CR #4 was cognitively intact with a BIMS score of 12 in section C. She was triggered for an indwelling catheter in section H for Bladder and Bowel.<BR/>Record review of urinary intake/out worksheet for CR#4 revealed that staff tracked output each shift from [DATE]-[DATE]. <BR/>Record review of progress note dated [DATE] completed by NP read in part, .Chief Complaint/Nature of Present Problem: SNF/ f/u. Reported that patient has been hallucinating at times. UA is still pending. Patient is pending transfer. Due to recent mental status change we will go ahead and check patient's ammonia level and UA C&S. If negative will consult psychiatry <BR/>Record review of CR#4's discharge summary report dated [DATE] did not indicate that there were any outstanding labs for CR#4 to test for UTI. <BR/>Record review of CR#4's laboratory order history report undated indicated the UA ordered [DATE] had a status of collection pending, no results. <BR/>Record review of CR #4's medical records from a local hospital dated [DATE] revealed that CR#4 was admitted to the hospital on [DATE] and discharged on [DATE], while admitted CR#4 was confirm with a UTI. Records revealed that CR#4 expired while at the hospital on [DATE] with a preliminary cause of death of acute hypoxemic respirator failure. <BR/>In an interview and observation on [DATE] at 9:08am with LVN A, she said that she has worked at the facility since [DATE], and she usually works the 6am-6pm shift. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that she had not completed a baseline care plan since she started her position, and they are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that CR#4 was admitted with a catheter, it was removed, but she could not remember the date of removal. She said that she completed catheter care for CR#4, and she documented the tasks in the EMR. She said that on [DATE] CR#4 started hallucinating, she notified the NP, the NP ordered a UA to check for an UTI, and she sent the order to the lab. She did she did not collect the sample, because the lab only picked up on Tuesday and Thursday, with the exception of stat orders, and the NP did not order the UA stat. She said that she told LVN B to collect the sample on the 6pm-6am shift, so that the sampled could be picked up on [DATE], and she entered a progress note. She said that when she started her shift on [DATE] LVN B told her that she collected the sample. She said that CR#4 discharged on [DATE]. She reviewed the physician order summary report, baseline care plan, and MAR for CR#4. She said that the documents did not address the catheter for CR#4. She said that based on the progress notes the admitting nurse was LVN D, and there were no orders entered at the time of admission to address the catheter for CR#4. She said that she could not remember what orders were being used when providing catheter care. She stated that without the orders entered there was no place to capture catheter care on the MAR, and she had no documentation that she completed the tasks. She reviewed the progress notes and said that she did not enter a progress note that LVN B would [NAME] CR#4 UA. She reviewed the laboratory order history report, and said the labs were still pending. She stated that the risks to CR#4 not receiving the UA was an untreated UTI. She stated that the risk of not entering physician orders and completing the baseline care plan upon admission is not receiving appropriate care. <BR/>In a phone interview on [DATE] at 9:44am with the Relative, she said that CR#4 admitted to the facility with a catheter, she expressed concern with the tube of the catheter being red, and the NP just gave an order to remove the catheter. She said that after the catheter was removed the CR#4 start hallucinating, and the NP order labs to see if CR#4 had a UTI on [DATE]. She said that staff never took the sample, and CR#4 was discharge with the sample never being taken on [DATE]. She said that CR#4 was taken to a new facility on [DATE], the sample was collected, diagnosed with an UTI, and started on antibiotics. She said that CR#4 was sent to the hospital on 05/02//2023 after she fainted and had respiratory problems. She said that while at in the emergency room CR#4 was eating, choked, was revived, placed on a ventilator, but continued to decline. She said that CR#4 died while in the hospital, and hospital was looking to see if the resident was septic. She said that the facility delayed getting the urine sample for CR#4, and that caused a delay in treatment for the UTI. <BR/>In an interview on [DATE] at 10:38pm with the CRN, she said that the admitting nurse is responsible for entering the physician orders and baseline care plan for newly admitted residents. She said upon her review, LVN D did not entering physician orders for catheter care for CR#4, so catheter care was not included on the MAR for nursing staff to chart that care was provided. She said that the facility has a standard ordered for catheter care that should have been entered upon admission. She said if there was no documentation enter that the tasks were completed. She said that the baseline care plan was completed on [DATE] by the CCM, but catheter care was not included. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet met regarding CR#4. She said that the IDT should consist of the CCM, DON, ADON, and DOR. She said that the DON is the oversite oversight and should ensure that all admission tasks are completed accurately. She said that LVN B should have ensured that the urine sample was collected for CR#4 on [DATE], LVN B disclosed that she failed to collect the sample because the resident did not have urine output on the shift and based on her review LVN B failed to document the efforts to collect the sample. She was not sure if LVN B contacted the doctor of CR#4, and she was not aware that the sample had not been collected until SSA requested documentation. She stated that the risk to residents of not having systems in place could cause residents to not receive appropriate care, delay in diagnosis, delay in treatment, and infection to include UTI.<BR/>In an interview on [DATE] at 11:01am with the CCM, she said that she is an LVN. She said that she has worked at the facility since [DATE], she completes all MDS assessments for the facility. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said the ADON checks for accuracy of the admission process. She stated that the IDT consists of the DON, ADON, CCM, DOR, and SW, and the IDT meets Monday-Friday, and review admission process for newly admitted residents. She said that she could not remember if the IDT meet regarding CR#4. She said that she helps the ADON audit baseline care plans, and the ADON and she will complete the care plan if had not been completed within 48 hours. She said that CR#4 admitted to the facility with catheter. She reviewed the baseline care plan, physician orders summary report, and MAR for CR#4. She said that the documents did not address the catheter for CR#4 from admission, and it was missed by everyone. She said that it should have been caught by anyone that needed to chart catheter for the resident. She stated that the risk of not having the systems in place could cause a resident not to receive appropriate care, and with out appropriate catheter a resident could get an infection. <BR/>In an interview on [DATE] at 11:49am with the DON, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the ADON is the oversite oversight to ensure that admitting nurse completed the admission process with accuracy. She said that the CCM is the oversite for ensure that baseline care plans are completed timely and accurately. She said that she is the oversite for the ADON and CCM. She stated that she completed an audit twice each week to ensure that the admitting nursing and ADON have completed the admission process accurately, she could not remember if she audited the records for CR#4, and she did not keep a record of her audits. She stated that IDT meets to discuss newly admitted residents a few days after admission. She stated that she could not recall if IDT reviewed the admission process CR#4. She said that if physician orders are not entered the tasks will not be triggered for documentation on the MAR. She stated that CR#4 did not have admission orders for a catheter, and it was not care planned. She said that LVN D was the admitting nurse and she was terminated on [DATE] after she did not show for two shifts that week. She said that LVN B attempt to collect a urine sample for CR#4 on [DATE], the resident did not have urine output, and LVN B failed to document efforts to collect the sample. She said that she was not sure if LVN B called the physician to inform that the sample had not been collected. She said that LVN B should have notified the physician as the physician could have given a new order to collect the sample by an alternative method, since the resident did not have output. She was not aware that the sample had not been collected until SSA requested documentation. She stated that the risk to the resident of not having systems in place is not receiving appropriate care a delay in diagnosis of the UTI, resident could have had delay in treatment, and that could have resulted in hospitalization. <BR/>In a phone interview on [DATE] at 12:30pm with LVN B, she said that she has worked at the facility since September of 2022, and she works the 6pm-6am shift. She said that she remembered CR#4. She said that during shift change on [DATE] LVN A told her that the doctor ordered a urine sample for labs for the resident. She said she did not collect the sample because CR#4 did not have urine output during the shift. She said that she could not remember if she called the physician. She said she would like to be able to review her documentation before she answered anymore questions, and she would be at the facility for a shift on [DATE] at 6pm. <BR/>In an interview on [DATE] at 12:57pm with the ADON, she said that she is a LVN, and she has worked at the facility for 16 months. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She stated that she audits the admission process the next business day for accuracy and completion. She said that CR#4 was admitted on [DATE] with a catheter. She said that she did not work on [DATE]-[DATE], and she worked the floor for the remaining days of the week. She said that the DON is the oversite, and ifs is not able to audit the DON is to complete the task. She said that she reviewed physician orders for CR#4, the resident did not have an order for catheter care, and that caused catheter care not to appear on the MAR for documentation. She said that she was aware that CR#4 was to have a UA completed to determine if she had a UTI at the time of her discharge on [DATE]. She stated that she completed the discharge for the resident, and at the time of discharge the relative present asked if the sample had been collected. She stated that when she told the relative that she would need to check, they declined to wait, and she did not follow up. She stated that the risk of not having the system in place is that a resident may not receive appropriate care and would be at risk for an UTI. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet regarding CR#4. <BR/>In an interview on [DATE] at 5:16pm with the Admin #2, he said that the DON is clinical oversite, and she should inform him of any clinical concerns. He said that the admitting nurse should enter orders upon admission. He said that he had not had a chance to look of admitting process since starting his position on [DATE]. He said that he was aware that CR#4 did not have a UA collected as ordered by the physician, as he spoke with relative after the resident discharged who inquired about the result. He said that he had a nurse whose name he could not remember to lock up the result, and he was told that the sample was not collected, and he relayed the information to the relative. He said that it would be concerning if a resident did not have physician orders, care plan, or MAR, or progress notes in place for catheter. He said that if a tasks is not documented it did not happen. He said that the risk of not having the system in place could cause a resident to not to receive proper care that could cause an infection or UTI. <BR/>In a follow-up interview and observation on [DATE] at 5:40 pm with LVN B, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that baseline care plans are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that CR#4 was admitted with a catheter, it was removed, she could not remember the date of removal, or the staff that removed it. She said that she completed catheter care for CR#4, and she documented the tasks in the EMR. She said that on [DATE] CR#4 LVN A told her that the NP ordered a UA to test for a UTI and asked her to collect the sample. She said that the lab collects samples on Tuesday and Thursday unless the orders are stat. She said that she could not remember if she collected the sample before the resident discharged , or if she notified the physician. She reviewed the physician order summary report, baseline care plan, progress notes, lab summary report, and MAR for CR#4. She said that she could not remember what orders were being used when providing catheter care. She said that the based on the documents the UA sample was not collect and there was no documentation that CR#4 received catheter care. She said that the admitting nurse LVND did not enter the orders for catheter and the baseline care plan did not address catheter care for CR#4. She said that the risk to CR#4 was having an untreated infection when she discharged charge, and without having orders, MAR, and care plan to address catheter care the resident could not have received appropriate care while the catheter was in place. <BR/>In an interview on [DATE] at 10:41am with LVN C, she said that she has worked at the facility since [DATE], and she works the 6am-6pm shift. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that baseline care plans are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that if a resident is admitted with a catheter the admitting nurse should entering the standard order for catheter, and that would trigger the care on the MAR. She said that she provided care for CR#4 while she was admitted to the facility, and the resident admitted with a catheter. She said that she provided catheter care to resident. She said that the NP gave an order to remove the catheter on approximately [DATE] in the 11:00am hour, and she removed the catheter. She said that the NP ordered that urine output be monitored for 3-6 hours after the catheter was removed and be notified if the resident had no urine output. She stated that when she removed the catheter CR#4 had urine output of 400cc in the catheter bag, and the resident voided her bladder in her brief sometime in the afternoon. She stated that she entered a progress note on the date that she removed the catheter, and she would have documented catheter care on the MAR in the EMR. She reviewed the physician order summary report, baseline care plan, progress notes, and MAR for CR#4. She said that the admitting nursing, LVN D, did not enter the standard order upon admission so catheter care for CR#4 was not on the MAR, and did not complete the baseline care plan time, and when it was competed it did not include catheter care. She said that she could not remember what orders were being used when providing catheter care. She said that all staff that provided catheter should have saw the error when it was time to chart and corrected the error. She said that the risk of not having physician orders, baseline care plan, and MAR in place is that a CR#4 may have not received care to the catheter, and without care the resident could have developed an UTI. She said that based on the progress notes there was concern that CR#4 had signs of UTI and the NP requested urine sample collected. She said that if the sample was not collected and the NP was not notified the resident was at risk of being discharged with an untreated infection that could caused the resident to be hospitalized . <BR/>In an interview on [DATE] at 1:42pm with LVN D, she said that she only worked at the facility for a short period of time, and her last day would have been the week of [DATE]. She said that the admitting nurse is usually responsible for entering physician orders for newly admitted residents. She said that she could not remember if she provided care for CR#4, and she did not feel comfortable with answering any more questions. <BR/>In a phone interview on [DATE] at 2:00pm with NP, he said that he was familiar with CR#4, and she admitted to the facility with a catheter from a local hospital after having a stroke and fall prior to admission. He said that he was not sure of what orders CR#4 had for catheter care upon admission, but the facility uses a standard order unless hospital discharge summary provided an order. He said that he gave an order for CR#4 to have the catheter removed on [DATE]. He said that staff notified him that resident was having behaviors on [DATE], and he ordered a UA as he wanted to confirm if the resident had a UTI before referring for a psychiatry consult. He said that the lab usually because of samples on Tuesday and Thursday, and he would have expected that the sample would have been collected and sent to the lab on [DATE]. He said that when he saw the resident on [DATE] the facility had not collected the sample. He said that he was not notified that there were problems with completing the lab after the order was given. He said that if the staff was having problems with collecting the sample, he should have been notified, and he could have given an order to collect the urine sample by straight cath (used for quick drainage of the bladder). He said that CR#4 was transferred on [DATE] to another facility. He said that since the physician he practiced under services the facility CR#4 transferred to, he updated his progress notes, and notified the receiving facility to collect the sample upon admission. He said that he is not the nurse practitioner for the facility that CR#4 transferred to, but he made the nurse practitioner aware of his concerns for UTI. He said resident labs confirmed a UTI, but he was not sure what treatment was given. <BR/>Record review of the facility policy and procedure entitled Catheter Care, Urinary dated 2018 read in part, .Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the residents care plan to assess for any special needs of the resident. Input/Output: 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Documentation: The following information may be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) given the catheter care. 3. All assessment data obtained when giving catheter care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of eternal feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormality for 1 (Resident #60) of 2 residents reviewed for g-tubes. <BR/>LVN A failed to administer Resident #60's water flush and medication to flow by gravity and instead LVN A pushed the water and medication through the g-tube (GT) using enteral feeding 60 ml syringe. <BR/>The facility failed to clarify GT medication order for Resident #60, with no amount of water to give before and after meds, and in between med administration, and dilute medication via GT.<BR/>LVN A did not follow the facility policy to verify that there was a physician order for GT med administration procedure.<BR/>These failures could place residents who receive g-tube medications at risk of aspiration pneumonia, diarrhea, vomiting, dehydration or over-hydration and metabolic abnormalities.<BR/>Findings Included:<BR/>Record review of Resident # 60's face sheet revealed, a [AGE] year-old female admitted to facility on 3/30/21 with diagnoses which included, difficulty swallowing (dysphagia and gastro-esophageal reflux disease. <BR/>Record review of Resident #60's entry MDS revealed she had moderately impaired cognition and had a feeding tube for dysphagia. She required extensive-total assist of 1-2 staff for most activities of daily living.<BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed the following orders:<BR/>-Metoprolol Succinate ER 25 mg, give &frac12; tab=12. 5 mg via gastrostomy tube (GT) BID, start date 8/19/21. No dx or indication for its use.<BR/>-Carbamazepine 100 mg/5 ml suspension give 15 ml =300 mg via GT BID, for epilepsy. No order to shake well before administered. <BR/>-Levetiracetam 100 mg/ml solution, give 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered. <BR/>- Give 50 cc water per GT every 6 hrs. for patency.<BR/>There were no orders that indicated the amount of water to dilute medication, the amount of water to give in between medication administration; and the amount of water flush before and after the medications administered to her GT. <BR/>Record review of Resident #60's MAR dated May 2022 - June 2022 revealed there was no order for the amount of water to dilute the medication, and in between medication administration, and no water flush before and after the meds administered to her GT.<BR/>Observation and interview on 06/07/22 at 4:15 p.m., revealed LVN A prepared medication for administration to Resident #60, there was no computer MAR use She entered into the resident's room and checked her blood pressure. LVN A retrieved 1/2 tablet of 25 mg Extended-Release (ER) Metoprolol Succinate, and one other tablet and 1 capsule opened and placed them in individual medication cups diluted with 10 ml of water. She crushed all 2 tablets including the Metoprolol Succinate ER. LVN A did not shake the Levetiracetam solution, and Carbamazepine suspension and administered all crushed tabs. She poured 30 ml water directly into the 60 ml syringe in between medication but the water did not flow, and again plunge the water down the tube. LVN A used the 60 ml syringe and pulled last dissolved crushed tab metoprolol 12.5 mg from the med cup and plunged the medication through the GT. LVN A said, I still have some residual in those cups. Before leaving the room, she was shown the medicine cups had medication residual. <BR/>Interview on 06/07/22 at 4:25 p.m., LVN A stated her computer was borrowed from the med cart, but she knew the dosage and time to administer Resident #60's scheduled meds. LVN A said she should have administered the medication and water by gravity, but GT was clogged. Further interview revealed she poured water directly into the 60 ml syringe in between medication instead of using a measuring medication cup to accurately measure water. <BR/>Interview on 6/07/22 at 5:00 p.m., RN C stated LVN A was in-serviced 1:1, and suspended due to LVN A administered medications without the computer MAR in eyesight, and did not allow meds to flow by gravity via GT. RN C said we give only 10 ml amount water in between med administration, and LVN A should use a measuring medication cup to measure 10 ml water accurately, instead of pouring directly to a syringe. RN C stated that LVN A to provide a return demonstration before she could return to work.<BR/>Interview on 6/09/22 at 12:15 p.m., the DON stated she expected nurses to administer medications and water to flow down the GT by gravity. She further stated Resident #60's GT medication order was incomplete, and the water flush order was missing. However, she stated LVN A should have called the MD to verify regarding Resident's incomplete order. The DON stated prior to giving meds, the orders must be verified using the MAR and nurse to clarify with the MD if the order was incomplete.<BR/>Interview on 6/09/22 at 1:15 p.m., the DON stated in-service was just conducted and reinforced to nurses to administer meds accurately, allow meds to flow by gravity, and use a measuring medication cup to accurately measure water. The DON stated we called the MD and obtained order, to give=10 ml water flush before and after meds and give 5-10 ml water in between meds for Resident #60. <BR/>Interview on 6/09/22 at 2:00 p.m., LVN B stated she would use a measuring medication cup to accurately measure amount of water and allow the medication to flow by gravity via GT. <BR/>In an interview on 06/09/22 at 3:30 p.m., RN C stated moving forward she will continue to in-service staff, to ensure GT orders and meds administered accurately and orders verified using the MAR. RN C stated new orders will be reviewed next day during daily AM meetings.<BR/>In an interview on 06/09/22 at 3:30 p.m., the Administrator stated that will follow-up all the medication issues with QAPI. <BR/>Record review of the facility's policy, Medication and Treatment Orders dated July 2016 read in part, .Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders for medication must include .Clinical condition or symptoms for which the medication is prescribed.<BR/>Record review of the facility's policy, Administering Medications through an Enteral Tube dated March 2015 read in part, .Verify that there is a physician 's medication order for this procedure. Check gastric residual (GRV) to assess for tolerance of enteral feeding .Do not crush enteric coated, sustained release meds .Place the MAR within easy viewing distance. If administering more than one medication, flush with 15 ml or prescribed amount, warm sterile or purified water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs for 1 (Residents #60) of 12 residents reviewed for pharmacy services. <BR/>The facility failed to ensure Resident #60 's GT medication order complete, with amount of water to give in between med administration, and before and after meds and water to dilute medication, to her GT. <BR/>The facility failed to ensure medication order was accurate, without an extended release (ER), a medication that should not be crushed, Metoprolol Succinate 12.5 mg BID to administer for Resident #60.<BR/>The facility failed to ensure Resident #60 's medication order was complete, with order to shake well anti-seizure meds Levetiracetam solution (Keppra) and Carbamazepine (Tegretol) suspension, before administration.<BR/>The facility failed to ensure Resident #60 's Levetiracetam solution (Keppra) and Metoprolol Succinate medication orders complete, with a diagnosis (dx) or indication for its use. <BR/>These failures could place all residents receiving medications at risk for receiving less than therapeutic benefits of their medication and worsening of medical condition.<BR/>Findings Include:<BR/>Record review of Resident # 60's face sheet revealed, a [AGE] year-old female admitted to facility on 3/30/21 with diagnoses which included, cerebral infarction due to embolism (blood clot), seizure disorder or epilepsy, difficulty swallowing (dysphagia), Lt hemiplegia (Lt side paralysis), gastro-esophageal reflux disease, HTN, chronic pain and polyneuropathy. <BR/>Record review of Resident #60's entry MDS revealed she had moderately impaired cognition with feeding tube for dysphagia. She required extensive-total assistance of 1-2 staff for most activities of daily living.<BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed Metoprolol Succinate ER 25 mg, give &frac12; tab=12. 5 mg via gastrostomy tube (GT) BID, start date 8/19/21. No dx or indication for its use. Carbamazepine 100 mg/5 ml suspension give 15 ml =300 mg via GT BID, for epilepsy. Levetiracetam 100 mg/ml solution, give 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered. <BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed give 50 cc water per GT every 6 hrs. for patency. No order with the amount of water to dilute medications. No order to give water in between med administration. No order to give water flush before and after meds administered to her GT. <BR/>Record review of MAR dated May 2022 - June 2022 revealed Resident #60 received Metoprolol Succinate ER 25 mg, crushed &frac12; tab=12. 5 mg via G-tube BID, start date 8/19/21. Carbamazepine 100 mg/5 ml suspension 15 ml =300 mg via GT BID. Levetiracetam 100 mg/ml solution, 10 ml via GT BID, start date 3/14/22. No dx or indication for its use. No order to shake well before administered.<BR/>Record review of Resident #60's MAR dated May 2022 - June 2022 revealed no order received with the amount of water to dilute medication, and in between med administration, and no water flush before and after the medications administered to her GT.<BR/>Interview on 6/09/22 at 12:15 p.m., the DON stated Resident #60's GT order was incomplete, and stated normally we give 30 ml water flush before and after meds and 10 ml water in between meds, and will call the MD. However, she stated LVN A should have also called the MD, since the Resident 's GT medication orders incomplete. The DON stated she was in-charge to reconcile monthly residents' physician orders along with the ADON. The DON stated moving forward she will ensure there are no missing medication orders, are accurate and irregularities were caught. The DON stated that Extended-Release (ER) Metoprolol Succinate should not be crushed, because by administering crushed ER Metoprolol, resident may not get a sufficient dose of the medication. The DON stated she will call the MD and instead use liquid form or dissolve Metoprolol tab. The DON stated she will call the MD to verify incomplete anti-seizure medication order for Carbamazepine (Tegretol) suspension and the Levetiracetam (Keppra) solution, to be shaken well before administered. The ADON was on training and unavailable for interview.<BR/>Interview on 6/09/22 at 2:00 p.m., LVN B stated she would not crush an extended-release medication, but she would clarify with physician if order was incomplete or missing order.<BR/>Interview on 06/09/22 at 1:15 p.m., the DON stated we verified with the MD and obtained water flush order for her GT meds, to give 5-10 ml water in between meds, and 5-10 ml water flush before and after meds given to her GT. The DON said moving forward the facility will conduct 100 % audit to ensure orders complete. The ADON was on training, unavailable for interview.<BR/>In an interview on 06/09/22 at 3:30 p.m., RN C stated she will follow-up and audit to ensure the residents' medication orders accurate and complete. She added new orders, will be reviewed the next day during daily AM meetings.<BR/>In an interview on 06/09/22 at 3:30 p.m. The Administrator stated that we will follow-up all the medication issues with QAPI. <BR/>Record review of the facility provided policy, Administering Medications through an Enteral Tube dated March 2015 read in part, . Verify that there is a physician 's medication order for this procedure .Do not crush enteric coated, sustained release meds .Place the MAR within easy viewing distance. If administering more than one medication, flush with 15 ml or prescribed amount, warm sterile or purified water.<BR/>Record review of the facility provided policy, Medication and Treatment Orders dated July 2016 read in part, .Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders for medication must include .Clinical condition or symptoms for which the medication is prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from the administration of unnecessary drugs for 1 of 12 residents (Resident #30) reviewed for unnecessary psychotropic medications.<BR/>Resident #30 was receiving the antipsychotic medication Risperdal for diagnosis (dx) of anxiety, without adequate indications for its use or inappropriate diagnosis, and the consent form for anxiety.<BR/>These failures could affect residents who received psychoactive medications at risk of receiving medications without adequate monitoring or indications for use and decline in physical and mental health status.<BR/>Findings included: <BR/>Record review of Resident #30's clinical record revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, depression, cognitive communication deficit and metabolic encephalopathy. He required 1 staff limited assist for most ADLs.<BR/>Record review of admission MDS, dated [DATE], revealed Resident #30 with moderately impaired cognition, and non-Alzheimer's dementia and depression as active diagnoses. No anxiety and bipolar disorder. No schizophrenia and psychotic disorder found. No hallucination, delusion, or delirium. He received antipsychotic along with antidepressant routinely for 7 days. <BR/>Record review of Resident #30's Care Plan dated 5/03 22, revealed he has a problem with cognitive loss and dementia. Resident will express or exhibit satisfaction. Further noted he was an elopement risk.<BR/>Record review of Resident #30's Physician Order dated June 2022 revealed give Risperdal (risperidone) 1 mg 1 tab po Q HS , start date 5/01/22. Risperdal 0.25 mg 1 tab po Q day, start date 4/15/22. No indication for antipsychotic use.<BR/>Record review of Resident #30's Consent for use of Psychoactive Medication, dated 4/21/22, revealed specific condition to be treated for Anxiety. No proposed course of the treatment.<BR/>Record review of the Pharmacist's MRR, dated May 2022, indicated Resident #30 received Risperidone. An antipsychotic medication should be used only for an appropriate diagnosis as determined by CMS regulation. Please provide an approved indication/diagnosis for this antipsychotic.<BR/>Record review of MAR dated June 2022 revealed Resident #30 received Risperdal (risperidone) 1 mg 1 tab po Q HS, start date 5/01/22. Risperdal 0.25 mg 1 tab po Q day, start date 4/15/22. No indication for antipsychotic use.<BR/>During interview on 6/08/22 at 1:30 p.m., CMA O stated she had been assigned to Resident since admit, and she had not observed any behaviors for Resident #30.<BR/>Interview 6/08/22 at 1:00 p.m., RN C stated moving forward will ensure the psychotropic orders and consents have adequate indications for its use or proper diagnosis. She said the ADON was designated the task to obtain consents for psychotropic meds. The ADON was on training, and unavailable for interview.<BR/>Interview 6/08/22 at 12:20 p.m., The DON stated she was designated to follow-up on the monthly Pharmacist MRR. The DON stated she was also assigned to reconcile monthly physician orders together with ADON and should have caught the irregularities. She stated that moving forward she will ensure the Pharmacist recommendations followed through within 72 hrs. and reported to the MD and order carried out. <BR/>Record review of the facility's policy, Behavioral Assessment, Intervention and Monitoring dated July 2019 read in part, .Appropriate assessment and treatment of behavioral symptoms requires differentiating between behavioral symptoms that can be managed by treating underlying factors, and those that cannot .The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 12%, based on 3errors out of 25 opportunities, which involved 1 of 7 residents (Resident #60), and 1 of 4 staff (LVN A) reviewed for medication errors.<BR/>LVN A crushed Extended Release (ER) Metoprolol Succinate 12.5 mg tab and administered it to Resident #60, with B/P was outside of parameters.<BR/>LVN A failed to shake well Resident #60's Carbamazepine (Tegretol) suspension and Levetiracetam (Keppra) solution, (for seizures or epilepsy), before administration.<BR/>These failures could affect residents who take medications and place them at risk of their medications not being administered per physician orders, and at risk of inadequate therapeutic outcomes and decline in health.<BR/>Findings Include:<BR/>Record review of Resident # 60's face sheet revealed, a [AGE] year-old female admitted to facility on 3/30/21 with diagnoses which included, cerebral infarction due to embolism (blood clot), difficulty swallowing (dysphagia), seizure disorder or epilepsy, Lt hemiplegia (Lt side paralysis), gastro-esophageal reflux disease, HTN, chronic pain and polyneuropathy. <BR/>Record review of Resident #60's entry MDS revealed she had moderately impaired cognition with feeding tube for dysphagia. She required extensive-total assist of 1-2 staff for most activities of daily living. <BR/>Record review of Resident #60's Physician Order dated May 2022 - June 2022 revealed Metoprolol Succinate ER 25 mg, give &frac12; tab=12. 5 mg via GT twice a day, start date 8/19/21. Hold for B/P&lt;130/60, HR&lt;60. Carbamazepine 100 mg/5 ml suspension give 15 ml =300 mg via GT twice a day, start date 3/30/22. Levetiracetam 100 mg/ml solution, give 10 ml via GT twice a day, start date 3/14/22. No order to shake well before administered. <BR/>Observation on 06/07/22 at 4:15 p.m., revealed LVN A prepared medication for administration to Resident #60. She entered into the resident's room and checked her blood pressure which read B/P=115/72, HR=66. LVN A retrieved 1/2 tablet of 25 mg Extended-Release (ER) Metoprolol Succinate, and one other tablet and 1 capsule opened and placed them in individual medication cups diluted with 10 ml of water. She crushed all 2 tablets including the Metoprolol Succinate ER. LVN A did not shake well the Levetiracetam solution, and Carbamazepine suspension med, and administered all crushed tabs. No computer MAR was in front of LVN A. There were parameters instructing to hold Metoprolol due to blood pressure. Her B/P=115/72, was outside of parameters. LVN A said, I still have some residual in those cups. Before leaving the room, she was shown the medicine cups with medication residual. <BR/>Record review of MAR dated May 2022 - June 2022 revealed Resident #60 received Metoprolol Succinate ER 25 mg, &frac12; tab=12. 5 mg crushed via G-tube BID. Hold B/P&lt;130/60, HR&lt;60, start date 8/19/21. Carbamazepine 100 mg/5 ml suspension, 15 ml =300 mg via GT BID. Levetiracetam 100 mg/ml solution, 10 ml via GT BID, start date 3/14/22. <BR/>In an interview on 06/07/22 at 4:35 p.m LVN A stated that her computer was borrowed from the med cart, but she knew the dosage and time to administer Resident #60's scheduled meds.<BR/>In an interview on 06/07/22 at 4:35 p.m., RN C stated the nurse or MA should not administer meds without the computer MAR in eyesight, and the MAR had to be in front of her when giving meds.<BR/>In an interview on 06/07/22 at 5:00 p.m RN C stated LVN A was removed from the med cart, suspended and to provide a return demonstration before she could return to work. <BR/>In an interview on 06/09/22 at 12:15 p.m., DON stated will in-service staff that meds must be verified using the MAR, and if the order was incomplete to clarify with physician.<BR/>In an interview on 06/09/22 at 12:15 p.m, DON stated the computer was not supposed to be removed from the med cart. She added LVN A should have verified incomplete order, to shake well before administering Carbamazepine suspension and the Levetiracetam solution. <BR/>In an interview on 06/09/22 at 12:15 p.m., the DON stated administering crushed Extended-Release (ER) Metoprolol, resident may not get a sufficient dose of the medication. She said Metoprolol ER should not be crushed, will call MD and instead use the liquid form or dissolved non-extended-release Metoprolol. <BR/>In an interview on 06/09/22 at 3:30 p.m., the Administrator stated will follow-up all the medication issues with QAPI. <BR/>Record review of the facility's policy, Medication and Treatment Orders dated July 2016 read in part, .Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders for medication must include .Clinical condition or symptoms for which the medication is prescribed.<BR/>Record review of the facility's policy, Administering Medications through an Enteral Tube dated March 2015 read in part, . Verify that there is a physician 's medication order for this procedure .Do not crush enteric coated, sustained release meds .Place the MAR within easy viewing distance.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that:<BR/> The walk-in refrigerator had Sliced American Cheese in a plastic bag container dated 5/30/22<BR/>The facility failed to maintain proper holding temperature for the following food<BR/>Mixed Vegetable 86 degrees Fahrenheit<BR/>Cooked [NAME] 74 degrees Fahrenheit<BR/>Mexicali Corn 94 degrees Fahrenheit<BR/>Baked Chicken 67 degrees Fahrenheit<BR/>This failure could place residents at risk of foodborne illness and disease.<BR/>Findings included:<BR/>Observation of the facility's kitchen on 6/08/22 between 9:00 am and 9:45 am revealed:<BR/>Sliced American Cheese in a plastic container dated 05/30/22 stored in the walk-in refrigerator<BR/>Interview with the Food Service Director on 6/08/22 at 9:30 AM revealed that items / food stored in the refrigerator should be discarded after seven days. She stated she was responsible for training staff on proper storage /temperature for potentially hazardous /time control for safety to prevent residents at risk of foodborne illness and disease. She discarded the sliced American Cheese dated 5/30/22. <BR/>Observation of the kitchen worktable on 6/08/22 from 12:35 to 3:35PM the following food temperature <BR/>taken by the Food Service Director revealed the following:<BR/>A plastic container of Mixed Vegetables on ice bed bath had a temperature of 86 degrees Fahrenheit<BR/>A plastic container of cooked [NAME] on ice bed bath had a temperature of 74 degrees Fahrenheit<BR/>A plastic container of Mexicali Corn on ice bed bath had a temperature of 94 degrees Fahrenheit.<BR/>A Plastic container of Baked Chicken on ice bed bath had a temperature of 67 degrees Fahrenheit.<BR/>Interview with the Food Service Director on 06/08/22 at 3:35 PM revealed that leftover food saved for later used should be cooled in an ice bath. She indicated that the staff were cooling the food since 12:35 after Lunch Service properly. The facility failed to chill leftover food properly by placing food in 4-inch to 6-inch-deep pans. Chill from 140 degrees Fahrenheit to 70 degrees Fahrenheit in 2 hours. Food was chilling since 12:30 to 3:30 PM therefore; not using the HACCP Chill Method. I requested to see the temperatures taken as the food is cooling. No documentation was done. She stated that she was responsible for training staff on proper cooling foods. <BR/>Record review of facility's Food and Nutrition Services Policy and Procedure Manual on Food Storage dated 06/01, 2019 read in part' .Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the State, Federal and US Food Codes and Hazard Analysis Critical Control Point Plan (HACCP). Procedure: 2. Refrigerators. E. Use all leftovers within 72 hours. Discard items that are over 72hours old.<BR/>Record review of facility's Food and Nutrition Services Policy and Procedure Manual on Cooling and Reheating Foods dated 10/01, 2018 read in part' .Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be cooled and reheated according to the state, US Food Codes and Hazard Analysis Critical Control Point Plan (HACCP). Procedure: 1. Cooling Foods. a. Rapidly cool all potentially hazardous food requiring refrigeration after preparation to an internal temperature of 41 degrees Fahrenheit or below with in six hours or less. The total cooling time may not exceed six hours. b. Use the HACCP Chill Methods: I. place food in 2-inch-deep pans ii. Chill from 140 degrees Fahrenheit to 70 degrees Fahrenheit in first two hours iii. Chill from 70 degrees AA to 41 degrees Fahrenheit or below in next four hours iv. Take and record temperatures every 30 minutes to assure temperatures are decreasing according to the above schedule.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 (Resident #5) of 3 residents reviewed for wound care. In that,<BR/>The facility failed to ensure Resident #5's wound vac was applied on her wound as ordered by the physician.<BR/>This deficient practice could place residents at-risk for improper care practices, infection, injury, and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), chronic pain, Essential (primary) hypertension (too high pressure in the blood vessel), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm.), cardiac arrhythmia (a disease process characterized by when electrical impulses in the heart don't work properly), congestive heart failure (occurs when the heart's capacity to pump blood cannot keep up with the body's need), constipation. <BR/>Record review of Resident #5's care plan dated 02/24/2024 revealed Resident #5 had surgical wounds with intervention to apply negative pressure at setting of (125) mm Hg continuous.<BR/>Record review of Resident #5's MDS (Minimum Data Set) dated 02/24/2024 revealed Resident #5 had surgical wounds. <BR/>Record review of Resident #5's order dated 02/01/2024 revealed order was given for wound treatment NPWT (KCI): Wound location (RUQ/ABD). Cleanse wound with wound cleanser, pat dry, apply foam to wound bed, cover with transparent dressing. Apply Negative Pressure at setting of (125) mm Hg (continuous). Change dressing/tubing/canister 2x weekly on M/F, once a day on Mon, Fri Resident #5 also had order for PRN (as needed) wound care dressing change for the wound to be cleansed with wound cleanser, and apply gauze soaked in Dakin's 0.25% solution to be applied on the wound and cover with dressing.<BR/>Record review of TAR (Treatment Administration Record) for the month of February 2024 revealed the wound vac was not applied on the following dates:<BR/>*02/11/2024 not administered: resident unavailable by Nurse D. <BR/>* 02/28/2024 not administered: drug/item unavailable comment: prn wet to dry dressing applied through applied. by the Wound Care Nurse.<BR/>Record review of Wound Care Doctor's note revealed the following wound measurement:<BR/>Site #1 surgical wound right abdomen full thickness<BR/>03/18/2024 = 19cm x 16cm x 2cm<BR/>03/11/2024 = 19.5cm x 16cm x 2cm<BR/>03/04/2024 = 28cm x 20cm x 3cm<BR/>02/29/2024 = 27cm x 20cm x 3cm<BR/>02/05/2024 = 27cm x 20cm x 3cm <BR/>Site #2 surgical wound left upper abdomen full thickness.<BR/>03/18/2024 = 2cm x 1.5cm x 1.5cm<BR/>03/11/2024 = 2cm x 2cm x 2cm<BR/>03/04/2024 = 5cm x 4cm x 2cm<BR/>02/29/2024 = 6cm x 4cm x 2cm<BR/>02/05/2024 = 6cm x 4cm x 2cm <BR/>Site #3 stage 3 pressure wound of the left buttock.<BR/>03/11/2024 = Resolved <BR/>03/04/2024 = 2cm x 2cm x 0.1cm<BR/>02/29/2024 = 2cm x 2cm x 0.1cm<BR/>02/05/2024 = 3cm x 3cm <BR/>On 02/23/2024 at 11:36am in an interview with Resident #5 stated they were not treating her wound very well, they were not helping her to apply the wound vac to her wound. She said every time she went to the hospital her wound would be very close to healing but when she comes back to the facility they did not do much for her wound. Resident #5 said she barely gets wound care in a day at the facility, she said if she was in hospital they could do her wound up to 3 three times sometime if needed, but at the facility, they did not do her wound regularly and they did not put the wound vac on her. She said they have Wound Care Nurse at the building who does her wound vac but if the wound care nurse was not in the building nobody does her wound vac. She said the wound care doctor only came one time and when he came he watched the wound care nurse do the wound vac. <BR/>On 02/23/2024 at 11:36am observation revealed the wound vac was not connected to Resident #5's wound. Resident #5 stated the floor nurse last night (02/22/2024) who took care of her could not fix the wound vac, she said the nurse told her that she did not know how to fix Resident #5's wound vac. She said the nurse came in to dress her wound when her wound was saturated but she was unable to put the wound vac back on her because she could not do it, the nurse (Nurse B) had to do wet to dry dressing. <BR/>On 02/23/2024 at 12:26pm in an interview with Nurse A, she stated said she never had the opportunity to do Resident #5's wound because the Resident #5 was on B-bed, and the B-beds were assigned to the night-shift nurses while the A-beds were assigned to the day-shift nurses. She stated the facility had a wound care nurse who was taking care of residents' wound, and if the wound care nurse was not in the building, the wound dressing change of patients were done by the nurses. Nurse A stated she was aware Resident #5 had wounds and a surgical wound where the wound vac was to be applied. Nurse A stated she did not know if the wound vac was to be applied weekly and she had to go look it up. She stated she had not done a wound vac before, even though as a nurse she had been trained to do wound vac, but she did not have any training at the facility to do wound vac. She stated the wound care nurse was not in the facility today. <BR/>On 03/04/2024 at 11:43am in an observation and interview with Resident #5, she stated she did not have any wound care yesterday Sunday 03/03/2024. She stated if the wound care nurse was not around, she would probably not get wound care. Surveyor observed the wound vac, and it was not connected to Resident #5's wound, the wound vac was on a table by the bedside. Resident stated she did not have the wound vac for many days when the wound care nurse was away. She stated the wound vac was placed by the Wound Care Nurse on the last weekend, the date on the canister revealed 2/29/2024. She said when the wound care nurse put the wound vac on her, it worked really well for about a day, but the wound vac canister was full and the wound vac stopped working and she believed that it was because the canister was full. She stated they disconnected the wound vac three days ago. She said all they needed to do was to empty it or change it and fix the wound vac back into her wound, but she did not know why they were not doing that.<BR/>On 03/04/2024 at 11:56am in a wound observation with the Wound Care Nurse, the surgical wound on the right abdomen was observed covered in clean dressing dated today (03/04/2024) the nurse removed the dressing and Surveyor observed the surgical wound at resident's right abdomen - it appeared red beefy about the size 28cm x 20cm the left buttock pressure wound appeared red beefy and round, about 4cm x 4cm in size. There was no concern with the process of the wound care and infection control. The wound care nurse stated she did not apply the wound vac today because Resident #5 was on her way to hospital for blood transfusion because resident's lab came back with low blood level.<BR/>On 03/04/2024 at 12:28pm in an interview with the Wound Care Nurse, she stated if she was not in the building, the nurses on the floor were responsible to do the wound, she was not aware that the nurses did not know how to operate the wound vac. The wound care nurse stated she was gone on vacation from Thursday 2/22/2024 till the Wednesday 2/28/2024. She did not know if they were doing the wound vac or placing the wet to dry on the resident. She said the wound vac keeps excess drainage from the wound because if the drainage was sitting in the wound dressing, it could grow bacteria and affect the wound the more, and could cause the wound to decline and the surrounding tissue could get damaged.<BR/>On 03/04/2024 at 12:51pm in an interview with Nurse A, she stated the floor nurses also did wound care for residents on weekends (Saturdays and Sundays) because the Wound Care Nurse' schedule was Monday to Friday and they did not have weekend wound care nurse. She stated if Resident #5's wound vac needed to be fixed or if anything happened she would not be able to apply the wound vac but she would do wet-to dry wound dressing. She stated she had not spoken with anyone in the past regarding her not able to apply wound vac, but she told the DON about the wound vac today 03/04/2024 and she (DON) said they would train the nurses and show them how to use it. She said generally, wound vac help to heal and control drainage so the wound can heal well. She stated they could do a wet-to-dry dressing if they were not able to do the wound vac. <BR/>On 03/04/2024 at 2:57pm in an interview with the Attending Physician, she stated she saw Resident #5 few weeks ago within the week of her admission, and she had been taking care of Resident #5 for about a month. She stated she saw Resident #5's wound and saw the Wound Care Nurse did the wound vac on that day. The Attending Physician stated the wounds were severe and large and Resident #5 was in pain when she saw her. She said she could not handle the wound alone, especially any wound with a wound vac. She said when it comes to wound vac, you need to know what you are doing she would have a wound specialist consulted to follow the resident, which was why the wound care Doctor followed Resident #5 to ensure proper management and monitoring of her wounds. She stated she was not aware that nurses were not able to apply wound vac on the resident. The Attending Physician stated wound care was not her specialist, but she knew the wound vac was an integral part of the resident's care and the Wound Care Doctor knew better why the wound vac had to be used. <BR/>On 3/5/2024 at 2:04pm in an interview with the Wound Care Doctor, he stated he had not been able to see the Resident #5 much, because the Resident #5 would go to dialysis Mondays Wednesdays and Fridays and sometimes she would be sent to hospital for non-wound related issue. The Wound Care Doctor said he came to the facility mostly on Mondays. He stated the wound vac was a very important as part of the care of Resident #5 because it was recommended by a specialist surgeon who did the surgery for her, and the wound vac would help residents wound to heal better. The Wound Care Doctor said compared to a wet to dry, the wound vac was recommended and more preferred by the specialist who recommended it, any he would not change that. He said there was order in place for wet to dry dressing change in case something happened to the wound vac. He said his expectation was that when orders were given, the order should be followed by the facility and the employees. He stated no one ever informed him that the floor nurses did not know how to apply wound vac for Resident #5. He said the order for wet-to-dry dressing change was given in case anything happened to the wound vac, there could be any accident, it could fall, it was a machine, and it could malfunction at any time, and that was why they gave the order for wet-to-dry dressing. The Wound Care Doctor stated but the main treatment for the wound was the wound vac according to the recommendation from the specialist surgeon.<BR/>On 03/05/2024 at 4:34pm in an interview with the ADON, she stated Resident #5 was always refusing her wound vac and she was told by the Wound Care Nurse that Resident #5 was refusing her wound vac, so the wound care nurse did wet to dry dressing. She stated she assisted in supervising and overseeing the duties of other nurses and to make sure their jobs and the documentation were done properly. She stated no nurse ever told her that they were not able to do wound vac. She said they did not have any training on wound vac or wound care, she said the nurses get the training in nursing school and they all should be able to apply wound vac. She stated the wound vac was to aide in the healing process of wounds and it was used to remove the drainage from the wound so it would not become infected.<BR/>On 03/05/2024 at 4:46pm in an interview with the Wound Care Nurse, she stated that Resident #5 did not refuse care or refuse wound vac for her. She stated she could not remember any day that the resident refused wound care or wound vac. She stated they would do wet to dry dressing for Resident #5's wound when going to dialysis on Mondays, Wednesdays, and Fridays. She was not sure if she selected the wrong reason for not doing the wound vac on 2/28/2024, that day was Wednesday and could be the resident was going for dialysis.<BR/>On 03/06/2024 at 9:37am in an interview with Nurse B, she stated she knew Resident #5 had abdominal wound, bottom wound, left abdominal wound and colostomy, she stated the facility Wound Care Nurse comes to the facility on Mondays to Fridays and the wound care nurse always did the wounds, while the floor nurses - dayshift nurses do A beds and the night shift do B beds whenever the Wound Care Nurse did not come to work. She said she had not been trained on the wound vac at the facility. Nurse B stated the resident did not have the wound vac functioning on the night of 2/22/24, the wound vac was attached but it was not working, and the dressing was due for the night. Nurse B stated she told the resident she did not know how to operate the wound vac and she would do the wet-to-dry dressing as in the order. She said the resident had never refused any care that she knew of. She stated the ADON was the supervisor who oversaw their work. She stated had not specifically told her supervisor she was not trained on wound vac but she was sure she must have mentioned it to them sometime. She said on 2/26/24 and 2/27/24 the wound vac was not on the resident at that time and she (Nurse B) did wet-to-dry dressing.<BR/>On 03/05/2024 at 3:48pmin an interview with Nurse C stated she did not regularly work with Resident #5's . Nurse C stated she may have assisted the resident with her wound once but the wound vac was malfunctioning at that time so she did wet- to-dry. She stated she was not confident on how to apply wound vac and she had not received any training to do wound vac at the facility but she had been trained somewhere else. She stated she had not mastered using the wound vac to the point that she would be able to do it confidently. She stated she had not told her supervisor to do wound vac training for her.<BR/>On 03/07/2024 at 2:22pm in an interview with Nurse D, she stated she worked night shift. She was usually the nurse taking care of Resident #5 every time she worked on that side of the facility hall. She stated she had not changed her wound vac before but have changed the canister for her wound vac in the past. She said she believe she was very competent to apply wound vac, she had done wound vac on another resident but had not applied wound vac on Resident #5 because Resident #5's wound vac was being done differently, and she was not able to do it. She stated on 2/23/2024 during the night shift she remembered she had to change Resident #5's wound dressing because it was saturated, and she changed the cannister but when she removed the dressing wound, she could not re-apply the wound vac, because she was not sure how to apply it properly, and she did not want to mess up anything. She stated she did wet to dry for that night on 2/23/2024. She stated Wound vac was useful for a wound with a lot of drainage because the wound vac removed body fluid drainage from the wound, she said if the drainage was not removed the wound would not heal and could be infected.<BR/>On 03/06/2024 in an interview with the DON, she stated none of the nurses informed her that they were not able to apply wound vac on Resident #5. The DON stated the wound vac promote healing of the wound and prevent infection by removing excess drainage from the wound. She stated they had started in servicing the nurses and they would also have the wound vac company come in to train the nurses on using the wound vac and have each nurse perform a return demonstration.<BR/>Facility policy titled 'Competency of Nursing Staff' dated May 2019 revealed in part . licensed nurses and nursing assistants employed or contracted by the facility will demonstrate specific competency and skill sets deemed necessary to care for the needs of residents as identified through resident assessments and described in the plans of care.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 8 days in May of 2023 and 3 days in June of 2023 . <BR/>The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 11 of 62 days.<BR/>This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.<BR/>Findings include: <BR/>Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2023, run date 07/13/23 revealed RN coverage was triggered.<BR/>Record review of facility provided RN coverage for the month of May 2023 and June 2023 indicated there wasere no RN coverage on the following days- <BR/>1. <BR/>05/06/23 <BR/>2. <BR/>05/08/23 <BR/>3. <BR/>05/13/23 <BR/>4. <BR/>05/14/23<BR/>5. <BR/>05/15/23<BR/>6. <BR/>05/18/23 <BR/>7. <BR/>05/20/23 <BR/>8. <BR/>05/21/23 <BR/>9. <BR/>05/22/23 <BR/>10. <BR/>06/17/23 <BR/>11. <BR/>08/18/23 <BR/>In an interview on 07/17/2023 at 10:05 AM, the Administrator said the failure occurred due to the weekend RN quitting at the last minutes. He said the facility had some weekends RN but resigned at the last minutes. The Administrator said the facility can easily called in an RN if needed. He denied any negative outcomes with the lack of RN coverage for the reported dates. He said the facility was actively looking for a DON . <BR/>In an interview with the interim DON on 07/18/23 at 2:00PM, she said she had been at the facility for 8 days and she was the company's traveling DON. She said she go anywhere as needed and was on call for 24-hours a day if needed. <BR/>Record review of staffing policy dated 2001 updated July 2021 reflected in part our center provides numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care and center assessment. The policy did not address RN coverage for 24 hours period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests in 6 (room [ROOM NUMBER], 106, 110, 122, 123, and 206) of 18 resident rooms, the North side shower, the North side resident hall, and the North side conference room. <BR/>1. There were flies in resident rooms 100, 106, 110, 122, 123, 206 and the North Side conference room.<BR/>2. There was a large roach in resident room [ROOM NUMBER] and on the North side resident hall.<BR/>3. There were gnats in the North side shower. <BR/>These failures could place residents at risk for the potential spread of infection, cross contamination, and decreased quality of life.<BR/>Findings include:<BR/>1. In an observation on 7/15/23 at 9:22am, a fly was seen in resident room [ROOM NUMBER].<BR/>In an observation on 7/15/23 at 10:06am, a fly was seen in resident room [ROOM NUMBER].<BR/>In an observation on 7/15/23 at 10:15am, a fly was seen in resident room [ROOM NUMBER].<BR/>In an observation on 7/16/23 at 10am, a fly was seen in resident room [ROOM NUMBER].<BR/>In an observation on 7/16/23 at 1:34pm, a fly was seen in resident room [ROOM NUMBER].<BR/>In an observation on 7/16/23 at 1:55pm, a fly was seen in resident room [ROOM NUMBER].<BR/>In an observation on 7/18/23 at 11:15am, a fly was seen in resident room [ROOM NUMBER].<BR/>In an observation on 7/18/23 at 12:30pm, a fly was seen in the North side conference room.<BR/>2. In an observation on 7/15/23 at 9:43am, a large roach was seen on the floor in resident room [ROOM NUMBER].<BR/>In an observation on 7/16/23 at 10:09am, a large roach was seen on the North side resident hallway. <BR/>3. In an observation on 7/15/23 at 2:12pm, gnats were seen in the North side shower room.<BR/>In an observation on 7/16/23 at 9:00am, the doors to the smoking area were seen wide open.<BR/>In an interview with the Maintenance Director on 7/16/23 at 10:47am, he stated the double doors that open to the outside smoking area had been constantly open and broken since he started working there in February 2023. He stated that leaving the doors open can allow pests and bugs to come inside but he did not think there was a problem with pest control. He also stated they were in the process of getting a quote to fix the doors.<BR/>In an observation on 7/16/23 at 3:00pm, the doors to the smoking area were wide open.<BR/>In an observation on 7/17/23 at 9:00am, the doors to the smoking area were seen wide open.<BR/>In an observation on 7/17/23 at 3:30pm, the doors to the smoking area were seen wide open.<BR/>In an interview with the Administrator on 7/17/23 at 4:00pm about the observation seen, he stated that the facility did not have a problem with pest control and that they kept up with the pest control program.<BR/>In an observation on 7/18/23 at 9:00am, the doors to the smoking area were seen wide open.<BR/>In an observation on 7/18/23 at 4:00pm, the doors to the smoking area were seen wide open.<BR/>Record review of the facility's pest control services from February 2023 to June 2023 revealed scheduled monthly pest services. The invoice for May 2023 revealed an Emergency Service and an extra Insecticide treatment. In April the invoice showed treatment for small flies.<BR/>Record review of the facility's policy and procedures on Pest Control (Revised May 2008) read in part: Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 8 of 8 anonymous residents reviewed for activities.<BR/>8 of 8 anonymous residents at the confidential group interview stated there were no organized activities on the weekends.<BR/>This failure affected 8 residents and placed 64 residents who could attend activities at risk of boredom, depression, and a decreased quality of life.<BR/>Findings included:<BR/>Record review of the facility's activities calendar for 05/2022 revealed the following:<BR/>1. <BR/>Saturday 05/07/22: 12:00 Mother's Day Brunch<BR/>2. <BR/>Saturday 05/14/22, 05/21/22, and 05/28/22 Independent Activities of Choice<BR/>3. <BR/>Sunday 05/08/22, 05/15/22, 05/22/22, and 05/29/22: Independent Activities of Choice<BR/>Record review of the facility's activities calendar for 06/2022 revealed the following:<BR/>1. <BR/> Saturday 06/04/22, 06/11/22, 06/18/22, and 06/25/22: Independent Activities of Choice <BR/>2. <BR/> Sunday 06/05/22, 06/12/22, 06/19/22 and 06/26/22: Independent Activities of Choice<BR/>Record review of the grievance log for March 2022, April 2022 and May 2022 had no grievances pertaining to activities.<BR/>During the confidential group interview on 06/08/22 at 01:30 PM revealed that 8 out of 8 residents all agreed that no organized activities on the weekend. Residents complained of boredom, having nothing to do, no music or no games because of the lack of activities. <BR/>An interview with AD on 06/09/22 at 10:33 AM revealed that the AD works Monday through Friday from 8:00 AM to 5:00 PM and off on weekends. She has worked with the facility since August 2021. Sinces she has been the AD she has had not AD assistance and no other staff do activities with the residents on weekends. On weekends, staff get the residents up early, but most of the residents prefer to sleep in and hang out in their room on weekends. She stated there is no activities policies, she just knows to do stimulatory activities with the residents and not to leave out or use toxic materials without supervision.<BR/>An interview with Administrator on 06/13/22 at 10:55 AM revealed that CNAs usually do activities with the residents on the weekends and follow whatever activities are listed on the activities calendar.<BR/>An interview with Administrator on 06/13/22 at 10:55 AM revealed that CNAs usually do activities with the residents on the weekends and follow whatever activities are listed on the activities calendar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for 1 (Resident #20) of 18 residents reviewed for food preferences and the accommodation of resident's meal choices.<BR/>The facility failed to honor Resident #20's food preferences of vegetarian and gluten free.<BR/>This failure could place residents at risk of not having their food preferences met which could cause weight loss and a decline in their quality of life.<BR/>The findings include:<BR/>Record review of Resident #20's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE] with diagnoses of demyelinating disease of central nervous system (multiple sclerosis which is an autoimmune attack on the coating of nerves and causes inflammation and damage to brain and/or spinal cord), muscle wasting and atrophy (decrease and thinning of muscle), dysphagia (trouble swallowing), contracture of muscle (muscles, tendons, joints, or other tissues tighten/shorten causing a deformity), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry about everyday issues and situations), pain, and repeated falls.<BR/>Record review of Resident # 20's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, which indicated normal cognition. The MDS also revealed she had a serious mental illness. Resident #20 indicated it was very important for her to choose what clothes to wear, to choose between a tub bath, shower, bed bath or sponge bath, and to do her favorite activities. She required extensive assistance with personal hygiene, dressing, transfer, and bed mobility, and total dependence with toilet use. She also required 1-2 people to assist her with the activities. She needed physical help with bathing and 1 person to physically help her. Resident #20 used a wheelchair for mobility. She was always incontinent of urine and bowel.<BR/>Record review of Resident #20's medical record revealed an order for Diet: Regular diet, Texture: Regular, Fluid Consistency: Thin, that was ordered on 10/13/21. No indication of vegetarian or gluten free was noted.<BR/>Record review of Resident #20's care plan, revised 6/6/23, revealed: I am not happy with being in a nursing home, I have been offered other placement choices-I will express/exhibit satisfaction: Allow to participate in daily care and decision/goal making. Nutritional Status Diet. I am at risk for vitamin and mineral deficits-Maintain stable weight, weigh monthly: Determine likes/dislikes. Resident uses adaptive equipment when eating-To assist her with her own feeding in allowing her independence: To allow independence Every Shift. Vegetarian, and gluten free was not on the care plan.<BR/>In an interview and observation on 7/15/23 at 1:26pm Resident #20 was eating her own snacks she bought. The resident stated that she was vegetarian and gluten free and the kitchen did not have any vegetarian food for her. She stated that she had asked for vegetarian, gluten free food before from the kitchen and the kitchen told her they did not have anything. The resident stated she stopped ordering meals from the kitchen, since they did not have anything for her. The resident stated she was lucky to have great friends who provided her with the snacks she could eat. The resident had a box next to her that had Kind bars and other snacks in it.<BR/>In an interview and observation on 7/16/23 at 10:00am, Resident #20 was waiting for her hot chocolate. She stated the kitchen made her hot chocolate with regular milk, but she did not drink regular milk. So the kitchen had to come get her own milk out of her personal fridge that she bought and took it back to the kitchen to make her hot chocolate.<BR/>In an interview on 7/17/23 at 10:54am with the Nutritionist, she said she did not know Resident #20 was vegetarian. She said the kitchen should accommodate since it was the resident's preference, and she would look into it.<BR/>In an interview on 7/18/23 at 9:00am with the Nutritionist, she said she spoke to Resident #20 and the facility will provide her with oat milk or nut milk, whichever she wants, and with gluten free bread. They will also accommodate her vegetarian diet.<BR/>In an interview and observation on 7/18/23 at 12:36pm, Resident #20 was eating mushroom risotto for lunch, that the kitchen had provided.<BR/>Record review of the facility's policy and procedure on Menu Substitutions (Revised 2018) read in part: 1. The menu will be served as written unless an emergency situation arises. 2. If a specific item is not available, the cook will consult with the Nutrition & Foodservice Manager or consultant RDN/NDTR regarding an appropriate substitution. If the Nutrition & Foodservice Manager or dietician is not available, the cook will refer to the Menu Substitution Guide included in this section. 3. All substitutions will be made in accordance with the Menu Substitution Guide to ensure that the meal is well-balanced and adequate. 4. All changes to the menu will be recorded on the Menu Substitution Approval Form. 5. The consultant RDN/NDTR will review the Menu Substitution Approval Form with the dietician on each visit to determine trends in substitutions and accuracy of substitutions so that appropriate training can be provided if needed. 6. The dietician will initial off the Menu Substitution Form after review.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 8 days in May of 2023 and 3 days in June of 2023 . <BR/>The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 11 of 62 days.<BR/>This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.<BR/>Findings include: <BR/>Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2023, run date 07/13/23 revealed RN coverage was triggered.<BR/>Record review of facility provided RN coverage for the month of May 2023 and June 2023 indicated there wasere no RN coverage on the following days- <BR/>1. <BR/>05/06/23 <BR/>2. <BR/>05/08/23 <BR/>3. <BR/>05/13/23 <BR/>4. <BR/>05/14/23<BR/>5. <BR/>05/15/23<BR/>6. <BR/>05/18/23 <BR/>7. <BR/>05/20/23 <BR/>8. <BR/>05/21/23 <BR/>9. <BR/>05/22/23 <BR/>10. <BR/>06/17/23 <BR/>11. <BR/>08/18/23 <BR/>In an interview on 07/17/2023 at 10:05 AM, the Administrator said the failure occurred due to the weekend RN quitting at the last minutes. He said the facility had some weekends RN but resigned at the last minutes. The Administrator said the facility can easily called in an RN if needed. He denied any negative outcomes with the lack of RN coverage for the reported dates. He said the facility was actively looking for a DON . <BR/>In an interview with the interim DON on 07/18/23 at 2:00PM, she said she had been at the facility for 8 days and she was the company's traveling DON. She said she go anywhere as needed and was on call for 24-hours a day if needed. <BR/>Record review of staffing policy dated 2001 updated July 2021 reflected in part our center provides numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care and center assessment. The policy did not address RN coverage for 24 hours period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, final status at discharge and a reconciliation of medications for 1 of 5 residents reviewed for discharge planning (Resident #67)<BR/>(Resident #67) clinical record did not contain a discharge summary. <BR/>These failures could affect residents who discharges from the facility and put them at risk of for adverse effects post discharge.<BR/>Findings include:<BR/>Record review of the Face Sheet revealed Resident #67 is a [AGE] year-old male with an admission date of 05/06/2022 and a discharge date of 05/08/22. Diagnoses included acute myocardial infarction (blockage of blood flow to the heart), unspecified, cardiovascular and coagulations (builtup of fatty deposits blocking blood flow), unspecified, traumatic hemorrhage of cerebrum (bleeding within the brain tissue), unspecified, without loss of consciousness, initial encounter, cognitive communication deficit, history of falling, atherosclerotic heart disease of native coronary artery without angina pectoris (thick blood vessels), and essential (primary) hypertension (high blood pressure).<BR/>Record review of the Base Line Care Plan dated 06/08/22 revealed Resident #67 has a history of falling, atherosclerotic heart disease of native coronary artery without angina pectoris (inadequate blood flow to the heart), other specified diabetes mellitus with diabetic neuropathy, unspecified, and pure hypercholesterolemia (elevated low-density lipoprotein (LDL) cholesterol levels and premature coronary heart disease), unspecified. <BR/>Record review of the Resident Clinical Progress Notes written by LVN C revealed a discharge date of 05/08/22 and Resident #67 discharged home.<BR/>Record review of nurses' notes dated 05/08/22 written by LVN C revealed Resident #67's responsible party was notified to pick up resident as soon as possible and that he could not stay at the facility after an incident.<BR/>Record review of Resident #67's Clinical Record revealed Resident did not have an Interdisciplinary Discharge Summary.<BR/>An interview on 06/08/22 at 12:27 PM with Administrator, admissions and discharge policy requested, not received.<BR/>An interview on 06/08/22 at 02:30 PM with CN A, Admissions and Discharge Policy and Discharge Summary for Resident #67 was requested, not received.<BR/>An interview on 06/08/22 at 03:29 PM with CN B revealed she does not work in the facility; she is at the facility to assist with the survey and not at the facility when Resident #67 was in the facility and is not aware if a discharge plan was created for the Resident #67. She stated a discharge summary should be completed for every discharge and be kept in the clinical record, and it should include a summary of the resident's stay, their final status, and their medications. Requested Admissions and Discharge Policy, not received. <BR/>An interview with SW on 06/13/22 at 10:27 AM revealed that the SW usually participate in the Interdisciplinary Discharge Summary meetings. SW stated she does not work Friday, Saturday, or Sundays. The resident admitted on a Friday and discharged on a Sunday; therefore, she did not participate in his Interdisciplinary Discharge Summary. She stated that the DON more than likely did the discharge with the resident since it was a Friday and even possibly it was the Administrator since the discharge was initiated based on the resident striking another resident. <BR/>An interview with Administrator on 06/13/22 at 10:48 AM revealed that LVN C did the resident's discharge. Administrator is not sure if the resident's medications were sent with the resident or if there was any follow-up with resident. The SW usually initiates the Interdisciplinary Discharge Summary and follow-up after discharge with the resident. Failure to create a discharge plan could place the resident in an environment that fails to provide him quality of care and safety. <BR/>An interview with DON on 06/13/22 at 11:12 AM revealed that the DON did not discharge the resident. <BR/>Attempts to contact and interview LVN C were unsuccessful.

Based on interview, and record review the facility failed to ensure the residents were being properly supervised to prevent accidents and hazards.<BR/>The facility staff failed to ensure resident's environment was safe and free from any potential harm. LVN-B did in fact bring in a weapon namely a pellet gun into the facility. <BR/>The facility failed to ensure that facility staff were trained on how to properly ensure the resident environment remains as free of accident hazards as possible. <BR/>Findings include:<BR/>Record review of Resident #1's care plan dated 12/05/2024 revealed Resident#1 was care planned for falls and that his medication should be administered to him as prescribed by his physician. <BR/>In an interview with CNA-A on 02/06/25 at 11:50am CNA-A said that on 02/05/25 on the overnight shift she asked LVN B if she had the keys to the CMA medication cart. CNA-A said that LVN-B told her no and that when CNA-A said that she saw LVN-B sticking something in her pocket. CNA-A said she asked LVN-B what you put in your pocket. CNA-A said that's when LVN-B put a gun on the counter and said this is what I have. <BR/>In an interview with DON on 02/06/25 at 1:20pm she said that LVN-B told her that she went to her car to get her bag and that when she returned to the nurse's station, she realized that the gun was in her bag. The DON said that LVN-B told her that it was a pellet gun. The DON said that she does not consider the gun to be lethal because it is a pellet gun. <BR/>In an interview with Administrator on 02/06/25 at 2:15pm he said that he wasn't made aware by his DON that there was an accusation of a gun being in the facility until 02/05/25. And that he was investigating to see if the accusation was true. He said that any kind of weapon should not be at the facility. <BR/>In an interview with LVN-B on 02/06/25 at 2:52pm she said I went to my car to get my bag that I carry my computer in and when I got back to the nurse's station and looked in my bag I realized that the gun was in my bag. LVN-B said she removed the gun from the bag and put it in her pocket to take it back to her car when LVN-A and CNA-A accused her of having keys. She said that she told them that she did not have the keys and that she slowly stood up and showed them the gun. LVN-B said she put the gun in her bag and took it to her car. <BR/>Record review on 02/06/25 of the facilities' policy Professional Behavior dated 12/2019 reflected that staff should not be in Possession of a firearm or other weapons and dangerous devices on facility property.

Based on interview, and record review the facility failed to ensure the residents were being properly supervised to prevent accidents and hazards.<BR/>The facility staff failed to ensure resident's environment was safe and free from any potential harm. LVN-B did in fact bring in a weapon namely a pellet gun into the facility. <BR/>The facility failed to ensure that facility staff were trained on how to properly ensure the resident environment remains as free of accident hazards as possible. <BR/>Findings include:<BR/>Record review of Resident #1's care plan dated 12/05/2024 revealed Resident#1 was care planned for falls and that his medication should be administered to him as prescribed by his physician. <BR/>In an interview with CNA-A on 02/06/25 at 11:50am CNA-A said that on 02/05/25 on the overnight shift she asked LVN B if she had the keys to the CMA medication cart. CNA-A said that LVN-B told her no and that when CNA-A said that she saw LVN-B sticking something in her pocket. CNA-A said she asked LVN-B what you put in your pocket. CNA-A said that's when LVN-B put a gun on the counter and said this is what I have. <BR/>In an interview with DON on 02/06/25 at 1:20pm she said that LVN-B told her that she went to her car to get her bag and that when she returned to the nurse's station, she realized that the gun was in her bag. The DON said that LVN-B told her that it was a pellet gun. The DON said that she does not consider the gun to be lethal because it is a pellet gun. <BR/>In an interview with Administrator on 02/06/25 at 2:15pm he said that he wasn't made aware by his DON that there was an accusation of a gun being in the facility until 02/05/25. And that he was investigating to see if the accusation was true. He said that any kind of weapon should not be at the facility. <BR/>In an interview with LVN-B on 02/06/25 at 2:52pm she said I went to my car to get my bag that I carry my computer in and when I got back to the nurse's station and looked in my bag I realized that the gun was in my bag. LVN-B said she removed the gun from the bag and put it in her pocket to take it back to her car when LVN-A and CNA-A accused her of having keys. She said that she told them that she did not have the keys and that she slowly stood up and showed them the gun. LVN-B said she put the gun in her bag and took it to her car. <BR/>Record review on 02/06/25 of the facilities' policy Professional Behavior dated 12/2019 reflected that staff should not be in Possession of a firearm or other weapons and dangerous devices on facility property.