Benbrook Nursing & Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care and nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for two of two medication aides (MA E and MA C) and two of three nurses (LVN A and LVN D ) reviewed for competent nursing staff .<BR/>The facility failed to ensure staff knew how to identify an overfilled sharps container. <BR/>This failure could place residents at risk of laceration or stick by sharps .<BR/>The findings include:<BR/>In an observation on 6/03/25 at 10:05 AM, revealed the sharps container hanging on the wall of the shower room in the 200 Hall was noted as overfilled beyond the manufacturer fill line and was still in use with the receptacle in the open position.<BR/>In an interview on 6/03/25 at 10:10 AM, LVN A reported she had been the regular nurse for Hall 200. LVN A stated sharps containers were supposed to be emptied when the flap (receptacle) would no longer shut. She stated she was not sure who was responsible for emptying the sharps containers in the shower room. LVN A stated the training she had received was for the sharp's container on her medication cart and that it would be placed into a biohazard box if the sharp's container no longer shut. She stated she could ask the DON who had the key to the sharps container as she did not know for sure. She stated the overfilled sharps container was definitely a safety concern for residents.<BR/>In an interview on 6/03/25 at 11:20 AM, MA C stated any staff using sharp's containers were responsible for emptying them and that, I will do it if it gets full. I don't let it get to where I can't flip it. If I can see stuff from the top, I change it out. I have a key to the sharp's container on this cart. MA C stated she believed she received training in the disposal of sharps but did not remember when it occurred. She stated if a sharp's box was overfilled, someone could get stuck.<BR/>In an interview on 6/03/25 at 12:10 PM, LVN D stated sharp's containers were emptied when they appeared from the top to be full. She was not aware of the manufacturer's fill line marked on the container . <BR/>In an interview on 6/03/25 at 02:34 PM, the ADM stated he expected sharp's containers to have been monitored and changed as needed. He stated sharp's containers should not be overfilled. The ADM stated it was the responsibility of anyone who used sharp's containers to change them when they were full. He stated the top of the sharp's containers was white and it could be seen when the lid was full. He stated the risk of a sharp box being overfilled would be someone could injure themselves. ADM did not asked and did not state what training staff had received regarding sharps or the importance of training or how residents could be affected by a lack of this training.<BR/>In an interview on 6/03/25 at 03:40 PM with the ADM revealed he did not have any policies related to nursing competency and any policies related to sharps disposal.<BR/>In an interview on 6/03/25 at 03:55 PM, the DON stated nurses were responsible for emptying full sharp's containers when the manufacturer fill line was reached. She stated the risk of an overfilled sharp box was the risk of getting stuck by a sharp. She reported staff in-service training began today (6/03/25) which included how to know when sharp's containers were full, when to empty them, how to empty them, and more. The DON reported the training included CNA's were to notify nurses should they notice full sharp's containers and for nurses and CNA's to be sure to monitor the sharp's containers in the shower room . The DON was not asked and did not state what training regarding sharps staff had previously received and did not provide in-service training records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 4 of 4 Residents (Resident #6, Resident #7, and Resident #9) reviewed for smoking, and 1 of 1 Resident (Resident #4) reviewed for environment.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were provided supervision while smoking.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were accurately assessed for smoking.<BR/>The facility failed to ensure Resident #9 was assessed for smoking per facility policy. <BR/>The facility failed to ensure Resident #4 did not have an electric kettle in her room on the secure unit. <BR/>These failures could place residents at risk of harm, injury, or accidents. <BR/>Findings included:<BR/>Record review of Resident #6's admission Record, dated [DATE], revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Encephalopathy (this is a brain disease that alters brain function or structure) and unspecified visual loss. <BR/>Record review of Resident #6's MDS, dated [DATE], revealed a BIMS score of 13 indicating the individual's cognition is intact.<BR/>Record review of Resident #6's Care Plan, date initiated [DATE], reflected the resident is a smoker. Goal: the resident will not suffer injury from unsafe smoking practices. Interventions: The resident requires supervision while smoking. <BR/>Record review of Resident #6's Smoking-safety screen, dated [DATE], revealed the resident is safe to smoke with supervision. Vision: Does resident have any visual deficit. 1. Yes. Safety: 6. Can resident light own cigarette? No. 7. Resident need for adaptive equipment. 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes F. IDTC Decision; 1 Notes on Safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): IDT agrees the resident requires supervision while smoking d/t unspecified visual loss. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t dx unspecified visual loss. <BR/>Record review of Resident #7's admission MDS, dated [DATE], revealed an admission date to the facility on [DATE]. Further review revealed a BIMS score of 14, indicating intact cognition. <BR/>Record review of Resident #7's care plan dated [DATE] revealed resident was a smoker. <BR/>Record review of Resident #7's smoking assessment, dated [DATE], revealed resident did not have cognitive loss or dexterity problems but did have visual deficits, could not light own cigarette and needed supervision. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t Hordeolum externum (an infection of an oil gland at the edge of eyelid) unspecified eye.<BR/>Record review of Resident #9's admission Record revealed, a [AGE] year-old male, initially admitted on [DATE] and re-admitted on [DATE] with diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), with (Acute) Exacerbation.<BR/>Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score of 13 indicating intact cognition. <BR/>Record review of Resident #9's Care Plan, date initiated: [DATE], reflected the resident is a smoker. Goal: The resident will not suffer injury from unsafe smoking practices. Interventions: the resident requires supervision while smoking. <BR/>Record review of Resident #9's Smoking- Safety Screen, dated [DATE], revealed, Category: Safe to smoke with supervision. <BR/>E. Safety- Can resident light own cigarette? No. 7. Resident need for adaptive equipment 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes. F. IDTC Decision: 1. Notes on Safety From IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. <BR/>No other smoking assessment had been completed for Resident #9. <BR/>Record review of Resident #4's admission Record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease , major depressive disorder, and anxiety. <BR/>Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment.<BR/>Record review of Resident #4's care plan, dated [DATE], did not reveal anything related to an electric kettle.<BR/>In an observation and interview on [DATE] at 11:21 AM, Resident #4 was in her room sitting up in her w/c drinking coffee. A small blue kettle was observed plugged in near the sink. Resident #4 stated her family member sent it to her. <BR/>In an observation and interview on [DATE] at 12:06 PM, Resident #6 walked out of her room holding a cigarette pack and a lighter. Resident #6 entered the code to go outside on the smoking area. Surveyors went outside and observed Resident #6 and Resident #7 smoking with no staff present. Resident #6 stated she knew the code to enter to go outside, staff were aware she smoked, and stated she was allowed to keep her smoking materials with her. Resident #6 stated she took about 3-5 smoke breaks a day and did not need an apron to smoke. Resident #7 was observed with a cigarette and lighter. Resident #7 stated she knew the codes and all residents knew the codes. Resident #7 stated she had been there about 4 months, and staff had never taken away her cigarettes or lighter. Resident #7 said the staff had nobody to bring them to smoke so she guessed that was why residents went out by themselves. <BR/>In an interview on [DATE] at 1:02 PM, LVN E stated residents were not allowed to have their cigarettes or lighters in their possession and smoking materials were locked up behind the nurse's station. She stated residents had designated smoke times and must be supervised during smoking unless they sign out and go out the front and leave the facility. She said supervision meant that one of the workers on shift must light the cigarettes, pass them out and stay until everyone was done smoking. She stated the risk to residents having cigarettes and lighters was they could set something on fire or hurt someone else or themselves. <BR/>In an interview on [DATE] at 1:04 PM, LVN G stated usually the aides supervised residents who smoked. He stated no residents were to have their lighters or cigarettes. He did not know who completed the smoking assessment and did not know what supervision meant since he did not complete the assessments. He stated if residents were not supervised while smoking, they could hurt themselves. <BR/>In an interview on [DATE] at 1:09 PM, CNA F stated residents were not supposed to have cigarettes or lighters on their person and staff were to supervise residents while smoking. She stated supervision meant they pass out the cigarettes, light them and stay with residents until done. She said cigarettes and lighters were kept in a container behind the nurse's station. CNA F stated there were no residents that she knew of that were allowed to keep their cigarettes or lighters. She stated the risk to the residents of having a cigarette or lighter was because there have been some incidents of them falling asleep and burning themselves. <BR/>In an interview on [DATE] at 1:15 PM, CNA H stated residents were not supposed to have their smoking materials and they were kept in the lock box behind the cart. She stated only staff can get into it or the person who smokes them. CNA H stated supervision meant making sure residents were smoking properly and they were safe. She said one staff member supervises and usually will light the cigarette or get the lighter back from the resident. She said residents were not allowed to go out in the smoking area with O2 because it could burn or blow up. She said the O2 tank should be inside at all times. She stated if residents were not supervised while smoking, they could burn themselves or anything could happen. <BR/>Observation and interview on [DATE] at 1:11 PM, revealed Resident #9 smoking without any staff present. He stated he goes outside to smoke every couple of hours and keeps his cigarettes and lighter in his possession. <BR/>In an interview on [DATE] at 1:26 PM, the DON stated according to their policy, if a resident was a safe smoker, the resident can have a lighter and cigarette, and if an unsafe smoker, smoking materials were locked up. She stated safe and unsafe smokers were determined by the assessment. The DON said supervision meant staff would be out there with unsafe smokers. For safe smokers, supervision meant that staff just have eyes on them She stated if residents who were deemed unsafe smokers smoked without supervision, they could be at risk for burns. <BR/>In an interview on [DATE] at 1:35 PM, the Administrator stated if residents were deemed safe smokers, they could have their paraphernalia. He said they encouraged residents to lock them up but also have a very able bodied population, and if they signed out and were able to purchase those items it would be hard to police. He said an assessment was completed to see if the resident would meet the criteria for safe smoking The Administrator stated his understanding of safe and unsafe smoking was whether under reasonable circumstances residents were safe to hold, light, smoke and extinguish a cigarette in a safe way. He stated residents on O2 were not supposed to go out on the smoking area with the O2 tank. He said the risk for residents who were deemed unsafe and went to smoke without direct supervision was they would have the potential for bodily harm and a burn. He stated if residents threw lit cigarettes on the ground, it could be a risk of fire. <BR/>In an interview and record review on [DATE] at 1:35 PM, the Administrator stated Resident #7 was a safe smoker. Review of EHR revealed a smoking assessment had just been completed and was dated [DATE] and Resident #7 was a safe smoker. Review of the previous smoking assessment dated [DATE] indicated supervision was required. The Administrator stated he was not expecting the assessment for Resident #7 to say smoke with supervision. <BR/>In an interview on [DATE] at 4:51 PM, the Social Worker stated she was responsible to do the smoking assessments when a resident first admits and then quarterly. She stated sometimes the nurse would assess but she mainly did them. She said she based the assessments on their BIMS, diagnoses and if they were a smoker and how often. She said especially when they first got there, she puts that they need supervision, since staff do not know them that well, and as a safety precaution. She said supervision meant having someone out there watching them smoke and having their smoking articles locked up at the nurse's station. She said if residents needed help with lighting cigarettes, then provide assistance with that. She stated there were residents who were safe smokers that were alert and oriented x3 (a person is alert and oriented to person, place and time), and had no impairments that may prevent them from smoking by themselves. She said she did see a risk if residents who were unsafe went to smoke by themselves. <BR/>In an interview on [DATE] at 8:11 AM, the Administrator stated he had done a QAPI meeting about smoking, had done inservice and was still inservicing staff and would provide them to Surveyor when all done. <BR/>In an interview on [DATE] at 3:00 PM, the DON supervision was based on diagnosis and case by case. She said some residents would be immediately unsafe and there was no way physically they could smoke safety.<BR/>In an interview on [DATE] at 3:14 PM, the Administrator stated he re-educated staff this morning, and in serviced the SW directly on smoking assessment. He said he found that the assessments were inconsistent with the policy, redid all smoking assessments and corrected them and inserviced staff on the smoking policy, what a safe smoker was, and guidelines. He stated a safe smoker verified by smoking assessment meant they were allowed to smoke without staff, have cigarettes and a disposable lighter and not allowed to share paraphernalia with other residents. He said unsafe smokers, which continued to be the entire secure unit due to cognition, would take scheduled smoke breaks and not keep their materials. The Administrator said Resident #4 was not to have an electric kettle in her room and was not aware there was one in the room. He stated the risk to residents could be burns. <BR/>Record review of facility policy, titled Smoking Policy - Residents Revised [DATE], revealed in part:<BR/>This facility shall establish and maintain safe resident smoking practices .<BR/>8. A resident's ability to smoke safety will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.<BR/>9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.<BR/>10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safety with the available levels of support and supervision.<BR/>11. Any resident 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. <BR/>12. Residents who have smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited .<BR/>No other policy on Accidents/Hazards was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one Resident (Resident #1) of seven residents reviewed for infection control. <BR/>-The facility failed to follow the physician's order for contact isolation for Resident #2, who was diagnosed with ESBL, when there were no effective interventions in place to keep the resident isolated in her room and prevent the spread of the infection. <BR/>This failure placed residents at risk for the spread of infections and decreased quality of life.<BR/>Findings include: <BR/>Record review of Resident 1's face sheet, dated 5/30/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: mixed anxiety and depressed mood (mood disorder), heart disease with presence of cardiac defibrillator (device that monitors heart rhythms), hypertension (high blood pressure), opioid dependence, and seizure. <BR/>Record review of Resident #1's admission MDS assessment, dated 4/09/25, reflected she had a BIMS score of 15, which indicated she was cognitively intact. The MDS Assessment under Section E-Behaviors, reflected Resident #1 exhibited behaviors of verbal aggression and wandering. Further review of the MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required supervision and partial to moderate assistance with all ADLs. <BR/>Record review of Resident #1's care plan, dated 4/24/25, reflected the resident had mixed bladder incontinence with interventions that included: ensuring the resident had unobstructed path to bathroom and to monitor and document for s/sx of a UTI. The care plan reflected Resident #1 had the need for enhanced barrier precautions due to wound dressing. Interventions included: placing enhanced barrier precautions signage on the resident's door to notify staff and visitors of precautionary measures. Further review of the document reflected Resident #1 had behavior problems that included: non-compliance with care, preferring to conduct own wound care, barricading room door, non-compliance with signing in and out, tearing down enhanced barrier signage, entering resident rooms without permission, and non-compliance with smoking policy, with interventions that included: anticipating and meeting the resident's needs, assisting the resident to develop more appropriate methods of coping and interacting, providing education on polies and procedures to ensure safety, entering through another room when door is barricaded to check on resident's wellness, and intervening as necessary to protect the rights and safety of others. <BR/>Record review of Resident #1's progress notes, dated 5/22/25 at 9:02 AM by LVN G, reflected the following:<BR/>[Resident #1] urine results ESBL. MD notified and N/O for ISO 7 days. [Resident #1] was asked to relocated [sic] for ISO [Resident #1] refused. [Resident #1] was given bed side commode and educated on the importance of ISO to stop the spread of infection and staying out of common areas. [Resident #1] refused to keep the bedside commode. [Resident #1] immediately removed the bedside commode once this nurse left the room. Continue to monitor.<BR/>Record review of Resident #1's progress notes, dated 5/23/25 at 12:08 PM by LVN G, reflected the following:<BR/>[Resident #1] is to remain on ISO for 7 days [Resident #1] observed ambulating throughout the facility and attending several smoking activities. [Resident #1] was educated on the importance of infectin [sic] control. [Resident #1] nodded in understanding has [Resident #1] continued to ambulate down the hallway. Continue to monitor.<BR/>Record review of Resident #1's progress notes, dated 5/26/25 at 8:14 AM by LVN G, reflected the following:<BR/>[Resident #1] refused to remain in room while on ISO and attended smoke breaks and roaming the halls visiting with other residents. [Resident #1] was educated on the importance of infection control. [Resident #1] stated to hell with infection control. as [Resident #1] continued to walk away from staff. Continuing to monitor.<BR/>Record review of Resident #1's progress notes, dated 5/28/25 at 10:19 AM by LVN G, reflected the following:<BR/>[Resident #1] was asked to use bedside commode to prevent the spread of infection. [Resident #1] refused to use bedside commode. Education provided. Continue to monitor.<BR/>Record review of Resident #1's progress notes, dated 5/28/25 at 2:20 PM by LVN/Wound Care Nurse, reflected the following:<BR/>[Resident #1] on contact isolation d/t ESBL [Resident #1] made aware; [Resident #1] offered to move rooms and [Resident #1] declined; [Resident #1] non- complaint with staying in room to prevent infection after education was provided; [Resident #1] stated she can go wherever she wants. MD made aware. Signage posted.<BR/>Record review of Resident #1's consolidated physician orders, dated 5/20/25, reflected in part the following:<BR/>-Isolation precautions: Contact; d/t ESBL-every shift for 7 days. Start date: 5/22/25; Discontinue date: 5/29/25<BR/>-Isolation precautions: Contact; d/t ESBL-every shift for 7 days. Start date: 5/29/25<BR/>In an observation and interview on 5/29/25 at 9:00 AM, Resident #1 was observed in her room on contact isolation. Resident had signage on her door with a bin stocked with PPE. Resident #1 stated she admitted to the facility after being at a psychiatric hospital for depression from losing [family] Resident #1 stated she had just returned to the facility a couple of days ago from another hospital visit where she was being treated for MRSA in the wound on her leg. Resident #1 stated she was also told that she had ESBL in her urine and so she was on two different antibiotics for the ESBL and MRSA. Resident #1 stated the nurses were not properly caring for her infection and the facility was not being cleaned with Clorox to kill the bacteria. She stated the housekeeper told her they could not use Clorox because some residents were allergic to it. She stated she was able to use the toilet on her own but wore an adult brief in case she had an accident. She stated she washed her hands after using the bathroom. Resident #2 became fixated on stating that she had doctors in her family, so she knew how the facility was supposed to be caring for her, and how she had an attorney she was talking to. Resident #1 exhibited signs of paranoia by stating that everyone was against her and did not believe anything she said. Resident #1 had difficulty focusing on one thing at time and was not clear with thoughts. <BR/>In an interview on 5/29/25 at 9:45 AM, the Housekeeping Supervisor stated she worked at the facility for a month. She stated the housekeepers were scheduled on 2 shifts (6:00 AM-2:30 PM and 2:00 PM-10:00 PM) on rotating days so there were housekeepers available during the weekdays and weekends. The Housekeeping Supervisor stated all resident rooms were cleaned and disinfected daily, and isolation rooms and common areas were disinfected multiple times a day and as needed. The Housekeeping Supervisor stated they used DC33 disinfectant and antibacterial solutions to clean. She stated housekeeping was responsible for gathering and cleaning residents' clothes and linens. She stated the clothes and linens were gathered and cleaned separately from all other laundry. She stated isolation laundry was identified by the different bag that it was placed in. <BR/>In an observation on 5/29/25 at 10:25 AM, Resident #1 was observed outside of her room. While State Surveyors were in the facility's' kitchen, Resident #1 opened the door and stepped halfway into the kitchen stating she needed to speak with the State Surveyors again. There were staff present but the State Surveyor had to redirect Resident #1 back to her room. <BR/>In an interview on 5/29/25 at 12:43 PM, the DON stated Resident #1 was the only resident on contact isolation for ESBL. She stated there were a few other residents on enhanced barrier precautions but there were no other known infections in the facility. The DON stated Resident #1 was going around telling everyone that she had MRSA; however, that had not been confirmed and the facility was waiting on results from the hospital. <BR/>In an interview on 5/29/25 at 1:18 PM, the LVN/Wound Care Nurse stated she was treating a wound on Resident #1's left leg, but the resident was often non-compliant with wound care from the nurse and MD. She stated Resident #1 would try to do wound care herself. The LVN/Wound Care Nurse stated she was not aware of Resident #1 having MRSA in her wound; however, she was on contact isolation or having ESBL in her urine. The LVN/Wound Care Nurse stated Resident #1 went to hospital earlier this week and her discharge paperwork showed there were pending results for a wound culture. She stated Resident #1 was already on abx for ESBL and was started on another one at the hospital for prevention of infection of her wound. <BR/>In an observation on 5/29/25 at 2:42 PM, Resident #1 was observed walking down the hallway near other residents with no staff present to redirect her. <BR/>In an interview on 5/29/25 at 5:13 PM, CNA B stated she worked with Resident #1 and the resident was on contact isolation in her room due to having ESBL. CNA B stated staff had to wear a gown, gloves, and face shield when entering Resident #1's room, and wash hands frequently when caring for her. CNA B stated Resident #1 was independent with most care, including toileting. She stated Resident #1 was not monitored while toileting so she could not confirm if the resident washed her hands after toileting. CNA B stated Resident #1 refused to stay isolated in her room and had to be constantly redirected but she would not comply. CNA B stated Resident #1 went out to smoke with other residents and visited in their rooms and common areas. CNA B stated Resident #1's behavior was reported to the nurses. <BR/>In an interview on 5/29/25 at 6:12 PM, the Administrator stated Resident #1 was able to use the toilet independently and only wore a brief in case she leaked from having a weak pelvic floor. The Administrator stated Resident #1 was cognitive enough to not urinate on the floor and the only way she could spread bacteria would be by putting her hand in her brief and touching surfaces or not using proper hand hygiene after toileting, which would place other residents at risk of infection. <BR/>In an interview on 5/30/25 at 11:50 AM, the MD stated the risk of Resident #1 spreading ESBL to other residents were low due to her wearing an adult brief; however, if she did not remain isolated there was still a risk of her spreading the infection by leaking urine through her brief on common surfaces or touching surfaces with unclean hands. The MD stated he would normally place a catheter in residents with ESBL to further contain the urine; however, Resident #1 refused so placing her on contact isolation was the safest way to prevent the spread of ESBL in the facility.<BR/>Record review of the facility's policy titled Isolation-Categories of Transmission-Based Precautions, revised October 2018, reflected in part the following:<BR/>Policy Statement:<BR/>Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. <BR/>Policy Interpretation and Implementation:<BR/>1. <BR/>Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status.<BR/>2. <BR/>Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne.<BR/>3. <BR/>The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions.<BR/> .<BR/>Contact Precautions:<BR/> 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.<BR/> 2. <BR/>The decision on whether contact precautions are necessary will be evaluated on a case by case basis.<BR/> 3. <BR/>The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 5 residents (Resident #1) reviewed for shower documentation. <BR/>The facility failed to ensure documentation reflected Resident #1 received showers as scheduled and desired. <BR/>This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life. <BR/>Findings Included: <BR/>Record review of Resident #1's Face Sheet dated 4-24-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Sequelae (a condition which is the consequence of a previous disease or injury) following nontraumatic subarachnoid hemorrhage (bleeding into the space between the brain and the thin tissues that cover it causing long-term or permanent neurological, cognitive, or physical consequences) and secondary diagnoses of anxiety disorder, unspecified dementia (a decline in mental ability severe enough to interfere with daily life), Hypokalemia (abnormally low levels of potassium in the blood), and lack of coordination. <BR/>Record review of Resident #1's Nursing Home PPS (NP) Item set (this is the initial 5-day assessment used to bill for Medicare Part A) MDS assessment dated [DATE] revealed a BIMS Score of 7 indicating severe cognitive impairment. Resident #1's Functional Abilities of the MDS indicated Resident #1 needed partial assistance (where the helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs in bathing or showering). <BR/>Record review of the facility's shower log on 4-24-2025 at 3:00 PM, indicated no shower sheets were filled out for Resident #1 from 4-3-2025 through 4-11-2025 (a 9-day period) and from 4-13-2025 through 4-15-2025 (a 3-day period). Record review of the facility's electronic medical record bathing log corroborated this finding. There were also no indications in the shower log or electronic medical record that Resident #1 ever refused a shower. <BR/>In an interview with the DON on 4-24-2025 at 10:30 AM she disclosed the facility keeps track of resident's showers by keeping shower sheets in on large binder for the entire facility. <BR/>In an observation and interview on 4-24-2025 at 11:00 AM, revealed Resident #1, whose room was an even-numbered room, in which showers were provided on Mondays, Wednesdays, and Fridays, appeared clean, and stated she was getting her showers. <BR/>In an interview on 4-24-2025 at 1:15 PM, CNA A stated she gives showers to the residents. CNA A said the facility keeps track of who gets showered on shower sheets, in the shower log, and it is kept in a binder. CNA A said if someone refuses a shower, they log it in the shower logbook on a shower sheet. CNA A stated the odd number rooms get showered on Tuesday, Thursday, and Saturday while the even number rooms get showed on Monday, Wednesday, and Friday. CNA A stated she makes rounds to ensure everyone gets a shower who is scheduled for one. <BR/>In an interview with the DON on 4-24-2025 at 4:00 PM it was conveyed that the DON's expectation was that every resident room be set for shower days having the odd number of rooms be offered a shower every Tuesday, Thursday, and Saturday and the even number rooms be offered a shower every Monday, Wednesday, and Friday. The DON said the potential harm to a resident not getting showered, in a 9-day period, was that it could cause hygiene issues. <BR/>In an interview with the Administrator on 4-24-2025 at 5:00 PM it was revealed that his expectation was that each resident get showered 3 times a week at a minimum and if they want more showers to tell the staff so the staff can give them more showers. The Administrator stated if a resident refuses a shower, he expected it to be logged on a shower sheet and put in the shower logbook. The Administrator said the risk for a resident not receiving a shower in a 9-day period was resident hygiene. <BR/>In an interview with the Administrator on 4-29-2025 at 1:22 PM it was revealed that the facility had a shower/bathing policy, and the Administrator was asked for the policy. However, the shower/bathing policy was never received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 1 (Resident #4) resident reviewed for misappropriation of property. <BR/>The facility failed to ensure CNA B did not take Resident #4's debit card to buy the resident items and for CNA B's personal use.<BR/>The noncompliance was identified as PNC. The noncompliance began on 11/20/2024 and ended on 12/04/2024. The facility had corrected the noncompliance before the survey began. <BR/>This failure could place residents at risk exploitation and misappropriation of property. <BR/>Findings included: <BR/>Record review of Resident #4's admission Record, dated 12/9/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), major depressive disorder, and anxiety. <BR/>Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment.<BR/>Record review of Resident #4's care plan, dated 09/09/2024, revealed Resident #4 was an elopement risk r/t history of attempts to leave the facility unattended and will reside on the secure unit for safety. <BR/>Record review of the PIR, dated 12/10/2024, revealed At approximately 11:15 am on 12/4 Administrator was notified that [Resident #4's family member] called the police stating that she believed CNA [Name] had used [Resident #4's] debit card for unauthorized transactions. Further review of the PIR revealed .Police recovered missing card from CNA [Name]. Card returned to [Resident Name] by police. [CNA Name] suspended pending investigation . [Resident #4's family member] provided bank statements detailing alleged unauthorized transactions on 12/4. Facility provided [Resident #4's family member] a check in the amount of the unauthorized charges, $1009.82, and assisted with depositing the check in to [Resident #4's] bank account on 12/4. Employee file of [CNA B] reviewed and shows no related disciplinary actions or concerns on CNA Abuse/Exploitation registry. [CNA B's Name] terminated .<BR/>Record review of undated handwritten statement revealed [Resident #4's Name] ask me to go to the store her [sic] a few times to do some shopping with [Resident #4] gave permission to use the card to get her things like cigarettes clothes shoes gas she gave me the pin number to the bank card. Written by [CNA B] Witnessed by [Administrator].<BR/>Review of screenshots Administrator received from Resident #4's family member of Resident #4's checking account revealed the following transaction details:<BR/>-11/20/2024 for $35.07 [gas station Name]<BR/>-11/21/2024 for $56.25 [gas station Name]<BR/>-11/22/2024 for $56.72 [grocery store and supermarket Name]<BR/>-11/29/2024 for $37.16 [gas station Name]<BR/>-11/29/2024 for $65.42 [grocery store and supermarket Name]<BR/>-12/02/2024 for $14.02 [grocery store and supermarket Name]<BR/>-12/03/2024 for $85.18 [grocery store and supermarket Name]<BR/>-11/21/2024 for $60.00 ATM withdrawal<BR/>-11/29/2024 for $200.00 ATM withdrawal<BR/>-11/30/2024 for $400.00 ATM withdrawal<BR/>In an interview on 03/11/2025 at 2:30 PM, Resident #4 stated no one had taken her money or bank card from her.<BR/>Attempted interview on 03/11/2025 at 3:04 PM with CNA B was unsuccessful as phone number was no longer in service.<BR/>In an interview on 03/11/2025 at 4:25 PM, the Administrator stated Resident #4's family member notified him of suspicious activity on Resident #4's account. He stated the family member said there was only one debit card. He said CNA B admitted she took the debit card and bought things for the resident and herself. He stated when the police arrived at the facility, CNA B had Resident #4's debit card in her pocket before handing it over to the police. The Administrator stated he was not able to verify which of the requested items were purchased and delivered to Resident #4, and CNA B did not tell him which items were for herself. He said when the family member presented the bank statements, anything that looked inappropriate or suspicious from the date of when the fraudulent activity started, the facility replaced. He stated CNA duties did not include doing errands or shopping for Residents.<BR/>In an interview on 03/12/2025 at 1:56 PM, CNA C stated she was in serviced after the incident. She stated she was to never take anything from a resident at all no matter what it was. She stated if a resident wanted to give her something, she would not accept it and let the Administrator know. CNA C stated it was a form of abuse and resident items could be misplaced or misused. <BR/>In an interview on 03/12/2025 at 2:11 PM, CNA D stated she was in-serviced regularly on abuse. CNA D stated she was not supposed to accept money to go buy items requested by residents because anything could happen, it could be misconstrued, lost or she could be accused, and she did not want to be responsible. She stated the right person should take the responsibility, and said it was usually the Activity Director. CNA D stated taking and using a resident's debit card or money could be considered abuse. <BR/>In an interview on 03/12/2025 at 3:00 PM, the DON stated her expectation was staff does not take anything from residents, not even to go to the vending machine. She said if residents requested items be purchased, staff should go to the department heads. She stated not following the policy could place residents at risk of getting money or belongings stolen. <BR/>In an interview on 03/12/2025 at 3:14 PM, the Administrator stated his expectation was staff report misappropriation to him immediately. He stated all staff were in-serviced and it was already part of the new hire packet. He stated the risk to residents was financial burden.<BR/>Record review of the facility policy titled Identifying Exploitation, Theft and Misappropriation of Resident Property revised April 2021 revealed: <BR/>1. Exploitation, theft and misappropriation of resident property are strictly prohibited.<BR/>2. It is understood by the leadership in this facility that preventing these occurrences requires staff education and training .<BR/>4. 'Misappropriation of resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. <BR/>5. Examples of misappropriation of resident property include:<BR/> .b. theft of money from bank accounts;<BR/>c. unauthorized or coerced purchases on the resident's credit card .

**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 unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs. (Resident # 1). <BR/>The facility failed to ensure staff provided Resident #1 with timely incontinence care before he ended up with feces on his hands, fingers, and hip.<BR/>This failure could place residents who need assistance from staff for toileting at risk for embarrassment, rashes, infections, discomfort, and skin break down. <BR/>Findings included: <BR/>Record review of a face sheet dated 01/28/2025 indicated Resident #1 was [AGE] years old, readmitted to facility on 05/31/2024 with an initial admission on [DATE]. Resident #1 resides on the Memory Care Unit. Resident's diagnoses included Unspecified Dementia severe, with other behavioral disturbance (patient who exhibits significant behavioral issues beyond the typical cognitive decline, such as agitation, aggression, wandering, or social disinhibition); Chronic Lymphocytic Leukemia of B-Cell Type not having achieved remission (a type of blood cancer where the abnormal B-cells continue to multiply and accumulate in the body); Essential (Primary) Hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). <BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed his BIMS score was 09/15 with memory being moderately impaired with decisions poor, cues, and supervision required. Resident #1's MDS indicated resident was understood and he usually understood others. Quarterly MDS revealed resident required supervision to touching assistance for toileting and personal hygiene and required partial to moderate assistance for dressing, and bathing. Quarterly MDS indicated that Resident #1 was continent of bowel and bladder. <BR/>Record review of a care plan dated 02/28/2024 and revised 04/16/2024 indicated Resident #1 had a self-care performance deficit r/t Neurocognitive Disorder and muscle wasting. The interventions included resident able to<BR/>complete tasks with supervision and set up r/t bathing and showing; r/t personal hygiene and oral care.<BR/>Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self r/t dressing. The resident can toilet with supervision r/t toileting. The resident requires skin inspection per facility protocol. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse r/t skin Inspection.<BR/>In an observation and interview on 01/28/2025 with LVN A at 11:50 AM revealed she was not aware of the soiled with bm. Resident #1 was in. Observed LVN A entering Resident #1's room and called out to resident who was sleeping. Resident #1 woke up and looked at LVN A. Heard LVN A state, Oh, no he has been digging. LVN A noticed resident had bm all over his hands, fingers, and under his nails. LVN A said she would clean him up right then. LVN A revealed that resident will usually go to the restroom and change his clothes when he is soiled. LVN A revealed that staff check residents every 2 hours. Observed that Resident #1 was not upset or concerned with his soiled condition when LVN A made him aware. <BR/>In an interview on 01/28/2025 with CNA B at 3:30 pm revealed that the facility policy is to check the residents every two hours and as needed while caring for them. CNA B works on the Memory Care Unit 2:00 pm to 10:00 pm and was caring for Resident #1 on his shift. CNA B revealed that Resident #1 normally is continent and will go into the bathroom and change his own clothes if he soils them. Resident #1 was waiting for his shower from CNA B and was anxious to be provided care. CNA B revealed that if a resident is not changed in a timely manner, they could develop skin breakdown.<BR/>In an interview on 01/28/2025 at 5:00 pm with the ADM and DON revealed that Resident #1 was found at 11:50 am with bm on his hands, fingers, fingernails, and left hip. Resident #1 was sleeping in his bed. Resident #1 had not been provided personal hygiene care by the staff. LVN A provided the personal hygiene care to Resident #1. <BR/>Review of the facility policy titled, Activities of Daily Living (ADL), Supporting revised March 2018, revealed under the documentation section Policy Statement, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 4 of 4 Residents (Resident #6, Resident #7, and Resident #9) reviewed for smoking, and 1 of 1 Resident (Resident #4) reviewed for environment.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were provided supervision while smoking.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were accurately assessed for smoking.<BR/>The facility failed to ensure Resident #9 was assessed for smoking per facility policy. <BR/>The facility failed to ensure Resident #4 did not have an electric kettle in her room on the secure unit. <BR/>These failures could place residents at risk of harm, injury, or accidents. <BR/>Findings included:<BR/>Record review of Resident #6's admission Record, dated [DATE], revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Encephalopathy (this is a brain disease that alters brain function or structure) and unspecified visual loss. <BR/>Record review of Resident #6's MDS, dated [DATE], revealed a BIMS score of 13 indicating the individual's cognition is intact.<BR/>Record review of Resident #6's Care Plan, date initiated [DATE], reflected the resident is a smoker. Goal: the resident will not suffer injury from unsafe smoking practices. Interventions: The resident requires supervision while smoking. <BR/>Record review of Resident #6's Smoking-safety screen, dated [DATE], revealed the resident is safe to smoke with supervision. Vision: Does resident have any visual deficit. 1. Yes. Safety: 6. Can resident light own cigarette? No. 7. Resident need for adaptive equipment. 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes F. IDTC Decision; 1 Notes on Safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): IDT agrees the resident requires supervision while smoking d/t unspecified visual loss. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t dx unspecified visual loss. <BR/>Record review of Resident #7's admission MDS, dated [DATE], revealed an admission date to the facility on [DATE]. Further review revealed a BIMS score of 14, indicating intact cognition. <BR/>Record review of Resident #7's care plan dated [DATE] revealed resident was a smoker. <BR/>Record review of Resident #7's smoking assessment, dated [DATE], revealed resident did not have cognitive loss or dexterity problems but did have visual deficits, could not light own cigarette and needed supervision. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t Hordeolum externum (an infection of an oil gland at the edge of eyelid) unspecified eye.<BR/>Record review of Resident #9's admission Record revealed, a [AGE] year-old male, initially admitted on [DATE] and re-admitted on [DATE] with diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), with (Acute) Exacerbation.<BR/>Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score of 13 indicating intact cognition. <BR/>Record review of Resident #9's Care Plan, date initiated: [DATE], reflected the resident is a smoker. Goal: The resident will not suffer injury from unsafe smoking practices. Interventions: the resident requires supervision while smoking. <BR/>Record review of Resident #9's Smoking- Safety Screen, dated [DATE], revealed, Category: Safe to smoke with supervision. <BR/>E. Safety- Can resident light own cigarette? No. 7. Resident need for adaptive equipment 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes. F. IDTC Decision: 1. Notes on Safety From IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. <BR/>No other smoking assessment had been completed for Resident #9. <BR/>Record review of Resident #4's admission Record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease , major depressive disorder, and anxiety. <BR/>Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment.<BR/>Record review of Resident #4's care plan, dated [DATE], did not reveal anything related to an electric kettle.<BR/>In an observation and interview on [DATE] at 11:21 AM, Resident #4 was in her room sitting up in her w/c drinking coffee. A small blue kettle was observed plugged in near the sink. Resident #4 stated her family member sent it to her. <BR/>In an observation and interview on [DATE] at 12:06 PM, Resident #6 walked out of her room holding a cigarette pack and a lighter. Resident #6 entered the code to go outside on the smoking area. Surveyors went outside and observed Resident #6 and Resident #7 smoking with no staff present. Resident #6 stated she knew the code to enter to go outside, staff were aware she smoked, and stated she was allowed to keep her smoking materials with her. Resident #6 stated she took about 3-5 smoke breaks a day and did not need an apron to smoke. Resident #7 was observed with a cigarette and lighter. Resident #7 stated she knew the codes and all residents knew the codes. Resident #7 stated she had been there about 4 months, and staff had never taken away her cigarettes or lighter. Resident #7 said the staff had nobody to bring them to smoke so she guessed that was why residents went out by themselves. <BR/>In an interview on [DATE] at 1:02 PM, LVN E stated residents were not allowed to have their cigarettes or lighters in their possession and smoking materials were locked up behind the nurse's station. She stated residents had designated smoke times and must be supervised during smoking unless they sign out and go out the front and leave the facility. She said supervision meant that one of the workers on shift must light the cigarettes, pass them out and stay until everyone was done smoking. She stated the risk to residents having cigarettes and lighters was they could set something on fire or hurt someone else or themselves. <BR/>In an interview on [DATE] at 1:04 PM, LVN G stated usually the aides supervised residents who smoked. He stated no residents were to have their lighters or cigarettes. He did not know who completed the smoking assessment and did not know what supervision meant since he did not complete the assessments. He stated if residents were not supervised while smoking, they could hurt themselves. <BR/>In an interview on [DATE] at 1:09 PM, CNA F stated residents were not supposed to have cigarettes or lighters on their person and staff were to supervise residents while smoking. She stated supervision meant they pass out the cigarettes, light them and stay with residents until done. She said cigarettes and lighters were kept in a container behind the nurse's station. CNA F stated there were no residents that she knew of that were allowed to keep their cigarettes or lighters. She stated the risk to the residents of having a cigarette or lighter was because there have been some incidents of them falling asleep and burning themselves. <BR/>In an interview on [DATE] at 1:15 PM, CNA H stated residents were not supposed to have their smoking materials and they were kept in the lock box behind the cart. She stated only staff can get into it or the person who smokes them. CNA H stated supervision meant making sure residents were smoking properly and they were safe. She said one staff member supervises and usually will light the cigarette or get the lighter back from the resident. She said residents were not allowed to go out in the smoking area with O2 because it could burn or blow up. She said the O2 tank should be inside at all times. She stated if residents were not supervised while smoking, they could burn themselves or anything could happen. <BR/>Observation and interview on [DATE] at 1:11 PM, revealed Resident #9 smoking without any staff present. He stated he goes outside to smoke every couple of hours and keeps his cigarettes and lighter in his possession. <BR/>In an interview on [DATE] at 1:26 PM, the DON stated according to their policy, if a resident was a safe smoker, the resident can have a lighter and cigarette, and if an unsafe smoker, smoking materials were locked up. She stated safe and unsafe smokers were determined by the assessment. The DON said supervision meant staff would be out there with unsafe smokers. For safe smokers, supervision meant that staff just have eyes on them She stated if residents who were deemed unsafe smokers smoked without supervision, they could be at risk for burns. <BR/>In an interview on [DATE] at 1:35 PM, the Administrator stated if residents were deemed safe smokers, they could have their paraphernalia. He said they encouraged residents to lock them up but also have a very able bodied population, and if they signed out and were able to purchase those items it would be hard to police. He said an assessment was completed to see if the resident would meet the criteria for safe smoking The Administrator stated his understanding of safe and unsafe smoking was whether under reasonable circumstances residents were safe to hold, light, smoke and extinguish a cigarette in a safe way. He stated residents on O2 were not supposed to go out on the smoking area with the O2 tank. He said the risk for residents who were deemed unsafe and went to smoke without direct supervision was they would have the potential for bodily harm and a burn. He stated if residents threw lit cigarettes on the ground, it could be a risk of fire. <BR/>In an interview and record review on [DATE] at 1:35 PM, the Administrator stated Resident #7 was a safe smoker. Review of EHR revealed a smoking assessment had just been completed and was dated [DATE] and Resident #7 was a safe smoker. Review of the previous smoking assessment dated [DATE] indicated supervision was required. The Administrator stated he was not expecting the assessment for Resident #7 to say smoke with supervision. <BR/>In an interview on [DATE] at 4:51 PM, the Social Worker stated she was responsible to do the smoking assessments when a resident first admits and then quarterly. She stated sometimes the nurse would assess but she mainly did them. She said she based the assessments on their BIMS, diagnoses and if they were a smoker and how often. She said especially when they first got there, she puts that they need supervision, since staff do not know them that well, and as a safety precaution. She said supervision meant having someone out there watching them smoke and having their smoking articles locked up at the nurse's station. She said if residents needed help with lighting cigarettes, then provide assistance with that. She stated there were residents who were safe smokers that were alert and oriented x3 (a person is alert and oriented to person, place and time), and had no impairments that may prevent them from smoking by themselves. She said she did see a risk if residents who were unsafe went to smoke by themselves. <BR/>In an interview on [DATE] at 8:11 AM, the Administrator stated he had done a QAPI meeting about smoking, had done inservice and was still inservicing staff and would provide them to Surveyor when all done. <BR/>In an interview on [DATE] at 3:00 PM, the DON supervision was based on diagnosis and case by case. She said some residents would be immediately unsafe and there was no way physically they could smoke safety.<BR/>In an interview on [DATE] at 3:14 PM, the Administrator stated he re-educated staff this morning, and in serviced the SW directly on smoking assessment. He said he found that the assessments were inconsistent with the policy, redid all smoking assessments and corrected them and inserviced staff on the smoking policy, what a safe smoker was, and guidelines. He stated a safe smoker verified by smoking assessment meant they were allowed to smoke without staff, have cigarettes and a disposable lighter and not allowed to share paraphernalia with other residents. He said unsafe smokers, which continued to be the entire secure unit due to cognition, would take scheduled smoke breaks and not keep their materials. The Administrator said Resident #4 was not to have an electric kettle in her room and was not aware there was one in the room. He stated the risk to residents could be burns. <BR/>Record review of facility policy, titled Smoking Policy - Residents Revised [DATE], revealed in part:<BR/>This facility shall establish and maintain safe resident smoking practices .<BR/>8. A resident's ability to smoke safety will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.<BR/>9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.<BR/>10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safety with the available levels of support and supervision.<BR/>11. Any resident 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. <BR/>12. Residents who have smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited .<BR/>No other policy on Accidents/Hazards was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to ensure a resident did not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provided care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers/injuries from developing for 1 (Resident #1) of 7 residents reviewed for pressure ulcers/injuries.<BR/>1.The facility failed to perform complete and accurate skin assessments for Resident #1, following LVN A's skin assessment on 11/06/24 which revealed moisture associated skin damage to Resident #1's buttocks.<BR/>These failures placed residents with pressure wounds at an unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection.<BR/>Findings included:<BR/>Review of Resident #1's face sheet on 02/08/24 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Hemiplegia and hemiparesis following cerebral infraction affecting left non dominant side (this is paralysis and weakness that affects one side of the body after a stroke), Chronic Obstructive Pulmonary Disease (this is a lung disease that blocks airflow and makes it difficult to breathe), neuromuscular dysfunction of the bladder (this is a condition where the nerves controlling the bladder function are damaged leading to problems with urine storage) , kidney stones, paroxysmal atrial fibrillation (an irregular heart rhythm), muscle weakness, and lack of coordination. <BR/>Review of Resident #1's discharge MDS dated [DATE] revealed Resident #1 required substantial/maximal help assist-helper does more than half the effort: Helper lifts or holds trunk or limbs and provides more than half the effort to eat, to complete ADL's, to sit and stand, and to transfer. Further MDS revealed Resident #1 required partial assistance-helper does less than half the effort. Helper lifts, holds, or supports trunk and limbs, but provides less than half the effort for rolling left to right to roll from lying on back to left to right and return to lying on her back while in the bed. MDS also revealed Resident #1 required a manual wheelchair and was occasionally incontinent and had an indwelling catheter for urine. MDS did not reflect BIMS score for cognitive. Further review of Resident #1's Discharge MDS Assessment indicated Resident #1 did not have one or more unhealed pressure ulcers/injuries.<BR/>Review of Resident #1's care plan initiated on 09/26/24 revealed Resident #1 had limited physical mobility related to muscle weakness. The goal was for Resident #1 to remain free of complications related to immobility, including contractures, thrombus (blood clots), skin breakdown, fall related injury through the target date 01/09/25. The interventions were PT, OT referrals as ordered, PRN. Further care plan revealed Resident #1 had actual impaired skin integrity to the left hip related to discoloration initiated on 11/25/24. The goal was for Resident #1 to maintain or develop clean and intact skin by the review date. The interventions were to follow facility protocols for treatment of injury, to monitor/document location and treatment of skin injury, to report abnormalities, failure to heal, s/sx of infection, maceration (softening of skin) etc to MD. <BR/>Review of Resident #1's November 2024 physician orders reflected apply skin prep to left hip discoloration and cover with foam dressing daily and as needed, order started on 11/25/24. The orders did not reflect pressure preventing measures such as air loss mattress or skin prep for the buttocks and sacral areas.<BR/>Review of hospital records dated 09/18/24 to 09/20/24, noted Resident #1 had impaired functional mobility with altered mental status and a recent Urinary tract infection. Resident #1 was noted as having no wounds, incisions, or pressure ulcers.<BR/>Review of Resident #1's weekly skin assessment dated [DATE] entered at 04:12 PM by LVN A reflected:<BR/>Sacrum Redness (tail bone area). Left and Right hand bruising. Skin intact with a few areas to monitor.<BR/>Review of Resident #1's weekly skin assessment dated [DATE] - 11/06/24 revealed no concerns with skin.<BR/>Review of Resident #1's weekly skin assessment dated [DATE] entered at 09:39 AM by LVN A reflected:<BR/>MASD (Moisture Associated Skin Damage) noted to resident buttocks; no open areas noted; new leg strap applied to resident right thigh; order received for triad paste application and was applied at the time of assessment.<BR/>Review of Resident #1's weekly skin assessment dated [DATE] - 11/20/24 revealed no concerns with skin.<BR/>Review of Resident #1's weekly skin assessment dated [DATE] entered at 11:08 AM by LVN A reflected: No new skin conditions at this time; discoloration continues to resident right hip and both hands. Skin assessment did not reflect the skin assessment of the buttocks nor the sacral areas.<BR/>Review of Resident #1's nursing progress note dated 12/02/24 entered at 3:07 PM by LVN B reflected:<BR/>Resident sent out to [Hospital name] for evaluation for failure to thrive per MD. Resident is observed fragile, weak, not eating for 3 days. Spo2 92% (oxygen), afebrile (no fever), pulse 98. Resident reports zero pain or discomfort.<BR/>Review of Resident #1's hospital record dated 12/02/24 revealed Resident #1 arrived at the hospital from the facility on 12/02/24 around 1:00 PM. The hospital ED provider diagnosed Resident #1 with a Decubitus ulcer of the back, stage 2, Pressure injury of deep tissue of left hip, left thigh, and sacral region (the tail bone). The hospital took pictures of the wounds on the left hip, left thigh, sacrum, and left shoulder . <BR/>Review of hospital pictures dated 12/02/24 revealed pictures of wounds on the left shoulder with three purple and red (bruise color) spots on the shoulder blade, one unshaped dark purple area with some skin missing on the left hip, a dark purple area near Resident#1's groin area left side, a purple and scabbed area near the left inner thigh, and irregular shaped open area with purple and red of the tail bone area.<BR/>In a phone interview with Resident #1's family on 02/07/25 at 2:25 PM, revealed Resident #1 had passed away on 12/06/24 after being placed on in hospital hospice. Resident #1's family stated Resident #1 lived with her prior to going to the facility for rehabilitation. She stated Resident 1 had a suprapubic catheter (this is a tube inserted directly into the bladder via the lower abdomen) before going to the facility due to some bladder complications. She stated Resident #1's catheter was changed to foley catheter (this is inserted in the bladder via the urethra) at the hospital. She stated Resident #1 had no wounds before going to the facility. She stated when she was notified that Resident #1 was sent to the hospital, she went to be with Resident #1. Resident #1's family stated she did not see Resident #1 while she was at the facility, and she was shocked and could not believe the condition of Resident #1 skinny and dehydrated. She stated when she saw Resident #1 skin at the hospital, I could not believe, they neglected her Resident #1's family stated she took some pictures of the wounds. <BR/>In an interview and observation with CNA H and CNA I on 02/08/25 at 10:01 AM, they both stated they had not taken care of Resident #1. They stated shower sheets had pictures where they could mark off any skin conditions and the nurse would sign off the shower sheet. They both stated it was important to inspect residents' skin so that wounds did not get worse, and areas could be treated immediately.<BR/>In an interview with CNA H on 02/08/25 at 12:07 PM, she stated she did not take care of Resident #1. She stated she had been employed at the facility for one month. She stated she was trained to report all skin change to the nurse. She stated that she documented on the shower sheets if there were any skin issues, and the nurse would sign off the shower sheet. She stated it was important to inspect residents' skin so that wounds did not get worse, and areas could be treated timely.<BR/>Interview with LVN C on 02/08/25 at 1:00 PM, revealed LVN C stated she did wound care and skin assessments when she worked as the floor nurse. After seeing Resident #1's hospital wound pictures, she would have immediately let the physician know, got an air mattress, wound physician consultation, dietary consult, make sure wounds were covered, and repositing resident every two hours. She stated the process was for the admission nurse to complete a skin assessment on admission, then the wound care nurse would follow up and do another skin assessment, then if any skin concerns came up, a wound care nurse would obtain wound care consult. She stated all these interventions were put in place because a resident had a right to not have pressure ulcers if they could be avoided. <BR/>In an interview with LVN F on 02/08/25 at 1:30 PM, revealed he had worked with Resident #1 on 11/19/24. He stated he did not do a skin assessment on Resident #1 because the task did not fall on his shift. He stated Resident #1 had been having issues with constipation and that was his focus and asked in report to follow up. He stated on the day that he worked with Resident #1, she did not have a bowel movement and he was not sure if the CNA gave the resident a shower or bed bath. He stated the expectation was that the CNAs would report to him any skin conditions or any changes they noticed to him as the nurse. He stated had he seen any wounds on Resident #1 he would have referred her to the wound care nurse. He stated it was both the nurses and the CNAs responsibility to report and to check the resident's skin when providing care. LVN F stated he did not complete a general skin assessment. He did not say why he did not complete it for a resident that had a wound. He sated he did not know that Resident #1 had any skin wounds or skin concerns.<BR/>In an interview with the DON on 02/08/25 at 2:00 PM she stated she was very confident in LVN A's skin assessment. The DON stated LVN A, who was the facility wound care nurse, completed thorough skin assessments. The DON stated if LVN A had seen any decubitus ulcers on a resident, she would have freaked out and let her know and put in place measures to prevent further skin injuries. The DON stated CNA G checked Resident #1's skin on 12/01/24 and she did not report any concerns per documentation in [electronic medical Record]. The DON stated LVN A did a weekly skin assessment of head to toe on Resident #1 on 11/29/24 and there was no report of DTI except for the left hip bruising which they had in place, interventions for it. The DON stated she could not find the wound care list for October and November 2024 to show that Resident #1 had been seen by the facility wound care physician for the hip and hand bruising. She stated Resident #1 was scheduled to be seen by the wound care physician for the left hip however Resident #1 was not seen because she went out to an appointment for her catheter . The DON did not provide wound care list with Resident #1 on it. The DON stated the expectation was that skin assessment was done on admission, during showers and weekly by the wound care nurse. DON stated the nurses will notify the resident's attending physician or physician on call when there has been a new skin observation to obtain treatment and the CNA will verbally inform the Charge nurse, and Nurses will document skin issues in EMR, and CNA's will document new skin issues or injuries in EMR.<BR/>In an interview with the Administrator on 02/08/25 at 4:15 PM, he stated the expectation was that skin assessments were completed weekly and as needed, nutrition consulted, wound consult, and treatments to be completed as ordered. He stated the wounds might have happened in the hospital because the hospital is more focused on breathing and not of the skin and it was likely that Resident #1 was not turned while she was in the emergency room.<BR/>During an interview with LVN A on 02/08/25 at 6:00 PM, she stated she did not see any pressure injury to Resident #1's buttocks . She stated she only saw the left hip bruise and she put measures in place to clean, apply wound paste and to cover the area because Resident #1 was slender and needed padding to boney hip area. LVN A stated, if I put all these interventions for her hip, I would have put more for her sacrum had I seen any issues. LVN A stated a resident with impaired skin would have to be seen by the wound care doctor, they would have a special mattress (depending on movement), vitamins and supplements including protein would be ordered for the residents. She stated the resident would be repositioned every two hours to offload off the area with skin breakdown. She stated Resident #1 was on the list to be seen by the wound doctor on 11/26/24 however, when he came to the facility Resident #1 was not seen because she was out for her catheter, and she missed wound care appointment. She stated Resident #1 was on the list to be seen the following week (12/05/24). LVN A stated Resident #1's skin was intact when she did a skin assessment on 11/29/24. She stated the only area of concern was the left hip. LVN A stated the facility only did weekly skin assessments and if the CNA or nurse noticed something new, they would let her know. LVN A stated the reason Resident #1 had not been seen by the wound care doctor before was because all the skin concerns had resolved. She stated it was important to check residents' skin to make sure no new issues or the wounds did not get worse. She stated the resident had a right to be free from pressure ulcers if they can be avoided. LVN A did not provide wound care list with Resident #1 on the list for September 2024, October 2024, and November 2024, she stated all documents had been given to medical records. <BR/>During a phone interview with CNA G on 02/10/24 at 10:58 AM, she stated she had worked with Resident #1 on 12/01/24 a double shift from 6 AM to 10 PM and she did not see any skin issues for Resident #1. CNA G stated she did not see the bruise on Resident #1 left hip. CNA G stated she repositioned Resident #1 every two hours and checked her for bowel movement however there was nowhere to document on [Electronic medical record]. CNA G stated she did not give Resident #1 a bed bath on that day because the facility did not do baths on Sundays. She stated she had been in-serviced in the past about skin and what to look out for and report to the nurse. She stated repositioning and checking the skin was important to prevent bed sores .<BR/>Phone interview attempted with physician on 02/10/25 at 11:20 AM, voicemail left to return phone call. No call returned.<BR/>In a phone interview with Resident #1's primary doctor on 02/17/25 at 2:35 PM, he stated any residents that had skin conditions and wounds were referred to wound care specialist that the facility used. He stated the facility also had a wound care nurse who followed all wound care related issues. He stated if a resident was seen by the wound Care team, and the resident was on a special diet with protein and vitamins and wound treatments and the resident's wound/s were not getting better that wound would be considered unavoidable.<BR/>In a phone interview with the Wound Care doctor on 02/17/25 at 3:47 PM, revealed he had not seen Resident #1 since she admitted to the facility [09/23/24]. He stated he normally went to the facility on Thursdays to do wound care rounds and treatments however, being thanksgiving holiday week, he went to the facility on a Tuesday 11/26/24 and missed seeing Resident #1 because she was out of the facility. He stated Resident #1 was on his schedule to be seen that week. The wound care physician stated he worked with the facility wound care nurse [LVN A] during his wound care rounds. The wound care physician stated a DTI can happen in a matter of hours depending on what was going on with the patient health wise. He stated the first therapeutic treatment is to keep off the area that is starting to have concerns. He stated unaviodable wounds happened at times because the patient was not compliant [not following] with the treatment put in place to reduce and prevent wounds. He stated an example was a diabetic with an A1C of 12 and they did not want to change their diet and wanted to smoke, or a patient was put on an air mattress, but the family wanted a sheet on the mattress with having the sheet covering the mattress prevented the purpose of an air mattress to help prevent pressure ulcers by air circulation. He stated all you can do is document all the treatments in place . The wound care doctor stated without him seeing the wounds it was hard to determine the severity of Resident #1's wounds.<BR/>Review of facility Wound Care skin and wound management policy and procedure provided by the facility, revised 10/2010 reflected Verify that there is a physician order Review the residents care plan to assess for any special needs for the resident .<BR/>Review of the facility's Prevention of Pressure Injuries policy and procedure provided by the facility, revised 04/2020 reflected . read in part The purpose is to provide information regarding identification of pressure ulcer/injury risk factors and interventions .conduct a comprehensive skin assessment upon admission .according to resident risk factors, and prior to discharge .during assessment inspect: presence of erythema (redness), .inspect pressure points sacrum, heel, buttocks, coccyx, elbows, ischium, trochanter, etc, .moisturize dry skin daily, Reposition the resident as indicated on the care plan, Choose a frequency for repositioning based on the residents risk factor and current clinical practice guidelines, teach residents who could turn Independently the importance of repositioning for prevention measures associated with specific devices, consult current clinical practice guidelines Evaluate, Report and Document potential changes in skin Review the interventions and strategies for effectiveness on an ONGOING Basis .

**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 unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs. (Resident # 1). <BR/>The facility failed to ensure staff provided Resident #1 with timely incontinence care before he ended up with feces on his hands, fingers, and hip.<BR/>This failure could place residents who need assistance from staff for toileting at risk for embarrassment, rashes, infections, discomfort, and skin break down. <BR/>Findings included: <BR/>Record review of a face sheet dated 01/28/2025 indicated Resident #1 was [AGE] years old, readmitted to facility on 05/31/2024 with an initial admission on [DATE]. Resident #1 resides on the Memory Care Unit. Resident's diagnoses included Unspecified Dementia severe, with other behavioral disturbance (patient who exhibits significant behavioral issues beyond the typical cognitive decline, such as agitation, aggression, wandering, or social disinhibition); Chronic Lymphocytic Leukemia of B-Cell Type not having achieved remission (a type of blood cancer where the abnormal B-cells continue to multiply and accumulate in the body); Essential (Primary) Hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). <BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed his BIMS score was 09/15 with memory being moderately impaired with decisions poor, cues, and supervision required. Resident #1's MDS indicated resident was understood and he usually understood others. Quarterly MDS revealed resident required supervision to touching assistance for toileting and personal hygiene and required partial to moderate assistance for dressing, and bathing. Quarterly MDS indicated that Resident #1 was continent of bowel and bladder. <BR/>Record review of a care plan dated 02/28/2024 and revised 04/16/2024 indicated Resident #1 had a self-care performance deficit r/t Neurocognitive Disorder and muscle wasting. The interventions included resident able to<BR/>complete tasks with supervision and set up r/t bathing and showing; r/t personal hygiene and oral care.<BR/>Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self r/t dressing. The resident can toilet with supervision r/t toileting. The resident requires skin inspection per facility protocol. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse r/t skin Inspection.<BR/>In an observation and interview on 01/28/2025 with LVN A at 11:50 AM revealed she was not aware of the soiled with bm. Resident #1 was in. Observed LVN A entering Resident #1's room and called out to resident who was sleeping. Resident #1 woke up and looked at LVN A. Heard LVN A state, Oh, no he has been digging. LVN A noticed resident had bm all over his hands, fingers, and under his nails. LVN A said she would clean him up right then. LVN A revealed that resident will usually go to the restroom and change his clothes when he is soiled. LVN A revealed that staff check residents every 2 hours. Observed that Resident #1 was not upset or concerned with his soiled condition when LVN A made him aware. <BR/>In an interview on 01/28/2025 with CNA B at 3:30 pm revealed that the facility policy is to check the residents every two hours and as needed while caring for them. CNA B works on the Memory Care Unit 2:00 pm to 10:00 pm and was caring for Resident #1 on his shift. CNA B revealed that Resident #1 normally is continent and will go into the bathroom and change his own clothes if he soils them. Resident #1 was waiting for his shower from CNA B and was anxious to be provided care. CNA B revealed that if a resident is not changed in a timely manner, they could develop skin breakdown.<BR/>In an interview on 01/28/2025 at 5:00 pm with the ADM and DON revealed that Resident #1 was found at 11:50 am with bm on his hands, fingers, fingernails, and left hip. Resident #1 was sleeping in his bed. Resident #1 had not been provided personal hygiene care by the staff. LVN A provided the personal hygiene care to Resident #1. <BR/>Review of the facility policy titled, Activities of Daily Living (ADL), Supporting revised March 2018, revealed under the documentation section Policy Statement, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 8 residents (Residents #17 and #25) reviewed for Comprehensive Care Plans. <BR/>The facility failed to complete a comprehensive care plan for Residents #17 and #25. <BR/>This failure could place residents at risk of not receiving necessary care and services. <BR/>Findings included: <BR/>1.Review of Resident #17's admission Record, dated August 08, 2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]/24 with diagnoses that included Unspecified Sequelae Of Unspecified Cerebrovascular Disease, Dysphagia, Oropharyngeal Phase, Unspecified Dementia, Unspecified Severity, With Agitation, Mild Neurocognitive Disorder Due To Known Physiological Condition With Behavioral Disturbance, Generalized Anxiety Disorder, Other Specified Disorders Of Brain, Muscle Weakness (Generalized), Unspecified Lack Of Coordination, as well as high blood pressure and high cholesterol. <BR/>Review of Resident #17's admission MDS, dated [DATE], reflected a BIMS score of 6, indicating severe cognition impairment. The MDS further reflected Resident #17 had physical and verbal symptoms directed towards others, exhibited wandering behaviors 4-6 times a week but not daily, required staff's moderate assistance for oral hygiene, personal hygiene, toileting and showering, and supervision for eating. The MDS revealed Resident #17 was frequently incontinent of bladder and bowel. The MDS reflected Resident #17 was taking an antipsychotic, antidepressant, antibiotic, and antiplatelet medications. <BR/>Review of Resident #17's care plan, dated July 19, 2024, revealed The resident has nutritional problem or potential nutritional problem (SPECIFY) r/t malnutrition. The care plan did not reflect any other care areas. <BR/>2.Record Review of Resident #25's admission Record dated August 08, 2024, revealed a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses that included Brief Psychotic Disorder, Generalized Anxiety Disorder, Dorsalgia, Unspecified (Pain in the Back), Complex Regional Pain Syndrome I, Unspecified, Complex Regional Pain Syndrome I, Unspecified, Muscle Wasting And Atrophy, Not Elsewhere Classified, Multiple Sites, and Unspecified Abnormalities Of Gait And Mobility. Resident was her own RP. <BR/>Review of Resident #25's admission Care Plan, dated July 23, 2024, revealed that not all focus areas had goals or resident specific information. There were no goals or interventions or indication if Resident #25 did nor did not take a sedative/hypnotic therapy or if an antidepressant medication was used, goals for gradual dose reduction of those medications, or a long term plan for administration of the medications related to Resident #25 diagnoses of Generalized Anxiety Disorder and Brief Psychotic Disorder. <BR/>In an interview on August 8, 2024, at 12:14PM, the SW stated that Comprehensive Care Plan categories were completed by the appropriate departments; the MDS LVN would monitor for completion by the departments, with the SW providing backup. The SW stated that the comprehensive care plans were usually completed on the same day as the IDT meeting. The EHR system would also notify when tasks such as comprehensive care plans were due on the responsible user's dashboard and then that user would alert the specific department that needed to complete their section if it was not their own area. The SW stated that the comprehensive care plan was to have been completed within 30 days of a resident admitting to the facility or within 7 days of the MDS being completed in the EHR. The SW also stated that if the MDS had been completed but there was no IDT meeting, or the resident did not want to participate, then the MDS LVN and SW would give the departments additional time to complete their sections of the comprehensive care plan to allow time for the RP to be contacted or the resident to change their mind and participate. <BR/>In an interview of LVN A on August 8, 2024, at 1:09PM, LVN A stated that it was the responsibility of the nursing team to complete the baseline assessment which triggered the EHR to alert for the Comprehensive Care Plan to be completed. LVN A stated that it was the goal to have the Comprehensive Care Plan completed within seven days of a resident's admission to the facility. LVN A stated there were processes in place to keep a resident from not receiving a baseline or comprehensive care plan such as level of care meetings each Tuesday, morning meetings to discuss any admits, discharges, or changes on conditions, as well as the EHR alerts for any census changes. LVN A stated that if a care plan, either baseline or comprehensive, were not done it would be addressed in the next meeting. LVN A shared that for a resident to not have had a timely baseline or comprehensive care plan then the resident care could be impacted like a staff member who was new to the resident would not have known the plan of care or what interventions to use that were most effective.<BR/>In an interview of LVN B on August 8, 2024, at 1:28PM, the LVN stated that resident care plans were normally reviewed briefly on Mondays, the first day on duty after scheduled days off. LVN B also stated that a 24-hour report was reviewed for any changes in residents while off as well. LVN B stated that if residents were not having care plans completed then residents would not be receiving the care they needed as staff would have no way to know what a resident required such as incontinent care, assistance with showering, would have been at risk from a fall if transfer status was not known, have elopement risk, and interventions for behaviors may have been unknown. <BR/>In an interview on August 8, 2024, at 1:40 PM, CNA C stated that comprehensive care plans were checked when there was a new resident to know what level of care to expect to provide, what behaviors a resident may exhibit and the interventions that may have to be used. CNA C stated that if the comprehensive care plans are not in the EMR, staff were to ask the floor nurse for information on the resident and advise the floor nurse and DON of the information that was missing. CNA C stated that risk of not having a baseline or comprehensive care plan could result in staff missing a change of condition, the resident not being assisted with meals, missed changes in sleep patterns, falls, missed need for incontinent care, behavioral issues and interventions or redirection not as effective. <BR/>In an interview on August 8, 2024, at 2:19 PM, CNA D stated that care plans were not reviewed very often but previously has looked at care plans when charting for more information on a resident that has had a change of condition or behavioral issues. CNA D stated that if there were no baseline or comprehensive care plan then the floor nurse would have been notified along with the ADON and DON. CNA D shared that missing care plans could have a negative impact on a resident by staff not knowing dietary needs such as if a resident was a choking risk, what incontinent care needs were, who a contact person was for the resident, who specialty care providers were, what behavior issues the resident had in the past and how to best redirect the resident. <BR/>In an interview with the DON on August 8, 2024, at 3;13PM, it was revealed that the goal was to have the baseline care plan complete within 24 hours of admission and the comprehensive care plan within 72 hours of admission when possible but no later than 30 days from admission. If a care plan is not entered, then that care plan was to be completed when discovered missing. The risk to residents who do not have care plans entered timely is inaccurate care being provided by staff. The DON stated that care plans were a process that began with the MDS nurse entering the baseline care plan and completing the MDS assessment, then the ADON and treatment nurses completing the comprehensive care plans and the DON would review daily for completion and sign off to close the comprehensive care plan when it was completed. When asked about the incomplete comprehensive care plans for residents #17 and #25, the DON stated she did not know what happened. <BR/>In an interview on August 8, 2024, at 3:48PM, the ADM stated that baseline care plans were to be entered within 72 hours of admission and comprehensive care plans were to be completed within 14 days of the baseline care plan. The ADM stated that care plans were the responsibility of the nurse managers to make sure they were completed timely. The ADM had expectations of all staff who notice a care plan was missing or incomplete should notify their supervisor of what was missing or incomplete or to make the entries themselves if capable and qualified to do so. The ADM shared that missing or incomplete care plans could impact a resident by causing a potential lapse in appropriate care if a resident was to have non-normal needs or requirements. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to report to the State Survey Agency the elopement of Resident #1 during July of 2025. This failure could place residents at risk for unresolved or future abuse or neglect.Findings included: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including Chronic Obstructive Pulmonary Disease (condition caused by damage to the lungs), coronary artery disease (disease caused by buildup of plaque in the arteries of the heart), anxiety disorder, and Depression. A BIMS score of 10 was reflected, indicating moderate cognitive impairment. Resident #1 scored 0 on wandering behaviors, which indicated the behavior was not exhibited. Review of Resident #1's Care Plan with start date 6/13/25 reflected Resident #1 had a focus of elopement risk r/t history of attempts to leave the facility unattended, and with impaired safety awareness with date initiated 9/09/24 and revised solely on 12/24/24. In an interview on 8/05/25 at 12:41 pm, CNA A stated that approximately two weeks prior (exact date unknown), Resident #1 had climbed out of a window on the female locked unit. She stated that she saw Resident #1's wheelchair sitting empty by an open window and had notified LVN B. She reported staff searched the unit and then the property, but that Resident #1 was not located, and staff began using their vehicles to search the community. She stated she found Resident #1 coming out of an auto parts store, the property adjacent to the facility, and escorted her back to the facility. She stated that the ADM arrived a short while later and threatened the jobs of staff if they were to say anything about the incident to anyone. In a telephone interview on 8/05/25 at 4:00 pm, LVN B stated about two weeks ago (exact date unknown), she was notified by CNA A that Resident #1 had gone out a window on the female locked unit. She stated that Resident #1 was not found at the facility but that she was returned to the facility by CNA A who reported that Resident #1 had been found at a nearby auto parts store. She stated she assessed Resident #1 upon her return to the facility and that she did not have any injuries. She stated that she called and notified the ADM and that he arrived approximately thirty minutes later and fixed the window that Resident #1 had kicked out. She stated she did not chart the elopement or her injury assessment because she was told by the ADM that he had to do an investigation, and he would take care of it. In an interview on 8/05/25 at 1:30 PM LVN C stated while working the evening shift approximately two weeks ago (exact date unknown) she was notified by CNA A that Resident #1 had gone out of a window on the female locked unit. She stated she immediately started looking for the resident after notifying LVN B. She stated she and other staff had been driving around the community looking for Resident #1. She reported she next saw Resident #1 walking up to the front of the building escorted by CNA A and was told that Resident #1 was found next door at an auto parts store. She stated that Resident #1 had not appeared to have any injuries. She reported that the ADM came to the facility about thirty minutes later but did not speak to her. She denied she was threatened or told not to say anything about the incident. She stated that when she worked the day shift the following day, she was told in report that Resident #1 had tried to elope, and she thought this was strange because Resident #1 had actually eloped. In an interview on 8/05/25 at 1:40 PM CNA D stated she was told by a CNA (name unknown) the day following the incident (date unknown) that Resident #1 had eloped and been found at an auto parts store on the prior evening shift and had been escorted back to the facility. She declined to state if her job had been threatened or she had been told not to say anything about the incident stating, I don't want to lose my job. They will retaliate against you and I don't want you writing anything that will cost me my job. In an interview and observation on 8/05/25 at 3:07 pm, Resident #1 stated she had left the facility through a window she had pushed through, maybe the start of last week (exact date unknown). She stated she went next door to an auto parts store and borrowed a lighter from a staff at the store because she wanted to smoke. She stated a female facility staff (name unknown) rolled up approximately twenty minutes later and escorted her back to the facility. She stated she left the facility because she missed her belongings and her apartment. She stated she did not think she spoke to the ADM that day. She denied she experienced any injury or adverse effects from leaving the facility. Resident #1 was observed with no obvious sign of injury. In an interview on 8/5/25 at 4:17 pm, the DON stated that Resident #1, sometimes gets on a rant about wanting to leave but that she had not heard anything about her going out a window or being over at an auto parts store. She reported that residents' windows have screws that prevent them from being raised enough for a resident to elope. She reported that preventing elopement for Resident #1 has included that Resident #1 was accommodated to go out for activities, she was on a secure unit, she was seeing psychiatric services, and she was placed on Q15 minute checks for behaviors as needed including aggression and elopement. She stated that staff were free to report any incidents without fear of retaliation and she had not received any complaints of staff being fearful of retaliation. The DON stated that all staff had received training on elopement and actions to take. She reported that part of the training included that the staff would notify the Administrator of an elopement incident. She stated in the event of a missing resident, all staff were to immediately search indoors and if not found would expand the search to the outdoor property, the Administrator would be notified, and a decision would be made if authorities needed to be notified. She stated she was not aware of any staff having been told not to document an incident and that they will do it instead. In an interview on 8/05/25 at 3:20 PM the ADM stated he was not informed of Resident #1 going out a window. He reported to his knowledge Resident #1 had never exited or tried to exit the facility. He stated Resident #1 had called a ride service and friends to come pick her up in the past. He stated there had not been any windows repaired in the past month except one window on the male unit. He stated he was not aware that Resident #1 was placed on Q15 minute checks but that this can be done for excessive wandering as well as aggressive or other behaviors. He reported that if a resident exited the facility, he expected staff to count all residents, search the facility, call a code silver, search the exterior property, and then the surrounding properties, and notify the DON, himself, the MD, and the family. He reported that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff have received training on handling and reporting elopements/code silver training. He stated that if staff had informed him, he would have notified the police if the Resident was not immediately found. He stated he would have notified the state if a resident had eloped. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now, and if he finds that Resident #1 did in fact elope, he will report it to the state.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, have evidence that all alleged violations were thoroughly investigated, prevent further potential abuse and neglect while the investigation was in progress, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and take appropriate corrective action if the alleged violation was verified one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to investigate and report to the State Survey Agency the results of the investigation of the elopement of Resident #1 during July of 2025. This failure could place residents at risk for unresolved or future abuse or neglect.Findings included: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including Chronic Obstructive Pulmonary Disease (condition caused by damage to the lungs), coronary artery disease (disease caused by buildup of plaque in the arteries of the heart), Anxiety Disorder, and Depression. A BIMS score of 10 was reflected, indicating moderate cognitive impairment. Resident #1 scored 0 on wandering behaviors, which indicated the behavior was not exhibited. Review of Resident #1's Care Plan with start date 6/13/25 reflected Resident #1 had a focus of elopement risk r/t history of attempts to leave the facility unattended, and with impaired safety awareness with date initiated 9/09/24 and revised solely on 12/24/24. In an interview on 8/05/25 at 12:41 pm, CNA A stated that approximately two weeks prior (exact date unknown), Resident #1 had climbed out of a window on the female locked unit. She stated that she saw Resident #1's wheelchair sitting empty by an open window and had notified LVN B. She reported staff searched the unit and then the property, but that Resident #1 was not located, and staff began using their vehicles to search the community. She stated she found Resident #1 coming out of an auto parts store, the property adjacent to the facility, and escorted her back to the facility. She stated that the ADM arrived a short while later and threatened the jobs of staff if they were to say anything about the incident to anyone. She reported she had received elopement training within the past six months. In a telephone interview on 8/05/25 at 4:00 pm, LVN B stated about two weeks ago (exact date unknown), she was notified by CNA A that Resident #1 had gone out a window on the female locked unit. She stated that Resident #1 was not found at the facility but that she was returned to the facility by CNA A who reported that Resident #1 had been found at a nearby auto parts store. She stated she assessed Resident #1 upon her return to the facility and that she did not have any injuries. She stated that she called and notified the ADM and that he arrived approximately thirty minutes later and fixed the window that Resident #1 had kicked out. She stated she did not chart the elopement or her injury assessment because she was told by the ADM that he had to do an investigation, and he would take care of it. She stated she was not aware of any prior elopement attempts by Resident #1. She reported she had received elopement training within the past six months. In an interview on 8/05/25 at 1:30 PM LVN C stated while working the evening shift approximately two weeks ago (exact date unknown) she was notified by CNA A that Resident #1 had gone out of a window on the female locked unit. She stated she immediately started looking for the resident after notifying LVN B. She stated she and other staff had been driving around the community looking for Resident #1. She reported she next saw Resident #1 walking up to the front of the building escorted by CNA A and was told that Resident #1 was found next door at an auto parts store. She stated that Resident #1 did not appear to have any injuries. She stated she was not aware of any prior elopement attempts by Resident #1. She reported that the ADM came to the facility about thirty minutes later but did not speak to her. She denied she was threatened or told not to say anything about the incident. She stated that when she worked the day shift the following day, she was told in report that Resident #1 had tried to elope, and she thought this was strange because Resident #1 had actually eloped. She stated that Resident #1 was placed on Q15 minute checks for elopement risks. She stated she had thought the windows were secured but that she noted someone working on the window the day following the incident. She reported she had received elopement training within the past six months. In an interview on 8/05/25 at 1:40 PM CNA D stated she was told by a CNA (name unknown) the day following the incident (date unknown) that Resident #1 had eloped and been found at an auto parts store on the prior evening shift and had been escorted back to the facility. She stated she was not aware of Resident #1 having eloped or attempting to elope prior to this incident. She declined to state if her job had been threatened or she had been told not to say anything about the incident stating, I don't want to lose my job. They will retaliate against you and I don't want you writing anything that will cost me my job. She reported she had received elopement training within the past six months. In an interview and observation on 8/05/25 at 3:07 pm, Resident #1 stated she had left the facility through a window she had pushed through, maybe the start of last week (exact date unknown). She stated she went next door to an auto parts store and borrowed a lighter from a staff at the store because she wanted to smoke. She stated a female facility staff (name unknown) rolled up approximately twenty minutes later and escorted her back to the facility. She stated she left the facility because she missed her belongings and her apartment. She stated she did not think she spoke to the ADM that day. She denied she experienced any injury or adverse effects from leaving the facility. Resident #1 was observed with no obvious sign of injury. A bolt and nail were observed preventing Resident #1's window from opening more than a few inches. In an interview on 8/5/25 at 4:17 pm, the DON stated that Resident #1, sometimes gets on a rant about wanting to leave but that she had not heard anything about her going out a window or being over at an auto parts store. She reported that residents' windows have screws that prevent them from being raised enough for a resident to elope. She reported that preventing elopement for Resident #1 has included that Resident #1 was accommodated to go out for activities, she was on a secure unit, she was seeing psychiatric services, and she was placed on Q15 minute checks for behaviors as needed including aggression and elopement. She stated that staff were free to report any incidents without fear of retaliation and she had not received any complaints of staff being fearful of retaliation. The DON stated that all staff had received training on elopement and actions to take. She reported that part of the training included that the staff would notify the Administrator of elopement incidents. She stated in the event of a missing resident, all staff were to immediately search indoors and if not found would expand the search to the outdoor property, the Administrator would be notified, and a decision would be made if authorities needed to be notified. She stated she was not aware of any staff having been told not to document an incident and that they will do it instead. In an interview on 8/05/25 at 3:20 PM the ADM stated he was not informed of Resident #1 going out a window. He reported to his knowledge Resident #1 had never exited or tried to exit the facility. He stated Resident #1 had called a ride service and friends to come pick her up in the past. He stated there had not been any windows repaired in the past month except one window on the male unit. He stated he was not aware that Resident #1 was placed on Q15 minute checks but that this can be done for excessive wandering as well as aggressive or other behaviors. He reported that if a resident exited the facility, he expected staff to count all residents, search the facility, call a code silver, search the exterior property, and then the surrounding properties, and notify the DON, himself, the MD, and the family. He reported that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff have received training on handling and reporting elopements/code silver training. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 4 of 4 Residents (Resident #6, Resident #7, and Resident #9) reviewed for smoking, and 1 of 1 Resident (Resident #4) reviewed for environment.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were provided supervision while smoking.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were accurately assessed for smoking.<BR/>The facility failed to ensure Resident #9 was assessed for smoking per facility policy. <BR/>The facility failed to ensure Resident #4 did not have an electric kettle in her room on the secure unit. <BR/>These failures could place residents at risk of harm, injury, or accidents. <BR/>Findings included:<BR/>Record review of Resident #6's admission Record, dated [DATE], revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Encephalopathy (this is a brain disease that alters brain function or structure) and unspecified visual loss. <BR/>Record review of Resident #6's MDS, dated [DATE], revealed a BIMS score of 13 indicating the individual's cognition is intact.<BR/>Record review of Resident #6's Care Plan, date initiated [DATE], reflected the resident is a smoker. Goal: the resident will not suffer injury from unsafe smoking practices. Interventions: The resident requires supervision while smoking. <BR/>Record review of Resident #6's Smoking-safety screen, dated [DATE], revealed the resident is safe to smoke with supervision. Vision: Does resident have any visual deficit. 1. Yes. Safety: 6. Can resident light own cigarette? No. 7. Resident need for adaptive equipment. 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes F. IDTC Decision; 1 Notes on Safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): IDT agrees the resident requires supervision while smoking d/t unspecified visual loss. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t dx unspecified visual loss. <BR/>Record review of Resident #7's admission MDS, dated [DATE], revealed an admission date to the facility on [DATE]. Further review revealed a BIMS score of 14, indicating intact cognition. <BR/>Record review of Resident #7's care plan dated [DATE] revealed resident was a smoker. <BR/>Record review of Resident #7's smoking assessment, dated [DATE], revealed resident did not have cognitive loss or dexterity problems but did have visual deficits, could not light own cigarette and needed supervision. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t Hordeolum externum (an infection of an oil gland at the edge of eyelid) unspecified eye.<BR/>Record review of Resident #9's admission Record revealed, a [AGE] year-old male, initially admitted on [DATE] and re-admitted on [DATE] with diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), with (Acute) Exacerbation.<BR/>Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score of 13 indicating intact cognition. <BR/>Record review of Resident #9's Care Plan, date initiated: [DATE], reflected the resident is a smoker. Goal: The resident will not suffer injury from unsafe smoking practices. Interventions: the resident requires supervision while smoking. <BR/>Record review of Resident #9's Smoking- Safety Screen, dated [DATE], revealed, Category: Safe to smoke with supervision. <BR/>E. Safety- Can resident light own cigarette? No. 7. Resident need for adaptive equipment 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes. F. IDTC Decision: 1. Notes on Safety From IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. <BR/>No other smoking assessment had been completed for Resident #9. <BR/>Record review of Resident #4's admission Record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease , major depressive disorder, and anxiety. <BR/>Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment.<BR/>Record review of Resident #4's care plan, dated [DATE], did not reveal anything related to an electric kettle.<BR/>In an observation and interview on [DATE] at 11:21 AM, Resident #4 was in her room sitting up in her w/c drinking coffee. A small blue kettle was observed plugged in near the sink. Resident #4 stated her family member sent it to her. <BR/>In an observation and interview on [DATE] at 12:06 PM, Resident #6 walked out of her room holding a cigarette pack and a lighter. Resident #6 entered the code to go outside on the smoking area. Surveyors went outside and observed Resident #6 and Resident #7 smoking with no staff present. Resident #6 stated she knew the code to enter to go outside, staff were aware she smoked, and stated she was allowed to keep her smoking materials with her. Resident #6 stated she took about 3-5 smoke breaks a day and did not need an apron to smoke. Resident #7 was observed with a cigarette and lighter. Resident #7 stated she knew the codes and all residents knew the codes. Resident #7 stated she had been there about 4 months, and staff had never taken away her cigarettes or lighter. Resident #7 said the staff had nobody to bring them to smoke so she guessed that was why residents went out by themselves. <BR/>In an interview on [DATE] at 1:02 PM, LVN E stated residents were not allowed to have their cigarettes or lighters in their possession and smoking materials were locked up behind the nurse's station. She stated residents had designated smoke times and must be supervised during smoking unless they sign out and go out the front and leave the facility. She said supervision meant that one of the workers on shift must light the cigarettes, pass them out and stay until everyone was done smoking. She stated the risk to residents having cigarettes and lighters was they could set something on fire or hurt someone else or themselves. <BR/>In an interview on [DATE] at 1:04 PM, LVN G stated usually the aides supervised residents who smoked. He stated no residents were to have their lighters or cigarettes. He did not know who completed the smoking assessment and did not know what supervision meant since he did not complete the assessments. He stated if residents were not supervised while smoking, they could hurt themselves. <BR/>In an interview on [DATE] at 1:09 PM, CNA F stated residents were not supposed to have cigarettes or lighters on their person and staff were to supervise residents while smoking. She stated supervision meant they pass out the cigarettes, light them and stay with residents until done. She said cigarettes and lighters were kept in a container behind the nurse's station. CNA F stated there were no residents that she knew of that were allowed to keep their cigarettes or lighters. She stated the risk to the residents of having a cigarette or lighter was because there have been some incidents of them falling asleep and burning themselves. <BR/>In an interview on [DATE] at 1:15 PM, CNA H stated residents were not supposed to have their smoking materials and they were kept in the lock box behind the cart. She stated only staff can get into it or the person who smokes them. CNA H stated supervision meant making sure residents were smoking properly and they were safe. She said one staff member supervises and usually will light the cigarette or get the lighter back from the resident. She said residents were not allowed to go out in the smoking area with O2 because it could burn or blow up. She said the O2 tank should be inside at all times. She stated if residents were not supervised while smoking, they could burn themselves or anything could happen. <BR/>Observation and interview on [DATE] at 1:11 PM, revealed Resident #9 smoking without any staff present. He stated he goes outside to smoke every couple of hours and keeps his cigarettes and lighter in his possession. <BR/>In an interview on [DATE] at 1:26 PM, the DON stated according to their policy, if a resident was a safe smoker, the resident can have a lighter and cigarette, and if an unsafe smoker, smoking materials were locked up. She stated safe and unsafe smokers were determined by the assessment. The DON said supervision meant staff would be out there with unsafe smokers. For safe smokers, supervision meant that staff just have eyes on them She stated if residents who were deemed unsafe smokers smoked without supervision, they could be at risk for burns. <BR/>In an interview on [DATE] at 1:35 PM, the Administrator stated if residents were deemed safe smokers, they could have their paraphernalia. He said they encouraged residents to lock them up but also have a very able bodied population, and if they signed out and were able to purchase those items it would be hard to police. He said an assessment was completed to see if the resident would meet the criteria for safe smoking The Administrator stated his understanding of safe and unsafe smoking was whether under reasonable circumstances residents were safe to hold, light, smoke and extinguish a cigarette in a safe way. He stated residents on O2 were not supposed to go out on the smoking area with the O2 tank. He said the risk for residents who were deemed unsafe and went to smoke without direct supervision was they would have the potential for bodily harm and a burn. He stated if residents threw lit cigarettes on the ground, it could be a risk of fire. <BR/>In an interview and record review on [DATE] at 1:35 PM, the Administrator stated Resident #7 was a safe smoker. Review of EHR revealed a smoking assessment had just been completed and was dated [DATE] and Resident #7 was a safe smoker. Review of the previous smoking assessment dated [DATE] indicated supervision was required. The Administrator stated he was not expecting the assessment for Resident #7 to say smoke with supervision. <BR/>In an interview on [DATE] at 4:51 PM, the Social Worker stated she was responsible to do the smoking assessments when a resident first admits and then quarterly. She stated sometimes the nurse would assess but she mainly did them. She said she based the assessments on their BIMS, diagnoses and if they were a smoker and how often. She said especially when they first got there, she puts that they need supervision, since staff do not know them that well, and as a safety precaution. She said supervision meant having someone out there watching them smoke and having their smoking articles locked up at the nurse's station. She said if residents needed help with lighting cigarettes, then provide assistance with that. She stated there were residents who were safe smokers that were alert and oriented x3 (a person is alert and oriented to person, place and time), and had no impairments that may prevent them from smoking by themselves. She said she did see a risk if residents who were unsafe went to smoke by themselves. <BR/>In an interview on [DATE] at 8:11 AM, the Administrator stated he had done a QAPI meeting about smoking, had done inservice and was still inservicing staff and would provide them to Surveyor when all done. <BR/>In an interview on [DATE] at 3:00 PM, the DON supervision was based on diagnosis and case by case. She said some residents would be immediately unsafe and there was no way physically they could smoke safety.<BR/>In an interview on [DATE] at 3:14 PM, the Administrator stated he re-educated staff this morning, and in serviced the SW directly on smoking assessment. He said he found that the assessments were inconsistent with the policy, redid all smoking assessments and corrected them and inserviced staff on the smoking policy, what a safe smoker was, and guidelines. He stated a safe smoker verified by smoking assessment meant they were allowed to smoke without staff, have cigarettes and a disposable lighter and not allowed to share paraphernalia with other residents. He said unsafe smokers, which continued to be the entire secure unit due to cognition, would take scheduled smoke breaks and not keep their materials. The Administrator said Resident #4 was not to have an electric kettle in her room and was not aware there was one in the room. He stated the risk to residents could be burns. <BR/>Record review of facility policy, titled Smoking Policy - Residents Revised [DATE], revealed in part:<BR/>This facility shall establish and maintain safe resident smoking practices .<BR/>8. A resident's ability to smoke safety will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.<BR/>9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.<BR/>10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safety with the available levels of support and supervision.<BR/>11. Any resident 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. <BR/>12. Residents who have smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited .<BR/>No other policy on Accidents/Hazards was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #83) of one resident reviewed for quality of care. The facility failed to monitor Resident #83's blood glucose levels before administering insulin. This failure could place residents at risk for not receiving appropriate care and treatment and decreased quality of life.Findings included: Record review of Resident #83's face sheet dated 09/11/2025 revealed a [AGE] year old female, admitted on [DATE] with primary diagnosis of fibromyalgia and other pertinent admitting diagnoses including type 2 diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, pure hypercholesterolemia, major depressive disorder, generalized anxiety disorder, heart failure, and hypertension. Record review of Resident #83's MDS dated [DATE] revealed a BIMS of 13.Record review of Resident #83's blood glucose levels from 06/01/2025-07/03/2025 and 08/22/2025-09/09/2025 revealed the resident blood glucose levels consistently above 100 mg/dL (the upper limit). Record review of Resident #83's care plan last revised on 03/20/2025 reflected:Focus - The resident has altered endocrine status (specify) r/tGoal - The resident will maintain blood glucose levels below (specify) through the review dateInterventions - Dietary consult for nutritional regimen and ongoing monitoring.; Fasting Blood Glucose (SPECIFY FREQ) as ordered by MD.; Monitor/document/report PRN for s/sx of hyperglycemia:. Monitor/document/report PRN s/sx of hypoglycemia:. take meds as ordered.Record review of Resident #83's insulin injection orders reflected:- Insulin Glargine Subcutaneous Solution (Insulin Glargine); Directions: inject 45 milliliter subcutaneously at bedtime for DM; Start date: 8/27/2024; End Date: 8/27/2024- Lantus SoloStar 100 UNIT/ML Solution pen-injector; Directions: Inject 45 unit subcutaneously at bedtime for diabetes inject 45u sub Q at bedtime; Start date: 8/28/2024; End date 7/4/2025- Lantus SoloStar 100 UNIT/ML Solution pen-injector; Directions: Inject 55 unit subcutaneously one time a day at bedtime for diabetes mellitus type 2; Start date: 7/4/2025; End date 9/8/2025- HumuLIN 70/30 Subcutaneous Suspension (70-30) 100 UNIT/ML (Insulin NPH Isophane & Reg (Human)); Directions: 35 unite subcutaneously two times a day for diabetes mellitus monitoring; Start date: 9/8/2025; End date: Indefinite Record review of Resident #83's medication administration summary for July 2025 revealed Resident #83's blood glucose was monitored and recorded before the medication was administered on July 1-3, 2025. Her blood glucose levels were not monitored for the remainder of the month. Record review of Resident #83's medication administration summary for August 2025 revealed Resident #83's blood glucose was not monitored between August 1-21, 2025. Her blood glucose began to resume monitoring on August 22, 2025. During an interview on 09/09/2025 at 1:20PM with Resident #83 she stated she had been receiving Lantus (long acting) insulin, and it was different than the insulin she used while she lived at home, Novolog 70/30 (rapid-acting) insulin. She stated she did not know why she was given Lantus, but she told her doctor it was not working and that her doctor was finally switching her insulin after a year of being at the facility. An interview with on 09/11/2025 at 4:56PM with LVN C revealed she had administered insulin to Resident #83. She explained she checked the resident's blood glucose level before administering insulin. She stated she was monitoring Resident #83's blood glucose levels after the medication was administered because she had a new order for her insulin, but normally after insulin was given she just monitors for signs and symptoms. LVN C stated before giving long acting insulin, she checked blood glucose level. She said it was best practice to monitor blood glucose levels before and after giving insulin because blood glucose levels could suddenly drop or the insulin may not be effective. LVN C stated she had not seen Resident #83's order say to check blood glucose levels before and after giving insulin, but if the orders did she would. She stated it would be beneficial to check blood glucose levels before and after administering insulin. During an interview on 09/11/2025 at 6:41PM with the DON, she stated she expected staff to check orders and make sure they give insulin as prescribed. She stated blood glucose levels were checked if ordered by the physician. If the resident's care plan says to monitor blood glucose levels and it was not in the physician order, the DON stated staff have to follow the physician order. If a resident had fluctuating blood glucose levels, she expected staff to still follow the physician's order (of not monitoring). The DON said nurses verify and check the physicians orders. The DON stated the difference in the levels can cause a risk of hypoglycemic episodes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:<BR/>Number of residents cited:<BR/>Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent complications of enteral feeding for 1 of 1 resident (Resident #8) observed for medication administration via gastrostomy tube. 1.LVN D did not raise the head of bed during medication administration and water flush via G-tube for Resident # 8. Resident #8 was laid flat on his back. 2. LVN D did not clean the syringe and plunger before placing it in the sealed bag after administering medications via G-tube to Resident #8. 3. Facility failed to obtain orders to elevate the head of bed to at least 30-45 degrees up for Resident #8 who received continuous feedings via G-tube. 4. Facility failed to care plan to elevate the head of bed to at least 30-45 degrees up for Resident #8 who received continuous feedings via G-tube. These failures could place residents at risk for aspiration and interactions between the formula and various medications. Findings included: Record review of Resident #8's face sheet dated 09/10/25 indicated Resident #8 was a [AGE] year-old male with an initial admission on [DATE] and readmitted to the facility on [DATE] with a primary diagnosis of Traumatic subdural hemorrhage without loss of consciousness (injury to the brain that caused bleeding). His secondary diagnoses include gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individuals who have difficulty swallowing), gastro-esophageal reflux diseases without esophagitis (this is non erosive reflux of stomach acid backflowing into the esophagus), protein-calorie malnutrition, and dysphagia (difficulty swallowing). Record review of Resident #8's Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #8 had a BIMS score of 8, indicating mild cognitive impairment. The MDS indicated he had a feeding tube and received 501 cc/day or more fluid through his g-tune. The MDS did not indicate the total amount of Resident #8's total calories obtained through tube feeding. Record review of Resident #8's care plan revised 05/20/25 indicated Resident #8 had swallowing problems related to dysphagia. The goal was to not have injury related to aspiration. The intervention was that all staff would be informed of residents' special dietary and safety needs. Further review of the care plan initiated 12/13/24 indicated Resident #8 had fluid overload related to brain injury. The intervention was to provide pillows; raise HOB as needed to facilitate breathing, increased comfort. Record review of Resident #8's September 2025 physician orders on 09/10/25 reflected the following:- [Brand Name of formular] at 66 cc/hr X 20 hours administered through her G-tube with down time from 8 am to 12 pm starting on 08/16/25.-SOB when lying flat. Every shift for monitoring. Starting 08/19/25- Levetiracetam Oral Tablet 500 MG (Levetiracetam) Give 1 tablet via G-Tube two times a day for anticonvulsants. Starting 04/28/25.Further revie of the orders did not indicate orders to elevate the head of bed to at least 30-45 degrees for a resident with g-tube feedings. During an observation and interview on 09/10/25 at 08:09 AM, it was revealed Resident #8 in his bed. LVN D raised the bed up for height comfort, she then laid the head of the bed down and administered 30 cc of water, then medication Levetiracetam (which had been crushed and dissolved in water), and another 30 cc of water after medication administration via gastrostomy tube to Resident #8. LVN D did not clean the 60cc syringe and plunger after the medication was administered, LVN D placed the syringe and plunger back into the sealed bag. LVN D stated she forgot to raise the head of Resident #8 bed up during medication administration. She said not raising the head up when administrating medication via the g-tube can cause the risk of aspiration. LVN D said she should have washed the syringe and plunger after the medication administration before placing it in the sealed bag for infection control. During an interview on 09/11/25 at 09:12 AM the DON said when medications are administered via gastrostomy tube, they expected the nurses to raise the head of bed prior medication administration via G-tube per policy and to wash out the syringe and plunger after medication administration prior to replacing them into the storage bag. The syringe and plunger were to be changed every 24 hours. The DON said not raising the head was bad, could cause a risk for aspiration and to not wash out the syringe and plunger would be an infection control issue. DON stated she had completed in-services for medications. In an interview on 09/11/25 at 6:42 PM, the DON said the expectation was that a resident on continuous feeds should have orders to elevate HOB at least 30 degrees up. She said she was not sure why Resident #8 did not have orders or care plan to elevate his bed while receiving feedings via G-tube. She said it was the responsibility of the nurse to check orders and herself and the ADON were responsible for monitoring that orders and care plan were accurate. She said the potential risk was aspiration. Record review of facility Inservice completed on 01/20/25 included topics of Medication administration, Medication rooms, Medication rights, Counting Narcotics at the beginning and end of shift with nurse led by DON revealed 13 staff including MA's, Med tech's, Nurses, and LVN D completed the Inservice. Record review of facility policy titled, Enteral Feedings-Safety Precautions revision date November 2018, revealed. The facility will remain current in and follow accepted best practices in enteral nutrition. Elevate the head of the bed (HOB) to at least 30 during tube feeding and at least 1 hour after feeding. If elevating the HOB is medically contraindicated, use the reverse Trendelenburg position. Symptoms of esophageal complications (e.g., stricture, fistula, ulcers):1. Pain;2. Difficulty swallowing; and3. Difficulty breathing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received food that was appetizing, appealing, and proper temperature prior to serving.The facility failed to ensure milk was at a safe temperature before serving. The facility failed to ensure the dinner roll item was appealing and appetizing food item. The facility failed to ensure the baked potatoes were appealing texture. This failure could result in residents' not being provided food that is nutritious and appealing, resulting in a decreased quality of life.Findings include: Record review of Resident #16's face sheet dated 09/11/2025, revealed a [AGE] year-old woman admitted on [DATE] from a psychiatric hospital. She was admitted with primary diagnoses chronic obstructive pulmonary disease and other pertinent diagnoses including post-traumatic stress disorder, anxiety disorder, adult financial abuse (confirmed, subsequent encounter), adult sexual abuse (confirmed, subsequent encounter), adult physical abuse (confirmed, subsequent encounter), and hypertension. Record review of Resident #16's MDS dated [DATE] revealed the resident had a BIMS (brief interview for mental status - tool used to assess cognitive function, and scores range from 0 to 15) of 15. Record review of Resident #83's face sheet dated 09/11/2025 revealed a [AGE] year-old female, admitted on [DATE] with primary diagnosis of fibromyalgia (chronic condition that causes widespread pain in muscles and soft tissues in the body) and other pertinent admitting diagnoses including type 2 diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, pure hypercholesterolemia, major depressive disorder, generalized anxiety disorder, heart failure, and hypertension. Record review of Resident #83's MDS dated [DATE] revealed a BIMS of 13.Record review of Resident #35's face sheet dated 09/11/2025 revealed a [AGE] year-old male, admitted on [DATE] with primary diagnosis of vascular dementia, unspecified severity, with other behavioral disturbance. Other diagnoses include COPD, chronic kidney disease stage 3, cognitive communication deficit, dysphagia, cerebral infarction, unspecified, metabolic encephalopathy, generalized anxiety disorder, unspecified lack of coordinationRecord review of Resident 35's MDS dated [DATE] revealed a BIMS of 05. Record review of Resident 35's dietary profile dated 09/03/2025 revealed the resident's current texture of food was mechanical soft. Record review of resident 35's dental visit dated 08/08/2025 revealed he had been getting fitted for dentures and was missing 17 teeth. During an interview on 09/09/2025 at 10:48AM with Resident #16, she described the food as having no flavor and discussed her meals were cold and she could ask to have her food heated up but there's many residents askingDuring a brief observation and interview on 09/09/2025 at 10:29AM with Resident 35, he said cold when asked how the food at the facility was. Observation and interview on 09/09/2025 at 12:24 PM with Resident #83 and Resident #35 while they dined for lunch revealed Resident 35 was given a baked potato with shredded cheese and sour cream, a slice of white bread, and dessert for lunch. Resident #83 said that Resident #35 typically gets a baked potato as a substitute for his meals, and his teeth (dentures) did not fit right. Resident 35 pointed to his teeth, revealing he was missing many teeth.During an interview on 09/09/2025 at 1:20PM with Resident #83, she stated she had a concern with the food at the facility. She said she was told if she ate in the dining room the food would be warm. She described the baked potatoes as half cooked and they are hard. During a confidential resident council meeting on 09/10/2025 at 10:30AM it was revealed that residents mentioned the food being cold, and many residents eat in their rooms, and the food was cold when they receive it. Residents discussed milk being a warmer temperature when received. During an observation of temperature checks for resident's lunch meal on 09/10/2025 at 12:00PM, resident drink temperatures had not been checked. At 12:25PM, before the meal tray cart left the kitchen, this surveyor asked what the temperatures for the resident's drinks were. Temperature checks with the DM revealed the orange juice was 64 F and the milk was 67 F. At this time, the DM had all orange juice and milk cups on the meal tray carts disposed and replaced. During an interview on 09/10/2025 at 11:20 AM with the DM revealed she alternates the dinner rolls item, and residents do receive other dinner roll and not just white bread slices. She explained that she orders dinner rolls but sometimes the vendor would be out of stock, and she has discussed this with the registered dietitian and ADM. The DM stated she would not like a slice of white bread instead of a dinner roll. She stated many residents complain of the slice of white bread and residents have the right to get what they want (an actual dinner roll). Observation on 09/10/2025 at 1:22PM of the lunch test tray, included BBQ chicken, a dinner roll, pasta salad, and lemon cake. A baked potato with shredded cheese was added as requested. The food was warm and palatable. The center of the baked potato was edible but not as soft as the outer edges, requiring more time to masticate without teeth. An interview on 09/11/2025 at 2:30PM with the registered dietitian revealed residents occasionally complain about food being cold but the facility recently purchased new insulated top and bottom plate covers. When asked if there was an issue with food orders, she stated the food vendor runs out of stock. She said the DM calls and informs her of what the truck did not provide and discuss alternatives until they receive the items. She discussed the food vendor truck did not deliver dinner rolls, so sliced white bread was used as a substitute. She stated the dietary staff try not to use sliced white bread and other options they could use include cornbread. Record review of the facility's Resident Food Preferences policy, revised July 2017 reflected: Policy Statement Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation1. Upon the resident's admission (or within seventy-two (72) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. 1. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 2. Nursing staff will document the residents' food and eating preferences. 3. The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. 4. The dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The physician and dietitian will communicate the risks and benefits of specialized therapeutic vs. liberalized diets. 5. Therapeutic diets will be ordered only after the resident/representative agrees with and consents to such a diet. 6. The resident has the right not to comply with therapeutic diets. 7. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 8. The facility's quality assessment and performance improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure the stand-by freezer food items were dated, labeled, and secured.2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and secured.3. The facility failed to ensure the dry storage food items were dated, labeled, and procured.4. The facility failed to ensure that canned good food items were free of dents.5. The facility failed to ensure that held food items were covered prior to serving.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included: Observation on 09/09/2025 at 7:45AM upon entrance to the kitchen revealed an uncovered metal tin of butter with a pastry brush inside the tin, sitting on the stove top griddle.Observation on 09/09/2025 at 7:46AM of the standby freezer revealed:- An unsealed bag of frozen pizza dated 9-3-25 and with no use by date. Ice crystals forming on the pizzas. - A unlabeled Ziploc bag of chicken tenders dated 9-3, with no use by date. - A box with an unsealed bag of frozen hamburger patties, with no opened on or use by date. Observation on 09/09/2025 at 7:49AM of the standby refrigerator revealed:- An opened bag of shredded mozzarella cheese dated 9-3, with no use by date.- An open bag of shredded cheddar cheese dated 9-3, with no use by date.- An unsealed Ziploc bag with half a yellow onion, dated 9-4 and no use by date- A large, opened container of pickles dated 3.5.25, with no use by date. Observation on 09/09/2025 at 7:53AM on the kitchen's spice rack revealed an unsealed bottle of Paprika seasoning. At this time, an interview with the DM revealed the pizza in the stand-by freezer were used on Saturday (09/06/2025) and the box was dated with the delivery date. The DM acknowledged the ice crystals formation on the pizzas due to the unsealed bag and stated the pizzas were contaminated and no good. The DM further stated that the unsealed bottle of paprika seasoning can be contaminated. Observation on 09/09/2025 at 7:56AM of the dry storage closet revealed:- An opened and 1/2 used jar of concord grape jelly, with no use by date. Text on the label of the jar stated REFRIGERATE AFTER OPENING.- An opened and used bottle of yellow mustard, dated 8/6/25 with no use by date. Text on the label of the bottle stated BEST IF USED BY MAY 19 2025 and REFRIGERATE AFTER OPENING - One can of tomato soup, undated. - One can of pinto beans, undated. - One dented can of baked beans. At this time, an interview with the DM revealed she was not aware the labels stated the jelly and mustard were to be refrigerator after opening. She stated the problem with dented cans were that the metal can come off, the canned food items can go bad and contaminate food. Observation on 09/09/2025 at 11:22AM of the facilities kitchen revealed cooked bread rolls sat on top of the stove top, uncovered. The meal tray carts were prepared with trays, dessert food item, and drinks including milk and orange juice. An interview with the DM on 09/10/2025 at 11:58AM revealed all dietary staff members were responsible for labeling and dating for items, including opened on dates and use by dates. The DM stated food items were used within 3 days after opening. She stated the importance of dating food items was that they could go bad, and residents could get sick (if they eat food items past use-by date). When asked if there was an issue with the uncovered bread rolls, the DM stated there can be cross contamination. The DM explained temperature for hot held food items must be held at a minimum of 135 F and cold food items must be held at 40 F or lower.During an observation of temperature checks for resident's lunch meal on 09/10/2025 at 12:00PM, resident drink temperatures had not been checked. At 12:25PM, before the meal tray cart left the kitchen, this surveyor asked what the temperatures for the resident's drinks were. Temperature checks with the DM revealed the orange juice was 64 F and the milk was 67 F. At this time, the DM had all orange juice and milk cups on the meal tray carts disposed and replaced. An interview with the Registered Dietitian on 09/11/2025 at 2:30PM revealed she works with the dietary staff and staff are expected to follow the expectations and regulations for dating and labeling food items. She explained the procedure to dating and labeling included the food item, the date used, and the use by date. She stated she expects opened food items to be covered and sealed. The registered dietitian stated holding temperature for hot food items was 135 F and for cold food items was 40 F. When asked how to keep resident drinks within holding temperatures prior to serving, she explained that was what the refrigerators and ice was for. She stated the importance of these expectations was for food safety, quality of food, and ultimately for resident safety. Record review of the facility's Food Receiving and Storage Policy, revised October 2017, reflected: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation .7. Dry foods that are stored in bins will be labeled and dated ( use by date). Such foods will be rotated using a first in - first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). 11. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. Record review of the U.S. FDA Food Code 2022 reflected: 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above. (2) At 5 C (41 F) or less.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:<BR/>Number of residents cited:<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 2 of 8 rooms (room [ROOM NUMBER] and 201) and for 4 of 8 Residents (Resident #12, # 22, 59 and #78) reviewed for refrigerators in the rooms. 1.Facility failed to monitor refrigerator temperature on 09/05/25, 09/06/25, 09/07/25, 09/08/25, and 09/09/25 in room [ROOM NUMBER] and room [ROOM NUMBER] 2.Facility failed to monitor and did not put thermometers or maintain temperature logs in Resident #59's and Resident #78's refrigerators. 3.Facility failed to monitor temperature and/or maintain temperature logs for Resident #12's and Resident #22's refrigerators. These failures could affect residents by placing them at risk for food-borne illnesses. Finding included: 1.Observation in room [ROOM NUMBER] on 09/09/25 at 08:46 AM revealed two personal refrigerators in the room. The temperature log was attached to the two refrigerator doors. The temp logs were missing entries for 09/05/25, 09/06/25, 09/07/25, 09/08/25, and 09/09/25. The refrigerators belonged to a resident in the hospital and was not available for interview. 2.Observation in room [ROOM NUMBER] on 09/09/25 at 09:09 AM revealed one personal refrigerator in the room. The temperature log was attached to the refrigerator door. The temp log was missing entries for 09/05/25, 09/06/25, 09/07/25, 09/08/25, and 09/09/25. The refrigerator belonged to a non-interviewable resident. 3.Observation and interview on 09/09/25 at 09:53 AM revealed Resident #59 and Resident #78 had two personal refrigerators in their room. They both said they bought them two months ago. Both residents opened their refrigerators and revealed no thermometer inside each refrigerator. Resident #78 stated she can feel from the door coolness and by looking at the icicles formed on the inside of the fridge to know that it was working and cool enough to keep her food fresh. Both residents said no one had checked their refrigerators or kept a log. They both said they cleaned out their own refrigerators and had no concerns. 4.Observation and interview on 09/09/25 at 10:37 AM revealed Resident #12 and Resident #22 both had personal refrigerators in their room. Both refrigerators had thermometers inside but there was no temp log. Resident #12 and Resident #22 said their temp was checked once a week. They said they clean out their own refrigerators. In an interview with CNA H on 09/10/25 at 5:21 PM, revealed she was not aware who was responsible for checking the refrigerator temps. She said maybe housekeeping was responsible or maintenance. In an interview with LVN G on 09/10/25 at 17:22 PM, revealed the 10 pm to 6 AM shift was responsible for checking the refrigerator temperatures in the medication room, but she was not aware who was responsible for the refrigerators in the rooms. She said that she had been working at the facility for 1 year and was never told that she was responsible for monitoring refrigerator temperatures in the rooms. She said it was most likely maintenance who was responsible. She said the reason for checking temps was to make sure that the temperature was correct, and that the food being kept is in good condition. Interview with the DON on 09/11/25 at 10:45 AM, revealed the night shift nursing staff monitored and documented the temperature in the med room refrigerators. She said all departments were responsible for refrigerators monitoring. The DON said the department heads are supposed to monitor the temp logs during their angel rounds and bring any issues to the meetings daily. She said the risk to the residents was not knowing the temperature of refrigerator and residents eating the food could cause gastric illness. Interview with maintenance on 09/11/25 at 12:05 PM revealed the nursing department was responsible for monitoring refrigerator temperatures in the rooms. He said he was new to the job, and he would double check on the frequency, but he believed it was checked daily. He said monitoring of fridge temps was done for food safety. In an Interview with the Administrator on 09/11/25 at 03:34 PM, revealed he was not aware Resident #59 and Resident #78 had no thermometers inside their refrigerators because had he known, he would have put thermometers in them. He said he had thermometers in his office and that the surveyor should let him know which rooms were missing thermometers because it was a food safety concern, not knowing which residents didn't have thermometers in their fridges to monitor their fridge temperatures. He said temperatures in fridges are expected to be checked daily by nursing staff. He said it was a food safety concern. Record Review of the Facility policy titled Foods Brought by family/visitors revised 10/2017 revealed Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The nursing and/or food service staff will discard any foods prepared for the residents that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates) The facility policy did not address temperature checks would be completed. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review the facility failed to ensure the facility's only garbage storage dumpster, and surrounding enclosed area, was maintained in a sanitary condition to prevent the attraction, nesting, and accumulation of pests. <BR/>The facility failed to ensure trash was not left outside of the dumpster on the ground. <BR/>These failures could place residents at risk of contracting disease by attracting pests, disease carrying rodents, and having debris dangerous to residents. <BR/>Findings included: <BR/>During an observation on August 8, 2024 at 3:45 PM of the dumpster area, on the north side of the building, there was trash debris including but not limited to used latex gloves, glass shards, broken overbed rolling tray tables, oscillating floor fans, bariatric bedside commode, well used recliner chair, well used mattress, split open bag of landscape mulch, opened individual dose medication blister packets, and base of a wheelchair scale. <BR/>In an interview on August 8, 2024, at 5:05PM with DM revealed that the dumpster area was the responsibility of the DM and kitchen staff. The DM stated that the DM and staff were to have picked up any trash or debris that was on the ground and place in the dumpster with the lid closed as there were to be no lose items on the ground and the dumpster was not to be overflowing. The DM stated that service company was to be called for an off schedule pick up when the dumpster got near full. The DM indicated that maintenance and the DM were ultimately responsible for the dumpster area. The DM stated the importance of being able to keep the dumpster area clean was to keep cats, rats, and animals in general out of the area. The DM stated the potential risk of the dumpster area not being kept clean could cause infection control issues. <BR/>In an interview on August 8, 2024, at 5:16PM with the MTNC it was revealed that each employee who used the dumpster was responsible to ensure the lid closed securely and there was no trash or items on the ground around the dumpster. The MTNCE stated that when the dumpster was overflowing, staff were to notify MTNC or DM for a call to the service company for off schedule pick up. MTNC stated that the service company was scheduled to pick up once a day Monday-Saturday and prn when called. The MTNC revealed the maintenance department and housekeeping, who also fall under maintenance, are the ones responsible for the dumpster area. The MTNC stated that it was important for the dumpster lid to be kept closed as unauthorized people or animals could have accessed the area. The MTNC stated when the dumpster area was not maintained properly, the area posed potential risks to residents of bad odors, comfortability, attracted insects and pests. Staff had been informed that when they notice the dumpster was getting full, they needed to let him know so off schedule pick up could be arranged. <BR/>In an interview on August 8, 2024, at 5:25PM, the ADM revealed the MTNC and housekeeping staff were responsible for the dumpster area daily to make sure all trash and items were securely in the dumpster and the lid closed. The ADM stated staff were to contact the MTNC and ADM if the dumpster reached a point of overflowing for the service company to make an off schedule pick up. The ADM stated the general upkeep to the dumpster area fell to the MTNC and ADM. The ADM stated it was important that the dumpster lid was kept closed to avoid smells and attracting pests. The ADM stated that when the dumpster area was not maintained correctly it posed a risk to residents of creating odors and infection control issues. <BR/>Record review of the Food and Drug Administration Food Code 2022 dated 1-18-2023 stated: <BR/>Chapter 5: Water, Plumbing and Waste <BR/>Operation and maintenance:<BR/>5-501.110 Storing Refuse, Recyclables, and Returnables.<BR/>REFUSE, recyclables, and returnables shall be stored in receptacles or waste <BR/>handling units so that they are inaccessible to insects and rodents. <BR/>5-501.111 Areas, Enclosures, and Receptacles, Good Repair.<BR/>Storage areas, enclosures, and receptacles for REFUSE, recyclables, and <BR/>returnables shall be maintained in good repair. <BR/>5-501.112 Outside Storage Prohibitions.<BR/>(A) Except as specified in (B) of this section, REFUSE receptacles not meeting <BR/>the requirements specified under 5-501.13(A) such as receptacles that are not <BR/>rodent-resistant, unprotected plastic bags and paper bags, or baled units that <BR/>contain materials with FOOD residue may not be stored outside. <BR/>(B) Cardboard or other packaging material that does not contain FOOD residues <BR/>and that is awaiting regularly scheduled delivery to a recycling or disposal site <BR/>may be stored outside without being in a covered receptacle if it is stored so that <BR/>it does not create a rodent harborage problem. <BR/>5-501.113 Covering Receptacles. <BR/>Receptacles and waste handling units for REFUSE, recyclables, and returnables <BR/>shall be kept covered: <BR/>(A) Inside the FOOD ESTABLISHMENT if the receptacles and units:<BR/>(1) Contain FOOD residue and are not in continuous use; or<BR/>(2) After they are filled; and<BR/>(B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. <BR/>5-501.115 Maintaining Refuse Areas and Enclosures.<BR/> A storage area and enclosure for REFUSE, recyclables, or returnables shall be maintained free of unnecessary items, as specified under &sect; 6-501.114, and clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain the residents right to be free from verbal abuse for one of five residents (Resident #3) reviewed for Abuse. <BR/>The facility failed to prevent Certified Nursing Aide A from verbally abusing (cursing) Resident #1. <BR/>This deficient practice could place residents at risk for decreased quality of life, depression, and psychosocial harm. <BR/>Review of Resident #3's admission Record reflected a [AGE] year-old male with an admission date of 10/19/2023 with the following diagnoses; A primary diagnosis of polyneuropathy, depression, cellulitis of right lower limb. <BR/>Review of Resident #3's Care Plan dated 11/04/2023 reflected: Resident #3 has a behavior problem (demanding, verbally aggressive and abusive with staff, sneaking alcohol into the facility, and attention-seeking behavior, false accusations) r/t OPIOID DEPENDENCE, drug-seeking behavior; If reasonable, discuss Resident's behavior. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Staff will try and redirect and deescalate situations with patient when behaviors. <BR/>Review of CNA's Abuse and Neglect Training dated 12/22/2023 reflected; CNA viewed traning video ABUSE, NEGLECT, & EXPLOITATION OF THE ELDERLY part 1of 2 and part 2 of 2. <BR/>In an interview on 01/23/2024 at 11:06 a.m Resident #3 stated the night before he was abused another way; he stated a young lady that worked here cursed at him. He was talking to another resident when CNA A came up to him and called him a womanizer. He stated she was close to him and he started swinging at her to get away from her. He stated that she was taken out of the building and he had not seen her since the day of the incident. <BR/>In an interview on 01/23/2024 at 2:21 p.m. Resident #4 stated when the incident happened CNA A did not deserve to get fired. Resident #3 was the one who started it. <BR/>In an interview on 01/23/2024 at 3:25 p.m. with CNA A stated she was helping another worker, a coworker asked for her assistance with a resident. On the way out another resident asked for help, she stated that she told the resident to hold on when Resident #3 said because you are lazy. Resident #3 got up from his wheelchair and acted like he was going to swing at CNA A. She stated I let you hit me one time that's not going to happen again. She stated Resident #3 cussed out females that's not a man, that's a bitch. She stated that LVN B came to get her from the nurses station, was just yelling and she was mad. She stated she immediately left the building and did not return. She stated she was informed she was suspended. She stated she received in-service regarding abuse and neglect. She scknowledged verbal abuse was cussing at a resident. <BR/>In an interview on 01/23/2024 at 3:55 p.m. with LVN B stated he was not there for the beginning of the incident. When he arrived he observed CNA. A call Resident #3 a punk bitch. He stated he observed Resident # 3 calling CNA A a bitch. He stated CNA A stated y'all cant be letting these patients treat us like this. He stated she was upset, he told her she can not lose control, you have to keep your own composure, you have to be able to process and work it out. He stated he took her down the back hall for her to leave and other staff members called the administrator. <BR/>In an interview on 01/23/2024 at 4:41 p.m. with DON stated she was not in the building at the time of the incident. She stated she was informed of the incident by phone. She stated that Resident #3 was assessed and no injuries. She stated the risk was an emotional concern, because it was verbal and could increase to physical abuse. Staff are in serviced on verbal abuse. The DON stated she interviewed CNA A and she stated CNA A should have walked away. If your resident was safe, walk away. The DON stated the CNA was relatively new still has a lot to learn. <BR/>In an interview on 01/23/2024 at 4:54 p.m. with Admin he stated the risk for verbal exchange could escalate or cause emotional or psychological damage. The CNA was suspended and will be terminated. <BR/>Review of Abuse/Neglect policy dated 09/2022 reflected the following:<BR/>All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to report to the State Survey Agency the elopement of Resident #1 during July of 2025. This failure could place residents at risk for unresolved or future abuse or neglect.Findings included: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including Chronic Obstructive Pulmonary Disease (condition caused by damage to the lungs), coronary artery disease (disease caused by buildup of plaque in the arteries of the heart), anxiety disorder, and Depression. A BIMS score of 10 was reflected, indicating moderate cognitive impairment. Resident #1 scored 0 on wandering behaviors, which indicated the behavior was not exhibited. Review of Resident #1's Care Plan with start date 6/13/25 reflected Resident #1 had a focus of elopement risk r/t history of attempts to leave the facility unattended, and with impaired safety awareness with date initiated 9/09/24 and revised solely on 12/24/24. In an interview on 8/05/25 at 12:41 pm, CNA A stated that approximately two weeks prior (exact date unknown), Resident #1 had climbed out of a window on the female locked unit. She stated that she saw Resident #1's wheelchair sitting empty by an open window and had notified LVN B. She reported staff searched the unit and then the property, but that Resident #1 was not located, and staff began using their vehicles to search the community. She stated she found Resident #1 coming out of an auto parts store, the property adjacent to the facility, and escorted her back to the facility. She stated that the ADM arrived a short while later and threatened the jobs of staff if they were to say anything about the incident to anyone. In a telephone interview on 8/05/25 at 4:00 pm, LVN B stated about two weeks ago (exact date unknown), she was notified by CNA A that Resident #1 had gone out a window on the female locked unit. She stated that Resident #1 was not found at the facility but that she was returned to the facility by CNA A who reported that Resident #1 had been found at a nearby auto parts store. She stated she assessed Resident #1 upon her return to the facility and that she did not have any injuries. She stated that she called and notified the ADM and that he arrived approximately thirty minutes later and fixed the window that Resident #1 had kicked out. She stated she did not chart the elopement or her injury assessment because she was told by the ADM that he had to do an investigation, and he would take care of it. In an interview on 8/05/25 at 1:30 PM LVN C stated while working the evening shift approximately two weeks ago (exact date unknown) she was notified by CNA A that Resident #1 had gone out of a window on the female locked unit. She stated she immediately started looking for the resident after notifying LVN B. She stated she and other staff had been driving around the community looking for Resident #1. She reported she next saw Resident #1 walking up to the front of the building escorted by CNA A and was told that Resident #1 was found next door at an auto parts store. She stated that Resident #1 had not appeared to have any injuries. She reported that the ADM came to the facility about thirty minutes later but did not speak to her. She denied she was threatened or told not to say anything about the incident. She stated that when she worked the day shift the following day, she was told in report that Resident #1 had tried to elope, and she thought this was strange because Resident #1 had actually eloped. In an interview on 8/05/25 at 1:40 PM CNA D stated she was told by a CNA (name unknown) the day following the incident (date unknown) that Resident #1 had eloped and been found at an auto parts store on the prior evening shift and had been escorted back to the facility. She declined to state if her job had been threatened or she had been told not to say anything about the incident stating, I don't want to lose my job. They will retaliate against you and I don't want you writing anything that will cost me my job. In an interview and observation on 8/05/25 at 3:07 pm, Resident #1 stated she had left the facility through a window she had pushed through, maybe the start of last week (exact date unknown). She stated she went next door to an auto parts store and borrowed a lighter from a staff at the store because she wanted to smoke. She stated a female facility staff (name unknown) rolled up approximately twenty minutes later and escorted her back to the facility. She stated she left the facility because she missed her belongings and her apartment. She stated she did not think she spoke to the ADM that day. She denied she experienced any injury or adverse effects from leaving the facility. Resident #1 was observed with no obvious sign of injury. In an interview on 8/5/25 at 4:17 pm, the DON stated that Resident #1, sometimes gets on a rant about wanting to leave but that she had not heard anything about her going out a window or being over at an auto parts store. She reported that residents' windows have screws that prevent them from being raised enough for a resident to elope. She reported that preventing elopement for Resident #1 has included that Resident #1 was accommodated to go out for activities, she was on a secure unit, she was seeing psychiatric services, and she was placed on Q15 minute checks for behaviors as needed including aggression and elopement. She stated that staff were free to report any incidents without fear of retaliation and she had not received any complaints of staff being fearful of retaliation. The DON stated that all staff had received training on elopement and actions to take. She reported that part of the training included that the staff would notify the Administrator of an elopement incident. She stated in the event of a missing resident, all staff were to immediately search indoors and if not found would expand the search to the outdoor property, the Administrator would be notified, and a decision would be made if authorities needed to be notified. She stated she was not aware of any staff having been told not to document an incident and that they will do it instead. In an interview on 8/05/25 at 3:20 PM the ADM stated he was not informed of Resident #1 going out a window. He reported to his knowledge Resident #1 had never exited or tried to exit the facility. He stated Resident #1 had called a ride service and friends to come pick her up in the past. He stated there had not been any windows repaired in the past month except one window on the male unit. He stated he was not aware that Resident #1 was placed on Q15 minute checks but that this can be done for excessive wandering as well as aggressive or other behaviors. He reported that if a resident exited the facility, he expected staff to count all residents, search the facility, call a code silver, search the exterior property, and then the surrounding properties, and notify the DON, himself, the MD, and the family. He reported that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff have received training on handling and reporting elopements/code silver training. He stated that if staff had informed him, he would have notified the police if the Resident was not immediately found. He stated he would have notified the state if a resident had eloped. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now, and if he finds that Resident #1 did in fact elope, he will report it to the state.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 24 residents (Resident #13) reviewed for resident call system.<BR/>The facility failed to ensure Resident #13 had a working call light in her room. <BR/>This failure could place residents at risk of not being able to get assistance when needed.<BR/>Findings included:<BR/>Record review of Resident #13 face sheet dated 06/22/2023 was a [AGE] year-old female admitted the facility on 09/27/2021 with diagnosis that include schizophrenia (Known to affect the ability to think), epilepsy (seizure disorder), osteoarthritis (joint disease), and type 2 diabetes.<BR/>Record review of Resident #13 care plan dated for the month of June 2023 reflected the resident requires one-person assist for dressing, toileting, personal hygiene, oral hygiene, and moving between surfaces. Also indicated in her care plan that the resident is encouraged to use her call bell for assistance. <BR/>Observation and interview of Resident #13 on 06/20/23 at 10:40 AM. revealed Resident #13 asked Surveyor for assistance to plug her phone into the wall. When Surveyor asked the resident to push her call light to notify staff of her need, she stated it doesn't work. She also stated the maintenance staff worked on it once before, but it had gone out again since then and she thinks it had a short in it. Resident #13 pushed the call light once more and no light was displayed on the outside of the room, which indicated the call light wasn't working to alert staff if she needed assistance.<BR/>Observation and interview on 06/20/23 at 03:43 PM reflected the call light still was not working. Resident #13 stated sometimes she had to get up on her own and unplug the call light and plug it back in to make it work but it does not always solve the problem.<BR/>Observation on 06/21/23 at 09:04 AM in Resident #13 room revealed the call light was still not working.<BR/>Interview on 06/21/23 at 12:40 PM, with Resident #13 revealed her roommate usually presses their call light on her behalf. Resident #13 stated she told someone yesterday about the call light issue but did not know who she informed. She said it has been about two days since the call light stopped working. She stated she usually just can get up and unplug it from the wall and plug it back in but she stated it no longer works when she unplugs and plugs back in.<BR/>Interview on 06/22/23 at 10:00 AM with the Maintenance Director revealed Resident #13 had a problem one time where the call light was bent and wouldn't push down but he changed it out and it started working. He stated the facility had a call light tester and if anything goes wrong, there was a logbook to document the issue. He stated the test was located at the nurse's station and it could be pushed to notify if the call light was working. The Maintenance Director stated call lights were tested daily. He stated there is a logbook at each nursing station with a work order form that is filled out and facility staff could also can also call him as well. <BR/>Interview on 06/22/23 at 10:35 AM with the Administrator revealed he went in the room to check Resident #13's call light and it worked the first two times he pushed it, but the third time he had to push it multiple times before the call light came on. He stated he would have the maintenance director, who was responsible for ensuring the call lights work to fix the whole call light system in Residents #13 room.<BR/>Record review of logbook for the month of June 2023 reflected the call light has last been checked for the entire facility on 6/9/2023 by The Maintenance Director. There were no other entries for June 2023 besides on 06/09/2023.<BR/>Record Review on 06/22/23 at 10:40 AM of the nursing station's logbook for the entire facility revealed no call light work orders had been placed in the book for the month of June 2023. <BR/>Record review of facility policy Answering the call light dated March 2021 revealed: <BR/>Purpose: the purpose of this procedure is to ensure timely responses to the resident's requests and needs<BR/>General Guidelines: <BR/>be sure the call light is plugged in and functioning at all times<BR/>report all defective call lights to the nursing supervisor promptly

**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 of each resident for one (Resident #1) of nine residents reviewed for pharmacy services.<BR/>The facility failed to order Resident #1's routine Oxycontin timely to prevent three missed doses, 5:00 AM and 5:00 PM on 09/26/2024 and 5:00 AM on 09/27/2024. <BR/>This failure placed residents at risk of worsening and/or exacerbation of their pain and medical conditions. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 09/27/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included: Chronic obstructive pulmonary disease (lung disease that causes restrictive airflow), anxiety disorder due to unknow psychological condition (a mental health condition that causes fear and dread), major depressive disorder (mental health condition impacting how a person feels, thinks and acts), bipolar disorder, current episode manic severe psychotic features (can include episodes of hallucinations, delusions, disordered thinking, and lack of awareness of reality), Paroxysmal Arterial fibrillation (irregular heartbeat), and old myocardial infarction (previous heart attack). <BR/>Record review of Resident #1's Initial MDS Assessment, dated 08/26/2024, reflected a BIMS score of 14 which indicated he was cognitively intact. He was independent for self-care and indoor mobility. He used a walker to ambulate. His pain assessment indicated persistent and occasional pain. <BR/>Record review of Resident #1's Care Plan dated 09/19/2024, reflected, Problem: [Resident #1] has a behavior problem (Throwing items, yelling) r/t poor impulse control. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet [Resident #1's] needs. Problem: [Resident #1] is verbally aggressive to staff regarding pain medications r/t Ineffective coping skills, Poor impulse control. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Assess resident's understanding of the situation. Allow time for [Resident #1] to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. [Resident #1's] triggers for verbal aggression are based around pain medication administration and seeking other narcotics. [Resident #1] behaviors is [sic] de-escalated by receiving pain medication. Problem: [Resident #1] is on pain medication therapy (NORCO, Oxycontin) r/t chronic pain. Intervention: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Monitor/document/report PRN adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus [itchy skin], respiratory distress/decreased respirations, sedation, urinary retention. Review for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required.<BR/>Record review of Resident #1's MAR reflected on 09/26/2024 Oxycontin scheduled at 5:00 AM and 5:00 PM was checked as administered although interviews refealed it was not given. Oxycontin scheduled on 09/27/2024 was marked as hold. PRN Hydrocodone 10-325 mg was given. <BR/>Record review of Resident #1's medication orders revealed, Hydrocodone-acetaminophen 10-325 mg by mouth every 6 hours as needed for pain, initiated 09/04/2024, with no stop date. Oxycontin extended release 12-hour 30 mg, administered by mouth two times a day for back pain, initiated 09/03/2024, with no end date. <BR/>Record review of Resident #1's progress note dated 09/26/2024 at 4:50 AM reflected, [Resident #1] requested Hydrocodone at this time and noted as effective, pain level 0 at 6:06 AM. <BR/>Record review of Resident #1's progress note dated 09/26/2024 at 12:30 PM reflected, after giving hydrocodone for pain management. I f/u with [Resident #1] who had been up and walking around and went out for cigarettes. [Resident #1] was not in distress and up in the dining room with other residents for lunch while [sic] taking and enjoying his lunch with other residents. Hydro working effectively. <BR/>Record review of Resident #1's progress note dated 09/26/2024 at 1:46 PM reflected, [Resident #1] screamed at night shift nurse bcus his oxy was not here but explained that it was called in an on its way. [Resident #1] was giving PRN hydrocodone at 4:50 AM for pain. [Resident #1] screamed and pointed the middle finger at other employee bcus she stated he did not have to talk so ugly to staff. [Resident #1] continue to call 911 to come and pick him up to go out for oxy. EMT arrived and took him out to [hospital]. [Resident #1] returned to the facility with no new orders and was giving two norco at 8:15 AM at the ER. On report from hospital, they stated that [Resident #1] should be good for remainder of the day. <BR/>Record review of Resident #1's progress note dated on 09/26/2024 at 4:56 PM reflected, nurse followed up with pharmacy in regard to res meds. Pharmacy said they would send remainder tonight. Pain management stated triplicate was sent. RP notified of update. No concerns to this nurse at his time. Care ongoing. <BR/>Record review of Resident #1's progress note dated 09/27/2024 at 5:28 AM, reflected, waiting for delivery from pharmacy. At 8:00 AM Hydrocodone 10-325 mg was administered and at 12:50 PM was noted as effective. <BR/>In an interview on 09/27/2024 at 2:18 PM, Resident #1 stated he did not get his scheduled Oxycontin on 09/26/2024 at 5:00 AM or 5:00 PM. He said staff told him they had run out and it was on order at the pharmacy. He said he did receive PRN Hydrocodone at 5:00 AM on 09/26/2024 and did not report any pain to the nurse. He said he felt anxious because the facility allowed his Oxycontin to run out and about 7:00 AM and called EMS to take him to the hospital. He said when he arrived at the hospital, they checked him out although he asked to get Oxycontin, they only gave him Hydrocodone and then sent him back to the facility. He said when he arrived back at the facility he was not in any pain. He said his Oxycontin was still not delivered at 5:00 PM and he missed the second dose. He said the Oxycontin was not delivered or available on 09/27/2024 at 5:00 AM and he also missed that dose. He said facility staff did administer PRN Hydrocodone ever six hours during this time and he did not have any pain. He said he checked himself out at about 8:00 AM today to visit a friend and just returned to the facility. He said he was told the Oxycontin was at the facility, and he received a dose at 2:00 PM. He said his next dose will be at 2:00 AM but he was okay with that. He said he had never missed any medication at the facility prior but wanted to be sure it would not happen again. <BR/>Record review of Resident #1's hospital record dated 09/26/2024 reflected the reason for visit was chest pain. Hydrocodone given and discharged to facility. <BR/>In an interview on 09/27/2024 at 9:00 AM, the Administrator stated Resident #1 did miss two scheduled doses of Oxycontin on 09/26/2024. He said there was a communication issue with the pharmacy and the medication was not in the facility. He said he was told that the Pain Nurse Practitioner sent the prescription yesterday and the medication was to arrive today. He said LVN A informed NP B on 09/25/2024 the script needed to be filled. He said staff would not contact the MD for refills on pain medications because the MD referred them to the Pain Doctor. <BR/>In an interview on 09/27/2024 at 9:48 AM, LVN A stated Resident #1 was on scheduled Oxycontin two times daily at 5:00 AM and 5:00 PM. She said he also had PRN Hydrocodone ordered every 6 hours. She said she called the pharmacy on 09/25/2024 to order Resident #1's Oxycontin and the pharmacy told her they needed a new script from the doctor. She said she informed Pain NP B on the same day when she was in the facility, that Resident #1's Oxycontin needed to be refilled and NP B said she would send the script. She said Resident #1did not have any Oxycontin left for administration on 09/26/2024. She said on 09/26/2024 the medication was not in the facility, and she followed up with the pharmacy again. She said she was told they did not have the script from the doctor. She said she checked the ekit (emergency medication kit) and the medication was not there. She said she did not contact the MD because he would refer her to the pain doctor. LVN A said she spoke to NP C on 09/26/2024 who said she would send the script. LVN A said when she followed up with the pharmacy today (09/27/2024), they told her they received the script at 4 AM. She said Resident #1 missed both scheduled doses of Oxycontin on 09/26/2024 and the dose scheduled for 09/27/2024 at 5:00 AM. She said Resident #1 did call EMS because he wanted to go to the hospital for anxiety due to missing his scheduled pain medication. LVN A said when he returned from the hospital a short time later, they instructed that they provided two Hydrocodone and Resident #1 should not require additional pain medication for at least 6 hours. LVN A stated the medications should be ordered when there was a week's supply of doses remaining. She said the pain NPs were in the facility twice a week and always asked if renewed scripts were needed. She said she did not know when Resident #1's Oxycontin was left to deplete before reordering. <BR/>In an interview on 09/27/2024 at 10:21 AM, NP C said she was notified on 09/26/2024 at 4:26 PM that Resident #1's Oxycontin needed to be refilled. She said she sent the script to the pharmacy last night (09/26/2024). She said she and NP A were in the facility twice a week and typically were on top of refills. She said facility staff also had access to her 24/7 via phone. She said Resident #1's Oxycontin was long-acting pain medication, and the PRN Hydrocodone was for short-term pain management. She said since Resident #1 received Hydrocodone at the facility and then again at the hospital on [DATE] and reported a 0 level for pain, the missed doses of Oxycontin did not seem to have any adverse effect. <BR/>In a telephone interview on 09/27/2024 at 10:30 AM, NP B said LVN A did tell her on 09/25/2024 Resident #1's Oxycontin needed to be refilled. NP B said she forgot and did not send the script to the pharmacy. She said Resident #1's pain seemed to be managed with the PRN Hydrocodone but if it had not, she would expect the facility to send him to the hospital. <BR/>In an interview on 09/27/2024 at 11:26 AM, MA D said when medications get low, she notified the nurses, and they would reorder. She stated Resident #1 did not have any Oxycodone on 09/26/2024 but he did get PRN Hydrocodone at 4:50 AM and did not indicate any pain. She said he did go to the hospital later in the morning on 09/26/24 and was sent back to the facility a short time later. <BR/>In an interview on 09/27/2024 at 11:50 AM, the Administrator stated he expected the facility nurses and the pain management team to communicate any resident needs. He said the facility should not have run out of Resident #1's Oxycontin which caused him to miss both doses on 09/26/2024. He said this could have caused Resident #1 increased pain. <BR/>In an interview on 09/27/2024 at 1:51 PM, the ADON stated she expected medications to be ordered when there was a 3-4 day's supply left. She said the facility was responsible to follow the doctors order for medication and notify the physician of any issues. She said LVN A did ask NP B to refill the prescription but NP B forgot. She said LVN A followed up with the pharmacy and NP C to get the Oxycontin refilled but Resident #1 did miss both doses on 09/26/2024. She said this could have caused him increased pain. She said Resident #1 did not report any increased pain due to the missed doses of Oxycontin. She said facility nurses contact the pain doctor or his NPs when they need pain medications refilled. She said they could have informed the MD but her experience is that he would have referred them to the pain doctor. <BR/>In an interview on 09/27/2024 at 3:24 PM, the MD said facility nurses could contact him regarding pain medications and he could have ordered a couple day supply until the pain doctor had the script refilled. He said he would follow up with the Administrator to remind them he was available to them in situations like this. <BR/>Record review of the facility's policy titled, Administering medications, revised April, 2019, reflected, .4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan . <BR/>Record review of the facility's policy titled, Controlled substances, dated 06/21/2017 reflected, .The prescriber must always provide a complete and valid prescription prior to the dispensing of controlled substance medications. It is the facility and prescriber's responsibility to obtain the required prescription needed to meet the needs of the resident . 6. Reordering/Refills Non-unit dose and controlled substances must be reordered by the Facility when there is no more than a four (4) day supply of medication remaining .<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 6 residents (Residents #1, #2, #3) reviewed for effective pest control.<BR/>The facility failed to maintain an effective pest control program to ensure the facility was free of flies and gnats for Resident #1, #2, and #3's rooms. <BR/>This failure could place the residents at risk for an unsanitary environment. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 7-18-2024, showed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had a diagnosis of cerebral infarction (stroke), schizophrenia (a chronic mental disorder that affects how people think, feel, and behave by disrupting thought processes and perceptions), bipolar disorder (a serious mental illness that causes extreme mood swings, from mania to depression), and lack of coordination. <BR/>Record review of Resident #1's quarterly MDS revealed a BIMS score of 9 which indicated being mildly cognitively impaired, was wheelchair bound, and needed maximal assistance to stand or transfer. <BR/>Record review of Resident #1's care plan dated 7-18-2024 revealed he had hemiplegia (had paralysis on one side of the body), was incontinent having incontinent episodes in public places such as on the front porch or in the hallway, was at risk for falls needing prompt response for assistance and had impaired visual function.<BR/>In an observation and interview on 7-18-2024 at 10:40 AM Resident #1 was observed to be in a wheelchair, next to his bed, with approximately 10-20 gnats and 5 flies flying around the bedroom and crawling on the bed and floor. Resident #1 stated the insects have been in his room for 2 months. He stated has told staff about the problem, and was told by the staff we are working on the problem. Resident #1 said having gnats and flies in his room made him nasty and he wanted them gone. <BR/>Record review of Resident #2's face sheet dated 7-18-2024, showed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses of seizures, morbid obesity, schizoaffective disorder (a chronic mental illness that causes people to experience both schizophrenia and a mood disorder at the same time), and gait and mobility abnormalities. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated a BIMS score of 11 revealing mild cognitive impairment, he used a walker to ambulate, was frequently incontinent, and needed supervision from sitting to standing or standing to sitting. <BR/>Record review of Resident #2's care plan dated 6-20-2024 revealed he was at risk for falls, had Parkinson's Disease, and ADL self-care performance deficit. <BR/>In an observation and interview on 7-18-2024 at 10:50 AM it was revealed Resident #2 was the roommate of Resident #1. Resident #2 was observed lying in bed and sitting up in bed with 3 flies hovering around his head. Approximately 10 gnats were observed flying around Resident #2's privacy curtain and over Resident #2's bed. Resident #2 said the flying insects in his bedroom make him feel nasty. <BR/>In an observation of Resident #1 and #2's restroom, approximately 3 flies were observed on the floor. <BR/>Record review of Resident #3's face sheet dated 7-18-2024 indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (a chronic lung disease that makes it difficult to breathe due to restricted airflow), asthma (a chronic lung disease that causes the airways in the lungs to narrow and swell, making it difficult to breathe), bipolar disorder (a serious mental illness that causes extreme mood swings, from mania to depression), gait and mobility abnormalities, and Human Immunodeficiency Virus. <BR/>Record review of Resident #3's comprehensive MDS dated [DATE], revealed a BIMS score of 15 indicating being cognitively intact. <BR/>In an observation and interview on 7-18-2024 at 4:04 PM Resident #3 was observed in his bedroom sitting on his bed while approximately 2 flies and 4 gnats were observed flying in the room. Resident #3 said the insects had been in his room for a month and the presence of the insects made him feel bad and miserable. <BR/>In an interview on 7-18-2024 at 4:15 PM, CMA A stated she had worked at the facility for 2 months. CMA A revealed she had noticed flies and gnats at the facility since she had worked at the facility. <BR/>In an interview on 7-18-2024 at 4:45 PM, the Maintenance Director stated he had worked at the facility for a month. The Maintenance Director said he was responsible for overseeing the pest control of the facility. The Maintenance Director said the facility contracts with a pest control company, and they were at the facility today treating the outside of the facility for ants, wasps, and rodents. The Maintenance Director said having insects in a resident's room would cause a quality-of-life issue for them. The Maintenance Director said gnats like moisture, and he will put hot water down a drain where they are coming in to stop them. <BR/>In an interview with the DON on 7-18-2024 at 5:08 PM, it was conveyed that her expectations were for flying insects to not be a nuisance to the residents and to decrease them as some rooms have a problem with them more than others due to hygienic choices. The DON said her concern for the residents was that they receive proper care, and it could be an infection control issue. The DON said the Maintenance Director and the Administrator were responsible for effective pest control. <BR/>In an interview with the Administrator on 7-18-2024 at 6:23 PM, it was stated that the Maintenance Director was responsible for ensuring effective pest control for the facility and the Administrator oversees him. The Administrator said he expected the facility to prevent having a lot of flying insects but preventing the facility from having any; would be difficult. The facility must be diligent to prevent insects from coming into the facility. The Administrator said the concern for the residents dealing with flying insects was a potential hazard for cleanliness and a homelike environment. <BR/>Record review of the facility's pest control service agreement, with an initial service date of 10-1-2022, stated Pest Control Company A will provide pest control services twice a month for roaches, ants, mice, rats, and occasional invaders. The contract failed to include flying insects. <BR/>Record review of the facility's special service agreement dated 3-24-2024, stated Pest Control Company A incorporated agreed to inspect and treat one room for bed bugs. <BR/>Record review of the facility's pest control log revealed the following:<BR/>On 3-25-2024, revealed Pest Control Company A treated the kitchen, food storage, dish washer, and entryways with a liquid residual pest control substance for crawling insects. The log stated the pest control company treated and inspected the kitchen for rodents, the exterior foundation with Termidor to prevent invaders, treated one room for bedbugs, and treated electrical outlets with dust. <BR/>On 4-11-2024, Pest Control Company A observed water in the kitchen near dish washer and it was stated it was the customer's responsibility to dry out the area to prevent pest build up. Pest control company treated the exterior for ants and rodents. <BR/>On 5-14-2024 Pest Control Company A treated the exterior for crawling pest, inspected, cleaned and replaced bait exterior for rodents, and treated exterior for ants. <BR/>On 6-13-2024 Pest Control Company A [NAME] Commercial Services treated the facility's exterior for crawling pest, replaced bait for exterior rodents, and place insect monitors in a room for invading pest. <BR/>Record review of the facility's Pest Control Policy dated May 2008 stated:<BR/>Pest Control<BR/>Policy Statement<BR/>Our facility shall maintain an effective pest control program.<BR/>Policy Interpretation and Implementation<BR/>References <BR/> This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.<BR/>References <BR/> Pest control services are provided by [blank line]. <BR/>References <BR/> Windows are screened at all times.<BR/>References <BR/> Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas.<BR/>References <BR/> Garbage and trash are not permitted to accumulate and are removed from the facility daily.<BR/>References <BR/> Maintenance services assist, when appropriate and necessary, in providing pest control services.<BR/>References<BR/>OBRA Regulatory <BR/>Reference Numbers &sect;483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.<BR/>Survey Tag Numbers - F925

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain the residents right to be free from verbal abuse for one of five residents (Resident #3) reviewed for Abuse. <BR/>The facility failed to prevent Certified Nursing Aide A from verbally abusing (cursing) Resident #1. <BR/>This deficient practice could place residents at risk for decreased quality of life, depression, and psychosocial harm. <BR/>Review of Resident #3's admission Record reflected a [AGE] year-old male with an admission date of 10/19/2023 with the following diagnoses; A primary diagnosis of polyneuropathy, depression, cellulitis of right lower limb. <BR/>Review of Resident #3's Care Plan dated 11/04/2023 reflected: Resident #3 has a behavior problem (demanding, verbally aggressive and abusive with staff, sneaking alcohol into the facility, and attention-seeking behavior, false accusations) r/t OPIOID DEPENDENCE, drug-seeking behavior; If reasonable, discuss Resident's behavior. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Staff will try and redirect and deescalate situations with patient when behaviors. <BR/>Review of CNA's Abuse and Neglect Training dated 12/22/2023 reflected; CNA viewed traning video ABUSE, NEGLECT, & EXPLOITATION OF THE ELDERLY part 1of 2 and part 2 of 2. <BR/>In an interview on 01/23/2024 at 11:06 a.m Resident #3 stated the night before he was abused another way; he stated a young lady that worked here cursed at him. He was talking to another resident when CNA A came up to him and called him a womanizer. He stated she was close to him and he started swinging at her to get away from her. He stated that she was taken out of the building and he had not seen her since the day of the incident. <BR/>In an interview on 01/23/2024 at 2:21 p.m. Resident #4 stated when the incident happened CNA A did not deserve to get fired. Resident #3 was the one who started it. <BR/>In an interview on 01/23/2024 at 3:25 p.m. with CNA A stated she was helping another worker, a coworker asked for her assistance with a resident. On the way out another resident asked for help, she stated that she told the resident to hold on when Resident #3 said because you are lazy. Resident #3 got up from his wheelchair and acted like he was going to swing at CNA A. She stated I let you hit me one time that's not going to happen again. She stated Resident #3 cussed out females that's not a man, that's a bitch. She stated that LVN B came to get her from the nurses station, was just yelling and she was mad. She stated she immediately left the building and did not return. She stated she was informed she was suspended. She stated she received in-service regarding abuse and neglect. She scknowledged verbal abuse was cussing at a resident. <BR/>In an interview on 01/23/2024 at 3:55 p.m. with LVN B stated he was not there for the beginning of the incident. When he arrived he observed CNA. A call Resident #3 a punk bitch. He stated he observed Resident # 3 calling CNA A a bitch. He stated CNA A stated y'all cant be letting these patients treat us like this. He stated she was upset, he told her she can not lose control, you have to keep your own composure, you have to be able to process and work it out. He stated he took her down the back hall for her to leave and other staff members called the administrator. <BR/>In an interview on 01/23/2024 at 4:41 p.m. with DON stated she was not in the building at the time of the incident. She stated she was informed of the incident by phone. She stated that Resident #3 was assessed and no injuries. She stated the risk was an emotional concern, because it was verbal and could increase to physical abuse. Staff are in serviced on verbal abuse. The DON stated she interviewed CNA A and she stated CNA A should have walked away. If your resident was safe, walk away. The DON stated the CNA was relatively new still has a lot to learn. <BR/>In an interview on 01/23/2024 at 4:54 p.m. with Admin he stated the risk for verbal exchange could escalate or cause emotional or psychological damage. The CNA was suspended and will be terminated. <BR/>Review of Abuse/Neglect policy dated 09/2022 reflected the following:<BR/>All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 1 of 25 residents reviewed for accommodation of needs. <BR/>The facility failed to ensure Resident #35's call light was within reach of the resident. <BR/>This failure could affect residents who needed assistance and could result in their needs not being met. <BR/>Findings included:<BR/>Record review of Resident #35's face sheet dated 8-8-2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of fracture of the left wrist and hand and secondary diagnosis of Parkinson's disease, dementia, altered mental status, and gait and mobility abnormalities. <BR/>Record review of Resident #35's MDS assessment dated [DATE], disclosed a BIMS score of 5 indicating a severe cognitive impairment. The assessment further indicated Resident #35 was totally dependent (helper does all the effort) putting his shoes on and substantial/maximal assistance dependent (helper does more than half the effort) to move from a lying position in bed to a sitting position on the side of his bed. The assessment indicated Resident #35 was wheelchair bound and cannot walk. <BR/>Record review of Resident #35's care plan dated 7-17-2024 indicated the resident had actual falls on 11-1-2023, 1-20-2024, 4-26-2024, and 5-24-2024. Resident #35's care plan stated he was at risk for falls and for staff to be sure the resident's call light was within reach and encourage Resident #35 to use the call light for assistance. <BR/>In an observation and interview on 8-6-2024 at 2:30 PM, Resident #35 was observed lying on his bed. Resident #35 indicated he did not know where his call light was, and that staff had moved it. Upon observation, Resident #35's call light was tucked underneath his bed frame, on the floor, from the wall where Resident #35 could not reach it. <BR/>In an observation and interview on 8-6-2024 at 2:35 PM, the Administrator entered Resident #35's room and was shown the call light being tucked under Resident #35's bed on the floor. The Administrator reached underneath the bed and put the call light within reach of Resident #35. Resident #35 was observed grabbing the call light and holding it in his hand. The Administrator stated the problem with the call light being underneath the Resident's bed was he could not reach it to call for help. The Administrator indicated Resident #35 yelled for help when he needs it. The Administrator expected staff to put the call light within reach of residents before they leave the room. <BR/>In an interview on 8-8-2024 at 11:00 AM, CNA E stated she has worked at the facility for 1.5 years and worked the hall Resident #35 resided on. CNA E stated she thought the reason Resident #35's call light was on the floor underneath his bed, out of reach, was because housekeeping came in his room, cleaned the bed, and forgot to put the call light back in place within reach of Resident #35. CNA E said the concern for Resident #35 not having his call light within reach was he was a fall risk and if he was having a hard time finding the call light, he could possibly fall. <BR/>In an interview on 8-8-2024 at 11:25 AM, LVN C stated she has worked at the facility for 10 months and works the hallway where Resident #35 resides. LVN C stated that it was everyone's responsibility to ensure residents have their call lights within reach. LVN C stated the risk to Resident #35 not having his call light within reach was if he needed help he would not be able to easily contact staff. LVN C stated Resident #35 has yelled out for help. <BR/>In an interview with the DON on 8-8-2024 at 12:00 PM revealed the concern for Resident #35 not having his call light within reach was that he was a fall risk and might need help. The DON stated that her expectation was for staff, before they exited resident's rooms, to ensure call lights are within reach. <BR/>Record review of the facility's call light policy dated 9-2022 on 8-8-2024 at 4:00 PM stated:<BR/>Call System, Resident<BR/>Policy Heading<BR/>Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.<BR/>Policy Interpretation and Implementation<BR/>1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 8 residents (Residents #17 and #25) reviewed for Comprehensive Care Plans. <BR/>The facility failed to complete a comprehensive care plan for Residents #17 and #25. <BR/>This failure could place residents at risk of not receiving necessary care and services. <BR/>Findings included: <BR/>1.Review of Resident #17's admission Record, dated August 08, 2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]/24 with diagnoses that included Unspecified Sequelae Of Unspecified Cerebrovascular Disease, Dysphagia, Oropharyngeal Phase, Unspecified Dementia, Unspecified Severity, With Agitation, Mild Neurocognitive Disorder Due To Known Physiological Condition With Behavioral Disturbance, Generalized Anxiety Disorder, Other Specified Disorders Of Brain, Muscle Weakness (Generalized), Unspecified Lack Of Coordination, as well as high blood pressure and high cholesterol. <BR/>Review of Resident #17's admission MDS, dated [DATE], reflected a BIMS score of 6, indicating severe cognition impairment. The MDS further reflected Resident #17 had physical and verbal symptoms directed towards others, exhibited wandering behaviors 4-6 times a week but not daily, required staff's moderate assistance for oral hygiene, personal hygiene, toileting and showering, and supervision for eating. The MDS revealed Resident #17 was frequently incontinent of bladder and bowel. The MDS reflected Resident #17 was taking an antipsychotic, antidepressant, antibiotic, and antiplatelet medications. <BR/>Review of Resident #17's care plan, dated July 19, 2024, revealed The resident has nutritional problem or potential nutritional problem (SPECIFY) r/t malnutrition. The care plan did not reflect any other care areas. <BR/>2.Record Review of Resident #25's admission Record dated August 08, 2024, revealed a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses that included Brief Psychotic Disorder, Generalized Anxiety Disorder, Dorsalgia, Unspecified (Pain in the Back), Complex Regional Pain Syndrome I, Unspecified, Complex Regional Pain Syndrome I, Unspecified, Muscle Wasting And Atrophy, Not Elsewhere Classified, Multiple Sites, and Unspecified Abnormalities Of Gait And Mobility. Resident was her own RP. <BR/>Review of Resident #25's admission Care Plan, dated July 23, 2024, revealed that not all focus areas had goals or resident specific information. There were no goals or interventions or indication if Resident #25 did nor did not take a sedative/hypnotic therapy or if an antidepressant medication was used, goals for gradual dose reduction of those medications, or a long term plan for administration of the medications related to Resident #25 diagnoses of Generalized Anxiety Disorder and Brief Psychotic Disorder. <BR/>In an interview on August 8, 2024, at 12:14PM, the SW stated that Comprehensive Care Plan categories were completed by the appropriate departments; the MDS LVN would monitor for completion by the departments, with the SW providing backup. The SW stated that the comprehensive care plans were usually completed on the same day as the IDT meeting. The EHR system would also notify when tasks such as comprehensive care plans were due on the responsible user's dashboard and then that user would alert the specific department that needed to complete their section if it was not their own area. The SW stated that the comprehensive care plan was to have been completed within 30 days of a resident admitting to the facility or within 7 days of the MDS being completed in the EHR. The SW also stated that if the MDS had been completed but there was no IDT meeting, or the resident did not want to participate, then the MDS LVN and SW would give the departments additional time to complete their sections of the comprehensive care plan to allow time for the RP to be contacted or the resident to change their mind and participate. <BR/>In an interview of LVN A on August 8, 2024, at 1:09PM, LVN A stated that it was the responsibility of the nursing team to complete the baseline assessment which triggered the EHR to alert for the Comprehensive Care Plan to be completed. LVN A stated that it was the goal to have the Comprehensive Care Plan completed within seven days of a resident's admission to the facility. LVN A stated there were processes in place to keep a resident from not receiving a baseline or comprehensive care plan such as level of care meetings each Tuesday, morning meetings to discuss any admits, discharges, or changes on conditions, as well as the EHR alerts for any census changes. LVN A stated that if a care plan, either baseline or comprehensive, were not done it would be addressed in the next meeting. LVN A shared that for a resident to not have had a timely baseline or comprehensive care plan then the resident care could be impacted like a staff member who was new to the resident would not have known the plan of care or what interventions to use that were most effective.<BR/>In an interview of LVN B on August 8, 2024, at 1:28PM, the LVN stated that resident care plans were normally reviewed briefly on Mondays, the first day on duty after scheduled days off. LVN B also stated that a 24-hour report was reviewed for any changes in residents while off as well. LVN B stated that if residents were not having care plans completed then residents would not be receiving the care they needed as staff would have no way to know what a resident required such as incontinent care, assistance with showering, would have been at risk from a fall if transfer status was not known, have elopement risk, and interventions for behaviors may have been unknown. <BR/>In an interview on August 8, 2024, at 1:40 PM, CNA C stated that comprehensive care plans were checked when there was a new resident to know what level of care to expect to provide, what behaviors a resident may exhibit and the interventions that may have to be used. CNA C stated that if the comprehensive care plans are not in the EMR, staff were to ask the floor nurse for information on the resident and advise the floor nurse and DON of the information that was missing. CNA C stated that risk of not having a baseline or comprehensive care plan could result in staff missing a change of condition, the resident not being assisted with meals, missed changes in sleep patterns, falls, missed need for incontinent care, behavioral issues and interventions or redirection not as effective. <BR/>In an interview on August 8, 2024, at 2:19 PM, CNA D stated that care plans were not reviewed very often but previously has looked at care plans when charting for more information on a resident that has had a change of condition or behavioral issues. CNA D stated that if there were no baseline or comprehensive care plan then the floor nurse would have been notified along with the ADON and DON. CNA D shared that missing care plans could have a negative impact on a resident by staff not knowing dietary needs such as if a resident was a choking risk, what incontinent care needs were, who a contact person was for the resident, who specialty care providers were, what behavior issues the resident had in the past and how to best redirect the resident. <BR/>In an interview with the DON on August 8, 2024, at 3;13PM, it was revealed that the goal was to have the baseline care plan complete within 24 hours of admission and the comprehensive care plan within 72 hours of admission when possible but no later than 30 days from admission. If a care plan is not entered, then that care plan was to be completed when discovered missing. The risk to residents who do not have care plans entered timely is inaccurate care being provided by staff. The DON stated that care plans were a process that began with the MDS nurse entering the baseline care plan and completing the MDS assessment, then the ADON and treatment nurses completing the comprehensive care plans and the DON would review daily for completion and sign off to close the comprehensive care plan when it was completed. When asked about the incomplete comprehensive care plans for residents #17 and #25, the DON stated she did not know what happened. <BR/>In an interview on August 8, 2024, at 3:48PM, the ADM stated that baseline care plans were to be entered within 72 hours of admission and comprehensive care plans were to be completed within 14 days of the baseline care plan. The ADM stated that care plans were the responsibility of the nurse managers to make sure they were completed timely. The ADM had expectations of all staff who notice a care plan was missing or incomplete should notify their supervisor of what was missing or incomplete or to make the entries themselves if capable and qualified to do so. The ADM shared that missing or incomplete care plans could impact a resident by causing a potential lapse in appropriate care if a resident was to have non-normal needs or requirements. <BR/>

Based on observation, interview, and record review the facility failed to ensure the facility's only garbage storage dumpster, and surrounding enclosed area, was maintained in a sanitary condition to prevent the attraction, nesting, and accumulation of pests. <BR/>The facility failed to ensure trash was not left outside of the dumpster on the ground. <BR/>These failures could place residents at risk of contracting disease by attracting pests, disease carrying rodents, and having debris dangerous to residents. <BR/>Findings included: <BR/>During an observation on August 8, 2024 at 3:45 PM of the dumpster area, on the north side of the building, there was trash debris including but not limited to used latex gloves, glass shards, broken overbed rolling tray tables, oscillating floor fans, bariatric bedside commode, well used recliner chair, well used mattress, split open bag of landscape mulch, opened individual dose medication blister packets, and base of a wheelchair scale. <BR/>In an interview on August 8, 2024, at 5:05PM with DM revealed that the dumpster area was the responsibility of the DM and kitchen staff. The DM stated that the DM and staff were to have picked up any trash or debris that was on the ground and place in the dumpster with the lid closed as there were to be no lose items on the ground and the dumpster was not to be overflowing. The DM stated that service company was to be called for an off schedule pick up when the dumpster got near full. The DM indicated that maintenance and the DM were ultimately responsible for the dumpster area. The DM stated the importance of being able to keep the dumpster area clean was to keep cats, rats, and animals in general out of the area. The DM stated the potential risk of the dumpster area not being kept clean could cause infection control issues. <BR/>In an interview on August 8, 2024, at 5:16PM with the MTNC it was revealed that each employee who used the dumpster was responsible to ensure the lid closed securely and there was no trash or items on the ground around the dumpster. The MTNCE stated that when the dumpster was overflowing, staff were to notify MTNC or DM for a call to the service company for off schedule pick up. MTNC stated that the service company was scheduled to pick up once a day Monday-Saturday and prn when called. The MTNC revealed the maintenance department and housekeeping, who also fall under maintenance, are the ones responsible for the dumpster area. The MTNC stated that it was important for the dumpster lid to be kept closed as unauthorized people or animals could have accessed the area. The MTNC stated when the dumpster area was not maintained properly, the area posed potential risks to residents of bad odors, comfortability, attracted insects and pests. Staff had been informed that when they notice the dumpster was getting full, they needed to let him know so off schedule pick up could be arranged. <BR/>In an interview on August 8, 2024, at 5:25PM, the ADM revealed the MTNC and housekeeping staff were responsible for the dumpster area daily to make sure all trash and items were securely in the dumpster and the lid closed. The ADM stated staff were to contact the MTNC and ADM if the dumpster reached a point of overflowing for the service company to make an off schedule pick up. The ADM stated the general upkeep to the dumpster area fell to the MTNC and ADM. The ADM stated it was important that the dumpster lid was kept closed to avoid smells and attracting pests. The ADM stated that when the dumpster area was not maintained correctly it posed a risk to residents of creating odors and infection control issues. <BR/>Record review of the Food and Drug Administration Food Code 2022 dated 1-18-2023 stated: <BR/>Chapter 5: Water, Plumbing and Waste <BR/>Operation and maintenance:<BR/>5-501.110 Storing Refuse, Recyclables, and Returnables.<BR/>REFUSE, recyclables, and returnables shall be stored in receptacles or waste <BR/>handling units so that they are inaccessible to insects and rodents. <BR/>5-501.111 Areas, Enclosures, and Receptacles, Good Repair.<BR/>Storage areas, enclosures, and receptacles for REFUSE, recyclables, and <BR/>returnables shall be maintained in good repair. <BR/>5-501.112 Outside Storage Prohibitions.<BR/>(A) Except as specified in (B) of this section, REFUSE receptacles not meeting <BR/>the requirements specified under 5-501.13(A) such as receptacles that are not <BR/>rodent-resistant, unprotected plastic bags and paper bags, or baled units that <BR/>contain materials with FOOD residue may not be stored outside. <BR/>(B) Cardboard or other packaging material that does not contain FOOD residues <BR/>and that is awaiting regularly scheduled delivery to a recycling or disposal site <BR/>may be stored outside without being in a covered receptacle if it is stored so that <BR/>it does not create a rodent harborage problem. <BR/>5-501.113 Covering Receptacles. <BR/>Receptacles and waste handling units for REFUSE, recyclables, and returnables <BR/>shall be kept covered: <BR/>(A) Inside the FOOD ESTABLISHMENT if the receptacles and units:<BR/>(1) Contain FOOD residue and are not in continuous use; or<BR/>(2) After they are filled; and<BR/>(B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. <BR/>5-501.115 Maintaining Refuse Areas and Enclosures.<BR/> A storage area and enclosure for REFUSE, recyclables, or returnables shall be maintained free of unnecessary items, as specified under &sect; 6-501.114, and clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to recognize the resident had the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law and the facility must treat the decisions of a resident representative as the decisions of the resident for one (Resident #1) of three residents reviewed for resident rights. <BR/>The facility failed to include Resident #1's RP when Resident #86 was asked to sign a disenrollment form in order to change her Medicare insurance. <BR/>This failure could place residents at risk of not having their RP included to make informed decisions regarding their care resulting in delayed treatment or a decline in condition. <BR/>Findings included: <BR/>Review of Resident #86's admission Record dated 08/08/24, reflected she was an [AGE] year-old woman, admitted on [DATE], with diagnoses of Alzheimer's dementia and other dementia. Resident #86 was listed as her only contact. <BR/>Review of Resident #86's admission MDS, dated [DATE], reflected she was able to make herself understood by others, and usually understood others. Resident #86 had a BIMS of zero, indicating severe cognitive impairment. Resident #86 exhibited fluctuating inattention and disorganized thinking, but had no intrusive behaviors during the seven-day lookback period. <BR/>Resident #86's care plan, dated 06/27/24, reflected she was an elopement risk, and used antidepressant and psychotropic medications. <BR/>Review of Resident #86's EMR reflected a document named Hospital Records , which contained the Resident #86's admission Record (face sheet) from the discharging facility, dated 06/25/24. The face sheet reflected Resident #86 noted as her own Responsible Party, and the name and contact information for a family member (her RP), as her emergency contact #1.<BR/>Review of the EMR for Resident #86, accessed on 08/08/24 at 3:00 PM, reflected her profile had her listed as her own sole contact and as Relationship: Self and No Contact Type Assigned. <BR/>An interview on 08/06/24 at 4:06 PM with Resident #86's RP revealed the resident had been discharged immediately after being admitted to another facility, due to being an elopement risk. She described how her experience with the two facilities involved (the discharging facility and this facility) left her very angry and frustrated, and on 07/18/24 she went to the facility and took the resident out. She said the staff refused to release Resident #86's medications, and when she attempted to get the prescriptions refilled, she learned that the facility had changed the resident's insurance, and she was unable to do so. She said that she was able to re-fill the three most urgent and important medications out-of-pocket, but she could not afford to buy all of them herself, so the resident went without some of her medications as a result of the facility changing her insurance. Resident #86's RP said when she contacted the facility she was informed that they had gotten Resident #86 to sign the form herself, and anybody could tell by interacting with the resident that she was not mentally able to understand what she was signing. She said Resident #86 was at home with her and because she was able to get some of the medications herself, Resident #86 did not appear to have suffered without her medications, but she found it disturbing that the facility would allow someone with advanced dementia to sign a form to change their insurance, and because they did she was left to handle the repercussions of it. <BR/>An interview on 08/08/24 at 2:19 PM with the HR/BOM revealed she did change Resident #86's insurance, because the facility was not contracted with the Medicare advantage insurance the resident had, and they needed to switch her to regular Medicare so she could get therapy. She showed the surveyor the form Resident #86 signed, and said she had the resident sign the form with two other staff present , and they explained it. She said at the time, she did not have contact information for Resident #86's RP, and the resident was listed as her own RP. She said if the resident had a family member listed, they would have been notified and asked to sign the form. She was not aware it had caused any problems for the resident, and said the regular Medicare should have paid for the resident's medications. <BR/>An interview on 08/08/24 at 2:48 PM with the DON revealed the facility only received minimal information with Resident #86 when she was admitted . She said she did come with a medication list, which she provided to the surveyor. She said Resident #86's family member was very upset, and felt the facility was attempting to block her from getting the resident into a facility nearer her, but they really were doing their best to get the information they needed. The other facility would not accept her without the clinical information, which they did not have. <BR/>An interview on 08/08/24 at 3:02 PM with the SW revealed she remembered Resident #86, but had witnessed so many residents signing forms she could not remember if she witnessed Resident #86 doing so. She said she did the BIMS assessment herself, and she would not be comfortable with a resident who was not cognitively aware, and could not understand, signing forms, and Resident 86 was not able to make decisions about things like insurance. She said when they had a resident who was unable to make decisions for themselves, she would look further for contact information for their family, for example in their hospital records, and contact the family to make decisions. She said if they did not have family, they would attempt to find guardianship for the resident. She said allowing a resident who was unable to understand to change their insurance might jeopardize their insurance or medications. <BR/>An interview on 08/08/24 at 3:21 with the Administrator revealed he did not remember the specific information, but he did remember that Resident #86's admission was a mess and the discharging facility barely sent any clinical information for her. He felt that the other facility had dumped her there. He said the other facility brought her to the facility, and even though they contacted them immediately for her clinical records, they were not forthcoming with the additional records. He said when the family member wanted her moved to another facility, having only two pages of clinical records caused problems because the other facility would not accept her without more records. He said they kept trying to get access to additional information about the resident, but it took some time. He said when they needed papers signed, and a resident could not understand, the staff should have contacted the RP or next-of-kin, and they did not have a representative who could sign, they attempted to get guardianship , but that was not a fast process, even when expedited. <BR/>Review of an Against Medical Advice (AMA) form, dated 07/18/24, reflected Resident #86's RP signed the document, which said the resident was requesting to leave without the authority of, and against the advice of the attending physician. The form said the medical risks were explained, and the [NAME] understood the risks, and released the facility, personnel, and physician from responsibility. Handwritten on the form was Resident discharge to the hospital. No other concerns were voiced. The forms was signed by Resident #86's RP, the physician, and a witness (signature was illegible and identity of staff member unknown.) <BR/>Review of the facility policy Discharging a Resident Without a Physician's Approval, revised October 2012, reflected: Policy statement: a physicians order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice.; Policy interpretation and implementation: 1. Should a resident or his or her representative (sponsor), request an immediate discharge, the resident's attending physician will be promptly notified. 2. If the resident or representative (sponsor) insists upon being discharged without the approval of the attending physician, the resident and/or representative (sponsor) must sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the residence medical record and witnessed by two staff members. ( .) <BR/>Review of an email from the DON, sent on 08/10/24, at 5:46 PM, reflected the facility did not have a policy which addressed a resident's cognitive fitness to sign their own documents, or notifying their RP of documents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident, for 1 of 8 residents (Residents #17) reviewed for baseline care plans. <BR/>The facility failed to ensure Resident #17's baseline care plan was completed. <BR/>This failure could affect newly admitted residents and place them at risk of not receiving appropriate interventions to meet their current needs and communication among nursing home staff to ensure their immediate care needs were met. <BR/>The findings included: <BR/>Review of the clinical care plans of Resident #17 on August 8, 2024, at 8:25 AM revealed that there was not a baseline care plan started or completed between June 28, 2024 and August 8, 2024. <BR/>Review of Resident #17's admission Record, dated August 08, 2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Unspecified Sequelae Of Unspecified Cerebrovascular Disease, Dysphagia, Oropharyngeal Phase, Unspecified Dementia, Unspecified Severity, With Agitation, Mild Neurocognitive Disorder Due To Known Physiological Condition With Behavioral Disturbance, Generalized Anxiety Disorder, Other Specified Disorders Of Brain, Muscle Weakness (Generalized), Unspecified Lack Of Coordination, as well as high blood pressure and high cholesterol. <BR/>Record review on August 8, 2024 of Resident #17's admission Assessments revealed a Nursing-Wandering Assessment completed on June 30, 2024, that showed the resident was at a moderate risk for wandering; reassessment on July 2, 2024 showed a change to high risk for wandering. A Nursing- Fall Risk Assessment completed on June 30, 2024, revealed resident was a high fall risk. MDS Brief Interview for Mental Status assessment revealed a score of 6 which indicated a severe impairment.<BR/>Review of Resident #17's admission MDS, dated [DATE], reflected a BIMS score of 6, indicating severe cognition impairment. The MDS further reflected Resident #17 had physical and verbal symptoms directed towards others, exhibited wandering behaviors 4-6 times a week but not daily, required staff's moderate assistance for oral hygiene, personal hygiene, toileting and showering, and supervision for eating. The MDS revealed Resident #17 was frequently incontinent of bladder and bowel. The MDS reflected Resident #17 was taking an antipsychotic, antidepressant, antibiotic, and antiplatelet medications. <BR/>In an interview on August 8, 2024, at 12:14PM, the SW stated that baseline care plans were the responsibility to be completed by the MDS nurse. <BR/>In an interview on August 8, 2024, at 1:09PM LVN A stated that baseline care plans were the responsibility of the nursing team. LVN A stated the completion of the baseline care plan, was done in the first two day of admission to the facility. LVN A stated that if the baseline care plan were missed in the first two days it would be noticed at the weekly level of care meetings held on Tuesdays. LVN A stated that if a baseline care plan were not completed it could possibly impact the care a new resident received, such as staff members not knowing the resident not knowing the needs or interventions for that resident. <BR/>In an interview of LVN B on August 8, 2024, at 1:28PM, the LVN stated that resident care plans were normally reviewed briefly on Mondays, the first day on duty after scheduled days off. LVN B also stated that a 24-hour report was reviewed for any changes in residents while off as well. LVN B shared that if a baseline care plan for a new resident were not completed it would be reported to the DON and would assist with completing if the missing area was nursing related. LVN B stated that if residents were not having care plans completed then residents would not be receiving the care they needed as staff would have no way to know what a resident required such as incontinent care, assistance with showering, would have been at risk from a fall if transfer status was not known, have elopement risk, and interventions for behaviors may have been unknown. <BR/>In an interview on August 8, 2024, at 1:40 PM, CNA C stated the risk of not having a baseline care plan could result in staff missing a change of condition, the resident not being assisted with meals, missed changes in sleep patterns, falls, missed need for incontinent care, behavioral issues and interventions or redirection not as effective. <BR/>In an interview on August 8, 2024, at 2:19 PM, CNA D stated if there were no baseline then the floor nurse would have been notified along with the ADON and DON. CNA D stated missing care plans could have a negative impact on a resident by staff not knowing dietary needs such as if a resident was a choking risk, what incontinent care needs were, who a contact person was for the resident, who specialty care providers were, what behavior issues the resident had in the past and how to best redirect the resident. <BR/>In an interview with the DON on August 8, 2024, at 3;13PM, it was revealed that the goal was to have the baseline care plan complete within 24 hours of admission. The risk to residents who do not have care plans entered timely was inaccurate care being provided by staff. The DON stated that care plans were a process that began with the MDS nurse entering the baseline care plan. The DON stated she did not know what happened to Resident #17's baseline care plan. <BR/>In an interview on August 8, 2024, at 3:48PM, the ADM stated that baseline care plans were to be entered within 72 hours of admission. The ADM stated that care plans were the responsibility of the nurse managers to make sure they were completed timely. The ADM shared that missing or incomplete care plans could impact a resident by causing a potential lapse in appropriate care if a resident was to have non-normal needs or requirements. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 4 of 4 Residents (Resident #6, Resident #7, and Resident #9) reviewed for smoking, and 1 of 1 Resident (Resident #4) reviewed for environment.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were provided supervision while smoking.<BR/>The facility failed to ensure Residents #6, Resident #7, and Resident #9 were accurately assessed for smoking.<BR/>The facility failed to ensure Resident #9 was assessed for smoking per facility policy. <BR/>The facility failed to ensure Resident #4 did not have an electric kettle in her room on the secure unit. <BR/>These failures could place residents at risk of harm, injury, or accidents. <BR/>Findings included:<BR/>Record review of Resident #6's admission Record, dated [DATE], revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Encephalopathy (this is a brain disease that alters brain function or structure) and unspecified visual loss. <BR/>Record review of Resident #6's MDS, dated [DATE], revealed a BIMS score of 13 indicating the individual's cognition is intact.<BR/>Record review of Resident #6's Care Plan, date initiated [DATE], reflected the resident is a smoker. Goal: the resident will not suffer injury from unsafe smoking practices. Interventions: The resident requires supervision while smoking. <BR/>Record review of Resident #6's Smoking-safety screen, dated [DATE], revealed the resident is safe to smoke with supervision. Vision: Does resident have any visual deficit. 1. Yes. Safety: 6. Can resident light own cigarette? No. 7. Resident need for adaptive equipment. 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes F. IDTC Decision; 1 Notes on Safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): IDT agrees the resident requires supervision while smoking d/t unspecified visual loss. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t dx unspecified visual loss. <BR/>Record review of Resident #7's admission MDS, dated [DATE], revealed an admission date to the facility on [DATE]. Further review revealed a BIMS score of 14, indicating intact cognition. <BR/>Record review of Resident #7's care plan dated [DATE] revealed resident was a smoker. <BR/>Record review of Resident #7's smoking assessment, dated [DATE], revealed resident did not have cognitive loss or dexterity problems but did have visual deficits, could not light own cigarette and needed supervision. Rationale/conditions: IDT agrees the resident requires supervision while smoking d/t Hordeolum externum (an infection of an oil gland at the edge of eyelid) unspecified eye.<BR/>Record review of Resident #9's admission Record revealed, a [AGE] year-old male, initially admitted on [DATE] and re-admitted on [DATE] with diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), with (Acute) Exacerbation.<BR/>Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score of 13 indicating intact cognition. <BR/>Record review of Resident #9's Care Plan, date initiated: [DATE], reflected the resident is a smoker. Goal: The resident will not suffer injury from unsafe smoking practices. Interventions: the resident requires supervision while smoking. <BR/>Record review of Resident #9's Smoking- Safety Screen, dated [DATE], revealed, Category: Safe to smoke with supervision. <BR/>E. Safety- Can resident light own cigarette? No. 7. Resident need for adaptive equipment 7c. Supervision. 8. Does resident need facility to store lighter and cigarettes? 1. Yes. F. IDTC Decision: 1. Notes on Safety From IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. 2. Team Decision: 2. Safe to smoke with supervision. 3. Rationale/conditions: Resident meets criteria for safe smoker. Smokers are supervised by staff during smoking breaks. <BR/>No other smoking assessment had been completed for Resident #9. <BR/>Record review of Resident #4's admission Record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease , major depressive disorder, and anxiety. <BR/>Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment.<BR/>Record review of Resident #4's care plan, dated [DATE], did not reveal anything related to an electric kettle.<BR/>In an observation and interview on [DATE] at 11:21 AM, Resident #4 was in her room sitting up in her w/c drinking coffee. A small blue kettle was observed plugged in near the sink. Resident #4 stated her family member sent it to her. <BR/>In an observation and interview on [DATE] at 12:06 PM, Resident #6 walked out of her room holding a cigarette pack and a lighter. Resident #6 entered the code to go outside on the smoking area. Surveyors went outside and observed Resident #6 and Resident #7 smoking with no staff present. Resident #6 stated she knew the code to enter to go outside, staff were aware she smoked, and stated she was allowed to keep her smoking materials with her. Resident #6 stated she took about 3-5 smoke breaks a day and did not need an apron to smoke. Resident #7 was observed with a cigarette and lighter. Resident #7 stated she knew the codes and all residents knew the codes. Resident #7 stated she had been there about 4 months, and staff had never taken away her cigarettes or lighter. Resident #7 said the staff had nobody to bring them to smoke so she guessed that was why residents went out by themselves. <BR/>In an interview on [DATE] at 1:02 PM, LVN E stated residents were not allowed to have their cigarettes or lighters in their possession and smoking materials were locked up behind the nurse's station. She stated residents had designated smoke times and must be supervised during smoking unless they sign out and go out the front and leave the facility. She said supervision meant that one of the workers on shift must light the cigarettes, pass them out and stay until everyone was done smoking. She stated the risk to residents having cigarettes and lighters was they could set something on fire or hurt someone else or themselves. <BR/>In an interview on [DATE] at 1:04 PM, LVN G stated usually the aides supervised residents who smoked. He stated no residents were to have their lighters or cigarettes. He did not know who completed the smoking assessment and did not know what supervision meant since he did not complete the assessments. He stated if residents were not supervised while smoking, they could hurt themselves. <BR/>In an interview on [DATE] at 1:09 PM, CNA F stated residents were not supposed to have cigarettes or lighters on their person and staff were to supervise residents while smoking. She stated supervision meant they pass out the cigarettes, light them and stay with residents until done. She said cigarettes and lighters were kept in a container behind the nurse's station. CNA F stated there were no residents that she knew of that were allowed to keep their cigarettes or lighters. She stated the risk to the residents of having a cigarette or lighter was because there have been some incidents of them falling asleep and burning themselves. <BR/>In an interview on [DATE] at 1:15 PM, CNA H stated residents were not supposed to have their smoking materials and they were kept in the lock box behind the cart. She stated only staff can get into it or the person who smokes them. CNA H stated supervision meant making sure residents were smoking properly and they were safe. She said one staff member supervises and usually will light the cigarette or get the lighter back from the resident. She said residents were not allowed to go out in the smoking area with O2 because it could burn or blow up. She said the O2 tank should be inside at all times. She stated if residents were not supervised while smoking, they could burn themselves or anything could happen. <BR/>Observation and interview on [DATE] at 1:11 PM, revealed Resident #9 smoking without any staff present. He stated he goes outside to smoke every couple of hours and keeps his cigarettes and lighter in his possession. <BR/>In an interview on [DATE] at 1:26 PM, the DON stated according to their policy, if a resident was a safe smoker, the resident can have a lighter and cigarette, and if an unsafe smoker, smoking materials were locked up. She stated safe and unsafe smokers were determined by the assessment. The DON said supervision meant staff would be out there with unsafe smokers. For safe smokers, supervision meant that staff just have eyes on them She stated if residents who were deemed unsafe smokers smoked without supervision, they could be at risk for burns. <BR/>In an interview on [DATE] at 1:35 PM, the Administrator stated if residents were deemed safe smokers, they could have their paraphernalia. He said they encouraged residents to lock them up but also have a very able bodied population, and if they signed out and were able to purchase those items it would be hard to police. He said an assessment was completed to see if the resident would meet the criteria for safe smoking The Administrator stated his understanding of safe and unsafe smoking was whether under reasonable circumstances residents were safe to hold, light, smoke and extinguish a cigarette in a safe way. He stated residents on O2 were not supposed to go out on the smoking area with the O2 tank. He said the risk for residents who were deemed unsafe and went to smoke without direct supervision was they would have the potential for bodily harm and a burn. He stated if residents threw lit cigarettes on the ground, it could be a risk of fire. <BR/>In an interview and record review on [DATE] at 1:35 PM, the Administrator stated Resident #7 was a safe smoker. Review of EHR revealed a smoking assessment had just been completed and was dated [DATE] and Resident #7 was a safe smoker. Review of the previous smoking assessment dated [DATE] indicated supervision was required. The Administrator stated he was not expecting the assessment for Resident #7 to say smoke with supervision. <BR/>In an interview on [DATE] at 4:51 PM, the Social Worker stated she was responsible to do the smoking assessments when a resident first admits and then quarterly. She stated sometimes the nurse would assess but she mainly did them. She said she based the assessments on their BIMS, diagnoses and if they were a smoker and how often. She said especially when they first got there, she puts that they need supervision, since staff do not know them that well, and as a safety precaution. She said supervision meant having someone out there watching them smoke and having their smoking articles locked up at the nurse's station. She said if residents needed help with lighting cigarettes, then provide assistance with that. She stated there were residents who were safe smokers that were alert and oriented x3 (a person is alert and oriented to person, place and time), and had no impairments that may prevent them from smoking by themselves. She said she did see a risk if residents who were unsafe went to smoke by themselves. <BR/>In an interview on [DATE] at 8:11 AM, the Administrator stated he had done a QAPI meeting about smoking, had done inservice and was still inservicing staff and would provide them to Surveyor when all done. <BR/>In an interview on [DATE] at 3:00 PM, the DON supervision was based on diagnosis and case by case. She said some residents would be immediately unsafe and there was no way physically they could smoke safety.<BR/>In an interview on [DATE] at 3:14 PM, the Administrator stated he re-educated staff this morning, and in serviced the SW directly on smoking assessment. He said he found that the assessments were inconsistent with the policy, redid all smoking assessments and corrected them and inserviced staff on the smoking policy, what a safe smoker was, and guidelines. He stated a safe smoker verified by smoking assessment meant they were allowed to smoke without staff, have cigarettes and a disposable lighter and not allowed to share paraphernalia with other residents. He said unsafe smokers, which continued to be the entire secure unit due to cognition, would take scheduled smoke breaks and not keep their materials. The Administrator said Resident #4 was not to have an electric kettle in her room and was not aware there was one in the room. He stated the risk to residents could be burns. <BR/>Record review of facility policy, titled Smoking Policy - Residents Revised [DATE], revealed in part:<BR/>This facility shall establish and maintain safe resident smoking practices .<BR/>8. A resident's ability to smoke safety will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.<BR/>9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.<BR/>10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safety with the available levels of support and supervision.<BR/>11. Any resident 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. <BR/>12. Residents who have smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited .<BR/>No other policy on Accidents/Hazards was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident has the right to be informed in advance, by the physician or other practitioner or other professional of the risks and benefits of proposed care, treatment and treatment alternatives for one (Resident #1) of five residents reviewed for consent of psychoactive medications.<BR/>Resident #1 did not consent for the use of Cymbalta (antidepressant) when his Prozac was discontinued after admission to the facility without his knowledge or input. He unknowingly received Cymbalta and did not feel like it was helping with his depression. <BR/>The failure could place residents prescribed antipsychotic medications at risk of receiving a medication without consent, which could cause duplicate therapy, sedation, side-effects and uncomfortable emotional changes. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 11/16/23, reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included depression (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (a feeling of fear, dread and uneasiness), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and chronic pain syndrome (occurs when pain remains long after an illness or injury has healed).<BR/> Review of Resident #1's clinical chart reflected he was his own responsible party.<BR/>Record review of Resident #1's annual MDS assessment dated [DATE] reflected no hearing, speech or vision issues and a BIMS score of 14, which indicated no cognitive impairment. Resident #1 had no behavioral issues. His mood issues related to feeling depressed, down and hopeless were noted as occurring every day. Resident #1 had scheduled and PRN pain management regimen. He had presence of pain frequently which occasionally affected his sleep but rarely interfered with therapy and day-to-day activities. Resident #1's pain intensity was listed at a seven out of ten during the assessment period. Resident #1 took high-risk drugs including opioids, antidepressant and antianxiety medications. <BR/>Record review of Resident #1's care plan dated 10/26/23 and last revised 11/15/23 did not discuss the use of Cymbalta. The care plan reflected:<BR/>- Focus: The resident has a mood problem r/t _____[blank]. Date Initiated: 11/15/2023. Goal: The resident will have improved mood state (SPECIFY: happier, calmer appearance, no s/sx of depression, anxiety or sadness) through the review date. No interventions were listed. <BR/>-Focus: The resident has depression r/t ________[blank]. Date Initiated: 11/15/2023. Goal: The resident will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood by/through review date. No interventions were listed. <BR/>Record review of Resident #1's current November 2023 physician orders reflected he was prescribed, Cymbalta Oral Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth one time a day for DX: GAD, neuropathic pain (verbal order given on 10/30/2023, medication started on 11/08/2023)<BR/>Review of Resident #1's hospital discharge records at the time of admission [DATE]) reflected he was sent to the facility with orders that included Fluoxetine (Prozac) 20 mg- three capsules every morning for depression. <BR/>Record review of Resident #1's October 2023 MAR reflected prior to starting Cymbalta, Resident #1 was being administered Fluoxetine (Prozac) 20 MG 3 capsules in the morning for Depression, then titrated to 20 MG 2 capsules in the morning for one week (Start date 10/20/23 and discontinued 11/06/23). <BR/>Record review of Resident #1's physician order dated 10/30/23 reflected, Cymbalta Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day for DX: GAD, neuropathic pain [Start Date: 11/08/2023.<BR/>Record review of Resident #1's November 2023 MAR reflected he was administered Cymbalta from 11/08/23 through 11/15/23. <BR/>Review of Resident #1's clinical chart revealed no consent for Cymbalta. <BR/>An observation and interview with Resident #1 on 11/15/23 at 2:56 PM revealed he was feeling depressed and felt that his Prozac was not working and needed to be seen by a psychiatrist. He stated he had been trying to locate a psychiatrist on his own by just looking online to see who took his insurance. He said he had bene taking Prozac for a long time prior to admission and felt the facility was not giving it to him. He said if they had changed it to Cymbalta, no one had ever told him. He denied being seen by a therapist or psychiatrist and said no one asked for his input on any antidepressant medication changes. Resident #1 denied being presented with any information to get his consent on changing medications form Prozac to Cymbalta and was upset that change had been made without his approval. He did not feel like the Cymbalta was effective and wanted to go back to Prozac. <BR/>An interview with the DON on 11/15/23 at 5:13 PM revealed the PMNHP saw Resident #1 off the books because he was having some behaviors after admission and We needed him to be seen while the psyche referral was in process. The DON stated the PMHNP changed Resident #1's medication from Prozac to Cymbalta, but the DON did not know why. The DON could not locate any clinical documentation from the PMHNP and stated she would reach out to try and obtain her progress notes for Resident #1.<BR/>An interview with the SW on 11/16/23 at 10:44 AM revealed Resident #1 had been referred to psyche services because of depression with the death of his family member . She had not reviewed the PMHNP's progress notes and looked in the chart for them and could not locate them. She did not know why his medications were changed. The SW said the psychiatry session notes were supposed to be reviewed to see what was going on, why medications were changed, see if residents were informed of the changes and it also let the facility what was going on in the session. The SW stated psychotropic consents were supposed to be completed by the charge nurse for the resident at the time the medication was ordered.<BR/>Review of Resident #1's Psychiatric Initial Assessment was provided by the facility on 11/16/23 and completed on 11/01/23 by the PMHNP. The assessment reflected Resident #1 was being seen for generalized anxiety disorder and depression. The assessment further reflected, Patient endorses current symptoms of sad moods, loss of interest, fatigue, psychomotor slowing, decreased concentration and appetite change and denies symptoms of guilt, feelings of worthlessness, psychomotor agitation and suicidal ideation/intent/plan. Severity is level 8 (Severe). Symptoms have been occurring for 2 weeks. The PMHNP recommended discontinuing Prozac and starting Cymbalta and stated, Informed Consent: This assessment is prepared in consultation with Staff, Physicians, Interview with the Patient/Resident and/or Family and Review of the Medical Records. Informed consent and limits of confidentiality were explained to the patient. In addition, the risks and benefit of psychotropic medications were discussed.<BR/>An interview with ADON C on 11/16/23 at 11:26 AM revealed psychotropic consents were supposed to be completed as soon as a resident admitted to the facility and when a new order was written. ADON C stated there were blank consent forms in every drawer at the nurses' station and anytime she saw a new order for a psyche med come in, she made a mental code to follow up, ask the nurse if they got the consent. ADON C stated any nurse could complete the consent. ADON C stated she remembered talked to Resident #1 about his psyche meds during the past week and he wanted his medication changed back to Prozac from Cymbalta. ADON C stated the PMHNP came to the facility every week so she told Resident #1 could talk to her about it when she was at the facility and he could discuss his goals with her. <BR/>Review of aa nursing progress note for Resident #1 written by ADON C on 10/20/23 at 12:45 PM reflected, Per Psyche- .(2) D/C current fluoxetine ord. Start Fluoxetine 40 mg PO QD x 1 week then D/C. (3) Start Cymbalta 30 mg PO QD once Fluoxetine is D/CED. DX: GAD. Neuropathic pain. RP notified. <BR/>A follow up interview with ADON C on 11/16/23 at 12:49 PM revealed she was the person who took the order for Resident #1's Cymbalta. She stated she did not get consent from Resident #1 to discontinue the Prozac and start the Cymbalta or explain the use/dosage/duration/reason for the change. ADON C stated she did not work on the floor and was probably just helping out that day the order came in. She said she would have just taken the order from the PMHNP along with other order for residents seen that day and then written the psyche consent form and given it to the charge nurse(s) to have them follow up and get it signed. ADON C stated she did not know if the nurses followed through and got Resident #1's consent for Cymbalta signed, she just was helping out. ADON C stated she did not get the resident to sign the psychotropic consent, even though she was the person who took the order. <BR/>A policy related to psychotropic medications and consent for treatment was requested on 11/16/23 at 10:00 AM to the DON but none was provided. The only policy provided was about Antipsychotic Medication use and did not address consent for medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 5 residents (Resident #1) reviewed for shower documentation. <BR/>The facility failed to ensure documentation reflected Resident #1 received showers as scheduled and desired. <BR/>This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life. <BR/>Findings Included: <BR/>Record review of Resident #1's Face Sheet dated 4-24-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Sequelae (a condition which is the consequence of a previous disease or injury) following nontraumatic subarachnoid hemorrhage (bleeding into the space between the brain and the thin tissues that cover it causing long-term or permanent neurological, cognitive, or physical consequences) and secondary diagnoses of anxiety disorder, unspecified dementia (a decline in mental ability severe enough to interfere with daily life), Hypokalemia (abnormally low levels of potassium in the blood), and lack of coordination. <BR/>Record review of Resident #1's Nursing Home PPS (NP) Item set (this is the initial 5-day assessment used to bill for Medicare Part A) MDS assessment dated [DATE] revealed a BIMS Score of 7 indicating severe cognitive impairment. Resident #1's Functional Abilities of the MDS indicated Resident #1 needed partial assistance (where the helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs in bathing or showering). <BR/>Record review of the facility's shower log on 4-24-2025 at 3:00 PM, indicated no shower sheets were filled out for Resident #1 from 4-3-2025 through 4-11-2025 (a 9-day period) and from 4-13-2025 through 4-15-2025 (a 3-day period). Record review of the facility's electronic medical record bathing log corroborated this finding. There were also no indications in the shower log or electronic medical record that Resident #1 ever refused a shower. <BR/>In an interview with the DON on 4-24-2025 at 10:30 AM she disclosed the facility keeps track of resident's showers by keeping shower sheets in on large binder for the entire facility. <BR/>In an observation and interview on 4-24-2025 at 11:00 AM, revealed Resident #1, whose room was an even-numbered room, in which showers were provided on Mondays, Wednesdays, and Fridays, appeared clean, and stated she was getting her showers. <BR/>In an interview on 4-24-2025 at 1:15 PM, CNA A stated she gives showers to the residents. CNA A said the facility keeps track of who gets showered on shower sheets, in the shower log, and it is kept in a binder. CNA A said if someone refuses a shower, they log it in the shower logbook on a shower sheet. CNA A stated the odd number rooms get showered on Tuesday, Thursday, and Saturday while the even number rooms get showed on Monday, Wednesday, and Friday. CNA A stated she makes rounds to ensure everyone gets a shower who is scheduled for one. <BR/>In an interview with the DON on 4-24-2025 at 4:00 PM it was conveyed that the DON's expectation was that every resident room be set for shower days having the odd number of rooms be offered a shower every Tuesday, Thursday, and Saturday and the even number rooms be offered a shower every Monday, Wednesday, and Friday. The DON said the potential harm to a resident not getting showered, in a 9-day period, was that it could cause hygiene issues. <BR/>In an interview with the Administrator on 4-24-2025 at 5:00 PM it was revealed that his expectation was that each resident get showered 3 times a week at a minimum and if they want more showers to tell the staff so the staff can give them more showers. The Administrator stated if a resident refuses a shower, he expected it to be logged on a shower sheet and put in the shower logbook. The Administrator said the risk for a resident not receiving a shower in a 9-day period was resident hygiene. <BR/>In an interview with the Administrator on 4-29-2025 at 1:22 PM it was revealed that the facility had a shower/bathing policy, and the Administrator was asked for the policy. However, the shower/bathing policy was never received.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 6 residents (Resident #1, Resident #2, and Resident #3) observed for environment.<BR/>The facility failed to:<BR/>- fix the light fixture above the sink in Resident #1's room <BR/>- fix the light fixture in the bathroom between Resident #1 and Resident #2's room.<BR/>-fix the light fixture above the sink and the footboard in Resident #3's room. <BR/>This failure could place residents at risk for injury and decreased quality of life.<BR/>Findings included:<BR/>Interview and observation on 08/23/2023 at 10:36 a.m., Resident #1 stated the light over the sink and in the bathroom does not work and he told staff last week. Observation in Resident #1's room revealed the light switch was in the on position, but the light was not working. Observation of the bathroom revealed the light did not turn on. <BR/>Interview on 08/23/2023 at 11:46 a.m., Resident #1 stated he told the new maintenance man about the light and the maintenance man said he would fix it by Monday (08/21/2023). Resident #1 stated when he uses the restroom, he leaves the door open so he can see. <BR/>Observation and interview on 08/23/2023 at 12:01 p.m., in Resident #3's room revealed the light fixture was missing over the sink and the foot board was not on her bed. Resident #3 stated her light had been out for a month and her foot board had been off for a week. Resident #3 stated she told the former maintenance director, and he replied that the light and footboard were on back order. <BR/>Interview on 08/23/2023 at 12:20 p.m., the Administrator stated he was currently covering the maintenance director duties. He stated a new maintenance director was hired and had been coming in at night since he had to finish his two weeks at another job until 08/28/2023. The Administrator said he was not aware the lights were out in Resident #1's room and believed the resident may have told the new maintenance director on Saturday (08/19/2023). The Administrator stated work orders were on a paper log and going forward they would be using a web-based work order system. He stated ideally, the resident would tell a staff member and they would log in to complete the work order. The Administrator stated the risk of not having working lights would be privacy and it could affect resident safety.<BR/>Interview on 08/23/2023 at 12:40 p.m., with the floor tech stated he was maintenance/housekeeping supervisor up until two weeks ago. He stated he was not aware the lights were out in Resident #1's room or the bathroom. The floor tech stated if a resident told him something needed to be fixed he would go fix it then or look at the maintenance log and most of the time residents will tell the nurse and the nurses write in the log. He stated he was responsible for checking the lights and replacing light bulbs. The floor tech stated he placed an order for Resident #3's light fixture about a month ago and it was out of stock. He stated the footboard just needs to be tightened and he did not tell Resident #3 the footboard was on order. <BR/>Interview on 08/23/2023 at 12:50 p.m., the Administrator stated he talked with the maintenance director and Resident #1 did tell him about the light but was not given a timeframe of when it would be fixed. <BR/>Interview on 08/23/2023 at 2:28 p.m., the Administrator stated the light fixture was swapped in Resident #1's room and the light in the bathroom was probably related to the breaker. <BR/>Review of paper maintenance logs for July and August 2023 revealed no work orders for Resident #1, Resident #2 or Resident #3's room. <BR/>Review of policy titled Maintenance Service, revised December 2009, reflected in part:<BR/>1. The Maintenance department is responsible for maintain the buildings, grounds, and equipment in a safe and operable manner at all times. <BR/>2. Functions of maintenance personnel include, but are not limited to:<BR/>a. maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines.<BR/>b. maintaining the building in good repair and free from hazards <BR/>c. maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.<BR/>e. maintaining lighting levels that are comfortable .<BR/>Review of policy titled Work Orders, Maintenance revised April 2010, reflected in part: <BR/>1. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.<BR/>Review of policy titled Homelike Environment revised February 2021, reflected in part:<BR/>1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.<BR/>2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:<BR/>a. clean, sanitary, and orderly environment;<BR/>b. comfortable (minimum glare) yet adequate (suitable to the task) lighting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 resident (Resident #4) reviewed for meals:<BR/>Resident #1 was served a piece of baked fish that was not cut into bite size pieces.<BR/>This failure placed residents who required their food to be cut into small bite size pieces at risk of choking/asphyxiation.<BR/>The findings included: <BR/>Review of Resident #1's face sheet revealed a [AGE] year-old female with a current admission date of 02/01/2005. Resident #1's diagnoses included Cerebrovascular Disease, Type 2 Diabetes Mellitus without Complications, Mild protein-calorie malnutrition, and unspecified lack of coordination <BR/>Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a BIMs Summary Score of 11, which indicated moderate cognitive impairment.<BR/>Record review of Care Plan dated Revision on 04/03/2023, revealed Resident #1Focus: The resident has an ADL self-care performance deficit r/t CVA, Hemiplegia, seizures, PVD. Interventions: EATING: The resident requires set up assistance by staff to eat. Position: CAN, LPN, RN. Focus: The resident had a cerebral vascular accident (CVA) r/t stroke. Interventions: Monitor intake to assure an adequate fluid intake to prevent dehydration. If resident is able to eat, make sure diet is the correct consistency to facilitate safe swallowing. Focus: The resident has potential nutritional problem r/t Diet restrictions, Protein-calorie malnutrition date initiated: 12/26/2021. Intervention: Provider serve diet as ordered. Monitor intake and record q (every) meal. Regular diet regular texture, cut food into small bite size pieces. <BR/>Record Review of Order Summary Report dated 05/18/22, revealed Regular diet, Regular texture, Cut food into small bite size pieces. <BR/>Record review of an undated Meal ticket for Resident #1, revealed Notes: CUT FOOD INTO BITE SIZE PIECES; gravy with all meals. <BR/>Observation of the noon meal in the main dining room on 04/06/23 (Thursday) at 12:20 PM, revealed Resident #1 sitting in a motorized wheelchair, leaning her head back opening mouth, holding fork in right hand lifting an intact personal serving of fish to her mouth. Resident #1 bite a piece of fish, lowered the fork, continued the motion serval times until the fish was consumed. There were no signs of choking.<BR/>Interview with Resident #1 on 04/06/23 at 12:48 PM, revealed when surveyor asked if fish was cut into bite size pieces Resident #1 responded No it was just a big slab of baked fish . <BR/>Interview with Dietary Manager on 04/04/23 at 1:54 PM, revealed that Resident #1 likes her food cut up because she does not like anyone to feed her, she is very independent. She stated that it is the cook's responsibility to cut it up. She stated that the nurse is responsible for verifying the meal ticket is correct. She stated that the following staff should verify that the food being served matches the meal ticket; the cook, dietary aid, nurse, and the person that serves the food to the resident. She stated that she did not know there was a risk to the resident I don't know because I always thought it was her hand. If she can't cut it up then she will lose her dignity. <BR/>Interview with [NAME] A on 04/04/23 at 2:00 PM, revealed it is her job responsibility to cut the meat before it is plated. She stated Honestly, I overlooked it today. I know that it is supposed to be cut. She stated that Resident # 1 is the only resident requiring meat to be cut. She stated she does not know the risk of the resident not having her meat cut into bite size pieces. <BR/>Interview with the ED on 04/04/23 at 2:21 PM, revealed ED entered the conference room during interview with [NAME] A and stated, the nurse left for the day, she did not have a lunch break. <BR/>Interview with ADON on 04/04/23 at 3:15 PM, revealed choking is a risk if the food is not cut up in bite size pieces. She stated, they should have cut it up. <BR/>Review of Policy Statement Tray Identification not dated, revealed 2. The food services manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. 4. If there is an error, the nurse supervisor will notify the dietary department immediately by phone so that appropriate food tray can be served.

Based on observation, interview, and record review, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted professional principles and assure that medications were secure and inaccessible to unauthorized staff and residents for 1 of 3 medication room <BR/>(200 hall) and 2 medication carts reviewed for storage.<BR/>1. <BR/>The medication cart was left unlocked and unattended in the common area adjacent to the nurse's station<BR/>2. <BR/>Expired medications were in the refrigerator in 200 hall medication storage room.<BR/>These failures could place residents at risk of ingestion of medications and/or lead to possible harm or drug diversion, and could place residents at risk of not receiving the therapeutic benefits of the medications. <BR/>The findings included:<BR/>1. During an observation on 01/20/23 at 5:30 AM revealed a medication cart located at the entrance of the building adjacent to the nurse's station was unlocked and unattended. At 5:32 AM revealed 6 prepackaged medications were left on top of the medication cart. LVN A, had 3 medication cups on top of the medication cart with medications in them. LVN A walked off with all three medication cups and left the medication cart unattended and unlocked with three prepacked medications on top of the medication cart. Observed 4 different staff members walk past the medication cart between 5:35 AM to 5:45 AM. LVN A returned to the medication cart and put the three prepackaged medications back into the medication cart. <BR/>During an interview on 01/20/23 at 5:55 AM LVN A revealed that she knew all the residents and she was familiar with their medications and would not mix up residents' medication. LVN A stated the three medication packages she put back in the cart belonged to two residents that were sent out to the hospital and the other resident wanted her medication right before dialysis. LVN A stated she knew what she was doing was not correct protocol. LVN A stated anyone could get into the medications and take them. <BR/>2. During an observation on 01/20/23 at 1:00 PM of medication storage room on 200 hall revealed expired medication in the refrigerator as followed:<BR/>*Lansoprazole suspension 15mg/ml (used to treat certain stomach and esophagus problems) expired on 10/02/22<BR/>*Bisacodyl 10mg suppository (Used for constipation) quantity of 10 expired on 12/07/22 <BR/>During an interview with the Regional DON on 01/20/23 at 4:00PM revealed the company policy on securing biologicals and administration of medications to residents must be followed. Regional DON stated expired medications should be documented and placed in the destruction bin. Regional DON stated all nursing staff were responsible for checking for expired medication . Regional DON revealed medication cart should be locked when not in use. <BR/>During an interview with the Administrator on 01/20/23 at 4:15 PM revealed she expected staff to administer medications on time, know what medications are given and follow State and company policy on securing biologicals and administration of medications to residents. <BR/>Record review of the facility's policy titled administering medication (revised April 2019) revealed 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. <BR/>Record review of the facility's job description of LVN (undated) revealed, Properly administer resident medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 24 residents (Resident #13) reviewed for resident call system.<BR/>The facility failed to ensure Resident #13 had a working call light in her room. <BR/>This failure could place residents at risk of not being able to get assistance when needed.<BR/>Findings included:<BR/>Record review of Resident #13 face sheet dated 06/22/2023 was a [AGE] year-old female admitted the facility on 09/27/2021 with diagnosis that include schizophrenia (Known to affect the ability to think), epilepsy (seizure disorder), osteoarthritis (joint disease), and type 2 diabetes.<BR/>Record review of Resident #13 care plan dated for the month of June 2023 reflected the resident requires one-person assist for dressing, toileting, personal hygiene, oral hygiene, and moving between surfaces. Also indicated in her care plan that the resident is encouraged to use her call bell for assistance. <BR/>Observation and interview of Resident #13 on 06/20/23 at 10:40 AM. revealed Resident #13 asked Surveyor for assistance to plug her phone into the wall. When Surveyor asked the resident to push her call light to notify staff of her need, she stated it doesn't work. She also stated the maintenance staff worked on it once before, but it had gone out again since then and she thinks it had a short in it. Resident #13 pushed the call light once more and no light was displayed on the outside of the room, which indicated the call light wasn't working to alert staff if she needed assistance.<BR/>Observation and interview on 06/20/23 at 03:43 PM reflected the call light still was not working. Resident #13 stated sometimes she had to get up on her own and unplug the call light and plug it back in to make it work but it does not always solve the problem.<BR/>Observation on 06/21/23 at 09:04 AM in Resident #13 room revealed the call light was still not working.<BR/>Interview on 06/21/23 at 12:40 PM, with Resident #13 revealed her roommate usually presses their call light on her behalf. Resident #13 stated she told someone yesterday about the call light issue but did not know who she informed. She said it has been about two days since the call light stopped working. She stated she usually just can get up and unplug it from the wall and plug it back in but she stated it no longer works when she unplugs and plugs back in.<BR/>Interview on 06/22/23 at 10:00 AM with the Maintenance Director revealed Resident #13 had a problem one time where the call light was bent and wouldn't push down but he changed it out and it started working. He stated the facility had a call light tester and if anything goes wrong, there was a logbook to document the issue. He stated the test was located at the nurse's station and it could be pushed to notify if the call light was working. The Maintenance Director stated call lights were tested daily. He stated there is a logbook at each nursing station with a work order form that is filled out and facility staff could also can also call him as well. <BR/>Interview on 06/22/23 at 10:35 AM with the Administrator revealed he went in the room to check Resident #13's call light and it worked the first two times he pushed it, but the third time he had to push it multiple times before the call light came on. He stated he would have the maintenance director, who was responsible for ensuring the call lights work to fix the whole call light system in Residents #13 room.<BR/>Record review of logbook for the month of June 2023 reflected the call light has last been checked for the entire facility on 6/9/2023 by The Maintenance Director. There were no other entries for June 2023 besides on 06/09/2023.<BR/>Record Review on 06/22/23 at 10:40 AM of the nursing station's logbook for the entire facility revealed no call light work orders had been placed in the book for the month of June 2023. <BR/>Record review of facility policy Answering the call light dated March 2021 revealed: <BR/>Purpose: the purpose of this procedure is to ensure timely responses to the resident's requests and needs<BR/>General Guidelines: <BR/>be sure the call light is plugged in and functioning at all times<BR/>report all defective call lights to the nursing supervisor promptly

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to receive registry verification that an individual had met competency evaluation requirements prior to the individual working in the facility as a Medication Aide for 1 of 1 MA's reviewed for training and competency. <BR/>The facility did not ensure MA B had met competency requirements to provide care and services for residents. <BR/>This failure placed residents at the facility at risk of not receiving care and services from staff who are properly trained.<BR/>Findings included:<BR/>During an interview on [DATE] at 2:15 PM, MA B stated she worked pretty much every day passing medications all day. The MA B stated she goes through Teamwork's of [local city], for recertification and she had an issue with her information being updated in the system. MA B stated the State was switching over systems and she has not received an updated certificate. <BR/>During an interview on [DATE] at 2:50 PM with HR revealed, the last surveyor accepted the information from shift key (online staffing agency for CNA'S) on MA B. HR reported she was in contact with Shift key and the expiration date of [DATE] was good for both certifications (MA and CNA). <BR/>Record review of the shift key print out (dated [DATE]) revealed MA B's, CNA certification did not expire till [DATE]. Further review of the company revealed it was an online staffing agency for CNAs. <BR/>During an interview and observation on [DATE] at 3:30 PM with the CFO of the partner company revealed HR and corporate received notification on their phone when staff certifications are about to expired and/or expired. The CFO demonstrated on his phone how he could search for employee's certifications. The CFO attempted to retrieve MA B updated information. CFO revealed he was not able to retrieve a current certification for MA B. <BR/>During an interview with the Administrator on [DATE] at 4:15 PM revealed ADP would send an email to HR and notify her when staff certifications are needed to be renewed. Administrator revealed, MA B had email (local company) to get a copy of certification and there was an delay. The Administrator revealed residents are at risk of injury if staff does not have the proper training and certifications. <BR/>Record review of Employability Status Check Search Results from Texas Health and Human Services, database updated on Friday [DATE] revealed MA B medication aide's permit lapsed on [DATE]. Record review of MA B'S registry status revealed this medication aide is not permitted by HHS to administer medications to facility residents. <BR/>Record review of facility's policy titled administering medication (revised [DATE]) revealed 1. Only persons licensed or permitted by the state to prepare, administer, and document the administration of medications may do so. <BR/>Record review of the facility's job description for Medication Aide (undated) revealed, Current Medication Administration Certification from state.

Based on observation, interview, and record review, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted professional principles and assure that medications were secure and inaccessible to unauthorized staff and residents for 1 of 3 medication room <BR/>(200 hall) and 2 medication carts reviewed for storage.<BR/>1. <BR/>The medication cart was left unlocked and unattended in the common area adjacent to the nurse's station<BR/>2. <BR/>Expired medications were in the refrigerator in 200 hall medication storage room.<BR/>These failures could place residents at risk of ingestion of medications and/or lead to possible harm or drug diversion, and could place residents at risk of not receiving the therapeutic benefits of the medications. <BR/>The findings included:<BR/>1. During an observation on 01/20/23 at 5:30 AM revealed a medication cart located at the entrance of the building adjacent to the nurse's station was unlocked and unattended. At 5:32 AM revealed 6 prepackaged medications were left on top of the medication cart. LVN A, had 3 medication cups on top of the medication cart with medications in them. LVN A walked off with all three medication cups and left the medication cart unattended and unlocked with three prepacked medications on top of the medication cart. Observed 4 different staff members walk past the medication cart between 5:35 AM to 5:45 AM. LVN A returned to the medication cart and put the three prepackaged medications back into the medication cart. <BR/>During an interview on 01/20/23 at 5:55 AM LVN A revealed that she knew all the residents and she was familiar with their medications and would not mix up residents' medication. LVN A stated the three medication packages she put back in the cart belonged to two residents that were sent out to the hospital and the other resident wanted her medication right before dialysis. LVN A stated she knew what she was doing was not correct protocol. LVN A stated anyone could get into the medications and take them. <BR/>2. During an observation on 01/20/23 at 1:00 PM of medication storage room on 200 hall revealed expired medication in the refrigerator as followed:<BR/>*Lansoprazole suspension 15mg/ml (used to treat certain stomach and esophagus problems) expired on 10/02/22<BR/>*Bisacodyl 10mg suppository (Used for constipation) quantity of 10 expired on 12/07/22 <BR/>During an interview with the Regional DON on 01/20/23 at 4:00PM revealed the company policy on securing biologicals and administration of medications to residents must be followed. Regional DON stated expired medications should be documented and placed in the destruction bin. Regional DON stated all nursing staff were responsible for checking for expired medication . Regional DON revealed medication cart should be locked when not in use. <BR/>During an interview with the Administrator on 01/20/23 at 4:15 PM revealed she expected staff to administer medications on time, know what medications are given and follow State and company policy on securing biologicals and administration of medications to residents. <BR/>Record review of the facility's policy titled administering medication (revised April 2019) revealed 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. <BR/>Record review of the facility's job description of LVN (undated) revealed, Properly administer resident medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, comfortable, and homelike environment for 2 (Resident #1 and Resident #2) of 6 residents reviewed for environment.<BR/>The facility failed to provide the necessary housekeeping and maintenance services to ensure Resident's #1 and #2's door opened without resistance.<BR/>This failure placed residents who resided in the facility at risk of for diminished quality of life.<BR/>Findings included:<BR/>Record Review of Resident #1's admission Record undated reflected; Resident #1 is a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1's principal diagnosis of Paraplegia. <BR/>Observation on 01/23/2024 at 11:47 a.m. revealed Resident #1's door rubbed the floor when open causing the door to require pressure to open. <BR/>Interview on 01/23/2024 at 11:47 a.m. with Resident #1 reflected he stated the door was hard to open when he was in his wheelchair. He stated he was scarred on an occasion when there was a fire evaluation and he needed help to leave the room. <BR/>Interview on 01/23/2024 at 12:00 p.m. with Cooperate Maintenance he stated that door is rubbing the floor; there were visible signs of friction. He was unable to give a time frame for how long the door rubbed the floor, but the floor may have buckled because of the recent rain. He stated that he was not aware of the door rubbing the floor. He assessed the door and stated the bottom door hinge was loose. <BR/>Interview on 01/23/2024 at 12:44 p.m. with Administrator stated either October or November of 2023 when the weather began to get colder the facility turned on buildings heaters. One of the heaters smoked, it was not a fire. He stated that they did evaluate the residents. The residents did not have to leave the building, but they were evacuated to the front lobby. He stated he was not aware the door to Resident #1's room rubbed the floor when opened. <BR/>Interview on 01/23/2024 at 1:45 p.m. with Maintenance Director he stated the facility has a TAILS system to report maintenance issues. He stated he checked the systems daily for issues in facility that need to be repaired. He stated the risk of the door not opening properly was the risk of the resident not being able to get out. <BR/>Record Review of the Work History Report dated 10/07/2023 to 01/20/2024 revealed no task description to repair Resident #1's door. <BR/>The facility's policy on Homelike Environment Revised February 2021 reflected; Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, comfortable, and homelike environment for 2 (Resident #1 and Resident #2) of 6 residents reviewed for environment.<BR/>The facility failed to provide the necessary housekeeping and maintenance services to ensure Resident's #1 and #2's door opened without resistance.<BR/>This failure placed residents who resided in the facility at risk of for diminished quality of life.<BR/>Findings included:<BR/>Record Review of Resident #1's admission Record undated reflected; Resident #1 is a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1's principal diagnosis of Paraplegia. <BR/>Observation on 01/23/2024 at 11:47 a.m. revealed Resident #1's door rubbed the floor when open causing the door to require pressure to open. <BR/>Interview on 01/23/2024 at 11:47 a.m. with Resident #1 reflected he stated the door was hard to open when he was in his wheelchair. He stated he was scarred on an occasion when there was a fire evaluation and he needed help to leave the room. <BR/>Interview on 01/23/2024 at 12:00 p.m. with Cooperate Maintenance he stated that door is rubbing the floor; there were visible signs of friction. He was unable to give a time frame for how long the door rubbed the floor, but the floor may have buckled because of the recent rain. He stated that he was not aware of the door rubbing the floor. He assessed the door and stated the bottom door hinge was loose. <BR/>Interview on 01/23/2024 at 12:44 p.m. with Administrator stated either October or November of 2023 when the weather began to get colder the facility turned on buildings heaters. One of the heaters smoked, it was not a fire. He stated that they did evaluate the residents. The residents did not have to leave the building, but they were evacuated to the front lobby. He stated he was not aware the door to Resident #1's room rubbed the floor when opened. <BR/>Interview on 01/23/2024 at 1:45 p.m. with Maintenance Director he stated the facility has a TAILS system to report maintenance issues. He stated he checked the systems daily for issues in facility that need to be repaired. He stated the risk of the door not opening properly was the risk of the resident not being able to get out. <BR/>Record Review of the Work History Report dated 10/07/2023 to 01/20/2024 revealed no task description to repair Resident #1's door. <BR/>The facility's policy on Homelike Environment Revised February 2021 reflected; Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, comfortable, and homelike environment for 2 (Resident #1 and Resident #2) of 6 residents reviewed for environment.<BR/>The facility failed to provide the necessary housekeeping and maintenance services to ensure Resident's #1 and #2's door opened without resistance.<BR/>This failure placed residents who resided in the facility at risk of for diminished quality of life.<BR/>Findings included:<BR/>Record Review of Resident #1's admission Record undated reflected; Resident #1 is a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1's principal diagnosis of Paraplegia. <BR/>Observation on 01/23/2024 at 11:47 a.m. revealed Resident #1's door rubbed the floor when open causing the door to require pressure to open. <BR/>Interview on 01/23/2024 at 11:47 a.m. with Resident #1 reflected he stated the door was hard to open when he was in his wheelchair. He stated he was scarred on an occasion when there was a fire evaluation and he needed help to leave the room. <BR/>Interview on 01/23/2024 at 12:00 p.m. with Cooperate Maintenance he stated that door is rubbing the floor; there were visible signs of friction. He was unable to give a time frame for how long the door rubbed the floor, but the floor may have buckled because of the recent rain. He stated that he was not aware of the door rubbing the floor. He assessed the door and stated the bottom door hinge was loose. <BR/>Interview on 01/23/2024 at 12:44 p.m. with Administrator stated either October or November of 2023 when the weather began to get colder the facility turned on buildings heaters. One of the heaters smoked, it was not a fire. He stated that they did evaluate the residents. The residents did not have to leave the building, but they were evacuated to the front lobby. He stated he was not aware the door to Resident #1's room rubbed the floor when opened. <BR/>Interview on 01/23/2024 at 1:45 p.m. with Maintenance Director he stated the facility has a TAILS system to report maintenance issues. He stated he checked the systems daily for issues in facility that need to be repaired. He stated the risk of the door not opening properly was the risk of the resident not being able to get out. <BR/>Record Review of the Work History Report dated 10/07/2023 to 01/20/2024 revealed no task description to repair Resident #1's door. <BR/>The facility's policy on Homelike Environment Revised February 2021 reflected; Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, comfortable, and homelike environment for 2 (Resident #1 and Resident #2) of 6 residents reviewed for environment.<BR/>The facility failed to provide the necessary housekeeping and maintenance services to ensure Resident's #1 and #2's door opened without resistance.<BR/>This failure placed residents who resided in the facility at risk of for diminished quality of life.<BR/>Findings included:<BR/>Record Review of Resident #1's admission Record undated reflected; Resident #1 is a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1's principal diagnosis of Paraplegia. <BR/>Observation on 01/23/2024 at 11:47 a.m. revealed Resident #1's door rubbed the floor when open causing the door to require pressure to open. <BR/>Interview on 01/23/2024 at 11:47 a.m. with Resident #1 reflected he stated the door was hard to open when he was in his wheelchair. He stated he was scarred on an occasion when there was a fire evaluation and he needed help to leave the room. <BR/>Interview on 01/23/2024 at 12:00 p.m. with Cooperate Maintenance he stated that door is rubbing the floor; there were visible signs of friction. He was unable to give a time frame for how long the door rubbed the floor, but the floor may have buckled because of the recent rain. He stated that he was not aware of the door rubbing the floor. He assessed the door and stated the bottom door hinge was loose. <BR/>Interview on 01/23/2024 at 12:44 p.m. with Administrator stated either October or November of 2023 when the weather began to get colder the facility turned on buildings heaters. One of the heaters smoked, it was not a fire. He stated that they did evaluate the residents. The residents did not have to leave the building, but they were evacuated to the front lobby. He stated he was not aware the door to Resident #1's room rubbed the floor when opened. <BR/>Interview on 01/23/2024 at 1:45 p.m. with Maintenance Director he stated the facility has a TAILS system to report maintenance issues. He stated he checked the systems daily for issues in facility that need to be repaired. He stated the risk of the door not opening properly was the risk of the resident not being able to get out. <BR/>Record Review of the Work History Report dated 10/07/2023 to 01/20/2024 revealed no task description to repair Resident #1's door. <BR/>The facility's policy on Homelike Environment Revised February 2021 reflected; Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, comfortable, and homelike environment for 2 (Resident #1 and Resident #2) of 6 residents reviewed for environment.<BR/>The facility failed to provide the necessary housekeeping and maintenance services to ensure Resident's #1 and #2's door opened without resistance.<BR/>This failure placed residents who resided in the facility at risk of for diminished quality of life.<BR/>Findings included:<BR/>Record Review of Resident #1's admission Record undated reflected; Resident #1 is a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1's principal diagnosis of Paraplegia. <BR/>Observation on 01/23/2024 at 11:47 a.m. revealed Resident #1's door rubbed the floor when open causing the door to require pressure to open. <BR/>Interview on 01/23/2024 at 11:47 a.m. with Resident #1 reflected he stated the door was hard to open when he was in his wheelchair. He stated he was scarred on an occasion when there was a fire evaluation and he needed help to leave the room. <BR/>Interview on 01/23/2024 at 12:00 p.m. with Cooperate Maintenance he stated that door is rubbing the floor; there were visible signs of friction. He was unable to give a time frame for how long the door rubbed the floor, but the floor may have buckled because of the recent rain. He stated that he was not aware of the door rubbing the floor. He assessed the door and stated the bottom door hinge was loose. <BR/>Interview on 01/23/2024 at 12:44 p.m. with Administrator stated either October or November of 2023 when the weather began to get colder the facility turned on buildings heaters. One of the heaters smoked, it was not a fire. He stated that they did evaluate the residents. The residents did not have to leave the building, but they were evacuated to the front lobby. He stated he was not aware the door to Resident #1's room rubbed the floor when opened. <BR/>Interview on 01/23/2024 at 1:45 p.m. with Maintenance Director he stated the facility has a TAILS system to report maintenance issues. He stated he checked the systems daily for issues in facility that need to be repaired. He stated the risk of the door not opening properly was the risk of the resident not being able to get out. <BR/>Record Review of the Work History Report dated 10/07/2023 to 01/20/2024 revealed no task description to repair Resident #1's door. <BR/>The facility's policy on Homelike Environment Revised February 2021 reflected; Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview, observation, and record review, the facility failed to use the services of a registered nurse for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2024 (Fiscal Year Quarter 2 January 1-March 31, and Quarter 3 April 1-June 30) PBJ reports reviewed for RN coverage. <BR/>The facility did not have RN coverage for 8 consecutive hours on weekends for: 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/2024, 01/21/2024, 01/27/2024, 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/18/2024, 02/24/2024, 02/25/2024, 03/02/2024, 03/03/2024, 03/09/2024, 03/10/2024, 03/16/2024, 03/17/2024, 04/06/2024, 04/07/2024, 04/08/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, 04/28/2024, 05/04/2024, 05/05/2024, 05/11/2024, and 05/12/2024.<BR/>This failure could place residents at risk of lack of nursing oversight and higher level of care needed. <BR/>Findings included:<BR/>Record review of the CMS PBJ reports indicated Quarter 2 2024 (January 1-March 31) there were no consecutive 8 hours of RN coverage on weekends. <BR/>Record review of the facility's time stamped/punched hours for RN coverage revealed there was no RN coverage on weekends for the Month of April 2024 (04/06/2024, 04/07/2024, 04/08/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024) and none on the weekends of May 2024 (05/04/2024, 05/05/2024, 05/11/2024, and 05/12/2024). <BR/>In an interview on 8-8-2024 at 12:00 PM, the DON stated she has worked at the facility for 1.5 years, was an RN, and worked full-time at the facility. The DON said the facility could not provide consecutive RN coverage on the weekends from January - May 2024 because they lost their weekend RN and were not able to obtain another one during that timeframe. The DON stated if there was a need for an RN, she makes herself available to come into the facility to meet the need. <BR/>Record review of the facility's Staffing Policy called Nursing Services and Procedures Manual for Long-Term Care dated 10-2017, stated:<BR/>Staffing<BR/>Policy Statement<BR/>Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.<BR/>Policy Interpretation and Implementation<BR/>1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services .

Based on interview and record review, the facility failed to ensure required in-service training for nurse aides was completed for 2 of 5 CNA's (CNA K and CNA L) reviewed for training. The facility failed to ensure nurse aides received no less than 12 hours of training annually.This failure could place residents at risk of abuse, neglect, and exploitation and receiving poor quality of care by untrained staff. Findings included:Record review of personnel files for CNA K revealed a hire date of 03/20/2014. Record review of personnel files for CNA L revealed a hire date of 08/30/2024. Review of in-services revealed CNA K and CNA L did not have the required 12 hours of annual training. Interview on 09/11/2025 at 5:57 pm, the Administrator stated they could not provide the required training for all the CNAs. He stated they were going to change their training program where everyone would complete the required training on their anniversary date. He stated they will still have monthly and annual in-services. He stated the risk to residents being cared for by untrained staff was failure to follow and complete policies and procedures in an effective way. Interview on 09/11/2025 at 6:41 pm, the DON stated the Administrator, and the DON were responsible to ensure CNAs had the required training annually. She stated staff should be trained upon orientation, annually and as needed. She said trainings were monitored by corporate, and they were implementing a new process where an active employee roster would be printed out and the employee would sign. Record review of facility policy titled, In-Service Training, All staff revised August 2022, revealed the following: All staff must participate in initial orientation and annual in-service training.6. Required training topics include the following:a. Effective communication with residents and family (direct care staff);b. Resident rights and responsibilitiesc. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property;(2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention.d. Elements and goals of the facility QAPI program;e. The infection prevention and control program standards, policies and procedures;f. Behavioral health; andg. The compliance and ethics program standards, policies and procedures.