Briarcliff Nursing and Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #1) reviewed for abuse. <BR/>The facility failed to prevent CNA A, from verbally abusing Resident #1 on 04/29/24 when she referred to her as ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you).<BR/>This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.<BR/> Record review of Resident #1's admission record dated 01/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included vascular dementia (a type of dementia caused by brain damage from impaired blood flow to the brain), Parkinson's disease (A brain disorder that causes movement problems, including shaking, difficulty walking, and rigidity in muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).<BR/>2) <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had been coded a 2 for speech clarity which indicated Resident#1 had no speech (absence of spoken words). She had been coded a 3 for making herself understood and ability to understand others which indicated Resident #1 rarely/never understood. Resident #1 did not have a BIMS score which indicated she was rarely/never understood. <BR/>Record review of Resident #1's quarterly care plan dated 12/04/24 reflected Resident #1 had a communication problem related to dementia. Resident #1 was unable to express clear thought and rarely never understood. Date initiated 09/02/23 and revised on 12/28/23. Her interventions were to monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed.<BR/>An observation on 01/28/25 at 1:29 p.m., Resident #1 was observed lying in bed awake. She was listening to the radio swaying side to side. She was did not respond to this surveyor's questions. She was quiet with no facial expression. <BR/>An attempted telephone interview on 01/28/25 at 2:27 p.m., CNA A did not answer.<BR/>An attempted telephone interview on 01/29/25 at 8:05 a.m., CNA A did not answer.<BR/>An interview on 01/28/25 at 5:04 p.m., Administrator said the cooperate hotline had received an anonymous complaint alleging CNA A was being verbally abusive towards Resident #1. She said the Assistant Administrator had completed the investigation. She said CNA A had admitted to using inappropriate language with greeting Resident #1. She said her number one priority was the safety and welfare of the residents. She said the facility took immediate action and CNA A was suspended on 04/29/24 and then later she was terminated. She said she had no knowledge of CNA 's behavior prior to 04/29/24. She said all staff were trained on ANE and how to speak to residents. The Administrator said, Resident #1 was non-verbal which to her was a concern because there was no way for her to say if she had been offended by CNA A's comment. She said CNA A's behavior was inappropriate and had been terminated to avoid any other resident being put at risk. <BR/>Record review of Resident #1's admission census reflected she was housed in the 200 hall on 04/29/24.<BR/>Record review of the Assistant Administrator's investigation summary completed on 05/16/24 reflected, that an anonymous report had been made to the facility's compliance line identifying CNA A had used profanity and vulgar language with residents. The facility's response included the alleged perpetrators were suspended (pending the investigation), abuse coordinator was informed, the facility reported to state, the facility-initiated an investigation which included interviews with direct and indirect care staff, residents, and family members. Head-to-toe assessments were initiated on all residents of 100 and 200 halls for any signs or symptoms of distress, and staff were in-serviced on ANE, professional communication, and resident care. The investigation summary reflected; upon interviewing [CNA A], it was identified that she acknowledged using bad words with her communication with Resident #1. CNA A stated she, on occasions, would greet Resident #1 using Spanish-language connotations of the word stupid. CNA A stated she would not use the word in an offensive manner, but instead used the word in part of her greeting [Resident #1] in a joking and loving manner. It was [CNA A] interpretation that the words were well-received by the resident because [Resident #1] would smile when she saw her. [CNA A] stated she felt her greetings and interactions cheered-up [Resident #1]. [CNA A] recognized that her communication may be offensive to [Resident #1] and others . Resident and residents' family interviews revealed no concerns of abuse or neglect. Monitoring of all residents in 100 and 200 halls did not identify any other concerns. Staff interviews revealed no concerns of abuse or neglect. No evidence of physical or emotional harm was identified. The IDT team concluded that the allegations of abuse was confirmed. Provider actions taken post-investigation included, CNA A had been terminated, the Administrator and Assistant Administrator re-educated 100 % of facility staff on the topics of ANE and professional communication. Staff were provided with the contact numbers for the administrator, ombudsman, and compliance hotline. Staff on leave were re-educated prior to the start of their next scheduled shift. The administrator/designee would conduct quarterly and as needed education to ensure facility staff remained knowledgeable on the identification and reporting of abuse, neglect, and exploitation. A media alert was sent to all employee's with the request to report any concerns without the fear of retaliation. A second media alert was sent to all employees with the contact information of the Ombudsman. A media alert was sent out to representative of the residents with the information n to report any concerns. <BR/>Record review of CNA A's statement written by the Assistant Administrator on 04/29/24 reflected, she had worked the 200 hall on said day. CNA A acknowledged she had used some words that could be interpreted as offensive to the recipient or others. CNA A acknowledged that on several occasions, she had greeting Resident #1 with a phrase of ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you). CNA A said she had used that phrase in a joking and loving manner and not to offend the resident. CNA A said she believed her words were well received by Resident #1 as she would smile when she would see her. CNA A said she would sing the phrase to Resident #1, and it would cheer her up. <BR/>Record review of CNA A's employee counseling report dated 05/06/24 reflected an other offence of a violation of any other policy or procedure contained in Employee Manual: Allegation of abuse.<BR/>Record review of CNA A's NAR search dated 04/08/24 reflected she had an active status (certification was current) and was not listed on the EMR. <BR/>Record review of facility's Resident abuse interview and observation sheets conducted between 04/29/24 through 05/01/24 reflected all residents in the 100 and 200 hall had been interviewed and observed with no concerns of abuse voiced. <BR/>Record review of the facility's in-service training report dated 04/29/24 reflected staff were in-serviced on the topics of ANE and professional communication.<BR/>An interview on 01/29/25 at 1:15 p.m. The DON said CNA A was re-hired on 04/07/2024 and terminated on 05/06/24. <BR/>An interview on 01/29/25 at 4:40 p.m., LVN B said she had conducted resident assessments on all residents in the 100 and 200 halls on 04/29/24 through 05/01/24. She said no concerns of abuse or neglect had been voiced and no residents had been observed to be in emotional distress. LVN B said Resident #1expressed herself by using facial expressions (smiling or grimacing). She said on 04/29/24, when Resident #1 was observed she had not shown any signs of being in distress. <BR/>Record review of CNA A's Student and Group Transcript Report reflected she had last been in-serviced on the topic of effective communication, reporting abuse, abuse, and neglect on 04/08/24. <BR/>Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected:<BR/>Policy:<BR/>It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.<BR/>Definitions:<BR/>Verbal Abuse: means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.<BR/>IV. Identification of Abuse, Neglect and Exploitation<BR/> B. Possible indicators of abuse include, but are not limited to:<BR/>1. Resident, staff, or family report of abuse<BR/>5. Verbal abuse of a resident overheard<BR/>VII. Reporting/Response<BR/>A. The facility will have written procedures that include:<BR/>1. Reporting oa all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #5) reviewed for abuse. <BR/>1)The facility failed to ensure CNA F communicated Resident #5's allegation of abuse on 11/17/24. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/20/24 and ended on 11/20/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.<BR/>The findings included: <BR/> Record review of Resident #5's admission record dated 1/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction (when blood flow to the brain is disrupted, which can lead to brain cell death), aphasia (a neurological disorder that impairs a person ' s ability to communicate), and mild intellectual disabilities. Resident #5 was discharged home with home health on 01/14/2025. <BR/>Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected she had short-term memory problem and cognitive skills for daily decision making were severely impaired. <BR/>Record review of intake investigation worksheet, for Resident #5 revealed On 11/17/24 at about 8-9 am CNA F when into resident's room to pick up breakfast tray and saw that resident seemed sad. Asked her how it went when she went out on pass with her sister. Resident began to cry and stated that she was hit while out on pass by her nephews. Did not go into detail about incident. When asked if she wanted to speak with someone, she stated no. During the rest of the shift resident remained sad. During incontinent care and care CNA did not see any visible injuries. Facility made aware of allegation on 11/20/24 and resident is currently out on pass with sister. Family to be called to have resident return to facility. Upon arrival, police will be called, head to toe assessment will be conducted, interview to be done with resident.<BR/>In an interview on 1/29/25 at 11:30 am with the police officer, he said no crime was discovered. He said they spoke to the resident, resident's family and staff and found that the resident may have referred to an incident that happened years ago, nothing recent. <BR/>In an interview on 1/29/25 at 12:30 pm with the facility's Social Services, she said she recalls CNA F reported to a nurse when CNA F returned to work on 11/20/24 and the nurse told her to talk to me. CNA F said she did not tell anyone because she was doing work and while she was off, she thought about it, and she told the nurse when she returned. Social Services said she called the administrator, and she took over from there. She said Resident #5 was out on pass so could not interview her. Social Services said she called the family member to bring the resident back so they could assess her. Social Services said she asked the family member if any males were around the resident and the family member denied. The family member said Resident #5 was never alone, she was always with the family member. Social Services said they called the PD, and they took a statement from Resident #5. Social Services said the resident denied allegations of abuse to police and the family also denied. Social Services said Resident #5 also denied allegations to her. Social Services said the police talked to the family, RP, resident, and staff. Social Services said she completed the one-to-one with CNA F. <BR/>In an interview on 1/29/25 at 5:54 pm with CNA F she said Resident #5 had gone on pass with a family member on 11/17/24. When Resident #5 returned, CNA F said she asked how it went, and Resident #5 began to cry. CNA F said Resident #5 said someone hit her while out on pass. She said it was the sobrinos (nephews). CNA F said after Resident #5 reported that to her, she never commented on it again. CNA F said Resident #5 went out on pass again on 11/20/24 with family and everything was normal. CNA F said she did not report to anyone at the time because it was a Sunday, and no one was there except a new nurse. CNA F said she got busy after she came out of the resident ' s room, so she forgot to report. She said after work that day she was off. CNA F said when she returned to work, she reported it to the nurse and then it was reported to the administrator. CNA F said she completed an Abuse, Neglect and Exploitation in-service after the incident, and they also completed a one-on-one. She said they ask them about the types of abuse and tell them who to report to. She said she should first report to the administrator. She said they tell them to report immediately. She said they tell them if the administrator is not there, they must report to Social Services or a nurse. She said allegations of abuse were not reported; she could lose her certification. She said residents could also continue to get abused. <BR/>In an interview on 1/30/25 at 11:05 am with LVN H, said she worked with resident the night shift of 11/17/24 to 11/18/24. She said Resident #5 did not voice complaints or show distress. She said Resident #5 was in good spirits and while she was awake, there were no concerns, reports of abuse, or any emotional distress noted LVN H said when an incident happens on the day shift, they pass on report to her and she follows up or monitors the resident. LVN H said during in-services, they were informed they must report physical, verbal, or sexual abuse. She said they must report any abnormalites or suspiciouns they of staff or family. She said they must report these examples to the Administrator as soon as they suspect. She said they are informed of alternative people to report to if the Administrator is not available such as the ADON or DON.<BR/>In an interview on 1/30/25 at 1:56 with the DON, she said that prior to the incident they drilled staff on abuse, neglect and exploitation and the importance of reporting timely, so for her to have voiced it was because she was off after or whatever reason she gave made no sense. The DON said staff know the phone numbers for who they need to report to. The DON said they use alert media to inform staff of the importance of reporting abuse, how to report abuse, who to report it to and the importance of reporting immediately. The DON said they sent the staff the Ombudsman ' s number, and they provided staff the 1-800 number in case they wanted to report anonymously. DON said they also have people from outside the facility to come and do random interviews and ask questions about who the abuse coordinator was and how do they make a report, and they get back to the administration if anyone needs any intervention. The DON said they come in twice a week. The DON said they even printed out and laminated cards to place behind the staff ' s ID with all the information, along with the Recognize, Remove and Report card as well. The DON said on those cards it even says to report immediately. The DON said right after the incident, they in-serviced on abuse, neglect, and exploitation. <BR/>In an interview on 1/30/25 at 3:10 pm with the Administrator, she said all she remembered was that there was no excuse for that, especially since Resident #5 went out on pass again and they weren't aware. The Administrator could recall the exact date she went on pass again. The administrator said they did a one-to-one with CNA F. When this was brought to their attention, the family was interviewed and they insisted Resident #5 was not around any males at the home.<BR/>The Administrator was notified on 02/10/2025 at 11:15 am, that a past noncompliance Immediate Jeopardy situation had been identified due to the above failures. <BR/>It was determined these failures placed Resident #5 in an Immediate Jeopardy situation on 11/17/24. <BR/>The facility had corrected the noncompliance before survey began.<BR/>Record review of continuing education transcript for CNA F revealed completion of Abuse and Neglect training and Incident Reporting on 6/20/24 and 7/24/24 and training on Reporting Abuse Attestation on 6/20/24.<BR/>Record review of Staff Individual Inservice Record One to One (1:1) Procedure dated 11/20/24 revealed, <BR/>Subject: Abuse, Neglect and Ex;loitation<BR/>How to Correct<BR/>Employee re-educated on ANE and the importance of reporting any allegations of abuse immediately to facilites abuse coordinator.<BR/>Record review of In-Service Training Report dated 11/22/24 - ongoing for General Staff revealed, <BR/>Topic Abuse, Neglect and Exploitation (ANE) training<BR/>Contents or summary of training session .<BR/>Re-educated staff on Abuse, Neglect and Exploitation (ANE training<BR/>acts that constitute abuse, neglect, and exploitation,<BR/>signs and symptoms of abuse, neglect, and exploitation,<BR/>methods to prevent abuse, neglect, and exploitation, and<BR/>how to report. Abuse Coordinator<BR/>Three Rs: Recognize, Remove, Report.<BR/>It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.<BR/>Definitions:<BR/>Verbal Abuse: means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.<BR/>IV. Identification of Abuse, Neglect and Exploitation<BR/> B. Possible indicators of abuse include, but are not limited to:<BR/>1. Resident, staff, or family report of abuse<BR/>5. Verbal abuse of a resident overheard<BR/>VII. Reporting/Response<BR/>A. The facility will have written procedures that include:<BR/>1. Reporting oa all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #4 and Resident #6) of 11 residents reviewed for accuracy of assessments. <BR/>1.The facility failed to ensure Resident #4 was coded in the MDS for a fall on 2/28/24.<BR/>2.The facility failed to accurately identify Resident #6's unstageable pressure ulcer on her Discharge Return Anticipated MDS Assessment on 01/30/24. <BR/>This failure could place residents at risk of receiving inadequate care and services based on inaccurate assessments. <BR/>The findings included: <BR/>1. Record review of Resident #4's admission record dated 1/29/2025 reflected Resident #4 was an [AGE] year-old male originally admitted on [DATE] with diagnoses of Intervertebral Disc Disorders (the breakdown and degeneration of the cushions between the vertebrae in the spine), Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), muscle wasting and atrophy (the shrinking or wasting away of muscle), and age-related osteoporosis (a skeletal disorder characterized by a decrease in bone mass and density, leading to increased bone fragility and an elevated risk of fractures). <BR/>Record review of Resident #4's comprehensive care plan dated 4/26/24 reflected: <BR/>Resident #4 had an actual fall Date Initiated: 02/28/2024 <BR/>Interventions included: <BR/>&middot; <BR/> Continue interventions on the at-risk plan. <BR/>2-28-24: Resident s/p fall, sustained small, raised area to back of head, OT may <BR/>evaluate and treat, safety inspection to restroom area. 3/1 PT will eval and treat instead of OT. <BR/>Date Initiated: 02/29/2024 Revision on: 03/01/2024 <BR/>&middot; <BR/>CT scan as ordered. Date Initiated: 02/29/2024 <BR/>&middot; <BR/>Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, new onset: <BR/>confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 02/29/2024 <BR/>&middot; <BR/>Neuro-checks as ordered Date Initiated: 02/29/2024 <BR/>Record review of Resident #4 ' s Quarterly MDS dated [DATE] revealed: <BR/>BIMS Score of 15 indicating mental status cognitively intact. <BR/>Required supervision or touching assistance for lower body dressing. <BR/>Required partial/moderate assistance for eating, oral hygiene, toileting hygiene, shower/bathe self, and upper body dressing. <BR/>Required substantial/maximal assistance for putting on/taking off footwear and personal hygiene. <BR/>Section J1800 - Number of falls since Admission/Entry or Reentry or Prior MDS Assessment. The facility entered 0. <BR/>Record review of the facility's incident log not dated revealed that on 2/28/24, Resident #4 had a witnessed fall. No other information is noted on the facility log. <BR/>During an interview on 1/29/25 at 4:30 pm with MDS E, she said the fall would have been entered on the Quarterly MDS Resident #4 had done after the fall on 4/26/24. She said, the question for J 1800 said, has the resident had any falls since admission, entry or reentry or the prior assessment. She said that the answer shows no, and that she was responsible for doing that MDS. She said the answer should be marked yes. She said she cannot recall why yes was not marked. She said an annual or an admission MDS would trigger for them to do a care plan. She said it did not affect the quarterlies. She said, yes, I should have coded it. She said since it was a quarterly assessment for level of payment, it did not affect the patient. <BR/>During an interview on 1/30/25 at 2:20 pm with DON, she said she gets an email anytime an RMS is completed. She said they review information on falls and other items in the morning meetings with MDS. The DON said MDS should document at the meetings so they could update the MDS. The DON said they also have a weekly meeting where MDS must attend, and they get information on the falls that have happened within the week, as well as other occurrences. The DON said the MDS was not the driver for the care plans. She said it was their MD orders and care plan updates from the nurses. The DON said a fall not on the MDS might have an effect if a resident was transferred to another location as the form of communication of resident 's information from SNF to SNF. <BR/>Record review of CMS's RAI Version 3.0 Manual dated April 2012, reflected section: <BR/>J1800: Any falls since admission/entry or Reentry or Prior to Assessment. Has the resident had any falls since admission/entry or reentry or the prior assessment .? <BR/>0. No - Skip to K0100<BR/>1. Yes - continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment . <BR/>2.Record review of Resident #6 face sheet dated 01/30/25 revealed Resident #6 was admitted to facility on 01/12/24 with diagnoses of chronic kidney disease, stage 3 (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood), acute pulmonary edema (a condition where excess fluid accumulates in the lungs), and vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain).<BR/>Record review of Resident #6's comprehensive care plan revealed Resident #6 had an unstageable pressure ulcer to the sacrum initiated on 01/29/24 with interventions to monitor for healing and provide treatment as ordered. <BR/>Record review of Resident #6's Discharge returned anticipated MDS dated [DATE] revealed:<BR/> Resident #6 had had severe cognitive impairment,<BR/> Required substantial/maximal assistance to roll left and right, sit to lying, and sit to stand. <BR/>Section M0300 - Does this resident have one or more unhealed pressure ulcers/injuries? The facility entered 0. <BR/>In an interview on 01/30/25 at 1:08 p.m., MDS/LVN E was observed checking Resident #6's electronic medical record and stated on 01/29/24, D/C orders for the MASD to sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) and was diagnosed with an unstageable pressure ulcer to sacrum. She said she had completed the discharge MDS for Resident #6. MDS/LVN E said she did not include resident's unstageable ulcer on the discharge MDS. She said the MDS was just a tool used for billing and the one's that would trigger the care plan were the annual, significant changes or admissions MDS. MDS/LVN E said she should have coded section M as yes on section M-100 (Determination of Pressure Ulcer/Injury Risk), M-210 (Unhealed Pressure Ulcers/Injuries) and M-300 (Current Number of Pressure Ulcers/Injuries at Each Stage)/F (Unstageable-Slough and eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). She said there were no negative outcome because it was on the care plan. <BR/>In an interview on 01/30/25 at 3:42 p.m., DON said Resident #6 had constant diarrhea and the constant wiping caused excoriation to her skin. The wound doctor called it an unstageable wound. The NP called it Moisture Associated Dermatitis. The DON said they have morning meetings to discuss any change of condition. The meetings were for all nursing staff including MDS so they would receive any change in conditions for residents. <BR/>In an interview on 01/30/25 at approximately 5:00 p.m., the DON said the facility did not have a policy for the MDS. <BR/>Record review of CMS's RAI Version 3.0 dated October 2013, revealed section: <BR/>M0210: Does this resident have one or more unhealed pressure ulcers/injuries?<BR/>0. <BR/>No - skip to N0415, High-Risk Drug Classes: Use and indication<BR/>1. <BR/>Yes - Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries Each Stage<BR/>M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 4 residents (Resident #2 and Resident #3) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #2's and Resident #3's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. <BR/>These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.<BR/>Finding included:<BR/>Record review of Resident #2's face sheet dated 1/29/25 indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record Review of Resident #2's significant change Minimum Data Set assessment dated [DATE] indicated she received oxygen therapy while a resident.<BR/>Record review of Resident #2's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift related to respiratory failure with hypercapnia (is a condition where there is too much carbon dioxide).<BR/>Record review of Resident #2's comprehensive care plan, dated 5/1/24, indicates Resident #2 required oxygen therapy related to difficulty breathing. The intervention of the care plan was OXYGEN SETTINGS: O2 as ordered.<BR/>During an observation on 1/29/25 at 2:57 p.m., Resident #2 was lying in her bed with oxygen set at 3 liters per minute via nasal cannula. <BR/>Record review of Resident #3's face sheet dated 1/29/25 indicated he was an [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses which included Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record Review of Resident #3's significant change Minimum Data Set assessment dated [DATE] indicated he received oxygen therapy while a resident.<BR/>Record review of Resident #3's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift for Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record review of Resident #3's comprehensive care plan, dated initiated 6/27/2023, indicates Resident #3 required oxygen therapy related to Ineffective gas exchange. The intervention of the care plan was OXYGEN SETTINGS: O2 via nasal cannula at 2 liters per minute.<BR/>During an observation on 1/29/25 at 3:35 p.m. Resident's #3 was lying in his bed with oxygen set at 1.5 liters per minute via nasal cannula. <BR/>During an interview on 1/29/25 at 3:05 p.m., RN C said Resident #2's oxygen rate was at 3 liters per minute per nasal cannula. He said she was supposed to run at 2 liters per minute as per the physician order. RN C said, I notice that the settings were different from the order since I started working here back in October, I told the nurse that was training me, but he said that was fine because she has been like that since she was admitted . RN C said that by not following the physician's orders it could harm the resident, and that the resident could have shortness of breath, exacerbation or the resident could get ill. RN C said that the last training he had on oxygen was back in October when he was hired.<BR/>During an interview on 1/29/25 at 3:40 p.m., LVN D said that nurses were responsible to check every shift the oxygen settings at the beginning of the shift and at the end of the shift. LVN D said that if not administered correctly per order the resident could be harmed, have respiratory distress or the oxygen level could drop. LVN D said that the last training on oxygen was 3 months ago but could not remember the exact day.<BR/>During an interview on 1/29/25 at 4:50 pm ADON said that the nurses were responsible to check the oxygen settings every shift, especially with continuous oxygen use. ADON said that management made morning rounds each morning. The ADON said that an adverse reaction to the resident was that the oxygen level could drop, shortness of breath or change in respiratory status if not administered the appropriate oxygen ordered by the physician. ADON said that the last training on oxygen was done two months ago, and this training was done quarterly.<BR/>During an interview on 1/29/25 at 5:06 p.m., the DON said the charge nurses were responsible for following the physician's orders and to check oxygen settings at the beginning of the shift and as needed during the shift and at the end of the shift. She said that if not given the correct oxygen as the physician prescribed the Resident could have a change in condition or shortness of breath. DON said that managers make rounds every morning and before leaving to make sure oxygen settings were at the correct setting. <BR/>During an interview on 1/30/25 at 9:30 a.m., DON said that this facility does not have a policy on Oxygen Administration.<BR/>Record review of facility policy titled, Medication Reconciliation date implemented as of April 10, 2023, revealed This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent.<BR/>Daily Processes: Verify medications labels match physician orders and consider rights of medication administration each time a medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 4 Residents reviewed for accuracy and completeness of clinical records.<BR/>1. <BR/>The facility failed to ensure LVN A accurately documented that Resident #1 was currently on an anti-coagulant. <BR/>2. <BR/>The facility failed to ensure LVN A accurately documented neurological check findings for Resident #1 post fall. <BR/>These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record, dated 02/14/24, revealed an [AGE] year-old female with diagnoses of vascular dementia (a type of dementia that occurs when blood vessels in the brain are damaged, reducing blood flow and oxygen supply), hypertension (a chronic condition where the force of blood in your arteries is consistently too high), muscle wasting and atrophy (referring to the loss of muscle mass and strength, often occurring due to lack of physical activity, injury, malnutrition, or certain medical conditions, resulting in a decrease in muscle size and function), and unspecified atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and out of sync with the lower chambers). <BR/>Record review of Resident #1's care plan, dated 02/14/24, revealed Resident #1 was on anticoagulant medication therapy Xarelto (drugs that prevent blood clots or slow down the process of clotting) related to disease process of atrial fibrillation with interventions of monitor patient frequently for signs and symptoms of neurological impairment. If neurological compromise was noted, urgent treatment was necessary.<BR/>Record review of Resident #1's order summary, dated 02/14/24, revealed an order for: anticoagulant medication (Xarelto) - monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds. <BR/>Record review of Resident #1's MAR, dated 02/14/24, revealed the resident had an anticoagulant medication (Xarelto) ordered and was being administered such medication once daily since upon admission to facility on 02/14/24. <BR/>Record review of Resident #1's medication administration audit report, effective date 02/14/24 revealed the resident was being administered anticoagulant medication (Xarelto) daily since upon admission and the resident continued with anticoagulant medication therapy daily. <BR/>Record review of Resident #1's quarterly change MDS assessment, dated 05/02/24, revealed the Resident was on high-risk drugs class of anti-coagulants (Xarelto). Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired.<BR/>Record review of Resident #1's neurological checks dated 07/28/24 at 4:15pm, revealed Resident #1's pupils were not reactive to light after the first 15 minutes following the fall. On the next 15 minutes and thereafter, documentation reflected that Resident #1's pupils were reactive to light. <BR/>Record review of Resident's #1 progress notes entered by LVN A dated 07/28/24at 3:45pm, revealed the resident sustained an un-witnessed fall in her bedroom with immediate findings of left clavicle appearing swollen and hematoma-like to left side of forehead. LVN A also documented that resident #1 was not on an anti-coagulant. <BR/>During observation and interview on 01/23/25 at 3:12pm Resident #1 stated she remembered her shoulder was broken. She stated no further pain to the area. Resident #1 was unable to recall accurately how she fell. <BR/>During an interview on 01/23/25 at 3:41pm LVN A stated she recalled when Resident #1 sustained a fall on 07/28/24. Stated upon visual inspection, she noted Resident #1's shoulder was bulged out (swollen) and there was a hematoma to the left side of her forehead. LVN A stated she called the nurse practitioner on call and continued with fall protocol. Stated protocol included head to toe assessment, start neurological checks, and follow orders given by the doctor. LVN A stated she remembered NP C gave her orders for x-rays to the left shoulder, to continue with neurological checks, and order medication for pain. LVN A recalled NP C did not give orders to have Resident #1 taken to the hospital. LVN A stated that when residents were on an anti-coagulant, residents get sent to the hospital for CT scans. She stated that the doctor or nurse practitioners were the ones who determine if a resident was to be sent to the ER. LVN A stated she did not remember if she checked if the resident was on an anti-coagulant. LVN A stated that negative outcomes for not have documented correctly could have resulted in that Resident #1 could have had a slow brain bleed. <BR/>During an interview on 01/23/25 at 5:20pm NP C stated as per their own protocol, when a nurse called to report a resident fall, they were to always ask the nurse if the resident sustained a head injury and if the resident was on anti-coagulant. NP C stated that in her notes for the day of 07/28/24 when Resident #1 sustained the fall, she was informed of the injury to left shoulder and the hematoma to the left side of Resident #1's head. NP C stated her notes had no documentation having been informed if Resident #1 was on an anti-coagulant, however stated had she been informed, she would have sent Resident #1 to the emergency room for further evaluation. NP C stated that as part of her order for neurological checks, she informed LVN A to monitor and report back with any abnormal findings. <BR/>During an interview on 01/24/25 at 11:03am LVN A stated she did not remember having documented that Resident #1's pupils were not reactive to light in the first 15-minute neurological check. Stated it was a typo because had it been a true finding, she would have notified NP C of abnormal findings. She stated abnormal findings need to be reported right away. <BR/>During an interview on 01/24/25 at 1:30pm the DON said NP C had remote access to Resident #1's medical chart where NP C could have also verified Resident #1's medication record. The DON read LVN A's progress note for Resident #1's fall and stated she did not know why LVN A documented that Resident #1 was not on an anti-coagulant when Resident #1's medication record, order summary, and plan of care indicated Resident #1 was on an anti-coagulant. The DON stated any change of condition, such as an abnormal neurological check findings should have been reported to the nurse practitioner or doctor immediately. The DON stated she was responsible to follow up on documentation regarding abnormal findings however admitted she did not. The DON stated there could have been many negative outcomes for Resident #1 due to poor documentation. She stated Resident #1 could have suffered neurological damage. She stated continued neurological checks were part of the fall protocol and were ordered by NP C to continue so that any abnormal findings could be reported immediately. <BR/>Record review of the facility's policy titled Documentation in the Medical Record, dated 10/24/22, stated Each Resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Principles of documentation include but are not limited to: Documentation shall be factual, objective, and resident centered. False information shall not be documented. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents out of 6 (Resident #119, Resident #124, and Resident #205) and 1 shower bed (hall 300) out of 4 that were reviewed for safe environment.<BR/>1. <BR/>The facility failed to ensure bathroom sinks' hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #119, Resident #124, and Resident #205.<BR/>2. <BR/>The facility failed to ensure the shower bed in Hall 300 shower room was in good condition.<BR/>These failures could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries.<BR/>Findings Included:<BR/>During an observation on 03/24/2025 at 04:14 p.m. with the Maintenance Director and using the maintenance director's digital thermometer, the bathroom sink hot water temperatures were:<BR/>1.Resident #119's bathroom sink hot water temperature was 124 degrees Fahrenheit, Resident #124's hot water temperature was 118 degrees Fahrenheit and Resident #205's hot water temperature was 116 degrees Fahrenheit.<BR/>Record review of Resident #119's face sheet dated 03/24/2025 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with original admit date [DATE]. His pertinent diagnoses included Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), Mood Disorder, Muscle wasting and Atrophy (loss of muscle tissue), Peripheral Vascular Disease (reduced circulation of blood to a body part, other than the brain or heart), Essential Hypertension (high blood pressure).<BR/>Record review of Resident #119's quarterly MDS assessment, dated 03/06/2025 revealed a BIMS score of 05, indicating Resident #119 was severely cognitively impaired. He required minimal assistance for mobility.<BR/>Record review of Resident #119's care plan revised dated 03/11/2025 revealed he had limited physical mobility. Interventions: The resident was able to ambulate self with a walker. <BR/>Record review of Resident #124's face sheet dated 03/26/2025 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE], with original admission date 08/28/2023. His pertinent diagnoses included Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Type 2 Diabetes Mellitus, Muscle wasting and Atrophy (loss of muscle tissue), Essential Hypertension (high blood pressure), Anxiety Disorder.<BR/>Record review of Resident #124's quarterly MDS assessment, dated 01/25/2025 revealed a BIMS score of 03, indicating Resident #124 was severely cognitively impaired. He required supervision for mobility.<BR/>Record review of Resident #124's care plan revision dated 08/05/2024 revealed he had Alzheimer's. Interventions: the resident requires supervision for toileting hygiene. <BR/>Record review of Resident #205's face sheet dated 03/24/25 reflected the resident was a [AGE] year-old female with an admission of 01/15/24 and initial admit date of 10/10/23. Her relevant diagnoses included need for assistance with personal care, and lack of coordination.<BR/>Record review of Resident #205's quarterly MDS dated [DATE] reflected she had a BIMS score of 14, which revealed her cognition was intact.<BR/>In an interview on 3/24/2025 at 4:20 p.m. with the Maintenance Director, he stated that he has a maintenance assistant who does rounds every day in the morning. His assistant was not working this afternoon. He stated the assistant checks the water temperatures at least one room in each hall every day and the last time he checked them was this morning (3/24/2025). The Maintenance Director stated that his assistant documented the temperature readings on a paper, and he received it on Fridays. He stated if they were not within range, that he would get notified right away. The Maintenance Director stated the hot water temperature should be between 100-110 degrees Fahrenheit. The Maintenance Director stated the negative outcome of the water temperature being too hot in the resident's restroom was that the residents can get burned since they have thinner skin.<BR/>In an interview on 03/24/2025 at 5:02 p.m. with Resident #124, he stated that he does use the restroom sink and he has not been burned. He stated that he adjusted the water temperature before he used it.<BR/>In an interview on 03/24/25 at 5:30 p.m., Resident #205 said she used the sink in her restroom daily but had not sustained any burns. She said she would open the cold and hot water at the same time to wash her hands. <BR/>In an interview on 03/25/2025 at 2:08 p.m. with the maintenance assistant, he stated that he checks the water temperatures every day. He stated that he checks one room in each hall randomly. He then documents these temperatures in a paper log. He enters this information in TELS on Fridays. He gives this log to his supervisor, the maintenance director, at the end of the week. He stated if he gets an out-of-range reading, he calls his supervisor right away at the time. He stated the hot water temperature should be between 100-105 degrees Fahrenheit. He checked them yesterday, 03/24/2025 in the morning and the temperature was within range. He stated the hot water does not come out hot right away, but the residents can get burned.<BR/>In an interview on 03/26/2025 at 1:45 p.m. with Resident #119, he stated that he does use the restroom sink to wash his hands. He stated he had not been burned.<BR/>In an interview on 03/27/2025 at 10:10 a.m. with the Administrator, she stated that the maintenance assistant randomly checked the water temperatures daily and enters the temperatures weekly in TELS. She stated that she does not look at these temperatures unless she receives an alert. The alert would be triggered when the temperature was out of range. The range should be between 100 -110 degrees Fahrenheit. The administrator stated there had not been any residents burned by hot water in their rooms. She stated the plumber was here on Tuesday, 03/25/2025, troubleshooted the water heater and tested the room temperatures. She stated the negative outcome of the hot water being too hot was that the resident's skin could be affected. <BR/>Record Review of the Water Temperature Log dated 03/24/2025 revealed residents' rooms were within normal range between 106 to 110 degrees Fahrenheit. Further review of the TELS Logbook documentation for the week of 03/17/2025-03/21/2025 revealed minimal variation of temperature between 101 to 105 degrees Fahrenheit.<BR/>Review of facility's incident and accidents logs dated 01/2025, 02/2025, and 03/2025 did not reveal any injuries to residents due to hot water.<BR/>Review of the facility's Grievance logs dated 01/2025, 02/2025, and 03/2025 did not reveal any complaints of water temperature being too hot.<BR/>2. In an observation on 03/25/25 at 5:45 p.m., the shower bed in Hall 300 made of pvc (polyvinyl chloride) and a blue mesh fabric. It had a have a white and black film in the middle of the shower bed that extended from the top to the bottom of the bed. Parts of the mesh were worn out and frayed throughout the shower bed. <BR/>In an observation and interview on 03/25/25 at 5:00 p.m., with the Central Supply Director as he inspected the shower bed in the Hall 300 shower room. He said the mesh on the sides were frayed and could potentially cause the mesh to tear. He described the middle part of the shower bed as having mold, dirty and frayed. He said the bottom pan of the shower bed had water residue. He said it was the CNA's responsibility to inspect the shower beds as they were the ones that used them on a daily basis. He said in his opinion, the shower bed needed to be replaced. The Central Supply Director said no one had told him that particular shower bed had signs of wear and tear. He said if the Administrator approved a new shower bed he would be responsible for ordering one. The Central Supply Director was not able to say what negative outcome that shower bed would have on the residents. <BR/>In an observation and interview on 03/25/25 at 6:00 PM, the DON was observed as she inspected the shower bed. The first thing the DON said when she saw the shower bed was, oh it needs to be sanitized. She was not able to say what if anything was the negative outcome to the residents in hall 300 for having a shower bed with frayed and dirty mesh. She said it was the responsibility of the CNAs to report any wear and tear to the administration. The DON said she had not been informed by any staff member that the shower bed was not in good condition. <BR/>In an observation and interview on 03/25/25 at 6:07 p.m., the Administrator said after seeing the shower bed that it needed to be taken out of commission and replaced. She said the frayed mesh needed to be replaced. She said she would be authorizing the Central Supply Director to order a new shower bed immediately. The Administrator said she had not been informed by any staff member that the shower bed was showing signs of wear and tear. She was not able to say if there were any negative outcomes to residents for having a shower bed that needed to be replaced. The Administrator said the facility did not have a policy related to shower beds. <BR/>In an interview on 03/26/25 at 8:15 am, CNA P said she used the shower room in hall 300. She said she had not noticed the shower bed needed repair. She said if she had noticed the shower bed needed repairs she would have immediately reported it to her charge nurse or the DON. She said she was regularly in-serviced on the topic of reporting anything that needed to be repaired as soon as possible to her charge nurse or administration in order to avoid resident accidents. <BR/>Review of the facility's Instructions Direct Supply TELS provided the following information:<BR/>1. Ensure patient room water temperatures are between 100 degrees and 110 degrees Fahrenheit or as specified by state requirement).<BR/> Texas 100-110 degrees Fahrenheit<BR/>5. Common area bathrooms, public bathrooms and any other areas having sinks should be checked and recorded as well. <BR/>Record results in the water temperature log<BR/>1. <BR/>Note any discrepancies<BR/>2. <BR/>Adjust water heater setting as required<BR/>3. <BR/>Retest as necessary

**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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 10 residents (Resident #101 and Resident #82) reviewed for comprehensive person-centered care plans. <BR/> 1.The facility failed to develop a comprehensive person-centered care plan for Resident #101 to address assist feeding.<BR/>2. The facility failed to develop a comprehensive person-centered care plan for Resident #82 to address identifiable triggers to his active diagnosis of Post Traumatic Stress Disorder.<BR/>This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. <BR/>The Findings include:<BR/> Record review of Resident #101's face sheet, dated 3/25/2025, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #101 had a diagnosis which included: Vascular Dementia (a type of cognitive decline caused by damaged to the blood vessels in the brain), Alzheimer's disease (caused by problems with blood supply to the brain, leading to damage and impaired function, and often involves difficulties with thinking, planning and problem solving), Needs assistance with personal care.<BR/>Record review of Resident #101's Care Plan initiated on 5/11/23 reflected she has an ADL self-care deficit related to decreased cognition secondary to Alzheimer's Dementia, and Amnesia. Resident #101's functional performance with eating: the Resident requires (supervision/or touching assistance) for eating.<BR/>Record review of Resident #101's quarterly MDS assessment, dated 1/30/25, reflected a BIMS score of 00, which indicated Resident #00's cognition was severely impaired. Eating assistance was marked on the MDS as 04 which indicated supervision or touching assistance (helper provides verbal cues and/or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>During an observation on 3/24/25 at 12:00PM Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an observation on 3/25/25 at 5:00PM, Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an interview on 3/24/25 at 4:00PM with CNA I stated that Resident #101 needs assistance with feeding because she was not able to feed by herself because of the resident's had Alzheimer's. CNA I stated Resident #101 did not know how to use the utensils. CNA I stated resident had been fed with all meals.<BR/> During an interview on 3/26/25 at 11:35AM with RN L stated Resident #101 needed total assistance with feeding with all her meals because of the resident's Alzheimer's disease. RN L stated that a negative outcome of care plan not been accurate could place Resident#101 at risk for weight loss.<BR/> During an interview on 3/26/25 at 10:00 AM with LVN K, MDS nurse, stated that the resident was able to grab finger food. LVN K, MDS nurse stated that she did not know that resident needed a lot of assistance. LVN K, MDS nurse stated that she did not update the care plan because she was not aware that resident was being assisted with feeding every meal.<BR/>During an interview on 3/26/25 at 4:40 PM, the DON said she was not aware that resident was needing total assistance with feedings. DON said Resident#101's care plan had to be accurate and this way all staff could know what the resident needed.<BR/>2. Record review of Resident #82's face sheet dated 03/27/25 reflected resident was a [AGE] year-old male admitted to the facility on [DATE] with original admit date of 12/19/2019. His pertinent diagnoses included post-traumatic stress disorder (mental condition that develops after experiencing or witnessing a traumatic event, war, violent crime, or personal loss), bipolar (a disorder associated with episode of mood swings ranging from depressive to manic highs), dementia (a group of thinking and social symptoms that interferes with daily function), cognitive communication deficit (a group of conditions that affect a person's ability to communicate effectively due to underlying cognitive impairments), major depressive disorder ( mental condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), delusional disorder (mental illness that caused people to have unshakeable false beliefs for at least a month), and schizoaffective disorder (disorder that affects a person's ability to think, feel, and behave clearly).<BR/>Record review of Resident #82's quarterly MDS assessment dated [DATE] reflected his BIMS score question was left blank, indicating his cognition was severely impaired. His active psychiatric/mood disorder diagnoses included depression, bipolar disorder, schizophrenia, post-traumatic stress disorder and psychotic disorder (mental disorder characterized by a disconnection from reality). It further reflected he had physical (hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal (threatening others, screaming at others, cursing at others) and other behavioral (not directed towards others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) symptoms that occurred 1 to 3 days during the review period. <BR/>Record review of Resident #82's order summary reflected he had a diagnosis of post-traumatic stress disorder effective 03/25/21.<BR/>Record review of Resident #82's quarterly comprehensive care plan dated 03/06/25 reflected he:<BR/>1. <BR/>used to be a boxer and suffered from post-traumatic stress disorder (date initiated/revised 08/25/23). His interventions included to administer medications as ordered, behavioral health consults as needed, monitor/document/report PRN any risk for harm to self (date initiated 01/10/24), monitor/record/report to MD prn mood patters signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols (date initiated 11/24/23 and revised 11/25/23) and monitor/record/report to MD prn risk for harming other, increased anger, labile mood ( a neurological condition that involves rapid and exaggerated mood changes) or agitation, feels threatened by others or thoughts of harming someone (date initiated 01/10/24<BR/>2. <BR/>had a psychosocial well-being problem related to post-traumatic disorder, bipolar disorder, dementia, and schizoaffective disorder (dated initiated/revised 11/19/24). Interventions included to encourage participation from resident who depended on others to make his own decisions, increased communication between resident/family/caregivers about care and living arrangements, provide opportunities for the resident and family to participle in care, should conflict arise, remove resident to a calm safe environment and allow to vent/share feelings.<BR/>In an observation on 03/24/25 at 10:35 a.m., Resident #82 was observed lying in bed awake and mumbling to himself with a blank stare.<BR/>In an interview on 03/25/25 at 10:00 a.m., the SW said when a resident was admitted , they were screened for any trauma. She said Resident #82 was admitted to the facility on [DATE] and diagnosed with post-traumatic stress disorder on 03/25/21. She said she would have to review her records to see if he had any identifiable triggers.<BR/>In an interview on 03/26/25 at 8:00 a.m., CNA R said she had cared for Resident #82 for almost one year. She said since she had cared for him he had not displayed any behaviors. She said he was bed bound, required total assistance for all ADLs, and was not able to communicate. CNA R said she would round Resident #82 more frequently because he was not able to communicate or use the call light. She said by rounding more often than every 2 hours, staff could anticipate his needs better. <BR/>In an observation and interview on 03/26/25 at 8:11 a.m., LVN F said Resident #82 used to be a hospice patient but had recently been discharged from hospice. She said for the most part his way to communicate was to moan. LVN F said, it was rare but there had been times in which Resident #82 was able to answer yes or no but for the most part he would just moan. She said staff were able to meet his needs by making more rounds to his room and trying to anticipate his needs better. LVN F said Resident #82 had a diagnosis of post-traumatic disorder. She was observed as she reviewed Resident #82's care plan and said she was not able to find any triggers listed under his problem of post-traumatic stress disorder. She said CNAs and nursing staff would constantly monitor Resident #82 for any signs or symptoms of any behaviors not only because of his diagnosis of post-traumatic stress disorder but for all his other mental disorders. She said in her experience as a nurse, Resident #82 had not displayed any behaviors that she could identify as triggers. She said there were no negative outcome for Resident #82 not having any triggers identified on his care plan because staff were monitoring all his behaviors because of his overall mental disorders. LVN F said she would be in-serviced at least every 12 months on the topic of post-traumatic disorder. <BR/>In an interview on 03/26/25 at 10:30 a.m., LVN S-MDS said Resident #82 was the only resident in the facility with an active diagnosis of post-traumatic stress disorder. She said she had not included any triggers because there were no identifiable triggers for him. She said in her opinion, if a resident with an active diagnosis of post-traumatic disorder did not have any identifiable triggers their care plan should include a statement that reflected no identifiable triggers, which she acknowledged Resident #82's care plan did not. She said there were no negative outcome to Resident #82 not having triggers listed on his care plan, because he was being monitored for all his other mental disorders which included post-traumatic stress disorder. <BR/>In an interview on 03/26/25 at 4:08 p.m., the Social Worker said she had reviewed Resident #82' progress notes and his counseling notes but had not found any documentation that identified any triggers for his post-traumatic stress disorder. She said Resident #82 had been referred to counseling in the past for his diagnosis of bipolar. She said when Resident #82 was initially admitted , he had behavior problems like wanting to punch staff and other residents. She said since his admission, Resident #82's health had declined and at one point he was under hospice. She said he was no longer under hospice, but his health continued declining. She said Resident #82 was not able to communicate, was bed bound. She said she had not been told by staff Resident #82 displayed any behaviors that could be identified as triggers. She said when Resident #82 was initially admitted , he was in the secure unit. She said since his health declined, he was transferred to a regular room as he was no longer displaying any behaviors or able to ambulate. <BR/>In an interview on 03/26/25 at 4:27 pm the DON said the care Resident #82 received was based on his current physical status/psychosocial status. She said his diagnosis of post-traumatic stress disorder did not infringe in the care he received. She said there were no negative outcome to Resident #82 not having triggers identified on his care plan because his dementia was too advanced, and he was being monitored for any behavior issues. <BR/>In an interview on 03/27/25 at 8:45 am, the Nurse Practitioner (Psychiatry) said when Resident #82 had initially been admitted to the facility, staff had a very hard time trying to diagnose him. She said Resident #82 was very aggressive, agitated, and difficult to manage. She Resident #82 was not a very good historian and it had taken a long time to stabilize him. She said she diagnosed Resident #82 with post-traumatic stress disorder along with other mental issues after his admission. She said at the time of his diagnosis, she was not able to identify any triggers and focused on his other more severe mental disorders. She explained Resident #82 had been a boxer in his younger years and had also been kidnapped for several weeks and severely beaten up in another country. She said the resident has had a rapid decline in health and in her medical opinion, he is beyond the point of having identifiable triggers because his dementia is too advanced.<BR/>Record review of the Comprehensive Person-Centered Policy, date implemented 10/24/2022, read in part It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #13) reviewed for accidents and hazards: <BR/> The facility failed to ensure Resident #13 did not have disposable razors in his room.<BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.<BR/>The findings included:<BR/>Record review of Resident #13's admission record, dated 03/24/25, reflected a [AGE] year-old male admitted to facility on 11/14/24. His relevant diagnoses included the need for assistance with personal care, epilepsy (disorder in which nerve cells activity in the brain is disturbed causing seizures), and intellectual disabilities (below average intelligence and set of life skills). <BR/>Record review of Resident #13's quarterly MDS dated [DATE] reflected he had a BIMS score of 08, which indicated his cognition was moderately impaired.<BR/>Record review of Resident #13's quarterly care plan dated 02/09/25 reflected he had an ADL self-care performance deficit related to weakness, history of spinal fractures, poor balance. His interventions in part included functional performance of personal hygiene, Resident #13 required partial or moderate assistance for personal hygiene (date initiated 11/14/24 and revised on 11/23/24).<BR/>An observation on 03/24/25 at 11:14 a.m., Resident #13 was observed sitting on his wheelchair. Surveyor asked him for permission to inspect his restroom, and he consented. In the restroom sink there was one disposable razor with the lid still on. <BR/>In an interview on 03/24/25 at 11:17 a.m., Resident #13 said he had just come back from the shower room where he had been showered and shaved. He said at times he preferred to shave himself. He said he kept a bag of disposable razors in his dresser drawer. Resident #13 said whenever he decided to shave himself, the CNAs would pull out a new disposable razor from his drawer for him to use. <BR/>In an interview and observation on 03/24/25 at 1:00 p.m., CNA A said Resident #13 had been showered earlier that day by CNA B. She was observed walking into Resident #13's restroom where she acknowledged seeing a disposable razor on his sink, she said she did not know who had placed it there. She said Resident #13 was independent and at times would shave himself while a CNA would observe him. She said her shift began at 6 am that day and had made several rounds to Resident #13's room but had not noticed the disposable razor on the sink. CNA A was not able to explain the facility's protocol regarding sharps. <BR/>In an interview on 03/24/25 at 1:30 p.m., CNA B said she had showered Resident #13 earlier that day and she had also shaved him while in the shower room. She said she did not know who had placed a disposable razor in his bathroom. She said on 03/24/25, her duties were to shower residents only. <BR/>In an interview and observation on 03/24/25 at 5:32 p.m., RN C said the facility's protocol regarding razors were that they needed to be kept under lock and key in the shower room or in a medication cart. She said if a family member provided residents with razors, facility staff would label them and would place them under lock and key in the shower room or in a medication cart. She said residents were not allowed to keep razors in their rooms. RN C was observed as she checked Resident #13's dresser drawer and pulled out a plastic bag that contained 18 new disposable razors. RN C said the negative outcome for residents having razors in their rooms could be that they could cut themselves or others and if another resident wandered into their restroom, they too could cut themselves or others. RN C advised Resident #13 that she needed to place his disposable razors under lock and key.<BR/>In an interview on 03/24/25 at 5:42 p.m., the DON said residents were not allowed to keep razors in their rooms. She said razors should be kept under lock and key in the shower room or medication cart. The DON said a negative outcome to Resident #13 having a razor in his room could be that he could cut himself or others and if another resident walked into his room, they too could cut themselves or others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 4 residents (Resident #2 and Resident #3) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #2's and Resident #3's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. <BR/>These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.<BR/>Finding included:<BR/>Record review of Resident #2's face sheet dated 1/29/25 indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record Review of Resident #2's significant change Minimum Data Set assessment dated [DATE] indicated she received oxygen therapy while a resident.<BR/>Record review of Resident #2's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift related to respiratory failure with hypercapnia (is a condition where there is too much carbon dioxide).<BR/>Record review of Resident #2's comprehensive care plan, dated 5/1/24, indicates Resident #2 required oxygen therapy related to difficulty breathing. The intervention of the care plan was OXYGEN SETTINGS: O2 as ordered.<BR/>During an observation on 1/29/25 at 2:57 p.m., Resident #2 was lying in her bed with oxygen set at 3 liters per minute via nasal cannula. <BR/>Record review of Resident #3's face sheet dated 1/29/25 indicated he was an [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses which included Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record Review of Resident #3's significant change Minimum Data Set assessment dated [DATE] indicated he received oxygen therapy while a resident.<BR/>Record review of Resident #3's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift for Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record review of Resident #3's comprehensive care plan, dated initiated 6/27/2023, indicates Resident #3 required oxygen therapy related to Ineffective gas exchange. The intervention of the care plan was OXYGEN SETTINGS: O2 via nasal cannula at 2 liters per minute.<BR/>During an observation on 1/29/25 at 3:35 p.m. Resident's #3 was lying in his bed with oxygen set at 1.5 liters per minute via nasal cannula. <BR/>During an interview on 1/29/25 at 3:05 p.m., RN C said Resident #2's oxygen rate was at 3 liters per minute per nasal cannula. He said she was supposed to run at 2 liters per minute as per the physician order. RN C said, I notice that the settings were different from the order since I started working here back in October, I told the nurse that was training me, but he said that was fine because she has been like that since she was admitted . RN C said that by not following the physician's orders it could harm the resident, and that the resident could have shortness of breath, exacerbation or the resident could get ill. RN C said that the last training he had on oxygen was back in October when he was hired.<BR/>During an interview on 1/29/25 at 3:40 p.m., LVN D said that nurses were responsible to check every shift the oxygen settings at the beginning of the shift and at the end of the shift. LVN D said that if not administered correctly per order the resident could be harmed, have respiratory distress or the oxygen level could drop. LVN D said that the last training on oxygen was 3 months ago but could not remember the exact day.<BR/>During an interview on 1/29/25 at 4:50 pm ADON said that the nurses were responsible to check the oxygen settings every shift, especially with continuous oxygen use. ADON said that management made morning rounds each morning. The ADON said that an adverse reaction to the resident was that the oxygen level could drop, shortness of breath or change in respiratory status if not administered the appropriate oxygen ordered by the physician. ADON said that the last training on oxygen was done two months ago, and this training was done quarterly.<BR/>During an interview on 1/29/25 at 5:06 p.m., the DON said the charge nurses were responsible for following the physician's orders and to check oxygen settings at the beginning of the shift and as needed during the shift and at the end of the shift. She said that if not given the correct oxygen as the physician prescribed the Resident could have a change in condition or shortness of breath. DON said that managers make rounds every morning and before leaving to make sure oxygen settings were at the correct setting. <BR/>During an interview on 1/30/25 at 9:30 a.m., DON said that this facility does not have a policy on Oxygen Administration.<BR/>Record review of facility policy titled, Medication Reconciliation date implemented as of April 10, 2023, revealed This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent.<BR/>Daily Processes: Verify medications labels match physician orders and consider rights of medication administration each time a medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #66 and Resident #145) of 8 residents observed for infection control.<BR/>1. LVN F failed to sanitize hands before administering G-tube medications to Resident #66. <BR/>2. CNA O did not remove their contaminated gloves after catheter care prior to cleansing Resident #145 of bowel movement. CNA O proceeded to clean without performing hand hygiene and maintained usage of dirty gloves while cleaning posterior area and used the same gloves to apply a clean brief. <BR/>These deficient practices could place residents at-risk for healthcare associated cross contamination and the spread of infection due to improper care practices.<BR/>Findings included:<BR/>1. Record review of Resident #66's face sheet dated 03/26/2025 revealed the resident was a [AGE] year-old female admitted on [DATE] with an original admission date of 02/04/2020. Her pertinent diagnoses included Cerebral Infarction (stroke), Gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach), Dysphagia following Cerebral Infarction (difficulty swallowing following a stroke), Muscle wasting and Atrophy (loss of muscle tissue), and Type 2 Diabetes Mellitus.<BR/>Record review of Resident #66's quarterly MDS assessment, dated 02/04/2025 revealed a BIMS score of 00, indicating Resident #66 was severely cognitively impaired. <BR/>Record review of Resident #66's physician order summary dated 11/17/2022 revealed Resident #66 Enteral Feed Order every shift flush feeding tube with 30mls of water before and after medication administration.<BR/>Record review of Resident #66's comprehensive care plan, revision date 05/02/2024, reflected Resident #66 has a gastric tube r/t Dysphagia Interventions: Monitor/document/report as needed signs and symptoms of .infection at tube site.<BR/>During an observation in Resident #66's room on 03/25/2025 at 07:42 a.m. LVN F washed her hands then touched the privacy curtain and donned gloves without sanitizing her hands. She touched the bed remote with the gloves, to adjust the height of the bed, and with the same pair of gloves she proceeded to touch the resident's G-tube and administer the medications.<BR/>In an interview on 03/25/25 at 08:02 a.m. with LVN F, she stated that she did well during the G-tube medication administration. She stated she does not use hand sanitizer because her skin gets irritated and washes her hands instead. LVN F stated that she was supposed to wash her hands before administering medications. She stated sanitizing hands after touching the privacy curtain and touching the bed remote was important to prevent infection to the resident. LVN F stated that we carry microbes all over our hands and Resident #66's G-tube site was a port of entrance for infection. <BR/>In an interview on 03/26/2025 at 10:40 a.m. with ADON G, she stated staff were trained to sanitize hands in between glove changes and to perform hand hygiene using soap and water for 20 seconds if their hands were visibly soiled. She stated LVN F should have sanitized after touching the privacy curtain without gloves after washing her hands. ADON G stated that when it comes down to touching the resident's bed remote it was iffy because it was the residence germs and not anyone else's germs. She stated that they were to wash their hands with soap and water if hand sanitizer was causing irritation. She stated she has not had any staff voice that they could not use hand sanitizer due to causing irritation. She stated there were other various hand sanitizers readily available. ADON G stated it was important to sanitize or wash hands to break the chain of infection.<BR/>In an interview on 03/27/2025 at 10:59 a.m. with the DON, she stated staff were trained to sanitize hands before patient care, in between glove changes, and when done with care that they were providing. She stated the privacy curtains were dirty and staff was to sanitize hands afterwards. The DON stated after touching the bed control, staff was to remove gloves, sanitize hands, and don a new pair of gloves. She stated if staff hands get irritated with hand sanitizer, they were encouraged to use soap and water, but they also have aloe vera hand sanitizer. The DON stated that the staff should sanitize or wash their hands to prevent infection.<BR/>2. Record review of Resident #145's Face Sheet dated 03/24/2025 revealed an [AGE] year-old male admitted originally on 08/15/2024. His diagnoses included, chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), benign prostatic hyperplasia with lower urinary tract symptoms (a condition in which the prostate gland, located below the bladder in men, enlarges), retention of urine (the inability to completely empty the bladder).<BR/>Record review of Resident #145's Comprehensive Care Plan initiated: 08/15/2024 documented, Problem: [Resident #145] is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations. Interventions: functional performance with personal care: the resident requires partial/moderate assistance for personal hygiene.<BR/>Record review of Resident #145's MDS dated [DATE] documented a Brief Interview of Mental Status score of 12/moderately impaired cognition, as well as extensive dependency of staff to assist in activities of daily living. An indwelling urninary catheter was used.<BR/>During an observation on 03/25/2025 at 11: 09AM, observed Resident #145 had an indwelling urinary catheter. CNA O commenced catheter care of Resident #145. CNA O entered Resident #145's room after knocking. CNA O began with washing hands for 30 seconds, gloved up, and prepared the table of needed supplies. CNA O continued by raising the bed and then discarded gloves. After discarding the gloves, CNA O continued with applying hand sanitizer and she did apply new gloves. CNA proceeded with catheter care and proceeded to clean bowel movement. Once bowel movement was cleaned, using the same pair of gloves, she removed the brief, and applied a new brief.<BR/>During an interview on 03/25/2025 at 11: 28AM, CNA O stated that they should have changed those gloves after cleaning the foley catheter, to minimize contraction of infection. CNA O stated they should have washed hands/used hand sanitizer and changed gloves, before, during, and after care to minimize chance of infection. CNA O stated their recognition of error and proceeded to state it was noted as a standard of practice. CNA O stated that Resident #145 could get an infection because she did not change gloves when changing from one area to another area.<BR/>During an interview on 03/25/25 at 4:40PM with the DON, the DON stated that after perineum care, hand hygiene should have been performed prior to moving to the second part of cleaning of the bowel movement. The DON stressed the importance of infection prevention and stated that personnel were educated and observed by her performing specific care during checkoffs, before being allowed to work on the floor independently. The DON stated this practice could put Resident #145 at risk for urinary tract infection.<BR/>Record review of the facility's Hand Hygiene Policy dated 10/24/2022 revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub.<BR/>Record Review of the facility's Infection Prevention and Control Program Policy dated 05/13/23 revealed Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.<BR/>Policy Explanation and Compliance Guidelines:<BR/>2. All staff are responsible for following all policies and procedures related to the program.<BR/>Standard Precautions:<BR/>b. Hand Hygiene shall be performed in accordance with our facility's established hand hygiene procedures.<BR/>d. Licensed staff shall adhere to safe injection and medication administration practices as described in relevant facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #1) reviewed for abuse. <BR/>The facility failed to prevent CNA A, from verbally abusing Resident #1 on 04/29/24 when she referred to her as ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you).<BR/>This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.<BR/> Record review of Resident #1's admission record dated 01/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included vascular dementia (a type of dementia caused by brain damage from impaired blood flow to the brain), Parkinson's disease (A brain disorder that causes movement problems, including shaking, difficulty walking, and rigidity in muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).<BR/>2) <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had been coded a 2 for speech clarity which indicated Resident#1 had no speech (absence of spoken words). She had been coded a 3 for making herself understood and ability to understand others which indicated Resident #1 rarely/never understood. Resident #1 did not have a BIMS score which indicated she was rarely/never understood. <BR/>Record review of Resident #1's quarterly care plan dated 12/04/24 reflected Resident #1 had a communication problem related to dementia. Resident #1 was unable to express clear thought and rarely never understood. Date initiated 09/02/23 and revised on 12/28/23. Her interventions were to monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed.<BR/>An observation on 01/28/25 at 1:29 p.m., Resident #1 was observed lying in bed awake. She was listening to the radio swaying side to side. She was did not respond to this surveyor's questions. She was quiet with no facial expression. <BR/>An attempted telephone interview on 01/28/25 at 2:27 p.m., CNA A did not answer.<BR/>An attempted telephone interview on 01/29/25 at 8:05 a.m., CNA A did not answer.<BR/>An interview on 01/28/25 at 5:04 p.m., Administrator said the cooperate hotline had received an anonymous complaint alleging CNA A was being verbally abusive towards Resident #1. She said the Assistant Administrator had completed the investigation. She said CNA A had admitted to using inappropriate language with greeting Resident #1. She said her number one priority was the safety and welfare of the residents. She said the facility took immediate action and CNA A was suspended on 04/29/24 and then later she was terminated. She said she had no knowledge of CNA 's behavior prior to 04/29/24. She said all staff were trained on ANE and how to speak to residents. The Administrator said, Resident #1 was non-verbal which to her was a concern because there was no way for her to say if she had been offended by CNA A's comment. She said CNA A's behavior was inappropriate and had been terminated to avoid any other resident being put at risk. <BR/>Record review of Resident #1's admission census reflected she was housed in the 200 hall on 04/29/24.<BR/>Record review of the Assistant Administrator's investigation summary completed on 05/16/24 reflected, that an anonymous report had been made to the facility's compliance line identifying CNA A had used profanity and vulgar language with residents. The facility's response included the alleged perpetrators were suspended (pending the investigation), abuse coordinator was informed, the facility reported to state, the facility-initiated an investigation which included interviews with direct and indirect care staff, residents, and family members. Head-to-toe assessments were initiated on all residents of 100 and 200 halls for any signs or symptoms of distress, and staff were in-serviced on ANE, professional communication, and resident care. The investigation summary reflected; upon interviewing [CNA A], it was identified that she acknowledged using bad words with her communication with Resident #1. CNA A stated she, on occasions, would greet Resident #1 using Spanish-language connotations of the word stupid. CNA A stated she would not use the word in an offensive manner, but instead used the word in part of her greeting [Resident #1] in a joking and loving manner. It was [CNA A] interpretation that the words were well-received by the resident because [Resident #1] would smile when she saw her. [CNA A] stated she felt her greetings and interactions cheered-up [Resident #1]. [CNA A] recognized that her communication may be offensive to [Resident #1] and others . Resident and residents' family interviews revealed no concerns of abuse or neglect. Monitoring of all residents in 100 and 200 halls did not identify any other concerns. Staff interviews revealed no concerns of abuse or neglect. No evidence of physical or emotional harm was identified. The IDT team concluded that the allegations of abuse was confirmed. Provider actions taken post-investigation included, CNA A had been terminated, the Administrator and Assistant Administrator re-educated 100 % of facility staff on the topics of ANE and professional communication. Staff were provided with the contact numbers for the administrator, ombudsman, and compliance hotline. Staff on leave were re-educated prior to the start of their next scheduled shift. The administrator/designee would conduct quarterly and as needed education to ensure facility staff remained knowledgeable on the identification and reporting of abuse, neglect, and exploitation. A media alert was sent to all employee's with the request to report any concerns without the fear of retaliation. A second media alert was sent to all employees with the contact information of the Ombudsman. A media alert was sent out to representative of the residents with the information n to report any concerns. <BR/>Record review of CNA A's statement written by the Assistant Administrator on 04/29/24 reflected, she had worked the 200 hall on said day. CNA A acknowledged she had used some words that could be interpreted as offensive to the recipient or others. CNA A acknowledged that on several occasions, she had greeting Resident #1 with a phrase of ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you). CNA A said she had used that phrase in a joking and loving manner and not to offend the resident. CNA A said she believed her words were well received by Resident #1 as she would smile when she would see her. CNA A said she would sing the phrase to Resident #1, and it would cheer her up. <BR/>Record review of CNA A's employee counseling report dated 05/06/24 reflected an other offence of a violation of any other policy or procedure contained in Employee Manual: Allegation of abuse.<BR/>Record review of CNA A's NAR search dated 04/08/24 reflected she had an active status (certification was current) and was not listed on the EMR. <BR/>Record review of facility's Resident abuse interview and observation sheets conducted between 04/29/24 through 05/01/24 reflected all residents in the 100 and 200 hall had been interviewed and observed with no concerns of abuse voiced. <BR/>Record review of the facility's in-service training report dated 04/29/24 reflected staff were in-serviced on the topics of ANE and professional communication.<BR/>An interview on 01/29/25 at 1:15 p.m. The DON said CNA A was re-hired on 04/07/2024 and terminated on 05/06/24. <BR/>An interview on 01/29/25 at 4:40 p.m., LVN B said she had conducted resident assessments on all residents in the 100 and 200 halls on 04/29/24 through 05/01/24. She said no concerns of abuse or neglect had been voiced and no residents had been observed to be in emotional distress. LVN B said Resident #1expressed herself by using facial expressions (smiling or grimacing). She said on 04/29/24, when Resident #1 was observed she had not shown any signs of being in distress. <BR/>Record review of CNA A's Student and Group Transcript Report reflected she had last been in-serviced on the topic of effective communication, reporting abuse, abuse, and neglect on 04/08/24. <BR/>Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected:<BR/>Policy:<BR/>It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.<BR/>Definitions:<BR/>Verbal Abuse: means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.<BR/>IV. Identification of Abuse, Neglect and Exploitation<BR/> B. Possible indicators of abuse include, but are not limited to:<BR/>1. Resident, staff, or family report of abuse<BR/>5. Verbal abuse of a resident overheard<BR/>VII. Reporting/Response<BR/>A. The facility will have written procedures that include:<BR/>1. Reporting oa all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: .

**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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 10 residents (Resident #101 and Resident #82) reviewed for comprehensive person-centered care plans. <BR/> 1.The facility failed to develop a comprehensive person-centered care plan for Resident #101 to address assist feeding.<BR/>2. The facility failed to develop a comprehensive person-centered care plan for Resident #82 to address identifiable triggers to his active diagnosis of Post Traumatic Stress Disorder.<BR/>This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. <BR/>The Findings include:<BR/> Record review of Resident #101's face sheet, dated 3/25/2025, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #101 had a diagnosis which included: Vascular Dementia (a type of cognitive decline caused by damaged to the blood vessels in the brain), Alzheimer's disease (caused by problems with blood supply to the brain, leading to damage and impaired function, and often involves difficulties with thinking, planning and problem solving), Needs assistance with personal care.<BR/>Record review of Resident #101's Care Plan initiated on 5/11/23 reflected she has an ADL self-care deficit related to decreased cognition secondary to Alzheimer's Dementia, and Amnesia. Resident #101's functional performance with eating: the Resident requires (supervision/or touching assistance) for eating.<BR/>Record review of Resident #101's quarterly MDS assessment, dated 1/30/25, reflected a BIMS score of 00, which indicated Resident #00's cognition was severely impaired. Eating assistance was marked on the MDS as 04 which indicated supervision or touching assistance (helper provides verbal cues and/or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>During an observation on 3/24/25 at 12:00PM Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an observation on 3/25/25 at 5:00PM, Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an interview on 3/24/25 at 4:00PM with CNA I stated that Resident #101 needs assistance with feeding because she was not able to feed by herself because of the resident's had Alzheimer's. CNA I stated Resident #101 did not know how to use the utensils. CNA I stated resident had been fed with all meals.<BR/> During an interview on 3/26/25 at 11:35AM with RN L stated Resident #101 needed total assistance with feeding with all her meals because of the resident's Alzheimer's disease. RN L stated that a negative outcome of care plan not been accurate could place Resident#101 at risk for weight loss.<BR/> During an interview on 3/26/25 at 10:00 AM with LVN K, MDS nurse, stated that the resident was able to grab finger food. LVN K, MDS nurse stated that she did not know that resident needed a lot of assistance. LVN K, MDS nurse stated that she did not update the care plan because she was not aware that resident was being assisted with feeding every meal.<BR/>During an interview on 3/26/25 at 4:40 PM, the DON said she was not aware that resident was needing total assistance with feedings. DON said Resident#101's care plan had to be accurate and this way all staff could know what the resident needed.<BR/>2. Record review of Resident #82's face sheet dated 03/27/25 reflected resident was a [AGE] year-old male admitted to the facility on [DATE] with original admit date of 12/19/2019. His pertinent diagnoses included post-traumatic stress disorder (mental condition that develops after experiencing or witnessing a traumatic event, war, violent crime, or personal loss), bipolar (a disorder associated with episode of mood swings ranging from depressive to manic highs), dementia (a group of thinking and social symptoms that interferes with daily function), cognitive communication deficit (a group of conditions that affect a person's ability to communicate effectively due to underlying cognitive impairments), major depressive disorder ( mental condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), delusional disorder (mental illness that caused people to have unshakeable false beliefs for at least a month), and schizoaffective disorder (disorder that affects a person's ability to think, feel, and behave clearly).<BR/>Record review of Resident #82's quarterly MDS assessment dated [DATE] reflected his BIMS score question was left blank, indicating his cognition was severely impaired. His active psychiatric/mood disorder diagnoses included depression, bipolar disorder, schizophrenia, post-traumatic stress disorder and psychotic disorder (mental disorder characterized by a disconnection from reality). It further reflected he had physical (hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal (threatening others, screaming at others, cursing at others) and other behavioral (not directed towards others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) symptoms that occurred 1 to 3 days during the review period. <BR/>Record review of Resident #82's order summary reflected he had a diagnosis of post-traumatic stress disorder effective 03/25/21.<BR/>Record review of Resident #82's quarterly comprehensive care plan dated 03/06/25 reflected he:<BR/>1. <BR/>used to be a boxer and suffered from post-traumatic stress disorder (date initiated/revised 08/25/23). His interventions included to administer medications as ordered, behavioral health consults as needed, monitor/document/report PRN any risk for harm to self (date initiated 01/10/24), monitor/record/report to MD prn mood patters signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols (date initiated 11/24/23 and revised 11/25/23) and monitor/record/report to MD prn risk for harming other, increased anger, labile mood ( a neurological condition that involves rapid and exaggerated mood changes) or agitation, feels threatened by others or thoughts of harming someone (date initiated 01/10/24<BR/>2. <BR/>had a psychosocial well-being problem related to post-traumatic disorder, bipolar disorder, dementia, and schizoaffective disorder (dated initiated/revised 11/19/24). Interventions included to encourage participation from resident who depended on others to make his own decisions, increased communication between resident/family/caregivers about care and living arrangements, provide opportunities for the resident and family to participle in care, should conflict arise, remove resident to a calm safe environment and allow to vent/share feelings.<BR/>In an observation on 03/24/25 at 10:35 a.m., Resident #82 was observed lying in bed awake and mumbling to himself with a blank stare.<BR/>In an interview on 03/25/25 at 10:00 a.m., the SW said when a resident was admitted , they were screened for any trauma. She said Resident #82 was admitted to the facility on [DATE] and diagnosed with post-traumatic stress disorder on 03/25/21. She said she would have to review her records to see if he had any identifiable triggers.<BR/>In an interview on 03/26/25 at 8:00 a.m., CNA R said she had cared for Resident #82 for almost one year. She said since she had cared for him he had not displayed any behaviors. She said he was bed bound, required total assistance for all ADLs, and was not able to communicate. CNA R said she would round Resident #82 more frequently because he was not able to communicate or use the call light. She said by rounding more often than every 2 hours, staff could anticipate his needs better. <BR/>In an observation and interview on 03/26/25 at 8:11 a.m., LVN F said Resident #82 used to be a hospice patient but had recently been discharged from hospice. She said for the most part his way to communicate was to moan. LVN F said, it was rare but there had been times in which Resident #82 was able to answer yes or no but for the most part he would just moan. She said staff were able to meet his needs by making more rounds to his room and trying to anticipate his needs better. LVN F said Resident #82 had a diagnosis of post-traumatic disorder. She was observed as she reviewed Resident #82's care plan and said she was not able to find any triggers listed under his problem of post-traumatic stress disorder. She said CNAs and nursing staff would constantly monitor Resident #82 for any signs or symptoms of any behaviors not only because of his diagnosis of post-traumatic stress disorder but for all his other mental disorders. She said in her experience as a nurse, Resident #82 had not displayed any behaviors that she could identify as triggers. She said there were no negative outcome for Resident #82 not having any triggers identified on his care plan because staff were monitoring all his behaviors because of his overall mental disorders. LVN F said she would be in-serviced at least every 12 months on the topic of post-traumatic disorder. <BR/>In an interview on 03/26/25 at 10:30 a.m., LVN S-MDS said Resident #82 was the only resident in the facility with an active diagnosis of post-traumatic stress disorder. She said she had not included any triggers because there were no identifiable triggers for him. She said in her opinion, if a resident with an active diagnosis of post-traumatic disorder did not have any identifiable triggers their care plan should include a statement that reflected no identifiable triggers, which she acknowledged Resident #82's care plan did not. She said there were no negative outcome to Resident #82 not having triggers listed on his care plan, because he was being monitored for all his other mental disorders which included post-traumatic stress disorder. <BR/>In an interview on 03/26/25 at 4:08 p.m., the Social Worker said she had reviewed Resident #82' progress notes and his counseling notes but had not found any documentation that identified any triggers for his post-traumatic stress disorder. She said Resident #82 had been referred to counseling in the past for his diagnosis of bipolar. She said when Resident #82 was initially admitted , he had behavior problems like wanting to punch staff and other residents. She said since his admission, Resident #82's health had declined and at one point he was under hospice. She said he was no longer under hospice, but his health continued declining. She said Resident #82 was not able to communicate, was bed bound. She said she had not been told by staff Resident #82 displayed any behaviors that could be identified as triggers. She said when Resident #82 was initially admitted , he was in the secure unit. She said since his health declined, he was transferred to a regular room as he was no longer displaying any behaviors or able to ambulate. <BR/>In an interview on 03/26/25 at 4:27 pm the DON said the care Resident #82 received was based on his current physical status/psychosocial status. She said his diagnosis of post-traumatic stress disorder did not infringe in the care he received. She said there were no negative outcome to Resident #82 not having triggers identified on his care plan because his dementia was too advanced, and he was being monitored for any behavior issues. <BR/>In an interview on 03/27/25 at 8:45 am, the Nurse Practitioner (Psychiatry) said when Resident #82 had initially been admitted to the facility, staff had a very hard time trying to diagnose him. She said Resident #82 was very aggressive, agitated, and difficult to manage. She Resident #82 was not a very good historian and it had taken a long time to stabilize him. She said she diagnosed Resident #82 with post-traumatic stress disorder along with other mental issues after his admission. She said at the time of his diagnosis, she was not able to identify any triggers and focused on his other more severe mental disorders. She explained Resident #82 had been a boxer in his younger years and had also been kidnapped for several weeks and severely beaten up in another country. She said the resident has had a rapid decline in health and in her medical opinion, he is beyond the point of having identifiable triggers because his dementia is too advanced.<BR/>Record review of the Comprehensive Person-Centered Policy, date implemented 10/24/2022, read in part It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide foot care and treatmenet to maintain mobility and good foot health for 1 (Resident #2) of 1 residents reviewed for foot care services.<BR/>The facility failed to ensure Resident #2 received podiatry services as Resident #2's toenails were long (about an inch overgrown), not trimmed, and Resident #2 was not treated by the in-house podiatrist during their last visits.<BR/>This failure could place residents at risk of potential negative outcomes related to foot health including pain, discomfort, poor foot hygiene, or a decline in residents' physical condition.<BR/>The findings included: <BR/>Record review of Resident #2's file dated 10/09/24 reflected an [AGE] year-old female with an original admission date of 06/04/24. Her diagnoses included: unspecified dementia, type 2 diabetes, hypertension, mood disorder, delusional disorders, depression, insomnia, need for assistance with personal care, abnormalities of gait and mobility, cognitive communication deficit, and adult failure to thrive.<BR/>Record review of Resident #2's MDS dated [DATE] reflected a BIMS score of 3 (severe cognitive impairment). Resident #2 required partial/moderate assistance (helper does less than half the effort) for personal hygiene (combing hair, shaving, applying makeup, washing/drying face, and hands), was dependent (helper does all of the effort) to shower/bathe (bathe, wash, rinse, and dry self), required substantial/maximal assistance (helper does more than half the effort) for lower body dressing (dress/undress below the waist), and required substantial/maximal assistance (helper does more than half the effort) for putting on/taking off footwear (put on/take off socks and shoes/footwear). <BR/>Record review of Resident #2's care plan dated 10/09/24 reflected Resident #2 was dependent for meeting emotional, intellectual, physical, and social needs related to dementia. Date initiated: 06/10/24. Resident #2 had an ADL self-care performance deficit related to dementia. Date initiated: 06/20/24. Interventions included: Resident #2 required substantial/maximal assistance for lower body dressing. Resident #2 required partial/moderate assistance for personal hygiene. Resident #2 required substantial/maximal assistance for footwear. Resident #2 was dependent for shower/bathe. Resident #2 required total assistance by 1 staff with bathing/showering per resident needs and as necessary. <BR/>Resident #2 required extensive assistance by 1 staff to dress. Resident #2 required skin inspection by skilled nurse weekly/PRN to observe for redness, open areas, scratches, cuts, bruises, and report changes to the MD. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. <BR/>Record review of Resident #2's order summary dated 10/14/24 reflected an order for the in-house podiatrist to treat and evaluate. Order date: 08/10/24.<BR/>Record review of Resident #2's pain evaluation dated 10/14/24 reflected no pain or discomfort to bilateral (both) feet.<BR/>Record review of Resident #2's weekly skin evaluation dated 10/14/24 reflected Resident #2 needed foot/nail care. Previous skin evaluations dated 09/01/24-10/01/24 did not reflect needing foot/nail care or injuries to bilateral feet.<BR/>Record review of Resident #2's progress notes dated 08/01/24-10/14/24 reflected there were no notes found that staff attempted to obtain the consent for the podiatrist or that Resident #2 was added to the podiatrist's visit list.<BR/>Interview with Resident #2 on 10/14/24 at 1:55 PM revealed Resident #2 said her toes and feet did not hurt. Resident #2 said she walked without issue. Resident #2 said she showered and cut her toenails on her own. Resident #2 said she left her toenails too long. Resident #2 said she wanted to cut her toenails.<BR/>Observation of Resident #2 on 10/14/24 at 2:00 PM revealed Resident #2 was not wearing shoes and her toenails were visible. Resident #2's toenails were about an inch longer than the nailbed.<BR/>Interview with CNA A on 10/14/24 at 4:15 PM revealed CNA A said she assisted Resident #2 to shower/bathe and Resident #2 did not bathe on her own. CNA A said she assisted Resident #2 to change and get dressed. CNA A said she was not sure if Resident #2 was diabetic. CNA A said she had not noticed if Resident #2's toenails were too long. CNA A said Resident #2 did not cut her own toenails. CNA A said Resident #2 had not complained about her feet or toes hurting. CNA A said she was not sure if the podiatrist would see Resident #2, but the nurse knew that information.<BR/>Interview with LVN T on 10/14/24 at 4:25 PM revealed LVN T said she had not noticed if Resident #2's toenails were too long. LVN T said Resident #2 had not complained of pain or discomfort. LVN T said the CNAs had not mentioned that Resident #2's toenails were too long. LVN T said Resident #2 had the diagnosis of diabetes and the nurses could cut her toenails. LVN T said the residents were usually referred to the podiatrist, especially when the resident was diabetic. LVN T said she was not sure if they had gotten the consent for the podiatrist or if Resident #2 was added to the podiatrist list. LVN T said the podiatrist came every month or so. LVN T said she was not sure when was the last time the podiatrist saw residents. <BR/>Interview with ADON P on 10/14/24 at 4:45 PM revealed ADON P said she saw Resident #2's toenails and agreed that her toenails were too long. ADON P said she asked Resident #2 if her toes or feet were hurting or if she had trouble walking and Resident #2 denied any pain or discomfort. ADON P said she asked Resident #2 if she wanted her toenails cut and Resident #2 said yes. ADON P said Resident #2 was able to ambulate without issue and Resident #2 said her shoes did not bother her toes or fit too tight. ADON P said she had not been informed that Resident #2's toenails were too long. ADON P said she was not sure if they had gotten consent for the podiatrist or if they had attempted to get consent from the family. ADON P said SW U was good about obtaining consents when needed. ADON P said she was not sure what the issue was or what happened that Resident #2's toenails were not addressed. <BR/>Review of Resident #2's progress notes revealed:<BR/>On 10/14/24 at 10:02 PM, documented by LVN T:<BR/>Foot/nail care to bilateral feet provided to resident, nails trimmed and cleaned under surface of the nails, skin intact between toes, applied moisturizing lotion, tolerated. <BR/>On 10/15/24 at 8:21 AM, documented by the SW:<BR/>The resident's RP verbally consented to the resident being referred to the podiatrist. <BR/>Record review of Resident #2's podiatrist consent dated 10/15/24 reflected verbal consent obtained for a podiatry visit from the RP.<BR/>Interview with SW U on 10/15/24 at 11:40 AM revealed SW U said the nurses told her if they needed a consent form for something specific. SW U said if the resident had diabetes, then the podiatrist had to see them. SW U said she usually asked the nurses if they needed any consents done before the podiatrist was going to do his rounds. SW U said the nurses never told her she needed to get a consent for Resident #2. SW U said the podiatrist last rounded on 10/10/24 and before that, the podiatrist was at the facility the last week of September 2024. SW U said the podiatrist did not have a set schedule but the visits depended on which residents needed to receive treatment. SW U said LVN T cut Resident #2's toenails yesterday , 10/14/24, so Resident #2 did not have to wait for the podiatrist. SW U said the nurses could cut the toenails but they had to be very careful. SW U said she visited Resident #2 yesterday and she did not see her toenails because she was wearing shoes. SW U said Resident #2 was walking in the hallway and did not complain of feet/toe pain. <BR/>Observation of Resident #2 on 10/15/24 at 1:30 PM revealed Resident #2's toenails were trimmed and filed to about 0.5 cm above the nailbed. <BR/>Interview with RN E on 10/15/24 at 1:40 PM revealed RN E said she had not seen Resident #2's toenails. RN E said the CNAs had not mentioned that Resident #2's toenails were too long. RN E said she was under the impression that the podiatrist would see Resident #2. RN E said the podiatrist came 2 weeks ago and did not see Resident #2. RN E said she was not sure if the podiatrist was pending to come back to see Resident #2 or had pending residents. RN E said LVN T did cut Resident #2's toenails yesterday, and LVN T applied cream. RN E said SW U got consent from the family for the podiatrist but RN E could also get the consent. RN E said she was not sure what happened after Resident #2 got the order on 08/10/24 for the podiatrist to treat her in-house. RN E said she did not know if the consent was obtained or not. RN E said Resident #2 had not complained of pain or discomfort to her toes or feet. RN E said the nurses were able to cut the toenails for the residents that have diabetes. RN E said the CNAs could not cut their toenails. RN E said Resident #2's toenails were currently trimmed and filed without issue.<BR/>Interview with the DON on 10/15/24 at 2:00 PM revealed the DON said Resident #2 had her toenails very long. The DON said it was brought up to their attention yesterday by the investigator. The DON said LVN T was able to trim Resident #2's toenails yesterday. The DON said the podiatrist emailed the DON to confirm the visit and to check if any residents needed to be added. The DON said she forwarded to the departments and asked if any resident needed to be added. The DON said if anyone needed to be added, they would have gotten the consent form and everything ready. The DON said SW U and the nurses worked well to obtain consents as needed but the consent was not obtained for Resident #2. The DON said Resident #2 was missed. The DON said it was a team effort and everyone failed to identify the concern. The DON said CNAs did shower Resident #2 and had the opportunity to see the toenails were very long to let the nurse know. The DON said the nurses could have at least trimmed the toenails. The DON said since Resident #2 was diabetic, the CNAs could not cut her toenails. The DON said at least the facility would have known and they would have added Resident #2 to the podiatrist list. The DON said if the toenails were not too thick, then the nurse could trim and file the toenails, which was what LVN T did yesterday. The DON said the podiatrist would visit for an emergency if there was something urgent that the nurses could not take care of. The DON said Resident #2 was not injured and was not in pain, but the overgrown toenails could have caused Resident #2 discomfort. The DON was shown the photo of Resident #2's toenails and the DON agreed that Resident #2's toenails were very long. The DON said they started an audit and in-service so that a resident's foot care was not missed again. The DON said she did not find a policy specific for foot care but the ADLs policy addressed grooming which included nail care. <BR/>Interview with the ADM on 10/15/24 at 3:00 PM revealed the ADM said Resident #2's toenails were just missed. The ADM said the nurse assessed Resident #2 and Resident #2 did not refuse to get her toenails cut. The ADM said they ensured Resident #2 was not in any pain, completed the skin assessment and pain assessment. The ADM said they obtained the consent and put Resident #2 on the podiatrist list. The ADM said LVN T trimmed Resident #2's toenails yesterday. The ADM said Resident #2 had not previously refused to have her toenails cut. The ADM said Resident #2's toenails fell through the cracks. The ADM said they were going to work on an audit tool to prevent another resident's foot care from being missed. The ADM said Resident #2 had no adverse effects. The ADM said the nurse could cut the toenails even if the resident had diabetes as long as the nurse was very careful. The ADM said the podiatrist may take months to come in and they did not want Resident #2 to wait so they had LVN T trim her toenails. The ADM said Resident #2 continued to be monitored and she was doing well. <BR/>Record review of Activities of Daily Living (ADLs) Policy date implemented 05/26/23 revealed:<BR/>Care and services will be provided for the following activities of daily living: <BR/>1. Bathing, dressing, grooming (including nail care), and oral care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for pest control. <BR/>The facility failed to ensure the current pest control program was effective to eradicate and contain common household pests including roaches in multiple areas including resident rooms, hallways, and dining room. <BR/>This failure could place all residents at risk of insect borne illnesses, to live in an uncomfortable/non-homelike environment free of pests, and a decreased quality of life.<BR/>The findings included: <BR/>Interview with Resident #1 on 10/09/24 at 12:45 PM revealed Resident #1 said she had seen roaches. Resident #1 said the last time she saw a roach was about a month ago, in her room, on the wall, and it was alive. Resident #1 said she told the staff but did not know if the roach was found or killed. Resident #1 said she did not have any injuries related to roaches, bugs, or other pests. <BR/>Interview with Resident #2 on 10/09/24 at 1:05 PM revealed Resident #2 said she had seen a roach in her room, on top of the dresser. Resident #2 said it was last week and it was alive. Resident #2 said she told the staff and they were able to kill it. Resident #2 said she did not remember which staff. Resident #2 said the staff cleaned her dresser and room after that. Resident #2 said she did not have any injuries related to roaches, bugs, or other pests.<BR/>Interview with CNA A on 10/09/24 at 2:05 PM revealed CNA A said she had seen roaches in the facility and it was an issue. CNA A said she was not sure if there was any fumigation done. CNA A said she had seen the roaches in the rooms and hallway of the 400 hall. CNA A said she documented the sightings in the log which was what she was supposed to do when she saw a roach or bug. CNA A said she did not remember what day that happened , but she had not worked at the facility very long. CNA A said if the roach was dead, she picked it up. CNA A said housekeeping cleaned the halls and rooms every day .<BR/>Interview with HK S on 10/09/24 at 2:40 PM revealed HK S said housekeeping staff cleaned the rooms every day, including the weekend. HK S said housekeeping also disinfected the bedframe, furniture, chairs, etc. HK S said pest control was taken care of by the maintenance department. HK S said if they saw a roach, ants, or other pests, they documented in the log for the pest control. HK S said he was not sure how often the pest control company visited, maybe weekly or monthly. HK S said housekeeping ensured to clean the rooms so that there was no food, crumbs, or anything hidden to avoid pests. <BR/>Interview with MN D on 10/09/24 at 3:00 PM revealed MN D said the pest control company serviced the building once a month. MN D said if they needed to be serviced more often, he called the company and the company came out the following day. MN D said they contracted with the company and called them if they needed more services if they saw an increase in pests or an issue came up. MN D said there was a sightings log kept at the nurse's station and staff knew to document any sightings on the log. MN D said the pest control company looked at that log and knew where to focus on during their visit. MN D said months ago, they had more of an issue with roaches, so the company came out more frequently to fumigate and service the building. MN D said recently, there had been 1 or 2 roaches, here and there, and it was not an issue or infestation. MN D said the logs noted mostly isolated incidents. MN D said the roaches have been noted on the floors, not on the residents' beds or belongings.<BR/>Interview with CNA B on 10/14/24 at 11:20 AM revealed CNA B said she saw roaches in the residents' rooms in the 400 hall. CNA B said she saw 1 roach at a time, crawling on the floor. CNA B said if she saw a roach, she documented in the log. CNA B said she had seen the fumigation company within the next few days. CNA B said she did not remember what day that was. CNA B said the housekeeping staff also disinfected the rooms. <BR/>Interview with CNA C on 10/14/24 at 11:45 AM revealed CNA C said she saw roaches in the hallway, but the pest control company fumigated. CNA C said she did not remember what day that happened. CNA C said she was not sure how often the pest control came out but she saw them every few weeks. CNA C said whenever she saw a roach, she told the nurse and the nurse input the information in the system for a work order to the maintenance. CNA C said they also documented in the binder at the nurse's station to log any roaches or ants. <BR/>Interview with Resident #4 on 10/14/24 at 12:20 PM revealed Resident #4 said she saw a roach this morning in the 200 hallway . Resident #4 said the roach was alive and it ran away. Resident #4 said she was not sure if the staff saw the roach or tried to kill it. Resident #4 said she did not tell anyone about the roach but hoped it would not go to her room. Resident #4 said she had not seen roaches or bugs in her room before. Resident #4 said she did not have any injuries related to roaches, bugs, or other pests.<BR/>Interview with Resident #9 on 10/14/24 at 12:40 PM revealed Resident #9 said she saw a roach in the 300 hallway , but she did not remember when. Resident #9 said when she saw the roach it was alive and it ran away. Resident #9 said she had seen some men spray the hallways but did not remember when. Resident #9 said she did not have any injuries related to roaches, bugs, or other pests.<BR/>Observation on 10/14/24 at 1:45-1:50 PM revealed a dead roach in the 300 hall and a dead roach in the 400 hall.<BR/>Interview with LVN G on 10/14/24 at 2:50 PM revealed LVN G said he saw a roach every now and then. LVN G said he usually saw it on the floor, in the hallway, or by the nurse's station. LVN G said he added it to the pest control binder. LVN G said he saw the man fumigate with the tank. LVN G said he was not sure if the man sprayed every room but the man went into different parts of the building. LVN G said there were no indications that residents were getting bit by ants or any kind bug/pest.<BR/>Interview with CNA H on 10/14/24 at 3:10 PM revealed CNA H said the families of residents had sometimes reported seeing pests like roaches. CNA H said she had seen the fumigation come out to fumigate. CNA H said the residents ate in their rooms and as much as the staff tried to clean, there was crumbs or food left. CNA H said she had seen roaches, dead and alive. CNA H said the staff used the 300 hall exit to throw out trash because the dumpsters were nearby. CNA H said it was easier for pests to be around those areas. CNA H said when she saw a roach, she told the nurse and the nurse reported it. <BR/>Interview with LVN J on 10/14/24 at 3:30 PM revealed LVN J said there were roaches in the hallway. LVN J said the roaches were usually small and dead or alive. LVN J said staff were supposed to kill the roach if it was not dead and document in the book. LVN J said they also disinfected the area. <BR/>Interview with SW U on 10/24/24 at 3:45 PM revealed SW U said she logged the sighting in October 2024 for pests. SW U said on 10/01/24, she saw 2 roaches in her office, a small one and a big one, she killed them and logged it in the book. SW U said on 10/01/24, she also logged sightings for other staff. SW U said she did not remember which staff but the staff saw a roach in room [ROOM NUMBER] and a little worm in room [ROOM NUMBER]. SW U said on 10/09/24, she was walking in the hall and saw a spider going down from the middle of the door frame with its web, it was gliding down and the CNA got it and killed it. SW U said there were other roaches after those sightings, this past week. SW U said from what she understood, the fumigation company did not fumigate each room because if they did the residents could not be in the rooms. <BR/>Interview with MN D on 10/14/24 at 3:55 PM revealed MN D said there were more sightings after 10/09/24. MN D provided an updated log. MN D said the last time the pest control company serviced the building was on 09/26/24. MN D said he called the pest control company and the company was supposed to service the building on Friday, 10/11/24, but the company was running behind. MN D said the company was supposed to service the building this week. MN D said if the residents voiced concerns during resident council regarding maintenance, he was not informed. MN D said he just based things off the binder (sightings log). MN D said when the pest control company came out, they did not fumigate every room. MN D said they fumigated the main entrances, the main doors of each hall, and the rooms or areas noted on the sighting logs.<BR/>Interview with Resident #6 on 10/14/24 at 4:05 PM revealed Resident #6 said he had concerns regarding roaches. Resident #6 said he saw roaches in his room and the roaches ran into the wall cracks (corners) of his room. Resident #6 said he had seen a lot of roaches on the floor and on the table. Resident #6 said that happened about a week ago. Resident #6 said he told staff but did not remember who. Resident #6 said he did not think his room was fumigated or sprayed. Resident #6 said he did not know if anything was done regarding his concerns. Resident #6 said he did not have any injury related to roaches, bugs, or other pests.<BR/>Interview with LVN T on 10/14/24 at 4:25 PM revealed LVN T said she had seen roaches in the 400 hallway . LVN T said the roaches came out more during the nighttime. LVN T said if they saw a roach, they inputted the information for the maintenance work order and documented in the sighting log. LVN T said she saw the fumigation company spray but maybe the building was just old.<BR/>Observation on 10/14/24 at 10:30 PM revealed the same dead roach in the 300 hall noted.<BR/>Interview with CNA K on 10/14/24 at 10:45 PM revealed CNA K said she saw roaches come out at night and the roaches were alive. CNA K said she killed the roaches or tried to kill them and reported it to the nurse. CNA K said the nurse reported it on the logbook. CNA K said she had seen roaches in the residents' rooms. CNA K said the residents had food and snack in their rooms. CNA K said the residents wanted to have those items and staff could not throw them away or the residents could become upset. <BR/>Observation on 10/14/24 at 11:00 PM revealed the same dead roach in the 400 hall noted.<BR/>Interview with CNA L on 10/14/24 at 11:15 PM revealed CNA L said there were roaches at night and the roaches were everywhere. CNA L said the roaches were on the floor, on the residents' beds, or the roaches were even the flying ones. CNA L said the residents were asleep and the roaches were on the residents. CNA L said if she saw a roach, she told the nurse. CNA L said she saw the residents trying to kill the roaches. CNA L said she redirected the residents and tried to kill the roach herself. CNA L said she did not remember which residents or what days this happened. CNA L said the residents were not injured or hurt but it was not okay for the roaches to be around the residents.<BR/>Observation on 10/14/24 at 11:25 PM revealed an alive roach was on the counter in the small dining room. The roach ran back into the cabinet and staff did not find it.<BR/>Interview with LVN M on 10/14/24 at 11:30 PM revealed LVN M said she saw roaches mostly when she worked at night. LVN M said she also saw roaches randomly during the day. LVN M said she saw roaches in the rooms, in the hallways, both dead and alive. LVN M said she had killed roaches before. LVN M said she also documented in the pest control book. <BR/>Interview with AD I on 10/15/24 at 10:50 AM revealed AD I said if there were any concerns brought up during resident council meetings, she would bring up the concerns to the specific department in charge of resolving the issue. AD I said if there was a concern for maintenance regarding rodents or roaches, she would have told MN D. AD I said she was sure she told MN D about the concern brought up in the September 2024 meeting. AD I said she had seen some roaches here and there in the hallway, mostly dead. <BR/>Interview with CNA O on 10/15/24 at 12:45 PM revealed CNA O said she saw roaches at the facility. CNA O said sometimes the roaches were dead and sometimes alive. CNA O said if the roach was alive, she tried to kill it but sometimes it was too fast. CNA O said if the roach was dead, she picked it up and threw it away. CNA O said she was not sure if they had to report or document anywhere about the roaches. <BR/>Interview with the DON on 10/15/24 at 2:00 PM revealed the DON said for the pest control visits, the ADM and maintenance department oversaw that service. The DON said it was a team effort to ensure they documented any pest sightings, cleaned, and disinfected the areas. The DON said the managers did environmental rounds and if they saw anything, whether it was in the hallways or the rooms, they ensured to document in the book. The DON said they discussed any issues with housekeeping, maintenance, and managers. The DON said the 300 hall exit door was used for the trash, the service door in the back also used, and constant in and out opening and closing the doors, so all that would not help with the issue of pests. The DON said as far as pest control extra visits and such, it would be up to the ADM to get those approved. The DON said they instructed staff to log any sightings in the book for pest control so that the pest control company knew where to go in the building. The DON said she believed the pest control came out every 2 weeks but was not exactly sure. The DON said there were no injuries resulting from roaches, ants, or pests. The DON said if there was no effective pest control, the residents would be at risk of harm, such as insect bites. <BR/>Interview with the ADM on 10/15/24 at 3:00 PM revealed the ADM said she thought the pest control company came out every couple of weeks but she was not sure. The ADM said the company came out as needed or if they saw an issue. The ADM said the company did not always come in the same day or the next day when they called them. The ADM said the company sometimes took longer to come in which was an issue. The ADM said the company they used was the pest control company that their corporation was contracted with. The ADM said she believed the service provided was enough or effective. The ADM said she was not sure if the temperature or what caused more roaches than other times. The ADM said some residents did not like their rooms very cold, or the temperatures outside varied and affected the roaches such as if it rained or different weather. The ADM said they told staff to report it in the pest control log so that if they saw multiple things, then they had the pest control company come in more times. The ADM said the pest control company fumigated the rooms that were on the logs, not all rooms. The ADM said if they put down the 400 hall, the company was not going to fumigate the entire 400 hall. The ADM said they needed to document which rooms to target, not just generalized. The ADM said they had done it in the past, if they saw a trend, where they asked for every room to be fumigated, but they had to document 401, 402, 403, etc. The ADM said they instructed staff to do that if that was the case. The ADM said they had not done that or asked for every room to be fumigated recently. The ADM said if the staff saw a roach, they should have killed it if it was alive, picked it up, and documented in the pest control. The ADM said that was the best way to prevent it from continuing. The ADM said if the roach was dead, the staff should have picked it up, not just left it there on the floor, and logged it in the book. The ADM said it was a team effort, not just housekeeping. The ADM said if there were any concerns brought up in the resident council meetings, then the issue was communicated with the specific department. The ADM said there was no facility policy for pest control, but she provided a copy of the pest control program specifications. The ADM said there were no residents with injuries or adverse effects resulting from roaches or pests concerns. <BR/>Record review of Resident council meeting minutes reviewed for July-September 2024 revealed:<BR/>For the September 2024 council meeting: Resident #6 had a maintenance related concern that roaches came out of wall trim. <BR/>Record review of Pest Control Visits revealed:<BR/>Dated 07/29/24 reflected sightings: large cockroaches reported in front nurse's station, housekeeping room in 300 hall, and therapy room. There were no sightings during service. Inspected and treated common areas, kitchen, laundry, offices, storage room, restrooms, boiler room, and maintenance area. Therapy room and housekeeping room in 300 hall also inspected. Inspected and treated perimeter of the building. <BR/>Dated 08/29/24 reflected sightings: ants. There were no sightings during service. Inspected and treated common areas, kitchen, laundry, offices, storage room, restrooms, boiler room, and maintenance area. Inspected rooms 306, 305, 301, 207, 102, and 607. Inspected and treated perimeter of the building. <BR/>Dated 09/19/24 reflected emergency service for ants. Sightings: flying ants. Found 20 different fire mounds, treated with extinguish and used demand at entry points.<BR/>Dated 09/26/24 reflected sightings: fire ants. There were no sightings during service. Inspected and treated common areas, offices, bathrooms, break rooms, laundry rooms, kitchen, nurse's stations, and hallways. Inspected and treated perimeter of the building. <BR/>Record review of the pest sightings log for 05/01/24-10/14/24 revealed:<BR/>Pests noted in different areas of the building (roaches in 400, 600, 300 halls, rooms 617, 618, 619, 609, 611, dining room, copy room, roach in 400 hall entrance, ants in room [ROOM NUMBER], flying roach in room [ROOM NUMBER], roach in room [ROOM NUMBER], bug in room [ROOM NUMBER], bug in room [ROOM NUMBER], bug in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants by 600 hall nurse's station, roaches in 300 hall, roach by front nurse's station, roach in activity office, roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants in room [ROOM NUMBER], roach on wall, roach in room [ROOM NUMBER], ant in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants and roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], 2 roaches in SW U's office, roach in room [ROOM NUMBER], worm in room [ROOM NUMBER], spider in room [ROOM NUMBER], roach in room [ROOM NUMBER], spider web in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], flying roaches in room [ROOM NUMBER], roaches all over 400 hall) and all halls noted. Not specific to one area. Roaches, ants, and other bugs reported 43 times since May 2024 by various staff.<BR/>Record review of Pest Control Company Services Program Specifications dated 04/01/17 revealed:<BR/>Service Frequency: During the regular service, the service specialist will perform services according to a specified service interval as detailed below.<BR/>Interior crawling insect and rodent programs: every month<BR/>Interior flying insect program (if applicable): every month<BR/>Exterior crawling insect and rodent programs: every month<BR/>Service log sightings: each service<BR/>Areas to be serviced: food service/dietary area, food service storage areas, dining areas, activity areas, office/administrative areas, public access areas, clean/soiled utility areas, bath/shower areas, health/beauty areas, gift shop/common areas, laundry/housekeeping areas, and mechanical/boiler room areas.<BR/>Availability: 24 hours/day 7 days/week<BR/>Emergency service: Personnel area on call 24 hours a day, 7 days a week. Should the need arise, calls from the facility requesting assistance to a pest issue will be responded to within 30 minutes of the call being received, and an on-site visit will be conducted within 24 hours. There is no charge for extra service requests for standard covered pests, or other pests covered by agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 4 residents (Resident #2 and Resident #3) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #2's and Resident #3's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. <BR/>These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.<BR/>Finding included:<BR/>Record review of Resident #2's face sheet dated 1/29/25 indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record Review of Resident #2's significant change Minimum Data Set assessment dated [DATE] indicated she received oxygen therapy while a resident.<BR/>Record review of Resident #2's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift related to respiratory failure with hypercapnia (is a condition where there is too much carbon dioxide).<BR/>Record review of Resident #2's comprehensive care plan, dated 5/1/24, indicates Resident #2 required oxygen therapy related to difficulty breathing. The intervention of the care plan was OXYGEN SETTINGS: O2 as ordered.<BR/>During an observation on 1/29/25 at 2:57 p.m., Resident #2 was lying in her bed with oxygen set at 3 liters per minute via nasal cannula. <BR/>Record review of Resident #3's face sheet dated 1/29/25 indicated he was an [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses which included Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record Review of Resident #3's significant change Minimum Data Set assessment dated [DATE] indicated he received oxygen therapy while a resident.<BR/>Record review of Resident #3's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift for Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record review of Resident #3's comprehensive care plan, dated initiated 6/27/2023, indicates Resident #3 required oxygen therapy related to Ineffective gas exchange. The intervention of the care plan was OXYGEN SETTINGS: O2 via nasal cannula at 2 liters per minute.<BR/>During an observation on 1/29/25 at 3:35 p.m. Resident's #3 was lying in his bed with oxygen set at 1.5 liters per minute via nasal cannula. <BR/>During an interview on 1/29/25 at 3:05 p.m., RN C said Resident #2's oxygen rate was at 3 liters per minute per nasal cannula. He said she was supposed to run at 2 liters per minute as per the physician order. RN C said, I notice that the settings were different from the order since I started working here back in October, I told the nurse that was training me, but he said that was fine because she has been like that since she was admitted . RN C said that by not following the physician's orders it could harm the resident, and that the resident could have shortness of breath, exacerbation or the resident could get ill. RN C said that the last training he had on oxygen was back in October when he was hired.<BR/>During an interview on 1/29/25 at 3:40 p.m., LVN D said that nurses were responsible to check every shift the oxygen settings at the beginning of the shift and at the end of the shift. LVN D said that if not administered correctly per order the resident could be harmed, have respiratory distress or the oxygen level could drop. LVN D said that the last training on oxygen was 3 months ago but could not remember the exact day.<BR/>During an interview on 1/29/25 at 4:50 pm ADON said that the nurses were responsible to check the oxygen settings every shift, especially with continuous oxygen use. ADON said that management made morning rounds each morning. The ADON said that an adverse reaction to the resident was that the oxygen level could drop, shortness of breath or change in respiratory status if not administered the appropriate oxygen ordered by the physician. ADON said that the last training on oxygen was done two months ago, and this training was done quarterly.<BR/>During an interview on 1/29/25 at 5:06 p.m., the DON said the charge nurses were responsible for following the physician's orders and to check oxygen settings at the beginning of the shift and as needed during the shift and at the end of the shift. She said that if not given the correct oxygen as the physician prescribed the Resident could have a change in condition or shortness of breath. DON said that managers make rounds every morning and before leaving to make sure oxygen settings were at the correct setting. <BR/>During an interview on 1/30/25 at 9:30 a.m., DON said that this facility does not have a policy on Oxygen Administration.<BR/>Record review of facility policy titled, Medication Reconciliation date implemented as of April 10, 2023, revealed This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent.<BR/>Daily Processes: Verify medications labels match physician orders and consider rights of medication administration each time a medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, and described in the plan of care for 1 of 7 residents (Resident #35) reviewed for nursing competencies, in that:<BR/>LVN K failed to administer Resident #35's blood pressure medication within the acceptable parameters for safe medication administration and did not obtain/document Resident #20's oxygen saturation readings prior to administering oxygen per the physician's orders. <BR/>This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. <BR/>The findings included:<BR/>Record review of Resident #35's face sheet, dated 12/18/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (high blood pressure), type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), chronic kidney disease stage 3 (kidneys are damaged and can't filter blood the way they should), and pure hypercholesterolemia (a genetic anomaly that causes high cholesterol levels).<BR/>Record review of Resident #35's most recent quarterly MDS assessment, dated 11/11/23 revealed the resident was severely cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #35's comprehensive care plan, revision date 8/9/23 revealed the resident had hypertension and was at risk for cardiovascular complications with interventions that included to give anti-hypertensive medications as ordered.<BR/>Record review of Resident #35's order summary report, dated 12/18/23 revealed the following:<BR/>- Amlodipine Besylate tablet 5 mg, give 1 tablet by mouth one time a day for hypertension, hold and call MD if blood pressure less than 110/60 or pulse less than 60<BR/>-Carvedilol 6.25 mg tablet, give 1 tablet by mouth two times a day for hypertension, hold and all MD if blood pressure less than 110/60 or pulse less than 60<BR/>Record review of the nursing competency dated 5/16/23 revealed LVN K had satisfied the requirements for medication administration.<BR/>Observation on 12/18/23 at 7:40 a.m. during the medication pass revealed, LVN K obtained Resident #35's blood pressure prior to medication administration. Resident #35's blood pressure reading was 121/58 and pulse reading was 58. LVN K then administered the following medications to Resient #35:<BR/>- Amlodipine 5 mg tablets, by mouth daily for hypertension<BR/>- Carvedilol 6.25 mg by mouth twice daily, hold for parameters<BR/>-Atorvastatin 20 mg by mouth daily<BR/>-Florastor probiotic, 1 capsule twice daily <BR/>During an interview on 12/18/23 at 8:26 a.m., LVN K stated the reason she administered the blood pressure medications outside of the ordered parameters was because, since I know Resident #35 and have worked with the resident for over a year, I know her blood pressure will go up later on. LVN K revealed she was not certain why the physician would place blood pressure and pulse parameters on the orders. LVN K stated she was trying to manage Resident #35's blood pressure as best she could. <BR/>During an interview on 12/18/23 at 2:51 p.m., ADON H revealed LVN K was using her nursing judgement when she administered the blood pressure medication outside the parameters to Resident #35 as LVN K knows the patient. ADON H revealed LVN K could have re-checked Resident #35's blood pressure and pulse and re-assessed.<BR/>During an interview on 12/18/23 at 5:25 p.m., the DON revealed blood pressure medications should be followed based on the physician's orders and as indicated on the comprehensive care plan. The DON revealed, the physician's orders outranked nursing judgement.<BR/>Record review of the facility policy and procedure titled Medication Administration, dated 10/24/22 revealed in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used within the facility to be labeled and stored in accordance with currently accepted professional standards, which included the appropriate cautionary instructions with the expiration date and open date, when applicable, for 2 of 7 carts (Nurse Medication Cart Hall 200, Nurse Medication Cart Hall 600 and Medication room in Hall 500. <BR/>1. <BR/>Nurse Medication Cart #2 contained fifteen open bottles of over-the-counter medications with no open dates on bottle. <BR/>2. <BR/>Nurse Medication Cart # 7 contained four open bottles of prescribed medications and two open bottles of over-the-counter medications with no open dates on the bottle.<BR/>3. <BR/>Medication room [ROOM NUMBER] contained one medication found in the refrigerator that was expired; various types of medical supplies (three) that were in the cabinets that were expired; and seven prescribed medications in the medication disposable cabinet that was unlocked. <BR/>These failures could place residents at risk of not receiving the benefit of medications, adverse reactions to medications, accidental dispensing of unidentified drugs, incorrect administration of medications, drug diversion, exposure to expired drugs, and/or accidental or intentional administration to the wrong resident. <BR/>Findings include: <BR/>During an observation on Sept. 29, 2022, beginning at 03:26 PM, revealed the Nurse medication cart located next to nurse's station in 600 Hall contained the following items: <BR/>In the Left First Drawer: No open date on bottle for listed prescribed medications: <BR/>Fluticasone Propionate Nasal Spray USP (used to treat allergy symptoms) 50mcg for Resident #35.<BR/>Fluticasone Propionate Nasal Spray USP 50mcg for Resident #15. <BR/>Fluticasone Propionate Nasal Spray USP 50mcg for Resident #135.<BR/>Fluticasone Propionate Nasal Spray USP 50mcg for Resident #45.<BR/>During an observation on Sept. 30, 2022, beginning at 11:13 AM of the Medication storage room in hall 500 with RN C the following was identified:<BR/>In the refrigerator: <BR/>Levemir insulin 100 Units/ml vial date opened Aug. 24, 2022, Expiration July 31, 2024, for Resident #47. (Use by date expired) <BR/>Medical supplies in cabinets/drawers/caddy:<BR/>Wolf-Pak Premium Dressing Change Kit with GuardVA and StatLock Expiration June 30, 2022 (drawer under sink); <BR/>Wolf-Pak Premium Dressing Change Kit with GuardVA and StatLock Expiration Nov.30, 2021 (cart next to MedBank tower pyxis, which is an automated medication dispensing system);<BR/>Insyte Autoguard 24 GAx 0.75 inches (0.7 x 19 millimeters) 20 milliliters/minute catheter expiration Feb. 01, 2022 (cart next to MedBank tower pyxis which is an automated medication dispensing system). <BR/>Medication Disposable Cabinet (unlocked) Contents inside include: Heparin Sodium injection, usp (unit-United States Pharmacopeia) 5,000 units/milliliters: inject 5000 unit subcutaneously three times a day for clotting prevent ion for thirty days expiration Sept. 13, 2023, x two boxes (twenty-seven vials between 2 boxes); <BR/>Olanzapine 2.5 milligrams: Give one tablet via PEG (percutaneous endoscopic gastrostomy) tube one time a day for delusional disorders expiration Sept. 19, 2023, one blister pack (fourteen tablets);<BR/>Trazodone 100 milligrams: Give one tablet via PEG tube/via G-Tube (gastrostomy tube) at bedtime for insomnia expiration [DATE], one blister pack (three tablets); <BR/>Carbamazepine 200 mg tablet: Give one tablet by mouth two times a day for convulsions expiration Aug. 11, 2023, one blister pack (one tablet); <BR/>Carbamazepine 200 mg tablet: Give one tablet by mouth two times a day for convulsions expiration Sept. 19, 2023, one blister pack (twenty-eight tablets); <BR/>Metoprolol Succinate ER (extended release) 50 milligrams: Give 50 milligrams via PEG Tube every twelve hours for hypertension hold medication if heart rate is less than 45 beats/minute or systolic blood pressure is less than 100 mm/HG (millimeters of mercury) expiration Sept. 28, 2023, one blister pack (twenty-seven tablets). <BR/>During an interview with LVN # A and ADON E, on Sept. 29, 2022, at 01:25 PM while at the nurse's station, LVN # A replied that a guy came to audit our carts not too long ago and ADON E responded, Pharmacist from Senior Solutions Pharmacy comes to audit our medication carts monthly and according to him over-the-counter medications do not have to have open dates. They go by expiration dates.<BR/>During an interview on [DATE], at 03:50 PM with the DON, Related to Medication storage/disposal she said, pharmacy is in charge of refilling our medication carts/rooms. Nurses are in charge of making sure they are refilled and that the counts are correct. Pharmacy does not deliver over-the-counter medications; central supply does. It is upon the licensed nurse to verify expiration date. The process for receiving over-the-counter medications from central supply is to check expiration date, check the order to make sure it is the right dose, strength. Unless it is a vial that has a shortened expiration date, such as Prostat, (which has a shortened date), the best practice is to date vials upon opening them. Multiuse vials brought by pharmacy are also dated upon opening, they have a space on the label for the date. All discharged resident's medications are disposed within 28 days. Nurses put the expired medications in the discontinued medications cabinet in medication room until they can be brought to the director of nursing and logged in. Then they go through medication destruction process with pharmacy and put in biohazard boxes and picked up by a biohazard company. If they are narcotics: they are kept in the locked boxes until they can be brought to director of nursing double locked office and properly disposed of. Medications do not have to be locked unless they are narcotics in the med room until they can be picked up by director of nursing. Consultant pharmacists do full cart audits biweekly and on staggered carts/rooms. Nurses and licensed staff are supposed to check medication carts daily. Medical supplies are checked weekly or daily by nurses, licensed staff and/or pharmacists (if able to). <BR/>During record review of the facility's Expiration Dating and Expired Medications policy dated 10/01/19, A continuous monitoring system will be designated by the director of nursing to identify expired medications and remove them from the medication system.<BR/>During record review of the facility's Discontinued Medications policy dated 10/01/19, Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until disposed of or returned to the pharmacy if credit is allowed. Medications are removed from the medication cart immediately upon receipt of an order to discontinue to avoid inadvertent administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 4 Residents reviewed for accuracy and completeness of clinical records.<BR/>1. <BR/>The facility failed to ensure LVN A accurately documented that Resident #1 was currently on an anti-coagulant. <BR/>2. <BR/>The facility failed to ensure LVN A accurately documented neurological check findings for Resident #1 post fall. <BR/>These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record, dated 02/14/24, revealed an [AGE] year-old female with diagnoses of vascular dementia (a type of dementia that occurs when blood vessels in the brain are damaged, reducing blood flow and oxygen supply), hypertension (a chronic condition where the force of blood in your arteries is consistently too high), muscle wasting and atrophy (referring to the loss of muscle mass and strength, often occurring due to lack of physical activity, injury, malnutrition, or certain medical conditions, resulting in a decrease in muscle size and function), and unspecified atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and out of sync with the lower chambers). <BR/>Record review of Resident #1's care plan, dated 02/14/24, revealed Resident #1 was on anticoagulant medication therapy Xarelto (drugs that prevent blood clots or slow down the process of clotting) related to disease process of atrial fibrillation with interventions of monitor patient frequently for signs and symptoms of neurological impairment. If neurological compromise was noted, urgent treatment was necessary.<BR/>Record review of Resident #1's order summary, dated 02/14/24, revealed an order for: anticoagulant medication (Xarelto) - monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds. <BR/>Record review of Resident #1's MAR, dated 02/14/24, revealed the resident had an anticoagulant medication (Xarelto) ordered and was being administered such medication once daily since upon admission to facility on 02/14/24. <BR/>Record review of Resident #1's medication administration audit report, effective date 02/14/24 revealed the resident was being administered anticoagulant medication (Xarelto) daily since upon admission and the resident continued with anticoagulant medication therapy daily. <BR/>Record review of Resident #1's quarterly change MDS assessment, dated 05/02/24, revealed the Resident was on high-risk drugs class of anti-coagulants (Xarelto). Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired.<BR/>Record review of Resident #1's neurological checks dated 07/28/24 at 4:15pm, revealed Resident #1's pupils were not reactive to light after the first 15 minutes following the fall. On the next 15 minutes and thereafter, documentation reflected that Resident #1's pupils were reactive to light. <BR/>Record review of Resident's #1 progress notes entered by LVN A dated 07/28/24at 3:45pm, revealed the resident sustained an un-witnessed fall in her bedroom with immediate findings of left clavicle appearing swollen and hematoma-like to left side of forehead. LVN A also documented that resident #1 was not on an anti-coagulant. <BR/>During observation and interview on 01/23/25 at 3:12pm Resident #1 stated she remembered her shoulder was broken. She stated no further pain to the area. Resident #1 was unable to recall accurately how she fell. <BR/>During an interview on 01/23/25 at 3:41pm LVN A stated she recalled when Resident #1 sustained a fall on 07/28/24. Stated upon visual inspection, she noted Resident #1's shoulder was bulged out (swollen) and there was a hematoma to the left side of her forehead. LVN A stated she called the nurse practitioner on call and continued with fall protocol. Stated protocol included head to toe assessment, start neurological checks, and follow orders given by the doctor. LVN A stated she remembered NP C gave her orders for x-rays to the left shoulder, to continue with neurological checks, and order medication for pain. LVN A recalled NP C did not give orders to have Resident #1 taken to the hospital. LVN A stated that when residents were on an anti-coagulant, residents get sent to the hospital for CT scans. She stated that the doctor or nurse practitioners were the ones who determine if a resident was to be sent to the ER. LVN A stated she did not remember if she checked if the resident was on an anti-coagulant. LVN A stated that negative outcomes for not have documented correctly could have resulted in that Resident #1 could have had a slow brain bleed. <BR/>During an interview on 01/23/25 at 5:20pm NP C stated as per their own protocol, when a nurse called to report a resident fall, they were to always ask the nurse if the resident sustained a head injury and if the resident was on anti-coagulant. NP C stated that in her notes for the day of 07/28/24 when Resident #1 sustained the fall, she was informed of the injury to left shoulder and the hematoma to the left side of Resident #1's head. NP C stated her notes had no documentation having been informed if Resident #1 was on an anti-coagulant, however stated had she been informed, she would have sent Resident #1 to the emergency room for further evaluation. NP C stated that as part of her order for neurological checks, she informed LVN A to monitor and report back with any abnormal findings. <BR/>During an interview on 01/24/25 at 11:03am LVN A stated she did not remember having documented that Resident #1's pupils were not reactive to light in the first 15-minute neurological check. Stated it was a typo because had it been a true finding, she would have notified NP C of abnormal findings. She stated abnormal findings need to be reported right away. <BR/>During an interview on 01/24/25 at 1:30pm the DON said NP C had remote access to Resident #1's medical chart where NP C could have also verified Resident #1's medication record. The DON read LVN A's progress note for Resident #1's fall and stated she did not know why LVN A documented that Resident #1 was not on an anti-coagulant when Resident #1's medication record, order summary, and plan of care indicated Resident #1 was on an anti-coagulant. The DON stated any change of condition, such as an abnormal neurological check findings should have been reported to the nurse practitioner or doctor immediately. The DON stated she was responsible to follow up on documentation regarding abnormal findings however admitted she did not. The DON stated there could have been many negative outcomes for Resident #1 due to poor documentation. She stated Resident #1 could have suffered neurological damage. She stated continued neurological checks were part of the fall protocol and were ordered by NP C to continue so that any abnormal findings could be reported immediately. <BR/>Record review of the facility's policy titled Documentation in the Medical Record, dated 10/24/22, stated Each Resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Principles of documentation include but are not limited to: Documentation shall be factual, objective, and resident centered. False information shall not be documented. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 4 of 32 residents (Residents #5, #15, #67, and #144) reviewed for advanced directives, in that:<BR/>1. Resident #5's OOH-DNR was missing the physician's license number.<BR/>2. Resident #15's OOH-DNR was missing the witness signatures.<BR/>3. Resident #67's OOH-DNR was missing the executor's signature. <BR/>4. Resident #144's OOH-DNR was witnessed two department heads, one of whom provided direct care. <BR/>These failures could place residents at-risk for residents' rights not being honored and having CPR performed against the residents' will. <BR/>The findings included:<BR/>1. Record review of Resident #5's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain, stroke), need for assistance with personal care and adult failure to thrive.<BR/>Record review of Resident #5's most recent quarterly MDS assessment, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #5's comprehensive care plan, revision date [DATE] revealed the resident was a DNR status with the goal to comply with resident/family wishes and interventions that included to ensure the signed DNR document was in the medical record.<BR/>Record review of Resident #5's order summary report, dated [DATE] revealed the following:<BR/>- DNR (Do Not Resuscitate), with order date [DATE] and no end date.<BR/>Record review of Resident #5's OOH-DNR, dated [DATE] was incomplete and was missing the physician's license number.<BR/>During an interview on [DATE] at 12:47 p.m., Social Worker AA revealed she was responsible for the residents who resided on the 400, 500, and 600 unit, which included Resident #5. Social Worker AA revealed, Resident #5's OOH-DNR document was missing the physician's license number therefore making the document invalid. Social Worker AA revealed she helped execute the OOH-DNR document but believed the Medical Records Staff checked behind her to ensure the form was complete. Social Worker AA revealed Resident #5's incomplete OOH-DNR would make the resident a full code and would be going against the family's wishes. <BR/>During an interview on [DATE] at 1:59 p.m., the LVN Medical Records staff revealed she often audited the OOH-DNR documents before uploading into the electronic record. The LVN Medical Records staff revealed the Social Services staff were responsible for executing the OOH-DNR, but the LVN Medical Records staffs' focus was to obtain the physician's signature before uploading into the electronic record. The LVN Medical Records staff revealed Resident #5's OOH-DNR was invalid because it was missing the physician's license number therefore making the resident a full code. The LVN Medical Records staff revealed it affected the way Resident #5 was cared for and it would go against the family's wishes.<BR/>2. Record review of Resident #15's face sheet, dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain, stroke), delusional disorders and cognitive communication deficit.<BR/>Record review of Resident #15's most recent quarterly MDS assessment, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #15's comprehensive care plan, revision date [DATE] revealed the resident was a DNR status with the goal to comply with resident/family wishes and interventions that included to ensure the signed DNR document was in the medical record.<BR/>Record review of Resident #15's order summary report, dated [DATE] revealed the following:<BR/>- DNR (Do Not Resuscitate), with order date [DATE] and no end date.<BR/>Record review of Resident #15's OOH-DNR, dated [DATE] revealed two witness signatures were missing.<BR/>During an interview on [DATE] at 12:33 p.m., Social Worker Z revealed she was responsible for the residents who resided on the 100, 200, and 300 unit, which included Resident #15. Social Worker Z revealed Resident #15's OOH-DNR document was missing the two witness signatures that were supposed to be on the bottom of the document therefore making the document invalid. Social Worker Z revealed, she and the Medical Records Staff audit the OOH-DNR documents to ensure they were completed. Social Worker Z revealed, Resident #15's OOH-DNR was invalid with the missing witness signatures and if something should happen to the resident the staff would have to initiate CPR which was against the family's wishes. <BR/>3. Record review of Resident #67's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's Disease, Legal Blindness, and Cognitive Communication Deficit. <BR/>Record review of Resident #67's Quarterly MDS, dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. <BR/>Record review of Resident #67's care plan, revised [DATE], [incorrectly] revealed, [Resident #67] is a full code.<BR/>Record review of Resident #67's Order Summary Report as of [DATE] revealed an order dated [DATE], DNR (Do Not Resuscitate).<BR/>Record review of Resident #67's OOH-DNR, dated [DATE], revealed the executor's second signature was missing from lower portion of the form. <BR/>During an interview with Social Worker Z on [DATE] at 10:42 a.m., Social Worker Z confirmed that the executor's second signature was missing from lower portion of Resident #67's OOH-DNR form, therefore invalidating the form, potentially causing confusion among facility staff or emergency services staff regarding the validity of the resident's OOH-DNR form, and potentially resulting in the resident and her representatives' wishes being dishonored. <BR/>4. Record review of Resident #144's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: Aftercare Following Joint Replacement Surgery, Type 2 Diabetes Mellitus with Unspecified Complications, and Chronic Pain Due to Trauma. <BR/>Record review of Resident #144's admission MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. <BR/>Record review of Resident #144's care plan, dated [DATE], revealed, Resident is a DNR.<BR/>Record review of Resident #144's Order Summary Report as of [DATE] revealed an order dated [DATE], DNR (Do Not Resuscitate).<BR/>Record review of Resident #144's OOH-DNR, dated [DATE], revealed the form had been witnessed by two department heads, one of whom provided direct care to residents. <BR/>During an interview with Resident #144 on [DATE] at 10:18 a.m., Resident #144 confirmed that she had executed an OOH-DNR form. <BR/>During an interview with Social Worker Z on [DATE] at 10:42 a.m., Social Worker Z confirmed that Resident #144's form had been witnessed by two department heads, one of whom provided direct care to residents, therefore invalidating the form, potentially causing confusion among facility staff or emergency services staff regarding the validity of the resident's OOH-DNR form, and potentially resulting in the resident's wishes being dishonored. <BR/>Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Sec. 166.003. WITNESSES. In any circumstance in which this chapter requires the execution of an advance directive or the issuance of a nonwritten advance directive to be witnessed: (1) each witness must be a competent adult; and (2) at least one of the witnesses must be a person who is not: . (F) an employee of a health care facility in which the declarant is a patient if the employee is providing direct patient care to the declarant or is an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility .<BR/>Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], accessed [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.<BR/>Record review of the facility policy and procedure titled Communication of Code Status, dated [DATE] revealed in part, .It is the policy of this facility to adhere to resident's rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive .

Based on observations, interviews, and record reviews the facility failed to support resident rights to voice grievances to the facility or other agency or entity that hears grievances for 1 of 29 residents (Resident #80) and the months reviewed (October, November, and December 2023) reviewed for grievances, in that;<BR/>LVN P did not initiate a grievance report on behalf of Resident #80 when Resident #80 reported mistreatment by CNA D. <BR/>This failure placed residents at risk by denying their right to make and have grievances heard and contributed to feelings of not being heard and unresolved issues. <BR/>The findings included:<BR/>A record review of Resident #80's admission record dated 12/21/2023 revealed an admission date of 03/24/2023 with diagnoses which included congested heart failure [AKA Heart Failure - a long-term condition in which your heart can't pump blood well enough to meet your body's needs.] and acute pain due to trauma. <BR/>A record review of Resident #80's quarterly MDS assessment, dated 12/13/2023, revealed Resident #80 was assessed with a BIMS score of 9 out of a possible 15, which indicated moderate cognitive impairment. <BR/>During an observation and interview on 12/17/2023 at 10:07 AM revealed Resident #80 was seated in his wheelchair at the threshold of his door at the hallway. Resident #80 was upset and loudly complaining he had a complaint of mistreatment. Further interview revealed Resident #80 stated CNA D had come in his room to provide incontinent care for his roommate and had thrown a dirty soiled adult brief and wipes on the floor adjacent to where he was seated, and stated, it was nasty .dirty!. During the interview CNA D and LVN P approached and interacted with Resident #80. Resident #80 stated CNA D had thrown the soiled dirty adult brief on the floor next to where he was seated. CNA D denied the accusation and Resident #80 replied Don't lie!. LVN P stated she was aware of the complaint and asked CNA D to attend other residents. Resident #80 reported to LVN P his senses were insulted by CNA D's throwing the brief on the floor. <BR/>During an interview on 12/17/2023 at 10:12 AM LVN P stated she was aware Resident #80 was upset and she had asked CNA D to attend to other residents and she would report the incident to the SW Z. LVN P was asked if there was anything else she might do for Resident #80's complaint and LVN P stated No. <BR/>A record review of the facility's grievance records dated 12/01/2023 through 12/20/2023 revealed no grievance report for Resident #80. <BR/>During an interview on 12/21/2023 at 8:50 AM Resident #80 stated no one had given him a report about his complaint about CNA D. Resident #80 stated They don't care.<BR/>During an interview on 12/20/2023 at 11:05 AM LVN P stated she had received a complaint from CNA D and Resident #80 about CNA D throwing a dirty soiled adult brief on the floor next to Resident #80 on 12/17/2023. LVN P stated she reported Resident #80's complaint to SW Z on 12/17/2023 and SW Z spoke with Resident #80 on 12/17/2023. LVN P stated she had not generated a grievance form for Resident #80 because she reported the complaint to SW Z. <BR/>During an interview on 12/20/2023 at 1:05 PM SW Z stated she had received a report from LVN P referring to an incident on 12/17/2023 and she had visited with Resident #80. SW Z stated Resident #80 reported he was offended by CNA D when CNA D threw a dirty adult brief on the floor while he provided incontinent care for Resident #80's roommate. SW Z stated she had not generated a grievance report because LVN P was the person who originally received the complaint, and stated, I only followed-up with the resident.<BR/>During an interview on 12/22/2023 at 5:00 PM the Administrator stated she had learned Resident #80 had made a grievance to LVN P on 12/17/2023 and LVN P and SW Z had interviewed Resident #80 without either of them generating a grievance report. The Administrator stated at a minimum she should have received 2 grievance reports from the same incident. The Administrator stated the potential harm would be residents' grievances would go unresolved.<BR/>A record review of the facility's Resident and Family Grievances policy dated 08/15/2022, revealed, It is the policy of this facility to support each resident and family members right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. Definition: prompt efforts to resolve. include facility acknowledgement of a complaint and or grievance and actively working towards resolution of that complaint and or grievance . grievances may be voiced in the following forms: verbal complaint to a staff member or grievance official . the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form . forward the grievance form to the grievance official as soon as practicable. the grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . all staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the grievance official. prompt efforts include acknowledgement of complaint and or grievances and actively working towards a resolution of that compliance and or grievance . the grievance official or designee will keep the resident appropriately apprised of progress towards the resolution of the grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #1) reviewed for abuse. <BR/>The facility failed to prevent CNA A, from verbally abusing Resident #1 on 04/29/24 when she referred to her as ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you).<BR/>This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.<BR/> Record review of Resident #1's admission record dated 01/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included vascular dementia (a type of dementia caused by brain damage from impaired blood flow to the brain), Parkinson's disease (A brain disorder that causes movement problems, including shaking, difficulty walking, and rigidity in muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).<BR/>2) <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had been coded a 2 for speech clarity which indicated Resident#1 had no speech (absence of spoken words). She had been coded a 3 for making herself understood and ability to understand others which indicated Resident #1 rarely/never understood. Resident #1 did not have a BIMS score which indicated she was rarely/never understood. <BR/>Record review of Resident #1's quarterly care plan dated 12/04/24 reflected Resident #1 had a communication problem related to dementia. Resident #1 was unable to express clear thought and rarely never understood. Date initiated 09/02/23 and revised on 12/28/23. Her interventions were to monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed.<BR/>An observation on 01/28/25 at 1:29 p.m., Resident #1 was observed lying in bed awake. She was listening to the radio swaying side to side. She was did not respond to this surveyor's questions. She was quiet with no facial expression. <BR/>An attempted telephone interview on 01/28/25 at 2:27 p.m., CNA A did not answer.<BR/>An attempted telephone interview on 01/29/25 at 8:05 a.m., CNA A did not answer.<BR/>An interview on 01/28/25 at 5:04 p.m., Administrator said the cooperate hotline had received an anonymous complaint alleging CNA A was being verbally abusive towards Resident #1. She said the Assistant Administrator had completed the investigation. She said CNA A had admitted to using inappropriate language with greeting Resident #1. She said her number one priority was the safety and welfare of the residents. She said the facility took immediate action and CNA A was suspended on 04/29/24 and then later she was terminated. She said she had no knowledge of CNA 's behavior prior to 04/29/24. She said all staff were trained on ANE and how to speak to residents. The Administrator said, Resident #1 was non-verbal which to her was a concern because there was no way for her to say if she had been offended by CNA A's comment. She said CNA A's behavior was inappropriate and had been terminated to avoid any other resident being put at risk. <BR/>Record review of Resident #1's admission census reflected she was housed in the 200 hall on 04/29/24.<BR/>Record review of the Assistant Administrator's investigation summary completed on 05/16/24 reflected, that an anonymous report had been made to the facility's compliance line identifying CNA A had used profanity and vulgar language with residents. The facility's response included the alleged perpetrators were suspended (pending the investigation), abuse coordinator was informed, the facility reported to state, the facility-initiated an investigation which included interviews with direct and indirect care staff, residents, and family members. Head-to-toe assessments were initiated on all residents of 100 and 200 halls for any signs or symptoms of distress, and staff were in-serviced on ANE, professional communication, and resident care. The investigation summary reflected; upon interviewing [CNA A], it was identified that she acknowledged using bad words with her communication with Resident #1. CNA A stated she, on occasions, would greet Resident #1 using Spanish-language connotations of the word stupid. CNA A stated she would not use the word in an offensive manner, but instead used the word in part of her greeting [Resident #1] in a joking and loving manner. It was [CNA A] interpretation that the words were well-received by the resident because [Resident #1] would smile when she saw her. [CNA A] stated she felt her greetings and interactions cheered-up [Resident #1]. [CNA A] recognized that her communication may be offensive to [Resident #1] and others . Resident and residents' family interviews revealed no concerns of abuse or neglect. Monitoring of all residents in 100 and 200 halls did not identify any other concerns. Staff interviews revealed no concerns of abuse or neglect. No evidence of physical or emotional harm was identified. The IDT team concluded that the allegations of abuse was confirmed. Provider actions taken post-investigation included, CNA A had been terminated, the Administrator and Assistant Administrator re-educated 100 % of facility staff on the topics of ANE and professional communication. Staff were provided with the contact numbers for the administrator, ombudsman, and compliance hotline. Staff on leave were re-educated prior to the start of their next scheduled shift. The administrator/designee would conduct quarterly and as needed education to ensure facility staff remained knowledgeable on the identification and reporting of abuse, neglect, and exploitation. A media alert was sent to all employee's with the request to report any concerns without the fear of retaliation. A second media alert was sent to all employees with the contact information of the Ombudsman. A media alert was sent out to representative of the residents with the information n to report any concerns. <BR/>Record review of CNA A's statement written by the Assistant Administrator on 04/29/24 reflected, she had worked the 200 hall on said day. CNA A acknowledged she had used some words that could be interpreted as offensive to the recipient or others. CNA A acknowledged that on several occasions, she had greeting Resident #1 with a phrase of ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you). CNA A said she had used that phrase in a joking and loving manner and not to offend the resident. CNA A said she believed her words were well received by Resident #1 as she would smile when she would see her. CNA A said she would sing the phrase to Resident #1, and it would cheer her up. <BR/>Record review of CNA A's employee counseling report dated 05/06/24 reflected an other offence of a violation of any other policy or procedure contained in Employee Manual: Allegation of abuse.<BR/>Record review of CNA A's NAR search dated 04/08/24 reflected she had an active status (certification was current) and was not listed on the EMR. <BR/>Record review of facility's Resident abuse interview and observation sheets conducted between 04/29/24 through 05/01/24 reflected all residents in the 100 and 200 hall had been interviewed and observed with no concerns of abuse voiced. <BR/>Record review of the facility's in-service training report dated 04/29/24 reflected staff were in-serviced on the topics of ANE and professional communication.<BR/>An interview on 01/29/25 at 1:15 p.m. The DON said CNA A was re-hired on 04/07/2024 and terminated on 05/06/24. <BR/>An interview on 01/29/25 at 4:40 p.m., LVN B said she had conducted resident assessments on all residents in the 100 and 200 halls on 04/29/24 through 05/01/24. She said no concerns of abuse or neglect had been voiced and no residents had been observed to be in emotional distress. LVN B said Resident #1expressed herself by using facial expressions (smiling or grimacing). She said on 04/29/24, when Resident #1 was observed she had not shown any signs of being in distress. <BR/>Record review of CNA A's Student and Group Transcript Report reflected she had last been in-serviced on the topic of effective communication, reporting abuse, abuse, and neglect on 04/08/24. <BR/>Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected:<BR/>Policy:<BR/>It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.<BR/>Definitions:<BR/>Verbal Abuse: means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.<BR/>IV. Identification of Abuse, Neglect and Exploitation<BR/> B. Possible indicators of abuse include, but are not limited to:<BR/>1. Resident, staff, or family report of abuse<BR/>5. Verbal abuse of a resident overheard<BR/>VII. Reporting/Response<BR/>A. The facility will have written procedures that include:<BR/>1. Reporting oa all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: .

**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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 10 residents (Resident #101 and Resident #82) reviewed for comprehensive person-centered care plans. <BR/> 1.The facility failed to develop a comprehensive person-centered care plan for Resident #101 to address assist feeding.<BR/>2. The facility failed to develop a comprehensive person-centered care plan for Resident #82 to address identifiable triggers to his active diagnosis of Post Traumatic Stress Disorder.<BR/>This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. <BR/>The Findings include:<BR/> Record review of Resident #101's face sheet, dated 3/25/2025, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #101 had a diagnosis which included: Vascular Dementia (a type of cognitive decline caused by damaged to the blood vessels in the brain), Alzheimer's disease (caused by problems with blood supply to the brain, leading to damage and impaired function, and often involves difficulties with thinking, planning and problem solving), Needs assistance with personal care.<BR/>Record review of Resident #101's Care Plan initiated on 5/11/23 reflected she has an ADL self-care deficit related to decreased cognition secondary to Alzheimer's Dementia, and Amnesia. Resident #101's functional performance with eating: the Resident requires (supervision/or touching assistance) for eating.<BR/>Record review of Resident #101's quarterly MDS assessment, dated 1/30/25, reflected a BIMS score of 00, which indicated Resident #00's cognition was severely impaired. Eating assistance was marked on the MDS as 04 which indicated supervision or touching assistance (helper provides verbal cues and/or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>During an observation on 3/24/25 at 12:00PM Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an observation on 3/25/25 at 5:00PM, Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an interview on 3/24/25 at 4:00PM with CNA I stated that Resident #101 needs assistance with feeding because she was not able to feed by herself because of the resident's had Alzheimer's. CNA I stated Resident #101 did not know how to use the utensils. CNA I stated resident had been fed with all meals.<BR/> During an interview on 3/26/25 at 11:35AM with RN L stated Resident #101 needed total assistance with feeding with all her meals because of the resident's Alzheimer's disease. RN L stated that a negative outcome of care plan not been accurate could place Resident#101 at risk for weight loss.<BR/> During an interview on 3/26/25 at 10:00 AM with LVN K, MDS nurse, stated that the resident was able to grab finger food. LVN K, MDS nurse stated that she did not know that resident needed a lot of assistance. LVN K, MDS nurse stated that she did not update the care plan because she was not aware that resident was being assisted with feeding every meal.<BR/>During an interview on 3/26/25 at 4:40 PM, the DON said she was not aware that resident was needing total assistance with feedings. DON said Resident#101's care plan had to be accurate and this way all staff could know what the resident needed.<BR/>2. Record review of Resident #82's face sheet dated 03/27/25 reflected resident was a [AGE] year-old male admitted to the facility on [DATE] with original admit date of 12/19/2019. His pertinent diagnoses included post-traumatic stress disorder (mental condition that develops after experiencing or witnessing a traumatic event, war, violent crime, or personal loss), bipolar (a disorder associated with episode of mood swings ranging from depressive to manic highs), dementia (a group of thinking and social symptoms that interferes with daily function), cognitive communication deficit (a group of conditions that affect a person's ability to communicate effectively due to underlying cognitive impairments), major depressive disorder ( mental condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), delusional disorder (mental illness that caused people to have unshakeable false beliefs for at least a month), and schizoaffective disorder (disorder that affects a person's ability to think, feel, and behave clearly).<BR/>Record review of Resident #82's quarterly MDS assessment dated [DATE] reflected his BIMS score question was left blank, indicating his cognition was severely impaired. His active psychiatric/mood disorder diagnoses included depression, bipolar disorder, schizophrenia, post-traumatic stress disorder and psychotic disorder (mental disorder characterized by a disconnection from reality). It further reflected he had physical (hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal (threatening others, screaming at others, cursing at others) and other behavioral (not directed towards others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) symptoms that occurred 1 to 3 days during the review period. <BR/>Record review of Resident #82's order summary reflected he had a diagnosis of post-traumatic stress disorder effective 03/25/21.<BR/>Record review of Resident #82's quarterly comprehensive care plan dated 03/06/25 reflected he:<BR/>1. <BR/>used to be a boxer and suffered from post-traumatic stress disorder (date initiated/revised 08/25/23). His interventions included to administer medications as ordered, behavioral health consults as needed, monitor/document/report PRN any risk for harm to self (date initiated 01/10/24), monitor/record/report to MD prn mood patters signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols (date initiated 11/24/23 and revised 11/25/23) and monitor/record/report to MD prn risk for harming other, increased anger, labile mood ( a neurological condition that involves rapid and exaggerated mood changes) or agitation, feels threatened by others or thoughts of harming someone (date initiated 01/10/24<BR/>2. <BR/>had a psychosocial well-being problem related to post-traumatic disorder, bipolar disorder, dementia, and schizoaffective disorder (dated initiated/revised 11/19/24). Interventions included to encourage participation from resident who depended on others to make his own decisions, increased communication between resident/family/caregivers about care and living arrangements, provide opportunities for the resident and family to participle in care, should conflict arise, remove resident to a calm safe environment and allow to vent/share feelings.<BR/>In an observation on 03/24/25 at 10:35 a.m., Resident #82 was observed lying in bed awake and mumbling to himself with a blank stare.<BR/>In an interview on 03/25/25 at 10:00 a.m., the SW said when a resident was admitted , they were screened for any trauma. She said Resident #82 was admitted to the facility on [DATE] and diagnosed with post-traumatic stress disorder on 03/25/21. She said she would have to review her records to see if he had any identifiable triggers.<BR/>In an interview on 03/26/25 at 8:00 a.m., CNA R said she had cared for Resident #82 for almost one year. She said since she had cared for him he had not displayed any behaviors. She said he was bed bound, required total assistance for all ADLs, and was not able to communicate. CNA R said she would round Resident #82 more frequently because he was not able to communicate or use the call light. She said by rounding more often than every 2 hours, staff could anticipate his needs better. <BR/>In an observation and interview on 03/26/25 at 8:11 a.m., LVN F said Resident #82 used to be a hospice patient but had recently been discharged from hospice. She said for the most part his way to communicate was to moan. LVN F said, it was rare but there had been times in which Resident #82 was able to answer yes or no but for the most part he would just moan. She said staff were able to meet his needs by making more rounds to his room and trying to anticipate his needs better. LVN F said Resident #82 had a diagnosis of post-traumatic disorder. She was observed as she reviewed Resident #82's care plan and said she was not able to find any triggers listed under his problem of post-traumatic stress disorder. She said CNAs and nursing staff would constantly monitor Resident #82 for any signs or symptoms of any behaviors not only because of his diagnosis of post-traumatic stress disorder but for all his other mental disorders. She said in her experience as a nurse, Resident #82 had not displayed any behaviors that she could identify as triggers. She said there were no negative outcome for Resident #82 not having any triggers identified on his care plan because staff were monitoring all his behaviors because of his overall mental disorders. LVN F said she would be in-serviced at least every 12 months on the topic of post-traumatic disorder. <BR/>In an interview on 03/26/25 at 10:30 a.m., LVN S-MDS said Resident #82 was the only resident in the facility with an active diagnosis of post-traumatic stress disorder. She said she had not included any triggers because there were no identifiable triggers for him. She said in her opinion, if a resident with an active diagnosis of post-traumatic disorder did not have any identifiable triggers their care plan should include a statement that reflected no identifiable triggers, which she acknowledged Resident #82's care plan did not. She said there were no negative outcome to Resident #82 not having triggers listed on his care plan, because he was being monitored for all his other mental disorders which included post-traumatic stress disorder. <BR/>In an interview on 03/26/25 at 4:08 p.m., the Social Worker said she had reviewed Resident #82' progress notes and his counseling notes but had not found any documentation that identified any triggers for his post-traumatic stress disorder. She said Resident #82 had been referred to counseling in the past for his diagnosis of bipolar. She said when Resident #82 was initially admitted , he had behavior problems like wanting to punch staff and other residents. She said since his admission, Resident #82's health had declined and at one point he was under hospice. She said he was no longer under hospice, but his health continued declining. She said Resident #82 was not able to communicate, was bed bound. She said she had not been told by staff Resident #82 displayed any behaviors that could be identified as triggers. She said when Resident #82 was initially admitted , he was in the secure unit. She said since his health declined, he was transferred to a regular room as he was no longer displaying any behaviors or able to ambulate. <BR/>In an interview on 03/26/25 at 4:27 pm the DON said the care Resident #82 received was based on his current physical status/psychosocial status. She said his diagnosis of post-traumatic stress disorder did not infringe in the care he received. She said there were no negative outcome to Resident #82 not having triggers identified on his care plan because his dementia was too advanced, and he was being monitored for any behavior issues. <BR/>In an interview on 03/27/25 at 8:45 am, the Nurse Practitioner (Psychiatry) said when Resident #82 had initially been admitted to the facility, staff had a very hard time trying to diagnose him. She said Resident #82 was very aggressive, agitated, and difficult to manage. She Resident #82 was not a very good historian and it had taken a long time to stabilize him. She said she diagnosed Resident #82 with post-traumatic stress disorder along with other mental issues after his admission. She said at the time of his diagnosis, she was not able to identify any triggers and focused on his other more severe mental disorders. She explained Resident #82 had been a boxer in his younger years and had also been kidnapped for several weeks and severely beaten up in another country. She said the resident has had a rapid decline in health and in her medical opinion, he is beyond the point of having identifiable triggers because his dementia is too advanced.<BR/>Record review of the Comprehensive Person-Centered Policy, date implemented 10/24/2022, read in part It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care.<BR/>Facility staff transferred Resident #2 three times after a fall before getting her in bed. Resident #2 was in pain before the transfers. Later x-rays showed resident had sustained a fractured hip.<BR/> This failure placed resident in unnecessary pain and discomfort with a potential for further injury.<BR/>Findings include: <BR/>Record review of Resident # 2 face sheet revealed she was an [AGE] year-old female admitted on [DATE]. Her diagnoses included T cognitive communication deficit, unsteadiness on feet, lack of coordination, syncope and collapse, muscle weakness and need of assistance with ADLs.<BR/>Record review of Resident #2 MDS assessment dated [DATE] revealed a BIMS score of 01 out of 15 indicating severe cognitive impairment. She required extensive assistance with ADL care.<BR/>In an interview on 11/29/2023 at 02:30 p.m., Resident # 2 said she has never sustained a fall. Resident was able to answer what her name was but was not oriented to time or day. Surveyor could not continue with the interview any further due to residents' current cognitive level.<BR/>In an observation on 11/29/2023 at 2:40pm, Resident #2 was observed sitting in her wheelchair, in the cafeteria, watching an activities session. Resident was well kempt and dressed appropriately for ambient temperature. She appeared to be enjoying herself and she showed no signs of distress or discomfort<BR/>In an interview on 11/29/23 at 03:00 p.m., LVN A stated she was sitting at nurses' station, and Resident #2 was sitting on her wheelchair next to her when she sustained a fall. LVN A said she assessed resident per facility post fall protocol. She stated noticed an abrasion to residents' right knee and that resident was touching her hip and grimacing in pain. LVN A stated, I knew it was bad from how I saw her in pain. LVN A said she completed Resident #2's assessment. LVN A said she told CNA B and CNA C were instructed by LVN A to move resident onto a dining chair. LVN A then instructed CNS's A and B to transfer resident from the chair onto her wheelchair and taken to her room where she was placed in bed. LVN A stated she followed the resident from the fall location (nurses' station) to her room while she was being transferred because she knew the resident had sustained a serious injury and wanted to make sure CNA B and CNA C were careful with resident #1's transfer. LVN A said she received orders from doctor for X-rays of hip which were performed sometime after the fall. LVN A said X-ray revealed fracture to the right hip and Resident #1 was then sent out to hospital and surgery was recommended. LVN A said resident #2 was given pain medication. <BR/>Record review of nursing documentation dated 09/12/2023 at 10:40pm Note Text: Resident noted getting up from wheelchair and lost balance due to unsteady gait, fell landing on her right side, LVN A sitting at nurses station witnessed fall but did not get to patient on time to prevent fall, assessed patient from head to toe, redness to her right knee and complain of pain to her right hip assessed head to toe, administer acetaminophen 325mg 2 tabs PO Q6 PRN, she notified nurse practitioner on call for ordered STAT X-ray to right hip and right knee and Tylenol 500mg PO BID X1 Day DX: pain, patient getting up from wheelchair constantly redirected patient to sit because she could fall<BR/>In an Interview on 11/29/2023 at 04:00 p.m., CNA B stated he saw resident #2 on the floor and LVN A doing an assessment. He said LVN A asked for resident #2 to be transferred to a dining chair. CNA B said the resident then was moved to a wheelchair, taken to her room and transferred to bed CNA B stated to surveyor that he saw the resident was placing her arm on her hip and guarding against being touched there. He said Resident #2 expressed being in pain in her hip area. <BR/>In an Interview at 12/30/2023 at 02:45 p.m., CNA C stated she has been trained not to move a resident until she has been cleared by the nurse on duty. CNA C stated she assisted resident from the floor to a chair once she was cleared by LVN A. She and CNA B then transferred resident to her wheelchair and then shortly after took Resident #2 to her room and then transferred her to bed. <BR/>In an interview on 11/29/2023 at 04:45 p.m., LVN A stated moving a resident after a fall could cause more injury, and very likely would cause more pain. LVN A said therefore nursing staff should not move a resident if a proper assessment indicated a probability of further damage. LVN A stated that Resident #2 was in pain and was guarding her hip and while sitting on chair would try to shift weight from the right hip. LVN A stated Resident #2 was once moved off the floor onto a chair, the second time was from the chair onto the resident's wheelchair and the third time was from the wheelchair onto the resident's bed to await Dr. ordered X-rays. LVN A said during this time Resident #2 complained of pain, however pain medication was given to her. LVN A stated she followed the facility post fall worksheet when she assessed Resident #2, She also stated she was motivated to move the resident because she did not want visitors to see the resident laying on the floor, but that in hindsight she would not have put the resident through unnecessary transfers. <BR/>Review of hospital documentation on 11/30/2023 at 10:30 a.m., indicated hospital physician assessment indicated resident in extreme pain and discomfort with any attempted motion of the hip.<BR/>In a review of nursing documentation on 11/30/2023 at 10:00 a.m. LVN A documented that she notified the DON and NP of X-ray results with orders for patient to be transferred to hospital, notified responsible party of patient status. <BR/>In a phone interview on 12/01/2023 at 05:00 p.m., with Resident #2's Doctor stated the likelihood of further damage to hip is minimal however the resident will be in pain with any movement of the hip. Doctor stated if movement must be made it should, however, be kept to a minimum. <BR/>In an interview on 12/01/2023 at 05:30 p.m., with Director of Therapy stated with hip injuries movements should be kept to a minimum and if they are necessary a pillow between the knees would be ideal. Director of Therapy answered resident is very likely to experience pain during transfers. <BR/>In an interview on 11/30/2023 at 01:00 p.m., with the DON stated the nurses should follow post fall protocol which included an assessment of the resident to determine whether it is safe to move the resident. DON stated that residents should not be moved if moving them would cause further injury. She stated residents should be made comfortable and await emergency medical Services (EMS) to transport resident to higher level of care. The DON also stated that nurses are in-serviced regularly regarding falls and fall prevention and if a nurse is observed to not be follow's facility protocol, that nurse would be retrained. <BR/>Record review of trainings showed staff was in serviced on 09/12/2023 regarding resident falls, Topics included falls management/minimizing trips, slips and falls, Bed in lowest position, bed against wall, floor mat, call lights within reach, non-slip socks, well-fitting shoes, hipsters, soft helmet, arm sleeves., wheelchair adjustments if needed, resident monitoring. <BR/>Record review of Fall prevention policy on 11/30/2023 Implemented on 8/15/22 which states the policy for the facility is that each resident will be assessed for fall risk and will receive care and services in accordance with their<BR/>individualized level of risk to minimize the likelihood of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure Residents are free of any significant medication errors, for 1 of 8 residents (Residents #87) reviewed for significant medication errors, in that:<BR/>1.Resident #87 was administered clonazepam 1mg without a physician's order by LVN G 77 times from 07/25/2023 to 12/19/2023. <BR/>These failures placed residents at risk for receiving medications not prescribed by a physician. <BR/>The findings included:<BR/>Record review of Resident #87's face sheet, dated 12/18/23 revealed a male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), hemiplegia and hemiparesis (weakness or loss of strength on one side of the body), and need for assistance with personal care.<BR/>Record review of Resident #87's quarterly MDS assessment, dated 11/29/2023, revealed a BIMS score of 09/15, signifying moderate cognitive impairment.<BR/>Record review of Resident #87's comprehensive care plan revealed Resident #87 shizophrenia and Bipolar at risk for behavioral problems, revised 12/18/2023, with an intervention of Administer medications as ordered.<BR/>A record review of Resident #87's May, June, July, August, September, October, November, and December 2023 physicians' orders revealed: <BR/>1.Resident #87 had an order to receive clonazepam 1mg daily which was discontinued on 05/31/2023. <BR/>2.Resident #87 received a new order for clonazepam 1mg to be given as needed for paranoia from 05/31/2023 to 06/13/2023. <BR/>3.Resident #87 received a new order for clonazepam 1mg to be given as needed for paranoia from 07/10/2023 to 07/24/2023. <BR/>4.Resident #87 received a new order for clonazepam 1mg to be given as needed for paranoia from 08/10/2023 to 08/24/2023.<BR/>Further review revealed no other orders for clonazepam.<BR/>Record reviews of Resident #87's clonazepam 1mg pharmacy count sheets revealed:<BR/>1.A clonazepam 1mg count sheet for Resident #87 dated 04/18/2023 with documentation for clonazepam dispensation to match physicians' orders until 07/24/2023 and again from 08/10/2023 to 08/24/2023. Further review of the document revealed on 07/25/2023 LVN G documented she administered 1 pill to Resident #87 at 02:00 PM without a physician's order. Further review revealed LVN G continued to document dispensation of clonazepam 1mg to Resident #87 without a physician's order until the exhaustion of the clonazepam supply on 09/20/2023 for a total of 28 dispensations from 07/25/2023 to 09/20/2023.<BR/>2.A clonazepam 1mg count sheet for Resident #87 dated 05/11/2023 with documentation by LVN G for clonazepam dispensation without a physician's order starting on 09/22/2023 thorough 12/19/2023 for a total of 49 dispensations from 09/22/2023 to 12/19/2023. Further review revealed the count sheet had 9 more pills available. <BR/>During an observation and interview on 12/20/2023 at 04:35 PM revealed LVN G at the 600-hll medication cart. LVN G stated she was the charge nurse for Resident #87 and Resident #87's medications were stored in the cart. LVN G demonstrated Resident #87's clonazepam 1mg drug card with 9 pills, out of a beginning inventory of 60, remaining. LVN G was asked if Resident #87 had an order for the clonazepam 1mg to which LVN G did not verbally reply and gestured with her arms and hands outstretched and shoulders raised. <BR/>During an interview on 12/21/2023 10:42 AM ADON H stated PharmD R alerted the facility on 12/12/2023 there was clonazepam 1mg in the medication cart for 600-hall, for Resident #87 which had no physicians' order for administration and the count sheet appeared as if was being administered. ADON H stated an investigation revealed LVN G had admitted she had been administering the medication without an order. ADON H stated LVN G had been suspended pending an investigation. <BR/>During an interview on 12/21/2023 at 04:10 PM the DON stated LVN G had admitted to administering clonazepam to Resident #87 without a physician's order and LVN G had been suspended pending an investigation. The DON stated residents would only receive medications per a physician's order and LVN G should not have administered any medication without a physician's order. The DON stated the risk for harm was residents may receive medications with effects not intended for them. <BR/>During an interview on 12/22/2023 at 05:10 PM the Administrator stated the expectation was for residents to receive medications per physician's orders. <BR/>A record review of the facility's Medication Administration policy dated 10/24/2022, revealed, medications are administered by licensed nurses, or other staff were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, any manner to prevent contamination or infection. Policy explanation and compliance guidelines: . review medication administration record to identify medication to be administered . Administer medication as ordered . sign medication administration record after administered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #66 and Resident #145) of 8 residents observed for infection control.<BR/>1. LVN F failed to sanitize hands before administering G-tube medications to Resident #66. <BR/>2. CNA O did not remove their contaminated gloves after catheter care prior to cleansing Resident #145 of bowel movement. CNA O proceeded to clean without performing hand hygiene and maintained usage of dirty gloves while cleaning posterior area and used the same gloves to apply a clean brief. <BR/>These deficient practices could place residents at-risk for healthcare associated cross contamination and the spread of infection due to improper care practices.<BR/>Findings included:<BR/>1. Record review of Resident #66's face sheet dated 03/26/2025 revealed the resident was a [AGE] year-old female admitted on [DATE] with an original admission date of 02/04/2020. Her pertinent diagnoses included Cerebral Infarction (stroke), Gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach), Dysphagia following Cerebral Infarction (difficulty swallowing following a stroke), Muscle wasting and Atrophy (loss of muscle tissue), and Type 2 Diabetes Mellitus.<BR/>Record review of Resident #66's quarterly MDS assessment, dated 02/04/2025 revealed a BIMS score of 00, indicating Resident #66 was severely cognitively impaired. <BR/>Record review of Resident #66's physician order summary dated 11/17/2022 revealed Resident #66 Enteral Feed Order every shift flush feeding tube with 30mls of water before and after medication administration.<BR/>Record review of Resident #66's comprehensive care plan, revision date 05/02/2024, reflected Resident #66 has a gastric tube r/t Dysphagia Interventions: Monitor/document/report as needed signs and symptoms of .infection at tube site.<BR/>During an observation in Resident #66's room on 03/25/2025 at 07:42 a.m. LVN F washed her hands then touched the privacy curtain and donned gloves without sanitizing her hands. She touched the bed remote with the gloves, to adjust the height of the bed, and with the same pair of gloves she proceeded to touch the resident's G-tube and administer the medications.<BR/>In an interview on 03/25/25 at 08:02 a.m. with LVN F, she stated that she did well during the G-tube medication administration. She stated she does not use hand sanitizer because her skin gets irritated and washes her hands instead. LVN F stated that she was supposed to wash her hands before administering medications. She stated sanitizing hands after touching the privacy curtain and touching the bed remote was important to prevent infection to the resident. LVN F stated that we carry microbes all over our hands and Resident #66's G-tube site was a port of entrance for infection. <BR/>In an interview on 03/26/2025 at 10:40 a.m. with ADON G, she stated staff were trained to sanitize hands in between glove changes and to perform hand hygiene using soap and water for 20 seconds if their hands were visibly soiled. She stated LVN F should have sanitized after touching the privacy curtain without gloves after washing her hands. ADON G stated that when it comes down to touching the resident's bed remote it was iffy because it was the residence germs and not anyone else's germs. She stated that they were to wash their hands with soap and water if hand sanitizer was causing irritation. She stated she has not had any staff voice that they could not use hand sanitizer due to causing irritation. She stated there were other various hand sanitizers readily available. ADON G stated it was important to sanitize or wash hands to break the chain of infection.<BR/>In an interview on 03/27/2025 at 10:59 a.m. with the DON, she stated staff were trained to sanitize hands before patient care, in between glove changes, and when done with care that they were providing. She stated the privacy curtains were dirty and staff was to sanitize hands afterwards. The DON stated after touching the bed control, staff was to remove gloves, sanitize hands, and don a new pair of gloves. She stated if staff hands get irritated with hand sanitizer, they were encouraged to use soap and water, but they also have aloe vera hand sanitizer. The DON stated that the staff should sanitize or wash their hands to prevent infection.<BR/>2. Record review of Resident #145's Face Sheet dated 03/24/2025 revealed an [AGE] year-old male admitted originally on 08/15/2024. His diagnoses included, chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), benign prostatic hyperplasia with lower urinary tract symptoms (a condition in which the prostate gland, located below the bladder in men, enlarges), retention of urine (the inability to completely empty the bladder).<BR/>Record review of Resident #145's Comprehensive Care Plan initiated: 08/15/2024 documented, Problem: [Resident #145] is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations. Interventions: functional performance with personal care: the resident requires partial/moderate assistance for personal hygiene.<BR/>Record review of Resident #145's MDS dated [DATE] documented a Brief Interview of Mental Status score of 12/moderately impaired cognition, as well as extensive dependency of staff to assist in activities of daily living. An indwelling urninary catheter was used.<BR/>During an observation on 03/25/2025 at 11: 09AM, observed Resident #145 had an indwelling urinary catheter. CNA O commenced catheter care of Resident #145. CNA O entered Resident #145's room after knocking. CNA O began with washing hands for 30 seconds, gloved up, and prepared the table of needed supplies. CNA O continued by raising the bed and then discarded gloves. After discarding the gloves, CNA O continued with applying hand sanitizer and she did apply new gloves. CNA proceeded with catheter care and proceeded to clean bowel movement. Once bowel movement was cleaned, using the same pair of gloves, she removed the brief, and applied a new brief.<BR/>During an interview on 03/25/2025 at 11: 28AM, CNA O stated that they should have changed those gloves after cleaning the foley catheter, to minimize contraction of infection. CNA O stated they should have washed hands/used hand sanitizer and changed gloves, before, during, and after care to minimize chance of infection. CNA O stated their recognition of error and proceeded to state it was noted as a standard of practice. CNA O stated that Resident #145 could get an infection because she did not change gloves when changing from one area to another area.<BR/>During an interview on 03/25/25 at 4:40PM with the DON, the DON stated that after perineum care, hand hygiene should have been performed prior to moving to the second part of cleaning of the bowel movement. The DON stressed the importance of infection prevention and stated that personnel were educated and observed by her performing specific care during checkoffs, before being allowed to work on the floor independently. The DON stated this practice could put Resident #145 at risk for urinary tract infection.<BR/>Record review of the facility's Hand Hygiene Policy dated 10/24/2022 revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub.<BR/>Record Review of the facility's Infection Prevention and Control Program Policy dated 05/13/23 revealed Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.<BR/>Policy Explanation and Compliance Guidelines:<BR/>2. All staff are responsible for following all policies and procedures related to the program.<BR/>Standard Precautions:<BR/>b. Hand Hygiene shall be performed in accordance with our facility's established hand hygiene procedures.<BR/>d. Licensed staff shall adhere to safe injection and medication administration practices as described in relevant facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care.<BR/>Facility staff transferred Resident #2 three times after a fall before getting her in bed. Resident #2 was in pain before the transfers. Later x-rays showed resident had sustained a fractured hip.<BR/> This failure placed resident in unnecessary pain and discomfort with a potential for further injury.<BR/>Findings include: <BR/>Record review of Resident # 2 face sheet revealed she was an [AGE] year-old female admitted on [DATE]. Her diagnoses included T cognitive communication deficit, unsteadiness on feet, lack of coordination, syncope and collapse, muscle weakness and need of assistance with ADLs.<BR/>Record review of Resident #2 MDS assessment dated [DATE] revealed a BIMS score of 01 out of 15 indicating severe cognitive impairment. She required extensive assistance with ADL care.<BR/>In an interview on 11/29/2023 at 02:30 p.m., Resident # 2 said she has never sustained a fall. Resident was able to answer what her name was but was not oriented to time or day. Surveyor could not continue with the interview any further due to residents' current cognitive level.<BR/>In an observation on 11/29/2023 at 2:40pm, Resident #2 was observed sitting in her wheelchair, in the cafeteria, watching an activities session. Resident was well kempt and dressed appropriately for ambient temperature. She appeared to be enjoying herself and she showed no signs of distress or discomfort<BR/>In an interview on 11/29/23 at 03:00 p.m., LVN A stated she was sitting at nurses' station, and Resident #2 was sitting on her wheelchair next to her when she sustained a fall. LVN A said she assessed resident per facility post fall protocol. She stated noticed an abrasion to residents' right knee and that resident was touching her hip and grimacing in pain. LVN A stated, I knew it was bad from how I saw her in pain. LVN A said she completed Resident #2's assessment. LVN A said she told CNA B and CNA C were instructed by LVN A to move resident onto a dining chair. LVN A then instructed CNS's A and B to transfer resident from the chair onto her wheelchair and taken to her room where she was placed in bed. LVN A stated she followed the resident from the fall location (nurses' station) to her room while she was being transferred because she knew the resident had sustained a serious injury and wanted to make sure CNA B and CNA C were careful with resident #1's transfer. LVN A said she received orders from doctor for X-rays of hip which were performed sometime after the fall. LVN A said X-ray revealed fracture to the right hip and Resident #1 was then sent out to hospital and surgery was recommended. LVN A said resident #2 was given pain medication. <BR/>Record review of nursing documentation dated 09/12/2023 at 10:40pm Note Text: Resident noted getting up from wheelchair and lost balance due to unsteady gait, fell landing on her right side, LVN A sitting at nurses station witnessed fall but did not get to patient on time to prevent fall, assessed patient from head to toe, redness to her right knee and complain of pain to her right hip assessed head to toe, administer acetaminophen 325mg 2 tabs PO Q6 PRN, she notified nurse practitioner on call for ordered STAT X-ray to right hip and right knee and Tylenol 500mg PO BID X1 Day DX: pain, patient getting up from wheelchair constantly redirected patient to sit because she could fall<BR/>In an Interview on 11/29/2023 at 04:00 p.m., CNA B stated he saw resident #2 on the floor and LVN A doing an assessment. He said LVN A asked for resident #2 to be transferred to a dining chair. CNA B said the resident then was moved to a wheelchair, taken to her room and transferred to bed CNA B stated to surveyor that he saw the resident was placing her arm on her hip and guarding against being touched there. He said Resident #2 expressed being in pain in her hip area. <BR/>In an Interview at 12/30/2023 at 02:45 p.m., CNA C stated she has been trained not to move a resident until she has been cleared by the nurse on duty. CNA C stated she assisted resident from the floor to a chair once she was cleared by LVN A. She and CNA B then transferred resident to her wheelchair and then shortly after took Resident #2 to her room and then transferred her to bed. <BR/>In an interview on 11/29/2023 at 04:45 p.m., LVN A stated moving a resident after a fall could cause more injury, and very likely would cause more pain. LVN A said therefore nursing staff should not move a resident if a proper assessment indicated a probability of further damage. LVN A stated that Resident #2 was in pain and was guarding her hip and while sitting on chair would try to shift weight from the right hip. LVN A stated Resident #2 was once moved off the floor onto a chair, the second time was from the chair onto the resident's wheelchair and the third time was from the wheelchair onto the resident's bed to await Dr. ordered X-rays. LVN A said during this time Resident #2 complained of pain, however pain medication was given to her. LVN A stated she followed the facility post fall worksheet when she assessed Resident #2, She also stated she was motivated to move the resident because she did not want visitors to see the resident laying on the floor, but that in hindsight she would not have put the resident through unnecessary transfers. <BR/>Review of hospital documentation on 11/30/2023 at 10:30 a.m., indicated hospital physician assessment indicated resident in extreme pain and discomfort with any attempted motion of the hip.<BR/>In a review of nursing documentation on 11/30/2023 at 10:00 a.m. LVN A documented that she notified the DON and NP of X-ray results with orders for patient to be transferred to hospital, notified responsible party of patient status. <BR/>In a phone interview on 12/01/2023 at 05:00 p.m., with Resident #2's Doctor stated the likelihood of further damage to hip is minimal however the resident will be in pain with any movement of the hip. Doctor stated if movement must be made it should, however, be kept to a minimum. <BR/>In an interview on 12/01/2023 at 05:30 p.m., with Director of Therapy stated with hip injuries movements should be kept to a minimum and if they are necessary a pillow between the knees would be ideal. Director of Therapy answered resident is very likely to experience pain during transfers. <BR/>In an interview on 11/30/2023 at 01:00 p.m., with the DON stated the nurses should follow post fall protocol which included an assessment of the resident to determine whether it is safe to move the resident. DON stated that residents should not be moved if moving them would cause further injury. She stated residents should be made comfortable and await emergency medical Services (EMS) to transport resident to higher level of care. The DON also stated that nurses are in-serviced regularly regarding falls and fall prevention and if a nurse is observed to not be follow's facility protocol, that nurse would be retrained. <BR/>Record review of trainings showed staff was in serviced on 09/12/2023 regarding resident falls, Topics included falls management/minimizing trips, slips and falls, Bed in lowest position, bed against wall, floor mat, call lights within reach, non-slip socks, well-fitting shoes, hipsters, soft helmet, arm sleeves., wheelchair adjustments if needed, resident monitoring. <BR/>Record review of Fall prevention policy on 11/30/2023 Implemented on 8/15/22 which states the policy for the facility is that each resident will be assessed for fall risk and will receive care and services in accordance with their<BR/>individualized level of risk to minimize the likelihood of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #13) reviewed for accidents and hazards: <BR/> The facility failed to ensure Resident #13 did not have disposable razors in his room.<BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.<BR/>The findings included:<BR/>Record review of Resident #13's admission record, dated 03/24/25, reflected a [AGE] year-old male admitted to facility on 11/14/24. His relevant diagnoses included the need for assistance with personal care, epilepsy (disorder in which nerve cells activity in the brain is disturbed causing seizures), and intellectual disabilities (below average intelligence and set of life skills). <BR/>Record review of Resident #13's quarterly MDS dated [DATE] reflected he had a BIMS score of 08, which indicated his cognition was moderately impaired.<BR/>Record review of Resident #13's quarterly care plan dated 02/09/25 reflected he had an ADL self-care performance deficit related to weakness, history of spinal fractures, poor balance. His interventions in part included functional performance of personal hygiene, Resident #13 required partial or moderate assistance for personal hygiene (date initiated 11/14/24 and revised on 11/23/24).<BR/>An observation on 03/24/25 at 11:14 a.m., Resident #13 was observed sitting on his wheelchair. Surveyor asked him for permission to inspect his restroom, and he consented. In the restroom sink there was one disposable razor with the lid still on. <BR/>In an interview on 03/24/25 at 11:17 a.m., Resident #13 said he had just come back from the shower room where he had been showered and shaved. He said at times he preferred to shave himself. He said he kept a bag of disposable razors in his dresser drawer. Resident #13 said whenever he decided to shave himself, the CNAs would pull out a new disposable razor from his drawer for him to use. <BR/>In an interview and observation on 03/24/25 at 1:00 p.m., CNA A said Resident #13 had been showered earlier that day by CNA B. She was observed walking into Resident #13's restroom where she acknowledged seeing a disposable razor on his sink, she said she did not know who had placed it there. She said Resident #13 was independent and at times would shave himself while a CNA would observe him. She said her shift began at 6 am that day and had made several rounds to Resident #13's room but had not noticed the disposable razor on the sink. CNA A was not able to explain the facility's protocol regarding sharps. <BR/>In an interview on 03/24/25 at 1:30 p.m., CNA B said she had showered Resident #13 earlier that day and she had also shaved him while in the shower room. She said she did not know who had placed a disposable razor in his bathroom. She said on 03/24/25, her duties were to shower residents only. <BR/>In an interview and observation on 03/24/25 at 5:32 p.m., RN C said the facility's protocol regarding razors were that they needed to be kept under lock and key in the shower room or in a medication cart. She said if a family member provided residents with razors, facility staff would label them and would place them under lock and key in the shower room or in a medication cart. She said residents were not allowed to keep razors in their rooms. RN C was observed as she checked Resident #13's dresser drawer and pulled out a plastic bag that contained 18 new disposable razors. RN C said the negative outcome for residents having razors in their rooms could be that they could cut themselves or others and if another resident wandered into their restroom, they too could cut themselves or others. RN C advised Resident #13 that she needed to place his disposable razors under lock and key.<BR/>In an interview on 03/24/25 at 5:42 p.m., the DON said residents were not allowed to keep razors in their rooms. She said razors should be kept under lock and key in the shower room or medication cart. The DON said a negative outcome to Resident #13 having a razor in his room could be that he could cut himself or others and if another resident walked into his room, they too could cut themselves or others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive appropriate treatment and services to prevent Urinary Tract Infections for 1 of 1 residents (Resident #76) reviewed for incontinence/UTI, in that:<BR/>The facility failed to ensure Resident # 76's indwelling urinary catheter bag covered with a privacy bag and tubing (not covered with tubing sheath) was off the floor away from potential infection and harm. <BR/>This deficient practice could affect residents with any indwelling urinary catheters by placing them at risk for not receiving proper catheter care and/or development of Urinary Tract Infections.<BR/>The findings include: <BR/>Record review of Resident # 76's face sheet dated Sept. 30, 2022, documented a male admitted [DATE], with the diagnoses including Chronic kidney disease Stage 3B (progressive loss of kidney function) vs. Acute Kidney Failure (sudden interruption of kidney function), Unspecified; Other obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract and backs up into the kidney). <BR/>Record review of Resident # 76's comprehensive care plan dated Aug. 20, 2022 revealed: The resident has an Indwelling Catheter due to urinary retention related to diagnosis: Obstructive and Reflux Uropathy, at risk for infection. Interventions: Check tubing for kinks each shift, Monitor/record/ report to medical doctor (MD) for signs and symptoms Urinary Tract Infection: pain, burning, blood tinged urine, cloudiness no output, deepening of urine color, increased pulse, increased temp. Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior change in eating patterns; Position catheter bag and tubing below the level of the bladder and away from entrance room door. <BR/>Record review of Resident # 76's Quarterly Minimum Data Set (MDS), which are indicators of quality of care for each resident assessed upon admission to the nursing facility and then periodically, within specific guidelines and timeframe, then transmitted electronically by nursing homes to the MDS database in the State; are dated Aug. 20, 2022, revealed he had clear speech, is able to understand and make himself understood by others. His Brief Interview for Mental Status score is 15 indicating of him being cognitively intact, he requires extensive assistance with two-person physical assist for bed mobility, transfers, dressing and personal hygiene. It was noted that he also uses a wheelchair for mobility and that he had an indwelling urinary catheter at this time. <BR/>Record review of Resident # 76's Active physician orders as of Sept. 30,2022 documented: Change indwelling foley catheter sixteen French (Foley catheter dimensions described in French units) every day shift every four weeks on Monday; Check Foley catheter every shift for placement related to Other Obstructive and Reflux Uropathy; Foley Catheter: Change drainage bag as needed for leaking; Irrigate foley catheter with (30 milliliters) of normal saline or water as needed for leaking or hematuria. <BR/>Record review of nurse's notes in Resident # 76 chart dated Aug. 21, 2022 reflected resident had dark urine from foley, new urinalysis (UA) culture and sensitivity collected .date entered [DATE] Interdisciplinary Care Team -Change of Cond: Follow up on report that resident had dark brown, tea-colored urine in foley catheter on Aug. 20, 2022 .UA showed: Bacteria urine 1, WBC (white blood cell count) urine 5-10, RBC (red blood cell count) urine 0-5, Squamous Epithelial Urine Trace, Mucous Urine Trace .Started on Levaquin (an antibiotic) 250 mg daily x 5 day. Pending culture and sensitivity report. <BR/>Record review of Incontinent Care Proficiency Checklists (with or without Foley) skills checks signed by several direct care staff and Instructor, ADON E, provided by Director of Nurses: Checklist does not contain information on Foley catheter bag/tubing care and management. <BR/>Record review of (Lippincott Nursing Procedures) documented Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI. However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI. <BR/>Observation of Resident # 76 on Sept. 27,2022 at 11:07 AM in room [ROOM NUMBER]-B: MDS (Minimum Data Set) Indicators include Insulin, Catheter use, ADL (activities of daily living); Slight odor of urine was noticed upon entering room. Bed in lowest position; call light within resident reach; Resident resting comfortably in semi-upright position on left side with bed slightly inclined; Resident on O2 (oxygen) 3 Liter via Nasal Cannula with humidifier. Resident has urinary catheter: Catheter covered with privacy cover. Urinary tube (not covered by privacy cover sheath) and bag touching floor. <BR/>Observation of Resident # 76 on [DATE] at 04:43 PM in room [ROOM NUMBER]-B: Bed in lowest position; call light within resident reach; Resident resting comfortably in semi-upright position on left side with bed slightly inclined; Resident on O2 (oxygen) 3 Liter via Nasal Cannula with humidifier. Resident has urinary catheter: Catheter covered with privacy cover. Urinary tube (not covered by privacy cover sheath) and bag touching floor. Resident unaware urinary bag and tubing on floor.)<BR/>Interview on Sept. 29,2022 04:13 PM in Resident # 76 room [ROOM NUMBER]-B: LVN B said that: Foley catheters get changed once a month. Sometimes we loop foley catheters and hang them together, so they do not fall. Foley bags and tubing is not supposed to be touching the floor. If foley bags and tubing are on the floor, we can make them leak if we step on them. Another negative outcome is the risk for infection. I am responsible for taking care of the Foley for residents I am taking care of<BR/>Interview on Sept. 29,2022 at 04:16 PM in Resident # 76 room [ROOM NUMBER]-B: CNA D stated, I was told to put the Foley bag towards the side the resident is laying on. I do Foley care training as it provided; competency will be coming up. Loop helps with the flow of urine as well. If it [foley bag/catheter] is on the floor it is a trip hazard. We [CNA's and other direct care staff] are responsible for taking care of the Foleys. <BR/>Interview on Sept. 29,2022, at 04:24 PM: ADON E, stated, Foley bags should be below the bladder; privacy covers over bags for dignity, privacy and infection. The drainage bag should not be touching the floor. I personally see the Foley tubing as oxygen tubing. The catheter is clean, the tubing is not clean, the bag because it has the port you want to keep it [port] off the floor. The tubing is soiled. The drainage port is not off the floor. The drainage bag goes into the privacy bag. If the port was on the floor it could lead to a UTI. Direct care staff are responsible for foley care. Training for Foley care is provided upon hire and annually and as the need arises. There is no need for the urinary sheath.<BR/>Interview on [DATE], at 03:48 PM: DON stated,: Related to Foley care: Licensed staff and the CNA (certified nurse assistant) who do incontinent care are the people responsible for doing Foley care. Licensed staff supervise Foley care of the residents. We do not necessarily provide Foley care in-services. We provide Incontinent care and were in-serviced about three months ago. In-services are provided annually and as needed and if any issues arise. If we see a Foley bag on the floor, we would address it by finding out who the staff member is, who is taking care of the resident, and provide additional staff education. If there is trauma related to the incident, we would then take action by calling the physician immediately. The infection prevention nurse is who is tracking our UTI trends, and we currently have none. DON stated they did not have a policy for indwelling catheter/foley care; all that was offered was an incontinent care proficiency checklist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #66 and Resident #145) of 8 residents observed for infection control.<BR/>1. LVN F failed to sanitize hands before administering G-tube medications to Resident #66. <BR/>2. CNA O did not remove their contaminated gloves after catheter care prior to cleansing Resident #145 of bowel movement. CNA O proceeded to clean without performing hand hygiene and maintained usage of dirty gloves while cleaning posterior area and used the same gloves to apply a clean brief. <BR/>These deficient practices could place residents at-risk for healthcare associated cross contamination and the spread of infection due to improper care practices.<BR/>Findings included:<BR/>1. Record review of Resident #66's face sheet dated 03/26/2025 revealed the resident was a [AGE] year-old female admitted on [DATE] with an original admission date of 02/04/2020. Her pertinent diagnoses included Cerebral Infarction (stroke), Gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach), Dysphagia following Cerebral Infarction (difficulty swallowing following a stroke), Muscle wasting and Atrophy (loss of muscle tissue), and Type 2 Diabetes Mellitus.<BR/>Record review of Resident #66's quarterly MDS assessment, dated 02/04/2025 revealed a BIMS score of 00, indicating Resident #66 was severely cognitively impaired. <BR/>Record review of Resident #66's physician order summary dated 11/17/2022 revealed Resident #66 Enteral Feed Order every shift flush feeding tube with 30mls of water before and after medication administration.<BR/>Record review of Resident #66's comprehensive care plan, revision date 05/02/2024, reflected Resident #66 has a gastric tube r/t Dysphagia Interventions: Monitor/document/report as needed signs and symptoms of .infection at tube site.<BR/>During an observation in Resident #66's room on 03/25/2025 at 07:42 a.m. LVN F washed her hands then touched the privacy curtain and donned gloves without sanitizing her hands. She touched the bed remote with the gloves, to adjust the height of the bed, and with the same pair of gloves she proceeded to touch the resident's G-tube and administer the medications.<BR/>In an interview on 03/25/25 at 08:02 a.m. with LVN F, she stated that she did well during the G-tube medication administration. She stated she does not use hand sanitizer because her skin gets irritated and washes her hands instead. LVN F stated that she was supposed to wash her hands before administering medications. She stated sanitizing hands after touching the privacy curtain and touching the bed remote was important to prevent infection to the resident. LVN F stated that we carry microbes all over our hands and Resident #66's G-tube site was a port of entrance for infection. <BR/>In an interview on 03/26/2025 at 10:40 a.m. with ADON G, she stated staff were trained to sanitize hands in between glove changes and to perform hand hygiene using soap and water for 20 seconds if their hands were visibly soiled. She stated LVN F should have sanitized after touching the privacy curtain without gloves after washing her hands. ADON G stated that when it comes down to touching the resident's bed remote it was iffy because it was the residence germs and not anyone else's germs. She stated that they were to wash their hands with soap and water if hand sanitizer was causing irritation. She stated she has not had any staff voice that they could not use hand sanitizer due to causing irritation. She stated there were other various hand sanitizers readily available. ADON G stated it was important to sanitize or wash hands to break the chain of infection.<BR/>In an interview on 03/27/2025 at 10:59 a.m. with the DON, she stated staff were trained to sanitize hands before patient care, in between glove changes, and when done with care that they were providing. She stated the privacy curtains were dirty and staff was to sanitize hands afterwards. The DON stated after touching the bed control, staff was to remove gloves, sanitize hands, and don a new pair of gloves. She stated if staff hands get irritated with hand sanitizer, they were encouraged to use soap and water, but they also have aloe vera hand sanitizer. The DON stated that the staff should sanitize or wash their hands to prevent infection.<BR/>2. Record review of Resident #145's Face Sheet dated 03/24/2025 revealed an [AGE] year-old male admitted originally on 08/15/2024. His diagnoses included, chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), benign prostatic hyperplasia with lower urinary tract symptoms (a condition in which the prostate gland, located below the bladder in men, enlarges), retention of urine (the inability to completely empty the bladder).<BR/>Record review of Resident #145's Comprehensive Care Plan initiated: 08/15/2024 documented, Problem: [Resident #145] is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations. Interventions: functional performance with personal care: the resident requires partial/moderate assistance for personal hygiene.<BR/>Record review of Resident #145's MDS dated [DATE] documented a Brief Interview of Mental Status score of 12/moderately impaired cognition, as well as extensive dependency of staff to assist in activities of daily living. An indwelling urninary catheter was used.<BR/>During an observation on 03/25/2025 at 11: 09AM, observed Resident #145 had an indwelling urinary catheter. CNA O commenced catheter care of Resident #145. CNA O entered Resident #145's room after knocking. CNA O began with washing hands for 30 seconds, gloved up, and prepared the table of needed supplies. CNA O continued by raising the bed and then discarded gloves. After discarding the gloves, CNA O continued with applying hand sanitizer and she did apply new gloves. CNA proceeded with catheter care and proceeded to clean bowel movement. Once bowel movement was cleaned, using the same pair of gloves, she removed the brief, and applied a new brief.<BR/>During an interview on 03/25/2025 at 11: 28AM, CNA O stated that they should have changed those gloves after cleaning the foley catheter, to minimize contraction of infection. CNA O stated they should have washed hands/used hand sanitizer and changed gloves, before, during, and after care to minimize chance of infection. CNA O stated their recognition of error and proceeded to state it was noted as a standard of practice. CNA O stated that Resident #145 could get an infection because she did not change gloves when changing from one area to another area.<BR/>During an interview on 03/25/25 at 4:40PM with the DON, the DON stated that after perineum care, hand hygiene should have been performed prior to moving to the second part of cleaning of the bowel movement. The DON stressed the importance of infection prevention and stated that personnel were educated and observed by her performing specific care during checkoffs, before being allowed to work on the floor independently. The DON stated this practice could put Resident #145 at risk for urinary tract infection.<BR/>Record review of the facility's Hand Hygiene Policy dated 10/24/2022 revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub.<BR/>Record Review of the facility's Infection Prevention and Control Program Policy dated 05/13/23 revealed Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.<BR/>Policy Explanation and Compliance Guidelines:<BR/>2. All staff are responsible for following all policies and procedures related to the program.<BR/>Standard Precautions:<BR/>b. Hand Hygiene shall be performed in accordance with our facility's established hand hygiene procedures.<BR/>d. Licensed staff shall adhere to safe injection and medication administration practices as described in relevant facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 4 residents (Resident #2 and Resident #3) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #2's and Resident #3's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. <BR/>These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.<BR/>Finding included:<BR/>Record review of Resident #2's face sheet dated 1/29/25 indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record Review of Resident #2's significant change Minimum Data Set assessment dated [DATE] indicated she received oxygen therapy while a resident.<BR/>Record review of Resident #2's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift related to respiratory failure with hypercapnia (is a condition where there is too much carbon dioxide).<BR/>Record review of Resident #2's comprehensive care plan, dated 5/1/24, indicates Resident #2 required oxygen therapy related to difficulty breathing. The intervention of the care plan was OXYGEN SETTINGS: O2 as ordered.<BR/>During an observation on 1/29/25 at 2:57 p.m., Resident #2 was lying in her bed with oxygen set at 3 liters per minute via nasal cannula. <BR/>Record review of Resident #3's face sheet dated 1/29/25 indicated he was an [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses which included Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record Review of Resident #3's significant change Minimum Data Set assessment dated [DATE] indicated he received oxygen therapy while a resident.<BR/>Record review of Resident #3's physician's order dated 1/29/25 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift for Hypoxia (A condition that occurs when the body's tissues don't have enough oxygen).<BR/>Record review of Resident #3's comprehensive care plan, dated initiated 6/27/2023, indicates Resident #3 required oxygen therapy related to Ineffective gas exchange. The intervention of the care plan was OXYGEN SETTINGS: O2 via nasal cannula at 2 liters per minute.<BR/>During an observation on 1/29/25 at 3:35 p.m. Resident's #3 was lying in his bed with oxygen set at 1.5 liters per minute via nasal cannula. <BR/>During an interview on 1/29/25 at 3:05 p.m., RN C said Resident #2's oxygen rate was at 3 liters per minute per nasal cannula. He said she was supposed to run at 2 liters per minute as per the physician order. RN C said, I notice that the settings were different from the order since I started working here back in October, I told the nurse that was training me, but he said that was fine because she has been like that since she was admitted . RN C said that by not following the physician's orders it could harm the resident, and that the resident could have shortness of breath, exacerbation or the resident could get ill. RN C said that the last training he had on oxygen was back in October when he was hired.<BR/>During an interview on 1/29/25 at 3:40 p.m., LVN D said that nurses were responsible to check every shift the oxygen settings at the beginning of the shift and at the end of the shift. LVN D said that if not administered correctly per order the resident could be harmed, have respiratory distress or the oxygen level could drop. LVN D said that the last training on oxygen was 3 months ago but could not remember the exact day.<BR/>During an interview on 1/29/25 at 4:50 pm ADON said that the nurses were responsible to check the oxygen settings every shift, especially with continuous oxygen use. ADON said that management made morning rounds each morning. The ADON said that an adverse reaction to the resident was that the oxygen level could drop, shortness of breath or change in respiratory status if not administered the appropriate oxygen ordered by the physician. ADON said that the last training on oxygen was done two months ago, and this training was done quarterly.<BR/>During an interview on 1/29/25 at 5:06 p.m., the DON said the charge nurses were responsible for following the physician's orders and to check oxygen settings at the beginning of the shift and as needed during the shift and at the end of the shift. She said that if not given the correct oxygen as the physician prescribed the Resident could have a change in condition or shortness of breath. DON said that managers make rounds every morning and before leaving to make sure oxygen settings were at the correct setting. <BR/>During an interview on 1/30/25 at 9:30 a.m., DON said that this facility does not have a policy on Oxygen Administration.<BR/>Record review of facility policy titled, Medication Reconciliation date implemented as of April 10, 2023, revealed This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent.<BR/>Daily Processes: Verify medications labels match physician orders and consider rights of medication administration each time a medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 4 shower rooms (Shower room [ROOM NUMBER]), in that: <BR/>Observation on 12/17/2023 at 10:42 a.m. in Shower room [ROOM NUMBER], next to resident room [ROOM NUMBER], revealed approximately six razors were found on top of a storage bin and within reach of residents. Additionally, the toilet located inside the shower room was loosely affixed to the wall and the toilet room had a foul odor resembling sewer gas. <BR/>During an interview with Social Worker AA on 12/17/2023 at 10:45 a.m., Social Worker AA confirmed approximately six razors were found on top of a storage bin and within reach of residents, the toilet located inside the shower room was loosely affixed to the wall, and the toilet room had a foul odor resembling sewer gas. Social Worker AA stated she would inform the Maintenance Director of the needed repair [electronic notification system]. <BR/>During an interview with the Maintenance Director on 12/22/2023 at 11:48 a.m., the Maintenance Director confirmed he had been informed that the toilet located inside the shower room was loosely affixed to the wall and the toilet room had a foul odor resembling sewer gas via [electronic notification system]. The Maintenance Director also confirmed the odor had been in place for a while.<BR/>During an interview with the Administrator on 12/21/2023 at 12:45 p.m., the Administrator stated the facility had no policy regarding Physical Environment.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to ensure 20 boxes of food were not on the floor in the dry storage room. <BR/>These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. <BR/>Findings included: <BR/>Observation during initial tour of the facility kitchen on 09/27/22 at 9:15 am revealed 20 boxes stacked on the floor in the kitchen's only walk in dry storage room. The boxes contained canned foods, wafers, bananas, and gallon jars of mayonnaise. <BR/>Interview on 09/27/22 at 9:15 am with the Dietary Manager revealed the food supplies had been delivered earlier in the morning and had not been placed on wooden pallets located inside the dry storage room under the racks used to store the food items. The food supplier had placed the food boxes on the floor before staff could ask them to place on wooden pallets. The Dietary Manager said they had been having problems with the current food supplier delivery person who did not want to spend time to arrange the boxes of food on the pallets that were provided for this process. The delivery person told the Dietary Manager it was a lot of trouble to maneuver the boxes into the dry storage room and place on pallets. <BR/>Interview on 09/29/22 at 9:09 am with Kitchen [NAME] F revealed when the food supplier delivery person came in on Tuesdays and Friday mornings the delivery person would immediately place the boxes on the floor instead of on the wooden pallets as needed. <BR/>Interview on 09/29/22 at 9:15 am with the Dietary Manager revealed that the boxes placed on the floor in the dry storage room could get wet from water spills and/or get contaminated by been placed on the floor. The Dietary Manager said she did not have a policy or procedure that addressed this concern. <BR/>Record review of the Food Code dated 2017, revealed in part.<BR/>3-305.11 Food Storage; Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food: (A) in a clean, dry location; (2) where it is not exposed to splash, dust, or other contamination and; (3) at least 15 cm (6 inches) above the floor.<BR/>

**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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 10 residents (Resident #101 and Resident #82) reviewed for comprehensive person-centered care plans. <BR/> 1.The facility failed to develop a comprehensive person-centered care plan for Resident #101 to address assist feeding.<BR/>2. The facility failed to develop a comprehensive person-centered care plan for Resident #82 to address identifiable triggers to his active diagnosis of Post Traumatic Stress Disorder.<BR/>This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. <BR/>The Findings include:<BR/> Record review of Resident #101's face sheet, dated 3/25/2025, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #101 had a diagnosis which included: Vascular Dementia (a type of cognitive decline caused by damaged to the blood vessels in the brain), Alzheimer's disease (caused by problems with blood supply to the brain, leading to damage and impaired function, and often involves difficulties with thinking, planning and problem solving), Needs assistance with personal care.<BR/>Record review of Resident #101's Care Plan initiated on 5/11/23 reflected she has an ADL self-care deficit related to decreased cognition secondary to Alzheimer's Dementia, and Amnesia. Resident #101's functional performance with eating: the Resident requires (supervision/or touching assistance) for eating.<BR/>Record review of Resident #101's quarterly MDS assessment, dated 1/30/25, reflected a BIMS score of 00, which indicated Resident #00's cognition was severely impaired. Eating assistance was marked on the MDS as 04 which indicated supervision or touching assistance (helper provides verbal cues and/or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>During an observation on 3/24/25 at 12:00PM Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an observation on 3/25/25 at 5:00PM, Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding.<BR/>During an interview on 3/24/25 at 4:00PM with CNA I stated that Resident #101 needs assistance with feeding because she was not able to feed by herself because of the resident's had Alzheimer's. CNA I stated Resident #101 did not know how to use the utensils. CNA I stated resident had been fed with all meals.<BR/> During an interview on 3/26/25 at 11:35AM with RN L stated Resident #101 needed total assistance with feeding with all her meals because of the resident's Alzheimer's disease. RN L stated that a negative outcome of care plan not been accurate could place Resident#101 at risk for weight loss.<BR/> During an interview on 3/26/25 at 10:00 AM with LVN K, MDS nurse, stated that the resident was able to grab finger food. LVN K, MDS nurse stated that she did not know that resident needed a lot of assistance. LVN K, MDS nurse stated that she did not update the care plan because she was not aware that resident was being assisted with feeding every meal.<BR/>During an interview on 3/26/25 at 4:40 PM, the DON said she was not aware that resident was needing total assistance with feedings. DON said Resident#101's care plan had to be accurate and this way all staff could know what the resident needed.<BR/>2. Record review of Resident #82's face sheet dated 03/27/25 reflected resident was a [AGE] year-old male admitted to the facility on [DATE] with original admit date of 12/19/2019. His pertinent diagnoses included post-traumatic stress disorder (mental condition that develops after experiencing or witnessing a traumatic event, war, violent crime, or personal loss), bipolar (a disorder associated with episode of mood swings ranging from depressive to manic highs), dementia (a group of thinking and social symptoms that interferes with daily function), cognitive communication deficit (a group of conditions that affect a person's ability to communicate effectively due to underlying cognitive impairments), major depressive disorder ( mental condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), delusional disorder (mental illness that caused people to have unshakeable false beliefs for at least a month), and schizoaffective disorder (disorder that affects a person's ability to think, feel, and behave clearly).<BR/>Record review of Resident #82's quarterly MDS assessment dated [DATE] reflected his BIMS score question was left blank, indicating his cognition was severely impaired. His active psychiatric/mood disorder diagnoses included depression, bipolar disorder, schizophrenia, post-traumatic stress disorder and psychotic disorder (mental disorder characterized by a disconnection from reality). It further reflected he had physical (hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal (threatening others, screaming at others, cursing at others) and other behavioral (not directed towards others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) symptoms that occurred 1 to 3 days during the review period. <BR/>Record review of Resident #82's order summary reflected he had a diagnosis of post-traumatic stress disorder effective 03/25/21.<BR/>Record review of Resident #82's quarterly comprehensive care plan dated 03/06/25 reflected he:<BR/>1. <BR/>used to be a boxer and suffered from post-traumatic stress disorder (date initiated/revised 08/25/23). His interventions included to administer medications as ordered, behavioral health consults as needed, monitor/document/report PRN any risk for harm to self (date initiated 01/10/24), monitor/record/report to MD prn mood patters signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols (date initiated 11/24/23 and revised 11/25/23) and monitor/record/report to MD prn risk for harming other, increased anger, labile mood ( a neurological condition that involves rapid and exaggerated mood changes) or agitation, feels threatened by others or thoughts of harming someone (date initiated 01/10/24<BR/>2. <BR/>had a psychosocial well-being problem related to post-traumatic disorder, bipolar disorder, dementia, and schizoaffective disorder (dated initiated/revised 11/19/24). Interventions included to encourage participation from resident who depended on others to make his own decisions, increased communication between resident/family/caregivers about care and living arrangements, provide opportunities for the resident and family to participle in care, should conflict arise, remove resident to a calm safe environment and allow to vent/share feelings.<BR/>In an observation on 03/24/25 at 10:35 a.m., Resident #82 was observed lying in bed awake and mumbling to himself with a blank stare.<BR/>In an interview on 03/25/25 at 10:00 a.m., the SW said when a resident was admitted , they were screened for any trauma. She said Resident #82 was admitted to the facility on [DATE] and diagnosed with post-traumatic stress disorder on 03/25/21. She said she would have to review her records to see if he had any identifiable triggers.<BR/>In an interview on 03/26/25 at 8:00 a.m., CNA R said she had cared for Resident #82 for almost one year. She said since she had cared for him he had not displayed any behaviors. She said he was bed bound, required total assistance for all ADLs, and was not able to communicate. CNA R said she would round Resident #82 more frequently because he was not able to communicate or use the call light. She said by rounding more often than every 2 hours, staff could anticipate his needs better. <BR/>In an observation and interview on 03/26/25 at 8:11 a.m., LVN F said Resident #82 used to be a hospice patient but had recently been discharged from hospice. She said for the most part his way to communicate was to moan. LVN F said, it was rare but there had been times in which Resident #82 was able to answer yes or no but for the most part he would just moan. She said staff were able to meet his needs by making more rounds to his room and trying to anticipate his needs better. LVN F said Resident #82 had a diagnosis of post-traumatic disorder. She was observed as she reviewed Resident #82's care plan and said she was not able to find any triggers listed under his problem of post-traumatic stress disorder. She said CNAs and nursing staff would constantly monitor Resident #82 for any signs or symptoms of any behaviors not only because of his diagnosis of post-traumatic stress disorder but for all his other mental disorders. She said in her experience as a nurse, Resident #82 had not displayed any behaviors that she could identify as triggers. She said there were no negative outcome for Resident #82 not having any triggers identified on his care plan because staff were monitoring all his behaviors because of his overall mental disorders. LVN F said she would be in-serviced at least every 12 months on the topic of post-traumatic disorder. <BR/>In an interview on 03/26/25 at 10:30 a.m., LVN S-MDS said Resident #82 was the only resident in the facility with an active diagnosis of post-traumatic stress disorder. She said she had not included any triggers because there were no identifiable triggers for him. She said in her opinion, if a resident with an active diagnosis of post-traumatic disorder did not have any identifiable triggers their care plan should include a statement that reflected no identifiable triggers, which she acknowledged Resident #82's care plan did not. She said there were no negative outcome to Resident #82 not having triggers listed on his care plan, because he was being monitored for all his other mental disorders which included post-traumatic stress disorder. <BR/>In an interview on 03/26/25 at 4:08 p.m., the Social Worker said she had reviewed Resident #82' progress notes and his counseling notes but had not found any documentation that identified any triggers for his post-traumatic stress disorder. She said Resident #82 had been referred to counseling in the past for his diagnosis of bipolar. She said when Resident #82 was initially admitted , he had behavior problems like wanting to punch staff and other residents. She said since his admission, Resident #82's health had declined and at one point he was under hospice. She said he was no longer under hospice, but his health continued declining. She said Resident #82 was not able to communicate, was bed bound. She said she had not been told by staff Resident #82 displayed any behaviors that could be identified as triggers. She said when Resident #82 was initially admitted , he was in the secure unit. She said since his health declined, he was transferred to a regular room as he was no longer displaying any behaviors or able to ambulate. <BR/>In an interview on 03/26/25 at 4:27 pm the DON said the care Resident #82 received was based on his current physical status/psychosocial status. She said his diagnosis of post-traumatic stress disorder did not infringe in the care he received. She said there were no negative outcome to Resident #82 not having triggers identified on his care plan because his dementia was too advanced, and he was being monitored for any behavior issues. <BR/>In an interview on 03/27/25 at 8:45 am, the Nurse Practitioner (Psychiatry) said when Resident #82 had initially been admitted to the facility, staff had a very hard time trying to diagnose him. She said Resident #82 was very aggressive, agitated, and difficult to manage. She Resident #82 was not a very good historian and it had taken a long time to stabilize him. She said she diagnosed Resident #82 with post-traumatic stress disorder along with other mental issues after his admission. She said at the time of his diagnosis, she was not able to identify any triggers and focused on his other more severe mental disorders. She explained Resident #82 had been a boxer in his younger years and had also been kidnapped for several weeks and severely beaten up in another country. She said the resident has had a rapid decline in health and in her medical opinion, he is beyond the point of having identifiable triggers because his dementia is too advanced.<BR/>Record review of the Comprehensive Person-Centered Policy, date implemented 10/24/2022, read in part It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used within the facility to be labeled and stored in accordance with currently accepted professional standards, which included the appropriate cautionary instructions with the expiration date and open date, when applicable, for 2 of 7 carts (Nurse Medication Cart Hall 200, Nurse Medication Cart Hall 600 and Medication room in Hall 500. <BR/>1. <BR/>Nurse Medication Cart #2 contained fifteen open bottles of over-the-counter medications with no open dates on bottle. <BR/>2. <BR/>Nurse Medication Cart # 7 contained four open bottles of prescribed medications and two open bottles of over-the-counter medications with no open dates on the bottle.<BR/>3. <BR/>Medication room [ROOM NUMBER] contained one medication found in the refrigerator that was expired; various types of medical supplies (three) that were in the cabinets that were expired; and seven prescribed medications in the medication disposable cabinet that was unlocked. <BR/>These failures could place residents at risk of not receiving the benefit of medications, adverse reactions to medications, accidental dispensing of unidentified drugs, incorrect administration of medications, drug diversion, exposure to expired drugs, and/or accidental or intentional administration to the wrong resident. <BR/>Findings include: <BR/>During an observation on Sept. 29, 2022, beginning at 03:26 PM, revealed the Nurse medication cart located next to nurse's station in 600 Hall contained the following items: <BR/>In the Left First Drawer: No open date on bottle for listed prescribed medications: <BR/>Fluticasone Propionate Nasal Spray USP (used to treat allergy symptoms) 50mcg for Resident #35.<BR/>Fluticasone Propionate Nasal Spray USP 50mcg for Resident #15. <BR/>Fluticasone Propionate Nasal Spray USP 50mcg for Resident #135.<BR/>Fluticasone Propionate Nasal Spray USP 50mcg for Resident #45.<BR/>During an observation on Sept. 30, 2022, beginning at 11:13 AM of the Medication storage room in hall 500 with RN C the following was identified:<BR/>In the refrigerator: <BR/>Levemir insulin 100 Units/ml vial date opened Aug. 24, 2022, Expiration July 31, 2024, for Resident #47. (Use by date expired) <BR/>Medical supplies in cabinets/drawers/caddy:<BR/>Wolf-Pak Premium Dressing Change Kit with GuardVA and StatLock Expiration June 30, 2022 (drawer under sink); <BR/>Wolf-Pak Premium Dressing Change Kit with GuardVA and StatLock Expiration Nov.30, 2021 (cart next to MedBank tower pyxis, which is an automated medication dispensing system);<BR/>Insyte Autoguard 24 GAx 0.75 inches (0.7 x 19 millimeters) 20 milliliters/minute catheter expiration Feb. 01, 2022 (cart next to MedBank tower pyxis which is an automated medication dispensing system). <BR/>Medication Disposable Cabinet (unlocked) Contents inside include: Heparin Sodium injection, usp (unit-United States Pharmacopeia) 5,000 units/milliliters: inject 5000 unit subcutaneously three times a day for clotting prevent ion for thirty days expiration Sept. 13, 2023, x two boxes (twenty-seven vials between 2 boxes); <BR/>Olanzapine 2.5 milligrams: Give one tablet via PEG (percutaneous endoscopic gastrostomy) tube one time a day for delusional disorders expiration Sept. 19, 2023, one blister pack (fourteen tablets);<BR/>Trazodone 100 milligrams: Give one tablet via PEG tube/via G-Tube (gastrostomy tube) at bedtime for insomnia expiration [DATE], one blister pack (three tablets); <BR/>Carbamazepine 200 mg tablet: Give one tablet by mouth two times a day for convulsions expiration Aug. 11, 2023, one blister pack (one tablet); <BR/>Carbamazepine 200 mg tablet: Give one tablet by mouth two times a day for convulsions expiration Sept. 19, 2023, one blister pack (twenty-eight tablets); <BR/>Metoprolol Succinate ER (extended release) 50 milligrams: Give 50 milligrams via PEG Tube every twelve hours for hypertension hold medication if heart rate is less than 45 beats/minute or systolic blood pressure is less than 100 mm/HG (millimeters of mercury) expiration Sept. 28, 2023, one blister pack (twenty-seven tablets). <BR/>During an interview with LVN # A and ADON E, on Sept. 29, 2022, at 01:25 PM while at the nurse's station, LVN # A replied that a guy came to audit our carts not too long ago and ADON E responded, Pharmacist from Senior Solutions Pharmacy comes to audit our medication carts monthly and according to him over-the-counter medications do not have to have open dates. They go by expiration dates.<BR/>During an interview on [DATE], at 03:50 PM with the DON, Related to Medication storage/disposal she said, pharmacy is in charge of refilling our medication carts/rooms. Nurses are in charge of making sure they are refilled and that the counts are correct. Pharmacy does not deliver over-the-counter medications; central supply does. It is upon the licensed nurse to verify expiration date. The process for receiving over-the-counter medications from central supply is to check expiration date, check the order to make sure it is the right dose, strength. Unless it is a vial that has a shortened expiration date, such as Prostat, (which has a shortened date), the best practice is to date vials upon opening them. Multiuse vials brought by pharmacy are also dated upon opening, they have a space on the label for the date. All discharged resident's medications are disposed within 28 days. Nurses put the expired medications in the discontinued medications cabinet in medication room until they can be brought to the director of nursing and logged in. Then they go through medication destruction process with pharmacy and put in biohazard boxes and picked up by a biohazard company. If they are narcotics: they are kept in the locked boxes until they can be brought to director of nursing double locked office and properly disposed of. Medications do not have to be locked unless they are narcotics in the med room until they can be picked up by director of nursing. Consultant pharmacists do full cart audits biweekly and on staggered carts/rooms. Nurses and licensed staff are supposed to check medication carts daily. Medical supplies are checked weekly or daily by nurses, licensed staff and/or pharmacists (if able to). <BR/>During record review of the facility's Expiration Dating and Expired Medications policy dated 10/01/19, A continuous monitoring system will be designated by the director of nursing to identify expired medications and remove them from the medication system.<BR/>During record review of the facility's Discontinued Medications policy dated 10/01/19, Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until disposed of or returned to the pharmacy if credit is allowed. Medications are removed from the medication cart immediately upon receipt of an order to discontinue to avoid inadvertent administration.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to ensure 20 boxes of food were not on the floor in the dry storage room. <BR/>These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. <BR/>Findings included: <BR/>Observation during initial tour of the facility kitchen on 09/27/22 at 9:15 am revealed 20 boxes stacked on the floor in the kitchen's only walk in dry storage room. The boxes contained canned foods, wafers, bananas, and gallon jars of mayonnaise. <BR/>Interview on 09/27/22 at 9:15 am with the Dietary Manager revealed the food supplies had been delivered earlier in the morning and had not been placed on wooden pallets located inside the dry storage room under the racks used to store the food items. The food supplier had placed the food boxes on the floor before staff could ask them to place on wooden pallets. The Dietary Manager said they had been having problems with the current food supplier delivery person who did not want to spend time to arrange the boxes of food on the pallets that were provided for this process. The delivery person told the Dietary Manager it was a lot of trouble to maneuver the boxes into the dry storage room and place on pallets. <BR/>Interview on 09/29/22 at 9:09 am with Kitchen [NAME] F revealed when the food supplier delivery person came in on Tuesdays and Friday mornings the delivery person would immediately place the boxes on the floor instead of on the wooden pallets as needed. <BR/>Interview on 09/29/22 at 9:15 am with the Dietary Manager revealed that the boxes placed on the floor in the dry storage room could get wet from water spills and/or get contaminated by been placed on the floor. The Dietary Manager said she did not have a policy or procedure that addressed this concern. <BR/>Record review of the Food Code dated 2017, revealed in part.<BR/>3-305.11 Food Storage; Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food: (A) in a clean, dry location; (2) where it is not exposed to splash, dust, or other contamination and; (3) at least 15 cm (6 inches) above the floor.<BR/>

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 Bistro refrigerators reviewed for food safety, in that:<BR/>The facility failed to ensure that the Bistro refrigerator had a temperature log attached to the refrigerator and the contents of refrigerator were labeled with date and name of the food product.<BR/>This failure could place residents at risk for food borne illnesses and at risk for choking.<BR/>Findings included: <BR/>During an observation on 12/17/23 at 11:20 AM, the Bistro room, there was where families brought outside foods and ate with residents, a refrigerator that contained food in several Styrofoam to-go containers. There were no names and no dates written on these containers to identify the food products. There was not a temperature log for this refrigerator. This refrigerator had no locks on the refrigerator doors making it easily accessible to anyone in the facility. <BR/>During an observation and interview on 12/17/23 at 11:25 AM, RN X confirmed that there was food in the Bistro refrigerator that was not labeled, no names and no dates. There was a digital number on the outside of the refrigerator and RN X revealed that it says 43 and it could be the temperature of the refrigerator. RN X revealed that the Bistro was used for families to eat with resident. RN X further revealed that not labeling the food products could be detrimental to residents that had dysphagia.<BR/>During an interview on 12/17/23 at 11:28 AM, the DON revealed that the refrigerator in the Bistro was used by family while they were dining in the Bistro. The DON revealed that there should not be any food left in the refrigerator. The DON revealed that mostly housekeeping staff used this refrigerator for their leftovers. The DON further revealed that their last in-service on not using the Bistro refrigerator was in October 2023, after using this refrigerator was noted as a past issue for the facility. <BR/>During an interview on 12/17/23 at 11:32 AM, RN Y revealed that leaving foods that were for a regular diet in the Bistro refrigerator could put residents at risk for choking if they had access to these foods, unsupervised. Later in the day and throughout the rest of the survey, it was observed that the Bistro refrigerator was turned off and had a sign put up to deter anyone from using it. No specific date or specific time noted. <BR/>During an interview on 12/21/23 at 3:35 PM, the RD reported that having food available in a communal fridge could pose food safety concerns, if residents were not aware of food safety practices. The RD further revealed that foods could be choking hazards if it was not appropriate for a resident's diet. <BR/>Record review of the facility policy Potluck Meals and Food from Home, approved October 1 2018, revealed The facility will provide the resident and family education on the basics of food safety and the use and storage of food to ensure safe consumption. And 1. When outside foods are brought in to the facility by resident family or friends, it must be labeled to clearly distinguish it from the food purchased or prepared by the facility and stored separately from the facility's food by placing on a distinguished shelf, labeled bag, or in a bin labeled resident food with the resident name on the items. Foods must be dated with food safety guidelines followed. And 5. Residents must be assisted on accessing and consuming outside foods and beverages in the safest manner possible.