PFLUGERVILLE CARE CENTER

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for food storage and sanitation.<BR/>1. The Dietary Supervisor failed to ensure all items in the walk-in refrigerator and dry storage were covered, labeled, dated, and discarded prior to their expiration date. <BR/>2. [NAME] A failed to change gloves and wash her hands when changing tasks. <BR/>3. [NAME] B, Dietary Aide A and [NAME] C failed to wear effective hair restraints.<BR/>These failures placed residents at risk of foodborne illness.<BR/>Findings included:<BR/>Observations of the walk-in refrigerator on 1/10/2023 from 9:06 a.m. to 9:19 a.m. revealed the following:<BR/>At 9:06 a.m. the walk-in refrigerator contained tomatoes in a metal steam pan with a use-by date of 1/04/2023. <BR/>At 9:07 a.m. the walk-in refrigerator contained two bowls of peaches which were uncovered and unlabeled.<BR/>At 9:08 a.m. the walk-in refrigerator contained a metal bowl filled with nine individually wrapped pieces of cornbread which were unlabeled and undated.<BR/>At 9:09 a.m. the walk-in refrigerator contained a sheet cake which was uncovered, unlabeled, and undated. <BR/>At 9:10 a.m. the walk-in refrigerator contained two two-ounce cups of ketchup which were uncovered, unlabeled, and undated. <BR/>At 9:11 a.m. the walk-in refrigerator contained two two-ounce cups of maple syrup which were unlabeled and undated. <BR/>At 9:12 a.m. the walk-in refrigerator contained eight individually wrapped bags of fruit which were unlabeled and undated. <BR/>At 9:13 a.m. the walk-in refrigerator contained a plastic tub of pickles, opened, and without an opened date. <BR/>At 9:18 a.m. the walk-in refrigerator contained a container of jalapenos labeled prep 11/4 and discard 11/11. <BR/>At 9:19 a.m. the walk-in refrigerator contained a plastic container of peaches which was unlabeled and undated. <BR/>In an interview on 1/13/2023 at 9:19 a.m., [NAME] A stated all items in the walk-in refrigerator should be covered, labeled and dated. [NAME] A stated items such as condiments needed to be labeled when they were opened. [NAME] A stated someone might have forgotten to label the tub of pickles and stated the tomatoes with the use-by date of 1/04/2023 should have been discarded. [NAME] A stated any food item past its expiration date or use-by date should be discarded.<BR/>An observation on 1/11/2023 at 10:12 a.m. revealed [NAME] A pureed meat, washed the food processor in the three compartment sink, then proceeded to puree vegetables without changing gloves or washing her hands. <BR/>Observations on 1/11/2023 at 10:20 a.m. revealed Dietary Aide A and [NAME] C were wearing hair restraints which did not completely cover their long hair. Dietary Aide A was washing dishes in the kitchen and [NAME] C was standing in the kitchen. Both Dietary Aide A and [NAME] C had long hair which hung free, out the side of their hair restraints.<BR/>An observation on 1/11/2023 at 10:22 a.m. revealed [NAME] A pureed vegetable, washed the food processor in the three compartment sink, then proceeded to prepare mashed potatoes without changing gloves or washing her hands. <BR/>In an interview on 1/11/2023 at 10:35 a.m., when asked if gloves should be changed and hands washed when going from doing dishes to cooking, [NAME] A stated, yes. [NAME] A stated, I thought I washed my hands but if I didn't do that, please forgive me. <BR/>An observation on 1/11/2023 at 10:37 a.m. revealed [NAME] B was making sandwiches in the kitchen and wearing a hair restraint which did not completely cover her long hair. [NAME] B was observed with strands of hair coming out the side of her hair restraint.<BR/>In an interview on 1/11/2023 at 10:37 a.m., when asked if all of her hair was covered, [NAME] B communicated she did not understand in English by stating, I only understand a little bit.<BR/>In an interview on 1/11/2023 at 10:40 a.m., when asked if all of his hair was covered, Dietary Aide A stated, no. When asked if it should be, Dietary Aide A stated, probably, yeah. <BR/>In an interview on 1/11/2023 at 10:43 a.m., when asked if his hair was completely covered by the hair restraint, [NAME] C stated, is it not? and then said, I'll go take care of it. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:44 a.m. revealed a bulk container of flour dated 11/1/2022 with the scoop stored inside the container on the flour. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:45 a.m. revealed a bulk container of rice unlabeled and undated. <BR/>In an interview on 1/11/2023 at 10:45 a.m., the Dietary Supervisor stated he had worked in the facility for one year, had worked as manager for six months, and that was his first survey. <BR/>In an interview on 1/11/2023 at 10:49 a.m., the Dietary Supervisor stated kitchen staff were taught upon hire how to label and date food items. The Dietary Supervisor stated he had not completed any written in-service training with kitchen staff since he started as manager, and that most training on food storage and sanitation was completed via observation and demonstration. The Dietary Supervisor stated himself, another experienced employee or [NAME] D would train employees on food storage and sanitation. The Dietary Supervisor stated [NAME] D was the most experienced cook so that is why kitchen staff trained with him. The Dietary Supervisor stated kitchen staff were trained on labeling and dating via demonstration. The Dietary Supervisor stated as far as glove usage, hand washing, and use of hair restraints, training was completed verbally. The Dietary Supervisor stated all staff went through a new hire process which included reading and signing off on an employee hand guide which covered food storage and sanitation. <BR/>In an interview on 1/12/2023 at 8:46 a.m., the LD stated food should be properly sealed if it had been opened, there should be a label and date on items when they were opened, and items such as condiments should have an opened date. The LD stated food should be adequately covered to prevent contamination or exposure of food and food items should be sealed on top. The LD stated yes that all food items should have a label and a date unless it was an unopened, prepackaged item such as a health shake. When asked if food items should be discarded prior to their use-by dates, the LD stated, yes, it's good practice. The LD stated kitchen staff should have some type of covering to cover their hair to prevent contamination. When asked if hair should be completely covered, the LD stated, yes, ideally they should try to tuck all the hair in. The LD stated she would expect handwashing to occur any time before handling food items. When asked how kitchen staff were trained on food storage and sanitation, the LD stated she did not know and it would be a good question for the Dietary Supervisor. The LD stated off hand she did not know whether kitchen staff had been trained, stating, I would ask the Dietary Supervisor. When asked who monitored the kitchen for food storage and sanitation, the LD stated, it would be the Dietary Supervisor and I complete monthly kitchen audits and give any recommendations to the Dietary Supervisor or discuss them with the ADM. The LD stated she was not sure how the Dietary Supervisor monitored the kitchen but stated she monitored through monthly audits. When asked if she had noticed any concerns, the LD stated there had been ongoing education with labeling and dating. The LD stated she had completed verbal education with the Dietary Supervisor on this. When asked what potential negative outcomes there could be if kitchen polices on food storage and sanitation were not followed, the LD stated there could potentially be contamination of food items, foods could be served past their use-by dates, and there could be potential for foodborne illness. <BR/>In an interview on 1/12/2023 at 6:13 p.m., when asked what the facility's policy was on food storage, the ADM stated things needed to be labeled when they were opened, labeled with a use-by and open date, and discarded after seven days. When asked if kitchen staff should have all hair covered, the ADM stated, yes. When asked how hands should be washed when going from dirty dishes to preparing a pureed food item, the ADM stated the best thing would be to take the food processor to the person washing dishes to wash. The ADM stated it was best practice to wash hands before starting a new task.<BR/>A record review of the facility's undated policy titled Food Storage reflected the following:<BR/>Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. These containers can be mounted on caster or dollies. All containers must be legibly and accurately labeled.<BR/>6. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are no to be stored in the food containers, but are kept covered in a protected area near the containers. <BR/>15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded.<BR/>A record review of the facility's policy titled Food Preparation and Service dated 2001 reflected the following: <BR/>Policy Statement: Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.<BR/>4. Food service staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays.<BR/>6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks.<BR/>A record review of the facility's undated Employee Handbook reflected it covered use of hair restraints only, and did not cover handwashing, glove usage, or food storage. <BR/>A record review of the facility's Hand Washing Competency forms dated 10/04/2022, 11/19/2022, and 12/21/2022 reflected [NAME] A's handwashing skill had been demonstrated to show competency. These documents reflected how to wash hands but did not cover when to wash hands. <BR/>A record review of the LD's Sanitation Audit dated 11/04/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Ingredient bins, the LD commented, Recommend view for outdated bulk bin items, discard as appropriate. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that some items were missing labels and dates and some items were outdated. <BR/>A record review of the LD's Sanitation Audit dated 12/02/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that items were missing labels and dates. <BR/>A record review of the FDA's 2017 Food Code reflected the following:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings<BR/>Hair Restraints<BR/>2-402.11 Effectiveness.<BR/>(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that medical records were accurately documented for four(Resident #1, Resident #2, Resident #3, and Resident #4) of six residents reviewed for accurate medical records.<BR/>The facility failed to have documentation that they provided care to Resident #1 from 10pm to 6am from [DATE] - [DATE]. Resident #1 was on hospice and found deceased around 6am and there was no information of what care was to be provided during rounds or that Resident #1 was having a change of condition that required intervention.<BR/>The facility failed to have documentation that they provided care to Residents #2, #3, and #4 from 10p to 6a from [DATE] - [DATE].<BR/>These failures could place residents at risk of not receiving timely care and services, accidents, harm, and death. <BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's admission Record, dated [DATE], reflected she was a [AGE] year old female who was admitted to the facility on [DATE], had a DNR, was receiving hospice services, and expired at the facility on [DATE]. Resident #1 had medical diagnoses that included spastic quadriplegic cerebral palsy (high muscle tone leading to stiffness and difficulty with movement that affects all four limbs, the trunk, and the face), intellectual disabilities, abnormalities of gait and mobility, other lack of coordination, and need for assistance with personal care. <BR/>Review of Resident #1's Quarterly MDS, dated [DATE], reflected no BIMS documented and she was dependent on staff for all ADL care. Resident #1 was also always incontinent with urine and bowel movements. <BR/>Review of Resident #1's Death in Facility MDS, dated [DATE], reflected she was discharged after expiring at the facility on [DATE]. <BR/>Review of Resident #1's Care Plan, initiated [DATE], reflected she required two CNAs to assist her with bed mobility and mechanical lift transfers, one CNA to assist her with eating/drinking, dressing, and was dependent on CNAs for incontinent care and personal hygiene. CNAs were required to turn/reposition and provide incontinent care at least every two hours. <BR/>Review of Resident #1's Progress Notes for [DATE] reflected there were no notes on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. <BR/>Review of Resident #1's MAR/TAR for [DATE] reflected there were three entries from LVN B on [DATE] during the night shift, but the entries did not indicate when LVN B administered medications and treatments on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE].<BR/>Review of Resident #1's MAR Audit Report for [DATE] reflected there were no results as to when LVN B documented the three entries on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE].<BR/>Review of Resident #1's Vital Summary reflected LVN B took the following vitals on [DATE] at 1:27 a.m.:<BR/>-Temperature 97.5 degrees Fahrenheit <BR/>-Respirations 18 breaths per minute <BR/>-Pulse 72 beats per minute <BR/>-Oxygen Saturation 95% <BR/>-Blood Pressure 124/74 millimeters of mercury <BR/>Review of Resident #1's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, personal hygiene, hands on assistance with eating/drinking, mechanical lift transfers, thickened liquids, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, and walk in room assistance on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE].<BR/>Review of Resident #1's Postmortem Assessment, signed by LVN A on [DATE] at 6:22 a.m., reflected Resident #1 was found in her bed in her room unresponsive, without respirations and pulse, fixed and dilated pupils, and body temperature indicated hypothermia and skin was cold relative to her baseline skin temperature. Resident #1 was pronounced dead by the Hospice Agency RN on [DATE] at 7:18 a.m. <BR/>Review of Resident #1's Discharge Summary, signed by LVN A on [DATE] at 9:39 a.m., reflected on [DATE] at 6:22 a.m., she was observed unresponsive, without carotid pulse and breath, and with fixed/dilated pupils. <BR/>Resident #2<BR/>Review of Resident #2's admission Record, dated [DATE], reflected she was an [AGE] year old female who was admitted to the facility on [DATE], had a DNR, and was receiving hospice services. Resident #2 had medical diagnoses that included senile degeneration of the brain (a group of neurological disorders that cause a progressive decline in cognitive function, including memory, reasoning, and problem-solving), generalized muscle weakness, other lack of coordination, adjustment insomnia (a type of sleep disorder that occurs when a specific stressful event or change in a person's life disrupts their normal sleep patterns), Alzheimer's disease (a progressive, neurodegenerative disorder that primarily affects the brain and causes a decline in cognitive function, particularly memory and thinking), other chronic pain, and repeated falls. <BR/>Review of Resident #2's Quarterly MDS, dated [DATE], reflected no BIMS documented and she was dependent on staff for all ADL care. Resident #2 was also always incontinent with urine and bowel movements.<BR/>Review of Resident #2's Care Plan, revised on [DATE], reflected she required two CNAs to assist her with bed mobility, toileting, dressing and mechanical lift transfers and one CNA to assist her with eating/drinking and personal hygiene. CNAs were required to provide incontinent care and turn/reposition her at least every two hours. <BR/>Review of Resident #2's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, personal hygiene, hands on assistance with eating/drinking, mechanical lift transfers, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, and walk in room assistance on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE].<BR/>Resident #3<BR/>Review of Resident #3's admission Record, dated [DATE], reflected she was a [AGE] year old female who was admitted to the facility on [DATE], had a DNR, and was receiving hospice services. Resident #3 had medical diagnoses that included vascular dementia (a type of dementia caused by damage to the blood vessels in the brain, leading to reduced blood flow and oxygen supply), overactive bladder, other lack of coordination, abnormalities of gait and mobility, dementia (a general term for the decline in memory, thinking, and reasoning skills, affecting daily life), insomnia, and need for assistance with personal care. <BR/>Review of Resident #3's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #3 also required supervision with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showering, dressing, personal hygiene, bed mobility, and dependent on staff for toileting, and transfers. Resident #3 was also always incontinent with urine and bowel movements.<BR/>Review of Resident #3's Care Plan, revised [DATE], reflected she required two CNAs to assist her with bed mobility, toileting, dressing and mechanical lift transfers, one CNA to supervise her with eating/drinking, and one CNA to assist her with personal hygiene. CNAs were required to provide incontinent care and turn/reposition her at least every two hours.<BR/>Review of Resident #3's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, high risk for falls monitoring, personal hygiene, hands on assistance with eating/drinking, mechanical lift transfers, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, walk in room assistance and behavior monitoring on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE].<BR/>Resident #4<BR/>Review of Resident #4's admission Record, dated [DATE], reflected she was an [AGE] year old female who was admitted to the facility on [DATE], had a DNR, and was receiving hospice services. Resident #4 had medical diagnoses that included Alzheimer's disease, convulsions (involuntary, rhythmic muscle contractions and relaxations that cause uncontrolled shaking and jerking of the body, often accompanied by a temporary loss of consciousness), generalized muscle weakness, abnormalities of gait and mobility, other lack of coordination, dementia and need for assistance with personal care. <BR/>Review of Resident #4's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 3, which indicated she had severe cognitive impairment and she was dependent on staff for all ADL care. Resident #4 was also always incontinent with urine and bowel movements. <BR/>Review of Resident #4's Care Plan, revised [DATE], reflected she required two CNAs to assist her with bed mobility, toileting, and mechanical lift transfers and one CNA to assist her with dressing, eating, and personal hygiene. CNAs were required to provide incontinent care and turn/reposition her throughout the day and as needed.<BR/>Review of Resident #4's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, personal hygiene, mechanical lift transfers, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, and walk in room assistance on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE].<BR/>Review of the facility's Staff Schedule, dated [DATE], reflected LVN B and CNA C were assigned to work on Residents #1, #2, #3, and #4's hallway on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. LVN A and CNA G were also assigned to work on Residents #1, #2, #3, and #4's hallway on [DATE] from 6:00 a.m. through 2:00 p.m. <BR/>Attempts to call CNA C were made on [DATE] at 12:48 p.m. and [DATE] at 9:44 a.m. CNA C did not return the calls before exit. <BR/>Attempts to call LVN B were made on [DATE] at 12:50 p.m. and [DATE] at 9:49 a.m. LVN B did not return the calls before exit. <BR/>During a group interview with CNA D and CNA E on [DATE] at 1:08 p.m., they stated CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours. They stated CNAs documented care in residents' POC during their shift. They stated residents needed to be checked on and provided treatment and care so they did not develop worsening conditions. They stated the DON reminded CNAs daily to check on and provide care to residents at least every two hours, as needed, or upon request. They stated the nurses, ADON and DON were responsible for overseeing and ensuring CNAs checked on and provided care to residents daily by asking the CNAs if they were performing care on residents. <BR/>During an interview with LVN A on [DATE] at 1:18 p.m., he stated the CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours. He stated CNAs documented care in residents' POC after completing the task and said, If the CNAs did not do it right away, then they could forget to document later. LVN A stated he did not know where the nurses documented treatment and care after completing the task. LVN A stated residents could be at risk of developing injuries and other worsening conditions if they were not being checked on and provided treatment and care. He stated the ADON reminded the CNAs and nurses every couple of days about checking on and providing treatment and care to residents. LVN A stated he did not know who was responsible for overseeing and ensuring CNAs and nurses checked on and provided treatment and care to residents, but he believed residents' POCs were reviewed to ensure CNAs completed the tasks. LVN A stated he believed he found Resident #1 unresponsive during his first set of rounds on [DATE]. LVN A stated he was unsure if Resident #1 had been expired for some time on [DATE] when he conducted her postmortem assessment on [DATE]. LVN A stated he described Resident #1's body temperature as hypothermia and skin was cold relative to her baseline skin temperature because that was one of the options the postmortem assessment provided while he completed the assessment. LVN A stated he recalled speaking with the previous shift (LVN B), who worked on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE] and he believed there were no reported concerns from the previous shift (LVN B). <BR/>During an interview with RN F on [DATE] at 1:39 p.m., she stated CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours, as needed, and as requested. She stated CNAs documented care in residents' POC after completing the task. She also stated nurses documented treatment and care in residents' TAR after completing the task. She stated residents could be at risk of worsening conditions if they were not being checked on and provided treatment and care. She stated the ADON and DON in-serviced CNAs and nurses on checking on and providing treatment and care frequently. She also stated the ADON and DON were responsible for overseeing and ensuring CNAs and nurses checked on and provided treatment and care to residents. <BR/>During an interview with the ADON on [DATE] at 2:23 p.m., she stated CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours, as needed, and upon request. She stated CNAs documented care in residents' POCs. She stated nurses documented care in residents' progress notes. She stated she and the DON reminded the CNAs and nurses daily about checking on and providing treatment and care. She stated she and the DON were also responsible for overseeing and ensuring CNAs and nurses were checking on and providing treatment and care by reviewing residents' POCs daily and reeducating if needed and said, Whatever was in the care plan was in POC and must be completed.<BR/>During an interview with the ADM on [DATE] at 9:30 a.m., he stated the facility did not have policy and procedure on rounding or checking on residents. <BR/>During an interview with the MD on [DATE] at 10:37 a.m., he stated that he was unsure what the facility's expectations were on checking on residents and what frequency was acceptable. He stated that he would think residents should be checked on at least once a shift and said, Anything could happen in that time. Residents should be peeked on. If a resident could not express their needs or access their call button, that could be a problem. Should get in touch with those residents. Residents who have specific needs, such as being changed, definitely need to be checked on at least once a shift. Any changes in mental status that would be important as well. He also stated it was unacceptable to not check on a resident for a whole shift. He also said, If a resident were cold to touch when found deceased , which would indicate that resident was not breathing, had no pulse, and then someone would pronounce their death. If someone was cold to touch, they were probably dead for at least 4 hours, maybe 6 hours or so. I would guess probably 4-6 hours or so, maybe closer to 6 hours because there is lots of mass to corroborate before becoming cold.<BR/>During an interview with the NP on [DATE] at 10:45 a.m., he stated that if a resident had a change in condition, he expected residents to be checked on more frequently. He also stated that he expected residents on hospice services to be checked on more frequently. He clarified that more frequently meant at least every two hours and explained the nurses and CNAs would alternate who checked on the residents every hour. He stated it was not acceptable to not check on residents for a whole shift and said, Still need to check on hospice or long term residents at least every two hours. Residents were different. If focus were pain management, resident could have uncontrollable pain and need to be checked on every shift. If resident were hospice resident, you never know when resident would have a change in condition. Residents needed to be checked on more often, that is why they were on hospice. He also said, If a resident is cold to touch when found deceased , it would indicate that resident was deceased for maybe 6 or 5 hours, but it depends on resident status and condition before the death.<BR/>During a confidential interview with the CE on [DATE] at 11:35 a.m., they stated CNAs were expected to check on residents every hour and as many times as needed. They also stated CNAs were expected to document care in residents' POCs during their shifts. They stated another female CNA (CNA G) was already working on Resident #1's hall on [DATE] at 6:00 a.m. because CNAs worked in pairs of two on each hallway. They observed Resident #1 lying in her bed, her eyes were not open or halfway open, stiff when they tried to lift her arm, cold when they touched her, pale, head was turned in one direction, and they suspected Resident #1 was dead on [DATE] at 6:00 a.m. They stated they notified LVN A, asked when Resident #1 passed away. LVN A rushed over to the room, and notified the night shift nurse (LVN B). They stated no one knew that Resident #1 passed away and LVN A and LVN B tried to argue that Resident #1 had just passed away during the 6:00 a.m. through 2:00 p.m. shift on [DATE]. <BR/>An attempt to call CNA G was made on [DATE] at 11:52 a.m. CNA G did not return the call before exit. <BR/>Review of the facility's Care Plan policy and procedure, undated, reflected,<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives.<BR/>Review of the facility's Documentation policy, dated 2003, reflected, <BR/>Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care.<BR/>Goal<BR/>1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.<BR/>2. The facility will ensure that information is comprehensive and timely and properly signed.<BR/>Procedure<BR/> .6. Document completed assessments in a timely manner and per policy.<BR/>7. Complete documentation in the electronic health record in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title.<BR/>8. Documentation during and following an acute episode, following an event, and during physiologic, mental, or emotional changes or instability .<BR/>10. Document or check information on flow sheets each shift or as appropriate for the care or treatment being monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to properly discharge and include all other necessary information, including a copy of the resident's discharge summary, and any other documentation, to ensure a safe and effective transition of care for 1 of 7 residents (Resident #1) reviewed for transfer and discharge requirements. <BR/>1. <BR/>The facility failed to provide all necessary information and/or documentation for a safe and effective transition to the resident, responsible party (RP), and ombudsman for Resident #1. <BR/>2. <BR/>The facility failed to document a discharge summary or plan for a safe discharge for Resident #1.<BR/>This failure could place residents at risk of not receiving the necessary care and services when discharged to meet their physical and psychological needs.<BR/>Findings include:<BR/>Review of Resident #1's face sheet dated 04/17/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included vascular dementia (dementia caused by damage to brain tissue resulting in changes to memory, thinking, and behavior) with mood disturbance, major depressive disorder (mental disorder characterized by a persistent low mood, loss of interest or pleasure in activities), type 2 diabetes mellitus (chronic condition characterized by insulin resistance and elevated blood sugar) with diabetic neuropathy (nerve damage), need for assistance with personal care, acquired absence of right leg below knee, and acquired absence of left leg below knee. Resident #1's face sheet also reflected he was not his own RP. <BR/>Review of Resident #1's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment . Section GG for Functional Abilities revealed Resident #1 required partial/moderate assistance with transfers (chair, bed, toilet, and tub/shower); Resident #1 also required partial/moderate assistance with toileting hygiene and dressing, and supervision or touch assistance with oral hygiene and showers/baths. <BR/>Review of Resident #1's additional BIMS assessment dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. <BR/>Review of Resident #1's care plan last revised 02/09/25 reflected Resident #1 has impaired cognitive function and impaired thought process related to dementia with interventions that include engage the resident in simple structured activities that avoid overly demanding tasks and needs supervision/assistance with all decision making. Care plan also reflected non-compliance with care and behavioral problems identified, Resident #1 refuses blood sugar checks most of the time, Resident #1 is non-compliant with diet which could prevent wound healing, Resident #1 resists ADL/incontinent care at times, and Resident #1 has a behavior problem related to throwing call light on the floor. Care plan also identified Resident #1 receives antidepressant medication.<BR/>Review of Resident #1's nursing progress notes from dates 04/01/25-04/17/25 did not reveal any notes from facility in discharge planning or discussion of discharge. It did not reflect notes on notification to Resident #1, Resident #1's RP, or Ombudsman of discharge. <BR/>Review of Resident #1's Notification of Discharge dated 04/15/25 revealed a discharge with an effective date of 05/15/25 for failure to pay for provided services. The address of discharge reflected, resident choice. <BR/>In an interview on 04/17/25 at 01:17 PM, Resident #1 stated he was issued a discharge notice for non-payment but was supposed to be getting help with a Medicaid application. He stated he believed he was not getting sufficient help in the process and that he relied on skilled nursing services because he was not able to do some things on his own. Resident #1 stated he believed he would be able to go back to his old home if he was discharged . <BR/>In an interview on 04/17/25 at 2:32 PM, the ADM stated Resident #1 was issued a discharge notice for non-payment and was not compliant with assisting the facility with his Medicaid application by providing bank statements. He stated Resident #1 was told by the facility that they would take him to the bank but that Resident #1 put it off. The ADM stated they have not taken the resident to the bank and have not been able to get him to provide bank statements. The ADM stated the Ombudsman was at the facility 04/15/25 and she was made aware of the discharge. He stated they are still working on a discharge plan and they would see if he was able to go back home, or find another SNF that would accept Resident #1 therefore there is no discharge summary or documentation other than the discharge notice. <BR/>In an interview on 04/17/25 at 03:10 PM, the DON stated Resident #1 is in skilled nursing because he needs assistance with his care. She stated the resident had Dementia and that he had family that is RP. The DON stated that to her knowledge the son did not have control of the finances for Resident #1 and was not able to assist. <BR/>In an interview on 04/17/25 at 03:34 PM, with the Ombudsman stated she was at the facility on 04/15/25 and asked the facility if Resident #1 was issued a discharge notice to which the facility said no. She stated she was told by the facility they would not be discharging the resident and that they would instead work on a payment plan and trying to get his Medicaid pending application completed. The Ombudsman stated that not having an address on the discharge notice is not appropriate and not considered an appropriate or safe discharge. She stated that it is everyone's right to a safe discharge, she said she would be returning to the facility to make an appeal to ensure they find appropriate placement for Resident #1 and have a plan in place. <BR/>In an interview on 04/17/25 at 3:43 PM, the SW stated she had spoken to Resident #1's RP and she was advised Resident #1 did not have a livable home to go to. The SW stated that the house Resident #1 speaks of has broken windows, no running water, and is not habitable. The SW stated Resident #1 was not cognitively intact and difficult to believe what he says because Resident #1 fabricates a lot of stories. The SW stated Resident #1's RP had attempted to get statements for Medicaid pending application but said it was difficult as Resident #1 is non-compliant. The SW stated that at this moment they were not sure where the resident would go and they were still trying to find placement. <BR/>In an interview on 04/17/25 at 04:41 PM, Resident #1's RP stated Resident #1 was not cognitively well and unable to make decisions for himself. The RP stated he had tried to assist Resident #1 in getting bank statements, but Resident #1 made it difficult for him even with having POA over him. The RP stated he lives out of the country and that it is difficult to assist with any care Resident #1 needs. The RP stated that at times Resident #1 has verbalized he does not care if he ends up at a homeless shelter and was not sure where the resident could safely be discharged to. The RP stated he did not want to have anything else to do with Resident #1's care and that Resident #1's family is not willing to help him. He stated Resident #1 lived with him before the SNF but that it was no longer an option. The RP stated Resident #1 had psych issues, and that he needs help with decision making and help with getting financial records and hopes the state or another government agency would take over his care. The RP stated he would like Resident #1 to have a safe discharge but is not sure where he would go and had not been advised what the facilities plan is. <BR/>Review of the facility Discharge or Transfer to Another Facility policy last revised 04/10/24 revealed:<BR/>Facility Initiated Discharge <BR/>The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges:<BR/>A. <BR/>The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;<BR/>B. <BR/>The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;<BR/>C. <BR/>The safety of individuals in the facility is endangered due to the clinical or behavioral status of the<BR/>resident;<BR/>D. <BR/>The health of individuals in the facility would otherwise be endangered;<BR/>E. <BR/>The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his or her stay at the facility.<BR/>F. <BR/>The facility ceases to operate.<BR/>Documentation <BR/>To demonstrate that any of the circumstances permissible for a facility to initiate a transfer or discharge as <BR/>specified in A-F on the previous page have occurred, the medical record will show documentation of the basis for transfer or discharge. This documentation must be made before, or as close as possible to the actual time of transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was assessed by a nurse before CNA A got him off the floor after an unwitnessed fall on 01/14/25. <BR/>This failure could place residents at risk of not receiving necessary medical care, harm, injury, and hospitalization.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, repeated falls, and age-related physical debility. <BR/>Review of Resident #1's quarterly MDS assessment, dated 01/08/25, reflected a BIMS could not be conducted due to him rarely/never being understood. Section J (Health Conditions) reflected he had two or more falls since the prior assessment.<BR/>Review of Resident #1's quarterly care plan, dated 10/01/24, reflected he was at risk for falls related to poor safety awareness and decreased balance/strength with an intervention of anticipating and meeting the resident's needs.<BR/>Review of Resident #1's admission (from the hospital) Fall-Risk Assessment, dated 01/15/25, reflected he was a high fall risk.<BR/>Review of Resident #1's progress note, dated 01/14/25 at 8:54 AM and documented by LVN B, reflected the following:<BR/>[CNA A] wheeled [Resident #1] to the NSG station and [sic] reported he was found OOB on the floor; she reported, she recovered him from the floor and put him in the W/C . <BR/>During an interview on 01/28/25 at 2:22 PM, CNA A stated she knew better than to pick a resident up off the floor before getting a nurse to assess them. She stated it was important for a nurse to assess the resident if found on the floor because they could be injured. She stated the day she found Resident #1 on the ground (sitting on his bottom), she panicked because he was impulsive, and she was worried he would try to get up on his own and fall again. She stated it was a mistake and it should not have happened. She stated she immediately took him to LVN B, and he assessed Resident #1. She stated she was in-serviced on resident falls after the incident. <BR/>During a telephone interview on 01/28/25 at 2:07 PM, the NP stated she was notified of Resident #1's fall. She stated if a fall was not witnessed, she would expect the aides to get a nurse to assess the resident before getting them off the ground. She stated a negative outcome could be if they had a head injury, it could make it worse.<BR/>During an interview on 01/28/25 at 2:10 PM, the DON stated she was aware of the incident regarding CNA A getting Resident #1 off the ground before a nurse assessed him. She stated Resident #1 was assessed by LVN B and was not injured. She stated CNA A received a disciplinary action, 1:1 training, and all the staff were in-serviced. She stated CNA A admitted what she did was wrong, and she made a mistake by impulsively getting him off the floor. She stated if a resident was found on the ground, a nurse needed to take their vitals and assess for possible injuries. She stated if not assessed first, a resident could be further injured. <BR/>An interview was attempted by telephone with LVN B on 01/28/25 at 12:49 PM. A call was not returned prior to exiting.<BR/>Review of in-services entitled Fall Prevention, dated 01/14/25 and 01/16/25 and conducted by the DON, reflected all staff were in-serviced on fall prevention and their fall policy and procedure. <BR/>Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised October 5, 2016, reflected the following:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for one (Resident #76) of eight residents reviewed for dignity. <BR/>CNA A referred to Resident #76 as a feeder.<BR/>This failure placed residents at risk of not being treated with dignity.<BR/>Findings included: <BR/>A record review of Resident #76's face sheet dated 1/11/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (language disorder), hyperlipidemia (high cholesterol), type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), chronic obstructive pulmonary disease (trouble breathing), and dysphagia (difficulty swallowing).<BR/>A record review of Resident #76's MDS assessment dated [DATE] reflected a BIMS was not conducted due to the resident rarely/never being understood. A review of Section G (Functional Status) reflected Resident #76 required extensive assistance and a one person physical assist with eating.<BR/>A record review of Resident #76's care plan last revised on 12/24/2022 reflected she had ADL self-care deficit related to general weakness and hemiparesis/hemiplegia. Resident #76's interventions reflected she needed assistance with ADLs as needed. <BR/>An observation of meal service on 1/10/2023 at 12:15 p.m. revealed CNA A referred to Resident #76 as a feeder when she asked another staff member, is Resident #76 a feeder?<BR/>During an interview and observation on 1/10/2023 at 12:16 p.m., Resident #76 was observed sitting in the dining room. Resident #76 was non-interviewable. <BR/>During an interview on 1/10/2023 at 1:38 p.m., when asked how she referred to residents that needed help with eating, CNA A asked, you mean the feeders? CNA A stated a resident who needed help eating was called a feeder and she learned that term about 25 years ago. CNA A stated she did not know whether there was another way to say it. When asked how she thought referring to residents as feeders would make them feel, CNA A stated, I guess it depends on who you're dealing with. <BR/>During an interview on 1/12/2023 at 5:23 p.m., when asked what the facility's policy was on treating resident with dignity, the DON stated, we in-service our staff on treating them with dignity. The DON stated, we train staff to refer to residents as residents who need assistance with feeding. When asked how staff should refer to residents who needed assistance with eating, the DON stated, we just say the resident needs assistance with eating. The DON stated no that residents should not be referred to as feeders. The DON stated perhaps staff might have thought that was the term years ago but things were changing in nursing. The DON stated, we make them aware that it's not the right term and resident rights is what we go by. When asked what a potential negative resident outcome was of referring to a resident as a feeder', the DON stated she could not say what negative outcome there would be but she said staff would be pulled and in-serviced immediately. <BR/>During an interview on 1/12/2023 at 6:13 p.m., the ADM stated no that staff should not refer to residents as feeders. The ADM stated no, it's not a dignified way to refer to a resident. The ADM stated feeder was a term staff were used to using for a long time, CMS made changes, and he would not blame staff. When asked if staff had been trained on those changes, the ADM stated no. When asked what a potential negative resident outcome of referring to a resident as a feeder could be, the ADM stated, I don't think it would have any effect.<BR/>A record review of the facility's policy titled Resident Rights dated August 2009 reflected the following:<BR/>Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation<BR/>2. Residents are entitled to exercise their rights and privileges to the fullest extent possible.<BR/>3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.<BR/>4. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee upon hire. Each employee has a duty to read and learn the residents' rights.<BR/>6. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.<BR/>7. Inquiries concerning residents' rights should be referred to the Social Services Director.<BR/>A record review of the facility's in-services from 2022 reflected no in-services on resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the 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 6 of 16 residents (Residents #7, #8, #15, #17, #49, and #56) reviewed for care plans.<BR/>1. The facility failed to ensure Resident #7's bowel incontinence was reflected in her care plan.<BR/>2. The facility failed to ensure Resident #8's need for assistance with her activities of daily living was developed in her care plan.<BR/>3. The facility failed to ensure Resident #15's pain was reflected in his care plan. <BR/>4. The facility failed to ensure Resident #17's need for TED Hose was reflected in her care plan.<BR/>5. The facility failed to ensure Resident #49's Hospice service and bowel and bladder incontinence were reflected in her care plan.<BR/>6. The facility failed to ensure Resident #56's need for assistance with toileting was reflected in his care plan. <BR/>These deficient practices could place residents at risk of not receiving proper care and services.<BR/>The findings included:<BR/>1. Record review of Resident #7's electronic face sheet dated 02/06/2024 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting right dominant side, depression (a common mental disorder .It involves a depressed mood or loss of pleasure or interest in activities for a long period of time) and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #7's quarterly MDS assessment with an ARD of 01/04/2024 reflected she scored an 8/15 on her BIMS which signified she was moderately cognitively impaired. She had functional limitation in range of motion .Impairment on one side .Upper extremity (shoulder, elbow, wrist, and hand) and Lower extremity (hip, knee, ankle, and foot). She was always incontinent of bowel and bladder.<BR/>Record review of Resident #7's comprehensive care plan revised on 06/08/2023 reflected Focus .has bladder incontinence r/t impaired mobility. No bowel incontinence was noted in the care plan.<BR/>Observation on 02/09/2024 at 10:15 am of Resident #7 as she received wound care to her right buttock revealed she wore an incontinent brief.<BR/>Interview on 02/08/2024 at 09:46 am with Resident #7, she stated she was incontinent of both bowel and bladder.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #7's unit, she stated Resident #7 was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #7's bowel status should have been in her care plan because it was an important part of her care, and it could be missed.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans need to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>2. Record review of Resident #8's face sheet, dated 02/08/2024, revealed Resident #8 was admitted to the facility on [DATE] with an original admission date of 08/19/2019 with diagnoses which included: metabolic encephalopathy, muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, cognitive communication deficit, unspecified abnormalities of gait and mobility, need for assistance with personal care, bilateral primary osteoarthritis of knee, and cerebral infarction unspecified.<BR/>Record review of Resident #8's Annual MDS assessment, dated 12/23/2023, revealed the resident's BIMS score was 10, which indicated moderate cognitive impairment. The resident's functional abilities required partial assistance from another person to complete any activities regarding self-care. Annual MDS assessment further revealed Resident #8 was dependent (helper does all of the effort resident does none) for toileting, needing substantial/maximal assistance (helper does more than half the effort) for showers, lower body dressing and putting on footwear, partial/moderate assistance (helpers does less than half the effort. Helper lift, lifts holds, or supports trunk or limbs) for upper body dressing.<BR/>Record review of Resident #8's care plan, revision date 01/10/2024 did not reflect her need for assistance in activities of daily living such as toileting, showers, lower body dressing, putting on footwear and upper body dressing.<BR/>During an interview on 02/09/2024 at 2:42 p.m. with the Regional Compliance Nurse she stated there was not an ADL (activities of daily living) care plan for Resident #8. The Regional Compliance Nurse further stated the ADL care plan was used to identify the residents need and would be reflected on the CNAs care plan so the CNAs would know what care to provide. The Regional Compliance Nurse stated the MDS Coordinator was responsible for updating the care plans while nursing would update with acute care plans. She further stated incorrect care could be provided without an accurate care plan. <BR/>3. Record review of Resident #15's face sheet, dated 02/07/2024, revealed Resident #15 was admitted to the facility on [DATE] with an original admission date of 08/07/2023 with diagnoses which included: postprocedural intestinal obstruction, unspecified as to partial versus complete, encounter for surgical aftercare following surgery on the digestive system, spastic quadriplegic cerebral palsy, muscle wasting and atrophy, pain in right shoulder, restless legs syndrome, incisional hernia with obstruction, without gangrene, and epilepsy, unspecified not intractable, without status epilepticus. <BR/>Record review of Resident #15's admission MDS assessment, dated 12/11/2023, revealed the resident's BIMS score was 15, which indicated intact cognition. The resident received scheduled pain medication with a pain assessment interview conducted on the admission MDS assessment revealed the resident had reported pain presence with the frequency being occasionally and occasionally affecting resident's sleep. <BR/>Record review of Resident #15's physician order summary, dated 02/07/2024 revealed an order dated 12/05/2023 with the start date of 12/05/2023 for Oxycodone-Acetaminophen oral table 5-325 MG give 1 tablet by mouth every 6 hours as needed for pain. Physician order summary further revealed order dated 12/28/2023 with the start date of 12/28/2023 for Oxycodone HCI oral tablet 5 MG give 1 tablet by mouth two times a day for pain and an order for Oxycodone-Acetaminophen oral tablet 5-325 MG give 1 tablet by mouth two times a day for pain. <BR/>Record review of Resident #15's care plan revision date, 12/28/2023 did not reflect his need for pain medication or how to assist him with pain relief. <BR/>During an interview on 02/09/2024 at 10:50 a.m. Resident #15 stated his pain could be bad sometimes. Resident #15 stated he received pain medications which helped with the pain and was receiving therapy services which also seemed to help. Resident #15 stated he had been experiencing the increase in pain since his surgery months ago and he was also being seen by a pain specialist. <BR/>During an interview on 02/09/2024 at 2:53 p.m. with the Regional Compliance Nurse she revealed pain was triggered for Resident #15's care plan but had not been activated on the care plan in PCC where it would show on the care plan. The Regional Compliance Nurse stated incorrect care could be provided without an accurate care plan.<BR/>4. Record review of Resident #17's electronic face sheet, dated 02/06/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting left non-dominant side, Alzheimer's Disease (the most common type of dementia. A progressive disease beginning with mild memory loss and possibility leading to loss of the ability to carry on a conversation and respond to the environment), chronic diastolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly) and depression (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for a long period of time).<BR/>Record review of Resident #17's quarterly MDS assessment with an ARD of 12/18/2023 reflected she scored an 11/15 on her BIMS which signified she was moderately cognitively impaired. She was noted to have an active diagnosis of heart failure.<BR/>Record review of Resident #17's comprehensive person-centered care plan revised date 11/16/2023 reflected Focus .has congestive heart failure .Interventions .monitor and report dependent edema of legs and feet.<BR/>Record review of Resident #17's Active Orders as of: 02/06/2024 reflected Apply TED hose to bilateral lower extremities daily in the morning and remove at bedtime two times a day for edema TED HOSE TO BLE: PUT ON IN THE MORNING AND TAKE OFF AT BEDTIME Active 06/23/2023.<BR/>Record review of Resident #17's MAR dated 02/01/2024 to 02/29/2024 reflected she had the TED hose applied to her bilateral lower extremities daily in the morning and removed at bedtime for edema.<BR/>Observation on 02/06/2024 of Resident #17 revealed she was sitting in her room in her wheelchair and had TED hose on both lower legs. <BR/>Interview on 02/08/2024 with Resident #17, she stated she had the TED hose applied to her lower legs twice a day because her legs swell.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #17's unit, she stated Resident #17 had TED hose applied to her lower legs twice a day because of swelling, and that was part of her care.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #17, he stated Resident #17 had TED hose applied to her bilateral lower legs every day.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #17's TED hose should have been in her care plan because it was an important part of her care, and it could be missed.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans needed to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>5. Record review of Resident #49's electronic face sheet dated 02/08/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Spastic quadriplegic cerebral palsy (a severe type that is characterized by paralysis of both arms and both legs, with muscle stiffness), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition), unspecified intellectual disabilities (impairment of intelligence) and dysphagia (difficulty swallowing).<BR/>Record review of Resident #49's quarterly MDS assessment with an ARD of 01/08/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She was always incontinent of bowel and bladder and was on Hospice services.<BR/>Record review of Resident #49's comprehensive person-centered care plan revised 12/09/2023 did not reflect she was incontinent of bowel and bladder. Resident #49's care plan did not reflect her Hospice services.<BR/>Record review of Resident #49's Active Orders as of: 02/08/2024 reflected she was admitted to Hospice services on 10/25/2023.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #49's unit, she stated Resident #49 was on Hospice, and was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #49, he stated Resident #49 was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #49's bowel and bladder status and Hospice services needed to be in the plan of care. She stated care provided could be missed without it noted in the care plan.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans needed to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>6. Record review of Resident #56's face sheet, dated 02/08/2024, revealed Resident #56 was admitted to the facility on [DATE] with an original admission date of 03/05/2023 with diagnoses which included: muscle wasting and atrophy, not elsewhere classified, multiple sites, end stage renal disease, unspecified viral hepatitis C without hepatic coma, gout, unspecified, hypothyroidism, and pain unspecified. <BR/>Record review of Resident #56's Optional State MDS assessment, dated 12/22/2023, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for toilet use.<BR/>Record review of Resident #56's care plan revision date, 11/13/2023 did not reflect his need for assistance with toilet use.<BR/>During an interview on 02/09/2024 at 2:46 p.m. with the Regional Compliance Nurse, she stated she did not see a care plan for Resident #56's toileting. The Regional Compliance Nurse further stated the MDS coordinator, and the IDT were responsible for the care plans.<BR/>During an interview on 02/09/2024 at 3:19 p.m. the DON stated the nurses, charge nurses, ADON, and DON were responsible for the acute care plans such as changes in conditions, [NAME], and changes in treatments. The DON further stated the MDS coordinator would be responsible for the comprehensive care plans, however the facility had just hired someone to replace the prior MDS coordinator. <BR/>Record review of the facility's undated policy and procedure titled Comprehensive Care Planning revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .Each resident will have a person-centered comprehensive care plan developed and implement to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's interdisciplinary team failed to review and revise all residents' care plans after each comprehensive and quarterly review assessments for one (Resident #6) of eight residents reviewed for comprehensive care plans. <BR/>The facility's interdisciplinary team failed to review and revise Resident #6's care plan after his most recently completed comprehensive assessment completed on 10/04/2022.<BR/>This failure placed residents at risk of having unrevised care plans.<BR/>Findings included:<BR/>A record review of Resident #6's face sheet dated 1/12/2023 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of local infection of the skin and subcutaneous tissue (innermost layer of skin), unstageable pressure ulcer (severe skin injury) of sacral region (base of the spine), non-pressure chronic ulcer of the right foot, non-pressure ulcer of the right heel and midfoot with necrosis (death) of muscle and fat layer exposed, unstageable pressure ulcer (severe skin injury) of right lower back, type 2 diabetes (uncontrolled blood sugar), peripheral vascular disease (circulatory issues), pruritis (itching), atopic dermatitis (rash), hyperlipidemia (high cholesterol), hypertension (high blood pressure), major depressive disorder (depression), and unspecified dementia.<BR/>A record review of Resident #6's chart reflected his most recently completed comprehensive assessment was completed on 10/04/2022. <BR/>A record review of Resident #6's quarterly MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated severely impaired cognition. A review of Section M (Skin Conditions) reflected Resident #6 was at risk of developing pressure ulcers/injuries and had three venous (open ulcer due to damaged veins) and arterial ulcers (open ulcer due to damaged arteries) present, including diabetic foot ulcer(s) (slow healing wounds). Resident #6's treatments included pressure reducing devices, nutrition or hydration interventions to manage skin problems, and applications of ointments/medications and application of dressing to feet. <BR/>A record review of Resident #6's care plan last revised on 7/10/2022 with an effective date of 8/25/2022 reflected Resident #6 had ADL self-care performance deficits related to tremors, dementia, hallucinations, delusions, and diabetes. Resident #6's care plan indicated he was at risk for malnutrition related to diabetes. Resident #6's care plan goal included Resident #6 will not develop complications related to obesity including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Resident #6's intervention for this goal, initiated on 6/26/2020, reflected provide and serve diet as ordered. Resident #6's care plan reflected he was at risk for injury related to dementia, frequent falls, and poor safety awareness. Resident #6's goal for this focus reflected he would remain free from injury through next review date. Interventions for this goal included notify physician and responsible party of any new skin tears or discolorations, skin observations by CNAs on bath days and with daily care, treatments as ordered by physician, and use lotion on dry skin. Resident #6's care plan did not reflect he had any chronic ulcers, arterial ulcers, or pressure injuries. Resident #6's care plan did not reflect he was at risk of skin breakdown. Resident #6's care plan did not include any interventions to prevent or manage current skin issues. <BR/>A record review of the facility's Care Plan Conference Summary dated 8/25/2022 reflected concerns and interventions related to Resident #6's recent elopement (unauthorized departure). The summarized discussion of care plan conference did not reflect any potential for or current skin alterations. Attendees of this care plan conference included the DON, the SW, the ADM and Resident #6's resident representative. <BR/>A record review of Resident #6's Social Services Note dated 12/22/2022 reflected Therapy informed MDS of resident's change of function. Changes include weight loss and wound on sacrum. SW called family to schedule a care plan meeting. Meeting is scheduled for 12/23/22 at 11 am. Will include resident, resident's brother, and sister-in-law, SW, DON, and Therapy Director.<BR/>A record review of Resident #6's Health Status Note dated 12/23/2022 at 10:55 a.m. reflected #6's representative consented to wound treatment and confirmed the care plan meeting scheduled for 11:00 a.m. that day (12/23/2022).<BR/>A record review of Resident #6's Health Status Note dated 12/23/2022 at 11:17 a.m. reflected Resident noted with pressure wound to sacrum. Recommendation: LAL mattress, to evaluate on diet texture due to the fact that resident do not like to wear his denture prior to admission to the facility, increase Prostat 90CC TID, continue vitamin C and multivitamin daily MD/NP, Dietary, RP notified. Social worker coordinate Care plan meeting with RP.<BR/>A record review of Resident #6's Social Services Note dated 1/11/2023 reflected Care Plan Meeting set for Tuesday 1/17/23 at 10 am with sister-in-law on behalf of the brother per RP request. RP stated he will be working and cannot attend most meetings. RP volunteered wife and stated this is why he appointed her the secondary emergency contact. DNR is still needed and will be requested at care plan meeting.<BR/>A record review of Resident #6's chart on 1/12/2023 reflected his care plan had not been updated since 8/25/2022. <BR/>A record review on 1/12/2023 of Resident #6's care plan tab reflected the last care plan was completed on 8/25/2022. <BR/>A record review on 1/12/2023 of Resident #6's miscellaneous section reflected the last care plan was completed on 8/25/2022. <BR/>During an interview and observation on 1/10/2023 at 10:51 a.m., Resident #6 was observed lying in bed with some redness on his skin. Resident #6 was non-interviewable and unable to answer questions about his care.<BR/>During an interview on 1/12/2023 at 1:15 p.m., the DON stated care plans were reviewed every 90 days and should be in PCC under the care plan tab or in the miscellaneous section. <BR/>During an interview on 1/12/2023 at 2:29 p.m., the DON stated she knew they had had a care plan meeting for Resident #6 in the past six months. The DON was unable to provide documentation of this prior to exit. <BR/>During an interview on 1/12/2023 at 2:30 p.m., the SW stated the were having a care plan meeting for Resident #6 the following Tuesday (1/17/2023). The SW stated they had a care plan meeting for Resident #6 in December. The SW stated she would provide documentation of this if she found it. The SW was unable to provide documentation of this prior to exit. <BR/>During an interview on 1/12/2023 at 4:20 p.m., the SW stated there was a care plan meeting held via phone call on 12/23/2022 but there was no care plan document. The SW stated the DON included updates in a progress note dated 12/23/2022. When asked what potential outcome there could be if a resident had multiple wounds and their care plan had not been revised, the SW stated, I just feel like it would not result in a good outcome.<BR/>During an interview on 1/12/2023 at 5:23 p.m., the DON stated the facility's policy on updating care plans was going to be based on the policy we have for care plans. When asked who ensured care plans were revised, the DON stated the MDS nurse. When asked if a wound should be included in a resident's care plan, the DON stated, yes. When asked what a potential negative outcome of not including skin breakdown or potential for skin issues in a resident who had skin alteration's care plan, the DON stated, I don't know what negative outcome there would be, I know we care plan a lot of things, as far as timing of care plan and reviewing it, it would be according to our policy. When asked if Resident #6's care plan should have been updated to reflect his wounds, the DON stated, everything should be included in the care plan.<BR/>During an interview on 1/12/2023 at 6:13 p.m., when asked how often care plans should be reviewed and revised, the ADM stated, comprehensive is 7 days and as far as updating the care plan, that should be done as needed if something came up or quarterly. When asked who ensured care plans were revised, the ADM stated it was done by the IDT then the MDS nurse would consolidate it into one. When asked who ensured care plans were being reviewed and revised, the ADM stated, the MDS coordinator will send out an email. When asked what potential for negative resident outcome there could be, if any, of failing to include skin breakdown or potential for skin issues in a resident who has skin impairment's care plan, the ADM stated, I don't think so because they track the wounds and make sure they're taking care of it. They might have missed it on the care plan but I don't think the care was missing.<BR/>A record review of the facility's policy titled Care Plans - Comprehensive dated December 2010 reflected the following: <BR/>Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.<BR/>Policy Interpretation and Implementation<BR/>1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.<BR/>2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS.<BR/>3. Each resident's comprehensive care plan is designed to:<BR/>a. Incorporate identified problem areas;<BR/>b. Incorporate risk factors associated with identified problems;<BR/>c. Build on the resident's strengths; <BR/>d. Reflect the resident's expressed wishes regarding care and treatment goals;<BR/>e. Reflect treatment goals, timetables and objective in measurable outcomes;<BR/>f. Identify the professional services that are responsible for each element of care;<BR/>g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels;<BR/>h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and<BR/>i. Reflect currently recognized standards of practice for problem areas and conditions.<BR/>4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan.<BR/>5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. <BR/>6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering. proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process.<BR/>7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).<BR/>8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.<BR/>9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans:<BR/>a. When there has been a significant change in the resident's condition; <BR/>b. When the desired outcome is not met;<BR/>c. When the resident has been readmitted to the facility from a hospital stay; and<BR/>d. At least quarterly.<BR/>10. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered in to the resident's clinical records in accordance with established policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 16 residents ( Residents #7 and #34) reviewed for assistance with ADL's.<BR/>1. Nursing staff failed to clean and file Resident #7's fingernails which were long and had a substance encrusted under them.<BR/>2. The facility staff failed to ensure Resident #34's fingernails were free of an encrusted substance under them.<BR/>These deficient practices could place residents at risk of decreased self-esteem and dignity.<BR/>The findings included:<BR/>1. Record review of Resident #7's electronic face sheet dated 02/06/2024 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting right dominant side, depression (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for a long period of time) and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #7's quarterly MDS assessment with an ARD of 01/04/2024 reflected she scored an 8/15 on her BIMS which signified she was moderately cognitively impaired. She had functional limitation in range of motion. Impairment on one side. Upper extremity (shoulder, elbow, wrist, and hand) and Lower extremity (hip, knee, ankle, and foot). She was always incontinent of bowel and bladder and the MDS did not reflect she was on a mechanically altered diet.<BR/>Record review of Resident #7's comprehensive care plan revised on 06/08/2023 reflected Focus .has an ADL Self Care Performance Deficit r/t hemiplegia .Interventions .requires staff assistance with care.<BR/>Observation on 02/07/2024 at 08:30 am of Resident #7 in her room eating breakfast revealed she had long (approximately 1/4 inch) fingernails on both hands, and they had dark substance encrusted beneath them.<BR/>In an interview on 02/07/2024 at 08:35 am with Resident #7, she stated she needed to have assistance in cleaning and filing her fingernails. She stated no one offered, even during baths. An emery board was sitting at her bedside table. She stated someone brought the emery board in for her to use, she could not remember who. <BR/>Interview on 02/09/2024 at 11:41 am with LVN A, who was the charge nurse for Resident #7's unit, she stated Resident #7 required assistance with her nail care.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #7, he stated Resident #7 required assistance with her nail care, and he could not remember ever assisting her.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #7's fingernails needed to be filed and cleaned by staff, and they needed to check with the resident.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the resident's needed assistance with their nail care, and it should be done when they were bathed.<BR/>2. Record review of Resident #34's face sheet, dated 02/08/2024, revealed Resident #34 was admitted to the facility on [DATE] with an original admission date of 03/05/2023 with diagnoses which included: Alzheimer's disease, delusional disorders, and other idiopathic peripheral autonomic neuropathy.<BR/>Record review of Resident #34's Quarterly MDS assessment, dated 09/11/2023, revealed the resident with long- and short-term memory loss. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for dressing and personal hygiene.<BR/>Record review of Resident #34's Optional State MDS assessment, dated 11/09/2023, revealed the resident with long- and short-term memory loss. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for bed mobility, transfers, and toilet use.<BR/>Record review of Resident #34's care plan with a revision of 12/22/2023 and a targeted date 03/31/2024, revealed Resident #34 had a Focus: ADL self-care deficit r/t: dementia, general weakness, osteoarthritis . Interventions: Personal hygiene: Extensive assistance one-person assist. Bathing: Total dependence one-person physical assist. Provide assistance with ADL's as needed . <BR/>Observation on 02/06/2024 at 12:31 p.m. revealed Resident #34 was in the dining room waiting for lunch with what looked to be dark brownish black substance built up under her short, trimmed fingernails. <BR/>Observation on 02/08/2024 at 10:53 a.m. revealed Resident #34 sitting in wheelchair in her room fidgeting with her Hoyer sling straps in her lap notable dark substance was under the resident's fingernails. <BR/>Observation on 02/08/2024 at 2:17 p.m. Resident #34 was observed in the dining room finishing her lunch and licking her fingers when puree food fell on them. Resident #34's nails continued to be noticeably dirty with buildup under several fingernails. <BR/>During observation and interview on 02/08/2024 at 2:25 p.m. revealed CNA C observed Resident #34 fingernails in the dining room and stated Oh, Lord those are dirty. CNA C stated she assisted Resident #34 in dressing and getting out of bed. CNA C further stated usually nail care was done on Sundays when there were no showers, and on shower days she would wash residents' hands good. CNA C stated prior to meals residents' hands were cleaned with wipes, however she didn't bring the resident to the dining room for lunch. <BR/>During an interview on 02/08/2024 at 2:29 p.m. the DON stated residents' nails were cleaned when CNAs did showers and whenever, they would see the nails were dirty. The DON further stated Resident #34's nails looked clipped but did need to be cleaned. <BR/>Record review of the facility's policy and procedure titled Nail Care, dated 2003, revealed Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath .Nail care will be performed regularly and safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and support the physical, mental, and psychosocial well-being for 3 of 28 residents (Resident #22, Resident #35, Resident #71) reviewed for activities. <BR/>The facility failed to provide an activity program designed to meet Resident #22's, #35's or #71's interests or needs.<BR/>This deficient practice placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. <BR/>The findings included:<BR/>Review of Resident #22's Face Sheet dated 01/12/23 reflected, [AGE] year-old female admitted to the facility on [DATE] with diagnosis of hemiplegia (paralysis of one side of the body) due to cerebral infarction (stroke), diabetes mellitus, abdominal pain, HTN (high blood pressure), and hyperlipidemia (high cholesterol).<BR/>Review of Resident #22's MDS dated [DATE] reflected, a BIMS score of 12 indicating moderately impaired cognition. MDS reflected no assessment conducted for the section F (for activity). MDS section G for functional status reflected Resident #22 required extensive assistance for transfer and bed mobility. <BR/>Review of Resident #22's Care Plans dated 12/01/21 revealed there were no care plans for activities. <BR/>Observation and interview on 01/10/23 at 10:00AM, Resident #22 was in bed watching TV. Resident #22 stated she does not attend activity as she requires a lot of assistance from staff due to being hemiplegic (paralysis of one side of the body). Resident #22 stated she does not do any activity inside her room which is the reason why she watches TV only. Resident #22 stated no one asked her what activity she likes or offered any activities for her. There was no activity materials observed inside the resident's room. <BR/>Review of Resident #35's Face Sheet dated 01/12/23 reflected, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, HTN (high blood pressure), hyperlipidemia (high cholesterol), and diabetes.<BR/>Review of Resident #35's MDS dated [DATE] reflected, a BIMS score of 14 indicating no cognitive impairment. MDS reflected no assessment conducted for the section F (for activity).<BR/>Review of Resident #35's Care Plans dated 11/07/20 reflected, Resident #35 will be encouraged to participate in activities in her room/hall. Resident enjoys reading, crafting and socializing with her roommate with intervention of resident will be provided with necessary materials in order to participate in activities on a regular basis.<BR/>Interview on 01/11/23 at 10:00AM, Resident #35 stated most of the residents and herself would like to go to the library and use the computer and check out reading materials but that never happened with the facility. Resident #35 stated she would like to have more outside time and reported of having walked one time with therapy last year. Resident #35 stated she will attend activities held inside the facility that interest her. <BR/>Review of Resident #71's Face Sheet dated 01/12/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of age-related cognitive decline, fatigue (feeling of tiredness or weakness), and hypercholesterolemia. <BR/>Review of Resident #71's MDS dated [DATE] reflected, a BIMS score of 13 indicating no cognitive impairment. MDS reflected no assessment conducted for the section F (for activity).<BR/>Review of Resident #71's Care Plans dated 09/12/22 revealed there were no care plans for activities.<BR/>Interview on 01/10/23 at 10:26AM, Resident #71 stated activity staff had never given her anything and that they asked her to attend activities that she does not like. Resident #71 stated she needs materials to make her brain work such as puzzles, crosswords and activities does not know what her preferences are. Resident #71 stated she gets her own materials for activity. <BR/>Interview on 01/12/23 at 2:30PM, the AD stated she recently started her position in December 2022. The AD stated she was responsible to create a monthly activity calendar and had completed the December and January activity calendar. AD stated she does not do care plans for activities, and said they were done by the social worker. The AD stated she is in the process of getting to the residents and finding out what they like and dislike. The AD stated she has not seen residents going outside for activities. The AD stated the impact of residents not having activities could be separation from life and they could go into depression. <BR/>Interview on 01/12/23 at 3:35PM, the ADON stated there should be an activity care plan created by the activity director. The ADON stated there should be activities every day to keep the residents healthier and keep their mental status. The ADON stated not having activities could impact their ADL decline, and mental status causing depression. <BR/>Interview on 01/12/23 at 4:17PM, the SW stated each department head is responsible of creating their own care plans. The SW stated she is responsible of conducting care plan meetings. <BR/>Interview on 01/12/23 at 5:30PM, the DON stated she is not aware of not having activities on the weekends. The DON stated her expectation is what is on the facility policy.<BR/>Interview on 01/12/23 at 6:12PM, the ADM stated the facility used a website that has a template for monthly activity calendars which the facility can customize according to the facility needs. The ADM stated the AD is responsible to customize the calendar and create it. The ADM stated activities should be provided every day. The ADM stated he does not think anything major will happen from not providing activities to residents other than having them stay in their rooms all day. The ADM stated there should be a care plan for activities. The ADM stated the impact of not having activity care plans would be not knowing what resident's activity preferences were. <BR/>Review of facility's policy titled Activities and Social Services dated December 2006 reflected, Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. 4.As much as possible, the facility will help the individual arrange to reach these outside activities, but the facility may not necessarily provide the transportation. 7. Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was assessed by a nurse before CNA A got him off the floor after an unwitnessed fall on 01/14/25. <BR/>This failure could place residents at risk of not receiving necessary medical care, harm, injury, and hospitalization.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, repeated falls, and age-related physical debility. <BR/>Review of Resident #1's quarterly MDS assessment, dated 01/08/25, reflected a BIMS could not be conducted due to him rarely/never being understood. Section J (Health Conditions) reflected he had two or more falls since the prior assessment.<BR/>Review of Resident #1's quarterly care plan, dated 10/01/24, reflected he was at risk for falls related to poor safety awareness and decreased balance/strength with an intervention of anticipating and meeting the resident's needs.<BR/>Review of Resident #1's admission (from the hospital) Fall-Risk Assessment, dated 01/15/25, reflected he was a high fall risk.<BR/>Review of Resident #1's progress note, dated 01/14/25 at 8:54 AM and documented by LVN B, reflected the following:<BR/>[CNA A] wheeled [Resident #1] to the NSG station and [sic] reported he was found OOB on the floor; she reported, she recovered him from the floor and put him in the W/C . <BR/>During an interview on 01/28/25 at 2:22 PM, CNA A stated she knew better than to pick a resident up off the floor before getting a nurse to assess them. She stated it was important for a nurse to assess the resident if found on the floor because they could be injured. She stated the day she found Resident #1 on the ground (sitting on his bottom), she panicked because he was impulsive, and she was worried he would try to get up on his own and fall again. She stated it was a mistake and it should not have happened. She stated she immediately took him to LVN B, and he assessed Resident #1. She stated she was in-serviced on resident falls after the incident. <BR/>During a telephone interview on 01/28/25 at 2:07 PM, the NP stated she was notified of Resident #1's fall. She stated if a fall was not witnessed, she would expect the aides to get a nurse to assess the resident before getting them off the ground. She stated a negative outcome could be if they had a head injury, it could make it worse.<BR/>During an interview on 01/28/25 at 2:10 PM, the DON stated she was aware of the incident regarding CNA A getting Resident #1 off the ground before a nurse assessed him. She stated Resident #1 was assessed by LVN B and was not injured. She stated CNA A received a disciplinary action, 1:1 training, and all the staff were in-serviced. She stated CNA A admitted what she did was wrong, and she made a mistake by impulsively getting him off the floor. She stated if a resident was found on the ground, a nurse needed to take their vitals and assess for possible injuries. She stated if not assessed first, a resident could be further injured. <BR/>An interview was attempted by telephone with LVN B on 01/28/25 at 12:49 PM. A call was not returned prior to exiting.<BR/>Review of in-services entitled Fall Prevention, dated 01/14/25 and 01/16/25 and conducted by the DON, reflected all staff were in-serviced on fall prevention and their fall policy and procedure. <BR/>Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised October 5, 2016, reflected the following:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents received food that accommodated their preferences for one (Resident #48) of eight residents reviewed for food and drink preferences. <BR/>The facility failed to ensure Resident #48 received tea, her beverage of choice, during three meals. <BR/>This failure placed residents at risk of not receiving their food and drink preferences. <BR/>Findings included:<BR/>A record review of Resident #48's face sheet dated 1/12/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hypertension (high blood pressure), fractured right femur, BMI of 70 or greater, repeated falls, anemia, and muscle weakness. <BR/>A record review of Resident #48's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #48's MDS assessment did not reflect food and drink preferences.<BR/>A record review of Resident #48's care plan last revised on 12/14/2022 reflected Resident #48 had ADL self-care deficit related to increased BMI, decreased endurance, fracture, and general weakness. Resident #48's care plan did not reflect food and drink preferences.<BR/>During an interview and observation on 1/10/2023 at 11:19 a.m., Resident #48 was observed lying in bed. Resident #48 stated she was supposed to get tea with each meal but staff gave her water and overly sweet Kool-Aid instead. She stated the SW was aware of the issue but did not do anything. <BR/>During an interview and observation on 1/10/2023 at 12:04 p.m., Resident #48 was observed eating lunch in bed. Resident #48 commented that her meal ticket reflected Add tea but she did not receive tea. Resident #48's meal tray contained juice and water, but no tea. Resident #48 stated staff knew she wanted tea. Resident #48's meal ticket reflected Add tea. <BR/>During an interview on 1/10/2023 at 12:18 p.m., CNA A stated as far as she knew, there was no tea. CNA A stated the kitchen portioned out all drinks inside the kitchen. CNA A stated the thought the kitchen might have tea inside if residents asked. <BR/>During an interview and observation on 1/10/2023 at 12:27 p.m., [NAME] A stated the kitchen had tea bags for hot tea. Observed tea bags on a shelf in the kitchen. <BR/>During an interview on 1/10/2023 at 12:34 p.m., the Dietary Supervisor stated residents had a choice of what they wanted to eat. The Dietary Supervisor stated CNAs asked residents whether they wanted the main menu or the alternate menu. <BR/>During an interview on 1/11/2023 at 11:36 a.m., [NAME] A stated kitchen staff did not go into resident's rooms, and that nursing staff would need to make teas for residents who ate in their rooms and could not get out of bed. [NAME] A stated the kitchen used to have iced tea mix but they had not had any since November 2022 because the new supplier ordered from did not have it. [NAME] A stated Resident #48 drank tea and there were not enough residents who liked iced tea to make a whole pitcher of it because it would become spoiled. [NAME] A stated because Resident #48 could not get out of bed, CNAs would communicate any dietary complaints she had. [NAME] A stated Resident #48 had not complained about not getting tea. [NAME] A stated some residents were particular with how they liked their tea so it was better for them to make it themselves. [NAME] A said Resident #1 was not one of the residents who was particular with how they liked their tea. [NAME] A stated kitchen staff were responsible for portioning out and preparing all drinks for residents. <BR/>During an interview and observation on 1/11/2023 at 11:45 a.m., Resident #48 was observed lying in bed. Resident #48 stated she liked either hot tea or iced tea. Resident #48 stated she had not received any tea in weeks, stating she hated the fruit punch they served because it was too sweet. <BR/>During an interview an observation on 1/11/2023 at 12:56 p.m., Resident #48 was observed eating lunch in bed. Resident #48's meal tray contained water and juice but no tea. Resident #48's meal ticket reflected Add tea. Resident #48 had a pitcher of tea on her bedside table and she stated she got it from a friend. <BR/>During an interview on 1/12/2023 at 8:46 a.m., the LD stated the Dietary Supervisor updated tray tickets to reflect residents' food preferences. The LD stated kitchen staff should follow whatever was on the tray ticket. When asked who ensured food preferences were honored, the LD stated, it would be up to the Dietary Supervisor. The LD stated that if whoever passed trays noticed something missing, they could be an additional set of eyes to help as well. The LD stated she thought dietary staff prepared drinks but she was not sure if other staff poured drinks as well. The LD stated the Dietary Supervisor updated preferences to the tray card and staff on the line would follow the ticket. The LD stated that once the tray was passed to the resident, the nurse aides or nurses would ideally check to ensure all items were there. When asked what a potential negative resident outcome could be if residents' drink preferences were not honored, the LD stated if it were something like iced tea and they were not able to get it on the truck, that might be why the resident would not receive it. The LD stated, but we definitely want to honor food preferences and accommodate them as much as we can.<BR/>During an interview and observation on 1/12/2023 at 9:10 a.m., Resident #48 was observed eating breakfast in bed. Resident #48's meal tray did not contain tea. Resident #48's meal ticket reflected Add tea. Resident #48 stated she got water and apple juice but the juice was too sweet and she had to add water to it. <BR/>During an interview on 1/12/2023 at 9:17 a.m., [NAME] E stated nurses put teas on residents' trays. [NAME] E stated kitchen staff placed the tea bags outside the serving window for nursing staff to make the teas since the hot water dispenser was in the dining room. <BR/>During an interview on 1/12/2023 at 9:20 a.m., the Dietary Supervisor stated sometimes kitchen staff placed tea bags out for nurses to make teas for residents who asked. When asked why a resident who had tea on their ticket would not receive tea when the kitchen had tea bags and the resident did not mind hot tea, the Dietary Supervisor stated, I guess we would have to give it.<BR/>During an interview on 1/12/2023 at 9:29 a.m., RN A stated nurses checked meal trays as they were being passed through the serving window of the dining room. RN A stated nurses checked to ensure what was on the ticket matched what was on the tray. RN A stated dietary staff checked trays for likes and dislikes. RN A stated dietary staff were responsible for placing teas on hall trays. When asked if dietary staff placed tea bags in the serving window for nursing staff to make teas, RN A stated, no. <BR/>During an interview on 1/12/2023 at 5:23 p.m., the DON stated residents' dietary preferences were usually on their tray card which was updated by the Dietary Supervisor. The DON stated residents' likes and dislikes were on meal tickets. The DON stated the Dietary Supervisor was responsible for ensuring residents' likes and dislikes were included on their meal tickets. The DON stated the Dietary Supervisor met with residents upon admission to update their dietary preferences. The DON stated nurses checked trays before giving them to CNAs to ensure preferences were on the tray. When asked why an item available in the kitchen would not be served to a resident whose meal ticket included that item, the DON stated if it's on the ticket they should get it. If the item isn't on the tray and they have it in the kitchen, the nurses could ask the kitchen for it. When asked what a potential negative resident outcome could be of failing to accommodate a resident's food preferences, the DON stated, I know the resident and I know she will ask for tea. If it's available, it should be given. If it's on the tray card, it should be given. Moving forward, we can investigate why she wasn't getting tea.<BR/>During an interview on 1/12/2023 at 6:13 p.m., when asked what the facility's policy was on honoring residents' food and drink preferences, the ADM stated, On the top of my head, I don't know what the policy says. We promote restaurant style of dining. We always have an always available menu. The ADM stated nurses checked meal tickets to make sure the right diet was there and to compare the plate with the meal card. When asked why Resident #48 would not have received an available item requested per her meal ticket, the ADM stated, If they had it in the kitchen, I don't know why they wouldn't have given it to her. When asked what a potential negative resident outcome could be of failing to provide a reasonable attempt to accommodate residents' food preferences, the ADM stated, I don't think there would be any impact.<BR/>A record review of the facility's undated policy titled Dietary Tray Cards reflected the following:<BR/>Policy: Each resident shall have a diet tray card. The diet tray card must be neat, legible, and clean. Tray cards can be either printed form an approved computer tray card system, or manual [NAME] tray cards. The tray card must identify the following information. <BR/>1. Resident's name<BR/>2. Resident's room number<BR/>3. Resident's bed number<BR/>4. Resident's diet exactly as ordered by a physician<BR/>5. Resident's beverage preference<BR/>6. Resident's food preferences<BR/>7. Resident's food dislikes and allergies<BR/>8. Location of meal<BR/>A record review of the facility's policy titled Resident Food Preferences dated December 2008 reflected the following:<BR/>Policy Statement: Nutritional assessments will include an evaluation of individual food preferences.<BR/>Policy Interpretation and Implementation<BR/>1. Upon the resident's admission, or within twenty-four (24) hours after his/her admission, the Dietitian or nursing staff will identify a resident's food preferences. When possible, this will be done by direct interview with the resident.<BR/>4. The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions. <BR/>5. The Dietitian will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests.<BR/>7. The facility's Quality Assessment and Assurance (QAA) program 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 observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for food storage and sanitation.<BR/>1. The Dietary Supervisor failed to ensure all items in the walk-in refrigerator and dry storage were covered, labeled, dated, and discarded prior to their expiration date. <BR/>2. [NAME] A failed to change gloves and wash her hands when changing tasks. <BR/>3. [NAME] B, Dietary Aide A and [NAME] C failed to wear effective hair restraints.<BR/>These failures placed residents at risk of foodborne illness.<BR/>Findings included:<BR/>Observations of the walk-in refrigerator on 1/10/2023 from 9:06 a.m. to 9:19 a.m. revealed the following:<BR/>At 9:06 a.m. the walk-in refrigerator contained tomatoes in a metal steam pan with a use-by date of 1/04/2023. <BR/>At 9:07 a.m. the walk-in refrigerator contained two bowls of peaches which were uncovered and unlabeled.<BR/>At 9:08 a.m. the walk-in refrigerator contained a metal bowl filled with nine individually wrapped pieces of cornbread which were unlabeled and undated.<BR/>At 9:09 a.m. the walk-in refrigerator contained a sheet cake which was uncovered, unlabeled, and undated. <BR/>At 9:10 a.m. the walk-in refrigerator contained two two-ounce cups of ketchup which were uncovered, unlabeled, and undated. <BR/>At 9:11 a.m. the walk-in refrigerator contained two two-ounce cups of maple syrup which were unlabeled and undated. <BR/>At 9:12 a.m. the walk-in refrigerator contained eight individually wrapped bags of fruit which were unlabeled and undated. <BR/>At 9:13 a.m. the walk-in refrigerator contained a plastic tub of pickles, opened, and without an opened date. <BR/>At 9:18 a.m. the walk-in refrigerator contained a container of jalapenos labeled prep 11/4 and discard 11/11. <BR/>At 9:19 a.m. the walk-in refrigerator contained a plastic container of peaches which was unlabeled and undated. <BR/>In an interview on 1/13/2023 at 9:19 a.m., [NAME] A stated all items in the walk-in refrigerator should be covered, labeled and dated. [NAME] A stated items such as condiments needed to be labeled when they were opened. [NAME] A stated someone might have forgotten to label the tub of pickles and stated the tomatoes with the use-by date of 1/04/2023 should have been discarded. [NAME] A stated any food item past its expiration date or use-by date should be discarded.<BR/>An observation on 1/11/2023 at 10:12 a.m. revealed [NAME] A pureed meat, washed the food processor in the three compartment sink, then proceeded to puree vegetables without changing gloves or washing her hands. <BR/>Observations on 1/11/2023 at 10:20 a.m. revealed Dietary Aide A and [NAME] C were wearing hair restraints which did not completely cover their long hair. Dietary Aide A was washing dishes in the kitchen and [NAME] C was standing in the kitchen. Both Dietary Aide A and [NAME] C had long hair which hung free, out the side of their hair restraints.<BR/>An observation on 1/11/2023 at 10:22 a.m. revealed [NAME] A pureed vegetable, washed the food processor in the three compartment sink, then proceeded to prepare mashed potatoes without changing gloves or washing her hands. <BR/>In an interview on 1/11/2023 at 10:35 a.m., when asked if gloves should be changed and hands washed when going from doing dishes to cooking, [NAME] A stated, yes. [NAME] A stated, I thought I washed my hands but if I didn't do that, please forgive me. <BR/>An observation on 1/11/2023 at 10:37 a.m. revealed [NAME] B was making sandwiches in the kitchen and wearing a hair restraint which did not completely cover her long hair. [NAME] B was observed with strands of hair coming out the side of her hair restraint.<BR/>In an interview on 1/11/2023 at 10:37 a.m., when asked if all of her hair was covered, [NAME] B communicated she did not understand in English by stating, I only understand a little bit.<BR/>In an interview on 1/11/2023 at 10:40 a.m., when asked if all of his hair was covered, Dietary Aide A stated, no. When asked if it should be, Dietary Aide A stated, probably, yeah. <BR/>In an interview on 1/11/2023 at 10:43 a.m., when asked if his hair was completely covered by the hair restraint, [NAME] C stated, is it not? and then said, I'll go take care of it. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:44 a.m. revealed a bulk container of flour dated 11/1/2022 with the scoop stored inside the container on the flour. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:45 a.m. revealed a bulk container of rice unlabeled and undated. <BR/>In an interview on 1/11/2023 at 10:45 a.m., the Dietary Supervisor stated he had worked in the facility for one year, had worked as manager for six months, and that was his first survey. <BR/>In an interview on 1/11/2023 at 10:49 a.m., the Dietary Supervisor stated kitchen staff were taught upon hire how to label and date food items. The Dietary Supervisor stated he had not completed any written in-service training with kitchen staff since he started as manager, and that most training on food storage and sanitation was completed via observation and demonstration. The Dietary Supervisor stated himself, another experienced employee or [NAME] D would train employees on food storage and sanitation. The Dietary Supervisor stated [NAME] D was the most experienced cook so that is why kitchen staff trained with him. The Dietary Supervisor stated kitchen staff were trained on labeling and dating via demonstration. The Dietary Supervisor stated as far as glove usage, hand washing, and use of hair restraints, training was completed verbally. The Dietary Supervisor stated all staff went through a new hire process which included reading and signing off on an employee hand guide which covered food storage and sanitation. <BR/>In an interview on 1/12/2023 at 8:46 a.m., the LD stated food should be properly sealed if it had been opened, there should be a label and date on items when they were opened, and items such as condiments should have an opened date. The LD stated food should be adequately covered to prevent contamination or exposure of food and food items should be sealed on top. The LD stated yes that all food items should have a label and a date unless it was an unopened, prepackaged item such as a health shake. When asked if food items should be discarded prior to their use-by dates, the LD stated, yes, it's good practice. The LD stated kitchen staff should have some type of covering to cover their hair to prevent contamination. When asked if hair should be completely covered, the LD stated, yes, ideally they should try to tuck all the hair in. The LD stated she would expect handwashing to occur any time before handling food items. When asked how kitchen staff were trained on food storage and sanitation, the LD stated she did not know and it would be a good question for the Dietary Supervisor. The LD stated off hand she did not know whether kitchen staff had been trained, stating, I would ask the Dietary Supervisor. When asked who monitored the kitchen for food storage and sanitation, the LD stated, it would be the Dietary Supervisor and I complete monthly kitchen audits and give any recommendations to the Dietary Supervisor or discuss them with the ADM. The LD stated she was not sure how the Dietary Supervisor monitored the kitchen but stated she monitored through monthly audits. When asked if she had noticed any concerns, the LD stated there had been ongoing education with labeling and dating. The LD stated she had completed verbal education with the Dietary Supervisor on this. When asked what potential negative outcomes there could be if kitchen polices on food storage and sanitation were not followed, the LD stated there could potentially be contamination of food items, foods could be served past their use-by dates, and there could be potential for foodborne illness. <BR/>In an interview on 1/12/2023 at 6:13 p.m., when asked what the facility's policy was on food storage, the ADM stated things needed to be labeled when they were opened, labeled with a use-by and open date, and discarded after seven days. When asked if kitchen staff should have all hair covered, the ADM stated, yes. When asked how hands should be washed when going from dirty dishes to preparing a pureed food item, the ADM stated the best thing would be to take the food processor to the person washing dishes to wash. The ADM stated it was best practice to wash hands before starting a new task.<BR/>A record review of the facility's undated policy titled Food Storage reflected the following:<BR/>Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. These containers can be mounted on caster or dollies. All containers must be legibly and accurately labeled.<BR/>6. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are no to be stored in the food containers, but are kept covered in a protected area near the containers. <BR/>15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded.<BR/>A record review of the facility's policy titled Food Preparation and Service dated 2001 reflected the following: <BR/>Policy Statement: Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.<BR/>4. Food service staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays.<BR/>6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks.<BR/>A record review of the facility's undated Employee Handbook reflected it covered use of hair restraints only, and did not cover handwashing, glove usage, or food storage. <BR/>A record review of the facility's Hand Washing Competency forms dated 10/04/2022, 11/19/2022, and 12/21/2022 reflected [NAME] A's handwashing skill had been demonstrated to show competency. These documents reflected how to wash hands but did not cover when to wash hands. <BR/>A record review of the LD's Sanitation Audit dated 11/04/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Ingredient bins, the LD commented, Recommend view for outdated bulk bin items, discard as appropriate. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that some items were missing labels and dates and some items were outdated. <BR/>A record review of the LD's Sanitation Audit dated 12/02/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that items were missing labels and dates. <BR/>A record review of the FDA's 2017 Food Code reflected the following:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings<BR/>Hair Restraints<BR/>2-402.11 Effectiveness.<BR/>(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was assessed by a nurse before CNA A got him off the floor after an unwitnessed fall on 01/14/25. <BR/>This failure could place residents at risk of not receiving necessary medical care, harm, injury, and hospitalization.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, repeated falls, and age-related physical debility. <BR/>Review of Resident #1's quarterly MDS assessment, dated 01/08/25, reflected a BIMS could not be conducted due to him rarely/never being understood. Section J (Health Conditions) reflected he had two or more falls since the prior assessment.<BR/>Review of Resident #1's quarterly care plan, dated 10/01/24, reflected he was at risk for falls related to poor safety awareness and decreased balance/strength with an intervention of anticipating and meeting the resident's needs.<BR/>Review of Resident #1's admission (from the hospital) Fall-Risk Assessment, dated 01/15/25, reflected he was a high fall risk.<BR/>Review of Resident #1's progress note, dated 01/14/25 at 8:54 AM and documented by LVN B, reflected the following:<BR/>[CNA A] wheeled [Resident #1] to the NSG station and [sic] reported he was found OOB on the floor; she reported, she recovered him from the floor and put him in the W/C . <BR/>During an interview on 01/28/25 at 2:22 PM, CNA A stated she knew better than to pick a resident up off the floor before getting a nurse to assess them. She stated it was important for a nurse to assess the resident if found on the floor because they could be injured. She stated the day she found Resident #1 on the ground (sitting on his bottom), she panicked because he was impulsive, and she was worried he would try to get up on his own and fall again. She stated it was a mistake and it should not have happened. She stated she immediately took him to LVN B, and he assessed Resident #1. She stated she was in-serviced on resident falls after the incident. <BR/>During a telephone interview on 01/28/25 at 2:07 PM, the NP stated she was notified of Resident #1's fall. She stated if a fall was not witnessed, she would expect the aides to get a nurse to assess the resident before getting them off the ground. She stated a negative outcome could be if they had a head injury, it could make it worse.<BR/>During an interview on 01/28/25 at 2:10 PM, the DON stated she was aware of the incident regarding CNA A getting Resident #1 off the ground before a nurse assessed him. She stated Resident #1 was assessed by LVN B and was not injured. She stated CNA A received a disciplinary action, 1:1 training, and all the staff were in-serviced. She stated CNA A admitted what she did was wrong, and she made a mistake by impulsively getting him off the floor. She stated if a resident was found on the ground, a nurse needed to take their vitals and assess for possible injuries. She stated if not assessed first, a resident could be further injured. <BR/>An interview was attempted by telephone with LVN B on 01/28/25 at 12:49 PM. A call was not returned prior to exiting.<BR/>Review of in-services entitled Fall Prevention, dated 01/14/25 and 01/16/25 and conducted by the DON, reflected all staff were in-serviced on fall prevention and their fall policy and procedure. <BR/>Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised October 5, 2016, reflected the following:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible for one (Resident #1) of 82 residents. <BR/>The facility failed to provide an environment free from accidents and hazards over which the facility had control and provided supervision to prevent avoidable accidents. On 02/18/2023, Resident #1 was able to elope from the facility using the 200-hallway emergency alarmed exit door. The 200-hallway door was used temporarily as the facility main entrance and exit from 02/04/2023 until 03/01/2023. After seeing Resident #1's wheelchair empty outside of the 200-hallway exit door, facility staff began looking for Resident #1 within the facility. When he was not located immediately, facility elopement procedures were followed. Approximately 12 hours later the resident telephoned his family member, who called the facility and informed them of Resident #1's location. According to wuweatherunderground (https://www.wunderground.com/history/daily/[NAME]/date/2023-2-18) the weather was as follows: High temperature - 55, Low temperature - 26, Average temperature - 41.88, Precipitation zero. The facility is in a high traffic area with a speed limit on of 45 miles per hour on street where the facility is located. Observation of street directly in front of the 200-hallway exit exhibited very high traffic with two-way lanes with a median separating the lanes. Resident #1 was retrieved by facility staff nurse at a location 5.13 driving miles away from the facility, was returned to the facility, was assessed, and found to have no injuries. <BR/>An IJ was identified on 3/9/2023. The IJ began on 2/18/2023 and removed on 2/18/2023. The facility took action to remove the IJ before the survey began. While the IJ was removed on 2/18/2023, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on elopement policies, in-services on exit seeking behaviors, and conduct a QAPI had not been conducted regarding the elopement incident. While the front door had been fixed the facility failed to retrain staff on elopement policies, in-services on exit seeking behaviors, and failed to conduct a QAPI regarding the elopement incident. <BR/>This deficient practice could place residents at risk for serious injury, serious harm, serious impairment, or death likely.<BR/>Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible. <BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, undated, revealed a [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis of schizophrenia, (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), unspecified. Unstable burst fracture (an injury in which the vertebra, the primary bone of the spine, breaks in multiple directions) of first lumbar vertebra (a bones forming the backbone, level with the anterior end of the ninth rib) subsequent encounter for fracture with routine healing. <BR/>Review of Resident #1's Care Plan, initiated 01/27/2023, revealed Resident #1 exhibited impaired social interaction, hallucinations (an experience involving the perception of something not present) and disturbed through process (altered understanding of situations) and cognition (the process of acquiring knowledge) that interfered with daily living. The care plan revealed he was, .at risk for elopement r/t (related to) able to ambulate/locomotion per self, desire to go home, exit seeking behaviors. The care plan revealed he demonstrated manipulative, destructive, insensitive, and disrespectful behavior. <BR/>Review of Resident #1's Elopement Risk Assessment, dated 01/27/2023, revealed a score of 23. The Risk Assessment evaluation scale revealed a score of 5 or more is considered to be a risk for elopement. <BR/>Review of Resident #1s Minimum Data Set (MDS) dated [DATE] revealed serious mental illness and a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Review of local Police Department accident data sheet dated 02/04/2023 revealed a car collided into the portico (a structure consisting of a roof supported by columns at regular intervals, typically attached as a porch to a building) of the main entrance of the nursing home. <BR/>Interview on 03/07/2023 at 9:50 AM with ADMIN revealed at the accident occurred at approximately 7:30 PM on 02/04/2023 and Resident #1 was missing for approximately 12 hours on 02/18/2023. <BR/>Interview on 03/08/2023 at 12:46 PM with the RDBO revealed when he arrived at the facility on the date of the collision the fire department was taping off the front entrance with caution tape and told him the regular entrance to the facility could not be used because safety concerns of structural damage. The RDBO revealed a decision was made to use the 200-hallway door for the entrance/exit. The RDBO revealed he was not concerned about using 200-hallway door because he installed a new Safety Technology International Exit Door Alarm: Key Lock. The RDBO revealed to disarm the 200-hallway exit door, a key was inserted at the bottom front of the box (the keyhole was clearly visible) and turned horizontally to turn off the alarm to allow people to enter and exit the facility and to arm the door, the key was inserted and turned vertically. <BR/>Observation on 03/07/2023 at 12:46 PM of the 200 Exit Alarm Key Lock revealed a visible to all viewers easy to follow diagram on in the alarm key lock that displayed the instructions on how to activate and deactivate the alarm on the 200-hallway. <BR/>Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed that beginning 02/06/2023 the receptionist, who worked 7:00 AM until 4:00 PM Monday - Friday was given the responsibility to let people in and out of the facility and to use the alarm key to arm and disarm the door. When the receptionist was not at the facility the AA, HA, or charge nurse for the 200-hallway were responsible for letting people in and out of the building with the alarm key and arming and disarming the door. <BR/>Interview on 03/07/2023 at 12:26 PM with the receptionist who explained she first saw the damage to the entry on Monday 02/06/2023. She said it was appeared that they absolutely could not go through the front door because it was cautioned off with tape. She explained there was a sign and arrows directing people enter using the 200-hallway door. After about a day and a half she moved her desk to the room across from the 200-hallway door. The facility had installed a doorbell and when someone would ring the bell, she would use the key to disarm the door and when they exited, she would use the key to arm the alarm. She revealed she kept the key in her pocket. Receptionist revealed that the key to the alarm that she used for the 200-hallway when the front door was not working with the administrator. The receptionist reported when she left for the day, she physically handed the key for the 200-hallway alarm to the evening a charge nurse or the administrator. <BR/>Observation on 03/07/2023 at 9:30 AM revealed facility front door fully functioning, and employee came to the front door and used keypad to allow access to the facility. No observations of residents approaching the front door or attempting to use the keypad. Nursing station and reception desk in clear view of front door with no obstruction of front door alarm and keypad. <BR/>Interview on 03/09/2023 at 3:23 PM with LVN A who worked PRN (as needed) revealed that when she worked on the 200-hallway during the time the front entrance was not being used, she kept the alarm key with her and did not leave the key in the keyhole. <BR/>Observation and interview on 03/08/2023 at 12:46 PM with the RDBO revealed small nail sized hole in the wall to the right of the nurse's station. The RDBO revealed the evening of 02/04/2023 he put a nail in the wall where the small hole was observed and put a, big red keyring holding the 200-hallway exit door disarm key on the nail. The RDBO said he put the key there so it would be easily accessible to the staff to let people in and out of the facility.<BR/>Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed he was unaware the RDBO had put the key that armed and disarmed the entry and exit to the 200-hallway on a key ring next to the nurse's station visible to residents.<BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed it took a long time to get the front door fixed and if any of staff heard the doorbell ring, they would let them in. At the beginning only the nurses had the alarm key but, it started to get too much and eventually the key was left in the emergency alarm. <BR/>Interview on 03/09/23 at 12:30 PM with the MD revealed that at some point the key was left in the keyhole of the 200-hallway because staff would get frustrated. <BR/>Interview on 03/09/2023 at 4:08 PM with R#2 in room [ROOM NUMBER]A located at the end of the 200-hallyway next to the exit door indicated he observed the key left in the alarm several times. <BR/>Review of in-service entitled Topic: Complete Visual Check on the 200 Hall Doors dated 02/04/2023 with trainer/education by the ADON. <BR/>Interview on 03/07/2023 at 12:26 PM the receptionist revealed Resident#1 vigilantly watched her letting people in and out of the 200-hallway door. She revealed Resident# 1 watched her for one full day. The receptionist did not tell the ADMIN, the DON, or the ADON about Resident#1 watching the door. When the receptionist asked if she felt Resident #1 was exit seeing the receptionist relayed, oh yea, he was exit seeking. She revealed that she kept the key in the desk draw of the room located across from the 200-hallway door. The receptionist revealed she was always in the room across the when she was working.<BR/>Interview on 03/09/2023 at 12:35 PM the receptionist revealed she told the SW Resident #1 was very intelligent and was watching her when she was letting people in and out of the 200-hallway door. <BR/>Interview on 03/07/2023 at 9:50 AM the ADMIN revealed that Resident #1 was exit seeking. <BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed Resident #1 was clearly exit seeking and he would punch the numbers on the 400-hallway exit door keypad and she would tell him, get back over here. She revealed Resident #1 was very smart and paid attention and was going down the 200-hallway paying attention, too much. CNA A revealed she told the ADON, all the time that he was punching in number on the keypad. <BR/>Interview on 03/07/2023 at 5:25 PM with ADMIN revealed that because the WanderGuard was not working it affected how the staff kept eyes on the residents and revealed that because of the possible harm to the resident the facility increased staffing and visual checks of the residents and conducted elopement drills. The ADMIN revealed he was pushing for corporate to fix the door. <BR/>Interview on 03/07/2023 at 9:50 PM the ADMIN revealed that Resident #1's room was on the 400- hallway but he walked around everywhere - sometimes he used his wheelchair and sometimes he did not. <BR/>Interview on 03/07/2023 at 1:25 PM with LVN B, the 200-hallwy nurse on 02/18/2023, and she works the 6:00 AM to 6:00 PM shift. She revealed she remembered him talking to her and he was unintelligible, and she was busy passing out medications and did not notice where he went or what time she spoke with him. She discovered Resident #1 was missing when the facility began elopement protocols. <BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed on 02/18/2023 at 7:15 AM she saw Resident #1's wheelchair, empty, outside of the emergency exit door of the 200-hallway and went to go look for him in his room on the 400-hallway. When CNA did not find him in his room, she located his nurse RN A and asked if RN A had seen him. RN A said she had not seen him. CNA A revealed that they began searching for Resident #1 both in and outside the facility. <BR/>Interview on 03/07/2023 at 9:50 AM with the ADMIN revealed that on 02/18/2023 at about 7:45 AM he received a call from RN A that Resident #1 could not be located in or around the facility and the ADMIN instructed RN A to initiate elopement protocols. The ADMIN revealed RN A told him she called the police and informed police about a missing resident, but RN A said the police.<BR/>Interview on 03/07/2023 at 9:50 AM with the ADON revealed that Resident #1 was retrieved by her at approximately 8:00 PM on 02/18/2023 from a CVS and the ADON returned with him to the facility. <BR/>Review of Resident #1's progress notes dated 02/19/2023 reveal that at approximately 8:00 PM on 02/18/2023 the ADON completed a bedside assessment revealing normal blood pressure and temperature with zero signs of distress or pain noted and zero skin issues noted. Resident was discharged Against Medical Advice on 02/18/2023. <BR/>Review of Resident #1's face sheet dated 03/08/2023 revealed under the area of contacts it read, responsible party - self. <BR/>Interview on 03/07/2023 at 9:50 the ADMIN revealed the front entrance was the most secure entrance and exit to the facility because it was visible from the nurse's station, visible from the receptionist area, and visual from the ADMIN office. Additionally, it had a secure keypad, and alarm, and is wired for WanderGuard (a device worn on the wrist or ankle to trigger alarms and prevent wander-prone residents from leaving unattended). <BR/>Review of Resident #1's order summary report dated 03/09/2023 reveals an order in place to check WanderGuard placement and function every shift beginning 02/15/2023.<BR/>Interview on 03/07/2023 at 9:50 AM of ADMIN revealed the front entrance of the building was not being used because of the collision from 02/04/2023 until 03/01/2023. The ADMIN revealed that he did not have the authority to make a financial decision regarding making building repairs to the facility. He revealed that on 02/04/2023 the CEO phoned him and said that he wanted to go through the insurance company of the owner of the car who collided with the building because it would increase the premium cost of the facility insurance if they used the facility insurance. <BR/>Interview on 03/09/2023 at 1:00 PM with the COO revealed the facility was waiting on the insurance company of owner of the car who caused the damage to the front of the facility to appraise the damage and make payment for the damages before making repairs to the main entrance. <BR/>Review of estimate from construction company dated 02/07/2023 reveals that the repair cost to the front entrance portico was $7,500. <BR/>Review of email from the facility owner to the facility CFO and ADMIN dated 02/27/2023 stating, we cant wait on insurance to cover this. It's a hazard to residents. We will have to get reimbursed from the insurance company.<BR/>Interview on 03/07/2023 at 1:26 PM with the FMD revealed that the facility was waiting for an estimate from the car insurance company of the owner of the car who caused the damages before they made the repairs. He constantly called the insurance company to make sure they were going to pay for it and the insurance company was non-responsive. He revealed that he told that to the insurance company that it was a safety concern. He revealed that the work to repair the front entry began on Monday 02/27/2023 and ended on 03/01/2023. <BR/>Review of facility Inservice Elopement Drill dated 02/17/2023, 02/19/2023, 02/19/2023, 02/22/2023.<BR/>Review of the facility's Elopement and Wandering policy revised December 2007 reveals:<BR/>1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement).<BR/>2. The staff will assess at risk individuals for pension initially correctable risk factors related to unsafe wandering<BR/>3. The resident care plan will indicate the resident is at risk for elopement or other safety issues interventions to try to maintain safety will be included in the resident care plan.<BR/>4. Nursing staff will document circumstances related to unsafe actions, including wandering, by resident. <BR/>5. Staff will institute a detailed monitoring plan, is indicated for residents who are assessed to have a high risk of allotment for other unsafe behavior.<BR/>6. Staff will notify the administrator and director of nursing's immediately and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.<BR/>Facility was notified on 03/09/2023 at 5:10 PM that an IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 02/18/2023.<BR/>The facility implemented the following interventions: On 03/04/2023 repairs were completed on the portico of the main front entry door equipped with a keypad entry and exit, WanderGuard Alarm, fire alarm, and visibility of residents from the nurse's station, receptionist, and ADMIN's office. After the completion of the front entry repairs neither the 200-hallways door or any other facility emergency exit doors were opened and closed using a key to alarm and disarm doors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was assessed by a nurse before CNA A got him off the floor after an unwitnessed fall on 01/14/25. <BR/>This failure could place residents at risk of not receiving necessary medical care, harm, injury, and hospitalization.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, repeated falls, and age-related physical debility. <BR/>Review of Resident #1's quarterly MDS assessment, dated 01/08/25, reflected a BIMS could not be conducted due to him rarely/never being understood. Section J (Health Conditions) reflected he had two or more falls since the prior assessment.<BR/>Review of Resident #1's quarterly care plan, dated 10/01/24, reflected he was at risk for falls related to poor safety awareness and decreased balance/strength with an intervention of anticipating and meeting the resident's needs.<BR/>Review of Resident #1's admission (from the hospital) Fall-Risk Assessment, dated 01/15/25, reflected he was a high fall risk.<BR/>Review of Resident #1's progress note, dated 01/14/25 at 8:54 AM and documented by LVN B, reflected the following:<BR/>[CNA A] wheeled [Resident #1] to the NSG station and [sic] reported he was found OOB on the floor; she reported, she recovered him from the floor and put him in the W/C . <BR/>During an interview on 01/28/25 at 2:22 PM, CNA A stated she knew better than to pick a resident up off the floor before getting a nurse to assess them. She stated it was important for a nurse to assess the resident if found on the floor because they could be injured. She stated the day she found Resident #1 on the ground (sitting on his bottom), she panicked because he was impulsive, and she was worried he would try to get up on his own and fall again. She stated it was a mistake and it should not have happened. She stated she immediately took him to LVN B, and he assessed Resident #1. She stated she was in-serviced on resident falls after the incident. <BR/>During a telephone interview on 01/28/25 at 2:07 PM, the NP stated she was notified of Resident #1's fall. She stated if a fall was not witnessed, she would expect the aides to get a nurse to assess the resident before getting them off the ground. She stated a negative outcome could be if they had a head injury, it could make it worse.<BR/>During an interview on 01/28/25 at 2:10 PM, the DON stated she was aware of the incident regarding CNA A getting Resident #1 off the ground before a nurse assessed him. She stated Resident #1 was assessed by LVN B and was not injured. She stated CNA A received a disciplinary action, 1:1 training, and all the staff were in-serviced. She stated CNA A admitted what she did was wrong, and she made a mistake by impulsively getting him off the floor. She stated if a resident was found on the ground, a nurse needed to take their vitals and assess for possible injuries. She stated if not assessed first, a resident could be further injured. <BR/>An interview was attempted by telephone with LVN B on 01/28/25 at 12:49 PM. A call was not returned prior to exiting.<BR/>Review of in-services entitled Fall Prevention, dated 01/14/25 and 01/16/25 and conducted by the DON, reflected all staff were in-serviced on fall prevention and their fall policy and procedure. <BR/>Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised October 5, 2016, reflected the following:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was assessed by a nurse before CNA A got him off the floor after an unwitnessed fall on 01/14/25. <BR/>This failure could place residents at risk of not receiving necessary medical care, harm, injury, and hospitalization.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, repeated falls, and age-related physical debility. <BR/>Review of Resident #1's quarterly MDS assessment, dated 01/08/25, reflected a BIMS could not be conducted due to him rarely/never being understood. Section J (Health Conditions) reflected he had two or more falls since the prior assessment.<BR/>Review of Resident #1's quarterly care plan, dated 10/01/24, reflected he was at risk for falls related to poor safety awareness and decreased balance/strength with an intervention of anticipating and meeting the resident's needs.<BR/>Review of Resident #1's admission (from the hospital) Fall-Risk Assessment, dated 01/15/25, reflected he was a high fall risk.<BR/>Review of Resident #1's progress note, dated 01/14/25 at 8:54 AM and documented by LVN B, reflected the following:<BR/>[CNA A] wheeled [Resident #1] to the NSG station and [sic] reported he was found OOB on the floor; she reported, she recovered him from the floor and put him in the W/C . <BR/>During an interview on 01/28/25 at 2:22 PM, CNA A stated she knew better than to pick a resident up off the floor before getting a nurse to assess them. She stated it was important for a nurse to assess the resident if found on the floor because they could be injured. She stated the day she found Resident #1 on the ground (sitting on his bottom), she panicked because he was impulsive, and she was worried he would try to get up on his own and fall again. She stated it was a mistake and it should not have happened. She stated she immediately took him to LVN B, and he assessed Resident #1. She stated she was in-serviced on resident falls after the incident. <BR/>During a telephone interview on 01/28/25 at 2:07 PM, the NP stated she was notified of Resident #1's fall. She stated if a fall was not witnessed, she would expect the aides to get a nurse to assess the resident before getting them off the ground. She stated a negative outcome could be if they had a head injury, it could make it worse.<BR/>During an interview on 01/28/25 at 2:10 PM, the DON stated she was aware of the incident regarding CNA A getting Resident #1 off the ground before a nurse assessed him. She stated Resident #1 was assessed by LVN B and was not injured. She stated CNA A received a disciplinary action, 1:1 training, and all the staff were in-serviced. She stated CNA A admitted what she did was wrong, and she made a mistake by impulsively getting him off the floor. She stated if a resident was found on the ground, a nurse needed to take their vitals and assess for possible injuries. She stated if not assessed first, a resident could be further injured. <BR/>An interview was attempted by telephone with LVN B on 01/28/25 at 12:49 PM. A call was not returned prior to exiting.<BR/>Review of in-services entitled Fall Prevention, dated 01/14/25 and 01/16/25 and conducted by the DON, reflected all staff were in-serviced on fall prevention and their fall policy and procedure. <BR/>Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised October 5, 2016, reflected the following:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible for one (Resident #1) of 82 residents. <BR/>The facility failed to provide an environment free from accidents and hazards over which the facility had control and provided supervision to prevent avoidable accidents. On 02/18/2023, Resident #1 was able to elope from the facility using the 200-hallway emergency alarmed exit door. The 200-hallway door was used temporarily as the facility main entrance and exit from 02/04/2023 until 03/01/2023. After seeing Resident #1's wheelchair empty outside of the 200-hallway exit door, facility staff began looking for Resident #1 within the facility. When he was not located immediately, facility elopement procedures were followed. Approximately 12 hours later the resident telephoned his family member, who called the facility and informed them of Resident #1's location. According to wuweatherunderground (https://www.wunderground.com/history/daily/[NAME]/date/2023-2-18) the weather was as follows: High temperature - 55, Low temperature - 26, Average temperature - 41.88, Precipitation zero. The facility is in a high traffic area with a speed limit on of 45 miles per hour on street where the facility is located. Observation of street directly in front of the 200-hallway exit exhibited very high traffic with two-way lanes with a median separating the lanes. Resident #1 was retrieved by facility staff nurse at a location 5.13 driving miles away from the facility, was returned to the facility, was assessed, and found to have no injuries. <BR/>An IJ was identified on 3/9/2023. The IJ began on 2/18/2023 and removed on 2/18/2023. The facility took action to remove the IJ before the survey began. While the IJ was removed on 2/18/2023, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on elopement policies, in-services on exit seeking behaviors, and conduct a QAPI had not been conducted regarding the elopement incident. While the front door had been fixed the facility failed to retrain staff on elopement policies, in-services on exit seeking behaviors, and failed to conduct a QAPI regarding the elopement incident. <BR/>This deficient practice could place residents at risk for serious injury, serious harm, serious impairment, or death likely.<BR/>Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible. <BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, undated, revealed a [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis of schizophrenia, (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), unspecified. Unstable burst fracture (an injury in which the vertebra, the primary bone of the spine, breaks in multiple directions) of first lumbar vertebra (a bones forming the backbone, level with the anterior end of the ninth rib) subsequent encounter for fracture with routine healing. <BR/>Review of Resident #1's Care Plan, initiated 01/27/2023, revealed Resident #1 exhibited impaired social interaction, hallucinations (an experience involving the perception of something not present) and disturbed through process (altered understanding of situations) and cognition (the process of acquiring knowledge) that interfered with daily living. The care plan revealed he was, .at risk for elopement r/t (related to) able to ambulate/locomotion per self, desire to go home, exit seeking behaviors. The care plan revealed he demonstrated manipulative, destructive, insensitive, and disrespectful behavior. <BR/>Review of Resident #1's Elopement Risk Assessment, dated 01/27/2023, revealed a score of 23. The Risk Assessment evaluation scale revealed a score of 5 or more is considered to be a risk for elopement. <BR/>Review of Resident #1s Minimum Data Set (MDS) dated [DATE] revealed serious mental illness and a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Review of local Police Department accident data sheet dated 02/04/2023 revealed a car collided into the portico (a structure consisting of a roof supported by columns at regular intervals, typically attached as a porch to a building) of the main entrance of the nursing home. <BR/>Interview on 03/07/2023 at 9:50 AM with ADMIN revealed at the accident occurred at approximately 7:30 PM on 02/04/2023 and Resident #1 was missing for approximately 12 hours on 02/18/2023. <BR/>Interview on 03/08/2023 at 12:46 PM with the RDBO revealed when he arrived at the facility on the date of the collision the fire department was taping off the front entrance with caution tape and told him the regular entrance to the facility could not be used because safety concerns of structural damage. The RDBO revealed a decision was made to use the 200-hallway door for the entrance/exit. The RDBO revealed he was not concerned about using 200-hallway door because he installed a new Safety Technology International Exit Door Alarm: Key Lock. The RDBO revealed to disarm the 200-hallway exit door, a key was inserted at the bottom front of the box (the keyhole was clearly visible) and turned horizontally to turn off the alarm to allow people to enter and exit the facility and to arm the door, the key was inserted and turned vertically. <BR/>Observation on 03/07/2023 at 12:46 PM of the 200 Exit Alarm Key Lock revealed a visible to all viewers easy to follow diagram on in the alarm key lock that displayed the instructions on how to activate and deactivate the alarm on the 200-hallway. <BR/>Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed that beginning 02/06/2023 the receptionist, who worked 7:00 AM until 4:00 PM Monday - Friday was given the responsibility to let people in and out of the facility and to use the alarm key to arm and disarm the door. When the receptionist was not at the facility the AA, HA, or charge nurse for the 200-hallway were responsible for letting people in and out of the building with the alarm key and arming and disarming the door. <BR/>Interview on 03/07/2023 at 12:26 PM with the receptionist who explained she first saw the damage to the entry on Monday 02/06/2023. She said it was appeared that they absolutely could not go through the front door because it was cautioned off with tape. She explained there was a sign and arrows directing people enter using the 200-hallway door. After about a day and a half she moved her desk to the room across from the 200-hallway door. The facility had installed a doorbell and when someone would ring the bell, she would use the key to disarm the door and when they exited, she would use the key to arm the alarm. She revealed she kept the key in her pocket. Receptionist revealed that the key to the alarm that she used for the 200-hallway when the front door was not working with the administrator. The receptionist reported when she left for the day, she physically handed the key for the 200-hallway alarm to the evening a charge nurse or the administrator. <BR/>Observation on 03/07/2023 at 9:30 AM revealed facility front door fully functioning, and employee came to the front door and used keypad to allow access to the facility. No observations of residents approaching the front door or attempting to use the keypad. Nursing station and reception desk in clear view of front door with no obstruction of front door alarm and keypad. <BR/>Interview on 03/09/2023 at 3:23 PM with LVN A who worked PRN (as needed) revealed that when she worked on the 200-hallway during the time the front entrance was not being used, she kept the alarm key with her and did not leave the key in the keyhole. <BR/>Observation and interview on 03/08/2023 at 12:46 PM with the RDBO revealed small nail sized hole in the wall to the right of the nurse's station. The RDBO revealed the evening of 02/04/2023 he put a nail in the wall where the small hole was observed and put a, big red keyring holding the 200-hallway exit door disarm key on the nail. The RDBO said he put the key there so it would be easily accessible to the staff to let people in and out of the facility.<BR/>Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed he was unaware the RDBO had put the key that armed and disarmed the entry and exit to the 200-hallway on a key ring next to the nurse's station visible to residents.<BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed it took a long time to get the front door fixed and if any of staff heard the doorbell ring, they would let them in. At the beginning only the nurses had the alarm key but, it started to get too much and eventually the key was left in the emergency alarm. <BR/>Interview on 03/09/23 at 12:30 PM with the MD revealed that at some point the key was left in the keyhole of the 200-hallway because staff would get frustrated. <BR/>Interview on 03/09/2023 at 4:08 PM with R#2 in room [ROOM NUMBER]A located at the end of the 200-hallyway next to the exit door indicated he observed the key left in the alarm several times. <BR/>Review of in-service entitled Topic: Complete Visual Check on the 200 Hall Doors dated 02/04/2023 with trainer/education by the ADON. <BR/>Interview on 03/07/2023 at 12:26 PM the receptionist revealed Resident#1 vigilantly watched her letting people in and out of the 200-hallway door. She revealed Resident# 1 watched her for one full day. The receptionist did not tell the ADMIN, the DON, or the ADON about Resident#1 watching the door. When the receptionist asked if she felt Resident #1 was exit seeing the receptionist relayed, oh yea, he was exit seeking. She revealed that she kept the key in the desk draw of the room located across from the 200-hallway door. The receptionist revealed she was always in the room across the when she was working.<BR/>Interview on 03/09/2023 at 12:35 PM the receptionist revealed she told the SW Resident #1 was very intelligent and was watching her when she was letting people in and out of the 200-hallway door. <BR/>Interview on 03/07/2023 at 9:50 AM the ADMIN revealed that Resident #1 was exit seeking. <BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed Resident #1 was clearly exit seeking and he would punch the numbers on the 400-hallway exit door keypad and she would tell him, get back over here. She revealed Resident #1 was very smart and paid attention and was going down the 200-hallway paying attention, too much. CNA A revealed she told the ADON, all the time that he was punching in number on the keypad. <BR/>Interview on 03/07/2023 at 5:25 PM with ADMIN revealed that because the WanderGuard was not working it affected how the staff kept eyes on the residents and revealed that because of the possible harm to the resident the facility increased staffing and visual checks of the residents and conducted elopement drills. The ADMIN revealed he was pushing for corporate to fix the door. <BR/>Interview on 03/07/2023 at 9:50 PM the ADMIN revealed that Resident #1's room was on the 400- hallway but he walked around everywhere - sometimes he used his wheelchair and sometimes he did not. <BR/>Interview on 03/07/2023 at 1:25 PM with LVN B, the 200-hallwy nurse on 02/18/2023, and she works the 6:00 AM to 6:00 PM shift. She revealed she remembered him talking to her and he was unintelligible, and she was busy passing out medications and did not notice where he went or what time she spoke with him. She discovered Resident #1 was missing when the facility began elopement protocols. <BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed on 02/18/2023 at 7:15 AM she saw Resident #1's wheelchair, empty, outside of the emergency exit door of the 200-hallway and went to go look for him in his room on the 400-hallway. When CNA did not find him in his room, she located his nurse RN A and asked if RN A had seen him. RN A said she had not seen him. CNA A revealed that they began searching for Resident #1 both in and outside the facility. <BR/>Interview on 03/07/2023 at 9:50 AM with the ADMIN revealed that on 02/18/2023 at about 7:45 AM he received a call from RN A that Resident #1 could not be located in or around the facility and the ADMIN instructed RN A to initiate elopement protocols. The ADMIN revealed RN A told him she called the police and informed police about a missing resident, but RN A said the police.<BR/>Interview on 03/07/2023 at 9:50 AM with the ADON revealed that Resident #1 was retrieved by her at approximately 8:00 PM on 02/18/2023 from a CVS and the ADON returned with him to the facility. <BR/>Review of Resident #1's progress notes dated 02/19/2023 reveal that at approximately 8:00 PM on 02/18/2023 the ADON completed a bedside assessment revealing normal blood pressure and temperature with zero signs of distress or pain noted and zero skin issues noted. Resident was discharged Against Medical Advice on 02/18/2023. <BR/>Review of Resident #1's face sheet dated 03/08/2023 revealed under the area of contacts it read, responsible party - self. <BR/>Interview on 03/07/2023 at 9:50 the ADMIN revealed the front entrance was the most secure entrance and exit to the facility because it was visible from the nurse's station, visible from the receptionist area, and visual from the ADMIN office. Additionally, it had a secure keypad, and alarm, and is wired for WanderGuard (a device worn on the wrist or ankle to trigger alarms and prevent wander-prone residents from leaving unattended). <BR/>Review of Resident #1's order summary report dated 03/09/2023 reveals an order in place to check WanderGuard placement and function every shift beginning 02/15/2023.<BR/>Interview on 03/07/2023 at 9:50 AM of ADMIN revealed the front entrance of the building was not being used because of the collision from 02/04/2023 until 03/01/2023. The ADMIN revealed that he did not have the authority to make a financial decision regarding making building repairs to the facility. He revealed that on 02/04/2023 the CEO phoned him and said that he wanted to go through the insurance company of the owner of the car who collided with the building because it would increase the premium cost of the facility insurance if they used the facility insurance. <BR/>Interview on 03/09/2023 at 1:00 PM with the COO revealed the facility was waiting on the insurance company of owner of the car who caused the damage to the front of the facility to appraise the damage and make payment for the damages before making repairs to the main entrance. <BR/>Review of estimate from construction company dated 02/07/2023 reveals that the repair cost to the front entrance portico was $7,500. <BR/>Review of email from the facility owner to the facility CFO and ADMIN dated 02/27/2023 stating, we cant wait on insurance to cover this. It's a hazard to residents. We will have to get reimbursed from the insurance company.<BR/>Interview on 03/07/2023 at 1:26 PM with the FMD revealed that the facility was waiting for an estimate from the car insurance company of the owner of the car who caused the damages before they made the repairs. He constantly called the insurance company to make sure they were going to pay for it and the insurance company was non-responsive. He revealed that he told that to the insurance company that it was a safety concern. He revealed that the work to repair the front entry began on Monday 02/27/2023 and ended on 03/01/2023. <BR/>Review of facility Inservice Elopement Drill dated 02/17/2023, 02/19/2023, 02/19/2023, 02/22/2023.<BR/>Review of the facility's Elopement and Wandering policy revised December 2007 reveals:<BR/>1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement).<BR/>2. The staff will assess at risk individuals for pension initially correctable risk factors related to unsafe wandering<BR/>3. The resident care plan will indicate the resident is at risk for elopement or other safety issues interventions to try to maintain safety will be included in the resident care plan.<BR/>4. Nursing staff will document circumstances related to unsafe actions, including wandering, by resident. <BR/>5. Staff will institute a detailed monitoring plan, is indicated for residents who are assessed to have a high risk of allotment for other unsafe behavior.<BR/>6. Staff will notify the administrator and director of nursing's immediately and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.<BR/>Facility was notified on 03/09/2023 at 5:10 PM that an IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 02/18/2023.<BR/>The facility implemented the following interventions: On 03/04/2023 repairs were completed on the portico of the main front entry door equipped with a keypad entry and exit, WanderGuard Alarm, fire alarm, and visibility of residents from the nurse's station, receptionist, and ADMIN's office. After the completion of the front entry repairs neither the 200-hallways door or any other facility emergency exit doors were opened and closed using a key to alarm and disarm doors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that Preadmission Screening and Resident Review (PASARR) federal requirements were met for 1 of 1 resident reviewed for delinquent PASARR processes. <BR/>The facility failed to ensure Resident #1 received the services recommended by the PASARR department when they failed to order her wheelchair by the required deadline. This failure caused a delay in her Medicaid Entitled Service. <BR/>This failure placed Resident #1 at risk of not achieving or maintaining her highest practicable level of physical functioning and could potentially result in increased disability. <BR/>Findings include: <BR/>Record Review on 3/01/24 at 12:37 PM of Resident #1's undated face sheet reflected she is a [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses include Mild Cognitive Impairment, Intellectual Disability, Abdominal Mass, Atrial Fibrillation (irregular heart rate), Peripheral Vascular Disease (poor circulation to limbs), and Unspecified Speech Disturbances.<BR/>Record review on 3/01/24 at 12:37 pm of Resident# 1's Occupational Therapy Recertification for 2/18/24-4/17/24 reflected additional diagnoses of Muscle Wasting and Atrophy, Lack of Coordination, and Unspecified Abnormalities of Gait and Mobility. The record plan of treatment included Self Care Management Training and Wheelchair Management Training.<BR/>Record review of 2/26/24 email correspondence between PSR-RN (Quality Monitoring Program-PASRR Team) and the facility RG-RN (Regional nurse) reflected that the Customized Manual Wheelchair (CMWC) was approved on 2/15/24 and per the Texas Administrative Code the facility had 5 business days to order the chair (2/22/24 deadline). The CMWC was not ordered by the deadline. Correspondence indicates chair was ordered on 2/26/24 after receiving an email from PSR-RN. <BR/>During an observation on 3/1/24 at 10:45 am, Resident #1 was lying in bed and writing in a notebook. <BR/>In an interview on 03/01/24 at 10:45 am Resident #1 stated we ordered a wheelchair and then I will get up. She did not remember how long it had taken to get the wheelchair. Resident #1 stated that Physical Therapy has ordered it. <BR/>In an interview with the ADM on 3/1/24 at 10:21 am he stated he had just worked on a PASARR problem that the state had called him about. He stated the facility corrected it the same day they were called (2/26/24). They have no Minimum Data Set (MDS) nurse now, but the Regional RN was helping with the MDS needs. He identified Resident #1 had a problem and he would present the documentation. He stated, The other State Department had notified him she had a problem. <BR/>In an interview on 3/1/24 at 4:10 pm the ADM stated PASARR gives residents who need them an extra benefit. He stated he was aware of a late PASARR process that was delaying a supply and he immediately talked to the MDS Nurse and got it submitted. The ADM stated the potential outcome if PASARR processes were not done timely were that a resident could miss Occupational Therapy, Physical Therapy, and a resident could fail to get up and be more mobile.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the 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 6 of 16 residents (Residents #7, #8, #15, #17, #49, and #56) reviewed for care plans.<BR/>1. The facility failed to ensure Resident #7's bowel incontinence was reflected in her care plan.<BR/>2. The facility failed to ensure Resident #8's need for assistance with her activities of daily living was developed in her care plan.<BR/>3. The facility failed to ensure Resident #15's pain was reflected in his care plan. <BR/>4. The facility failed to ensure Resident #17's need for TED Hose was reflected in her care plan.<BR/>5. The facility failed to ensure Resident #49's Hospice service and bowel and bladder incontinence were reflected in her care plan.<BR/>6. The facility failed to ensure Resident #56's need for assistance with toileting was reflected in his care plan. <BR/>These deficient practices could place residents at risk of not receiving proper care and services.<BR/>The findings included:<BR/>1. Record review of Resident #7's electronic face sheet dated 02/06/2024 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting right dominant side, depression (a common mental disorder .It involves a depressed mood or loss of pleasure or interest in activities for a long period of time) and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #7's quarterly MDS assessment with an ARD of 01/04/2024 reflected she scored an 8/15 on her BIMS which signified she was moderately cognitively impaired. She had functional limitation in range of motion .Impairment on one side .Upper extremity (shoulder, elbow, wrist, and hand) and Lower extremity (hip, knee, ankle, and foot). She was always incontinent of bowel and bladder.<BR/>Record review of Resident #7's comprehensive care plan revised on 06/08/2023 reflected Focus .has bladder incontinence r/t impaired mobility. No bowel incontinence was noted in the care plan.<BR/>Observation on 02/09/2024 at 10:15 am of Resident #7 as she received wound care to her right buttock revealed she wore an incontinent brief.<BR/>Interview on 02/08/2024 at 09:46 am with Resident #7, she stated she was incontinent of both bowel and bladder.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #7's unit, she stated Resident #7 was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #7's bowel status should have been in her care plan because it was an important part of her care, and it could be missed.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans need to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>2. Record review of Resident #8's face sheet, dated 02/08/2024, revealed Resident #8 was admitted to the facility on [DATE] with an original admission date of 08/19/2019 with diagnoses which included: metabolic encephalopathy, muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, cognitive communication deficit, unspecified abnormalities of gait and mobility, need for assistance with personal care, bilateral primary osteoarthritis of knee, and cerebral infarction unspecified.<BR/>Record review of Resident #8's Annual MDS assessment, dated 12/23/2023, revealed the resident's BIMS score was 10, which indicated moderate cognitive impairment. The resident's functional abilities required partial assistance from another person to complete any activities regarding self-care. Annual MDS assessment further revealed Resident #8 was dependent (helper does all of the effort resident does none) for toileting, needing substantial/maximal assistance (helper does more than half the effort) for showers, lower body dressing and putting on footwear, partial/moderate assistance (helpers does less than half the effort. Helper lift, lifts holds, or supports trunk or limbs) for upper body dressing.<BR/>Record review of Resident #8's care plan, revision date 01/10/2024 did not reflect her need for assistance in activities of daily living such as toileting, showers, lower body dressing, putting on footwear and upper body dressing.<BR/>During an interview on 02/09/2024 at 2:42 p.m. with the Regional Compliance Nurse she stated there was not an ADL (activities of daily living) care plan for Resident #8. The Regional Compliance Nurse further stated the ADL care plan was used to identify the residents need and would be reflected on the CNAs care plan so the CNAs would know what care to provide. The Regional Compliance Nurse stated the MDS Coordinator was responsible for updating the care plans while nursing would update with acute care plans. She further stated incorrect care could be provided without an accurate care plan. <BR/>3. Record review of Resident #15's face sheet, dated 02/07/2024, revealed Resident #15 was admitted to the facility on [DATE] with an original admission date of 08/07/2023 with diagnoses which included: postprocedural intestinal obstruction, unspecified as to partial versus complete, encounter for surgical aftercare following surgery on the digestive system, spastic quadriplegic cerebral palsy, muscle wasting and atrophy, pain in right shoulder, restless legs syndrome, incisional hernia with obstruction, without gangrene, and epilepsy, unspecified not intractable, without status epilepticus. <BR/>Record review of Resident #15's admission MDS assessment, dated 12/11/2023, revealed the resident's BIMS score was 15, which indicated intact cognition. The resident received scheduled pain medication with a pain assessment interview conducted on the admission MDS assessment revealed the resident had reported pain presence with the frequency being occasionally and occasionally affecting resident's sleep. <BR/>Record review of Resident #15's physician order summary, dated 02/07/2024 revealed an order dated 12/05/2023 with the start date of 12/05/2023 for Oxycodone-Acetaminophen oral table 5-325 MG give 1 tablet by mouth every 6 hours as needed for pain. Physician order summary further revealed order dated 12/28/2023 with the start date of 12/28/2023 for Oxycodone HCI oral tablet 5 MG give 1 tablet by mouth two times a day for pain and an order for Oxycodone-Acetaminophen oral tablet 5-325 MG give 1 tablet by mouth two times a day for pain. <BR/>Record review of Resident #15's care plan revision date, 12/28/2023 did not reflect his need for pain medication or how to assist him with pain relief. <BR/>During an interview on 02/09/2024 at 10:50 a.m. Resident #15 stated his pain could be bad sometimes. Resident #15 stated he received pain medications which helped with the pain and was receiving therapy services which also seemed to help. Resident #15 stated he had been experiencing the increase in pain since his surgery months ago and he was also being seen by a pain specialist. <BR/>During an interview on 02/09/2024 at 2:53 p.m. with the Regional Compliance Nurse she revealed pain was triggered for Resident #15's care plan but had not been activated on the care plan in PCC where it would show on the care plan. The Regional Compliance Nurse stated incorrect care could be provided without an accurate care plan.<BR/>4. Record review of Resident #17's electronic face sheet, dated 02/06/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting left non-dominant side, Alzheimer's Disease (the most common type of dementia. A progressive disease beginning with mild memory loss and possibility leading to loss of the ability to carry on a conversation and respond to the environment), chronic diastolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly) and depression (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for a long period of time).<BR/>Record review of Resident #17's quarterly MDS assessment with an ARD of 12/18/2023 reflected she scored an 11/15 on her BIMS which signified she was moderately cognitively impaired. She was noted to have an active diagnosis of heart failure.<BR/>Record review of Resident #17's comprehensive person-centered care plan revised date 11/16/2023 reflected Focus .has congestive heart failure .Interventions .monitor and report dependent edema of legs and feet.<BR/>Record review of Resident #17's Active Orders as of: 02/06/2024 reflected Apply TED hose to bilateral lower extremities daily in the morning and remove at bedtime two times a day for edema TED HOSE TO BLE: PUT ON IN THE MORNING AND TAKE OFF AT BEDTIME Active 06/23/2023.<BR/>Record review of Resident #17's MAR dated 02/01/2024 to 02/29/2024 reflected she had the TED hose applied to her bilateral lower extremities daily in the morning and removed at bedtime for edema.<BR/>Observation on 02/06/2024 of Resident #17 revealed she was sitting in her room in her wheelchair and had TED hose on both lower legs. <BR/>Interview on 02/08/2024 with Resident #17, she stated she had the TED hose applied to her lower legs twice a day because her legs swell.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #17's unit, she stated Resident #17 had TED hose applied to her lower legs twice a day because of swelling, and that was part of her care.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #17, he stated Resident #17 had TED hose applied to her bilateral lower legs every day.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #17's TED hose should have been in her care plan because it was an important part of her care, and it could be missed.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans needed to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>5. Record review of Resident #49's electronic face sheet dated 02/08/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Spastic quadriplegic cerebral palsy (a severe type that is characterized by paralysis of both arms and both legs, with muscle stiffness), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition), unspecified intellectual disabilities (impairment of intelligence) and dysphagia (difficulty swallowing).<BR/>Record review of Resident #49's quarterly MDS assessment with an ARD of 01/08/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She was always incontinent of bowel and bladder and was on Hospice services.<BR/>Record review of Resident #49's comprehensive person-centered care plan revised 12/09/2023 did not reflect she was incontinent of bowel and bladder. Resident #49's care plan did not reflect her Hospice services.<BR/>Record review of Resident #49's Active Orders as of: 02/08/2024 reflected she was admitted to Hospice services on 10/25/2023.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #49's unit, she stated Resident #49 was on Hospice, and was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #49, he stated Resident #49 was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #49's bowel and bladder status and Hospice services needed to be in the plan of care. She stated care provided could be missed without it noted in the care plan.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans needed to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>6. Record review of Resident #56's face sheet, dated 02/08/2024, revealed Resident #56 was admitted to the facility on [DATE] with an original admission date of 03/05/2023 with diagnoses which included: muscle wasting and atrophy, not elsewhere classified, multiple sites, end stage renal disease, unspecified viral hepatitis C without hepatic coma, gout, unspecified, hypothyroidism, and pain unspecified. <BR/>Record review of Resident #56's Optional State MDS assessment, dated 12/22/2023, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for toilet use.<BR/>Record review of Resident #56's care plan revision date, 11/13/2023 did not reflect his need for assistance with toilet use.<BR/>During an interview on 02/09/2024 at 2:46 p.m. with the Regional Compliance Nurse, she stated she did not see a care plan for Resident #56's toileting. The Regional Compliance Nurse further stated the MDS coordinator, and the IDT were responsible for the care plans.<BR/>During an interview on 02/09/2024 at 3:19 p.m. the DON stated the nurses, charge nurses, ADON, and DON were responsible for the acute care plans such as changes in conditions, [NAME], and changes in treatments. The DON further stated the MDS coordinator would be responsible for the comprehensive care plans, however the facility had just hired someone to replace the prior MDS coordinator. <BR/>Record review of the facility's undated policy and procedure titled Comprehensive Care Planning revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .Each resident will have a person-centered comprehensive care plan developed and implement to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 16 residents ( Residents #7 and #34) reviewed for assistance with ADL's.<BR/>1. Nursing staff failed to clean and file Resident #7's fingernails which were long and had a substance encrusted under them.<BR/>2. The facility staff failed to ensure Resident #34's fingernails were free of an encrusted substance under them.<BR/>These deficient practices could place residents at risk of decreased self-esteem and dignity.<BR/>The findings included:<BR/>1. Record review of Resident #7's electronic face sheet dated 02/06/2024 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting right dominant side, depression (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for a long period of time) and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #7's quarterly MDS assessment with an ARD of 01/04/2024 reflected she scored an 8/15 on her BIMS which signified she was moderately cognitively impaired. She had functional limitation in range of motion. Impairment on one side. Upper extremity (shoulder, elbow, wrist, and hand) and Lower extremity (hip, knee, ankle, and foot). She was always incontinent of bowel and bladder and the MDS did not reflect she was on a mechanically altered diet.<BR/>Record review of Resident #7's comprehensive care plan revised on 06/08/2023 reflected Focus .has an ADL Self Care Performance Deficit r/t hemiplegia .Interventions .requires staff assistance with care.<BR/>Observation on 02/07/2024 at 08:30 am of Resident #7 in her room eating breakfast revealed she had long (approximately 1/4 inch) fingernails on both hands, and they had dark substance encrusted beneath them.<BR/>In an interview on 02/07/2024 at 08:35 am with Resident #7, she stated she needed to have assistance in cleaning and filing her fingernails. She stated no one offered, even during baths. An emery board was sitting at her bedside table. She stated someone brought the emery board in for her to use, she could not remember who. <BR/>Interview on 02/09/2024 at 11:41 am with LVN A, who was the charge nurse for Resident #7's unit, she stated Resident #7 required assistance with her nail care.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #7, he stated Resident #7 required assistance with her nail care, and he could not remember ever assisting her.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #7's fingernails needed to be filed and cleaned by staff, and they needed to check with the resident.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the resident's needed assistance with their nail care, and it should be done when they were bathed.<BR/>2. Record review of Resident #34's face sheet, dated 02/08/2024, revealed Resident #34 was admitted to the facility on [DATE] with an original admission date of 03/05/2023 with diagnoses which included: Alzheimer's disease, delusional disorders, and other idiopathic peripheral autonomic neuropathy.<BR/>Record review of Resident #34's Quarterly MDS assessment, dated 09/11/2023, revealed the resident with long- and short-term memory loss. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for dressing and personal hygiene.<BR/>Record review of Resident #34's Optional State MDS assessment, dated 11/09/2023, revealed the resident with long- and short-term memory loss. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for bed mobility, transfers, and toilet use.<BR/>Record review of Resident #34's care plan with a revision of 12/22/2023 and a targeted date 03/31/2024, revealed Resident #34 had a Focus: ADL self-care deficit r/t: dementia, general weakness, osteoarthritis . Interventions: Personal hygiene: Extensive assistance one-person assist. Bathing: Total dependence one-person physical assist. Provide assistance with ADL's as needed . <BR/>Observation on 02/06/2024 at 12:31 p.m. revealed Resident #34 was in the dining room waiting for lunch with what looked to be dark brownish black substance built up under her short, trimmed fingernails. <BR/>Observation on 02/08/2024 at 10:53 a.m. revealed Resident #34 sitting in wheelchair in her room fidgeting with her Hoyer sling straps in her lap notable dark substance was under the resident's fingernails. <BR/>Observation on 02/08/2024 at 2:17 p.m. Resident #34 was observed in the dining room finishing her lunch and licking her fingers when puree food fell on them. Resident #34's nails continued to be noticeably dirty with buildup under several fingernails. <BR/>During observation and interview on 02/08/2024 at 2:25 p.m. revealed CNA C observed Resident #34 fingernails in the dining room and stated Oh, Lord those are dirty. CNA C stated she assisted Resident #34 in dressing and getting out of bed. CNA C further stated usually nail care was done on Sundays when there were no showers, and on shower days she would wash residents' hands good. CNA C stated prior to meals residents' hands were cleaned with wipes, however she didn't bring the resident to the dining room for lunch. <BR/>During an interview on 02/08/2024 at 2:29 p.m. the DON stated residents' nails were cleaned when CNAs did showers and whenever, they would see the nails were dirty. The DON further stated Resident #34's nails looked clipped but did need to be cleaned. <BR/>Record review of the facility's policy and procedure titled Nail Care, dated 2003, revealed Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath .Nail care will be performed regularly and safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 residents out of 24 (Resident #7 and 10)residents reviewed for MDS assessments.<BR/>1. Facility failed to ensure Resident #7's quarterly MDS, dated [DATE], assessment accurately reflected she was on a mechanically altered diet.<BR/>2. Facility failed to ensure Resident #10's quarterly MDS, dated [DATE], accurately reflected her cognitive status related to her ability to communicate.<BR/>These deficient practices could place residents at [NAME] of inadequate care.<BR/>The findings included:<BR/>1. Record review of Resident #7's electronic face sheet, dated 02/06/2024, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting right dominant side, depression (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for a long period of time) and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #7's quarterly MDS assessment with an ARD of 01/04/2024 reflected she scored an 8/15 on her BIMS which signified she was moderately cognitively impaired. She had functional limitation in range of motion. Impairment on one side. Upper extremity (shoulder, elbow, wrist, and hand) and Lower extremity (hip, knee, ankle, and foot). She was always incontinent of bowel and bladder and the MDS did not reflect she was on a mechanically altered diet.<BR/>Record review of Resident #7's comprehensive care plan revised on 11/14/2023 reflected Focus .has order regular diet mechanical soft texture, thin/regular consistency.<BR/>Record review of Resident #7's Active Orders as of: 02/07/2024 reflected Regular diet Mechanical Soft texture, Thin /Regular consistency, Risks of mech soft texture (choking/malnutrition) have been explained to pt, who.<BR/>chooses the upgraded texture over puree Verbal Active 09/18/2023.<BR/>Observation on 02/06/2024 at 1:00 pm of Resident #7 in the dining room for lunch revealed she had a regular diet with mechanical soft texture.<BR/>Observation on 02/07/2024 at 08:30 am of Resident #7 in her room eating breakfast revealed she had a regular diet with mechanical soft texture.<BR/>Record review on 02/07/2024 at 1:00 pm of Resident #7's meal ticket revealed she was on a regular diet, mechanical soft texture.<BR/>In an interview on 02/07/2024 at 08:35 am with Resident #7, she stated she needed to have her food soft, and that was the diet she wanted.<BR/>Interview on 02/09/2024 at 01:30 pm with the Regional Reimbursement Nurse revealed she would not say if the MDS was inaccurate, and she would have to review everything. She stated the MDS assessment focused on care areas that assisted in development of the care plan. She stated the mechanical soft diet should be reflected in the MDS and it was important because it would trigger the care plan for the correct texture of diet.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse revealed the facility was presently without an MDS nurse so the Regional Reimbursement Nurse was available.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the MDS needed to be accurate because it was the documentation of care areas for the resident. She stated the company had just hired a new MDS nurse.<BR/>2. Record review of Resident #10's face sheet, dated 02/06/2024, revealed Resident #10 was admitted to the facility on [DATE] with an original admission date of 06/17/2020 with diagnoses which included: Alzheimer's disease, anxiety disorder, metabolic encephalopathy, and major depressive disorder.<BR/>Record review of Resident #10's Quarterly MDS, dated [DATE], coded resident made herself understood and had the ability to understand others in Section B Hearing, Speech, and Vision. The BIMS was not completed due coding of resident rarely/never understood in Section C0100 of Cognitive Patterns. <BR/>Record review of Resident #10's care plan with a revision of 11/13/2023 and a targeted date 02/11/2024, revealed Resident #10 had a Focus: [resident's name] has a communication problem r/t she only speak Korean and an Interventions: Monitor effectiveness of communication strategies and assistive devices. Allow adequate time to respond, repeat as necessary . <BR/>During observation and interview on 02/06/2024 at 1:00 p.m. Resident #10 was observed eating her lunch with the speech therapist assisting another resident with their meal and making simple statements to Resident #10. The ST stated the resident spoke Vietnamese and the staff would use translators on their cellphones they had downloaded to help communicate with the resident however, sometimes Resident #10 would slap the phones from their hands. <BR/>During an interview on 02/09/2024 at 1:34 p.m. with the Regional Reimbursement Nurse she stated she would want the sections B and C to match regarding ability to be understood, however she would need to clarify with the social worker regarding why she coded sections B and C that way on the Quarterly MDS Assessement.<BR/>During an interview on 02/09/2024 at 1:53 p.m. the SW stated Resident #10 understood the daily things, however, had behaviors sometimes where she acted out and it seemed she didn't understand. The SW further stated Resident #10 had a language barrier. The SW stated regarding the coding in Section C she could see where it might have been contradicting, however due to resident's behaviors and language barrier this was why Section C0100 was coded as rarely or never understood while Section B was coded as resident having been understood. <BR/>During an interview on 02/09/2024 at 3:14 p.m. the administrator stated the facility did not have a policy for MDS accuracy but followed the RAI Manual. <BR/>Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 0600, Regulation FF14<BR/>Based on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of six residents reviewed for pain, in that:<BR/>Facility nursing staff failed to apply a fentanyl patch for pain on Resident #1 on 11/15/23 as ordered and he experienced pain.<BR/>This failure could place residents at risk of experiencing pain and/or not getting therapeutic benefits of prescribed medications.<BR/>The findings included:<BR/>Review of Resident #1's face sheet, dated 09/8/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted on hospice services. Resident #1 had diagnoses which included neoplasm (tumor) of cheek mucosa (soft tissue) and chronic respiratory failure with hypoxia (lack of adequate oxygen at tissue level).<BR/>Review of Resident #1's admission MDS assessment, dated 08/21/23, indicated Resident #1 had a BIMS of 06, which indicated moderate impaired cognition. <BR/>ADVANCE<BR/>Review of Resident #1's Care plan, revised 8/18/23, revealed a focus on the potential of uncontrolled pain related to cancer of the cheek mucosa. The goal listed is Resident #1 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions listed include, Administer analgesia PER MD ORDER AND VALIDATE EFFECTIVENESS and Anticipate [Resident #1's] need for pain relief and respond immediately to any complaint of pain.<BR/>Review of the facility Medication Error report, dated 11/17/23, revealed a description of the following: It was noted today that resident had fentanyl patch on, dated 11/12/23 and was expected to be changed on 11/15/23. Family visited and was concerned. Resident was provided pain medication immediately and investigated on fentanyl patch placement on 11/15/23. Medication Mar was audited immediately and was confirmed that fentanyl patch was not applied on 2-10 p.m. shift on 11/15/23 but the nurse documented administered. Hospice, MD/NP notified. The report notes LVN A stated he had made a mistake by documenting that he applied the patch but did not. <BR/>Review of Resident #1's Physician Orders Summary, dated 11/18/23, revealed the following medications for pain:<BR/>On 11/16/23 an updated order for fentanyl 100mcg /hour patch to be applied every 72 hours for pain and fentanyl 25mcg/hour patch to be applied every 72 hours for pain. <BR/>On 8/15/23 orders for morphine sulfate oral solution 20 mg/ml, give 0.25 ml by mouth every 1 hour as needed for moderate pain, Morphine sulfate oral solution 20 mg/ml, give 0.5 ml by mouth every 1 hour as needed for moderate pain. Morphine sulfate oral solution 20 mg/ml, give 0.75 ml by mouth every 1 hour as needed for moderate pain. Morphine sulfate oral solution 20 mg/ml, give 1 ml by mouth every 1 hour as needed for moderate to severe pain. <BR/>On 10/26/23 orders were added for Hydrocodone-Acetaminophen oral tablet 10-325mg every 6 hours as needed for pain. <BR/>Review of Resident #1's September TAR revealed on 11/15/23, LVN A initialed the site for administration of a fentanyl patch 100 mcg/hour at 6:09 p.m. and initialed for removal of the previous patch at the same time. On 11/17/23 at 3:15 p.m. and 3:17pm the fentanyl 100mcg and 25 mcg patches were initialed as applied. <BR/>Continued review revealed Hydrocodone-Acetaminophen 10-325mg one tablet had been given on 11/16/23 at 1:37 p.m. and 11/17/23 at 12:08 p.m. none was documented as given on 11/15/23. No Morphine sulfate was given on 11/15/23, 11/16/23 or 11/17/23. <BR/>Review of Resident #1's control substances count sheets revealed on 11/15/23 at 11:30 p.m. five fentanyl patches of 100 mcg had been delivered. The first usage of the 100mcg patch was administered on 11/17/23. On 11/10/23 fentanyl 25mcg/hour patch had been delivered. The first usage of the 25mcg patch was administered on 11/17/23. <BR/>Review of Resident #1's Progress Notes revealed on 11/15/23 LVN A documented at 9:04 p.m. an order was placed for fentanyl patch every 72 hours, 25mg/hour. Apply one patch transdermal (to skin) every 72 hours for pain place with 100 mcg patch. Remove old patch before placing new one and remove per schedule. <BR/>Interview on 11/18/23 at 1:44 p.m. with LVN A revealed he stated that the omission of Resident #1's Fentanyl patch not having been applied was a mistake. He stated Resident #1 was new to his hall and the 100-mcg patch was not available, but the 25mcg patch were in cart. LVN A stated he went to the previous hall to check if they had the 100 mcg patches, and they did not. LVN A stated on that same day the hospice nurse had changed the order for fentanyl dosage and he had documented the changed order and intended to give the medication when it arrived. LVN A confirmed he had not notified the MD or NP about the missed dosage due to the medication not being available. LVN A stated the medication did not arrive before the end of his shift and he had forgotten about it as it was a hectic day. LVN A stated he did receive counseling from the DON about initialing the TAR when he had not yet given the medication or removed the patch to be replaced. LVN A stated had initialed the TAR in error. LVN A stated Resident #1 does notify the staff when he is in pain and had as needed orders for pain relief. LVN A did not recall if he had given other pain medications on 11/15/23 but does not recall the Resident #1 indicating he was in pain. <BR/>Interview on 11/18/23 at 11:37 a.m. with a FM revealed they had visited Resident #1 after receiving a call from the hospice aide on 11/17/23 stating Resident #1 was acting like he was in pain or was anxious. The FM was not aware if the hospice aide had informed the facility nurse. The FM stated Resident #1 could let the facility nursing staff know that he wanted pain medication and will say, give me the shot. The FM stated none of the medications are in an injection form but that is how he communicates pain, and the staff know what he means. The FM stated they had recently received a call from the hospice nurse stating she had increased the dosage of fentanyl so they were looking to see if he had the new dosage amount and saw the patch, he had on was dated 11/12/23, when it should have said 11/15/23 and it was not the increased dosage as it was just one patch instead of two. The FM stated they informed the nurse who told the DON, and the DON came to talk to them. The DON had initially told the FM a patch had been given on the 15th according to the TAR, but she would investigate it. She said later the DON came back and said she had spoken to the nurse and the medication was not available, but he had signed indicating it had been given. The FM did not know the circumstances of why the fentanyl was not available on the 15th as it should have been, but it was there on the 17th. The FM stated after the DON's investigation they gave Resident #1 the correct dosage which, they had but Resident #1 had to wait till the investigation was over and they knew he was in pain. The FM was uncertain how long of a time it had been, but it seemed like hours to them. The FM did not know if another pain medication had been given at the time they were waiting. <BR/>Interview on 11/18/23 at 12:20 p.m., 2:07 p.m. and 5:30 p.m. with the facility DON revealed she first became aware of Resident #1 not receiving his fentanyl patch on 11/17/23. DON stated when she looked at the TAR it indicated it had been given but when she looked at the control sign out sheet the previous box had been emptied with all patches accounted for and the replacement box was not received until 11:30 p.m. on 11/15/23 with no dosages out of the new box so the fentanyl could not have been given by LVN A at the time he documented. LVN A admitted he had incorrectly initialed the medication as given. The nurse should notify the MD or NP if a dose of medication was missed but he had forgotten it was not administered so he had not notified. The dosage comes five in a pack, and it should have been ordered by the nurse that applied the patch on 11/12/23 as there were no more 100mcg patches. The hospice nurse calls the order into the pharmacy but our nurses document that an order was changed. DON stated it was recognized there was a problem and conducted an inservice on initialing and checking the placement. We included on the TAR a check off for each shift to check the placement and date of the patch to ensure it has been given. A coaching form was completed for LVN A on 11/17/23. <BR/>Interview on 11/18/23 at with the facility Adm revealed that it was recognize that there was a medication error. The nurse had documented incorrectly and do think that the medication should had been ordered at the time of last dose or prior. Will have inservice on reordering medications. The nurse that made the documentation that was not accurate had been counseled and the DON is performing checks on similar medications. <BR/>Review of the facility's abuse/neglect policy and procedure revised on 03/29/2018 revealed the following: <BR/>Abuse/Neglect <BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. And a definition which included,<BR/>7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.<BR/>Review of the facility policy and or procedure for reordering medications was requested was not provided prior to exiting

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that each resident had a right to be free from neglect for 1 of 65 residents (Resident #2) reviewed for neglect. <BR/>The facility failed to check the AED device to ensure it had an active status, was cleaned, without visible defects, did not have a low battery, and in operating condition before using it on Resident #2 prior to EMS arrival on 08/18/2023. Resident #2 passed away at the facility on 08/18/2023. <BR/>An IJ was identified on 08/18/2023. The IJ template was provided to the facility on [DATE] at 9:08 P.M. While the IJ was removed on 08/21/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at risk of pain, mental anguish, emotional distress, physical harm, diminished quality of life, and death. <BR/>Findings include: <BR/>Review of Resident #2's face sheet dated 08/18/2023. revealed he was a [AGE] year-old male with an admission date of 07/14/2023. Resident #2 was diagnosed with unspecified chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related issues), unspecified sepsis (when an infection a person already had triggered a chain reaction throughout their body), unspecified pneumonia (an infection that affects one or both lungs), unspecified dementia, generalized muscle weakness, oral phase dysphagia (occurs when it is difficult to control the bolus (mass) of food and transporting it to the back of the mouth), unspecified hyperlipidemia (an excess of lipids or fats in a person's blood that can increase their risk of heart attack and stroke because the blood cannot easily flow through their arteries), unspecified hypothyroidism (a condition where there is not enough thyroid hormone in a person's bloodstream and their metabolism slows down), unspecified thrombocytopenia (a condition that occurs when the platelet count in a person's blood was too low), umbilical hernia without obstruction or gangrene (soft swelling or bulge near the naval), and unspecified Alzheimer's disease. Resident #2 had full code status, which indicated CPR and all other resuscitation procedures would be provided to keep him alive. Resident #2 was discharged on 08/18/2023. <BR/>Review of Resident #2's entry MDS assessment dated [DATE] revealed he reentered the facility from an acute hospital on [DATE] and was originally admitted to the facility on [DATE].<BR/>Review of Resident #2's comprehensive MDS assessment dated [DATE] revealed there was no BIMS score indicated. The assessment also revealed Resident #2 required extensive assistance with one person physical assistance for bed mobility, dressing, eating, and personal hygiene. The assessment revealed Resident #2 also required extensive assistance with two person physical assistance with toilet use. <BR/>Review of Resident #2's care plan reviewed and completed on 08/09/2023 revealed he had impairments such as Alzheimer's disease, unspecified and dementia without behavioral disturbance, had a behavior problem related to picking objects off the floor that were not food items, wandering and pacing, had COPD, had episodes of nausea and vomiting, was disoriented to place, had memory loss, had hyperlipidemia related to elevated cholesterol levels, had hypothyroidism, had chewing/swallowing problems, had hypertension, had communication problem related to Alzheimer's Dementia, soft spoken, mumbled his words, unable to make needs known and relied on staff to meet his needs, had depression and history of symptoms such as sadness and self isolation, had ADL self care deficit related to decreased endurance, dementia, depression and general weakness, had potential for complications and/or injury related to anticoagulant therapy, had a full code status, and had severe impairment with decision making skills as evidenced by staff and family assuming wants and needs at most times and did not typically voice wants and needs to staff. <BR/>Review of Resident #2's pulse summary revealed the last entry was on 08/15/2023 at 7:42 P.M. and indicated 74 BPM regular, which indicated he had a normal heart rate range. <BR/>Review of Resident #2's O2 stats summary revealed the last entry was on 08/15/2023 at 7:41 P.M. and indicated 95.0 % room air, which indicated he had a normal oxygen level range. <BR/>Review of Resident #2's blood pressure summary revealed the last entry was on 08/17/2023 at 11:53 A.M. and indicated 125/78 MMHG sitting I/arm, which indicated he had a normal blood pressure range. <BR/>Review of Resident #2's assessments revealed the most recent assessments completed was a 12-hour skilled nurse's note and weekly nurse's summary note on 08/17/2023. <BR/>Review of Resident #2's 12-hour skilled nurse's note dated 08/17/2023 at 6:00 P.M. revealed he had no chest pains, edema, shortness of breath, cough, unclear lung sounds, irregular respirations, loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, complaints of difficulty or pain when swallowing, and other skin findings present. The note also revealed Resident #2's decision making was severely impaired, he never or rarely made decisions, was rarely/never understood when making himself understood, and his memory was okay. The note revealed the physician/NP was not notified of any negative changes. The note also revealed Resident #2 was not on any transmission-based precautions and had no new physician drug orders. The note was signed on 08/17/2023 by RN C. <BR/>Review of Resident #2's weekly nursing summary dated 08/17/2023 at 6:05 P.M. revealed he had short-term memory impairment, Alzheimer's, severely impaired cognitive skills for decision making, did not have cognition changes during the day, exhibited wandering one to three days, did not exhibit verbal behavioral symptoms directed toward others, exhibited physical behavioral symptoms directed towards others one to three days, was rarely/never understood when expressing ideas and wants, unable to make needs known, was always continent of bowel and urinary, had no changes in bowel or bladder continence, walked unassisted, self-transferred, had no pain, had no decrease in food intake, no significant weight loss, able to get out of bed and chair without assistance, and had not suffered any psychological stress or acute disease in the past three months. The note was signed by RN C on 08/17/2023. <BR/>Review of Resident #2's nursing progress note dated 08/18/2023 at 1:17 A.M. revealed the following: Resident #2 lying in bed with eyes closed. Opened when spoken to. No vomiting observed. No complaints at this time. Respiration rate even and unlabored. Skin was warm and dry to touch. Safety precautions in place. Note was signed by LVN D. <BR/>Review of Resident #2's nursing progress note dated 08/18/2023 at 8:37 A.M. revealed the following: 5:00 A.M. Resident #2 was observed lying in bed with his eyes closed. Head of bed elevated. Noticed dark thin fluid on his face. Attempted to arouse Resident #2 without success. Alerted team for assistance to bring AED device and crash cart. Attempted to get BP and 02 Sat, no reading. Assessed blood glucose reading 120. Palpated pulse, very faint pulse observed. No lung sound on auscultation. Nothing observed in Resident #2's oral cavity at this time. Alerted staff to call EMS. Resident #2 laid on floor. AED device pads placed and compression started per AED instructions. Per EMS continue CPR until paramedics arrived. Paramedics arrived and continued CPR unsuccessfully. EMS MD called time of death at 6:07 A.M. Notified ON-CALL NP reported death .Family was notified and they gave funeral home of choice .Resident #2 was cleaned, and put back in bed for arrival of family. Family arrived. Local PD gave case number and left the building. Mortician arrived and transported body until the Funeral home had a chance to pick up Resident #2. Note was signed by LVN D. <BR/>During an interview on 08/18/2023 at 1:35 P.M., ADM stated Resident #2 passed away at the facility on 08/18/2023. <BR/>During an interview on 08/18/2023 at 4:22 P.M., ADM stated LVNs used the AED device when administering basic emergency life support to a resident. <BR/>Observation on 08/18/2023 at 4:26 P.M. revealed there was a light, green-colored AED device on the crash cart and a yellow-colored AED device in a case mounted to the wall behind the crash cart. <BR/>During an interview on 08/18/2023 at 4:27 P.M., ADON A stated an LVN, who worked on the night shift from 6:00 PM through 6:00 AM, checked the light, green-colored AED device once daily. ADON A stated the night shift LVN documented the status of the light, green-colored AED device on a AED device status sheet located in a binder that was stored on the crash cart. <BR/>Observation on 08/18/2023 at 4:38 P.M. revealed ADON A turned on the light, green-colored AED device. The device displayed a green check mark and indicated, Change battery. Battery low. Charge device. The pads were disposable, sealed in its original packaging, and had an expiration date indicating 07/24/2026. <BR/>During an interview on 08/18/2023 at 4:40 P.M., ADON A stated the LVN changed the battery whenever the light, green-colored AED device indicated it had a low battery. ADON A stated the facility was replacing the light, green-colored AED device because it had a low battery. ADON A stated she was not sure if an AED device would work on a resident if the battery indicated it was low. ADON A stated the light-green colored AED device was used on Resident #2 on 08/18/2023. ADON A stated the AED device was not working when it was used on Resident #2. ADON A stated LVN D used the AED device on Resident #2 when he coded. ADON A stated LVN E and LVN F were present when LVN D used the AED device on Resident #2. <BR/>During an interview on 08/18/2023 at 5:03 P.M., LVN D stated she saw Resident #2 to check his thyroid between 4:15 A.M. and 4:30 A.M. on 08/18/2023. LVN D stated she attempted to check Resident #2's vitals and found he had a faint pulse. LVN D stated she alerted LVN E and LVN F to bring the crash cart. LVN D stated she checked Resident #2's blood sugar, which was 120. LVN D stated she then had a CNA help her bring Resident #2 to the floor. LVN D did not know the name of the CNA. LVN D stated she connected the light, green-colored AED device to the disposable pads, turned on the AED device, and the AED device indicated low battery after she started compressions. LVN D stated the AED device did not initially indicate low battery. LVN D stated the AED device directed her when to clear Resident #2, there was no shock, and to start compressions. LVN D stated the AED device did not shock Resident #2 when she used it on him. LVN D stated EMS was alerted and en route. LVN D stated before EMS arrived at the facility, she started compressions until the police came. LVN D stated she switched to using the police's AED device because the light, green-colored AED device indicated low battery and batteries needed to be changed. LVN D stated she continued compressions and using the police's AED device until EMS arrived at the facility. LVN D stated EMS took over when they arrived at the facility and started using their automatic compression device. LVN D stated EMS was on the phone with their MD, conducted a procedural documentation check, vital check on Resident #2, and system check. LVN D stated EMS worked on Resident #2 for 40 minutes, were unsuccessful, and had their MD call his time of death. LVN D stated the AED device was checked daily. LVN D stated night shift staff checked daily and day shift staff checked at times daily. LVN D stated the AED check was documented on a AED device status sheet that was in a binder stored on the crash cart. LVN D stated she was not sure if the AED device was checked before it was used on Resident #2. LVN D stated she was trained on AED device usage and maintenance. LVN D could not recall when she was given the training and last in-serviced on AED device. <BR/>During an interview on 08/18/2023 at 5:20 P.M., LVN E stated she was passing out the morning medications to residents when LVN D called her to bring over the crash cart. LVN E stated she took the crash cart over to LVN D and saw Resident #2 laying in his bed. LVN E stated LVN D told her that Resident #2 was warm and responding when she checked on him earlier around 4:00 A.M. and 4:30 A.M. LVN E stated LVN D told her that Resident #2 was not responding when she checked on him around 5:00 A.M. LVN E stated LVN D asked her to call 911. LVN E stated she called 911 and provided EMS with information over the phone. LVN E stated she saw a CNA run out of Resident #2's room, grab the light, green-colored AED device, and return to the room. LVN E did not know the name of the CNA. LVN E stated there was one AED device for the facility. LVN E stated when she came back to the room, she saw Resident #2 was on the floor. LVN E stated she saw another CNA was also in the room. LVN E did not know the name of the CNA. LVN E stated LVN D started performing CPR and administering the AED device on Resident #2. LVN E stated the AED device indicated the battery was low and needed to be changed. LVN E stated LVN D applied the AED device on Resident #2 twice. LVN E stated she ran out to call LVN F. LVN E stated the AED device indicated battery was low and needed to be changed when LVN F was in the room. LVN E stated LVN F and LVN D switched back and forth with performing CPR on Resident #2. LVN E stated she went and let EMS into building and EMS took over. LVN E stated she was not sure if EMS used their own AED device or the facility's light, green-colored AED device. LVN E stated LVN D called and informed the DON about Resident #2 passing away. LVN E stated she was not sure when the police arrived at the facility. LVN E stated she did not know how often the AED device was supposed to be checked. LVN E stated AED device checks were documented on a AED device status sheet in a binder that was stored on the crash cart. LVN E stated she did not know if the AED device was checked before it was used on Resident #2. LVN E stated she was trained on AED device use, maintenance, and documentation. LVN E stated she did not receive the training at the facility. LVN E stated she was not recently in-serviced on AED device at the facility. <BR/>During an interview on 08/18/2023 at 5:44 P.M., LVN F stated she was at 200 hall when LVN E informed her that something was happening on 300 hall. LVN F stated she went to Resident #2's room. LVN F stated LVN D informed her that Resident #2 coded. LVN F stated she saw Resident #2 was already on the floor and LVN D was performing CPR. LVN F stated she saw the light, green-colored AED device was already on and indicating charge battery. LVN F stated she saw LVN D attempt to use the AED device on Resident #2. LVN F stated when LVN D put the pad on Resident #2's body, the AED device indicated do not touch resident, clear away, battery low, and need a new battery. LVN F stated she tried to figure out how to charge the AED device battery while LVN D performed CPR before EMS arrived. LVN F stated when EMS took over, they used their own AED device. LVN F stated every shift was supposed to check the AED device daily. LVN F stated LVNs checked the AED device and documented the check on a AED device status sheet in the binder stored at the crash cart. LVN F stated she was not sure if the AED device was checked before it was used on Resident #2. LVN F stated she was trained on AED device use and maintenance when she started her employment at the facility. LVN F stated she was in-serviced on AED device use and maintenance. LVN F could not remember when she was last in-serviced on AED device.<BR/>During an interview on 08/18/2023 at 6:18 P.M., ADM stated he did not know what was handwritten on the bottom of the facility's emergency cart checklist for August 2023 because it was not initialed by anyone. <BR/>During an interview on 08/18/2023 at 6:41 P.M., ADM stated the light, green-colored AED device was used on Resident #2. ADM stated the AED device was checked daily for operating status and as needed. ADM stated the AED device status was documented on a AED device status sheet in the binder stored next to the AED device. ADM stated the LVNs on the night shift checked the AED device daily. ADM stated the nurse manager checked the AED device status sheet. ADM stated nurse management was defined as the DON, ADON, treatment nurse, or any staff member who oversaw the LVNs. ADM stated according to nurse's progress note, the AED device was in operating condition when it was used on Resident #2. ADM did not know if the AED device indicated low battery and battery needed to be changed when it was used on Resident #2. ADM did not know if the AED device went off when it was turned on and used on Resident #2. ADM stated according to the nurse's progress note, staff used the AED device on Resident #2 prior to EMS arriving at the facility. ADM did not know if EMS used the facility's AED device or their own AED device. ADM stated he started his employment in July 2023 and since he started, there was no training given to staff on AED device use and maintenance. ADM stated he was not sure if staff were in-serviced on AED device use and maintenance. ADM did not know why the AED device status stopped being checked and documented after 08/10/2023. ADM stated he was not sure if the nurse managers were supposed to check the AED device status sheets daily or weekly. ADM stated according to the nurse's progress note, Resident #2 coded in the morning on 08/18/2023, staff performed CPR, grabbed additional staff, got the crash cart and AED device, and Resident #2 passed away. ADM stated he was not sure if there were any other emergency units that arrived other than EMS. ADM stated Resident #2 never had an incident in the past where staff had to perform CPR and administer the AED device on him.<BR/>During an interview on 08/18/2023 at 8:12 P.M., DON stated LVN D contacted her on 08/18/2023 at 5:41 A.M. and informed her that Resident #2 coded and EMS was at the facility. DON stated she thought LVN D was informing her that Resident #2 was going to the hospital. DON stated She asked LVN D at 5:47 A.M. if she performed CPR on Resident #2. DON stated LVN D told her that she performed CPR on Resident #2 until EMS arrived at the facility. DON stated she later missed two calls from LVN D at 6:14 A.M. DON stated she returned LVN D's call at 6:18 A.M. DON stated LVN D told her to check her text message sent at 6:08 A.M. DON stated the text message said, 607 TOD EMS MD. DON stated she called LVN D at 6:18 A.M. and asked clarification on TOD, which was time of death, and who was EMS MD. DON stated LVN D explained to her that EMS MD was EMS's MD, who pronounced Resident #2's death. DON stated she contacted ADON A and instructed her to have LVN D notify law enforcement, Resident #2's RP and NP. DON stated she came to the facility and saw law enforcement was still at the facility and LVN D filling out documents. DON stated LVN D informed her that Resident #2 had a history gastrointestinal issues and aspiration. DON stated LVN D also told her that Resident #2's vitals were fine. DON stated LVN D told her that around 4:00 A.M., she observed Resident #2 had liquid by around his mouth . DON stated LVN D also told her that CPR was performed before EMS arrived. DON stated LVN D also informed her that the AED device needed to be checked out because it kept giving a warning indicating low battery. DON stated LVN D told her that the AED device kept operating and giving the indicator to change battery. DON stated LVN D told her that staff ended up using EMS's AED device. DON stated she asked LVN D if the AED device had been showing the indicator of low battery. DON stated LVN De told her that LVN F or another nurse mentioned the AED device indicated low battery and change battery before. DON stated LVN D told her that she did not know when LVN F or another nurse mentioned the AED device indicated low battery and change battery. DON stated LVNs were supposed to check to make sure the AED device worked at the beginning of the night shift. DON stated the first time the AED device was reported not working was the morning of 08/18/2023. DON stated she went to the crash cart to check the inventory sheet. DON stated she informed ADON A because she was in charge of checking the crash cart. DON stated staff determined the AED device was working if the green light was indicated when turning it on. DON stated she informed ADON A or one of the other management staff about the AED device not working. DON stated she checked the emergency cart inventory sheet and found handwritten notes from staff who checked the AED device on 08/18/2023 and indicated AED needed servicing. DON stated the handwritten notes on the bottom of emergency cart checklist should have been entered onto the AED device status sheets. DON stated she did not know who made the handwritten notes on the emergency cart inventory sheet. DON stated according to crash cart inventory sheet, the last time the AED device was checked was during the night shift on 08/17/2023. DON stated staff did not notify management about the AED device status. DON stated the night shift LVN checked the AED device daily. DON stated the AED device battery was low because the machine was failing and the battery needed to be replaced. DON stated the light, green-colored AED device was used on Resident #2. DON stated the ADON verified LVNs checked the AED device and documented the status on the AED device status sheets. DON stated the ADON was supposed to check the AED device once every morning and sporadically. DON stated ADON A told her that she notified the ADM about the AED device needing to be changed. DON stated she did not know when ADON A told the ADM about the AED device needing to be changed. DON stated ADON A did not notify her of the AED device batteries needing to be changed nor the AED device having a low battery. <BR/>During an interview on 08/18/2023 at 8:48 P.M., ADM stated he was not notified by ADON A about the AED device needing to have batteries changed nor it having low battery until the morning of 08/18/2023. ADM stated he had never been told prior to 08/18/2023 about the AED device status. <BR/>During an interview on 08/18/2023 at 8:52 P.M., ADON A stated she checked to make sure LVNs checked the AED device and documented the status on the AED device status sheets. ADON A stated she checked once daily during the day shift. ADON A stated two weeks ago, she reviewed the emergency cart inventory sheet and saw handwritten notes indicating the AED device needed servicing. ADON A stated she did not know who made the handwritten notes on the emergency cart inventory sheet. ADON A stated she knew an LVN from the night shift made the handwritten notes. ADON A stated she went to the ADM two weeks ago and informed him about the AED device battery needing a service. ADON A stated she saw the ADM contact Corporate MR and informed her about the AED device status. ADON A stated Corporate MR told her and the ADM that the battery was back ordered. ADON A stated the facility got a new AED device on 08/18/2023 because the battery in the light, green colored AED device was not functioning and the battery was back ordered. ADON A stated staff did not notify her about the AED device battery being low and needing to be replaced. ADON A later stated LVN D informed her that the AED device battery was low and needed to be changed . ADON A stated she informed the ADM on 8/18/23 that the AED device battery needed to be changed because it was indicating low. ADON A stated LVN D did not explain why the AED battery was low. <BR/>During an interview on 08/18/2023 at 9:25 P.M., ADM stated he contacted and asked Corporate MR prior to Resident #2's incident on 08/18/2023 to order a new AED device because the light, green-colored device looked outdated and old. <BR/>Review of the facility's grievance logs from July and August 2023 revealed there were no grievances filed regarding neglect, falls, or pain. <BR/>Review of the facility in-services revealed staff were trained on the following: <BR/>-Resident neglect and abuse 07/03/2023 8:00 A.M.-9:00 A.M.<BR/>-Use of progress notes documentation 07/12/2023 6:00 P.M.-07/17/2023 6:00 P.M.<BR/>-Reporting of concerns and incidents 07/12/2023 6:00 P.M.-07/12/2023 6:00 P.M.<BR/>-Ongoing and oncoming shift staff to do rounds 08/01/2023 <BR/>-Abuse and neglect 08/01/2023 <BR/>-Abuse and neglect 08/17/2023 <BR/>Review of the facility's Defibtech DDU-100 Operator Checklist (AED Device Status Sheet) for August 2023 revealed the light, green-colored AED device was checked from 08/01/2023 through 08/10/2023. The checklist also revealed the Active Status indicator did not flash green from 08/01/2023 through 08/10/2023. The checklist revealed the unit was clean and without visual defects from 08/01/2023 through 08/02/2023. The checklist also revealed the unit was not clean and without visible defects from 08/03/2023 through 08/10/2023 . There were no other entries completed on the checklist. The checklist also revealed the manually run initiated test was not performed and pads were not replaced. The checklist revealed the date of battery pack expiration and date of pad expiration was not indicated.<BR/>Review of the facility's emergency cart checklist for August 2023 revealed there were entries from 08/01/2023 through 08/17/2023 reflecting all emergency crash cart items were accounted for. The checklist also revealed below the page there were handwritten entries in black pen indicating the following: <BR/>8/5 AED needs service<BR/>8/6 AED needs service<BR/>8/8 AED needs service<BR/>8/9 AED <BR/>8/10 AED <BR/>8/11 AED needs servicing <BR/>8/13 AED needs servicing <BR/>8/14 AED <BR/>8/15 AED <BR/>8/16 AED needs servicing <BR/>8/17 AED <BR/>Review of the facility's know your AED machine reference guide dated November 2021 revealed the following: <BR/> .However, if you are needing a replacement, it must be approved prior to submitting the purchase order due to the cost . Also be mindful of the battery pack which can run low and need to be replaced or that may expire and need to be replaced. Documenting the date of your AED battery is now part of your monthly central supply sweep. When your battery gets within two months of expiring, submit a purchase order and order a new one.<BR/>Review of the facility's abuse/neglect policy and procedure revised on 03/29/2018 revealed the following: <BR/>Abuse/Neglect <BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and <BR/>exploitation as defined in this subpart . <BR/>7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. <BR/>Review of the facility's cardiopulmonary resuscitation policy and procedure revised on 05/19/2011 revealed the following: <BR/>Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or pulmonary arrest. Once initiated, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. CPR can be delivered by one or two persons. In residents with a terminal or irreversible disorder and in whom death is anticipated, an order can be w1itten and recorded indicated that resuscitation should not be performed. This decision is identified by a No Code order that is documented on the clinical record. The decision for No Code is usually made by the physician and family members and can also be included in the resident's advance directive. The facility will have at least 1 staff member who is trained in CPR/BLS at all times in the facility. Complications that result from the procedure include rib fracture, mural thrombi or emboli, and abdominal distention. <BR/>Goals <BR/>Breathing and pulse will be reestablished in the resident.<BR/>Procedure<BR/>1. Assess for unresponsiveness. Tap the resident's shoulder and ask the resident if he/she is alright.<BR/>2. When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call for emergency assistance. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). If you are alone and cannot alert anyone to call EMS. YOU MUST call EMS prior to beginning CPR and obtain the AED.<BR/>3. After EMS has been called, implement the CPR protocol as outlined below (Chest compressions - Airway- Breathing (C-A-B)).<BR/>4. Ensure that the resident is not in dangerous area. If the resident is located in a dangerous area, move the resident to a safe location to perform CPR<BR/>5. Check the unresponsive resident for a pulse for no longer than 10 seconds .<BR/>c. Adult - check for pulse at carotid artery<BR/>6. If no pulse, place a back board under the resident if the resident is in bed. Ensure that the resident is lying on their back on a hard surface (floor, back board)<BR/>7. Begin chest compressions at a rate of 100 compressions per minute.<BR/>16. Complete 5 sequences of chest compressions/breaths before checking the pulse again .<BR/>Note: No matter what stage of CPR you are in, when the AED arrives stop what you are doing and connect the AED to the resident<BR/>17. As soon as the AED is available power the device on and apply the pads as indicated to the resident's chest wall. If hair is present, quickly shave the area. so that the pads come in contact with the skin.<BR/>18. Follow all directions the AED provides.<BR/>19. Continue CPR as directed by the AED until EMS arrives<BR/>20. The facility will maintain an emergency cart with at least the following supplies:<BR/>a. Backboard<BR/>b. Ambu bag<BR/>c. 02 and administration set<BR/>d. Disposable Gloves<BR/>e. Crash cart (ER cart/AED) is checked daily. PRN and restocked immediately after a code is completed.<BR/>21. The family member and/or legal representative will be notified immediately in the change of the resident's status. The nurse will notify the attending physician immediately of the change in the resident's status.<BR/>22. Document all care given and resident's response to treatment.<BR/>23. The facility will document all code blue episodes. <BR/>This failure resulted in the identification of an IJ on 08/18/2023 at 7:54 P.M. The ADM was notified and provided with the IJ template on 08/18/2023 at 9:08 P.M. The following Plan of Removal was submitted by the facility and accepted on 08/21/2023 at 2:59 P.M.:<BR/>Plan of Removal<BR/>Immediate Jeopardy<BR/>On 8/18/23 an abbreviated survey was initiated at the facility. On 8/18/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: state the issue you will find the info on the template you were provided.<BR/>F600<BR/>The facility failed to check the AED device to ensure it had an active status, clean, without visible defects, did not have a low battery, and in operating condition after 8/18/23. <BR/>Action: As of 8/18/23 the AED has been replaced with a new AED by the Administrator. <BR/>Start Date: 8/18/2023<BR/>Completion Date: 8/18/2023<BR/>Responsible: The Administrator. <BR/>Action: An in-service was on 8/18/2023 that the night shift charge nurses will check that the AED is functioning properly as evidence by the machine is clean without visual effects and that indicator light is flashing green 7 days per week. All charge nurses and agency nurses if used that are not present on 8/18/2023 will be in-serviced before the start of their next scheduled shift in-service will be provided by DON/designee. All new staff and agency nurses if used will be

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide basic emergency life support immediately when needed, including cardiopulmonary resuscitation (CPR), for 1 of 65 residents (Resident #2) reviewed for advance directives. <BR/>The facility failed to check the AED device to ensure it had an active status, was cleaned, without visible defects, did not have a low battery, and in operating condition before using it on Resident #2 prior to EMS arrival on 08/18/2023. Resident #2 passed away at the facility on 08/18/2023. <BR/>An IJ was identified on 08/18/2023. The IJ template was provided to the facility on [DATE] at 9:08 PM. While the IJ was removed on 08/21/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents who are full code status at risk of death.<BR/>Findings include:<BR/>Review of Resident #2's face sheet dated 08/18/2023. revealed he was a [AGE] year-old male with an admission date of 07/14/2023. Resident #2 was diagnosed with unspecified chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related issues), unspecified sepsis (when an infection a person already had triggered a chain reaction throughout their body), unspecified pneumonia (an infection that affects one or both lungs), unspecified dementia, generalized muscle weakness, oral phase dysphagia (occurs when it is difficult to control the bolus (mass) of food and transporting it to the back of the mouth), unspecified hyperlipidemia (an excess of lipids or fats in a person's blood that can increase their risk of heart attack and stroke because the blood cannot easily flow through their arteries), unspecified hypothyroidism (a condition where there is not enough thyroid hormone in a person's bloodstream and their metabolism slows down), unspecified thrombocytopenia (a condition that occurs when the platelet count in a person's blood was too low), umbilical hernia without obstruction or gangrene (soft swelling or bulge near the naval), and unspecified Alzheimer's disease. Resident #2 had full code status, which indicated CPR and all other resuscitation procedures would be provided to keep him alive. Resident #2 was discharged on 08/18/2023. <BR/>Review of Resident #2's entry MDS assessment dated [DATE] revealed he reentered the facility from an acute hospital on [DATE] and was originally admitted to the facility on [DATE].<BR/>Review of Resident #2's comprehensive MDS assessment dated [DATE] revealed there was no BIMS score indicated. The assessment also revealed Resident #2 required extensive assistance with one person physical assistance for bed mobility, dressing, eating, and personal hygiene. The assessment revealed Resident #2 also required extensive assistance with two person physical assistance with toilet use. <BR/>Review of Resident #2's care plan reviewed and completed on 08/09/2023 revealed he had impairments such as Alzheimer's disease, unspecified and dementia without behavioral disturbance, had a behavior problem related to picking objects off the floor that were not food items, wandering and pacing, had COPD, had episodes of nausea and vomiting, was disoriented to place, had memory loss, had hyperlipidemia related to elevated cholesterol levels, had hypothyroidism, had chewing/swallowing problems, had hypertension, had communication problem related to Alzheimer's Dementia, soft spoken, mumbled his words, unable to make needs known and relied on staff to meet his needs, had depression and history of symptoms such as sadness and self isolation, had ADL self care deficit related to decreased endurance, dementia, depression and general weakness, had potential for complications and/or injury related to anticoagulant therapy, had a full code status, and had severe impairment with decision making skills as evidenced by staff and family assuming wants and needs at most times and did not typically voice wants and needs to staff. <BR/>Review of Resident #2's pulse summary revealed the last entry was on 08/15/2023 at 7:42 P.M. and indicated 74 BPM regular, which indicated he had a normal heart rate range. <BR/>Review of Resident #2's O2 stats summary revealed the last entry was on 08/15/2023 at 7:41 P.M. and indicated 95.0 % room air, which indicated he had a normal oxygen level range. <BR/>Review of Resident #2's blood pressure summary revealed the last entry was on 08/17/2023 at 11:53 A.M. and indicated 125/78 MMHG sitting I/arm, which indicated he had a normal blood pressure range. <BR/>Review of Resident #2's assessments revealed the most recent assessments completed was a 12-hour skilled nurse's note and weekly nurse's summary note on 08/17/2023. <BR/>Review of Resident #2's 12-hour skilled nurse's note dated 08/17/2023 at 6:00 P.M. revealed he had no chest pains, edema, shortness of breath, cough, unclear lung sounds, irregular respirations, loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, complaints of difficulty or pain when swallowing, and other skin findings present. The note also revealed Resident #2's decision making was severely impaired, he never or rarely made decisions, was rarely/never understood when making himself understood, and his memory was okay. The note revealed the physician/NP was not notified of any negative changes. The note also revealed Resident #2 was not on any transmission-based precautions and had no new physician drug orders. The note was signed on 08/17/2023 by RN C. <BR/>Review of Resident #2's weekly nursing summary dated 08/17/2023 at 6:05 P.M. revealed he had short-term memory impairment, Alzheimer's, severely impaired cognitive skills for decision making, did not have cognition changes during the day, exhibited wandering one to three days, did not exhibit verbal behavioral symptoms directed toward others, exhibited physical behavioral symptoms directed towards others one to three days, was rarely/never understood when expressing ideas and wants, unable to make needs known, was always continent of bowel and urinary, had no changes in bowel or bladder continence, walked unassisted, self-transferred, had no pain, had no decrease in food intake, no significant weight loss, able to get out of bed and chair without assistance, and had not suffered any psychological stress or acute disease in the past three months. The note was signed by RN C on 08/17/2023. <BR/>Review of Resident #2's nursing progress note dated 08/18/2023 at 1:17 A.M. revealed the following: Resident #2 lying in bed with eyes closed. Opened when spoken to. No vomiting observed. No complaints at this time. Respiration rate even and unlabored. Skin was warm and dry to touch. Safety precautions in place. Note was signed by LVN D. <BR/>Review of Resident #2's nursing progress note dated 08/18/2023 at 8:37 A.M. revealed the following: 5:00 A.M. Resident #2 was observed lying in bed with his eyes closed. Head of bed elevated. Noticed dark thin fluid on his face. Attempted to arouse Resident #2 without success. Alerted team for assistance to bring AED device and crash cart. Attempted to get BP and 02 Sat, no reading. Assessed blood glucose reading 120. Palpated pulse, very faint pulse observed. No lung sound on auscultation. Nothing observed in Resident #2's oral cavity at this time. Alerted staff to call EMS. Resident #2 laid on floor. AED device pads placed and compression started per AED instructions. Per EMS continue CPR until paramedics arrived. Paramedics arrived and continued CPR unsuccessfully. EMS MD called time of death at 6:07 A.M. Notified ON-CALL NP reported death .Family was notified and they gave funeral home of choice .Resident #2 was cleaned, and put back in bed for arrival of family. Family arrived. Local PD gave case number and left the building. Mortician arrived and transported body until the Funeral home had a chance to pick up Resident #2. Note was signed by LVN D. <BR/>During an interview on 08/18/2023 at 1:35 P.M., ADM stated Resident #2 passed away at the facility on 08/18/2023. <BR/>During an interview on 08/18/2023 at 4:22 P.M., ADM stated LVNs used the AED device when administering basic emergency life support to a resident. <BR/>Observation on 08/18/2023 at 4:26 P.M. revealed there was a light, green-colored AED device on the crash cart and a yellow-colored AED device in a case mounted to the wall behind the crash cart. <BR/>During an interview on 08/18/2023 at 4:27 P.M., ADON A stated an LVN, who worked on the night shift from 6:00 PM through 6:00 AM, checked the light, green-colored AED device once daily. ADON A stated the night shift LVN documented the status of the light, green-colored AED device on a AED device status sheet located in a binder that was stored on the crash cart. <BR/>Observation on 08/18/2023 at 4:38 P.M. revealed ADON A turned on the light, green-colored AED device. The device displayed a green check mark and indicated, Change battery. Battery low. Charge device. The pads were disposable, sealed in its original packaging, and had an expiration date indicating 07/24/2026. <BR/>During an interview on 08/18/2023 at 4:40 P.M., ADON A stated the LVN changed the battery whenever the light, green-colored AED device indicated it had a low battery. ADON A stated the facility was replacing the light, green-colored AED device because it had a low battery. ADON A stated she was not sure if an AED device would work on a resident if the battery indicated it was low. ADON A stated the light-green colored AED device was used on Resident #2 on 08/18/2023. ADON A stated the AED device was not working when it was used on Resident #2. ADON A stated LVN D used the AED device on Resident #2 when he coded. ADON A stated LVN E and LVN F were present when LVN D used the AED device on Resident #2. <BR/>During an interview on 08/18/2023 at 5:03 P.M., LVN D stated she saw Resident #2 to check his thyroid between 4:15 A.M. and 4:30 A.M. on 08/18/2023. LVN D stated she attempted to check Resident #2's vitals and found he had a faint pulse. LVN D stated she alerted LVN E and LVN F to bring the crash cart. LVN D stated she checked Resident #2's blood sugar, which was 120. LVN D stated she then had a CNA help her bring Resident #2 to the floor. LVN D did not know the name of the CNA. LVN D stated she connected the light, green-colored AED device to the disposable pads, turned on the AED device, and the AED device indicated low battery after she started compressions. LVN D stated the AED device did not initially indicate low battery. LVN D stated the AED device directed her when to clear Resident #2, there was no shock, and to start compressions. LVN D stated the AED device did not shock Resident #2 when she used it on him. LVN D stated EMS was alerted and en route. LVN D stated before EMS arrived at the facility, she started compressions until the police came. LVN D stated she switched to using the police's AED device because the light, green-colored AED device indicated low battery and batteries needed to be changed. LVN D stated she continued compressions and using the police's AED device until EMS arrived at the facility. LVN D stated EMS took over when they arrived at the facility and started using their automatic compression device. LVN D stated EMS was on the phone with their MD, conducted a procedural documentation check, vital check on Resident #2, and system check. LVN D stated EMS worked on Resident #2 for 40 minutes, were unsuccessful, and had their MD call his time of death. LVN D stated the AED device was checked daily. LVN D stated night shift staff checked daily and day shift staff checked at times daily. LVN D stated the AED check was documented on a AED device status sheet that was in a binder stored on the crash cart. LVN D stated she was not sure if the AED device was checked before it was used on Resident #2. LVN D stated she was trained on AED device usage and maintenance. LVN D could not recall when she was given the training and last in-serviced on AED device. <BR/>During an interview on 08/18/2023 at 5:20 P.M., LVN E stated she was passing out the morning medications to residents when LVN D called her to bring over the crash cart. LVN E stated she took the crash cart over to LVN D and saw Resident #2 laying in his bed. LVN E stated LVN D told her that Resident #2 was warm and responding when she checked on him earlier around 4:00 A.M. and 4:30 A.M. LVN E stated LVN D told her that Resident #2 was not responding when she checked on him around 5:00 A.M. LVN E stated LVN D asked her to call 911. LVN E stated she called 911 and provided EMS with information over the phone. LVN E stated she saw a CNA run out of Resident #2's room, grab the light, green-colored AED device, and return to the room. LVN E did not know the name of the CNA. LVN E stated there was one AED device for the facility. LVN E stated when she came back to the room, she saw Resident #2 was on the floor. LVN E stated she saw another CNA was also in the room. LVN E did not know the name of the CNA. LVN E stated LVN D started performing CPR and administering the AED device on Resident #2. LVN E stated the AED device indicated the battery was low and needed to be changed. LVN E stated LVN D applied the AED device on Resident #2 twice. LVN E stated she ran out to call LVN F. LVN E stated the AED device indicated battery was low and needed to be changed when LVN F was in the room. LVN E stated LVN F and LVN D switched back and forth with performing CPR on Resident #2. LVN E stated she went and let EMS into building and EMS took over. LVN E stated she was not sure if EMS used their own AED device or the facility's light, green-colored AED device. LVN E stated LVN D called and informed the DON about Resident #2 passing away. LVN E stated she was not sure when the police arrived at the facility. LVN E stated she did not know how often the AED device was supposed to be checked. LVN E stated AED device checks were documented on a AED device status sheet in a binder that was stored on the crash cart. LVN E stated she did not know if the AED device was checked before it was used on Resident #2. LVN E stated she was trained on AED device use, maintenance, and documentation. LVN E stated she did not receive the training at the facility. LVN E stated she was not recently in-serviced on AED device at the facility. <BR/>During an interview on 08/18/2023 at 5:44 P.M., LVN F stated she was at 200 hall when LVN E informed her that something was happening on 300 hall. LVN F stated she went to Resident #2's room. LVN F stated LVN D informed her that Resident #2 coded. LVN F stated she saw Resident #2 was already on the floor and LVN D was performing CPR. LVN F stated she saw the light, green-colored AED device was already on and indicating charge battery. LVN F stated she saw LVN D attempt to use the AED device on Resident #2. LVN F stated when LVN D put the pad on Resident #2's body, the AED device indicated do not touch resident, clear away, battery low, and need a new battery. LVN F stated she tried to figure out how to charge the AED device battery while LVN D performed CPR before EMS arrived. LVN F stated when EMS took over, they used their own AED device. LVN F stated every shift was supposed to check the AED device daily. LVN F stated LVNs checked the AED device and documented the check on a AED device status sheet in the binder stored at the crash cart. LVN F stated she was not sure if the AED device was checked before it was used on Resident #2. LVN F stated she was trained on AED device use and maintenance when she started her employment at the facility. LVN F stated she was in-serviced on AED device use and maintenance. LVN F could not remember when she was last in-serviced on AED device.<BR/>During an interview on 08/18/2023 at 6:18 P.M., ADM stated he did not know what was handwritten on the bottom of the facility's emergency cart checklist for August 2023 because it was not initialed by anyone. <BR/>During an interview on 08/18/2023 at 6:41 P.M., ADM stated the light, green-colored AED device was used on Resident #2. ADM stated the AED device was checked daily for operating status and as needed. ADM stated the AED device status was documented on a AED device status sheet in the binder stored next to the AED device. ADM stated the LVNs on the night shift checked the AED device daily. ADM stated the nurse manager checked the AED device status sheet. ADM stated nurse management was defined as the DON, ADON, treatment nurse, or any staff member who oversaw the LVNs. ADM stated according to nurse's progress note, the AED device was in operating condition when it was used on Resident #2. ADM did not know if the AED device indicated low battery and battery needed to be changed when it was used on Resident #2. ADM did not know if the AED device went off when it was turned on and used on Resident #2. ADM stated according to the nurse's progress note, staff used the AED device on Resident #2 prior to EMS arriving at the facility. ADM did not know if EMS used the facility's AED device or their own AED device. ADM stated he started his employment in July 2023 and since he started, there was no training given to staff on AED device use and maintenance. ADM stated he was not sure if staff were in-serviced on AED device use and maintenance. ADM did not know why the AED device status stopped being checked and documented after 08/10/2023. ADM stated he was not sure if the nurse managers were supposed to check the AED device status sheets daily or weekly. ADM stated according to the nurse's progress note, Resident #2 coded in the morning on 08/18/2023, staff performed CPR, grabbed additional staff, got the crash cart and AED device, and Resident #2 passed away. ADM stated he was not sure if there were any other emergency units that arrived other than EMS. ADM stated Resident #2 never had an incident in the past where staff had to perform CPR and administer the AED device on him.<BR/>During an interview on 08/18/2023 at 8:12 P.M., DON stated LVN D contacted her on 08/18/2023 at 5:41 A.M. and informed her that Resident #2 coded and EMS was at the facility. DON stated she thought LVN D was informing her that Resident #2 was going to the hospital. DON stated She asked LVN D at 5:47 A.M. if she performed CPR on Resident #2. DON stated LVN D told her that she performed CPR on Resident #2 until EMS arrived at the facility. DON stated she later missed two calls from LVN D at 6:14 A.M. DON stated she returned LVN D's call at 6:18 A.M. DON stated LVN D told her to check her text message sent at 6:08 A.M. DON stated the text message said, 607 TOD EMS MD. DON stated she called LVN D at 6:18 A.M. and asked clarification on TOD, which was time of death, and who was EMS MD. DON stated LVN D explained to her that EMS MD was EMS's MD, who pronounced Resident #2's death. DON stated she contacted ADON A and instructed her to have LVN D notify law enforcement, Resident #2's RP and NP. DON stated she came to the facility and saw law enforcement was still at the facility and LVN D filling out documents. DON stated LVN D informed her that Resident #2 had a history gastrointestinal issues and aspiration. DON stated LVN D also told her that Resident #2's vitals were fine. DON stated LVN D told her that around 4:00 A.M., she observed Resident #2 had liquid by around his mouth . DON stated LVN D also told her that CPR was performed before EMS arrived. DON stated LVN D also informed her that the AED device needed to be checked out because it kept giving a warning indicating low battery. DON stated LVN D told her that the AED device kept operating and giving the indicator to change battery. DON stated LVN D told her that staff ended up using EMS's AED device. DON stated she asked LVN D if the AED device had been showing the indicator of low battery. DON stated LVN De told her that LVN F or another nurse mentioned the AED device indicated low battery and change battery before. DON stated LVN D told her that she did not know when LVN F or another nurse mentioned the AED device indicated low battery and change battery. DON stated LVNs were supposed to check to make sure the AED device worked at the beginning of the night shift. DON stated the first time the AED device was reported not working was the morning of 08/18/2023. DON stated she went to the crash cart to check the inventory sheet. DON stated she informed ADON A because she was in charge of checking the crash cart. DON stated staff determined the AED device was working if the green light was indicated when turning it on. DON stated she informed ADON A or one of the other management staff about the AED device not working. DON stated she checked the emergency cart inventory sheet and found handwritten notes from staff who checked the AED device on 08/18/2023 and indicated AED needed servicing. DON stated the handwritten notes on the bottom of emergency cart checklist should have been entered onto the AED device status sheets. DON stated she did not know who made the handwritten notes on the emergency cart inventory sheet. DON stated according to crash cart inventory sheet, the last time the AED device was checked was during the night shift on 08/17/2023. DON stated staff did not notify management about the AED device status. DON stated the night shift LVN checked the AED device daily. DON stated the AED device battery was low because the machine was failing and the battery needed to be replaced. DON stated the light, green-colored AED device was used on Resident #2. DON stated the ADON verified LVNs checked the AED device and documented the status on the AED device status sheets. DON stated the ADON was supposed to check the AED device once every morning and sporadically. DON stated ADON A told her that she notified the ADM about the AED device needing to be changed. DON stated she did not know when ADON A told the ADM about the AED device needing to be changed. DON stated ADON A did not notify her of the AED device batteries needing to be changed nor the AED device having a low battery. <BR/>During an interview on 08/18/2023 at 8:48 P.M., ADM stated he was not notified by ADON A about the AED device needing to have batteries changed nor it having low battery until the morning of 08/18/2023. ADM stated he had never been told prior to 08/18/2023 about the AED device status. <BR/>During an interview on 08/18/2023 at 8:52 P.M., ADON A stated she checked to make sure LVNs checked the AED device and documented the status on the AED device status sheets. ADON A stated she checked once daily during the day shift. ADON A stated two weeks ago, she reviewed the emergency cart inventory sheet and saw handwritten notes indicating the AED device needed servicing. ADON A stated she did not know who made the handwritten notes on the emergency cart inventory sheet. ADON A stated she knew an LVN from the night shift made the handwritten notes. ADON A stated she went to the ADM two weeks ago and informed him about the AED device battery needing a service. ADON A stated she saw the ADM contact Corporate MR and informed her about the AED device status. ADON A stated Corporate MR told her and the ADM that the battery was back ordered. ADON A stated the facility got a new AED device on 08/18/2023 because the battery in the light, green colored AED device was not functioning and the battery was back ordered. ADON A stated staff did not notify her about the AED device battery being low and needing to be replaced. ADON A later stated LVN D informed her that the AED device battery was low and needed to be changed . ADON A stated she informed the ADM on 8/18/23 that the AED device battery needed to be changed because it was indicating low. ADON A stated LVN D did not explain why the AED battery was low. <BR/>During an interview on 08/18/2023 at 9:25 P.M., ADM stated he contacted and asked Corporate MR prior to Resident #2's incident on 08/18/2023 to order a new AED device because the light, green-colored device looked outdated and old. <BR/>Review of the facility's Defibtech DDU-100 Operator Checklist (AED Device Status Sheet) for August 2023 revealed the light, green-colored AED device was checked from 08/01/2023 through 08/10/2023. The checklist also revealed the Active Status indicator did not flash green from 08/01/2023 through 08/10/2023. The checklist revealed the unit was clean and without visual defects from 08/01/2023 through 08/02/2023. The checklist also revealed the unit was not clean and without visible defects from 08/03/2023 through 08/10/2023 . There were no other entries completed on the checklist. The checklist also revealed the manually run initiated test was not performed and pads were not replaced. The checklist revealed the date of battery pack expiration and date of pad expiration was not indicated.<BR/>Review of the facility's emergency cart checklist for August 2023 revealed there were entries from 08/01/2023 through 08/17/2023 reflecting all emergency crash cart items were accounted for. The checklist also revealed below the page there were handwritten entries in black pen indicating the following: <BR/>8/5 AED needs service<BR/>8/6 AED needs service<BR/>8/8 AED needs service<BR/>8/9 AED <BR/>8/10 AED <BR/>8/11 AED needs servicing <BR/>8/13 AED needs servicing <BR/>8/14 AED <BR/>8/15 AED <BR/>8/16 AED needs servicing <BR/>8/17 AED <BR/>Review of the facility's know your AED machine reference guide dated November 2021 revealed the following: <BR/> .However, if you are needing a replacement, it must be approved prior to submitting the purchase order due to the cost . Also be mindful of the battery pack which can run low and need to be replaced or that may expire and need to be replaced. Documenting the date of your AED battery is now part of your monthly central supply sweep. When your battery gets within two months of expiring, submit a purchase order and order a new one.<BR/>Review of the facility's cardiopulmonary resuscitation policy and procedure revised on 05/19/2011 revealed the following: <BR/>Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or pulmonary arrest. Once initiated, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. CPR can be delivered by one or two persons. In residents with a terminal or irreversible disorder and in whom death is anticipated, an order can be w1itten and recorded indicated that resuscitation should not be performed. This decision is identified by a No Code order that is documented on the clinical record. The decision for No Code is usually made by the physician and family members and can also be included in the resident's advance directive. The facility will have at least 1 staff member who is trained in CPR/BLS at all times in the facility. Complications that result from the procedure include rib fracture, mural thrombi or emboli, and abdominal distention. <BR/>Goals <BR/>Breathing and pulse will be reestablished in the resident.<BR/>Procedure<BR/>1. Assess for unresponsiveness. Tap the resident's shoulder and ask the resident if he/she is alright.<BR/>2. When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call for emergency assistance. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). If you are alone and cannot alert anyone to call EMS. YOU MUST call EMS prior to beginning CPR and obtain the AED.<BR/>3. After EMS has been called, implement the CPR protocol as outlined below (Chest compressions - Airway- Breathing (C-A-B)).<BR/>4. Ensure that the resident is not in dangerous area. If the resident is located in a dangerous area, move the resident to a safe location to perform CPR<BR/>5. Check the unresponsive resident for a pulse for no longer than 10 seconds .<BR/>c. Adult - check for pulse at carotid artery<BR/>6. If no pulse, place a back board under the resident if the resident is in bed. Ensure that the resident is lying on their back on a hard surface (floor, back board)<BR/>7. Begin chest compressions at a rate of 100 compressions per minute.<BR/>16. Complete 5 sequences of chest compressions/breaths before checking the pulse again .<BR/>Note: No matter what stage of CPR you are in, when the AED arrives stop what you are doing and connect the AED to the resident<BR/>17. As soon as the AED is available power the device on and apply the pads as indicated to the resident's chest wall. If hair is present, quickly shave the area. so that the pads come in contact with the skin.<BR/>18. Follow all directions the AED provides.<BR/>19. Continue CPR as directed by the AED until EMS arrives<BR/>20. The facility will maintain an emergency cart with at least the following supplies:<BR/>a. Backboard<BR/>b. Ambu bag<BR/>c. 02 and administration set<BR/>d. Disposable Gloves<BR/>e. Crash cart (ER cart/AED) is checked daily. PRN and restocked immediately after a code is completed.<BR/>21. The family member and/or legal representative will be notified immediately in the change of the resident's status. The nurse will notify the attending physician immediately of the change in the resident's status.<BR/>22. Document all care given and resident's response to treatment.<BR/>23. The facility will document all code blue episodes. <BR/>This failure resulted in the identification of an IJ on 08/18/2023 at 7:54 P.M. The ADM was notified and provided with the IJ template on 08/18/2023 at 9:08 P.M. The following Plan of Removal was submitted by the facility and accepted on 08/21/2023 at 2:59 P.M.: <BR/>Plan of Removal<BR/>Immediate Jeopardy<BR/>On 8/18/23 an abbreviated survey was initiated at the facility. On 8/18/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: state the issue you will find the info on the template you were provided.<BR/>F678<BR/>The facility failed to check the AED device to ensure it had an active status, clean, without visible defects, did not have a low battery, and in operating condition after 8/18/23. <BR/>Action: As of 8/18/23 the AED has been replaced with a new AED by the Administrator. <BR/>Start Date: 8/18/2023<BR/>Completion Date: 8/18/2023<BR/>Responsible: The Administrator. <BR/>Action: An in-service was on 8/18/2023 that the night shift charge nurses will check that the AED is functioning properly as evidence by the machine is clean without visual effects and that indicator light is flashing green 7 days per week. All charge nurses and agency nurses if used that are not present on 8/18/2023 will be in-serviced before the start of their next scheduled shift in-service will be provided by DON/designee. All new staff and agency nurses if used will be in-serviced/trained at new hire orientation on going prior to start shift. <BR/>Start Date: 8/18/2023<BR/>Completion Date: 8/19/2023<BR/>Responsible: DON/DESIGNEE<BR/>Action: An in-service was started on 8/18/2023 with all charge nurses that if they notice that the indicator light is not flashing green the charge nurse is to notify the Administrator and DON immediately 7 days a week. All charge nurses that are not present on 8/18/2023 will be in-serviced before the start of their next scheduled shift. All new staff / agency staff if used will be in-serviced at new hire orientation on going. <BR/>Start Date: 8/18/2023<BR/>Completion Date: 8/19/2023 <BR/>Responsible: DON/DESIGNEE.<BR/>Action: An ADHOC QAPI meeting was conducted on 8/19/23 to conduct a root cause analysis, discuss the deficient practice and plan of correct. Attendees interdisciplinary team (department heads)<BR/>Start Date: 8/18/2023<BR/>Completion Date: 8/19/2023<BR/>Responsible: Area director of Operations, Regional Compliance Nurse, Administrator, DON, and Medical Director. <BR/>Action: The Medical Director was noti[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was assessed by a nurse before CNA A got him off the floor after an unwitnessed fall on 01/14/25. <BR/>This failure could place residents at risk of not receiving necessary medical care, harm, injury, and hospitalization.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, repeated falls, and age-related physical debility. <BR/>Review of Resident #1's quarterly MDS assessment, dated 01/08/25, reflected a BIMS could not be conducted due to him rarely/never being understood. Section J (Health Conditions) reflected he had two or more falls since the prior assessment.<BR/>Review of Resident #1's quarterly care plan, dated 10/01/24, reflected he was at risk for falls related to poor safety awareness and decreased balance/strength with an intervention of anticipating and meeting the resident's needs.<BR/>Review of Resident #1's admission (from the hospital) Fall-Risk Assessment, dated 01/15/25, reflected he was a high fall risk.<BR/>Review of Resident #1's progress note, dated 01/14/25 at 8:54 AM and documented by LVN B, reflected the following:<BR/>[CNA A] wheeled [Resident #1] to the NSG station and [sic] reported he was found OOB on the floor; she reported, she recovered him from the floor and put him in the W/C . <BR/>During an interview on 01/28/25 at 2:22 PM, CNA A stated she knew better than to pick a resident up off the floor before getting a nurse to assess them. She stated it was important for a nurse to assess the resident if found on the floor because they could be injured. She stated the day she found Resident #1 on the ground (sitting on his bottom), she panicked because he was impulsive, and she was worried he would try to get up on his own and fall again. She stated it was a mistake and it should not have happened. She stated she immediately took him to LVN B, and he assessed Resident #1. She stated she was in-serviced on resident falls after the incident. <BR/>During a telephone interview on 01/28/25 at 2:07 PM, the NP stated she was notified of Resident #1's fall. She stated if a fall was not witnessed, she would expect the aides to get a nurse to assess the resident before getting them off the ground. She stated a negative outcome could be if they had a head injury, it could make it worse.<BR/>During an interview on 01/28/25 at 2:10 PM, the DON stated she was aware of the incident regarding CNA A getting Resident #1 off the ground before a nurse assessed him. She stated Resident #1 was assessed by LVN B and was not injured. She stated CNA A received a disciplinary action, 1:1 training, and all the staff were in-serviced. She stated CNA A admitted what she did was wrong, and she made a mistake by impulsively getting him off the floor. She stated if a resident was found on the ground, a nurse needed to take their vitals and assess for possible injuries. She stated if not assessed first, a resident could be further injured. <BR/>An interview was attempted by telephone with LVN B on 01/28/25 at 12:49 PM. A call was not returned prior to exiting.<BR/>Review of in-services entitled Fall Prevention, dated 01/14/25 and 01/16/25 and conducted by the DON, reflected all staff were in-serviced on fall prevention and their fall policy and procedure. <BR/>Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised October 5, 2016, reflected the following:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1(Resident #1) of 4 residents reviewed for pest control. <BR/>1. The facility failed to ensure the building was free of roaches.<BR/>2. The facility failed to ensure Resident #1 didn't have roaches crawling on her, which caused bites on her arm and upper back.<BR/>These failures placed residents at risk for disease, infection, harm, and a diminished quality of life.<BR/>Findings included: <BR/>Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old-female with an admission date of 09/29/2021. Resident #1 had diagnoses which included hemiplegia and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infraction (A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting the left non-dominant side and chronic pain.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/21/2023, revealed a BIMS score of 08, which indicated moderately impaired cognition. <BR/>Record review of Resident #1's progress notes, dated 07/14/2023, reflected: The Hospice Aide reported to nurse that while she was attending to Resident in room [ROOM NUMBER], the bed and whole room was infected with cockroaches. Please follow.<BR/>Record review of the facility's pest control treatment record, dated 07/14/2023, reflected: Rm 216 German Roaches. Facility requested additional service- Met with maintenance to take care of German roach issue happening in room [ROOM NUMBER]. Upon inspection I could confirm that there were German roaches around the nightstands and around the bed . I successfully killed about 60 German roaches .the 2 rooms adjacent room [ROOM NUMBER] were also treated.<BR/>Record review of Resident #1's Care Plan, revised 07/17/2023, revealed Resident #1 was at risk for pain related to neuropathy (disease or dysfunction of one or more peripheral nerves typically causing numbness or weakness). The resident had limited physical mobility related to Contractures, Neurological deficits, weakness, had an ADL Self Care Performance Deficit Activity Intolerance, Disease Process related to neurological disease.<BR/>Record review of Resident #1's physician order, dated 07/17/2023, reflected:<BR/>Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 25 mg by mouth every 8 hours as needed for Itching for 5 Days.<BR/>Hydrocortisone External Cream 1 % (Hydrocortisone [Topical]) apply to affected area topically two times a day every 5 day(s) for Insect bites.<BR/>Record review of Resident #1's skin assessment, dated 07/17/2023, reflected: Insect bites (3 total) right medial forearm: 1 at medial posterior, 2 at medial antecubital fold. 2 at right scapula.<BR/>During an observation on 07/18/2023 at about 11:25 a.m., revealed Resident #1 had two spots on the right upper, inner hand: 3 spots at right upper lateral back. The spots were small red bumps with white centers (pus-like).<BR/>During an interview on 07/18/2023 at 11:22 a.m., Resident #1 stated she saw the roaches on her bedside table, and some were crawling on her. Resident #1 stated one of the roaches bit her on her neck and she was immediately moved to another room while her room was sprayed. Resident # 1 stated the bites itched. Resident #1 stated she would like to go back to her original room. Resident #1 stated she kept snacks in the bed with her to eat as needed.<BR/>During an interview on 07/18/2023 at 11:30 a.m., the DON stated she was made aware of roaches being in Resident #1's room on 07/14/2023. The DON stated Resident #1's bed was immediately stripped off bedding and Resident #1 was taken to the shower. The DON stated a skin assessment was done while Resident #1 was in the shower and there were no skin issues noted. The DON stated all residents on the 200 hall were assessed and there was no evidence of roaches . The DON stated on 07/17/2023, while Resident #1 was being showered, the staff noted some spots on Resident #1 and a skin assessment was conducted. The DON stated the NP was notified via pictures and the NP ordered medications (Benadryl and Hydrocortisone) to treat insect bites and itching. The pictures were no longer on the DON's phone.<BR/>During an interview on 07/18/2023 at 12:27 p.m., the Maintenance Director stated there was a pest control and maintenance logbook at the nurse's station for staff to communicate with him. The Maintenance Director also stated the Pest Control company usually treated the facility once a month and as needed. He stated he was made aware of Resident #1's room, on 07/14/2023. He stated Resident #1 was immediately transferred to another room and pest control came out and treated the room. Along with the 2 adjacent rooms. The Maintenance Director stated he again treated Resident #1's room on 07/17/2023 with raid roaches' bombs.<BR/>During an interview on 07/18/2023 at 12:42 p.m., CNA A stated she worked with Resident #1 on 07/14/2023, the day the cockroaches were found on the resident. CNA A stated the Hospice Aide notified her (CNA A) of the cockroaches and she notified the DON, ADON and the Maintenance Director. CNA A stated Resident #1 was immediately moved to another room and the room was treated by pest control same day. CNA A stated staff were asked to check all rooms and beds in the facility for roaches and there were no other rooms noted with roaches. CNA A stated Resident #1 usually ate in bed and had lots of food in her room brought by family. CNA A stated they were in-serviced on pest control on 07/17/2023.<BR/>During an interview on 07/18/2023 at 2:24 p.m., the Administrator stated he had been employed at the facility for about a week. The Administrator stated pest control went to the facility monthly and as needed. The Administrator stated pest control was at the facility on 07/14/2023 after roaches were seen on Resident #1. The Administrator stated on 07/17/2023 the DON sent pictures to the NP regarding the marks on Resident #1 and the NP told the DON it was bites from the roaches. <BR/>During an observation on 07/18/2023 at about 2:20 p.m. in room [ROOM NUMBER] revealed had multiple dead cockroaches in the restroom, in the draws and on the floor.<BR/>On 07/18/2023 at 2:38 p.m. an interview was attempted with the NP and was unsuccessful.<BR/>Record review of the facility's in-services reflected an in-service titled Pest Control, dated 07/17/2023 with 14 participants.<BR/>Record review of the facility's Pest control and maintenance log reflected no documentation of cockroaches in room [ROOM NUMBER].<BR/>Record review of facility's grievance log from 05/2023 to 07/18/2023 reflected no concerns of cockroaches.<BR/>Record review of the facility's policy titled, Insect and Rodent Control, dated 2012, reflected: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents.<BR/>According to the CDC, The cockroach is considered an allergen source and an asthma trigger for residents. Although little evidence exists to link the cockroach to specific disease outbreaks, it has been demonstrated to carry Salmonella typhimurium, Entamoeba histolytica, and the poliomyelitis virus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify Resident #1, Resident #1's representative (RP), and a representative of the Office of the State Long-Term Care Ombudsman in writing and in a language they understood, of:<BR/>a) the discharge and the reasons for the discharge for Resident #1, <BR/>b) the effective date of the discharge for Resident #1, <BR/>c) a statement of Resident #1's appeal rights and how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, <BR/>d) the name, address and telephone number of the Office of the State Long-Term Care Ombudsman, <BR/>e) the mailing and email address and telephone number of the agency responsible for the protection and advocacy of Resident #1 under the Protection and Advocacy for Mentally Ill Individuals Act. <BR/>These failures caused Resident #1 to develop psychosocial distress and emotional harm in the setting of mental illness when resident was discharged from BHH #1 and taken to an alternate nursing facility. <BR/>These failures caused Resident #1 to be inappropriately discharged and without benefit of advocacy by representative of Office of the State Long-Term Care Ombudsman and/or agency responsible for the protection and advocacy of individuals with a mental disorder. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated [DATE] revealed he was an [AGE] year-old male that was initially admitted to the facility on [DATE]. Responsible party, RP, per face sheet dated [DATE], was indicated to be family member. Face sheet dated [DATE] included diagnoses of: Memory Deficit following Cerebrovascular Disease (memory deficit after a stroke), Major Depressive Disorder, Transient Ischemic Attack (a brief stroke-like attack), Lack of Coordination, Muscle Wasting and Atrophy (decrease in size of muscle due to loss of muscle tissue), Cerebral Infarction (blockage of blood flow in the brain which causes a stroke or stroke-like symptoms), Occlusion and stenosis of bilateral carotid arteries (blockage and narrowing of arteries which supply blood to the brain), Cognitive Communication Deficit (difficulty with thinking and verbalization to communicate), among other diagnoses.<BR/>Record review of Resident #1's Quarterly MDS (resident assessment tool required by Centers for Medicare and Medicaid) dated [DATE] indicated that:<BR/>Resident #1 had clear comprehension of understanding verbal content according to section B0700 of the MDS dated [DATE].<BR/>Resident #1 was able to make himself understood in expressing ideas and wants through verbal or non-verbal expression according to section B0700 of the [DATE] MDS. <BR/>Resident #1 had a BIMS score of 11/15, indicating moderately impaired cognition, according to his MDS dated [DATE], section C0200 through section C0500. <BR/>There was no evidence of acute change in mental status from Resident #1's baseline per section C1310 of MDS dated [DATE].<BR/>Resident #1 did not have inattentive behavior, disorganized thinking, or altered level of consciousness according to section C1310 of the [DATE] MDS. <BR/>Section D0200, Resident Mood Interview on the [DATE] MDS indicated: <BR/>Resident #1 did have little interest or pleasure in doing things 7-11 days over the previous two-week period; <BR/>had felt down, depressed, or hopeless 7-11 days over the previous two-week period;<BR/>felt tired/had little energy for 7-11 days over the previous two-week period; <BR/>had trouble concentrating for 7-11 days over the previous two-week period. <BR/>had thoughts that he would be better off dead or of hurting himself in the previous two-week period, 0 days;<BR/>was having trouble sleeping or was overeating or had poor appetite 0 days over the previous two-week period. <BR/>Section E0100 of the MDS dated [DATE] indicated that there were no potential indicators of psychosis.<BR/>Section E0200 of the MDS dated [DATE] indicated that Resident #1 was having no behavioral symptoms; behavioral symptoms were further defined as physical or verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. <BR/>Section E0800 of the MDS dated [DATE] indicated that Resident #1 was not exhibiting care rejection or wandering behaviors. <BR/>Record review of RN Progress Note dated [DATE] revealed that Resident #1 .was trying to exit the building, pt (patient) verbalized wanting to die because he feels he is useless and his son also calls him useless and .was crying all morning between 9 am and 1030 when he tried to escape and was decline (sic) by staff members. Pt (patient) is still on Q15 (every 15 minutes checks) and one on one.<BR/>Record review of LVN A's Progress Note dated [DATE] revealed that Resident #1 was being monitored one on one for suicidal ideation and self-harm, slept well, and was being checked on every 15 minutes. <BR/>Record Review of LVN B's Progress Note dated [DATE] revealed Resident continues one on one observation due to suicide/self harm prevention. Q15 (every 15 minutes) checks are also in place. No behaviors changes noted during shift .<BR/>Record review of SW Progress Note dated [DATE] revealed that SW was attempting placement of Resident #1 in BHH #1; note revealed placement attempts of Resident #1 at three other facilities; note did not include consultation with RP or Resident #1 in determining alternate facility placement.<BR/>Record review of SW progress note dated [DATE] revealed that Resident #1 was accepted into BHH #1; note stated Resident was accepted into (BHH #1) and will complete evaluation and treatment over the next two weeks. The acceptance came after the resident agreed to voluntarily get help from (BHH #1) then return .<BR/>Record review of Resident #1's Care Plan with review date of [DATE] revealed that recent hospitalization for suicidal ideation was added to Resident #1's Care Plan on [DATE] and was active at time of discharge. Interventions for Resident #1 included: Notify physician and family, one on one monitoring and observation, approaching resident calmly/unhurriedly, attempting to refocus, counsel/listen, psych (psychology, psychiatry services) consult, medication (psychotropics), and medication review. Interventions for Resident #1 Care Plan suicidal ideation entry did not include behavioral health rehospitalization and/or attempts to find alternate nursing facility which may better meet Resident #1's needs.<BR/>Record review of Resident #1's Care Plan with review date of [DATE] revealed the following: Resident #1 and family wish to remain at the facility for long term care, initiated [DATE] and active at discharge. Resident #1 has a diagnosis of depression, initiated on [DATE] and current at time of discharge. Interventions for Resident #1 related to depression include: administer medications as ordered and monitor/document for side effects and effectiveness, arrange for a psych (psychology/psychiatry services) consult and follow up as indicated, and monitor/document/report to Practitioner (APRN, MD) signs and symptoms of depression.<BR/>Record review of Resident #1's Care Plan, with [DATE] review date, revealed initially Resident #1 refused service coordination with local mental health authority but accepted coordination with local mental health authority on [DATE] and active at time of discharge. Resident #1 was identified as having PASRR positive status related to mental illness: mood disorder related to attempt to harm self, identified on [DATE]. <BR/>Record review of Resident #1's Care Plan, with review date of [DATE] revealed interventions including: the staff will continue to encourage and praise Resident #1 for making independent decisions, the staff will respect the choices that Resident #1 makes, the staff will take time explaining to Resident #1. These interventions were initiated on [DATE] and active at time of discharge. Resident #1 is able and does make wants/needs known to staff, initiated [DATE] and active at time of discharge. <BR/>Care Plan with review date of [DATE] indicated that Resident #1 demonstrated independence in decision-making.<BR/>Record review of Resident #1 Care Plan indicated that Resident #1 is at risk for depression related to recent death of spouse (who had lived in facility with him) and had behavior problem in the form of verbalizing threat of self-harm, initiated [DATE] and active at time of discharge. <BR/>Resident #1 has had inappropriate behavior related to acute episodes of suicidal ideations, initiated [DATE] and active at time of discharge. <BR/>Resident #1 had a hearing deficit, initiated [DATE] and active at time of discharge. <BR/>Record review of the facility-initiated Discharge Notification dated [DATE] was signed by ADM. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement contained within Discharge Notification was signed by MD and dated [DATE]. Discharge Notification dated [DATE] and MD statement contained therein dated [DATE] indicated that discharge was necessary for Resident #1's welfare as the facility was not able to provide the level of care required for Resident #1's exhibition of self-harming behaviors. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement, dated [DATE], contained within the Discharge Notification dated [DATE], indicated that the facility efforts to meet Resident #1's needs included being seen by psychiatrist and psychological services and one on one monitoring until Resident #1 was discharged to a more appropriate setting. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement, dated [DATE], indicated that the new facility would provide the following to meet the needs of Resident #1: Resident was sent to the hospital for further evaluation and treatment. The resident needs a facility that is geared towards psychiatric issues in a geriatric resident. The Discharge Notification dated [DATE] did not indicate the name of a receiving nursing facility or behavioral health hospital where Resident #1 would be discharged to. Documentation which indicated that Resident #1 and/or OMB and/or RP received a written copy of Discharge Notification could not be provided by facility. Documentation which indicated that Resident #1 and/or OMB and/or RP was verbally notified could not be provided by facility. There was no evidence of an additional Discharge Notification issued after resident was accepted to an alternate nursing facility as noted in SW Progress Notes of [DATE]. <BR/>Record review of written notification that OMB was notified of Resident #1 discharge was inclusive of an email dated [DATE] from OMB to SW which indicated that OMB was trying to reach SW to have a conversation with SW regarding a safe discharge; OMB indicated in email that she was unable to reach SW by phone. It is unknown if Resident #1 was the subject of the safe discharge that was indicated on the email dated [DATE]. ADM was unable to provide other written record of discharge notification to OMB regarding Resident #1 after request made by investigator on [DATE] at 5:30 pm. <BR/>Record review of the SW Progress Note dated [DATE] indicated that a transfer packet was submitted to BHH #1 at RP request. SW Progress Note dated [DATE] indicated that SW had also contacted three nursing facilities to attempt placement for Resident #1. There is no documentation to indicate that RP or Resident #1 were consulted regarding alternate nursing facility placement or that this had been requested or initiated by Resident #1 or RP. Record review of the Progress Note dated [DATE], written by SW, stated that .resident agreed to voluntarily get help from (BHH #1) then return to (facility). Progress Notes dated [DATE], written by SW, revealed that Resident #1 was sent to BHH #1 on [DATE] at 8:30 pm, the day prior to the written entry. Progress note dated [DATE], written by SW, indicated that ADM scheduled transportation to BHH #1. Further review of the Progress Note by SW dated [DATE] revealed that Resident #1 would be re-evaluated prior to re-entering the facility. Progress note by SW dated [DATE] revealed that Resident #1 had been accepted by an alternate nursing facility. <BR/>Record review of the APRN Progress Note dated [DATE] revealed that Resident #1 was oriented to person, place, and situation and had appropriate insight. APRN Progress Note dated [DATE] indicated that Resident #1 had mild MDD with situational depression and was started on an anti-depressant medication and a psychology/psychiatry consult was placed. <BR/>Record review of the Psychology Diagnostic Assessment signed by PSP on [DATE] revealed that Resident #1 had a remote (1967) past-history of suicide threat involving a gun, more recent history (December, year unknown) of suicide attempt using a telephone cord for which the facility hospitalized him at BHH #2 and history at facility of trying to bite his wrist to make himself bleed to death (date unknown) after his roommate's TV was left on for consecutive nights. Current risk factors indicated on Psychology Diagnostic Assessment on [DATE] revealed Suicidal Ideation: None, History of, history of ideation when wife became very ill and died. Recent suicide attempt - sent to (BHH #2). No current suicidal ideation. <BR/>Record review of Psychology Diagnostic Assessment signed by PSP on [DATE] revealed that Resident #1 was scored 12/15 on Geriatric Depression Scale, indicative of severe depression. <BR/>Further review of the Psychology Diagnostic Assessment revealed that Resident #1 is not currently a danger to self or others and has situational depression; treatment plan indicated combined mental health therapy services once every 1-2 weeks for ten sessions with medication to manage his depression. <BR/>There were no records provided by facility to indicate that local or State mental health authority was notified or consulted in pending discharge of Resident #1. There was no evaluation found in EMR or provided by facility to indicate that Resident #1 was re-evaluated at facility after discharge from BHH #1. <BR/>Record review of undated facility Suicide Threat policy indicated Policy Statement and Policy Interpretation and Implementation. Suicide Threat Policy Interpretation and Implementation section indicated the actions to take during the acute suicide threat and then actions which would be taken once the resident is stable. The policy does not include or list an intervention involving alternate placement outside of facility or transferring or discharging a resident when this occurs. <BR/>There was no Discharge Summary located in electronic medical record for record review. Facility was unable to provide Discharge Summary for Resident #1. <BR/>Interview with the ADM on [DATE] at 5:30 pm revealed that Resident #1 was discharged to BHH #1 on [DATE]. The ADM stated that she told RP that Resident #1 would be re-evaluated when he came back from BHH #1 to determine if he was appropriate for the facility. The ADM stated that Resident #1 was banging head against the rails of bed and wall trying to kill himself. The ADM stated that Resident #1 had been in facility for four years and that his family member had been there for many years; Resident #1's family member had recently passed away in [DATE] and ADM stated that being at facility was felt to be a trigger for Resident #1's suicidal behavioral The ADM stated that acceptance at alternate nursing facility #1 was obtained prior to Resident #1's discharge to BHH #1. The ADM did not indicate reason for plan to re-evaluate Resident #1 after he was discharged from BHH #1 for re-admission to facility while simultaneously obtaining acceptance for Resident #1 at alternate nursing facility #1. ADM stated that Resident #1 had past-history of attempting to harm himself prior to and after admission to the facility which was exacerbated a few months prior to discharge with death of family member who had been in the facility with him. <BR/>Interview with the SW on [DATE] at 1:55 pm revealed that Resident #1 had past suicide attempts prior to entering facility. The SW stated that Resident #1's behavior at facility included banging head on floor and walls while stating that he wanted to die. The SW stated that Resident #1 had been placed one on one with a caregiver who could supervise him. The SW stated that she did not see paperwork submitted to facility from BHH #1 when Resident #1 was being discharged from BHH #1. The SW stated that the plan for Resident #1, when he was sent to BHH #1 on [DATE], was that at discharge time from BHH #1, Resident #1 would be re-evaluated for return. The SW stated that Resident #1 was not notified in writing or verbally prior to leaving for BHH #1 that he would be going to Alternate Nursing Facility #1 as the plan was to re-evaluate Resident #1 after he finished treatment at BHH #1. The SW stated that she felt that the discharge paperwork from BHH #1 contained information which was the deciding factor against return of resident #1 to facility. The SW stated that she did not see the information sent from BHH #1 to facility at time of discharge from BHH #1. <BR/>Interview with the RP on [DATE] at 12:00 pm revealed that call was made from ADM on [DATE]; The ADM stated to RP that facility was not taking Resident #1 back. The RP stated that BHH #1 also called her on [DATE] and stated that it was their understanding that Resident #1 was being returned to facility upon discharge that day; BHH #1 stated that there had been an agreement made prior to admission of Resident #1 for inpatient behavioral health that the facility would accept Resident #1 back. The RP received a phone call at 6:30 pm on [DATE] from Resident #1 and stated that Resident #1 was upset and crying on the phone. The RP stated that Resident #1 had been picked up at BHH #1, put in a transport van, and taken to Alternate Nursing Facility #1 without explanation or information. The RP stated that Resident #1 was disoriented and scared being in a new environment that he was unfamiliar with. The RP stated that Resident #1 stated that he had not agreed to go to Alternate Nursing Facility #1. The RP stated that Resident #1 had not been notified by facility of discharge and had trouble getting information from anyone at BHH #1 on [DATE], date of discharge from BHH #1. Resident #1 stated that he asked the transportation personnel where he was going when he was being transported to Alternate Nursing Facility #1 and did not get an answer. The RP stated that an emailed copy of the Discharge Notification for Resident #1 from the facility was received to personal email on [DATE]. RP stated in interview that she had been notified by phone on unknown date by SW and ADM that Resident #1 had been accepted at Alternate Nursing Facility #1. <BR/>Discharge Protocol Packet:<BR/>Page 1:<BR/>discharge date : <BR/>Perform the following actions: (enter the date completed for each action):<BR/>Discharge - Unable to Meet Needs - Physician/NP/PA Statement on page 2 completed.,<BR/>Discharge Notice on page 3 completed.<BR/>Discharge Notice Provided to the following:<BR/>Resident Representative: Check if Not Applicable/Present:<BR/>Ombudsman:<BR/>Other Facility: (Only required if the resident is currently at another facility, i,e, hospital; psych center, etc.)<BR/>Check if Not Applicable<BR/>Has APS been notified of this discharge? If Yes, date of notification:<BR/>Page 2:<BR/>Discharge- Unable to Meet Needs- Physician/NP/PA Statement:<BR/>Resident Name:<BR/>1. What are the specific resident needs the facility cannot meet?<BR/>2. What were the facility efforts to meet those needs?<BR/>3. What are the specific services the new facility will provide to meet the needs of the resident<BR/>which cannot be met at the current facility?<BR/>MD/NP/PA Signature:<BR/>Date:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify Resident #1, Resident #1's representative (RP), and a representative of the Office of the State Long-Term Care Ombudsman in writing and in a language they understood, of:<BR/>a) the discharge and the reasons for the discharge for Resident #1, <BR/>b) the effective date of the discharge for Resident #1, <BR/>c) a statement of Resident #1's appeal rights and how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, <BR/>d) the name, address and telephone number of the Office of the State Long-Term Care Ombudsman, <BR/>e) the mailing and email address and telephone number of the agency responsible for the protection and advocacy of Resident #1 under the Protection and Advocacy for Mentally Ill Individuals Act. <BR/>These failures caused Resident #1 to develop psychosocial distress and emotional harm in the setting of mental illness when resident was discharged from BHH #1 and taken to an alternate nursing facility. <BR/>These failures caused Resident #1 to be inappropriately discharged and without benefit of advocacy by representative of Office of the State Long-Term Care Ombudsman and/or agency responsible for the protection and advocacy of individuals with a mental disorder. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated [DATE] revealed he was an [AGE] year-old male that was initially admitted to the facility on [DATE]. Responsible party, RP, per face sheet dated [DATE], was indicated to be family member. Face sheet dated [DATE] included diagnoses of: Memory Deficit following Cerebrovascular Disease (memory deficit after a stroke), Major Depressive Disorder, Transient Ischemic Attack (a brief stroke-like attack), Lack of Coordination, Muscle Wasting and Atrophy (decrease in size of muscle due to loss of muscle tissue), Cerebral Infarction (blockage of blood flow in the brain which causes a stroke or stroke-like symptoms), Occlusion and stenosis of bilateral carotid arteries (blockage and narrowing of arteries which supply blood to the brain), Cognitive Communication Deficit (difficulty with thinking and verbalization to communicate), among other diagnoses.<BR/>Record review of Resident #1's Quarterly MDS (resident assessment tool required by Centers for Medicare and Medicaid) dated [DATE] indicated that:<BR/>Resident #1 had clear comprehension of understanding verbal content according to section B0700 of the MDS dated [DATE].<BR/>Resident #1 was able to make himself understood in expressing ideas and wants through verbal or non-verbal expression according to section B0700 of the [DATE] MDS. <BR/>Resident #1 had a BIMS score of 11/15, indicating moderately impaired cognition, according to his MDS dated [DATE], section C0200 through section C0500. <BR/>There was no evidence of acute change in mental status from Resident #1's baseline per section C1310 of MDS dated [DATE].<BR/>Resident #1 did not have inattentive behavior, disorganized thinking, or altered level of consciousness according to section C1310 of the [DATE] MDS. <BR/>Section D0200, Resident Mood Interview on the [DATE] MDS indicated: <BR/>Resident #1 did have little interest or pleasure in doing things 7-11 days over the previous two-week period; <BR/>had felt down, depressed, or hopeless 7-11 days over the previous two-week period;<BR/>felt tired/had little energy for 7-11 days over the previous two-week period; <BR/>had trouble concentrating for 7-11 days over the previous two-week period. <BR/>had thoughts that he would be better off dead or of hurting himself in the previous two-week period, 0 days;<BR/>was having trouble sleeping or was overeating or had poor appetite 0 days over the previous two-week period. <BR/>Section E0100 of the MDS dated [DATE] indicated that there were no potential indicators of psychosis.<BR/>Section E0200 of the MDS dated [DATE] indicated that Resident #1 was having no behavioral symptoms; behavioral symptoms were further defined as physical or verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. <BR/>Section E0800 of the MDS dated [DATE] indicated that Resident #1 was not exhibiting care rejection or wandering behaviors. <BR/>Record review of RN Progress Note dated [DATE] revealed that Resident #1 .was trying to exit the building, pt (patient) verbalized wanting to die because he feels he is useless and his son also calls him useless and .was crying all morning between 9 am and 1030 when he tried to escape and was decline (sic) by staff members. Pt (patient) is still on Q15 (every 15 minutes checks) and one on one.<BR/>Record review of LVN A's Progress Note dated [DATE] revealed that Resident #1 was being monitored one on one for suicidal ideation and self-harm, slept well, and was being checked on every 15 minutes. <BR/>Record Review of LVN B's Progress Note dated [DATE] revealed Resident continues one on one observation due to suicide/self harm prevention. Q15 (every 15 minutes) checks are also in place. No behaviors changes noted during shift .<BR/>Record review of SW Progress Note dated [DATE] revealed that SW was attempting placement of Resident #1 in BHH #1; note revealed placement attempts of Resident #1 at three other facilities; note did not include consultation with RP or Resident #1 in determining alternate facility placement.<BR/>Record review of SW progress note dated [DATE] revealed that Resident #1 was accepted into BHH #1; note stated Resident was accepted into (BHH #1) and will complete evaluation and treatment over the next two weeks. The acceptance came after the resident agreed to voluntarily get help from (BHH #1) then return .<BR/>Record review of Resident #1's Care Plan with review date of [DATE] revealed that recent hospitalization for suicidal ideation was added to Resident #1's Care Plan on [DATE] and was active at time of discharge. Interventions for Resident #1 included: Notify physician and family, one on one monitoring and observation, approaching resident calmly/unhurriedly, attempting to refocus, counsel/listen, psych (psychology, psychiatry services) consult, medication (psychotropics), and medication review. Interventions for Resident #1 Care Plan suicidal ideation entry did not include behavioral health rehospitalization and/or attempts to find alternate nursing facility which may better meet Resident #1's needs.<BR/>Record review of Resident #1's Care Plan with review date of [DATE] revealed the following: Resident #1 and family wish to remain at the facility for long term care, initiated [DATE] and active at discharge. Resident #1 has a diagnosis of depression, initiated on [DATE] and current at time of discharge. Interventions for Resident #1 related to depression include: administer medications as ordered and monitor/document for side effects and effectiveness, arrange for a psych (psychology/psychiatry services) consult and follow up as indicated, and monitor/document/report to Practitioner (APRN, MD) signs and symptoms of depression.<BR/>Record review of Resident #1's Care Plan, with [DATE] review date, revealed initially Resident #1 refused service coordination with local mental health authority but accepted coordination with local mental health authority on [DATE] and active at time of discharge. Resident #1 was identified as having PASRR positive status related to mental illness: mood disorder related to attempt to harm self, identified on [DATE]. <BR/>Record review of Resident #1's Care Plan, with review date of [DATE] revealed interventions including: the staff will continue to encourage and praise Resident #1 for making independent decisions, the staff will respect the choices that Resident #1 makes, the staff will take time explaining to Resident #1. These interventions were initiated on [DATE] and active at time of discharge. Resident #1 is able and does make wants/needs known to staff, initiated [DATE] and active at time of discharge. <BR/>Care Plan with review date of [DATE] indicated that Resident #1 demonstrated independence in decision-making.<BR/>Record review of Resident #1 Care Plan indicated that Resident #1 is at risk for depression related to recent death of spouse (who had lived in facility with him) and had behavior problem in the form of verbalizing threat of self-harm, initiated [DATE] and active at time of discharge. <BR/>Resident #1 has had inappropriate behavior related to acute episodes of suicidal ideations, initiated [DATE] and active at time of discharge. <BR/>Resident #1 had a hearing deficit, initiated [DATE] and active at time of discharge. <BR/>Record review of the facility-initiated Discharge Notification dated [DATE] was signed by ADM. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement contained within Discharge Notification was signed by MD and dated [DATE]. Discharge Notification dated [DATE] and MD statement contained therein dated [DATE] indicated that discharge was necessary for Resident #1's welfare as the facility was not able to provide the level of care required for Resident #1's exhibition of self-harming behaviors. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement, dated [DATE], contained within the Discharge Notification dated [DATE], indicated that the facility efforts to meet Resident #1's needs included being seen by psychiatrist and psychological services and one on one monitoring until Resident #1 was discharged to a more appropriate setting. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement, dated [DATE], indicated that the new facility would provide the following to meet the needs of Resident #1: Resident was sent to the hospital for further evaluation and treatment. The resident needs a facility that is geared towards psychiatric issues in a geriatric resident. The Discharge Notification dated [DATE] did not indicate the name of a receiving nursing facility or behavioral health hospital where Resident #1 would be discharged to. Documentation which indicated that Resident #1 and/or OMB and/or RP received a written copy of Discharge Notification could not be provided by facility. Documentation which indicated that Resident #1 and/or OMB and/or RP was verbally notified could not be provided by facility. There was no evidence of an additional Discharge Notification issued after resident was accepted to an alternate nursing facility as noted in SW Progress Notes of [DATE]. <BR/>Record review of written notification that OMB was notified of Resident #1 discharge was inclusive of an email dated [DATE] from OMB to SW which indicated that OMB was trying to reach SW to have a conversation with SW regarding a safe discharge; OMB indicated in email that she was unable to reach SW by phone. It is unknown if Resident #1 was the subject of the safe discharge that was indicated on the email dated [DATE]. ADM was unable to provide other written record of discharge notification to OMB regarding Resident #1 after request made by investigator on [DATE] at 5:30 pm. <BR/>Record review of the SW Progress Note dated [DATE] indicated that a transfer packet was submitted to BHH #1 at RP request. SW Progress Note dated [DATE] indicated that SW had also contacted three nursing facilities to attempt placement for Resident #1. There is no documentation to indicate that RP or Resident #1 were consulted regarding alternate nursing facility placement or that this had been requested or initiated by Resident #1 or RP. Record review of the Progress Note dated [DATE], written by SW, stated that .resident agreed to voluntarily get help from (BHH #1) then return to (facility). Progress Notes dated [DATE], written by SW, revealed that Resident #1 was sent to BHH #1 on [DATE] at 8:30 pm, the day prior to the written entry. Progress note dated [DATE], written by SW, indicated that ADM scheduled transportation to BHH #1. Further review of the Progress Note by SW dated [DATE] revealed that Resident #1 would be re-evaluated prior to re-entering the facility. Progress note by SW dated [DATE] revealed that Resident #1 had been accepted by an alternate nursing facility. <BR/>Record review of the APRN Progress Note dated [DATE] revealed that Resident #1 was oriented to person, place, and situation and had appropriate insight. APRN Progress Note dated [DATE] indicated that Resident #1 had mild MDD with situational depression and was started on an anti-depressant medication and a psychology/psychiatry consult was placed. <BR/>Record review of the Psychology Diagnostic Assessment signed by PSP on [DATE] revealed that Resident #1 had a remote (1967) past-history of suicide threat involving a gun, more recent history (December, year unknown) of suicide attempt using a telephone cord for which the facility hospitalized him at BHH #2 and history at facility of trying to bite his wrist to make himself bleed to death (date unknown) after his roommate's TV was left on for consecutive nights. Current risk factors indicated on Psychology Diagnostic Assessment on [DATE] revealed Suicidal Ideation: None, History of, history of ideation when wife became very ill and died. Recent suicide attempt - sent to (BHH #2). No current suicidal ideation. <BR/>Record review of Psychology Diagnostic Assessment signed by PSP on [DATE] revealed that Resident #1 was scored 12/15 on Geriatric Depression Scale, indicative of severe depression. <BR/>Further review of the Psychology Diagnostic Assessment revealed that Resident #1 is not currently a danger to self or others and has situational depression; treatment plan indicated combined mental health therapy services once every 1-2 weeks for ten sessions with medication to manage his depression. <BR/>There were no records provided by facility to indicate that local or State mental health authority was notified or consulted in pending discharge of Resident #1. There was no evaluation found in EMR or provided by facility to indicate that Resident #1 was re-evaluated at facility after discharge from BHH #1. <BR/>Record review of undated facility Suicide Threat policy indicated Policy Statement and Policy Interpretation and Implementation. Suicide Threat Policy Interpretation and Implementation section indicated the actions to take during the acute suicide threat and then actions which would be taken once the resident is stable. The policy does not include or list an intervention involving alternate placement outside of facility or transferring or discharging a resident when this occurs. <BR/>There was no Discharge Summary located in electronic medical record for record review. Facility was unable to provide Discharge Summary for Resident #1. <BR/>Interview with the ADM on [DATE] at 5:30 pm revealed that Resident #1 was discharged to BHH #1 on [DATE]. The ADM stated that she told RP that Resident #1 would be re-evaluated when he came back from BHH #1 to determine if he was appropriate for the facility. The ADM stated that Resident #1 was banging head against the rails of bed and wall trying to kill himself. The ADM stated that Resident #1 had been in facility for four years and that his family member had been there for many years; Resident #1's family member had recently passed away in [DATE] and ADM stated that being at facility was felt to be a trigger for Resident #1's suicidal behavioral The ADM stated that acceptance at alternate nursing facility #1 was obtained prior to Resident #1's discharge to BHH #1. The ADM did not indicate reason for plan to re-evaluate Resident #1 after he was discharged from BHH #1 for re-admission to facility while simultaneously obtaining acceptance for Resident #1 at alternate nursing facility #1. ADM stated that Resident #1 had past-history of attempting to harm himself prior to and after admission to the facility which was exacerbated a few months prior to discharge with death of family member who had been in the facility with him. <BR/>Interview with the SW on [DATE] at 1:55 pm revealed that Resident #1 had past suicide attempts prior to entering facility. The SW stated that Resident #1's behavior at facility included banging head on floor and walls while stating that he wanted to die. The SW stated that Resident #1 had been placed one on one with a caregiver who could supervise him. The SW stated that she did not see paperwork submitted to facility from BHH #1 when Resident #1 was being discharged from BHH #1. The SW stated that the plan for Resident #1, when he was sent to BHH #1 on [DATE], was that at discharge time from BHH #1, Resident #1 would be re-evaluated for return. The SW stated that Resident #1 was not notified in writing or verbally prior to leaving for BHH #1 that he would be going to Alternate Nursing Facility #1 as the plan was to re-evaluate Resident #1 after he finished treatment at BHH #1. The SW stated that she felt that the discharge paperwork from BHH #1 contained information which was the deciding factor against return of resident #1 to facility. The SW stated that she did not see the information sent from BHH #1 to facility at time of discharge from BHH #1. <BR/>Interview with the RP on [DATE] at 12:00 pm revealed that call was made from ADM on [DATE]; The ADM stated to RP that facility was not taking Resident #1 back. The RP stated that BHH #1 also called her on [DATE] and stated that it was their understanding that Resident #1 was being returned to facility upon discharge that day; BHH #1 stated that there had been an agreement made prior to admission of Resident #1 for inpatient behavioral health that the facility would accept Resident #1 back. The RP received a phone call at 6:30 pm on [DATE] from Resident #1 and stated that Resident #1 was upset and crying on the phone. The RP stated that Resident #1 had been picked up at BHH #1, put in a transport van, and taken to Alternate Nursing Facility #1 without explanation or information. The RP stated that Resident #1 was disoriented and scared being in a new environment that he was unfamiliar with. The RP stated that Resident #1 stated that he had not agreed to go to Alternate Nursing Facility #1. The RP stated that Resident #1 had not been notified by facility of discharge and had trouble getting information from anyone at BHH #1 on [DATE], date of discharge from BHH #1. Resident #1 stated that he asked the transportation personnel where he was going when he was being transported to Alternate Nursing Facility #1 and did not get an answer. The RP stated that an emailed copy of the Discharge Notification for Resident #1 from the facility was received to personal email on [DATE]. RP stated in interview that she had been notified by phone on unknown date by SW and ADM that Resident #1 had been accepted at Alternate Nursing Facility #1. <BR/>Discharge Protocol Packet:<BR/>Page 1:<BR/>discharge date : <BR/>Perform the following actions: (enter the date completed for each action):<BR/>Discharge - Unable to Meet Needs - Physician/NP/PA Statement on page 2 completed.,<BR/>Discharge Notice on page 3 completed.<BR/>Discharge Notice Provided to the following:<BR/>Resident Representative: Check if Not Applicable/Present:<BR/>Ombudsman:<BR/>Other Facility: (Only required if the resident is currently at another facility, i,e, hospital; psych center, etc.)<BR/>Check if Not Applicable<BR/>Has APS been notified of this discharge? If Yes, date of notification:<BR/>Page 2:<BR/>Discharge- Unable to Meet Needs- Physician/NP/PA Statement:<BR/>Resident Name:<BR/>1. What are the specific resident needs the facility cannot meet?<BR/>2. What were the facility efforts to meet those needs?<BR/>3. What are the specific services the new facility will provide to meet the needs of the resident<BR/>which cannot be met at the current facility?<BR/>MD/NP/PA Signature:<BR/>Date:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after incident occurs or is suspected, to State Agency for 2 (Resident #1 and Resident #2) of 3 residents reviewed for reporting.<BR/>The facility did not report to State Agency Resident #1 and Resident #2 had an altercation on 03/02/23, which resulted in Resident #1 sustaining two skin tears and Resident #1 and #2 being taken to the hospital. Resident #1 was taken to the hospital to receive treatment for the sustained skin tear. Resident #2 was taken to the hospital for evaluation on his altered mental status. The facility reported the incident to State Agency on 03/08/23, six days after the altercation. <BR/>This failure could place residents at risk for having an incident go unreported and uninvestigated.<BR/>Findings included: <BR/>An MDS dated [DATE] indicated Resident #1's BIMS summary score was 5, did not present any behavioral fluctuations, and required supervision or limited assistance with his activities of daily living. <BR/>A care plan dated 03/10/23 indicated Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, depression, difficulty making decisions, impaired decision-making, psychotropic drug use, and short-term memory loss. Interventions included: Provide the resident with a homelike environment, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, use task segmentation to support short term memory deficits, administer medications as ordered, and engage the resident in simple, structured activities that avoid overly demanding<BR/>tasks. The care plan also indicated Resident #1 was at risk for impaired skin integrity related to decreased mobility, dry skin, impaired circulation, and impaired sensation. Resident #1 had actual skin tear to his left forearm on 11/11/22. <BR/>A Medical Diagnosis List dated 04/05/23 indicated Resident #1 was [AGE] years old with diagnoses that included dementia, unsteadiness on feet, adjustment disorder with mixed anxiety and depressed mood, and psychotic disorder with delusions due to known physiological condition. <BR/>A Clinical Resident List dated 04/05/23 indicated Resident #1 was admitted on [DATE].<BR/>A Medical Diagnosis List dated 04/05/23 indicated Resident #2 was [AGE] years old with diagnoses that included kidney failure, dementia, psychotic disorder with delusions due to known physiological condition, and dementia with agitation. <BR/>A Clinical Resident List dated 04/05/23 indicated Resident #2 was admitted on [DATE].<BR/>An MDS dated [DATE] indicated Resident #2's BIMS summary score was 8, presented behavioral fluctuations with disorganized thinking, wandered, and required supervision or limited assistance with his activities of daily living. <BR/>A care plan dated 03/03/23 indicated Resident #2 used psychotropic medications related to behavior. The care plan also indicated Resident #2 had aggressive behavior management related to his dementia on 02/04/23, yelled at another resident on 02/09/23, and hit on doors pulling on exit doors on 02/12/23. The care plan indicated Resident #2 was an elopement risk/wanderer. The care plan also indicated Resident #2 wandered all throughout the facility on 01/08/22 and wandered on 02/09/23, 02/10/23, 02/12/23.<BR/>During an interview on 04/05/23 at 10:00 am, LVN A said she witnessed and intervened when Residents #1 and #2 had an altercation on 03/02/23. LVN A said staff notified the facility's nursing station, the SW, the ADM, Resident #1 and #2's families, and law enforcement about the incident on 03/02/23. LVN A said the ADM was the abuse coordinator. <BR/>During an interview on 04/05/23 at 10:14 am, the DON said Residents #1 and #2 had an altercation on 03/02/23. The DON said staff notified the facility's nursing station, the SW, the ADM, Resident #1 and #2's families, and law enforcement about the incident on 03/02/23 The DON said the ADM was the abuse coordinator. <BR/>The Provider Investigation Report indicated Resident #1 and #2's incident occurred on 03/02/23 at 6:50 am and was reported to State Agency on 03/08/23 at 12:39 pm. The cover sheet was addressed to State Agency's Complaint and Incident Intake. <BR/>The Incident Report dated 03/02/23, written by LVN A, indicated Resident #2's NP, RP, SW, the ADM, law enforcement, and EMS was notified. The ADM was notified about the incident on 03/02/23 at 8:37 am. <BR/>The Incident Report dated 03/02/23 indicated Resident #1's NP and RP was notified. <BR/>The falls investigation worksheet dated 03/02/23 indicated Resident #1 was pushed from behind by Resident #2.<BR/>The Accident/Incident Report dated 03/02/23 indicated Resident #1's NP and RP was notified. The report also indicated Resident #1 was taken to the hospital to receive treatment for his sustained skin tears on his right elbow and left forearm. <BR/>During an interview on 04/05/23 at 4:03 pm, the ADM said he was the abuse coordinator and responsible for submitting the provider investigation report to State Agency. The ADM said he prepared the provider investigation report on 03/02/23. The ADM said he forgot to submit the provider investigation report to State Agency. The ADM said he realized he forgot to submit the provider investigation report to State Agency and submitted it on 03/08/23. The ADM said he would provide a policy and procedure for reporting abuse to State Agency. The ADM provided a copy of the Long-Term Care Regulatory Provider Letter dated 07/10/19 as a policy and procedure for reporting abuse to State Agency.<BR/>The Long-Term Care Regulatory Provider Letter dated 07/10/19 indicated, A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A missing resident, Misappropriation, Drug theft, Suspicious injuries of unknown source, Fire, and Emergency situations that pose a threat to resident health and safety. The letter also indicated abuse (with or without serious bodily injury) must be reported immediately, but not later than two hours after the incident occurs or is suspected. <BR/>An in-service dated 02/20/23, titled Abuse and Neglect, Misconduct, Misappropriation of Funds indicated 21 staff members were in-serviced on the policy. <BR/>An in-service dated 03/02/23, titled Abuse, Neglect, Exploitation, and Misappropriation indicated 23 staff members were in-serviced on the policy. One of the trainers/educators was the ADM. <BR/>An in-service dated 03/02/23, titled, Communicating with POAs/RPs indicated 24 staff members were in-serviced on the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after incident occurs or is suspected, to State Agency for 2 (Resident #1 and Resident #2) of 3 residents reviewed for reporting.<BR/>The facility did not report to State Agency Resident #1 and Resident #2 had an altercation on 03/02/23, which resulted in Resident #1 sustaining two skin tears and Resident #1 and #2 being taken to the hospital. Resident #1 was taken to the hospital to receive treatment for the sustained skin tear. Resident #2 was taken to the hospital for evaluation on his altered mental status. The facility reported the incident to State Agency on 03/08/23, six days after the altercation. <BR/>This failure could place residents at risk for having an incident go unreported and uninvestigated.<BR/>Findings included: <BR/>An MDS dated [DATE] indicated Resident #1's BIMS summary score was 5, did not present any behavioral fluctuations, and required supervision or limited assistance with his activities of daily living. <BR/>A care plan dated 03/10/23 indicated Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, depression, difficulty making decisions, impaired decision-making, psychotropic drug use, and short-term memory loss. Interventions included: Provide the resident with a homelike environment, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, use task segmentation to support short term memory deficits, administer medications as ordered, and engage the resident in simple, structured activities that avoid overly demanding<BR/>tasks. The care plan also indicated Resident #1 was at risk for impaired skin integrity related to decreased mobility, dry skin, impaired circulation, and impaired sensation. Resident #1 had actual skin tear to his left forearm on 11/11/22. <BR/>A Medical Diagnosis List dated 04/05/23 indicated Resident #1 was [AGE] years old with diagnoses that included dementia, unsteadiness on feet, adjustment disorder with mixed anxiety and depressed mood, and psychotic disorder with delusions due to known physiological condition. <BR/>A Clinical Resident List dated 04/05/23 indicated Resident #1 was admitted on [DATE].<BR/>A Medical Diagnosis List dated 04/05/23 indicated Resident #2 was [AGE] years old with diagnoses that included kidney failure, dementia, psychotic disorder with delusions due to known physiological condition, and dementia with agitation. <BR/>A Clinical Resident List dated 04/05/23 indicated Resident #2 was admitted on [DATE].<BR/>An MDS dated [DATE] indicated Resident #2's BIMS summary score was 8, presented behavioral fluctuations with disorganized thinking, wandered, and required supervision or limited assistance with his activities of daily living. <BR/>A care plan dated 03/03/23 indicated Resident #2 used psychotropic medications related to behavior. The care plan also indicated Resident #2 had aggressive behavior management related to his dementia on 02/04/23, yelled at another resident on 02/09/23, and hit on doors pulling on exit doors on 02/12/23. The care plan indicated Resident #2 was an elopement risk/wanderer. The care plan also indicated Resident #2 wandered all throughout the facility on 01/08/22 and wandered on 02/09/23, 02/10/23, 02/12/23.<BR/>During an interview on 04/05/23 at 10:00 am, LVN A said she witnessed and intervened when Residents #1 and #2 had an altercation on 03/02/23. LVN A said staff notified the facility's nursing station, the SW, the ADM, Resident #1 and #2's families, and law enforcement about the incident on 03/02/23. LVN A said the ADM was the abuse coordinator. <BR/>During an interview on 04/05/23 at 10:14 am, the DON said Residents #1 and #2 had an altercation on 03/02/23. The DON said staff notified the facility's nursing station, the SW, the ADM, Resident #1 and #2's families, and law enforcement about the incident on 03/02/23 The DON said the ADM was the abuse coordinator. <BR/>The Provider Investigation Report indicated Resident #1 and #2's incident occurred on 03/02/23 at 6:50 am and was reported to State Agency on 03/08/23 at 12:39 pm. The cover sheet was addressed to State Agency's Complaint and Incident Intake. <BR/>The Incident Report dated 03/02/23, written by LVN A, indicated Resident #2's NP, RP, SW, the ADM, law enforcement, and EMS was notified. The ADM was notified about the incident on 03/02/23 at 8:37 am. <BR/>The Incident Report dated 03/02/23 indicated Resident #1's NP and RP was notified. <BR/>The falls investigation worksheet dated 03/02/23 indicated Resident #1 was pushed from behind by Resident #2.<BR/>The Accident/Incident Report dated 03/02/23 indicated Resident #1's NP and RP was notified. The report also indicated Resident #1 was taken to the hospital to receive treatment for his sustained skin tears on his right elbow and left forearm. <BR/>During an interview on 04/05/23 at 4:03 pm, the ADM said he was the abuse coordinator and responsible for submitting the provider investigation report to State Agency. The ADM said he prepared the provider investigation report on 03/02/23. The ADM said he forgot to submit the provider investigation report to State Agency. The ADM said he realized he forgot to submit the provider investigation report to State Agency and submitted it on 03/08/23. The ADM said he would provide a policy and procedure for reporting abuse to State Agency. The ADM provided a copy of the Long-Term Care Regulatory Provider Letter dated 07/10/19 as a policy and procedure for reporting abuse to State Agency.<BR/>The Long-Term Care Regulatory Provider Letter dated 07/10/19 indicated, A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A missing resident, Misappropriation, Drug theft, Suspicious injuries of unknown source, Fire, and Emergency situations that pose a threat to resident health and safety. The letter also indicated abuse (with or without serious bodily injury) must be reported immediately, but not later than two hours after the incident occurs or is suspected. <BR/>An in-service dated 02/20/23, titled Abuse and Neglect, Misconduct, Misappropriation of Funds indicated 21 staff members were in-serviced on the policy. <BR/>An in-service dated 03/02/23, titled Abuse, Neglect, Exploitation, and Misappropriation indicated 23 staff members were in-serviced on the policy. One of the trainers/educators was the ADM. <BR/>An in-service dated 03/02/23, titled, Communicating with POAs/RPs indicated 24 staff members were in-serviced on the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the 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 6 of 16 residents (Residents #7, #8, #15, #17, #49, and #56) reviewed for care plans.<BR/>1. The facility failed to ensure Resident #7's bowel incontinence was reflected in her care plan.<BR/>2. The facility failed to ensure Resident #8's need for assistance with her activities of daily living was developed in her care plan.<BR/>3. The facility failed to ensure Resident #15's pain was reflected in his care plan. <BR/>4. The facility failed to ensure Resident #17's need for TED Hose was reflected in her care plan.<BR/>5. The facility failed to ensure Resident #49's Hospice service and bowel and bladder incontinence were reflected in her care plan.<BR/>6. The facility failed to ensure Resident #56's need for assistance with toileting was reflected in his care plan. <BR/>These deficient practices could place residents at risk of not receiving proper care and services.<BR/>The findings included:<BR/>1. Record review of Resident #7's electronic face sheet dated 02/06/2024 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting right dominant side, depression (a common mental disorder .It involves a depressed mood or loss of pleasure or interest in activities for a long period of time) and pain (physical suffering or discomfort caused by illness or injury).<BR/>Record review of Resident #7's quarterly MDS assessment with an ARD of 01/04/2024 reflected she scored an 8/15 on her BIMS which signified she was moderately cognitively impaired. She had functional limitation in range of motion .Impairment on one side .Upper extremity (shoulder, elbow, wrist, and hand) and Lower extremity (hip, knee, ankle, and foot). She was always incontinent of bowel and bladder.<BR/>Record review of Resident #7's comprehensive care plan revised on 06/08/2023 reflected Focus .has bladder incontinence r/t impaired mobility. No bowel incontinence was noted in the care plan.<BR/>Observation on 02/09/2024 at 10:15 am of Resident #7 as she received wound care to her right buttock revealed she wore an incontinent brief.<BR/>Interview on 02/08/2024 at 09:46 am with Resident #7, she stated she was incontinent of both bowel and bladder.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #7's unit, she stated Resident #7 was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #7's bowel status should have been in her care plan because it was an important part of her care, and it could be missed.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans need to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>2. Record review of Resident #8's face sheet, dated 02/08/2024, revealed Resident #8 was admitted to the facility on [DATE] with an original admission date of 08/19/2019 with diagnoses which included: metabolic encephalopathy, muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, cognitive communication deficit, unspecified abnormalities of gait and mobility, need for assistance with personal care, bilateral primary osteoarthritis of knee, and cerebral infarction unspecified.<BR/>Record review of Resident #8's Annual MDS assessment, dated 12/23/2023, revealed the resident's BIMS score was 10, which indicated moderate cognitive impairment. The resident's functional abilities required partial assistance from another person to complete any activities regarding self-care. Annual MDS assessment further revealed Resident #8 was dependent (helper does all of the effort resident does none) for toileting, needing substantial/maximal assistance (helper does more than half the effort) for showers, lower body dressing and putting on footwear, partial/moderate assistance (helpers does less than half the effort. Helper lift, lifts holds, or supports trunk or limbs) for upper body dressing.<BR/>Record review of Resident #8's care plan, revision date 01/10/2024 did not reflect her need for assistance in activities of daily living such as toileting, showers, lower body dressing, putting on footwear and upper body dressing.<BR/>During an interview on 02/09/2024 at 2:42 p.m. with the Regional Compliance Nurse she stated there was not an ADL (activities of daily living) care plan for Resident #8. The Regional Compliance Nurse further stated the ADL care plan was used to identify the residents need and would be reflected on the CNAs care plan so the CNAs would know what care to provide. The Regional Compliance Nurse stated the MDS Coordinator was responsible for updating the care plans while nursing would update with acute care plans. She further stated incorrect care could be provided without an accurate care plan. <BR/>3. Record review of Resident #15's face sheet, dated 02/07/2024, revealed Resident #15 was admitted to the facility on [DATE] with an original admission date of 08/07/2023 with diagnoses which included: postprocedural intestinal obstruction, unspecified as to partial versus complete, encounter for surgical aftercare following surgery on the digestive system, spastic quadriplegic cerebral palsy, muscle wasting and atrophy, pain in right shoulder, restless legs syndrome, incisional hernia with obstruction, without gangrene, and epilepsy, unspecified not intractable, without status epilepticus. <BR/>Record review of Resident #15's admission MDS assessment, dated 12/11/2023, revealed the resident's BIMS score was 15, which indicated intact cognition. The resident received scheduled pain medication with a pain assessment interview conducted on the admission MDS assessment revealed the resident had reported pain presence with the frequency being occasionally and occasionally affecting resident's sleep. <BR/>Record review of Resident #15's physician order summary, dated 02/07/2024 revealed an order dated 12/05/2023 with the start date of 12/05/2023 for Oxycodone-Acetaminophen oral table 5-325 MG give 1 tablet by mouth every 6 hours as needed for pain. Physician order summary further revealed order dated 12/28/2023 with the start date of 12/28/2023 for Oxycodone HCI oral tablet 5 MG give 1 tablet by mouth two times a day for pain and an order for Oxycodone-Acetaminophen oral tablet 5-325 MG give 1 tablet by mouth two times a day for pain. <BR/>Record review of Resident #15's care plan revision date, 12/28/2023 did not reflect his need for pain medication or how to assist him with pain relief. <BR/>During an interview on 02/09/2024 at 10:50 a.m. Resident #15 stated his pain could be bad sometimes. Resident #15 stated he received pain medications which helped with the pain and was receiving therapy services which also seemed to help. Resident #15 stated he had been experiencing the increase in pain since his surgery months ago and he was also being seen by a pain specialist. <BR/>During an interview on 02/09/2024 at 2:53 p.m. with the Regional Compliance Nurse she revealed pain was triggered for Resident #15's care plan but had not been activated on the care plan in PCC where it would show on the care plan. The Regional Compliance Nurse stated incorrect care could be provided without an accurate care plan.<BR/>4. Record review of Resident #17's electronic face sheet, dated 02/06/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke, lack of oxygen to brain) affecting left non-dominant side, Alzheimer's Disease (the most common type of dementia. A progressive disease beginning with mild memory loss and possibility leading to loss of the ability to carry on a conversation and respond to the environment), chronic diastolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly) and depression (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for a long period of time).<BR/>Record review of Resident #17's quarterly MDS assessment with an ARD of 12/18/2023 reflected she scored an 11/15 on her BIMS which signified she was moderately cognitively impaired. She was noted to have an active diagnosis of heart failure.<BR/>Record review of Resident #17's comprehensive person-centered care plan revised date 11/16/2023 reflected Focus .has congestive heart failure .Interventions .monitor and report dependent edema of legs and feet.<BR/>Record review of Resident #17's Active Orders as of: 02/06/2024 reflected Apply TED hose to bilateral lower extremities daily in the morning and remove at bedtime two times a day for edema TED HOSE TO BLE: PUT ON IN THE MORNING AND TAKE OFF AT BEDTIME Active 06/23/2023.<BR/>Record review of Resident #17's MAR dated 02/01/2024 to 02/29/2024 reflected she had the TED hose applied to her bilateral lower extremities daily in the morning and removed at bedtime for edema.<BR/>Observation on 02/06/2024 of Resident #17 revealed she was sitting in her room in her wheelchair and had TED hose on both lower legs. <BR/>Interview on 02/08/2024 with Resident #17, she stated she had the TED hose applied to her lower legs twice a day because her legs swell.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #17's unit, she stated Resident #17 had TED hose applied to her lower legs twice a day because of swelling, and that was part of her care.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #17, he stated Resident #17 had TED hose applied to her bilateral lower legs every day.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #17's TED hose should have been in her care plan because it was an important part of her care, and it could be missed.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans needed to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>5. Record review of Resident #49's electronic face sheet dated 02/08/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Spastic quadriplegic cerebral palsy (a severe type that is characterized by paralysis of both arms and both legs, with muscle stiffness), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition), unspecified intellectual disabilities (impairment of intelligence) and dysphagia (difficulty swallowing).<BR/>Record review of Resident #49's quarterly MDS assessment with an ARD of 01/08/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She was always incontinent of bowel and bladder and was on Hospice services.<BR/>Record review of Resident #49's comprehensive person-centered care plan revised 12/09/2023 did not reflect she was incontinent of bowel and bladder. Resident #49's care plan did not reflect her Hospice services.<BR/>Record review of Resident #49's Active Orders as of: 02/08/2024 reflected she was admitted to Hospice services on 10/25/2023.<BR/>Interview on 02/09/2024 at 11:41 am with LVN A who was the charge nurse for Resident #49's unit, she stated Resident #49 was on Hospice, and was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 1:14 pm with CNA B who collaborated with Resident #49, he stated Resident #49 was always incontinent of bowel and bladder.<BR/>Interview on 02/09/2024 at 2:12 pm with the Regional Compliance Nurse, she stated Resident #49's bowel and bladder status and Hospice services needed to be in the plan of care. She stated care provided could be missed without it noted in the care plan.<BR/>Interview on 02/09/2024 at 3:23 pm with the DON, she stated the residents care plans needed to reflect the care required by the patient, and it could be missed or wrong if not included in the care plan.<BR/>6. Record review of Resident #56's face sheet, dated 02/08/2024, revealed Resident #56 was admitted to the facility on [DATE] with an original admission date of 03/05/2023 with diagnoses which included: muscle wasting and atrophy, not elsewhere classified, multiple sites, end stage renal disease, unspecified viral hepatitis C without hepatic coma, gout, unspecified, hypothyroidism, and pain unspecified. <BR/>Record review of Resident #56's Optional State MDS assessment, dated 12/22/2023, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. The resident required extensive assistance (staff provide weight bearing support) with two person's physical assistance for toilet use.<BR/>Record review of Resident #56's care plan revision date, 11/13/2023 did not reflect his need for assistance with toilet use.<BR/>During an interview on 02/09/2024 at 2:46 p.m. with the Regional Compliance Nurse, she stated she did not see a care plan for Resident #56's toileting. The Regional Compliance Nurse further stated the MDS coordinator, and the IDT were responsible for the care plans.<BR/>During an interview on 02/09/2024 at 3:19 p.m. the DON stated the nurses, charge nurses, ADON, and DON were responsible for the acute care plans such as changes in conditions, [NAME], and changes in treatments. The DON further stated the MDS coordinator would be responsible for the comprehensive care plans, however the facility had just hired someone to replace the prior MDS coordinator. <BR/>Record review of the facility's undated policy and procedure titled Comprehensive Care Planning revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .Each resident will have a person-centered comprehensive care plan developed and implement to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible for one (Resident #1) of 82 residents. <BR/>The facility failed to provide an environment free from accidents and hazards over which the facility had control and provided supervision to prevent avoidable accidents. On 02/18/2023, Resident #1 was able to elope from the facility using the 200-hallway emergency alarmed exit door. The 200-hallway door was used temporarily as the facility main entrance and exit from 02/04/2023 until 03/01/2023. After seeing Resident #1's wheelchair empty outside of the 200-hallway exit door, facility staff began looking for Resident #1 within the facility. When he was not located immediately, facility elopement procedures were followed. Approximately 12 hours later the resident telephoned his family member, who called the facility and informed them of Resident #1's location. According to wuweatherunderground (https://www.wunderground.com/history/daily/[NAME]/date/2023-2-18) the weather was as follows: High temperature - 55, Low temperature - 26, Average temperature - 41.88, Precipitation zero. The facility is in a high traffic area with a speed limit on of 45 miles per hour on street where the facility is located. Observation of street directly in front of the 200-hallway exit exhibited very high traffic with two-way lanes with a median separating the lanes. Resident #1 was retrieved by facility staff nurse at a location 5.13 driving miles away from the facility, was returned to the facility, was assessed, and found to have no injuries. <BR/>An IJ was identified on 3/9/2023. The IJ began on 2/18/2023 and removed on 2/18/2023. The facility took action to remove the IJ before the survey began. While the IJ was removed on 2/18/2023, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on elopement policies, in-services on exit seeking behaviors, and conduct a QAPI had not been conducted regarding the elopement incident. While the front door had been fixed the facility failed to retrain staff on elopement policies, in-services on exit seeking behaviors, and failed to conduct a QAPI regarding the elopement incident. <BR/>This deficient practice could place residents at risk for serious injury, serious harm, serious impairment, or death likely.<BR/>Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible. <BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, undated, revealed a [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis of schizophrenia, (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), unspecified. Unstable burst fracture (an injury in which the vertebra, the primary bone of the spine, breaks in multiple directions) of first lumbar vertebra (a bones forming the backbone, level with the anterior end of the ninth rib) subsequent encounter for fracture with routine healing. <BR/>Review of Resident #1's Care Plan, initiated 01/27/2023, revealed Resident #1 exhibited impaired social interaction, hallucinations (an experience involving the perception of something not present) and disturbed through process (altered understanding of situations) and cognition (the process of acquiring knowledge) that interfered with daily living. The care plan revealed he was, .at risk for elopement r/t (related to) able to ambulate/locomotion per self, desire to go home, exit seeking behaviors. The care plan revealed he demonstrated manipulative, destructive, insensitive, and disrespectful behavior. <BR/>Review of Resident #1's Elopement Risk Assessment, dated 01/27/2023, revealed a score of 23. The Risk Assessment evaluation scale revealed a score of 5 or more is considered to be a risk for elopement. <BR/>Review of Resident #1s Minimum Data Set (MDS) dated [DATE] revealed serious mental illness and a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Review of local Police Department accident data sheet dated 02/04/2023 revealed a car collided into the portico (a structure consisting of a roof supported by columns at regular intervals, typically attached as a porch to a building) of the main entrance of the nursing home. <BR/>Interview on 03/07/2023 at 9:50 AM with ADMIN revealed at the accident occurred at approximately 7:30 PM on 02/04/2023 and Resident #1 was missing for approximately 12 hours on 02/18/2023. <BR/>Interview on 03/08/2023 at 12:46 PM with the RDBO revealed when he arrived at the facility on the date of the collision the fire department was taping off the front entrance with caution tape and told him the regular entrance to the facility could not be used because safety concerns of structural damage. The RDBO revealed a decision was made to use the 200-hallway door for the entrance/exit. The RDBO revealed he was not concerned about using 200-hallway door because he installed a new Safety Technology International Exit Door Alarm: Key Lock. The RDBO revealed to disarm the 200-hallway exit door, a key was inserted at the bottom front of the box (the keyhole was clearly visible) and turned horizontally to turn off the alarm to allow people to enter and exit the facility and to arm the door, the key was inserted and turned vertically. <BR/>Observation on 03/07/2023 at 12:46 PM of the 200 Exit Alarm Key Lock revealed a visible to all viewers easy to follow diagram on in the alarm key lock that displayed the instructions on how to activate and deactivate the alarm on the 200-hallway. <BR/>Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed that beginning 02/06/2023 the receptionist, who worked 7:00 AM until 4:00 PM Monday - Friday was given the responsibility to let people in and out of the facility and to use the alarm key to arm and disarm the door. When the receptionist was not at the facility the AA, HA, or charge nurse for the 200-hallway were responsible for letting people in and out of the building with the alarm key and arming and disarming the door. <BR/>Interview on 03/07/2023 at 12:26 PM with the receptionist who explained she first saw the damage to the entry on Monday 02/06/2023. She said it was appeared that they absolutely could not go through the front door because it was cautioned off with tape. She explained there was a sign and arrows directing people enter using the 200-hallway door. After about a day and a half she moved her desk to the room across from the 200-hallway door. The facility had installed a doorbell and when someone would ring the bell, she would use the key to disarm the door and when they exited, she would use the key to arm the alarm. She revealed she kept the key in her pocket. Receptionist revealed that the key to the alarm that she used for the 200-hallway when the front door was not working with the administrator. The receptionist reported when she left for the day, she physically handed the key for the 200-hallway alarm to the evening a charge nurse or the administrator. <BR/>Observation on 03/07/2023 at 9:30 AM revealed facility front door fully functioning, and employee came to the front door and used keypad to allow access to the facility. No observations of residents approaching the front door or attempting to use the keypad. Nursing station and reception desk in clear view of front door with no obstruction of front door alarm and keypad. <BR/>Interview on 03/09/2023 at 3:23 PM with LVN A who worked PRN (as needed) revealed that when she worked on the 200-hallway during the time the front entrance was not being used, she kept the alarm key with her and did not leave the key in the keyhole. <BR/>Observation and interview on 03/08/2023 at 12:46 PM with the RDBO revealed small nail sized hole in the wall to the right of the nurse's station. The RDBO revealed the evening of 02/04/2023 he put a nail in the wall where the small hole was observed and put a, big red keyring holding the 200-hallway exit door disarm key on the nail. The RDBO said he put the key there so it would be easily accessible to the staff to let people in and out of the facility.<BR/>Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed he was unaware the RDBO had put the key that armed and disarmed the entry and exit to the 200-hallway on a key ring next to the nurse's station visible to residents.<BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed it took a long time to get the front door fixed and if any of staff heard the doorbell ring, they would let them in. At the beginning only the nurses had the alarm key but, it started to get too much and eventually the key was left in the emergency alarm. <BR/>Interview on 03/09/23 at 12:30 PM with the MD revealed that at some point the key was left in the keyhole of the 200-hallway because staff would get frustrated. <BR/>Interview on 03/09/2023 at 4:08 PM with R#2 in room [ROOM NUMBER]A located at the end of the 200-hallyway next to the exit door indicated he observed the key left in the alarm several times. <BR/>Review of in-service entitled Topic: Complete Visual Check on the 200 Hall Doors dated 02/04/2023 with trainer/education by the ADON. <BR/>Interview on 03/07/2023 at 12:26 PM the receptionist revealed Resident#1 vigilantly watched her letting people in and out of the 200-hallway door. She revealed Resident# 1 watched her for one full day. The receptionist did not tell the ADMIN, the DON, or the ADON about Resident#1 watching the door. When the receptionist asked if she felt Resident #1 was exit seeing the receptionist relayed, oh yea, he was exit seeking. She revealed that she kept the key in the desk draw of the room located across from the 200-hallway door. The receptionist revealed she was always in the room across the when she was working.<BR/>Interview on 03/09/2023 at 12:35 PM the receptionist revealed she told the SW Resident #1 was very intelligent and was watching her when she was letting people in and out of the 200-hallway door. <BR/>Interview on 03/07/2023 at 9:50 AM the ADMIN revealed that Resident #1 was exit seeking. <BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed Resident #1 was clearly exit seeking and he would punch the numbers on the 400-hallway exit door keypad and she would tell him, get back over here. She revealed Resident #1 was very smart and paid attention and was going down the 200-hallway paying attention, too much. CNA A revealed she told the ADON, all the time that he was punching in number on the keypad. <BR/>Interview on 03/07/2023 at 5:25 PM with ADMIN revealed that because the WanderGuard was not working it affected how the staff kept eyes on the residents and revealed that because of the possible harm to the resident the facility increased staffing and visual checks of the residents and conducted elopement drills. The ADMIN revealed he was pushing for corporate to fix the door. <BR/>Interview on 03/07/2023 at 9:50 PM the ADMIN revealed that Resident #1's room was on the 400- hallway but he walked around everywhere - sometimes he used his wheelchair and sometimes he did not. <BR/>Interview on 03/07/2023 at 1:25 PM with LVN B, the 200-hallwy nurse on 02/18/2023, and she works the 6:00 AM to 6:00 PM shift. She revealed she remembered him talking to her and he was unintelligible, and she was busy passing out medications and did not notice where he went or what time she spoke with him. She discovered Resident #1 was missing when the facility began elopement protocols. <BR/>Interview on 03/08/2023 at 9:42 AM with CNA A revealed on 02/18/2023 at 7:15 AM she saw Resident #1's wheelchair, empty, outside of the emergency exit door of the 200-hallway and went to go look for him in his room on the 400-hallway. When CNA did not find him in his room, she located his nurse RN A and asked if RN A had seen him. RN A said she had not seen him. CNA A revealed that they began searching for Resident #1 both in and outside the facility. <BR/>Interview on 03/07/2023 at 9:50 AM with the ADMIN revealed that on 02/18/2023 at about 7:45 AM he received a call from RN A that Resident #1 could not be located in or around the facility and the ADMIN instructed RN A to initiate elopement protocols. The ADMIN revealed RN A told him she called the police and informed police about a missing resident, but RN A said the police.<BR/>Interview on 03/07/2023 at 9:50 AM with the ADON revealed that Resident #1 was retrieved by her at approximately 8:00 PM on 02/18/2023 from a CVS and the ADON returned with him to the facility. <BR/>Review of Resident #1's progress notes dated 02/19/2023 reveal that at approximately 8:00 PM on 02/18/2023 the ADON completed a bedside assessment revealing normal blood pressure and temperature with zero signs of distress or pain noted and zero skin issues noted. Resident was discharged Against Medical Advice on 02/18/2023. <BR/>Review of Resident #1's face sheet dated 03/08/2023 revealed under the area of contacts it read, responsible party - self. <BR/>Interview on 03/07/2023 at 9:50 the ADMIN revealed the front entrance was the most secure entrance and exit to the facility because it was visible from the nurse's station, visible from the receptionist area, and visual from the ADMIN office. Additionally, it had a secure keypad, and alarm, and is wired for WanderGuard (a device worn on the wrist or ankle to trigger alarms and prevent wander-prone residents from leaving unattended). <BR/>Review of Resident #1's order summary report dated 03/09/2023 reveals an order in place to check WanderGuard placement and function every shift beginning 02/15/2023.<BR/>Interview on 03/07/2023 at 9:50 AM of ADMIN revealed the front entrance of the building was not being used because of the collision from 02/04/2023 until 03/01/2023. The ADMIN revealed that he did not have the authority to make a financial decision regarding making building repairs to the facility. He revealed that on 02/04/2023 the CEO phoned him and said that he wanted to go through the insurance company of the owner of the car who collided with the building because it would increase the premium cost of the facility insurance if they used the facility insurance. <BR/>Interview on 03/09/2023 at 1:00 PM with the COO revealed the facility was waiting on the insurance company of owner of the car who caused the damage to the front of the facility to appraise the damage and make payment for the damages before making repairs to the main entrance. <BR/>Review of estimate from construction company dated 02/07/2023 reveals that the repair cost to the front entrance portico was $7,500. <BR/>Review of email from the facility owner to the facility CFO and ADMIN dated 02/27/2023 stating, we cant wait on insurance to cover this. It's a hazard to residents. We will have to get reimbursed from the insurance company.<BR/>Interview on 03/07/2023 at 1:26 PM with the FMD revealed that the facility was waiting for an estimate from the car insurance company of the owner of the car who caused the damages before they made the repairs. He constantly called the insurance company to make sure they were going to pay for it and the insurance company was non-responsive. He revealed that he told that to the insurance company that it was a safety concern. He revealed that the work to repair the front entry began on Monday 02/27/2023 and ended on 03/01/2023. <BR/>Review of facility Inservice Elopement Drill dated 02/17/2023, 02/19/2023, 02/19/2023, 02/22/2023.<BR/>Review of the facility's Elopement and Wandering policy revised December 2007 reveals:<BR/>1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement).<BR/>2. The staff will assess at risk individuals for pension initially correctable risk factors related to unsafe wandering<BR/>3. The resident care plan will indicate the resident is at risk for elopement or other safety issues interventions to try to maintain safety will be included in the resident care plan.<BR/>4. Nursing staff will document circumstances related to unsafe actions, including wandering, by resident. <BR/>5. Staff will institute a detailed monitoring plan, is indicated for residents who are assessed to have a high risk of allotment for other unsafe behavior.<BR/>6. Staff will notify the administrator and director of nursing's immediately and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.<BR/>Facility was notified on 03/09/2023 at 5:10 PM that an IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 02/18/2023.<BR/>The facility implemented the following interventions: On 03/04/2023 repairs were completed on the portico of the main front entry door equipped with a keypad entry and exit, WanderGuard Alarm, fire alarm, and visibility of residents from the nurse's station, receptionist, and ADMIN's office. After the completion of the front entry repairs neither the 200-hallways door or any other facility emergency exit doors were opened and closed using a key to alarm and disarm doors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for one (Resident #76) of eight residents reviewed for dignity. <BR/>CNA A referred to Resident #76 as a feeder.<BR/>This failure placed residents at risk of not being treated with dignity.<BR/>Findings included: <BR/>A record review of Resident #76's face sheet dated 1/11/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (language disorder), hyperlipidemia (high cholesterol), type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), chronic obstructive pulmonary disease (trouble breathing), and dysphagia (difficulty swallowing).<BR/>A record review of Resident #76's MDS assessment dated [DATE] reflected a BIMS was not conducted due to the resident rarely/never being understood. A review of Section G (Functional Status) reflected Resident #76 required extensive assistance and a one person physical assist with eating.<BR/>A record review of Resident #76's care plan last revised on 12/24/2022 reflected she had ADL self-care deficit related to general weakness and hemiparesis/hemiplegia. Resident #76's interventions reflected she needed assistance with ADLs as needed. <BR/>An observation of meal service on 1/10/2023 at 12:15 p.m. revealed CNA A referred to Resident #76 as a feeder when she asked another staff member, is Resident #76 a feeder?<BR/>During an interview and observation on 1/10/2023 at 12:16 p.m., Resident #76 was observed sitting in the dining room. Resident #76 was non-interviewable. <BR/>During an interview on 1/10/2023 at 1:38 p.m., when asked how she referred to residents that needed help with eating, CNA A asked, you mean the feeders? CNA A stated a resident who needed help eating was called a feeder and she learned that term about 25 years ago. CNA A stated she did not know whether there was another way to say it. When asked how she thought referring to residents as feeders would make them feel, CNA A stated, I guess it depends on who you're dealing with. <BR/>During an interview on 1/12/2023 at 5:23 p.m., when asked what the facility's policy was on treating resident with dignity, the DON stated, we in-service our staff on treating them with dignity. The DON stated, we train staff to refer to residents as residents who need assistance with feeding. When asked how staff should refer to residents who needed assistance with eating, the DON stated, we just say the resident needs assistance with eating. The DON stated no that residents should not be referred to as feeders. The DON stated perhaps staff might have thought that was the term years ago but things were changing in nursing. The DON stated, we make them aware that it's not the right term and resident rights is what we go by. When asked what a potential negative resident outcome was of referring to a resident as a feeder', the DON stated she could not say what negative outcome there would be but she said staff would be pulled and in-serviced immediately. <BR/>During an interview on 1/12/2023 at 6:13 p.m., the ADM stated no that staff should not refer to residents as feeders. The ADM stated no, it's not a dignified way to refer to a resident. The ADM stated feeder was a term staff were used to using for a long time, CMS made changes, and he would not blame staff. When asked if staff had been trained on those changes, the ADM stated no. When asked what a potential negative resident outcome of referring to a resident as a feeder could be, the ADM stated, I don't think it would have any effect.<BR/>A record review of the facility's policy titled Resident Rights dated August 2009 reflected the following:<BR/>Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation<BR/>2. Residents are entitled to exercise their rights and privileges to the fullest extent possible.<BR/>3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.<BR/>4. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee upon hire. Each employee has a duty to read and learn the residents' rights.<BR/>6. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.<BR/>7. Inquiries concerning residents' rights should be referred to the Social Services Director.<BR/>A record review of the facility's in-services from 2022 reflected no in-services on resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for 1 (Resident #79) of 6 residents reviewed for baseline care plans.<BR/>The facility failed to develop a baseline care plan for Resident #79 within the required 48-hour timeframe. <BR/>This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.<BR/>Findings included: <BR/>Resident #79<BR/>Review of Resident #79's face sheet dated 01/12/23 revealed Resident #79 was a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural brain disease), idiopathic epilepsy (group of seizure disorders that come about from abnormal electrical activity in the brain), schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis), and altered mental status (general changes in brain function, such as confusion, amnesia, memory loss, loss of alertness, disorientation, defects in judgement or thought, unusual or strange behavior, poor regulation of emotions, and disruption in perception, psychomotor skills, and behavior).<BR/>Review of the most recent MDS dated [DATE] reflected Resident #79 had a BIMS score of 15 indicating Resident #79 was cognitively intact and able to complete the interview.<BR/>Review of Resident #79's clinical record revealed a baseline care plan was not completed.<BR/>In an interview on 01/12/23 at 5:23 PM, the DON stated the charge nurse and other IDT members were responsible for completing baseline care plans. She stated the baseline care plans were in the electronic records. She stated baseline care plans should have been done within 24 hours of admission. She stated it is the facility policy that baseline care plans should be done for every resident that admitted to the facility. She stated if a resident does not have a baseline care plan done then she does not know what it could cause but that staff could refer to the hospital discharge orders and physician orders to care for Resident # 79. She stated she was not able to find a baseline care plan for Resident # 79 in the facility or in Resident # 79's electronic records. She stated staff had been in-serviced on completing preliminary/baseline care plans.<BR/>In an interview on 01/12/23 at 5:52 PM, the ADM stated the IDT was responsible for completing baseline care plans and parts of the IDT, such as the Social Worker, Dietary Manager, and Activities Director, completed a section also. He stated the IDT consists of nursing, dietary, social services, activities, and therapy. He stated baseline care plans should have been done within 24 hours of a resident admitting. He stated it was the facility policy that baseline care plans should be done for every resident that admitted to the facility. He stated if a resident did not have a baseline care plan done then it could have interrupted coordination of care. He stated he was not able to find a baseline care plan for Resident # 79 in the facility or in Resident # 79's electronic records. He stated staff had been in-serviced on completing preliminary/baseline care plans.<BR/>Review of facility policy titled: Care Plans - Preliminary dated 2001 (revised August 2006) reflected: Policy statement - A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. Policy interpretation and implementation - 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. 2. The Interdisciplinary Team will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatments, etc.), and implement a nursing care plan. 3. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan.<BR/>Review of facility in-servicing titled Staff Development/In-service dated 04/04/22 with Topic: admission Assessment reflected in Objectives: Complete all admission assessments. Please ensure the interim care plan is completed and signed by nurse and resident's responsible party (RP).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and support the physical, mental, and psychosocial well-being for 3 of 28 residents (Resident #22, Resident #35, Resident #71) reviewed for activities. <BR/>The facility failed to provide an activity program designed to meet Resident #22's, #35's or #71's interests or needs.<BR/>This deficient practice placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. <BR/>The findings included:<BR/>Review of Resident #22's Face Sheet dated 01/12/23 reflected, [AGE] year-old female admitted to the facility on [DATE] with diagnosis of hemiplegia (paralysis of one side of the body) due to cerebral infarction (stroke), diabetes mellitus, abdominal pain, HTN (high blood pressure), and hyperlipidemia (high cholesterol).<BR/>Review of Resident #22's MDS dated [DATE] reflected, a BIMS score of 12 indicating moderately impaired cognition. MDS reflected no assessment conducted for the section F (for activity). MDS section G for functional status reflected Resident #22 required extensive assistance for transfer and bed mobility. <BR/>Review of Resident #22's Care Plans dated 12/01/21 revealed there were no care plans for activities. <BR/>Observation and interview on 01/10/23 at 10:00AM, Resident #22 was in bed watching TV. Resident #22 stated she does not attend activity as she requires a lot of assistance from staff due to being hemiplegic (paralysis of one side of the body). Resident #22 stated she does not do any activity inside her room which is the reason why she watches TV only. Resident #22 stated no one asked her what activity she likes or offered any activities for her. There was no activity materials observed inside the resident's room. <BR/>Review of Resident #35's Face Sheet dated 01/12/23 reflected, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, HTN (high blood pressure), hyperlipidemia (high cholesterol), and diabetes.<BR/>Review of Resident #35's MDS dated [DATE] reflected, a BIMS score of 14 indicating no cognitive impairment. MDS reflected no assessment conducted for the section F (for activity).<BR/>Review of Resident #35's Care Plans dated 11/07/20 reflected, Resident #35 will be encouraged to participate in activities in her room/hall. Resident enjoys reading, crafting and socializing with her roommate with intervention of resident will be provided with necessary materials in order to participate in activities on a regular basis.<BR/>Interview on 01/11/23 at 10:00AM, Resident #35 stated most of the residents and herself would like to go to the library and use the computer and check out reading materials but that never happened with the facility. Resident #35 stated she would like to have more outside time and reported of having walked one time with therapy last year. Resident #35 stated she will attend activities held inside the facility that interest her. <BR/>Review of Resident #71's Face Sheet dated 01/12/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of age-related cognitive decline, fatigue (feeling of tiredness or weakness), and hypercholesterolemia. <BR/>Review of Resident #71's MDS dated [DATE] reflected, a BIMS score of 13 indicating no cognitive impairment. MDS reflected no assessment conducted for the section F (for activity).<BR/>Review of Resident #71's Care Plans dated 09/12/22 revealed there were no care plans for activities.<BR/>Interview on 01/10/23 at 10:26AM, Resident #71 stated activity staff had never given her anything and that they asked her to attend activities that she does not like. Resident #71 stated she needs materials to make her brain work such as puzzles, crosswords and activities does not know what her preferences are. Resident #71 stated she gets her own materials for activity. <BR/>Interview on 01/12/23 at 2:30PM, the AD stated she recently started her position in December 2022. The AD stated she was responsible to create a monthly activity calendar and had completed the December and January activity calendar. AD stated she does not do care plans for activities, and said they were done by the social worker. The AD stated she is in the process of getting to the residents and finding out what they like and dislike. The AD stated she has not seen residents going outside for activities. The AD stated the impact of residents not having activities could be separation from life and they could go into depression. <BR/>Interview on 01/12/23 at 3:35PM, the ADON stated there should be an activity care plan created by the activity director. The ADON stated there should be activities every day to keep the residents healthier and keep their mental status. The ADON stated not having activities could impact their ADL decline, and mental status causing depression. <BR/>Interview on 01/12/23 at 4:17PM, the SW stated each department head is responsible of creating their own care plans. The SW stated she is responsible of conducting care plan meetings. <BR/>Interview on 01/12/23 at 5:30PM, the DON stated she is not aware of not having activities on the weekends. The DON stated her expectation is what is on the facility policy.<BR/>Interview on 01/12/23 at 6:12PM, the ADM stated the facility used a website that has a template for monthly activity calendars which the facility can customize according to the facility needs. The ADM stated the AD is responsible to customize the calendar and create it. The ADM stated activities should be provided every day. The ADM stated he does not think anything major will happen from not providing activities to residents other than having them stay in their rooms all day. The ADM stated there should be a care plan for activities. The ADM stated the impact of not having activity care plans would be not knowing what resident's activity preferences were. <BR/>Review of facility's policy titled Activities and Social Services dated December 2006 reflected, Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. 4.As much as possible, the facility will help the individual arrange to reach these outside activities, but the facility may not necessarily provide the transportation. 7. Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents received proper treatment and care to maintain mobility and good foot health for one (Resident #16) of eight residents reviewed for nail care.<BR/>The facility failed to ensure Resident #16 received nail care. <BR/>The failure placed residents at risk of overgrown nails, poor hygiene, and infection.<BR/>Findings included:<BR/>A record review of Resident #16's face sheet dated 1/11/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes (uncontrolled blood sugar), anemia, unspecified dementia, hypertension (high blood pressure), lymphedema (tissue swelling), and xerosis cutis (dry skin). <BR/>A record review of Resident #16's MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. Section G (Functional Status) reflected Resident #16 required extensive assistance and a two+ persons physical assist with personal hygiene. <BR/>A record review of Resident #16's care plan last revised on 1/11/2023 reflected he had diabetes mellitus and an intervention initiated on 9/07/2022 reflected Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails.<BR/>A record review of Resident #16's physician orders reflected an order dated 8/26/2022 for may see podiatrist as needed. <BR/>A record review of the facility's Podiatry Authorization form dated 10/25/2022 reflected Resident #16's responsible party signed a consent form for Resident #16 to be evaluated and treated by the Podiatrist. <BR/>During an observation and interview on 1/11/2023 at 1:07 p.m., Resident #16's fingernails were observed to be long and overgrown. Resident #16 stated he had a fungus which made his nails hard to trim. Resident #16 stated it bothered him how long they were. Resident #16 stated he had not seen a podiatrist since he came to that facility. <BR/>During an interview on 1/12/2023 at 9:14 a.m., the SW stated the podiatrist came once a month and did everyone's nails.<BR/>During an observation and interview on 1/12/2023 at 2:30 p.m., the SW stated she sent signed consent forms via email to the Podiatrist. The SW stated if she had sent a consent form, it would be in her email. Observed the SW look through her sent emails around the time Resident #16's consent form was signed and she could not find the email. The SW stated she would look some more to verify whether she had sent the consent form to the podiatry group. <BR/>During an interview on 1/12/2023 at 2:53 p.m., the Podiatry Marketer stated she did not see Resident #16 in her system as a patient. The Podiatry Marketer stated they required a one-time consent form and a consent sheet, stating, it may be that we don't have their paperwork and we don't know about the resident.<BR/>During an interview on 1/12/2023 at 3:16 p.m., the Podiatry Logistics Manager stated Resident #16's last date of service was 7/07/2022 and that was at a different facility. The Podiatry Logistics Manager stated Resident #16 was discharged from that facility and we either weren't notified of him transitioning or we need to update our records. The Podiatry Logistics Manager stated Resident #16 had not been seen by the podiatrist since he was at the current facility. The Podiatry Logistics Manager stated they podiatry group did not have a consent form for Resident #16, and that the last consent form they had for him was from the previous facility he was at. <BR/>During an interview on 1/12/2023 at 3:48 p.m., CNA B stated Resident #16's fingernails had brown stuff underneath them, they looked too long, and they looked like they needed cut. <BR/>During an interview on 1/12/2023 at 3:58 p.m., the SW stated the Podiatrist did not have Resident #16's consent form and since they did not know he existed, they would not have been providing care. The SW stated, I think I just forgot to send it.<BR/>During an interview on 1/12/2023 at 5:23 p.m., the DON stated the facility's policy on providing nail care to diabetics was going to be according to the policy. The DON stated if residents were seen by the podiatrist, there was usually a reason. The DON stated with Resident #16, staff should not cut his nails. When asked if she had seen Resident #16's nails, the DON stated, we did an order for him to be seen by the podiatrist and that should be followed up with by the SW. When asked how often residents should be seen by the podiatrist, the DON stated, we do the referral as needed and it's going to be case by case. The DON stated the SW knew the frequency of visits. The DON stated she had not seen Resident #16's nails recently. When asked who monitored to ensure nail care was done, the DON stated nurses. The DON stated nails were monitored by nurses during weekly skin checks. When asked who ensured compliance of the facility's nail care policy, the DON stated, most of the time the SW oversees anything podiatry-related. When asked what a potential negative resident outcome was if nail care was not completed, the DON stated, everything has to go in line with the basic care of patients and I can't say there would be a negative outcome for him because he has a history of refusal of care. <BR/>During an interview on 1/12/2023 at 6:13 p.m., when asked what the facility's policy was on providing nail care to diabetic residents, the ADM stated nurses could do fingernails but for toes, residents were referred to the podiatrist. The ADM stated he had been told Resident #16 refused care, spat on staff when they provided care, and did inappropriate things. The ADM stated if Resident #16's nails were not trimmed, it was because he refused. When asked how often nail care in diabetics was done, the ADM stated the Podiatrist came every 90 days or as needed. The ADM stated he would trust staff more than the vendor because the podiatrist group was not perfect. The ADM stated the SW handled podiatry referrals and monitored when residents were to be seen. The ADM stated charge nurses monitored residents' nails. When asked what, if any, potential negative resident outcome there would be if nail care were not completed, the ADM stated, it's possible but I really don't know what can happen. <BR/>A record review of the facility's policy titled Fingernails/Toenails, Care of dated February 2018 reflected the following: <BR/>The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.<BR/>Preparation<BR/>1. Review the resident's care plan to assess for any special needs of the resident.<BR/>2. Assemble the equipment and supplies needed.<BR/>General Guidelines<BR/>1. Nail care includes daily cleaning and regular trimming.<BR/>2. Proper nail care can aid in the prevention of skin problems around the nail bed.<BR/>3. Unless otherwise permitted, do not trim the nail of diabetic residents or residents with circulatory impairments.<BR/>4. Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin.<BR/>5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. <BR/>6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.<BR/>A record review of the facility's undated policy titled Foot Care reflected the following:<BR/>Purpose: Ensure that residents receive proper treatment and care to maintain mobility and good foot to prevent complications from conditions such as diabetes, peripheral vascular disease or immobility. <BR/>Procedure: This facility will:<BR/>oProvide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and<BR/>oIf necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments<BR/>Residents requiring foot care who have complicating disease process (i.e. diabetes mellitus, peripheral vascular disease, etc.) must be referred to qualified professionals, such as:<BR/>oPodiatrist<BR/>oDoctor of Medicine and<BR/>oDoctor of Osteopathy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents were offered sufficient fluid intake to maintain proper hydration to 11 of 28 residents (Resident #13, Resident #23, Resident #30, Resident #33, Resident #35, Resident #37, Resident #42, Resident #44, Resident #48, Resident #50, Resident #59, and Resident #70) reviewed for hydration.<BR/>The facility did not ensure Resident #13, Resident #23, Resident #30, Resident #33, Resident #35, Resident #37, Resident #42, Resident #44, Resident #48, Resident #50, Resident #59, and Resident #70 were provided fluids routinely.<BR/>This failure could place residents at risk for dehydration.<BR/>The findings included:<BR/>Review of Resident #33's Face Sheet dated 01/12/23 reflected, [AGE] year-old female admitted to the facility on [DATE] with diagnosis of CHF (chronic condition in which the heart does not pump enough blood as well as it should), obesity, systemic lupus (inflammatory disease caused when immune system attacks its own tissues) and pressure ulcer. <BR/>Review of Resident #33's MDS dated [DATE] reflected, BIMS score of 15, indicating no cognitive impairment. <BR/>Review of Resident #33's Care Plans dated 11/30/22 reflected Resident #33 has ADL self-care deficit related to diagnosis of CHF, decreased endurance, and general weakness with intervention to provide assistance with ADLs as needed. <BR/>Observation and interview on 01/11/23 at 10:34 AM, Resident #33 stated, residents have to go get their own water. Resident #33 stated she had another resident get water for her and pointed to the water pitcher on the side table, since she could not get out of bed on her own. Resident #33 stated the facility does not pass out water and reported of asking at nighttime once for ice water and staff told her they do not have ice water at night time and provided her with water with no ice. <BR/>Review of Resident #35's Face Sheet dated 01/12/23 reflected, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, HTN (high blood pressure), hyperlipidemia (high cholesterol), and diabetes.<BR/>Review of Resident #35's MDS dated [DATE] reflected, a BIMS score of 14 indicating no cognitive impairment. <BR/>Review of Resident #35's Care Plans dated 11/19/21 reflected, Resident #35 is at risk for malnutrition related to diabetes, dementia, wandering, and anemia with intervention to provide, serve diet as ordered and monitor intake and record every meal.<BR/>Interview on 01/11/23 at 10:00AM, Resident #35 stated, No one passed out ice water and either we have to ask or get it ourselves. Resident #35 stated she passes out water to another resident because that other resident is not capable of getting her own water for herself. Resident #35 had water pitcher inside her room and stated she gets her own water from the dining room. <BR/>A record review of Resident #48's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hypertension (high blood pressure), fractured right femur, BMI of 70 or greater, repeated falls, anemia, and muscle weakness. <BR/>A record review of Resident #48's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. <BR/>A record review of Resident #48's care plan last revised on 12/14/2022 reflected Resident #48 had ADL self-care deficit related to increased BMI, decreased endurance, fracture, and general weakness.<BR/>During an observation and interview on 1/10/2023 at 11:19 a.m., Resident #48 was observed eating lunch in bed. Resident #48 stated staff did not pass out water between meals. <BR/>During a confidential meeting of residents, two anonymous residents reported staff did not pass out water.<BR/>Observation on 01/11/23 at 10:19AM, Resident #50 and Resident #42 did not have a water pitcher or water at the bedside. <BR/>Observation on 01/11/23 at 10:20AM, Resident #37 with no water at the bedside and Resident #44 with water inside the water pitcher with no date.<BR/>Observation on 01/11/23 at 10:21AM, Resident #30 did not have water at the bedside.<BR/>Observation on 01/11/23 at 10:23AM, Resident #59 and Resident #13 did not have water at the bedside.<BR/>Observation on 01/11/23 at 10:24AM, Resident #70 and Resident #23 did not have water at the bedside. <BR/>Interview on 01/12/23 at 3:35PM, the ADON stated the facility has a hospitality aide who provided water and CNAs also pass out water to the residents. The ADON stated residents should be provided with hydration during meals, after morning care, during snacks and periodically thought out the shifts. The ADON stated ice water is available at nighttime.<BR/>Interview on 01/12/23 at 5:30PM, the DON stated all residents who does not have fluid restriction have a water pitcher in their rooms and the hospitality aide passes the water. <BR/>Review of facility policy titled Hydration-Clinical Protocol dated September 2017 reflected, 2. The staff will provide supportive measures such as providing fluids and adjusting environmental temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 2 (Resident #139 and Resident #140) of 2 residents reviewed for respiratory care, in that:<BR/>The facility failed to:<BR/>A.) date the oxygen tubing for Resident #139 and Resident #140.<BR/>These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. <BR/>Findings Included:<BR/>Resident #139<BR/>Record Review of Resident #139's face sheet dated 01/11/23 revealed the resident was a [AGE] year old female admitted on [DATE]. Her diagnoses were displaced fracture of third cervical vertebra (end of the bones have come out of alignment), dementia (disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease), hyperlipidemia (abnormally elevated levels of any or all lipids or lipoproteins in the blood), and anxiety (a feeling of worry, nervousness, or unease).<BR/>Record review of Resident #139's clinical physician orders dated as of 01/11/23 revealed an order to keep resident's oxygen saturation at 92% or above and to apply oxygen at 2L via nasal cannula if oxygen saturation gets below 92%.<BR/>Record review of resident #139's quarterly MDS dated [DATE] revealed the resident's BIMS was 12 indicating she was moderately cognitively impaired. The MDS indicated the resident required extensive assistance during mobility in bed and transferring but required the assistance of one person while performing activities of daily living (dressing, eating, and toileting). <BR/>Record review of resident #139's care plan dated 01/12/2023 read in part: <BR/>Resident #139 has utilized oxygen as needed.<BR/>Goal: Resident #139 will have no s/sx of poor oxygen absorption through the review date.<BR/>Interventions: Check oxygen levels every shift and administer oxygen per orders as needed.<BR/>Resident #140<BR/>Record Review of Resident #140's face sheet dated 01/11/23 revealed the resident was a [AGE] year old male admitted on [DATE]. His diagnoses were non-pressure chronic ulcer (results from inadequate blood supply due to peripheral vascular disease, diabetes mellitus, trauma, or advanced age) of right heel, right ankle, right calf, right lower leg, and left calf.<BR/>Record review of Resident #140's clinical physician orders dated as of 01/11/23 revealed an order for oxygen at 2L per nasal canula PRN for SOB and to change oxygen tubing and humidifier weekly every night shift on Sundays.<BR/>Record review of Resident #140's quarterly MDS dated [DATE] revealed the resident's BIMS was 12 indicating he was moderately cognitively impaired. <BR/>Record review of Resident #140's baseline care plan dated 01/07/23 read in part: 3. Health conditions - A. Health conditions/special treatments - 1. Special treatments, procedures, and programs - 1a. Oxygen therapy - while a resident which was checked for resident use. <BR/>During an observation on 01/10/23 at 11:29 AM, Resident #139 was lying in bed with a nasal cannula in her nose and it was connected to the oxygen concentrator. The oxygen concentrator flowmeter was set to deliver 2 liters of oxygen per minute to the resident. <BR/>During an observation on 01/10/2023 at 11:30 AM, of Resident #139's oxygen tubing, observation revealed that tubing was not dated or initialed.<BR/>During an interview on 01/10/2023 at 11:31 AM Resident #139 stated she did not know if or when the staff change her oxygen tubing. She stated she used the oxygen mostly all of the time.<BR/>During an interview on 01/10/23 at 11:36 AM, LVN A stated oxygen tubing is changed every Sunday night and the tubing should be dated when it is changed.<BR/>During an observation on 01/10/23 at 11:43 AM, Resident #140 was lying in bed with a nasal cannula in his nose and it was connected to the oxygen concentrator. The oxygen concentrator flowmeter was set to deliver 2 liters of oxygen per minute to the resident. <BR/>During an observation on 01/10/2023 at 11:44 AM, of Resident #140's oxygen tubing, observation revealed that tubing was not dated or initialed.<BR/>During an interview on 01/10/2023 at 11:45 AM Resident #140 stated he did not know if the staff would change his oxygen tubing or not. He stated he had only been here for about a week, and he used the oxygen all of the time.<BR/>During an interview on 01/10/23 at 01:22 PM, LVN B stated oxygen tubing should be changed every 72 hours and when it becomes dirty, and it should always be labelled and dated on the day it is changed. She stated if oxygen tubing was not changed there could be bacteria build up which could cause infection, or it could not work properly due to blockage. She stated she has been here a month and she has received training on cleaning oxygen concentrators and changing and labeling oxygen tubing. <BR/>During an interview on 01/11/2023 at 10:59 AM, the DON stated oxygen tubing was changed weekly and as needed. She stated when oxygen tubing was changed, staff were supposed to replace and date the oxygen tubing. She stated it was the facility's routine procedure to date the oxygen tubing when it was replaced. She stated even if oxygen tubing was replaced as needed it still must be dated. She stated if oxygen tubing was not dated the staff cannot determine when the tubing was changed, and it could cause issues with infection control. She stated staff has been in-serviced on dating and initialing oxygen tubing when changed.<BR/>During an interview on 01/11/2023 at 1:27 PM, the ADM stated oxygen tubing was changed weekly and PRN and it should have been dated and initialed by staff when changed. He stated there should have been orders given by the physician that said when to change oxygen tubing. He stated the staff have been in-serviced on dating oxygen tubing when it was changed. He stated if the oxygen tubing is not dated and goes without being changed it could possibly cause and the tubing to get dirty which could decrease the flow of oxygen.<BR/>Review of facility's in-service dated 10/15/2022 and titled with topic: O2 therapy - weekly and PRN changing of O2 tubing (must date) revealed staff was in-serviced on changing and dating oxygen tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents received food that accommodated their preferences for one (Resident #48) of eight residents reviewed for food and drink preferences. <BR/>The facility failed to ensure Resident #48 received tea, her beverage of choice, during three meals. <BR/>This failure placed residents at risk of not receiving their food and drink preferences. <BR/>Findings included:<BR/>A record review of Resident #48's face sheet dated 1/12/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hypertension (high blood pressure), fractured right femur, BMI of 70 or greater, repeated falls, anemia, and muscle weakness. <BR/>A record review of Resident #48's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #48's MDS assessment did not reflect food and drink preferences.<BR/>A record review of Resident #48's care plan last revised on 12/14/2022 reflected Resident #48 had ADL self-care deficit related to increased BMI, decreased endurance, fracture, and general weakness. Resident #48's care plan did not reflect food and drink preferences.<BR/>During an interview and observation on 1/10/2023 at 11:19 a.m., Resident #48 was observed lying in bed. Resident #48 stated she was supposed to get tea with each meal but staff gave her water and overly sweet Kool-Aid instead. She stated the SW was aware of the issue but did not do anything. <BR/>During an interview and observation on 1/10/2023 at 12:04 p.m., Resident #48 was observed eating lunch in bed. Resident #48 commented that her meal ticket reflected Add tea but she did not receive tea. Resident #48's meal tray contained juice and water, but no tea. Resident #48 stated staff knew she wanted tea. Resident #48's meal ticket reflected Add tea. <BR/>During an interview on 1/10/2023 at 12:18 p.m., CNA A stated as far as she knew, there was no tea. CNA A stated the kitchen portioned out all drinks inside the kitchen. CNA A stated the thought the kitchen might have tea inside if residents asked. <BR/>During an interview and observation on 1/10/2023 at 12:27 p.m., [NAME] A stated the kitchen had tea bags for hot tea. Observed tea bags on a shelf in the kitchen. <BR/>During an interview on 1/10/2023 at 12:34 p.m., the Dietary Supervisor stated residents had a choice of what they wanted to eat. The Dietary Supervisor stated CNAs asked residents whether they wanted the main menu or the alternate menu. <BR/>During an interview on 1/11/2023 at 11:36 a.m., [NAME] A stated kitchen staff did not go into resident's rooms, and that nursing staff would need to make teas for residents who ate in their rooms and could not get out of bed. [NAME] A stated the kitchen used to have iced tea mix but they had not had any since November 2022 because the new supplier ordered from did not have it. [NAME] A stated Resident #48 drank tea and there were not enough residents who liked iced tea to make a whole pitcher of it because it would become spoiled. [NAME] A stated because Resident #48 could not get out of bed, CNAs would communicate any dietary complaints she had. [NAME] A stated Resident #48 had not complained about not getting tea. [NAME] A stated some residents were particular with how they liked their tea so it was better for them to make it themselves. [NAME] A said Resident #1 was not one of the residents who was particular with how they liked their tea. [NAME] A stated kitchen staff were responsible for portioning out and preparing all drinks for residents. <BR/>During an interview and observation on 1/11/2023 at 11:45 a.m., Resident #48 was observed lying in bed. Resident #48 stated she liked either hot tea or iced tea. Resident #48 stated she had not received any tea in weeks, stating she hated the fruit punch they served because it was too sweet. <BR/>During an interview an observation on 1/11/2023 at 12:56 p.m., Resident #48 was observed eating lunch in bed. Resident #48's meal tray contained water and juice but no tea. Resident #48's meal ticket reflected Add tea. Resident #48 had a pitcher of tea on her bedside table and she stated she got it from a friend. <BR/>During an interview on 1/12/2023 at 8:46 a.m., the LD stated the Dietary Supervisor updated tray tickets to reflect residents' food preferences. The LD stated kitchen staff should follow whatever was on the tray ticket. When asked who ensured food preferences were honored, the LD stated, it would be up to the Dietary Supervisor. The LD stated that if whoever passed trays noticed something missing, they could be an additional set of eyes to help as well. The LD stated she thought dietary staff prepared drinks but she was not sure if other staff poured drinks as well. The LD stated the Dietary Supervisor updated preferences to the tray card and staff on the line would follow the ticket. The LD stated that once the tray was passed to the resident, the nurse aides or nurses would ideally check to ensure all items were there. When asked what a potential negative resident outcome could be if residents' drink preferences were not honored, the LD stated if it were something like iced tea and they were not able to get it on the truck, that might be why the resident would not receive it. The LD stated, but we definitely want to honor food preferences and accommodate them as much as we can.<BR/>During an interview and observation on 1/12/2023 at 9:10 a.m., Resident #48 was observed eating breakfast in bed. Resident #48's meal tray did not contain tea. Resident #48's meal ticket reflected Add tea. Resident #48 stated she got water and apple juice but the juice was too sweet and she had to add water to it. <BR/>During an interview on 1/12/2023 at 9:17 a.m., [NAME] E stated nurses put teas on residents' trays. [NAME] E stated kitchen staff placed the tea bags outside the serving window for nursing staff to make the teas since the hot water dispenser was in the dining room. <BR/>During an interview on 1/12/2023 at 9:20 a.m., the Dietary Supervisor stated sometimes kitchen staff placed tea bags out for nurses to make teas for residents who asked. When asked why a resident who had tea on their ticket would not receive tea when the kitchen had tea bags and the resident did not mind hot tea, the Dietary Supervisor stated, I guess we would have to give it.<BR/>During an interview on 1/12/2023 at 9:29 a.m., RN A stated nurses checked meal trays as they were being passed through the serving window of the dining room. RN A stated nurses checked to ensure what was on the ticket matched what was on the tray. RN A stated dietary staff checked trays for likes and dislikes. RN A stated dietary staff were responsible for placing teas on hall trays. When asked if dietary staff placed tea bags in the serving window for nursing staff to make teas, RN A stated, no. <BR/>During an interview on 1/12/2023 at 5:23 p.m., the DON stated residents' dietary preferences were usually on their tray card which was updated by the Dietary Supervisor. The DON stated residents' likes and dislikes were on meal tickets. The DON stated the Dietary Supervisor was responsible for ensuring residents' likes and dislikes were included on their meal tickets. The DON stated the Dietary Supervisor met with residents upon admission to update their dietary preferences. The DON stated nurses checked trays before giving them to CNAs to ensure preferences were on the tray. When asked why an item available in the kitchen would not be served to a resident whose meal ticket included that item, the DON stated if it's on the ticket they should get it. If the item isn't on the tray and they have it in the kitchen, the nurses could ask the kitchen for it. When asked what a potential negative resident outcome could be of failing to accommodate a resident's food preferences, the DON stated, I know the resident and I know she will ask for tea. If it's available, it should be given. If it's on the tray card, it should be given. Moving forward, we can investigate why she wasn't getting tea.<BR/>During an interview on 1/12/2023 at 6:13 p.m., when asked what the facility's policy was on honoring residents' food and drink preferences, the ADM stated, On the top of my head, I don't know what the policy says. We promote restaurant style of dining. We always have an always available menu. The ADM stated nurses checked meal tickets to make sure the right diet was there and to compare the plate with the meal card. When asked why Resident #48 would not have received an available item requested per her meal ticket, the ADM stated, If they had it in the kitchen, I don't know why they wouldn't have given it to her. When asked what a potential negative resident outcome could be of failing to provide a reasonable attempt to accommodate residents' food preferences, the ADM stated, I don't think there would be any impact.<BR/>A record review of the facility's undated policy titled Dietary Tray Cards reflected the following:<BR/>Policy: Each resident shall have a diet tray card. The diet tray card must be neat, legible, and clean. Tray cards can be either printed form an approved computer tray card system, or manual [NAME] tray cards. The tray card must identify the following information. <BR/>1. Resident's name<BR/>2. Resident's room number<BR/>3. Resident's bed number<BR/>4. Resident's diet exactly as ordered by a physician<BR/>5. Resident's beverage preference<BR/>6. Resident's food preferences<BR/>7. Resident's food dislikes and allergies<BR/>8. Location of meal<BR/>A record review of the facility's policy titled Resident Food Preferences dated December 2008 reflected the following:<BR/>Policy Statement: Nutritional assessments will include an evaluation of individual food preferences.<BR/>Policy Interpretation and Implementation<BR/>1. Upon the resident's admission, or within twenty-four (24) hours after his/her admission, the Dietitian or nursing staff will identify a resident's food preferences. When possible, this will be done by direct interview with the resident.<BR/>4. The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions. <BR/>5. The Dietitian will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests.<BR/>7. The facility's Quality Assessment and Assurance (QAA) program 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 observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for food storage and sanitation.<BR/>1. The Dietary Supervisor failed to ensure all items in the walk-in refrigerator and dry storage were covered, labeled, dated, and discarded prior to their expiration date. <BR/>2. [NAME] A failed to change gloves and wash her hands when changing tasks. <BR/>3. [NAME] B, Dietary Aide A and [NAME] C failed to wear effective hair restraints.<BR/>These failures placed residents at risk of foodborne illness.<BR/>Findings included:<BR/>Observations of the walk-in refrigerator on 1/10/2023 from 9:06 a.m. to 9:19 a.m. revealed the following:<BR/>At 9:06 a.m. the walk-in refrigerator contained tomatoes in a metal steam pan with a use-by date of 1/04/2023. <BR/>At 9:07 a.m. the walk-in refrigerator contained two bowls of peaches which were uncovered and unlabeled.<BR/>At 9:08 a.m. the walk-in refrigerator contained a metal bowl filled with nine individually wrapped pieces of cornbread which were unlabeled and undated.<BR/>At 9:09 a.m. the walk-in refrigerator contained a sheet cake which was uncovered, unlabeled, and undated. <BR/>At 9:10 a.m. the walk-in refrigerator contained two two-ounce cups of ketchup which were uncovered, unlabeled, and undated. <BR/>At 9:11 a.m. the walk-in refrigerator contained two two-ounce cups of maple syrup which were unlabeled and undated. <BR/>At 9:12 a.m. the walk-in refrigerator contained eight individually wrapped bags of fruit which were unlabeled and undated. <BR/>At 9:13 a.m. the walk-in refrigerator contained a plastic tub of pickles, opened, and without an opened date. <BR/>At 9:18 a.m. the walk-in refrigerator contained a container of jalapenos labeled prep 11/4 and discard 11/11. <BR/>At 9:19 a.m. the walk-in refrigerator contained a plastic container of peaches which was unlabeled and undated. <BR/>In an interview on 1/13/2023 at 9:19 a.m., [NAME] A stated all items in the walk-in refrigerator should be covered, labeled and dated. [NAME] A stated items such as condiments needed to be labeled when they were opened. [NAME] A stated someone might have forgotten to label the tub of pickles and stated the tomatoes with the use-by date of 1/04/2023 should have been discarded. [NAME] A stated any food item past its expiration date or use-by date should be discarded.<BR/>An observation on 1/11/2023 at 10:12 a.m. revealed [NAME] A pureed meat, washed the food processor in the three compartment sink, then proceeded to puree vegetables without changing gloves or washing her hands. <BR/>Observations on 1/11/2023 at 10:20 a.m. revealed Dietary Aide A and [NAME] C were wearing hair restraints which did not completely cover their long hair. Dietary Aide A was washing dishes in the kitchen and [NAME] C was standing in the kitchen. Both Dietary Aide A and [NAME] C had long hair which hung free, out the side of their hair restraints.<BR/>An observation on 1/11/2023 at 10:22 a.m. revealed [NAME] A pureed vegetable, washed the food processor in the three compartment sink, then proceeded to prepare mashed potatoes without changing gloves or washing her hands. <BR/>In an interview on 1/11/2023 at 10:35 a.m., when asked if gloves should be changed and hands washed when going from doing dishes to cooking, [NAME] A stated, yes. [NAME] A stated, I thought I washed my hands but if I didn't do that, please forgive me. <BR/>An observation on 1/11/2023 at 10:37 a.m. revealed [NAME] B was making sandwiches in the kitchen and wearing a hair restraint which did not completely cover her long hair. [NAME] B was observed with strands of hair coming out the side of her hair restraint.<BR/>In an interview on 1/11/2023 at 10:37 a.m., when asked if all of her hair was covered, [NAME] B communicated she did not understand in English by stating, I only understand a little bit.<BR/>In an interview on 1/11/2023 at 10:40 a.m., when asked if all of his hair was covered, Dietary Aide A stated, no. When asked if it should be, Dietary Aide A stated, probably, yeah. <BR/>In an interview on 1/11/2023 at 10:43 a.m., when asked if his hair was completely covered by the hair restraint, [NAME] C stated, is it not? and then said, I'll go take care of it. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:44 a.m. revealed a bulk container of flour dated 11/1/2022 with the scoop stored inside the container on the flour. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:45 a.m. revealed a bulk container of rice unlabeled and undated. <BR/>In an interview on 1/11/2023 at 10:45 a.m., the Dietary Supervisor stated he had worked in the facility for one year, had worked as manager for six months, and that was his first survey. <BR/>In an interview on 1/11/2023 at 10:49 a.m., the Dietary Supervisor stated kitchen staff were taught upon hire how to label and date food items. The Dietary Supervisor stated he had not completed any written in-service training with kitchen staff since he started as manager, and that most training on food storage and sanitation was completed via observation and demonstration. The Dietary Supervisor stated himself, another experienced employee or [NAME] D would train employees on food storage and sanitation. The Dietary Supervisor stated [NAME] D was the most experienced cook so that is why kitchen staff trained with him. The Dietary Supervisor stated kitchen staff were trained on labeling and dating via demonstration. The Dietary Supervisor stated as far as glove usage, hand washing, and use of hair restraints, training was completed verbally. The Dietary Supervisor stated all staff went through a new hire process which included reading and signing off on an employee hand guide which covered food storage and sanitation. <BR/>In an interview on 1/12/2023 at 8:46 a.m., the LD stated food should be properly sealed if it had been opened, there should be a label and date on items when they were opened, and items such as condiments should have an opened date. The LD stated food should be adequately covered to prevent contamination or exposure of food and food items should be sealed on top. The LD stated yes that all food items should have a label and a date unless it was an unopened, prepackaged item such as a health shake. When asked if food items should be discarded prior to their use-by dates, the LD stated, yes, it's good practice. The LD stated kitchen staff should have some type of covering to cover their hair to prevent contamination. When asked if hair should be completely covered, the LD stated, yes, ideally they should try to tuck all the hair in. The LD stated she would expect handwashing to occur any time before handling food items. When asked how kitchen staff were trained on food storage and sanitation, the LD stated she did not know and it would be a good question for the Dietary Supervisor. The LD stated off hand she did not know whether kitchen staff had been trained, stating, I would ask the Dietary Supervisor. When asked who monitored the kitchen for food storage and sanitation, the LD stated, it would be the Dietary Supervisor and I complete monthly kitchen audits and give any recommendations to the Dietary Supervisor or discuss them with the ADM. The LD stated she was not sure how the Dietary Supervisor monitored the kitchen but stated she monitored through monthly audits. When asked if she had noticed any concerns, the LD stated there had been ongoing education with labeling and dating. The LD stated she had completed verbal education with the Dietary Supervisor on this. When asked what potential negative outcomes there could be if kitchen polices on food storage and sanitation were not followed, the LD stated there could potentially be contamination of food items, foods could be served past their use-by dates, and there could be potential for foodborne illness. <BR/>In an interview on 1/12/2023 at 6:13 p.m., when asked what the facility's policy was on food storage, the ADM stated things needed to be labeled when they were opened, labeled with a use-by and open date, and discarded after seven days. When asked if kitchen staff should have all hair covered, the ADM stated, yes. When asked how hands should be washed when going from dirty dishes to preparing a pureed food item, the ADM stated the best thing would be to take the food processor to the person washing dishes to wash. The ADM stated it was best practice to wash hands before starting a new task.<BR/>A record review of the facility's undated policy titled Food Storage reflected the following:<BR/>Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. These containers can be mounted on caster or dollies. All containers must be legibly and accurately labeled.<BR/>6. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are no to be stored in the food containers, but are kept covered in a protected area near the containers. <BR/>15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded.<BR/>A record review of the facility's policy titled Food Preparation and Service dated 2001 reflected the following: <BR/>Policy Statement: Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.<BR/>4. Food service staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays.<BR/>6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks.<BR/>A record review of the facility's undated Employee Handbook reflected it covered use of hair restraints only, and did not cover handwashing, glove usage, or food storage. <BR/>A record review of the facility's Hand Washing Competency forms dated 10/04/2022, 11/19/2022, and 12/21/2022 reflected [NAME] A's handwashing skill had been demonstrated to show competency. These documents reflected how to wash hands but did not cover when to wash hands. <BR/>A record review of the LD's Sanitation Audit dated 11/04/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Ingredient bins, the LD commented, Recommend view for outdated bulk bin items, discard as appropriate. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that some items were missing labels and dates and some items were outdated. <BR/>A record review of the LD's Sanitation Audit dated 12/02/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that items were missing labels and dates. <BR/>A record review of the FDA's 2017 Food Code reflected the following:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings<BR/>Hair Restraints<BR/>2-402.11 Effectiveness.<BR/>(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's interdisciplinary team failed to review and revise all residents' care plans after each comprehensive and quarterly review assessments for one (Resident #6) of eight residents reviewed for comprehensive care plans. <BR/>The facility's interdisciplinary team failed to review and revise Resident #6's care plan after his most recently completed comprehensive assessment completed on 10/04/2022.<BR/>This failure placed residents at risk of having unrevised care plans.<BR/>Findings included:<BR/>A record review of Resident #6's face sheet dated 1/12/2023 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of local infection of the skin and subcutaneous tissue (innermost layer of skin), unstageable pressure ulcer (severe skin injury) of sacral region (base of the spine), non-pressure chronic ulcer of the right foot, non-pressure ulcer of the right heel and midfoot with necrosis (death) of muscle and fat layer exposed, unstageable pressure ulcer (severe skin injury) of right lower back, type 2 diabetes (uncontrolled blood sugar), peripheral vascular disease (circulatory issues), pruritis (itching), atopic dermatitis (rash), hyperlipidemia (high cholesterol), hypertension (high blood pressure), major depressive disorder (depression), and unspecified dementia.<BR/>A record review of Resident #6's chart reflected his most recently completed comprehensive assessment was completed on 10/04/2022. <BR/>A record review of Resident #6's quarterly MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated severely impaired cognition. A review of Section M (Skin Conditions) reflected Resident #6 was at risk of developing pressure ulcers/injuries and had three venous (open ulcer due to damaged veins) and arterial ulcers (open ulcer due to damaged arteries) present, including diabetic foot ulcer(s) (slow healing wounds). Resident #6's treatments included pressure reducing devices, nutrition or hydration interventions to manage skin problems, and applications of ointments/medications and application of dressing to feet. <BR/>A record review of Resident #6's care plan last revised on 7/10/2022 with an effective date of 8/25/2022 reflected Resident #6 had ADL self-care performance deficits related to tremors, dementia, hallucinations, delusions, and diabetes. Resident #6's care plan indicated he was at risk for malnutrition related to diabetes. Resident #6's care plan goal included Resident #6 will not develop complications related to obesity including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Resident #6's intervention for this goal, initiated on 6/26/2020, reflected provide and serve diet as ordered. Resident #6's care plan reflected he was at risk for injury related to dementia, frequent falls, and poor safety awareness. Resident #6's goal for this focus reflected he would remain free from injury through next review date. Interventions for this goal included notify physician and responsible party of any new skin tears or discolorations, skin observations by CNAs on bath days and with daily care, treatments as ordered by physician, and use lotion on dry skin. Resident #6's care plan did not reflect he had any chronic ulcers, arterial ulcers, or pressure injuries. Resident #6's care plan did not reflect he was at risk of skin breakdown. Resident #6's care plan did not include any interventions to prevent or manage current skin issues. <BR/>A record review of the facility's Care Plan Conference Summary dated 8/25/2022 reflected concerns and interventions related to Resident #6's recent elopement (unauthorized departure). The summarized discussion of care plan conference did not reflect any potential for or current skin alterations. Attendees of this care plan conference included the DON, the SW, the ADM and Resident #6's resident representative. <BR/>A record review of Resident #6's Social Services Note dated 12/22/2022 reflected Therapy informed MDS of resident's change of function. Changes include weight loss and wound on sacrum. SW called family to schedule a care plan meeting. Meeting is scheduled for 12/23/22 at 11 am. Will include resident, resident's brother, and sister-in-law, SW, DON, and Therapy Director.<BR/>A record review of Resident #6's Health Status Note dated 12/23/2022 at 10:55 a.m. reflected #6's representative consented to wound treatment and confirmed the care plan meeting scheduled for 11:00 a.m. that day (12/23/2022).<BR/>A record review of Resident #6's Health Status Note dated 12/23/2022 at 11:17 a.m. reflected Resident noted with pressure wound to sacrum. Recommendation: LAL mattress, to evaluate on diet texture due to the fact that resident do not like to wear his denture prior to admission to the facility, increase Prostat 90CC TID, continue vitamin C and multivitamin daily MD/NP, Dietary, RP notified. Social worker coordinate Care plan meeting with RP.<BR/>A record review of Resident #6's Social Services Note dated 1/11/2023 reflected Care Plan Meeting set for Tuesday 1/17/23 at 10 am with sister-in-law on behalf of the brother per RP request. RP stated he will be working and cannot attend most meetings. RP volunteered wife and stated this is why he appointed her the secondary emergency contact. DNR is still needed and will be requested at care plan meeting.<BR/>A record review of Resident #6's chart on 1/12/2023 reflected his care plan had not been updated since 8/25/2022. <BR/>A record review on 1/12/2023 of Resident #6's care plan tab reflected the last care plan was completed on 8/25/2022. <BR/>A record review on 1/12/2023 of Resident #6's miscellaneous section reflected the last care plan was completed on 8/25/2022. <BR/>During an interview and observation on 1/10/2023 at 10:51 a.m., Resident #6 was observed lying in bed with some redness on his skin. Resident #6 was non-interviewable and unable to answer questions about his care.<BR/>During an interview on 1/12/2023 at 1:15 p.m., the DON stated care plans were reviewed every 90 days and should be in PCC under the care plan tab or in the miscellaneous section. <BR/>During an interview on 1/12/2023 at 2:29 p.m., the DON stated she knew they had had a care plan meeting for Resident #6 in the past six months. The DON was unable to provide documentation of this prior to exit. <BR/>During an interview on 1/12/2023 at 2:30 p.m., the SW stated the were having a care plan meeting for Resident #6 the following Tuesday (1/17/2023). The SW stated they had a care plan meeting for Resident #6 in December. The SW stated she would provide documentation of this if she found it. The SW was unable to provide documentation of this prior to exit. <BR/>During an interview on 1/12/2023 at 4:20 p.m., the SW stated there was a care plan meeting held via phone call on 12/23/2022 but there was no care plan document. The SW stated the DON included updates in a progress note dated 12/23/2022. When asked what potential outcome there could be if a resident had multiple wounds and their care plan had not been revised, the SW stated, I just feel like it would not result in a good outcome.<BR/>During an interview on 1/12/2023 at 5:23 p.m., the DON stated the facility's policy on updating care plans was going to be based on the policy we have for care plans. When asked who ensured care plans were revised, the DON stated the MDS nurse. When asked if a wound should be included in a resident's care plan, the DON stated, yes. When asked what a potential negative outcome of not including skin breakdown or potential for skin issues in a resident who had skin alteration's care plan, the DON stated, I don't know what negative outcome there would be, I know we care plan a lot of things, as far as timing of care plan and reviewing it, it would be according to our policy. When asked if Resident #6's care plan should have been updated to reflect his wounds, the DON stated, everything should be included in the care plan.<BR/>During an interview on 1/12/2023 at 6:13 p.m., when asked how often care plans should be reviewed and revised, the ADM stated, comprehensive is 7 days and as far as updating the care plan, that should be done as needed if something came up or quarterly. When asked who ensured care plans were revised, the ADM stated it was done by the IDT then the MDS nurse would consolidate it into one. When asked who ensured care plans were being reviewed and revised, the ADM stated, the MDS coordinator will send out an email. When asked what potential for negative resident outcome there could be, if any, of failing to include skin breakdown or potential for skin issues in a resident who has skin impairment's care plan, the ADM stated, I don't think so because they track the wounds and make sure they're taking care of it. They might have missed it on the care plan but I don't think the care was missing.<BR/>A record review of the facility's policy titled Care Plans - Comprehensive dated December 2010 reflected the following: <BR/>Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.<BR/>Policy Interpretation and Implementation<BR/>1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.<BR/>2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS.<BR/>3. Each resident's comprehensive care plan is designed to:<BR/>a. Incorporate identified problem areas;<BR/>b. Incorporate risk factors associated with identified problems;<BR/>c. Build on the resident's strengths; <BR/>d. Reflect the resident's expressed wishes regarding care and treatment goals;<BR/>e. Reflect treatment goals, timetables and objective in measurable outcomes;<BR/>f. Identify the professional services that are responsible for each element of care;<BR/>g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels;<BR/>h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and<BR/>i. Reflect currently recognized standards of practice for problem areas and conditions.<BR/>4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan.<BR/>5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. <BR/>6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering. proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process.<BR/>7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).<BR/>8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.<BR/>9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans:<BR/>a. When there has been a significant change in the resident's condition; <BR/>b. When the desired outcome is not met;<BR/>c. When the resident has been readmitted to the facility from a hospital stay; and<BR/>d. At least quarterly.<BR/>10. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered in to the resident's clinical records in accordance with established policies.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for food storage and sanitation.<BR/>1. The Dietary Supervisor failed to ensure all items in the walk-in refrigerator and dry storage were covered, labeled, dated, and discarded prior to their expiration date. <BR/>2. [NAME] A failed to change gloves and wash her hands when changing tasks. <BR/>3. [NAME] B, Dietary Aide A and [NAME] C failed to wear effective hair restraints.<BR/>These failures placed residents at risk of foodborne illness.<BR/>Findings included:<BR/>Observations of the walk-in refrigerator on 1/10/2023 from 9:06 a.m. to 9:19 a.m. revealed the following:<BR/>At 9:06 a.m. the walk-in refrigerator contained tomatoes in a metal steam pan with a use-by date of 1/04/2023. <BR/>At 9:07 a.m. the walk-in refrigerator contained two bowls of peaches which were uncovered and unlabeled.<BR/>At 9:08 a.m. the walk-in refrigerator contained a metal bowl filled with nine individually wrapped pieces of cornbread which were unlabeled and undated.<BR/>At 9:09 a.m. the walk-in refrigerator contained a sheet cake which was uncovered, unlabeled, and undated. <BR/>At 9:10 a.m. the walk-in refrigerator contained two two-ounce cups of ketchup which were uncovered, unlabeled, and undated. <BR/>At 9:11 a.m. the walk-in refrigerator contained two two-ounce cups of maple syrup which were unlabeled and undated. <BR/>At 9:12 a.m. the walk-in refrigerator contained eight individually wrapped bags of fruit which were unlabeled and undated. <BR/>At 9:13 a.m. the walk-in refrigerator contained a plastic tub of pickles, opened, and without an opened date. <BR/>At 9:18 a.m. the walk-in refrigerator contained a container of jalapenos labeled prep 11/4 and discard 11/11. <BR/>At 9:19 a.m. the walk-in refrigerator contained a plastic container of peaches which was unlabeled and undated. <BR/>In an interview on 1/13/2023 at 9:19 a.m., [NAME] A stated all items in the walk-in refrigerator should be covered, labeled and dated. [NAME] A stated items such as condiments needed to be labeled when they were opened. [NAME] A stated someone might have forgotten to label the tub of pickles and stated the tomatoes with the use-by date of 1/04/2023 should have been discarded. [NAME] A stated any food item past its expiration date or use-by date should be discarded.<BR/>An observation on 1/11/2023 at 10:12 a.m. revealed [NAME] A pureed meat, washed the food processor in the three compartment sink, then proceeded to puree vegetables without changing gloves or washing her hands. <BR/>Observations on 1/11/2023 at 10:20 a.m. revealed Dietary Aide A and [NAME] C were wearing hair restraints which did not completely cover their long hair. Dietary Aide A was washing dishes in the kitchen and [NAME] C was standing in the kitchen. Both Dietary Aide A and [NAME] C had long hair which hung free, out the side of their hair restraints.<BR/>An observation on 1/11/2023 at 10:22 a.m. revealed [NAME] A pureed vegetable, washed the food processor in the three compartment sink, then proceeded to prepare mashed potatoes without changing gloves or washing her hands. <BR/>In an interview on 1/11/2023 at 10:35 a.m., when asked if gloves should be changed and hands washed when going from doing dishes to cooking, [NAME] A stated, yes. [NAME] A stated, I thought I washed my hands but if I didn't do that, please forgive me. <BR/>An observation on 1/11/2023 at 10:37 a.m. revealed [NAME] B was making sandwiches in the kitchen and wearing a hair restraint which did not completely cover her long hair. [NAME] B was observed with strands of hair coming out the side of her hair restraint.<BR/>In an interview on 1/11/2023 at 10:37 a.m., when asked if all of her hair was covered, [NAME] B communicated she did not understand in English by stating, I only understand a little bit.<BR/>In an interview on 1/11/2023 at 10:40 a.m., when asked if all of his hair was covered, Dietary Aide A stated, no. When asked if it should be, Dietary Aide A stated, probably, yeah. <BR/>In an interview on 1/11/2023 at 10:43 a.m., when asked if his hair was completely covered by the hair restraint, [NAME] C stated, is it not? and then said, I'll go take care of it. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:44 a.m. revealed a bulk container of flour dated 11/1/2022 with the scoop stored inside the container on the flour. <BR/>An observation of the kitchen's dry storage area on 1/11/2023 at 10:45 a.m. revealed a bulk container of rice unlabeled and undated. <BR/>In an interview on 1/11/2023 at 10:45 a.m., the Dietary Supervisor stated he had worked in the facility for one year, had worked as manager for six months, and that was his first survey. <BR/>In an interview on 1/11/2023 at 10:49 a.m., the Dietary Supervisor stated kitchen staff were taught upon hire how to label and date food items. The Dietary Supervisor stated he had not completed any written in-service training with kitchen staff since he started as manager, and that most training on food storage and sanitation was completed via observation and demonstration. The Dietary Supervisor stated himself, another experienced employee or [NAME] D would train employees on food storage and sanitation. The Dietary Supervisor stated [NAME] D was the most experienced cook so that is why kitchen staff trained with him. The Dietary Supervisor stated kitchen staff were trained on labeling and dating via demonstration. The Dietary Supervisor stated as far as glove usage, hand washing, and use of hair restraints, training was completed verbally. The Dietary Supervisor stated all staff went through a new hire process which included reading and signing off on an employee hand guide which covered food storage and sanitation. <BR/>In an interview on 1/12/2023 at 8:46 a.m., the LD stated food should be properly sealed if it had been opened, there should be a label and date on items when they were opened, and items such as condiments should have an opened date. The LD stated food should be adequately covered to prevent contamination or exposure of food and food items should be sealed on top. The LD stated yes that all food items should have a label and a date unless it was an unopened, prepackaged item such as a health shake. When asked if food items should be discarded prior to their use-by dates, the LD stated, yes, it's good practice. The LD stated kitchen staff should have some type of covering to cover their hair to prevent contamination. When asked if hair should be completely covered, the LD stated, yes, ideally they should try to tuck all the hair in. The LD stated she would expect handwashing to occur any time before handling food items. When asked how kitchen staff were trained on food storage and sanitation, the LD stated she did not know and it would be a good question for the Dietary Supervisor. The LD stated off hand she did not know whether kitchen staff had been trained, stating, I would ask the Dietary Supervisor. When asked who monitored the kitchen for food storage and sanitation, the LD stated, it would be the Dietary Supervisor and I complete monthly kitchen audits and give any recommendations to the Dietary Supervisor or discuss them with the ADM. The LD stated she was not sure how the Dietary Supervisor monitored the kitchen but stated she monitored through monthly audits. When asked if she had noticed any concerns, the LD stated there had been ongoing education with labeling and dating. The LD stated she had completed verbal education with the Dietary Supervisor on this. When asked what potential negative outcomes there could be if kitchen polices on food storage and sanitation were not followed, the LD stated there could potentially be contamination of food items, foods could be served past their use-by dates, and there could be potential for foodborne illness. <BR/>In an interview on 1/12/2023 at 6:13 p.m., when asked what the facility's policy was on food storage, the ADM stated things needed to be labeled when they were opened, labeled with a use-by and open date, and discarded after seven days. When asked if kitchen staff should have all hair covered, the ADM stated, yes. When asked how hands should be washed when going from dirty dishes to preparing a pureed food item, the ADM stated the best thing would be to take the food processor to the person washing dishes to wash. The ADM stated it was best practice to wash hands before starting a new task.<BR/>A record review of the facility's undated policy titled Food Storage reflected the following:<BR/>Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. These containers can be mounted on caster or dollies. All containers must be legibly and accurately labeled.<BR/>6. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are no to be stored in the food containers, but are kept covered in a protected area near the containers. <BR/>15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded.<BR/>A record review of the facility's policy titled Food Preparation and Service dated 2001 reflected the following: <BR/>Policy Statement: Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.<BR/>4. Food service staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays.<BR/>6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks.<BR/>A record review of the facility's undated Employee Handbook reflected it covered use of hair restraints only, and did not cover handwashing, glove usage, or food storage. <BR/>A record review of the facility's Hand Washing Competency forms dated 10/04/2022, 11/19/2022, and 12/21/2022 reflected [NAME] A's handwashing skill had been demonstrated to show competency. These documents reflected how to wash hands but did not cover when to wash hands. <BR/>A record review of the LD's Sanitation Audit dated 11/04/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Ingredient bins, the LD commented, Recommend view for outdated bulk bin items, discard as appropriate. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that some items were missing labels and dates and some items were outdated. <BR/>A record review of the LD's Sanitation Audit dated 12/02/2022 reflected no was indicated next to Refrigerators: Food dated, labeled, and covered. Next to Covered/labeled/dated/old food discarded in the Refrigerator and Freezer section, the LD commented that items were missing labels and dates. <BR/>A record review of the FDA's 2017 Food Code reflected the following:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings<BR/>Hair Restraints<BR/>2-402.11 Effectiveness.<BR/>(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES.

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 development and transmission of communicable diseases and infections and follow accepted national standards for 4 of 9 staff (CNA J, CNA I, LVN B, HA) reviewed for infection control.<BR/>The facility failed to<BR/>-ensure CNA J performed hand hygiene before assisting Resident #5 with meals.<BR/>-ensure CNA I performed hand hygiene before assisting Resident #5 with meals.<BR/>-ensure LVN B performed hand hygiene before assisting Resident #76 with meals. <BR/>-ensure HA performed hand hygiene between passing trays to residents.<BR/>These deficient practices placed residents at risk of transmission and/or spread of infection.<BR/>The findings included:<BR/>Observation on 01/10/23 at 12:09PM, the HA passed a tray to Resident #54 and touched part of the clothes and did not perform hand hygiene and passed a tray to Resident #35. <BR/>Observation on 01/10/23 at 12:20PM, CNA J assisted Resident #72 get positioned up right in the chair by grabbing on the resident's clothes and arms and did not perform hand hygiene and assisted Resident #5 with meals. <BR/>Observation on 01/10/23 at 12:27PM, LVN B placed a dirty tray that was used on an empty cart and did not perform hand hygiene and grabbed a new tray with meals and gave it to Resident #76 and continued to assist Resident #76. <BR/>Observation on 01/11/23 at 12:59PM, CNA I moved Resident #76 from a table to another table and did not perform hand hygiene and began to assist Resident #5.<BR/>Interview on 01/10/23 at 1:03PM, CNA J stated she moves fast sometime and must have forgotten about hand washing. CNA J stated she should have washed hands and that it is to prevent infection and could get residents sick. CNA J stated she had been in-serviced on hand hygiene but cannot recall when.<BR/>Interview on 01/10/23 at 1:22PM, LVN B stated it was her first time working and had she had not assisted with meals before. LVN B stated the impact of not washing hands could introduce germs she might have on her hands to other residents. LVN B stated she had in-service on hand hygiene by the DON about two weeks ago. <BR/>Interview on 01/12/23 at 1:28PM, CNA I stated she does not remember washing hands before assisting Resident #5. CNA I stated the impact of not performing hand hygiene could be some kind of infection.<BR/>Interview on 01/10/23 at 1:39PM, the HA stated she did not realize that she did not perform hand hygiene while passing tray between residents. The HA stated hand hygiene is to keep things sanitary and to prevent spread of germs. The HA stated she received in-service in December conducted by the DON. <BR/>Interview on 01/12/23 at 3:35PM, the ADON stated staff should perform hand hygiene before assisting residents with meals due to infection control. The ADON stated the impact of not performing hand hygiene could transfer bacteria into food and/or to the residents. <BR/>Interview on 01/12/23 at 5:30PM, the DON stated it is part of the employee's training to perform hand hygiene prior to assisting residents with care. The DON stated she does not know what impact it could have if employees do not perform hand hygiene prior to assisting residents with meals. <BR/>Interview on 01/12/23 at 6:12PM, the ADM stated his expectation of hand hygiene is that of the facility's policy. The ADM stated he cannot state what impact could occur due to failure of hand hygiene. <BR/>Review of facility's policy titled Handwashing/ Hand hygiene dated December 2009 reflected, 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: g. Before and after assisting a resident with meals.

Based on observation, interview the facility failed to ensure medications and biologicals were stored in the medication refrigerator located in 1 of 1 medication room. <BR/>The over-the-counter medication of Probiotics was stored in the locked refrigerator on the secure unit where food and open drink containers that belonged to staff were also being stored. <BR/>This facility failure placed the facility's residents at risk of being administered contaminated medication and or supplements. <BR/>Findings included:<BR/>Observation/ Interview on 03/17/2025 at 12:16 PM revealed the refrigerator located in the dining room on the secure unit had three bottles of 100 capsules of Probiotic over the counter medication stored on the shelf located in the door of the refrigerator with staff food and open drinks. LVN B stated the Probiotic medication was stored in the refrigerator on secure unit to be given to the residents resided on the secure unit. She stated she did receive in-service on medication policy but did not recall the date. <BR/>Interview on 03/17/2025 at 12:20 PM CNA E stated all the staff had access to the refrigerator where the Probiotics were stored. She stated the staff kept their food and drinks in the same refrigerator where medications were stored on secure unit . She stated she did received in-service on medications were to be locked but did not recall the date of the in-service. <BR/>Observation on 03/17/2025 at 12:24 PM revealed there was not a refrigerator temperature log located on the secure unit. <BR/>Interview on 03/17/2025 at 12:26 PM LVN B stated they did not keep temperatures of the refrigerator. She stated she never documented the temperature of the refrigerator on any type of paper log or in the computer system. <BR/>Interview on 03/17/2025 at 12:28 PM CNA E stated she was not aware of any temperature log for the refrigerator on secure unit. She stated all staff on the secure unit had access to the refrigerator in the dining room on the secure unit. She stated the key was usually with the nurse. <BR/>Interview on 03/17/2025 at 12: 40 PM The Director of Nurses stated the Probiotic over the counter medication was expected to be stored in the medication refrigerator in the medication room. She stated the medication room was not located on the secure unit. The Director of Nurses stated she did not know if all staff had access to the locked refrigerator on the secure unit. She stated all refrigerated medication was not to be stored with staff food and drinks. She stated it was not in best nursing practice to store medication in any refrigerator except the medication refrigerator. She stated nurse administration was responsible for training staff on medication storage facility protocol. Requested the medication storage policy and it was not provided at time of exit.

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 development and transmission of communicable diseases and infections and follow accepted national standards for 4 of 9 staff (CNA J, CNA I, LVN B, HA) reviewed for infection control.<BR/>The facility failed to<BR/>-ensure CNA J performed hand hygiene before assisting Resident #5 with meals.<BR/>-ensure CNA I performed hand hygiene before assisting Resident #5 with meals.<BR/>-ensure LVN B performed hand hygiene before assisting Resident #76 with meals. <BR/>-ensure HA performed hand hygiene between passing trays to residents.<BR/>These deficient practices placed residents at risk of transmission and/or spread of infection.<BR/>The findings included:<BR/>Observation on 01/10/23 at 12:09PM, the HA passed a tray to Resident #54 and touched part of the clothes and did not perform hand hygiene and passed a tray to Resident #35. <BR/>Observation on 01/10/23 at 12:20PM, CNA J assisted Resident #72 get positioned up right in the chair by grabbing on the resident's clothes and arms and did not perform hand hygiene and assisted Resident #5 with meals. <BR/>Observation on 01/10/23 at 12:27PM, LVN B placed a dirty tray that was used on an empty cart and did not perform hand hygiene and grabbed a new tray with meals and gave it to Resident #76 and continued to assist Resident #76. <BR/>Observation on 01/11/23 at 12:59PM, CNA I moved Resident #76 from a table to another table and did not perform hand hygiene and began to assist Resident #5.<BR/>Interview on 01/10/23 at 1:03PM, CNA J stated she moves fast sometime and must have forgotten about hand washing. CNA J stated she should have washed hands and that it is to prevent infection and could get residents sick. CNA J stated she had been in-serviced on hand hygiene but cannot recall when.<BR/>Interview on 01/10/23 at 1:22PM, LVN B stated it was her first time working and had she had not assisted with meals before. LVN B stated the impact of not washing hands could introduce germs she might have on her hands to other residents. LVN B stated she had in-service on hand hygiene by the DON about two weeks ago. <BR/>Interview on 01/12/23 at 1:28PM, CNA I stated she does not remember washing hands before assisting Resident #5. CNA I stated the impact of not performing hand hygiene could be some kind of infection.<BR/>Interview on 01/10/23 at 1:39PM, the HA stated she did not realize that she did not perform hand hygiene while passing tray between residents. The HA stated hand hygiene is to keep things sanitary and to prevent spread of germs. The HA stated she received in-service in December conducted by the DON. <BR/>Interview on 01/12/23 at 3:35PM, the ADON stated staff should perform hand hygiene before assisting residents with meals due to infection control. The ADON stated the impact of not performing hand hygiene could transfer bacteria into food and/or to the residents. <BR/>Interview on 01/12/23 at 5:30PM, the DON stated it is part of the employee's training to perform hand hygiene prior to assisting residents with care. The DON stated she does not know what impact it could have if employees do not perform hand hygiene prior to assisting residents with meals. <BR/>Interview on 01/12/23 at 6:12PM, the ADM stated his expectation of hand hygiene is that of the facility's policy. The ADM stated he cannot state what impact could occur due to failure of hand hygiene. <BR/>Review of facility's policy titled Handwashing/ Hand hygiene dated December 2009 reflected, 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: g. Before and after assisting a resident with meals.

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 development and transmission of communicable diseases and infections and follow accepted national standards for 4 of 9 staff (CNA J, CNA I, LVN B, HA) reviewed for infection control.<BR/>The facility failed to<BR/>-ensure CNA J performed hand hygiene before assisting Resident #5 with meals.<BR/>-ensure CNA I performed hand hygiene before assisting Resident #5 with meals.<BR/>-ensure LVN B performed hand hygiene before assisting Resident #76 with meals. <BR/>-ensure HA performed hand hygiene between passing trays to residents.<BR/>These deficient practices placed residents at risk of transmission and/or spread of infection.<BR/>The findings included:<BR/>Observation on 01/10/23 at 12:09PM, the HA passed a tray to Resident #54 and touched part of the clothes and did not perform hand hygiene and passed a tray to Resident #35. <BR/>Observation on 01/10/23 at 12:20PM, CNA J assisted Resident #72 get positioned up right in the chair by grabbing on the resident's clothes and arms and did not perform hand hygiene and assisted Resident #5 with meals. <BR/>Observation on 01/10/23 at 12:27PM, LVN B placed a dirty tray that was used on an empty cart and did not perform hand hygiene and grabbed a new tray with meals and gave it to Resident #76 and continued to assist Resident #76. <BR/>Observation on 01/11/23 at 12:59PM, CNA I moved Resident #76 from a table to another table and did not perform hand hygiene and began to assist Resident #5.<BR/>Interview on 01/10/23 at 1:03PM, CNA J stated she moves fast sometime and must have forgotten about hand washing. CNA J stated she should have washed hands and that it is to prevent infection and could get residents sick. CNA J stated she had been in-serviced on hand hygiene but cannot recall when.<BR/>Interview on 01/10/23 at 1:22PM, LVN B stated it was her first time working and had she had not assisted with meals before. LVN B stated the impact of not washing hands could introduce germs she might have on her hands to other residents. LVN B stated she had in-service on hand hygiene by the DON about two weeks ago. <BR/>Interview on 01/12/23 at 1:28PM, CNA I stated she does not remember washing hands before assisting Resident #5. CNA I stated the impact of not performing hand hygiene could be some kind of infection.<BR/>Interview on 01/10/23 at 1:39PM, the HA stated she did not realize that she did not perform hand hygiene while passing tray between residents. The HA stated hand hygiene is to keep things sanitary and to prevent spread of germs. The HA stated she received in-service in December conducted by the DON. <BR/>Interview on 01/12/23 at 3:35PM, the ADON stated staff should perform hand hygiene before assisting residents with meals due to infection control. The ADON stated the impact of not performing hand hygiene could transfer bacteria into food and/or to the residents. <BR/>Interview on 01/12/23 at 5:30PM, the DON stated it is part of the employee's training to perform hand hygiene prior to assisting residents with care. The DON stated she does not know what impact it could have if employees do not perform hand hygiene prior to assisting residents with meals. <BR/>Interview on 01/12/23 at 6:12PM, the ADM stated his expectation of hand hygiene is that of the facility's policy. The ADM stated he cannot state what impact could occur due to failure of hand hygiene. <BR/>Review of facility's policy titled Handwashing/ Hand hygiene dated December 2009 reflected, 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: g. Before and after assisting a resident with meals.