ROWLETT HEALTH AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #78) of eight residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #78's rooms were in a position that was accessible to the residents.<BR/>This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.<BR/>Findings included: <BR/>Review of Resident #78's Face Sheet, dated 06/19/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included difficulty walking, unsteadiness of feet, and weakness.<BR/>Review of Resident #78's Quarterly MDS Assessment, dated 04/19/2024, reflected Resident #78 had a moderate impairment in cognition with a BIMS score of 11. Resident #15 required moderate assistance for upper body dressing and lower body dressing.<BR/>Review of Resident #78's Comprehensive Care Plan, dated 05/02/2024, reflected Resident #78 was at risk for falls related to poor balance and lack of coordination, and weakness and one of the interventions be sure the call light is within reach and encourage to use it to call for assistance as needed.<BR/>Review of Resident #78's Joint Mobility Evaluation, dated 05/22/2024, reflected resident had limited range of motion to both shoulders, both elbows, and both wrists.<BR/>Review of Resident #78's Fall Risk Assessment, dated 05/16/2024, reflected resident had a minimum risk for fall.<BR/>Observation and interview with Resident #78 on 06/18/2024 at 11:25 AM revealed that Resident #78 was sitting at the side of her bed. Resident #78's call light was noted pinned between the bed and the wall. Resident #78 reached out her left arm and tried to pull the cord of the call light but stated she cannot pull it because it was trapped between the bed and the wall. She stated that whoever fixed her bed did not notice that the call light could not be accessed and was not able to pull it back to put it on top of the bed. She stated she would use her roommates call light if she needed assistance. She said the staff should put her call light where she could reach it because her arms were not strong enough to pull it. <BR/>Observation on 06/19/20204 at 7:55 AM revealed that Resident #78 was sitting on her bed talking to a visitor. Her call light was still pinned between the bed and the wall and resident still cannot pull it.<BR/>In an interview with CNA C on 06/19/2024 at 10:57 AM, CNA C stated she was assigned on Resident #78's hall. CNA C said she did her round at the start of her shift to check if any resident needed to be changed or transferred to the wheelchair. She said she also monitor if the call lights were with the residents. She said she did not notice that Resident #78's call light was pinned between the bed and the wall and cannot be pulled. She said Resident #78 seldom use the call light but said she must still make sure the call light was accessible when needed. She said call light must always be accessible because the residents use them to call the staff for any need and in cases of emergencies. CNA C added that if the call lights were not with the residents, the needs of the resident will not be known and addressed. She said she was responsible in ensuring the call lights were accessible for her assigned residents. She said she would her round and make sure the call lights were accessible to her assigned residents.<BR/>In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the call lights were inside the residents' rooms for a reason. He added the residents used the call lights to call for assistance, for a glass of water, for a pain medication, or for incontinent care. The DON added without the call lights, the residents would not be able to tell the staff what they needed and eventually their needs would not be met. The DON further added when the residents cannot pull or access their call lights, unfavorable incidents like falls, minor hurts, or major injuries could happen. The DON said the expectation was for the staff to ensure that the call lights were within reach of the residents at all times. The DON concluded that moving forward, he would educate the staff of the importance of call lights for the residents and would include the issue on their morning meeting. <BR/>In an interview with LVN A on 06/20/2024 at 7:32 AM, LVN A stated call lights should be within the reach of the residents at all times. LVN A said the call lights should not be in position where the resident cannot pull it or access it. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said the residents also use the call lights if they needed to be changed or they needed a pain medication. LVN A said the residents might fall trying to get up and get what they needed. LVN A said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would check her rooms to see if the residents had their call lights<BR/>Record review of facility's policy Call Light/Bell Policy/Procedure - Nursing Clinical revised 05/2007 revealed, Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff . Procedures . 5 . Place the call device withing resident's reach before leaving room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #321 and Resident #322) of ten residents reviewed for respiratory care.<BR/>The facility failed to ensure Resident #321's nebulizer masks and nasal cannula was properly stored.<BR/>The facility failed to ensure Resident #322's nasal cannula was properly stored.<BR/>The facility failed to ensure a Physician's Order was in place for Resident #322's oxygen administration.<BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>Resident #321<BR/>Review of Resident #321's Face Sheet, dated 06/19/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with exacerbation and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body).<BR/>Review of Resident #321's Comprehensive MDS Assessment, dated 06/08/2024, reflected resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated Resident #321's primary medical condition was chronic obstructive pulmonary disease with exacerbation.<BR/>Review of Resident #321's Comprehensive Care Plan, dated 06/08/2024, reflected resident had an altered cardiovascular status related to COPD (chronic obstructive pulmonary disease) and respiratory failure and the interventions were to administer nebulizer treatment and oxygen as ordered.<BR/>Review of Resident 321's Physician Order, dated 06/04/2024, reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally three times a day for wheezing, sob (shortness of breath).<BR/>Review of Resident 321's Physician Order, dated 06/18/2024, reflected, O2 AT 2-4 L/MIN CONTINUOUS PER via NC, every shift.<BR/>Observation and interview with Resident #321 on 06/18/2024 at 9:40 AM revealed that Resident #321 was on her bed resting. Resident #321 was on oxygen administration via nasal cannula. It was also noted that her mask for breathing treatment was on top of the side table. The breathing mask was not bagged. Resident #321 also had a portable oxygen tank at the back of her wheelchair. A nasal cannula was attached to the portable oxygen tank. The tubing of the nasal cannula was hanging on the backrest of the wheelchair with the prongs of the nasal cannula touching the seat of the wheelchair. The nasal cannula was not bagged. According to the resident, she had breathing treatment every morning. She said the nurse would put it on and would take it off. <BR/>Observation and interview with CNA B on 06/19/2024 at 7:51 AM, CNA B stated the Resident #321's nasal cannula was hanging at the backrest of her wheelchair. She said the nasal cannula should not be hanging and touching the wheelchair because the wheelchair could be dirty. She said it should be bagged when the resident was not using it so the nasal cannula will not be contaminated. She said whoever assist the resident from transferring from wheelchair to bed should put the nasal cannula in a bag. CNA B went inside the room to get the nasal cannula but then stopped halfway and said she would call the nurse to replace the nasal cannula.<BR/>Observation and interview with LVN A on 06/19/2024 at 8:38 AM, LVN A stated the breathing mask and the nasal cannula should not have been exposed nor touching anything because it could cause contamination and possible infection. LVN A said the breathing mask and the nasal cannula should be bagged when not in use. LVN A went to Resident #321's room and saw the nasal cannula at the back of the wheelchair. LVN A disconnected the nasal cannula from the portable oxygen and threw it on the trash can. She said she would get a new nasal cannula for Resident #321. She said she would also change Resident #321's breathing mask because it was placed on top of the table.<BR/>Resident #322<BR/>Review of Resident #322's Face Sheet dated 06/19/2024 reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (long term condition where the lungs cannot get enough oxygen into the blood).<BR/>Review of Resident #322's Care Plan on 06/19/2024 reflected no care plan for oxygen administration.<BR/>Review of Resident #322's Physician Order on 06/19/2024 revealed no Physician Order for oxygen administration.<BR/>Observation and interview with Resident #322 on 06/18/2024 at 9:48 AM revealed Resident #322 was on her bed, resting. It was noted that the resident had an oxygen concentrator at bedside. The oxygen concentrator was off. A nasal cannula was connected to the oxygen concentrator. The nasal cannula was hanging on top of the concentrator and was not bagged. Resident #322 stated she only use the oxygen if she needed it, like if she was having a hard time to breath. She said she had no recollection when was the last time she used her oxygen.<BR/>Observation and interview with LVN A on 06/19/2024 at 8:41 AM, after coming out of Resident #321's room, LVN A then went to Resident #322's room and saw the nasal cannula hanging on the oxygen concentrator. LVN A disconnected the nasal cannula hanging on the oxygen concentrator and threw it on the trash can. She went to the supply room to get a new nasal cannula, a breathing mask, and plastic bags. LVN A stated she needed to change the nasal cannula and the breathing mask to prevent any respiratory infection. <BR/>Observation and interview with LVN A on 06/20/2024 at 8:12 AM, LVN A stated Resident #322's order for oxygen was PRN. She logged on to her laptop to verify the order. LVN A said there was no order for oxygen. She said there should be an order for Resident #322's oxygen supplement so the staff would know that the resident had respiratory needs. She said the order for oxygen should be reflected on the resident's physician orders on the system. LVN A said since resident #322 as her resident, she was responsible in putting in the order for oxygen. She added she would put in the order and then started typing the order in the system.<BR/>In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the breathing mask and the nasal cannula should be bagged when not in use. The DON said it was the proper way to store the breathing mask and the nasal cannula. He said if those breathing apparatus were not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result to contamination and infection. He said the staff, including him, were responsible for monitoring that the nasal cannula and the breathing mask were bagged when not in use. He said that if a resident was using some oxygen, there should be an order specific for oxygen concentration to reflect the amount of oxygen, the duration, and the delivery device. He said the order is essential so the staff would be on the same page in caring for the respiratory need of the resident. He said without the order, the respiratory need of the resident will not be met. He said the expectation was for the breathing mask and the nasal cannula would be stored properly. He continued that another expectation was the staff to put the order on the system if there was an order for oxygen administration. The DON concluded that moving forward, he would educate the staff and would continually remind them to be diligent in making sure the procedures for respiratory care were followed.<BR/>Record review of facility's policy, Oxygen Administration Nursing Manual - Nursing Care rev. 06/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues . III. Infection Control . A. All oxygen tubing, humidifiers, masks, and cannulas . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.<BR/>Record review of facility's policy, Physician's Order, Telephone Orders and Recapitulation Process revised 11/2007 revealed, Policy: 1. Physician's orders shall be obtained prior to the initiation of any medication or treatment . Guidelines . 1 . order to the facility is necessary to show that the resident was admitted by a physician to this level of care . b.) Medication (Name, strength/dose, frequency, route of administration, diagnosis, PRN is to include specific reason).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. <BR/>The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines.<BR/>The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines.<BR/>The facility failed to ensure the ice machine scoop holder, located in the facility's kitchen, was cleaned. <BR/>The facility failed to ensure kitchen equipment (storage bins) was cleaned and sanitary.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings included: <BR/>Observations on 06/18/24 from 09:05 AM to 09:25 AM in the facility's only kitchen reflected:<BR/>Observation of the ice machine, in the facility kitchen revealed the ice scoop was stored in a blue container, and the bottom of the containers had black stains in it. <BR/>Two large white storage bins containing sugar and flour had black dirt stains along the outer and inner entrance of the container. The sugar had black particles in it.<BR/>Two medium white storage bins containing brown sugar and rice had black dirt stains along the outer and inner entrance of the containers. <BR/>One large bag of bread sticks with the date 6/17, and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month.<BR/>One bag of large pretzels with the date 6/7 and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month <BR/>10 large frozen tubes of meat were unlabeled undated. The items apppeared to be in its original package but there were no visible label indicating the type of meat and date items were receiverd.<BR/>An interview on 06/19/24 at 1:00 PM with the Dietary Manager and the dietitian, they were advised of the findings in the kitchen. The Dietary Manager advised that she had made all the corrections that were observed during the initial walkthrough on 06/18/24. The Dietary Manager advised that she had dropped the ball in ensuring that the foods were stored, labeled, and dated correctly. She stated that all of the items mentioned should include the full [NAME] day and year when labeling items being stored upon arrival. The DM stated that she would in-service her team on proper labeloinng and dating items upon arrival and ensure the bins are checked for cleanliness for frequently. They advised the risk of these concerns not being addressed could result in cross contamination and airborne illnesses.<BR/>An interview on 06/20/24 at 10:45 AM with the DON, he was made aware of the findings in the kitchen. He stated that he expects his kitchen staff to meet all required expectations. He stated the risk of the concerns not being addressed could result in residents getting sick. <BR/>Record Review of the Facility's policy on Food Storage dated 08/2007, revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. 1. <BR/>Food storage areas shall be clean at all times. <BR/>Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under &sect; 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. <BR/>The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines.<BR/>The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines.<BR/>The facility failed to ensure the ice machine scoop holder, located in the facility's kitchen, was cleaned. <BR/>The facility failed to ensure kitchen equipment (storage bins) was cleaned and sanitary.<BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings included: <BR/>Observations on 06/18/24 from 09:05 AM to 09:25 AM in the facility's only kitchen reflected:<BR/>Observation of the ice machine, in the facility kitchen revealed the ice scoop was stored in a blue container, and the bottom of the containers had black stains in it. <BR/>Two large white storage bins containing sugar and flour had black dirt stains along the outer and inner entrance of the container. The sugar had black particles in it.<BR/>Two medium white storage bins containing brown sugar and rice had black dirt stains along the outer and inner entrance of the containers. <BR/>One large bag of bread sticks with the date 6/17, and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month.<BR/>One bag of large pretzels with the date 6/7 and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month <BR/>10 large frozen tubes of meat were unlabeled undated. The items apppeared to be in its original package but there were no visible label indicating the type of meat and date items were receiverd.<BR/>An interview on 06/19/24 at 1:00 PM with the Dietary Manager and the dietitian, they were advised of the findings in the kitchen. The Dietary Manager advised that she had made all the corrections that were observed during the initial walkthrough on 06/18/24. The Dietary Manager advised that she had dropped the ball in ensuring that the foods were stored, labeled, and dated correctly. She stated that all of the items mentioned should include the full [NAME] day and year when labeling items being stored upon arrival. The DM stated that she would in-service her team on proper labeloinng and dating items upon arrival and ensure the bins are checked for cleanliness for frequently. They advised the risk of these concerns not being addressed could result in cross contamination and airborne illnesses.<BR/>An interview on 06/20/24 at 10:45 AM with the DON, he was made aware of the findings in the kitchen. He stated that he expects his kitchen staff to meet all required expectations. He stated the risk of the concerns not being addressed could result in residents getting sick. <BR/>Record Review of the Facility's policy on Food Storage dated 08/2007, revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. 1. <BR/>Food storage areas shall be clean at all times. <BR/>Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under &sect; 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #78) of eight residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #78's rooms were in a position that was accessible to the residents.<BR/>This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.<BR/>Findings included: <BR/>Review of Resident #78's Face Sheet, dated 06/19/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included difficulty walking, unsteadiness of feet, and weakness.<BR/>Review of Resident #78's Quarterly MDS Assessment, dated 04/19/2024, reflected Resident #78 had a moderate impairment in cognition with a BIMS score of 11. Resident #15 required moderate assistance for upper body dressing and lower body dressing.<BR/>Review of Resident #78's Comprehensive Care Plan, dated 05/02/2024, reflected Resident #78 was at risk for falls related to poor balance and lack of coordination, and weakness and one of the interventions be sure the call light is within reach and encourage to use it to call for assistance as needed.<BR/>Review of Resident #78's Joint Mobility Evaluation, dated 05/22/2024, reflected resident had limited range of motion to both shoulders, both elbows, and both wrists.<BR/>Review of Resident #78's Fall Risk Assessment, dated 05/16/2024, reflected resident had a minimum risk for fall.<BR/>Observation and interview with Resident #78 on 06/18/2024 at 11:25 AM revealed that Resident #78 was sitting at the side of her bed. Resident #78's call light was noted pinned between the bed and the wall. Resident #78 reached out her left arm and tried to pull the cord of the call light but stated she cannot pull it because it was trapped between the bed and the wall. She stated that whoever fixed her bed did not notice that the call light could not be accessed and was not able to pull it back to put it on top of the bed. She stated she would use her roommates call light if she needed assistance. She said the staff should put her call light where she could reach it because her arms were not strong enough to pull it. <BR/>Observation on 06/19/20204 at 7:55 AM revealed that Resident #78 was sitting on her bed talking to a visitor. Her call light was still pinned between the bed and the wall and resident still cannot pull it.<BR/>In an interview with CNA C on 06/19/2024 at 10:57 AM, CNA C stated she was assigned on Resident #78's hall. CNA C said she did her round at the start of her shift to check if any resident needed to be changed or transferred to the wheelchair. She said she also monitor if the call lights were with the residents. She said she did not notice that Resident #78's call light was pinned between the bed and the wall and cannot be pulled. She said Resident #78 seldom use the call light but said she must still make sure the call light was accessible when needed. She said call light must always be accessible because the residents use them to call the staff for any need and in cases of emergencies. CNA C added that if the call lights were not with the residents, the needs of the resident will not be known and addressed. She said she was responsible in ensuring the call lights were accessible for her assigned residents. She said she would her round and make sure the call lights were accessible to her assigned residents.<BR/>In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the call lights were inside the residents' rooms for a reason. He added the residents used the call lights to call for assistance, for a glass of water, for a pain medication, or for incontinent care. The DON added without the call lights, the residents would not be able to tell the staff what they needed and eventually their needs would not be met. The DON further added when the residents cannot pull or access their call lights, unfavorable incidents like falls, minor hurts, or major injuries could happen. The DON said the expectation was for the staff to ensure that the call lights were within reach of the residents at all times. The DON concluded that moving forward, he would educate the staff of the importance of call lights for the residents and would include the issue on their morning meeting. <BR/>In an interview with LVN A on 06/20/2024 at 7:32 AM, LVN A stated call lights should be within the reach of the residents at all times. LVN A said the call lights should not be in position where the resident cannot pull it or access it. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said the residents also use the call lights if they needed to be changed or they needed a pain medication. LVN A said the residents might fall trying to get up and get what they needed. LVN A said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would check her rooms to see if the residents had their call lights<BR/>Record review of facility's policy Call Light/Bell Policy/Procedure - Nursing Clinical revised 05/2007 revealed, Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff . Procedures . 5 . Place the call device withing resident's reach before leaving room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #321 and Resident #322) of ten residents reviewed for respiratory care.<BR/>The facility failed to ensure Resident #321's nebulizer masks and nasal cannula was properly stored.<BR/>The facility failed to ensure Resident #322's nasal cannula was properly stored.<BR/>The facility failed to ensure a Physician's Order was in place for Resident #322's oxygen administration.<BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>Resident #321<BR/>Review of Resident #321's Face Sheet, dated 06/19/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with exacerbation and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body).<BR/>Review of Resident #321's Comprehensive MDS Assessment, dated 06/08/2024, reflected resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated Resident #321's primary medical condition was chronic obstructive pulmonary disease with exacerbation.<BR/>Review of Resident #321's Comprehensive Care Plan, dated 06/08/2024, reflected resident had an altered cardiovascular status related to COPD (chronic obstructive pulmonary disease) and respiratory failure and the interventions were to administer nebulizer treatment and oxygen as ordered.<BR/>Review of Resident 321's Physician Order, dated 06/04/2024, reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally three times a day for wheezing, sob (shortness of breath).<BR/>Review of Resident 321's Physician Order, dated 06/18/2024, reflected, O2 AT 2-4 L/MIN CONTINUOUS PER via NC, every shift.<BR/>Observation and interview with Resident #321 on 06/18/2024 at 9:40 AM revealed that Resident #321 was on her bed resting. Resident #321 was on oxygen administration via nasal cannula. It was also noted that her mask for breathing treatment was on top of the side table. The breathing mask was not bagged. Resident #321 also had a portable oxygen tank at the back of her wheelchair. A nasal cannula was attached to the portable oxygen tank. The tubing of the nasal cannula was hanging on the backrest of the wheelchair with the prongs of the nasal cannula touching the seat of the wheelchair. The nasal cannula was not bagged. According to the resident, she had breathing treatment every morning. She said the nurse would put it on and would take it off. <BR/>Observation and interview with CNA B on 06/19/2024 at 7:51 AM, CNA B stated the Resident #321's nasal cannula was hanging at the backrest of her wheelchair. She said the nasal cannula should not be hanging and touching the wheelchair because the wheelchair could be dirty. She said it should be bagged when the resident was not using it so the nasal cannula will not be contaminated. She said whoever assist the resident from transferring from wheelchair to bed should put the nasal cannula in a bag. CNA B went inside the room to get the nasal cannula but then stopped halfway and said she would call the nurse to replace the nasal cannula.<BR/>Observation and interview with LVN A on 06/19/2024 at 8:38 AM, LVN A stated the breathing mask and the nasal cannula should not have been exposed nor touching anything because it could cause contamination and possible infection. LVN A said the breathing mask and the nasal cannula should be bagged when not in use. LVN A went to Resident #321's room and saw the nasal cannula at the back of the wheelchair. LVN A disconnected the nasal cannula from the portable oxygen and threw it on the trash can. She said she would get a new nasal cannula for Resident #321. She said she would also change Resident #321's breathing mask because it was placed on top of the table.<BR/>Resident #322<BR/>Review of Resident #322's Face Sheet dated 06/19/2024 reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (long term condition where the lungs cannot get enough oxygen into the blood).<BR/>Review of Resident #322's Care Plan on 06/19/2024 reflected no care plan for oxygen administration.<BR/>Review of Resident #322's Physician Order on 06/19/2024 revealed no Physician Order for oxygen administration.<BR/>Observation and interview with Resident #322 on 06/18/2024 at 9:48 AM revealed Resident #322 was on her bed, resting. It was noted that the resident had an oxygen concentrator at bedside. The oxygen concentrator was off. A nasal cannula was connected to the oxygen concentrator. The nasal cannula was hanging on top of the concentrator and was not bagged. Resident #322 stated she only use the oxygen if she needed it, like if she was having a hard time to breath. She said she had no recollection when was the last time she used her oxygen.<BR/>Observation and interview with LVN A on 06/19/2024 at 8:41 AM, after coming out of Resident #321's room, LVN A then went to Resident #322's room and saw the nasal cannula hanging on the oxygen concentrator. LVN A disconnected the nasal cannula hanging on the oxygen concentrator and threw it on the trash can. She went to the supply room to get a new nasal cannula, a breathing mask, and plastic bags. LVN A stated she needed to change the nasal cannula and the breathing mask to prevent any respiratory infection. <BR/>Observation and interview with LVN A on 06/20/2024 at 8:12 AM, LVN A stated Resident #322's order for oxygen was PRN. She logged on to her laptop to verify the order. LVN A said there was no order for oxygen. She said there should be an order for Resident #322's oxygen supplement so the staff would know that the resident had respiratory needs. She said the order for oxygen should be reflected on the resident's physician orders on the system. LVN A said since resident #322 as her resident, she was responsible in putting in the order for oxygen. She added she would put in the order and then started typing the order in the system.<BR/>In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the breathing mask and the nasal cannula should be bagged when not in use. The DON said it was the proper way to store the breathing mask and the nasal cannula. He said if those breathing apparatus were not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result to contamination and infection. He said the staff, including him, were responsible for monitoring that the nasal cannula and the breathing mask were bagged when not in use. He said that if a resident was using some oxygen, there should be an order specific for oxygen concentration to reflect the amount of oxygen, the duration, and the delivery device. He said the order is essential so the staff would be on the same page in caring for the respiratory need of the resident. He said without the order, the respiratory need of the resident will not be met. He said the expectation was for the breathing mask and the nasal cannula would be stored properly. He continued that another expectation was the staff to put the order on the system if there was an order for oxygen administration. The DON concluded that moving forward, he would educate the staff and would continually remind them to be diligent in making sure the procedures for respiratory care were followed.<BR/>Record review of facility's policy, Oxygen Administration Nursing Manual - Nursing Care rev. 06/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues . III. Infection Control . A. All oxygen tubing, humidifiers, masks, and cannulas . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.<BR/>Record review of facility's policy, Physician's Order, Telephone Orders and Recapitulation Process revised 11/2007 revealed, Policy: 1. Physician's orders shall be obtained prior to the initiation of any medication or treatment . Guidelines . 1 . order to the facility is necessary to show that the resident was admitted by a physician to this level of care . b.) Medication (Name, strength/dose, frequency, route of administration, diagnosis, PRN is to include specific reason).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all injuries of unknown origin were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of six residents reviewed for abuse.<BR/>MA A, LVN B and LVN C failed to immediately report an allegation of suspected abuse to the abuse coordinator when they noticed bruises on Resident #1<BR/>This failure could place residents at risk for abuse and neglect. <BR/>Findings include:<BR/>Review of Resident #1's face sheet, dated 01/23/23, reflected the resident was an [AGE] year-old female. She was admitted to the facility on [DATE]. She was admitted with dementia, generalized anxiety, dysphagia (difficulty swallowing foods or liquids) major depressive disorder, hypertension (high or raised blood pressure), speech and language deficit and lack of coordination. <BR/>Review of the quarterly MDS (Minimum Data Set) assessment, dated 12/03/22, reflected Resident #1 had a BIMS (Brief Interview Mental Status) score of 1, indicating Resident #1 had a severe cognitive impairment. She had minimal difficulty with hearing, she had unclear speech, and needed limited to extensive assistance with activities of daily living. <BR/>Review of the care plan not dated reflected Resident #1 had cognitive impairment related to dementia, also indicated the resident had impaired communication related to impaired cognition. <BR/>Review of the skin assessment for Resident #1, dated 01/05/23, reflected the resident had a bruise to left knee and another bruise to the right chest measuring 1cm x 1cm and the bruise was fading. <BR/>In an interview on 01/23/23 at 10:18 am with MA A, he stated he had taken care of the resident. MA A stated Resident #1 was able to respond to simple commands. The resident needed extensive assistance with activities of daily living with one staff. MA A said towards the end of last month, when she was taking care of the resident, she had bruises to both breasts. He stated the bruises were medium sizes, they were in the front area of the breast. The resident did not complain of pain to the bruised area. MA A stated he was not aware what had caused the bruises. The bruises were still present, but they were fading away. When MA A stated he did not report the bruises to anyone because he assumed the bruises had been reported by the charge nurse. He stated he was aware that if a resident had bruise or injury of unknow origin, it was to be reported to the Administrator who was the abuse coordinator. <BR/>An interview on 01/2/23 on 11:12 am with LVN B revealed she was the charge nurse for the resident. She stated Resident #1 was pleasant, but very confused but at times she was able to voice needs. The resident used a wheelchair to get around and she needed extensive assistance with activities of daily living. The resident was incontinent of bowel and bladder and some days she would say she wanted to use the bathroom. The resident was showered on Tuesday, Thursday, and Saturday. LVN B also stated the resident's skin assessment was completed weekly and the last time she completed the resident's skin assessment was on 01/19/23 and the resident had old bruises to the chest/breast area and left knee and the bruises were yellowish. LVN B stated the bruises on both breasts were quarter size and the bruises were spreading to the chest area but the bruise on the chest area was a small area. The staff stated she was not the one who initially noticed the bruises, but she was the one completing the weekly skin assessments because she worked in the morning shift. LVN B stated the bruises had been there since the beginning of the month. She stated she thought the bruises were caused from the resident leaning on the bedrail although she had not seen the resident leaning on the side rails. LVN B stated she did not report the bruises to anyone because they looked like old bruises. She also stated for any bruises or injury of unknown origin she was supposed to report to the Administrator because he was the abuse coordinator. <BR/>An interview with LVN C on 01/23/23 at 1:30 pm revealed she had worked in the memory care unit for about 2 years on the 2-10 shift. LVN C stated she took care of Resident #1, and the resident was oriented to her name, and she was confused. She was able to follow simple commands, but she was anxious at times. She required extensive assistance with activities of daily living. She was incontinent and sometimes she will use the toilet by herself without assistance. LVN C stated Resident #1 had old bruising to bilateral lower extremities, chest areas including breast areas, no bruises on the upper thighs. She stated she noticed the bruises on the chest area around Christmas. She stated she did not report to anyone of the bruises, because she assumed it had been reported. LVN C stated the last time she saw the bruises was on 01/19/23 before the resident was being transferred to the hospital. She stated the bruises were still there, but they were yellowish, and they were fading away. Bruises on the chest area spread towards the right and left breast. The bruises were dime sized on each leg and they were yellowish. She stated the cause of breast bruises on the chest area was due to the resident pressing on the side rail when getting up. LVN C stated she had not been concerned of the resident bruises because the resident transferred herself or positioned herself in bed which might have caused the bruises. She also stated the bruises on the lower extremities could have been caused from resident hitting somewhere although LVN C had not witnessed the resident hit anywhere. She stated she was not aware if the bruises had been reported to the abuse coordinator. <BR/>An interview on 01/23/23 at 1:48 pm with the ADON revealed the facility did not currently have a DON. He stated he was not aware of Resident #1 having bruises until it was reported from the hospital. He stated when he reviewed the resident's records after it had been reported that the resident had bruises, he noticed the staff had documented the resident having bruises. The ADON stated his expectation, for the staff, was to report immediately to the abuse coordinator any bruises or injury of unknown origin and then fill out an incident report. The ADON stated even if the charge nurse knew what had caused the bruise, they still had to report it. Failure of the staff to report cases of bruises, placed residents at risk of abuse. <BR/>In an interview on 01/23/23 at 2:13 pm with the clinical resource nurse, she stated she had been in the facility since the DON quit, that was early this year. She stated she noticed there were some issues with documentation, communication amongst the staff members and she had completed in-services. She stated there were concerns identified with skin in the facility and there was a skin assessment on all of the residents on 01/05/23. She on 01/05/23 it was documented bruise was noted on Resident #1's chest area and knee. In-services were provided and reviewed.<BR/>In an interview on 01/23/23 at 2:25pm with the Administrator, he stated he was the abuse coordinator. He stated the facility staff were to report to him, immediately, any bruises or injuries of unknown origin. He stated he was not aware Resident #1 had bruises until it was reported from the hospital. He stated after the report of the bruises, he started the investigation immediately. On 01/22/23 he completed safe surveys and none of the residents indicated being abused. He stated he also in-serviced the staff on abuse and neglect. The Administrator stated he had not reported any incident of abuse to HHS pertaining to the resident. <BR/>Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised 10/2022 reflected, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.E. Identification. 1. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. The facility will assist to identify abuse, neglect . 2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or had occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tears and injuries on unknown source .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure special eating equipment and utensils were provided for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 3 residents (Resident #69) reviewed for feeding assistance. <BR/>The facility failed to provide Resident #69 an adaptive aid to assist her to eat independently.<BR/>The failure could place residents who required adaptive feeding equipment at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. <BR/>Findings:<BR/>Record review of Resident #69s quarterly MDS assessment dated [DATE] reflected Resident #69 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses unspecified severe protein-calorie malnutrition (Malnutrition is an imbalance between the nutrients your body needs to function and the nutrients it gets) Rheumatoid arthritis (A chronic inflammatory disease that affects the joints. This results in painful joints, swelling and stiffness in the joints.), pain in right arm, unspecified lack of coordination, and muscle weakness generalized. Resident #69 BIMS was 15 which indicated cognitive intact. She required limited assistance with eating.<BR/>Record review of Resident #69's Comprehensive Care Plan, dated 11/10/22, reflected the following: recommend use of divided plates for all meals . Goal: maintain adequate nutritional status . Interventions: follow diet ordered by physician and aid with meals as needed. Record review of Resident #69 weights revealed on 04/02/23, the resident weighed 86.2 lbs. On 05/03/2023, the resident weighed 86.2 pounds which is a 0.00 % Gain. On 12/02/22, the resident weighed 82.6 lbs. On 05/03/23, the resident weighed 86.2 pounds which is a 4.36 % Gain.<BR/>Record review of Resident #69's orders revealed divided plate with all meals ordered by phone on 04/18/2023. Resident#69 orders revealed continue total assist with meals for weight loss ordered by phone on 01/20/23.<BR/>During an interview and observation on 05/08/23 at 01:00 PM Resident #69 had trouble lifting her food off her plate. I get so tried trying to eat the food off of the plate, I give up most of the time. Resident#69 stated the divided plate was helpful and she did not have to chase her food around her plate. Resident#69 stated she was having trouble today gripping her utensil and she was still hungry and liked the food. Surveyor asked Resident#69 if she wanted staff to assist her and she stated no. <BR/>During observation on 05/10/23 at 08:42 AM Resident#69's plate did not have dividers and Resident#69 had orange juice and was not ready to eat her breakfast plate. <BR/>During interview and observation on 05/10/23 at 08:42 AM the DON stated that Resident#69'plate did not have dividers. DON stated it was the kitchen staff responsibility to make sure residents' food was plated on the correct plate. <BR/>During interview on 05/10/23 at 11:45 AM Occupational Therapist T stated patients could use the plate dividers to help lift food. Occupational Therapist T stated not having the plate dividers would not cause the resident harm, but it would make the process of eating take longer to do. Occupational Therapist T stated that Occupational Therapy and Speech Therapy work ed together to determine the residents needs and goals. Occupational therapist T stated they have tried different assistive equipment with the resident and saw what would work the best. The Dietary Manager and Charge nurse should receive printed tickets with special equipment needs noted. Occupational Therapist T stated someone is supposed to make sure she finished her meals. Occupational Therapist T stated one of Resident#69 goals are to independently feed herself. Occupational Therapist T stated the Ticket system recently changed at the beginning of last week. Occupational therapist T stated Occupational therapy made sure resident information was updated and correct. <BR/>During interview on 05/10/23 at 12:05 PM, the Speech Therapist stated they usually consult ed with Occupational therapy to see what the best things for resident will be, copy of order for divided plate was given to kitchen and nursing. Speech Therapist M stated the care plan was updated with information for special equipment. Speech Therapist M stated the divided plates made it easier to eat. Speech T herapist M stated she had assisted Resident#69 with feeding her cereal and she was able to get toast on her own. <BR/>During interview on 05/10/23 at 12:17 PM DON stated it would take the resident longer to finish eating if the plate did not have the dividers. The kitchen staff was supposed to check the tray to make sure residents are getting the right things. DON stated Resident#69 would have asked for help from nursing staff when she needed it. DON stated Resident#69 usually does not ask for assist. <BR/>During interview and Record review a on 05/10/23 at 01:50 PM with Regional Dietitian, she stated not having the divided plates would mess up the resident by mouth intake and could cause weight loss. The Regional Dietitian stated the facility switched over to a new meal ticket system the previous week and she thought she had transferred all the information over. Record review revealed dietary instructions were in Resident#69 orders and care plan.<BR/>During an interview and observation on 05/10/23 at 2:30 PM, the Dietary Manager stated dietary staff were made aware of orders for adapted devices such as divided plates for their meals. Dietary Manager stated the facility recently switched over to a new ticket system for their trays. Dietary Manager pointed to a section on the ticket titled Tray Instructions and stated any orders for things like divided plates and weighted silverware would show there. Dietary Manager stated in their other facilities, the ticket system communicated with the facility's Electronic Medical Record System-Point Click Care so orders automatically carried over. That was not the case in this facility, and they worked to correct it. Dietary Manager stated all new orders were sent to the Regional Dietitian, who manually entered all orders. She stated the Speech Therapist gave her a list of all residents requiring adaptive aides and that was sent to the Regional Dietitian as well. The Dietary Manager stated, without the dividers, the residents would be unable to get the food onto their utensil and food would wind up on the table, and not in their mouth. The Dietary Manager stated this could lead to weight loss and lack of nutrition needed for healing and well-being. Dietary Manager stated staff was in service on 05/10/23 on the new ticketing system.<BR/>Record review of the facility physician orders (revised 05/2007), revealed no policy related to assistive devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment.<BR/>The facility failed to ensure Resident #1's walls in her room were in good repair. <BR/>This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. <BR/>Findings include: <BR/>Record review of Resident #1's Annual MDS assessment, dated 02/02/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes, hyperlipidemia, schizophrenia, and Non-Alzheimer's Dementia. Her BIMS score was 0 out of 15, which revealed she was severely cognitively impaired.<BR/>Observation on 03/09/23 at 11:36 AM of Resident #1's room revealed there was a hole in her wall behind the headboard of her bed. The hole in her wall was aproximately 1 ft long and 6 inches wide. Resident #1 was not at the facility during the observation and did not return prior to surveyor exiting the facility. Resident #1's RP was not contacted. <BR/>Review of the monthly grievance log for December 2022 - February 2023, reflected there were no concerns regarding holes in residents' walls. <BR/>Interview with the Maintenance Supervisor on 03/09/23 at 11:51 AM revealed he was responsible for facility repairs. He stated 03/09/23 was the first time he had been in Resident #1's room. He stated he had not received any maintenance requests to repair the wall in her room. He stated he did not know how long the hole had been in the wall. He stated the hole was caused by her bed being positioned too close to the wall. He stated the hole was too large to be patched. He stated he would have to replace the drywall where the hole was located. He stated the hole in the wall did not create any physical risk but was a cosmetic issue. He stated the hole in the wall did not create a home like environment for Resident #1. <BR/>Interview with the Administrator on 03/09/23 at 3:29 PM revealed he was not aware there was a hole in the wall behind Resident #1's bed. He stated the Maintenance Supervisor was currently making repairs to the wall in Resident #1's room. He stated the hole in Resident #1's wall did not create a homelike environment. He stated wear and tear was normal and the facility was constantly being made. He stated his expectation was for needed repairs to be reported to the Maintenance Supervisor and for repairs to be completed. <BR/>Record review of the facility policy titled Environmental Services-Housekeeping, dated November 2016, revealed Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for one (300-unit shower room) of four facility shower rooms reviewed for infection control. <BR/>The facility failed to ensure soiled laundry and bedding was not stored in the 300-unit shower room to prevent the spread of infection. <BR/>This failure could affect staff and residents placing them at risk for the spread of infection. <BR/>Findings included: <BR/>An observation on 03/15/23 at 8:42 AM of the 300-unit shower room revealed, assorted towels, one blanket, and a pair of resident's socks in direct contact with the shower floor. The soiled resident's laundry and bedding was not bagged. <BR/>An interview and observation on 3/15/23 at 8:45 AM with the ADON revealed, he observed assorted linens, a towel, and a pair of resident's socks in direct contact with the shower room floor not bagged. The ADON stated soiled laundry should be placed in a plastic bag and then placed in a yellow bin for laundry personnel to retrieve. He stated the items in direct contact with the floor not being bagged posed an infection control issue with the potential for transmission of germs to anyone who would handle them. <BR/>In an interview on 03/15/23 at 12:20 PM the DON stated, facility staff were in serviced 03/15/23 on Infection Control/Disposal of Soiled Linens. He stated they were in serviced that resident laundry and linens should be bagged in the shower room as they are completing a shower and once bagged should be placed in the yellow laundry barrel. He stated, resident laundry and linens should not be placed in direct contact with the floor due to the risk of infection control and to prevent cross contamination of dirty and clean materials. <BR/>Review of the facility policy dated 08/29/17 titled Infection Prevention and Control Program Section Infection Prevention and Control Program-Linens reflected, I. Policy Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. II. 1. Soiled laundry and bedding (e.g. personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towel, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment.<BR/>The facility failed to ensure Resident #1's walls in her room were in good repair. <BR/>This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. <BR/>Findings include: <BR/>Record review of Resident #1's Annual MDS assessment, dated 02/02/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes, hyperlipidemia, schizophrenia, and Non-Alzheimer's Dementia. Her BIMS score was 0 out of 15, which revealed she was severely cognitively impaired.<BR/>Observation on 03/09/23 at 11:36 AM of Resident #1's room revealed there was a hole in her wall behind the headboard of her bed. The hole in her wall was aproximately 1 ft long and 6 inches wide. Resident #1 was not at the facility during the observation and did not return prior to surveyor exiting the facility. Resident #1's RP was not contacted. <BR/>Review of the monthly grievance log for December 2022 - February 2023, reflected there were no concerns regarding holes in residents' walls. <BR/>Interview with the Maintenance Supervisor on 03/09/23 at 11:51 AM revealed he was responsible for facility repairs. He stated 03/09/23 was the first time he had been in Resident #1's room. He stated he had not received any maintenance requests to repair the wall in her room. He stated he did not know how long the hole had been in the wall. He stated the hole was caused by her bed being positioned too close to the wall. He stated the hole was too large to be patched. He stated he would have to replace the drywall where the hole was located. He stated the hole in the wall did not create any physical risk but was a cosmetic issue. He stated the hole in the wall did not create a home like environment for Resident #1. <BR/>Interview with the Administrator on 03/09/23 at 3:29 PM revealed he was not aware there was a hole in the wall behind Resident #1's bed. He stated the Maintenance Supervisor was currently making repairs to the wall in Resident #1's room. He stated the hole in Resident #1's wall did not create a homelike environment. He stated wear and tear was normal and the facility was constantly being made. He stated his expectation was for needed repairs to be reported to the Maintenance Supervisor and for repairs to be completed. <BR/>Record review of the facility policy titled Environmental Services-Housekeeping, dated November 2016, revealed Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for one (300-unit shower room) of four facility shower rooms reviewed for infection control. <BR/>The facility failed to ensure soiled laundry and bedding was not stored in the 300-unit shower room to prevent the spread of infection. <BR/>This failure could affect staff and residents placing them at risk for the spread of infection. <BR/>Findings included: <BR/>An observation on 03/15/23 at 8:42 AM of the 300-unit shower room revealed, assorted towels, one blanket, and a pair of resident's socks in direct contact with the shower floor. The soiled resident's laundry and bedding was not bagged. <BR/>An interview and observation on 3/15/23 at 8:45 AM with the ADON revealed, he observed assorted linens, a towel, and a pair of resident's socks in direct contact with the shower room floor not bagged. The ADON stated soiled laundry should be placed in a plastic bag and then placed in a yellow bin for laundry personnel to retrieve. He stated the items in direct contact with the floor not being bagged posed an infection control issue with the potential for transmission of germs to anyone who would handle them. <BR/>In an interview on 03/15/23 at 12:20 PM the DON stated, facility staff were in serviced 03/15/23 on Infection Control/Disposal of Soiled Linens. He stated they were in serviced that resident laundry and linens should be bagged in the shower room as they are completing a shower and once bagged should be placed in the yellow laundry barrel. He stated, resident laundry and linens should not be placed in direct contact with the floor due to the risk of infection control and to prevent cross contamination of dirty and clean materials. <BR/>Review of the facility policy dated 08/29/17 titled Infection Prevention and Control Program Section Infection Prevention and Control Program-Linens reflected, I. Policy Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. II. 1. Soiled laundry and bedding (e.g. personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towel, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for one (Resident #85) of five residents reviewed for clinical records.<BR/>The facility failed to ensure that Resident #85's physician's orders for tramadol were written to be given orally and not enterally.<BR/>This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided.<BR/>Findings included:<BR/>Review of Resident #85's face sheet, dated 05/10/23, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, unspecified dementia, and schizoaffective disorder. <BR/>Review of Resident #85's physician's orders reflected: Tramadol tablet 50 MG, give 50 MG enterally every 6 hours as needed for for lower back pain [sic] with a start date of 09/11/20.<BR/>Review of Resident #85's most recent quarterly MDS assessment, dated 01/10/23, reflected she had a BIMS of 01 indicating severe cognitive impairment.<BR/>An observation and interview on 05/10/23 at 12:30 PM with Resident #85 revealed she was sitting in the dining room area at a table eating her lunch. Resident #85 was not able to answer questions but there was no indication she had a g-tube. <BR/>An interview on 05/10/23 at 12:35 PM with MA G revealed she did not provide Resident #85 her PRN tramadol, but that the nurse did instead. MA G said Resident #85 should receive all her medications by mouth since she did not have a g-tube.<BR/>An interview on 05/10/23 at 1:10 PM with LVN T revealed Resident #85 had not been provided her PRN Tramadol for a while because she had not needed it. LVN T said that Resident #85 did not use a g-tube and should receive all her medications by mouth instead. LVN T said she had only been at the facility for a little while and was not sure why the Tramadol order was written to be given to her enterally when that was not an option for her.<BR/>An interview on 05/10/23 at 1:25 PM with the DON revealed Resident #85 did not have a g-tube and should receive her medications by mouth and not enterally. The DON said he was not sure why Resident #85's tramadol was written to be given enterally instead of by mouth. The DON did not provide a concern regarding the medication order written incorrectly.<BR/>Review of the facility's policy, revised 05/07, reflected: 6. Orders for medications must include: .D. Route of administration if other than oral; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for one (Resident #85) of five residents reviewed for clinical records.<BR/>The facility failed to ensure that Resident #85's physician's orders for tramadol were written to be given orally and not enterally.<BR/>This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided.<BR/>Findings included:<BR/>Review of Resident #85's face sheet, dated 05/10/23, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, unspecified dementia, and schizoaffective disorder. <BR/>Review of Resident #85's physician's orders reflected: Tramadol tablet 50 MG, give 50 MG enterally every 6 hours as needed for for lower back pain [sic] with a start date of 09/11/20.<BR/>Review of Resident #85's most recent quarterly MDS assessment, dated 01/10/23, reflected she had a BIMS of 01 indicating severe cognitive impairment.<BR/>An observation and interview on 05/10/23 at 12:30 PM with Resident #85 revealed she was sitting in the dining room area at a table eating her lunch. Resident #85 was not able to answer questions but there was no indication she had a g-tube. <BR/>An interview on 05/10/23 at 12:35 PM with MA G revealed she did not provide Resident #85 her PRN tramadol, but that the nurse did instead. MA G said Resident #85 should receive all her medications by mouth since she did not have a g-tube.<BR/>An interview on 05/10/23 at 1:10 PM with LVN T revealed Resident #85 had not been provided her PRN Tramadol for a while because she had not needed it. LVN T said that Resident #85 did not use a g-tube and should receive all her medications by mouth instead. LVN T said she had only been at the facility for a little while and was not sure why the Tramadol order was written to be given to her enterally when that was not an option for her.<BR/>An interview on 05/10/23 at 1:25 PM with the DON revealed Resident #85 did not have a g-tube and should receive her medications by mouth and not enterally. The DON said he was not sure why Resident #85's tramadol was written to be given enterally instead of by mouth. The DON did not provide a concern regarding the medication order written incorrectly.<BR/>Review of the facility's policy, revised 05/07, reflected: 6. Orders for medications must include: .D. Route of administration if other than oral; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 (Resident #46) of 1 resident reviewed. for quality of care.<BR/>The facility failed to to obtain physician orders and assess Resident #46 for a scoop mattress and obtain physician orders prior to installing the scoop mattress. <BR/>This failure could prevent the resident to be free from of any physical or chemical restraints.<BR/>Findings included:<BR/>Record review of Resident #46's Face Sheet, dated 06/19/2024, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia (memory decline), lack of coordination, and repeated falls. <BR/>Record review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 06 (severe cognitive impairment) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance.<BR/>Record review of Resident #46's physician orders dated 06/19/24 revealed no orders for a scoop mattress.<BR/>Observation on 06/18/24 at 11:03 AM of Resident #46's bed revealed she was observed having a scoop mattress. <BR/>An interview and observation on 06/19/24 at 10:00 AM with LVN L, she stated she was the nurse for Resident #46. She stated the resident is totally independent and did not require assistance to get into or out of her bed. She stated the resident should not have a scoop mattress. LVN L went into Resident #46's room and observed that the resident did have a scoop mattress on her bed. She stated she was not sure how the resident got the mattress. She stated the resident had just changed rooms and they may have just left the scoop mattress and not replace it. She stated the risk of the resident having the scoop mattress without physician orders or an assessment could result in the result having a fall when trying to get into and out of bed. <BR/>An interview on 06/20/24 at 10:45 AM with the DON, he stated he was made aware of Resident #46 having a scoop mattress. He stated the residents had recently changed rooms and when the resident was moved into the room, staff failed to change the mattress. He stated they have since changed out the mattress to a more appropriate one. He stated the risk of the resident having a scoop mattress could result in her injuring herself.<BR/>Record review of facility policy on Physician orders, dated 08/2007, stated It is the policy of this facility to ensure that no resident is placed in physical restraints for the purpose of discipline or convenience and that restraints are only applied to treat the resident's medical symptoms. All residents requiring physical restrains will be assessed for least restrictive measures prior to restraint application and restraints will be reduced as appropriate to the resident's medical condition. No resident will have a physical restraint placed for positioning purposes unless there is clearly no other alternative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment.<BR/>The facility failed to ensure Resident #1's walls in her room were in good repair. <BR/>This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. <BR/>Findings include: <BR/>Record review of Resident #1's Annual MDS assessment, dated 02/02/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes, hyperlipidemia, schizophrenia, and Non-Alzheimer's Dementia. Her BIMS score was 0 out of 15, which revealed she was severely cognitively impaired.<BR/>Observation on 03/09/23 at 11:36 AM of Resident #1's room revealed there was a hole in her wall behind the headboard of her bed. The hole in her wall was aproximately 1 ft long and 6 inches wide. Resident #1 was not at the facility during the observation and did not return prior to surveyor exiting the facility. Resident #1's RP was not contacted. <BR/>Review of the monthly grievance log for December 2022 - February 2023, reflected there were no concerns regarding holes in residents' walls. <BR/>Interview with the Maintenance Supervisor on 03/09/23 at 11:51 AM revealed he was responsible for facility repairs. He stated 03/09/23 was the first time he had been in Resident #1's room. He stated he had not received any maintenance requests to repair the wall in her room. He stated he did not know how long the hole had been in the wall. He stated the hole was caused by her bed being positioned too close to the wall. He stated the hole was too large to be patched. He stated he would have to replace the drywall where the hole was located. He stated the hole in the wall did not create any physical risk but was a cosmetic issue. He stated the hole in the wall did not create a home like environment for Resident #1. <BR/>Interview with the Administrator on 03/09/23 at 3:29 PM revealed he was not aware there was a hole in the wall behind Resident #1's bed. He stated the Maintenance Supervisor was currently making repairs to the wall in Resident #1's room. He stated the hole in Resident #1's wall did not create a homelike environment. He stated wear and tear was normal and the facility was constantly being made. He stated his expectation was for needed repairs to be reported to the Maintenance Supervisor and for repairs to be completed. <BR/>Record review of the facility policy titled Environmental Services-Housekeeping, dated November 2016, revealed Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for one (300-unit shower room) of four facility shower rooms reviewed for infection control. <BR/>The facility failed to ensure soiled laundry and bedding was not stored in the 300-unit shower room to prevent the spread of infection. <BR/>This failure could affect staff and residents placing them at risk for the spread of infection. <BR/>Findings included: <BR/>An observation on 03/15/23 at 8:42 AM of the 300-unit shower room revealed, assorted towels, one blanket, and a pair of resident's socks in direct contact with the shower floor. The soiled resident's laundry and bedding was not bagged. <BR/>An interview and observation on 3/15/23 at 8:45 AM with the ADON revealed, he observed assorted linens, a towel, and a pair of resident's socks in direct contact with the shower room floor not bagged. The ADON stated soiled laundry should be placed in a plastic bag and then placed in a yellow bin for laundry personnel to retrieve. He stated the items in direct contact with the floor not being bagged posed an infection control issue with the potential for transmission of germs to anyone who would handle them. <BR/>In an interview on 03/15/23 at 12:20 PM the DON stated, facility staff were in serviced 03/15/23 on Infection Control/Disposal of Soiled Linens. He stated they were in serviced that resident laundry and linens should be bagged in the shower room as they are completing a shower and once bagged should be placed in the yellow laundry barrel. He stated, resident laundry and linens should not be placed in direct contact with the floor due to the risk of infection control and to prevent cross contamination of dirty and clean materials. <BR/>Review of the facility policy dated 08/29/17 titled Infection Prevention and Control Program Section Infection Prevention and Control Program-Linens reflected, I. Policy Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. II. 1. Soiled laundry and bedding (e.g. personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towel, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items.

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (medication aide cart) of 4 medication carts reviewed for medication storage.<BR/>The facility failed to ensure the medications were placed inside of the medication cart when MA H left the medication cart on the hallway. <BR/>This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences. <BR/>Findings included:<BR/>Observation on 05/08/23 at 09:20 AM during the medication administration revealed MA H leaving the resident's medication on top of the medication cart and stated she was going to get a blood pressure machine. When MA H returned, she proceeded to the resident's room. The medications were still on top of the medication cart. There were staff members on the hallway going in an out of the residents rooms. <BR/>In an interview on 05/08/23 at 09:48 AM with MA H she stated she forgot the medications on top of the cart when she left to get the blood pressure machine. MA H stated the medications were to be locked in the medication cart when she was not near the medication cart to prevent someone from taking the medications.<BR/>In an interview on 05/10/23 at 12:25 PM with DON he stated MA H had informed him of leaving cards of medications on top of the medication cart when she went to another resident's room. DON stated the staff was supposed to be locking up the medication in the medication cart due to the safety because anyone can pick up the medications from the cart. DON stated he completed an in-service with all the medication aides and check off completed on medication administration. In-service reviewed.<BR/>Review of the facility policy revised 05/2007 and titled Medication Administration reflected, .9. The medication cart is to be kept in clear view and in reach of the person administering medications at all times. It is to be locked when the medication nurse is away from the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment.<BR/>The facility failed to ensure Resident #1's walls in her room were in good repair. <BR/>This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. <BR/>Findings include: <BR/>Record review of Resident #1's Annual MDS assessment, dated 02/02/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes, hyperlipidemia, schizophrenia, and Non-Alzheimer's Dementia. Her BIMS score was 0 out of 15, which revealed she was severely cognitively impaired.<BR/>Observation on 03/09/23 at 11:36 AM of Resident #1's room revealed there was a hole in her wall behind the headboard of her bed. The hole in her wall was aproximately 1 ft long and 6 inches wide. Resident #1 was not at the facility during the observation and did not return prior to surveyor exiting the facility. Resident #1's RP was not contacted. <BR/>Review of the monthly grievance log for December 2022 - February 2023, reflected there were no concerns regarding holes in residents' walls. <BR/>Interview with the Maintenance Supervisor on 03/09/23 at 11:51 AM revealed he was responsible for facility repairs. He stated 03/09/23 was the first time he had been in Resident #1's room. He stated he had not received any maintenance requests to repair the wall in her room. He stated he did not know how long the hole had been in the wall. He stated the hole was caused by her bed being positioned too close to the wall. He stated the hole was too large to be patched. He stated he would have to replace the drywall where the hole was located. He stated the hole in the wall did not create any physical risk but was a cosmetic issue. He stated the hole in the wall did not create a home like environment for Resident #1. <BR/>Interview with the Administrator on 03/09/23 at 3:29 PM revealed he was not aware there was a hole in the wall behind Resident #1's bed. He stated the Maintenance Supervisor was currently making repairs to the wall in Resident #1's room. He stated the hole in Resident #1's wall did not create a homelike environment. He stated wear and tear was normal and the facility was constantly being made. He stated his expectation was for needed repairs to be reported to the Maintenance Supervisor and for repairs to be completed. <BR/>Record review of the facility policy titled Environmental Services-Housekeeping, dated November 2016, revealed Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for one (300-unit shower room) of four facility shower rooms reviewed for infection control. <BR/>The facility failed to ensure soiled laundry and bedding was not stored in the 300-unit shower room to prevent the spread of infection. <BR/>This failure could affect staff and residents placing them at risk for the spread of infection. <BR/>Findings included: <BR/>An observation on 03/15/23 at 8:42 AM of the 300-unit shower room revealed, assorted towels, one blanket, and a pair of resident's socks in direct contact with the shower floor. The soiled resident's laundry and bedding was not bagged. <BR/>An interview and observation on 3/15/23 at 8:45 AM with the ADON revealed, he observed assorted linens, a towel, and a pair of resident's socks in direct contact with the shower room floor not bagged. The ADON stated soiled laundry should be placed in a plastic bag and then placed in a yellow bin for laundry personnel to retrieve. He stated the items in direct contact with the floor not being bagged posed an infection control issue with the potential for transmission of germs to anyone who would handle them. <BR/>In an interview on 03/15/23 at 12:20 PM the DON stated, facility staff were in serviced 03/15/23 on Infection Control/Disposal of Soiled Linens. He stated they were in serviced that resident laundry and linens should be bagged in the shower room as they are completing a shower and once bagged should be placed in the yellow laundry barrel. He stated, resident laundry and linens should not be placed in direct contact with the floor due to the risk of infection control and to prevent cross contamination of dirty and clean materials. <BR/>Review of the facility policy dated 08/29/17 titled Infection Prevention and Control Program Section Infection Prevention and Control Program-Linens reflected, I. Policy Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. II. 1. Soiled laundry and bedding (e.g. personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towel, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items.