Williamsburg Village Healthcare Campus

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included:Record review of Resident #1's Discharge MDS assessment, dated 09/11/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and discharged on 09/11/25 to Nursing Home. Resident #1 entry/discharge reporting - Discharge assessment -return not anticipated. The residents' diagnoses included unspecified dementia (brain disorders that cause a progressive decline in cognitive abilities), hypertension (high blood pressure) and malnutrition. The MDS reflected Resident #1 had severe cognitive impairment with a BIMS score of 03. Record review of Resident #1's care plan, dated 07/24/25, reflected: Care Area/Problem: Discharge Plan. Goal: Resident and/or representative will be assisted in planning for discharge to safest environment over the next 90 days. Interventions: Assess residents overall expectations concerning discharge. Record review of Resident #1's progress notes written by LVN B on 09/11/25 at 6:00 PM reflected: Resident discharged to a Nursing Home per request. All belongings and Medication given upon discharge. Record review of Resident #1's Physician Discharge Summary signed by physician on 09/30/25 reflected Resident #1 discharged to another nursing facility on 09/11/25. Record review of Resident #1's clinical record reflected there was no documented evidence showing that a discharge summary had been completed for Resident #1. Interview on 10/01/25 at 1:51 PM, LVN B revealed she was the nurse assigned to Resident #1 when she discharged on 09/11/25. LVN B stated she documented a progress note regarding the discharge; however, she was not able to complete the discharge summary because she did not know how. She stated the facility had started a new system and she was not able to figure out how to do it. LVN B stated she notified ADON A that she was not able to complete a discharge summary and ADON A told her to just do a progress note. She stated she did not follow up to ensure it was completed. Interview on 10/01/25 at 2:42 PM, ADON A revealed she was the ADON A assigned to Resident #1. She stated a discharge summary should had been completed on Resident #1. She stated the nurse who discharged the resident would be responsible for completing the discharge summary. She stated she was not aware Resident #1 discharge summary was not completed, she stated LVN B never informed her. ADON A stated it would be her responsibility to ensure a discharge summary was completed when Resident #1 was discharged . She stated there was no potential risk to the resident if a discharge summary was not completed. Interview on 10/01/25 at 3:24 PM, the DON revealed discharge summary should be completed by nursing team when the resident discharges. She stated she was not aware Resident #1 did not have discharge summary. The DON stated the nursing team should all be following up to ensure the discharge summary was completed. She stated prior to the new system the discharge summary should be completed within 10 days. She stated there was no potential risk to the resident for not having a discharge summary. Interview on 10/01/25 at 4:37 PM, the Administrator revealed when a resident discharges from the facility the resident should have a discharge summary and a physician discharge summary. He stated the discharge summary should be completed by the nursing team. He stated the expectation was for discharge summary to be developed and completed. Record review of the facility's Discharge / Transfer policy, dated 04/24/24, reflected the following: The resident will be discharged /transferred (home/another entity) by order of his/her attending physician in accordance with standard practice guidelines.2. Notify resident, their legal representative, if any, or an interested family member and document the discharge. 3. Provide written discharge instructions/education to the resident and family when discharged to a lower of care, in a language they can understand and document in a medical record. EHR>Discharge>Instructions if discharged to an equal or lower level of care setting to transfer if discharged to a higher level of care such as an acute hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of COVID-19 for 1 of 2 (Resident # 2) residents and 3 of 5 (CNA B, CNA C, and Med Aide D) staff reviewed for infection control. <BR/>The facility failed to ensure CNA B, CNA C, and Med Aide D were wearing appropriate PPE and following infection control practices during care of residents positive with COVID-19. The staff subsequently entered rooms of residents who were negative for COVID-19 and did not perform hand hygiene during meal service.<BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>These failures could place residents at risk of exposure of Covid-19 virus which could result in serious illness, hospitalization, and/or death. <BR/>Findings included: <BR/>Record review of Resident # 2's face sheet, dated 12/23/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Record review Resident # 2's consolidated orders, dated 12/23/22, revealed she had a diagnosis of COVID-19.<BR/>Review of the Resident Census Roster dated 12/20/22 revealed as of 12/20/22 two residents (including Resident # 2) were positive for COVID-19 and Resident # 2 was assigned to RM [ROOM NUMBER]. <BR/>Review of Admission/Discharge log revealed Resident # 2 went to the hospital on [DATE] and returned to the facility on [DATE].<BR/>Review of Isolation list revealed Resident # 2 was placed on isolation upon return to the facility on [DATE] because she tested positive for COVID-19 while at the hospital. <BR/>Interview with Resident # 2's family representative on 12/20/22 at 8:54 AM revealed there was a camera in Resident # 2's room. <BR/>Review of video footage on 12/20/22 at 9:15 AM revealed CNA A and an unknown agency staff were at bedside of Resident # 2 to perform incontinent care at 4:40 AM that morning. Both staff wore a N95 mask and gloves. No eye protection or gowns were noted. CNA A wore two N95 masks with the top strap of both masks behind her head, while the bottom straps of both masks hung underneath her chin.<BR/>Review of the staff schedule dated 12/19/22 revealed CNA A was assigned to 23 residents on 12/19/22 10PM-6AM shift, including Residents #2 and #3. The schedule also revealed 2 agency aides had worked on that shift as well.<BR/>Interview via telephone with CNA A on 12/21/22 at 7:07 AM revealed she did not know the name of the aide that helped her change Resident # 2 in the morning on 12/20/22. When asked what the appropriate PPE was for entering a covid-19 positive room, CNA A stated gown, gloves, face shield and mask.<BR/>Interview with Staffing Coordinator on 12/20/22 at 3:30 PM revealed she did not have access to the phone numbers of the staff sent to her from the agency company with whom the facility had a contract. <BR/>Observation on 12/20/22 at 5:56 PM revealed CNA B entered Resident # 2's room to answer the call light. CNA B was wearing an N95 and a face shield. He did not wear a gown.<BR/>Review of video footage of Resident # 2's room from 12/20/22 at 5:56 PM when CNA B answered the call light revealed CNA B reached over without gloves, grabbed the resident with both hands and pulled her over so that she was positioned in the center of the bed. The video footage revealed hand hygiene was not performed while CNA B was in the room. <BR/>Observation on 12/20/22 at 5:58 PM revealed CNA B exited Resident # 2's room pushed his face shield up to his forehead leaving the face shield at an angle and pulled his N95 down below his chin and turned around to speak with the resident from the doorway. No hand hygiene was performed. <BR/>Observation on 12/20/22 at 6:02 PM to 6:14 PM revealed CNA B in a COVID-19 negative room delivering dinner meals. CNA B exited the COVID-19 negative room and proceeded to the beverage cart on the hallway. CNA B picked up drinking cups by the rim and lined them up on the cart, grabbed pitchers of water and iced tea and poured drinks into the respective cups. CNA C then grabbed those same beverage pitchers to pour drinks that were delivered to other residents as well. CNA B delivered resident meals and beverages, and helped residents get set up to eat in four covid negative resident rooms. Each room housed two residents each (8 residents total). CNA B used hand sanitizer only once upon exit of one of the four rooms.<BR/>Observation on 12/20/22 at 6:15 PM revealed CNA C and the kitchen server pushed the beverage and hot food cart down to the other side of the 100 hall to continue serving meals to covid negative residents (the same cart CNA B had touched to deliver food to residents after entering Resident #2's room). <BR/>Interview via telephone on 12/21/22 at 12:36 PM with CNA B revealed he recalled entering Resident # 2's room without a gown during the evening shift on 12/20/22. CNA B stated there were gowns available in the gray container outside the resident's room and stated he could not explain why he did not wear a gown before entering the room. He stated he had been in-serviced recently on the need to wear N95, face shield and gown to enter a covid positive room. He stated handwashing was covered in the recent in-services. CNA B stated entering a covid positive room without proper PPE and then entering a covid negative room could increase the chances of getting other residents sick or contamination of other things. <BR/>Review of video footage revealed on 12/20/22 at 7:13 PM Med aide D entered Resident # 2's room with medications and a cup. Med aide D wore gloves, N95 mask and goggles. He was not wearing a gown.<BR/>Observation on 12/20/22 at 7:30 PM revealed Med aide D entered a covid negative room to administer medications to both residents in that room.<BR/>In an interview on 12/21/22 at 4:10 PM Med aide D revealed he gave Resident # 2 her medications first for the 7PM medication pass on 12/20/22. Med aide D stated after Resident # 2, he gave meds to two residents on the same side of the hall as Resident # 2, and then gave meds to the residents on the A side of 100 hall as most of the residents on that hall had 7PM meds ordered. Med aide D stated it escaped his mind to use the gown when he administered meds to Resident # 2 on 12/20/22. He stated the risk for entering covid negative rooms after not wearing appropriate PPE in a covid positive room was transmission of covid-19. <BR/>Record review of the Coronavirus Management Plan Texas Phase 2 & 3, which the facility was using as their policy, dated 11/03/22, revealed COVID Positive Unit .Personnel who enter the room will wear N95 respirators. In addition, staff should wear a gown, gloves, and face shield or goggles.<BR/>Review of the CDC Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-10) Pandemic, dated 09/23/22, reflected HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>On 12/21/22 at 1:11 PM the Assistant Administrator, DON and Regional Director of Operations were notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>The facility's Plan of Removal was accepted on 12/22/22 at 12:14 PM and reflected the following: [name of the facility]<BR/>PLAN OF REMOVAL<BR/>FOR <BR/>IMMEDIATE JEOPARDY on 12/21/22<BR/>To Whom it May Concern,<BR/>Infection Control<BR/>F880- The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. <BR/>Identify residents who could be affected<BR/>All residents have the potential to be affected by this alleged proficient practice<BR/>Problem<BR/>Staff members were seen providing care for a COVID positive resident without wearing appropriate PPE and/or wearing PPE in an inappropriate manner.<BR/>Staff members were seen not performing hand hygiene after entering a COVID positive resident's room and when passing meal trays to residents.<BR/>Action Taken <BR/>Infection Control<BR/>&cent; <BR/>ICP will re-educate Director of Nursing and Assistant Director of Nursing on company's infection control policy related to Covid 19 by end of day on 12/22/2022.<BR/>&cent; <BR/>Use of alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer<BR/>&cent; <BR/>Donning/Doffing of proper PPE for N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms<BR/>&cent; <BR/>ICP is responsible for monitoring the education of the Director of Nursing and the Assistant Director of Nursing on company's infection control policy related to Covid 19<BR/>Hand Hygiene and Competency<BR/>&cent; <BR/>Staff in-servicing on alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer with competency conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or Designee include staff handwashing and when to use hand sanitizer. <BR/>&cent; <BR/>Competencies consist of review of necessary steps and 100 % accuracy on return demonstration.<BR/>&cent; <BR/>Inservicing was implemented on 12/21/2022. All staff to be included in training. Training to be completed by 12/23/22. Staff not physically in community to receive their education in person prior to their next shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their next shift. <BR/>&cent; <BR/>Monitoring will begin 12/22/2022 and will be conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or designee to observe and document hand hygiene compliance twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>PPE and Competency<BR/>&cent; <BR/>ICP, Director of Nursing, Assistant Director of Nursing, and Designee in-serviced all staff on what PPE to wear to include type of mask i.e. N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms <BR/>&cent; <BR/>All staff will be in-serviced in person prior to working their shift. Training to be completed by 12/23/22 Those not physically in community will receive their education in-service in person prior to working their shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration prior to working their next shift. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their first shift. <BR/>&cent; <BR/>Monitoring began 12/22/2022 and will be done by ICP, Director of Nursing, Assistant Director of Nursing, or designee through random questioning on PPE and hand hygiene to ensure knowledge has been retained on various eight hour shifts to begin 12/22/2022. <BR/>&cent; <BR/>Director of Nursing or designee is rounding twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance ensuring proper infection control practices are in place through observation and questioning. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>On 12/22/22 to 12/23/22 the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by:<BR/>Review of the facility's in-service and competency testing records revealed:<BR/>1.The DON's name was listed as the facilitator of the in-services. The in-service topic was Infection Control, Covid-19 with an emphasis on hand hygiene and donning/doffing PPE.<BR/>2.As of 12/23/22 at 4:40 PM a total of 132 staff employed at the facility had been in-serviced and passed the hand hygiene and PPE competency.<BR/>Observations conducted from 12/22/22 at 10:55 AM to 5:00 PM on 12/23/22 revealed staff were donning and doffing PPE appropriately upon entrance and exit of covid-19 positive rooms. <BR/>Interviews conducted on 12/23/22 from 9:48 AM to 5:30 PM with staff from all three shifts(LVN E, Med aide F, CNA G, CNA H, CNA I, CNA J, COTA, ST Assistant Director, LVN K, Housekeeper L, Environmental Director, Laundry aide, Dietary cook M, Dietary cook N, PT O, CNA P, RN Q, CNA R, LVN S, CNA T, LVN U, LVN V, Housekeeper Z, LVN W, RN X, CNA Y, and Rehab tech), revealed staff were knowledgeable about what PPE was required to enter a COVID-19 positive room and why hand hygiene was important after doffing to prevent the spread of infection. The staff stated they had to watch videos on hand hygiene and PPE and had to perform a skills test.<BR/>In an interview with the ADON on 12/23/22 at 4:56 PM it was revealed that utilizing PPE and performing hand hygiene was the way to ensure COVID-19 was not being spread when going from a positive room to a negative room. The ADON stated charge nurses, direct supervisors and everyone was in charge of going behind staff to ensure they followed infection control protocols. They could make rounds and address any issues at that time. The ADON stated an IJ was identified because the staff were not following the proper PPE and hand hygiene protocols, thereby placing residents at risk. The ADON stated the facility was going to implement ongoing monitoring, monitoring tools and schedules to ensure proper infection control measures were followed. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated an IJ was identified because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated she understood why this was identified as an IJ because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview on 12/23/22 at 5:48 PM, the Assistant Administrator stated an IJ was identified because of the failure of staff to wear the proper PPE, going in and out of resident rooms that were covid positive and negative in addition to concerns with handwashing and sanitizing. She stated all this could lead to potential harm or spread of infections and diseases. <BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems.

**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 abuse for one of six residents (Resident #6) reviewed for abuse.<BR/>The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 punched and then pushed her on 02/05/25 located on a secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury.<BR/>The noncompliance was identified as PNC. The IJ began on 02/05/25 and ended on 02/05/25. The facility had corrected the noncompliance before the survey began.<BR/>This failure placed residents at risk for abuse.<BR/>Findings included: <BR/>Record review of Resident #6's face sheet, dated 02/26/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE].<BR/>Record review of Resident #6's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her diagnoses included hip fracture, anxiety disorder, and other orthopedic condition. The MDS indicated she had no behaviors of any kind and that she utilized a wheelchair. <BR/>Record review of Resident #6's care plan, updated 01/13/25, reflected she was a fall risk.<BR/>Record review of Resident #6's Nurses Notes reflected the following: <BR/>- Resident noted standing up off from couch when another resident pushed her, and she went down landing on her sacral area resident removed from area made safe during assessment resident screaming and protecting right leg and hip area prn apap given dr [Physician Z] called 911 called DON preset and aware family called and message left resident transferred to [Hospital Y] for evaluation. Written on 02/05/25 by LVN X.<BR/>- 1830; Met with [Resident #6's RP] in person to discuss fall and injury. She was made aware, per investigation, fellow resident pushed her as she was standing from sofa, she lost her balance and fell landing on her buttocks. [Resident #6] complained of pain to her right hip and thigh area, could not recall event or how she landed on floor. [Resident #6's RP] informed resident was sent to ER at [Hospital Y] due to c/o pain and inability to bear weight on right leg . written on 02/05/25 by the DON.<BR/>- Resident returned from [Hospital Y] via stretcher and EMT with oxygen therapy at 2L/min via nasal cannula at 1810. Resident diagnosed with subcapital fracture of the right femoral neck. Resident surgical wound is clean and dry, with no signs of infection . Written by RN W on 02/08/25.<BR/>Record review of Resident #6's hospital records reflected the following: Hospital Course: patient got into physical altercation with another resident, they pushed to this patient [sic] to the ground when she landed on her bottom, she developed severe pain in the right hip, presented to the ER where she was found to have right neck femur fracture, s/p surgery 02/06 .Active Problems: Closed fracture of neck of right femur .<BR/>Observation and interview on 02/26/25 at 1:40 PM with Resident #6 revealed she was sitting on the couch in the common area. Resident #6 had her wheelchair next to her and said she was doing okay. Resident #6 said she was not in any pain and felt safe in the facility. Resident #6 said she never had a fall or had anyone push her in the facility before. <BR/>Attempted phone interview on 02/26/25 at 1:57 PM with Resident #6's RP was unsuccessful as they did not answer or call back. <BR/>Record review of Resident #7's face sheet, dated 02/26/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #7's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 07, indicating severe cognitive impairment. Her diagnoses included other neurological conditions, Alzheimer's disease, and anxiety disorder. Her MDS indicated she did not have any behaviors towards anyone. <BR/>Record review of Resident #7's care plan, updated 04/08/25, did not reflect or include anything about her behaviors.<BR/>Record review of Resident #7's Nurses Notes reflected the following: <BR/>- Resident very disruptive and verbally aggressive with other residents, walked over to sofa and pushed another resident unprovoked and then went directly to her room. Dose not recall incident but is paranoid that fellow residents are taking her belongings. DON notified and gave directive to contact PCP for order to send resident to [Hospital S] for eval and treatment, message left with [Resident #7's RP] NO ANSWER WHEN CALLED, [NP N] contacted, order received to send out for eval. Resident placed on 1:1 monitoring until transferred to [Hospital S]. written on 02/05/25 by the DON.<BR/>- Resident return from [Hospital S] via EMT at 10:19. Resident is alert, appears calm and cooperative at this time. DON and family member notified. Plan of care continues. Written on 02/05/25 by the DON.<BR/>Record review of Resident #7's Psychiatric Periodic Evaluation, dated 02/07/25, reflected the following: .[Resident #7] is seen today per staff request due to reports of increased anxiety, compulsivity, restlessness, and for psychotropics management. Resident is sitting up in the common area, she is calm at the moment and denying any pain or discomfort. Aspiration of reports of recent mood swing, agitation, and restlessness reported by nursing staff, patient started crying, and reports that people are 'getting to her face'. She reports mood swing, and spontaneous anxiety and agitation. Chart reviewed, medication profile reviewed, she is on the following psychotropics with no noticeable adverse effects: Aricept 10mg po daily for dementia, Levothyroxine 100 mcg for hypothyroidism, Cymbalta 20 mg p.o. twice daily for depression/anxiety lamotrigine 25 mg p.o. twice for mood regulation, and Atarax 25 mg po daily for anxiety. Due to reports of mood swing, and spontaneous combativeness, will increase lamotrigine and monitor closely. Nursing staff notified.<BR/>Observation and interview on 02/26/25 at 1:42 PM with Resident #7 revealed she was sitting on a different couch in the common area. Resident #7 said she was doing okay and sometimes argued with others, but she never got into a fight with anyone or pushed anyone down. Resident #7 said she felt safe in the facility. <BR/>Attempted phone interview on 02/26/25 at 1:55 PM with Resident #7's RP was unsuccessful as they did not answer or call back. <BR/>Interview on the phone on 02/26/25 at 12:15 PM with CNA V revealed Resident #7 had a tendency to go off and always think someone was in her room. CNA V said she was down the hall making up a resident's bed when Resident #7 was upset at another resident saying things like she's going to jail and I'm going to kill her. CNA V said Resident #7 was not referring to Resident #6 at this time, but she de-escalated the situation and sat Resident #7 down on the couch. CNA V said she turned around and started to walk to the nurse's station when Resident #6 asked to go to the bathroom and stood up to get off the couch. CNA V said Resident #7 went over to Resident #6, punched her, then pushed her to the ground. CNA V said she ran over to the residents and asked Resident #7 why she did that and noticed Resident #7 was still trying to go after Resident #6 who was on the ground. CNA V said everything happened so fast but she was trying to get Resident #7 away from the situation and have her go to her room. CNA V said Resident #6 went to the hospital that night and did not come back for a few days and had a hip fracture. CNA V said Resident #7 was more alert than other residents on the secured unit because one of her triggers was when residents went down the hall who did not have rooms down there. CNA V said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. <BR/>Interview on the phone on 02/26/25 at 12:43 PM with CNA U revealed it was after a meal one day (02/05/25), Resident #7 said that Resident #6 went to her room and stole something and then there was a lot of commotion. CNA U said she went towards Residents #6 and #7 to divide them up because Resident #7 had punched Resident #6 and then pushed her down to the ground. CNA U said she told Resident #7 not to do that and to let staff handle the situation but Resident #6 was already on the ground. CNA U said she was not working on the secured unit at the time but had just stopped by to drop something off. CNA U said she thought Resident #6 was injured when she said her head was hurting and she could not walk. CNA U said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on 02/26/25 at 1:34 PM with LVN X revealed Resident #6 was a sweet lady and Resident #7 was very nasty with her mouth and bossy. LVN X said on 02/05/25, Resident #7 was amped up for whatever reason and staff were not sure why. LVN X said Resident #6 was getting off the couch while talking to Resident #7 when Resident #7 pushed Resident #6. LVN X said she did not witness what happened but heard about it from another aide. LVN X said when Resident #6 was on the ground she called 911 and sent her to the hospital. LVN X said during her assessment while checking Resident #6's range of motion, she yelled when assessing her right side. LVN X said after the incident happened, the NP came to see Resident #7 and adjusted her medications which seems to have worked because she's been extremely pleasant and calm ever since. LVN X said she's never seen Resident #7 be physically aggressive towards others, only verbally aggressive. LVN X said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on 02/26/25 at 1:43 PM with CNA T revealed she was leaving the shower room and heard Resident #7 talking loudly and arguing about something when she hauled off and hit Resident #6 who fell down. CNA T said Resident #7 did not have any injuries from this situation but Resident #6 did because she was grabbing her leg and crying and saying her leg was hurting. CNA T said Resident #6 was sent to the hospital afterwards. CNA T said Resident #7 yells at others when she thought someone was stealing her clothes, but no one was. CNA T said she had never seen Resident #7 be physically aggressive towards anyone before this. CNA T said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on the phone on 02/26/25 at 2:14 PM with NP O revealed Resident #7 she had episodes of psychosis based on her thinking people were taking her things from her room. NP O said Resident #7 was very paranoid and had mood swings with agitation, so she was eventually moved to the all-female secured unit. NP O said he was informed Resident #7 was involved in a resident-to-resident altercation, so he went to assess her and review her medications. NP O said based on the assessment, he thought she needed mood stabilizers, so he added those to her orders. NP O said since then, Resident #7 was more stable and engaged in activities that she's participating more in. NP O said he was not aware of any other physical altercation Resident #7 was involved in. NP O said Resident #7 was now more redirectable.<BR/>Interview on 02/26/25 at 3:19 PM with the DON revealed the day the incident occurred, LVN X was here and came to get the DON because she was concerned about Resident #6's leg. The DON said she was told that Resident #6 was trying to stand and Resident #7 pushed her, causing Resident #6 to lose her balance and fall in a squatting position since she's so tall. The DON said Resident #6 fell on her bottom and complained of her leg hurting. The DON said she was worried Resident #6 had a fracture from the incident. The DON said Resident #7 had walked away from the situation and went to her room but was clueless about what had just happened. The DON said Resident #7 was put on one-to-one care until she was sent to [Hospital S] where she was evaluated and sent back to the facility the same day. The DON said Resident #7 was also seen by the NP who adjusted her meds and she had been quiet ever since. The DON said Resident #7 had a behavior of thinking someone was stealing her clothes and would get upset but never became violent with anyone. The DON said she was not told that Resident #7 had first punched Resident #6 before pushing her down. The DON said after the situation happened, staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents. <BR/>Interview on 02/26/25 at 4:01 PM with the Administrator revealed he was the abuse coordinator for the whole campus, but he had an Administrator's Assistant who was also the abuse coordinator for the South building where Residents #6 and #7 were. The Administrator said he understood that Resident #6 stood up from the sofa and Resident #7 pushed her causing her to fall to the ground when she started to complain of pain. The Administrator said Resident #6 was sent out to have x-rays done which showed she had a fracture. The Administrator said all staff were responsible for monitoring resident's and their behaviors to ensure they were not getting into an altercation with each other. The Administrator said several things could happen to residents if they were to get into an altercation with each other such as harm. The Administrator said because of the resident's diagnoses a lot of times they did not remember what they did or who they did something to. <BR/>Interview on 02/26/25 at 4:17 PM with the Administrator's Assistant revealed based on what she heard and through her investigation, Resident #7 was the aggressor towards Resident #6. The Administrator's Assistant said Resident #6 was on the couch and as she was getting up, Resident #7 pushed her causing her to fall to the ground. The Administrator's Assistant said the charge nurse did an assessment on Resident #6 and found that she was complaining of pain, so she was sent to the hospital. The Administrator's Assistant said at the hospital, x-rays were done where it was found she had a fracture which required surgery to repair it. The Administrator's Assistant said there had not been any other instances of physical aggression from Resident #7 before this. The Administrator's Assistant said she was also the abuse coordinator for the facility and staff were to report any instance or allegation of abuse to her. The Administrator's Assistant said all residents have the right to be free from abuse in the facility. The Administrator's Assistant said she was not told that Resident #7 punched Resident #6 in the face. The Administrator's Assistant said staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents.<BR/>Record review of a provider investigation report reflected the following information:<BR/>Investigation Summary: On 2/5/25, a resident-to-resident altercation occurred between [Resident #6] and [Resident #7], both residing in the South Memory Community. The incident occurred when [Resident #7], who was loudly fussing, accused [Resident #6] of entering her room. As [Resident #6] attempted to rise from the couch in the dining room, [Resident #7] pushed [Resident #6], causing [Resident #6] to fall to the floor and land on her sacral area. Nursing staff were present and immediately intervened, separating the residents. A head-to-toe assessment was conducted for both residents by the charge nurse, [LVN X]. [Resident #6] complained of right hip pain, held her right leg, and was unable to bear weight on it. Although no visible injuries were noted and vital signs stable. Pain medication was administered and [Resident #6] was sent to the ER for further evaluation and treatment. [Resident #7], [sic] no adverse effect and injuries noted, vital signs stable. Placed on 1:1 supervision pending a transfer to [Hospital S]. Notifications made to Family, [Resident #6's RP and Resident #7's RP] notified. [Physician R and Physician Q] notified. Interview and statements collected from witnesses present attached. Social worker conducted safety survey, noting no concerns. Staff in-service [sic] resident to resident altercation, resident behaviors, resident 1:1, abuse and neglect. <BR/>[Resident #6] was admitted to the hospital and underwent surgery for a right hip repair. She returned to the facility on 2/8/25 with new order for Tylenol 3 and a follow-up appointment scheduled with [Physician P] on 2/20/25 at 11:30 AM. She is currently alert and resting in bed. [Resident #7] was placed on 1:1 supervision pending a transfer to [Hospital S]. On 2/5/25, [Resident #7] was evaluated by [Hospital S] and cleared to return to the facility the same day. Q15-minute checks were conducted for 72 hours per facility. [Resident #7] is currently cooperative and participating in normal activities without further incidents.<BR/>Record review of resident safe surveys revealed 5 were completed with residents on 02/05/25 with no additional findings of any other abuse in the facility. <BR/>Record review of an in-service, dated 02/05/25, reflected staff were in-serviced regarding abuse, falls, resident monitoring, injury of unknown origin, and resident-to-resident altercation. <BR/>Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 02/12/20, reflected: Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property.<BR/>The Administrator was notified on 03/12/25 at 10:00 AM that a past non-compliance IJ situation had been identified due to the above failures.<BR/>It was determined this failure placed Resident #6 in an IJ situation on 02/05/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #2 and #5) of 2 residents reviewed for pressure ulcer treatment.<BR/>The facility failed to ensure Resident #2 and #5 received wound care according to physician orders.<BR/>This failure could place the resident at risk of worsening wounds.<BR/>Findings included:<BR/>1. Review of Resident #5's face sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).<BR/>Review of Resident #5's MDS assessment, dated 04/02/2024, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment and Resident #5 was at risk of developing pressure ulcers/injuries.<BR/>Review of Resident #5's care plan, dated 04/10/24, indicated skin breakdown: At risk for/actual skin, Cleanse Wound every am shift (6am-2pm). Cleanse Wound as Needed as Needed Dislodged. She was care planned for open area will be healed over the next 90 days. Interventions: Treatments and dressings as ordered per physician.<BR/>Review of Resident #5's physician orders revealed the following wound care orders, dated 04/10/24, reflected the following orders: <BR/>Cleanse Wound every am shift (6am-2pm) WOUND OF THE RIGHT BUTTOCK: Cleanse with normal saline or wound cleanser pat dry. Apply mupirocin topical 2% and Santyl. Cover with a dry dressing daily.<BR/>Cleanse Wound as Needed Dislodged WOUND OF THE RIGHT BUTTOCK: Cleanse with normal saline or wound cleanser, pat dry. Apply mupirocin topical 2% and Santyl. Cover with a dry dressing as needed. <BR/>Review of Resident #5's Treatment Record for April 2024 indicated wound care was not provided on 04/17/24 and 04/18/24.<BR/>Observation on 04/18/24 at 12:10 PM with CNA D revealed Resident #5 had a dressing on her coccyx dated 04/16/24. <BR/>Observation and interview on 04/18/24 at 3:05 PM with LVN E, who was the Wound Care Nurse, revealed she was not responsible for performing wound care on the North Side. She stated the floor nurses were responsible for their residents since the wound care nurse was off duty. She assessed the resident and confirmed the dressing was dated 04/16/23. She stated failure to follow the doctor's orders could result in the wound getting worse and getting infected. She then prepared and disinfected the table, put supplies together, and she changed the resident's wound dressing.<BR/>Interview on 04/18/24 at 5:20 PM with LVN B revealed she was not aware Resident #5's wound care was not performed by the 6:00 AM-2:00 PM shift, and the nurse had not told her during shift change. LVN B stated failure to perform wound care as indicated could worsen the wound and slow the healing. <BR/>2. Review of Resident #2's Face sheet, dated, 04/18/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral ischemic (common mechanism of acute brain injury that results from impaired blood flow to the brain).<BR/>Review of Resident #2's MDS assessment, dated 03/18/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment. Her Skin Conditions indicated she was at risk of developing pressure ulcers/injuries. Resident has open lesion.<BR/>Review of Resident #2's care plan, dated 02/20/24, indicated skin breakdown: At risk for/actual skin, cleanse wound as needed if dislodged. She was care planned for open area will be healed over the next 90 days. Interventions: Treatments and dressings as ordered per physician. <BR/>Review of Resident #2's physician orders revealed the following wound care orders, dated 04/03/24:<BR/>Cleanse Wound every am shift (6am-2pm) NON-PRESSURE WOUND OF THE LEFT BUTTOCK: Cleanse wound with NS/WC, pat dry. Apply anapest and collagen sheet, then cover with a dry dressing daily. <BR/>Review of Resident #2's Treatment Record for April 2024 indicated wound care was provided on 04/19/24 and 04/20/24. <BR/>Observation on 04/21/24 at 11:25 AM with LVN A revealed him performing wound care. He washed his hands and put on gloves. He disinfected the table and let to dry. He removed the gloves and washed his hands. He explained the procedure to Resident #2. He put supplies together, washed his hands, put on gloves, and explained the procedure to Resident #2. He unfastened the resident's brief, and Resident #2's wound dressing was dated 04/18/24. He removed the old dressing, doffed his gloves, washed his hands, and put on new gloves. LVN A then cleansed the wound, patted it dry, doffed his gloves, washed his hands, and put on new gloves. The wound was healing with no signs of infection. LVN A next applied anapest, collagen sheet then covered the wound with a dry dressing. He then doffed his gloves and washed his hands. <BR/>Interview on 04/21/24 at 11:35 AM with LVN A revealed the dressing was dated 04/18/24. He stated he was responsible for performing wound care on 04/19/24 and 04/20/24, and he had not managed to perform wound care for all residents because there were many. He stated Resident #2's wound care was supposed to be done daily on the 6:00 AM-2:00 PM shift. He stated the risk of not performing wound care as per the doctor's order was that it could lead to the wound worsening. He stated he did not understand how he signed the treatment administration record as wound care was performed while it was not performed. He stated he understood signing without performing wound care could make the resident miss the treatment as per physicians' orders and could worsen the wound. <BR/>Interview on 04/21/24 at 11:38 AM with the DON revealed the nursing staff knew they had to follow physician orders as they were written. The DON stated the facility had a Wound Care Nurse, but she was out. She stated they had requested for nurses on the floor to perform wound care on their halls. Staff nurses were responsible for wound care when the Wound Care Nurse was not available. The DON stated she was not aware that nurses were not performing wound care and were signing treatment administration records before administering care. She stated she would perform a wound sweep on all residents and ensure all the wounds were taken care of. She stated failure to follow the doctors' orders could result in the wounds worsening. She stated she was responsible for ensuring wound care was being provided. She stated she was responsible for monitoring that wound care was being provided.<BR/>Interview on 04/22/24 at 11:40 AM with LVN N revealed she worked the 6:00 AM-2:00 PM shift with Resident #5. She stated she was aware the resident's wound care was supposed to be done, but the resident refused. She stated she had not notified the on-coming nurse, and she had not notified the management or documented in the progress notes. She stated failure to perform wound care as indicated could result in the the wound getting worse or getting infected. She stated she was also supposed to let the doctor know about the refusal.<BR/>Review of the facility's current policy dated July 2018 titled, Treatment of Wounds: Dressing Changes-Performing reflected:<BR/> . 1. Review orders and treatments and gather supplies. <BR/>2. Follow standard precautions and infection control methods depending on the appropriate<BR/>type of transmission-based precautions.<BR/> .4. Ensure all wound dressing products are completely removed with each dressing change if present

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision. <BR/>The facility failed to ensure Resident #1 who had a history of wandering and exit-seeking, was provided with adequate supervision to prevent her from eloping on 06/09/25. Resident #1 was found 5 minutes away from the facility by police and was transported to the hospital for evaluation due to the resident experiencing hallucinations and delusions. <BR/>The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/10/25. The facility had corrected the noncompliance before the survey began. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 06/18/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 06/05/25, reflected her diagnoses included unspecified dementia, severe, with other behavioral disturbance, schizophrenia, and delusional disorders. Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further revealed Section E - Behaviors indicated Resident #1 exhibited wandering behaviors. <BR/>Record review of Resident #1's care plan, dated 06/04/25, reflected: Care Area/Problem: Attempted to Elopement: Resident is Exit seeking, high elopement risk. Goal: Resident safety will be maintained over the next 90 days. Interventions: Assess for contributing sensory. Check resident location every 15 minutes. Maintain behavior log. Notify physician and family/responsible party. Remove resident from immediate situation to assure safety. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.<BR/>Record review of Resident #1's Resident Visual Monitoring dated 06/04/25-06/05/25 reflected Resident #1 was on 1:1 supervision. <BR/>Record review of Resident #1's Nurse Visual Check Individual Resident Monitoring dated 06/06/25 - 06/09/25 reflected Resident #1 was on 15 minutes checks.<BR/>Record review of Resident #1's progress notes dated 06/09/25 at 6:54 PM by LVN A reflected the following entries: <BR/>7:30 AM - in room dressed for the day<BR/>7:46 AM - CNA summoned resident to the dining room for breakfast and noted resident not in room and window broken. CNA notified nurse and I contacted DON and Administrator. Staff began searching unit and grounds. All other doors and courtyard exit found to be in locked position.<BR/>8:00 AM - unable to find resident in building or on grounds, contacted PD [Police Number] for missing resident. <BR/>8:15 AM [Police Department] police contacted nurse, [LVN A], LVN stating they have resident in custody.<BR/>8:20 AM - Administrator and nursing staff attempting to calm resident along with PD, but resident remained belligerent and psychotic. Currently, she is delusional and believes buzzards are raping her and nursing staff are putting a curse on her.<BR/>8:25 AM - Attempted to transport resident for further evaluation and care via facility van without success.<BR/>8:39 AM - [Police Department] PD unable to coax resident in car or ambulance and were forced to restrain resident with handcuffs for everyone's safety and then transported to [Hospital] for further evaluation and treatment.<BR/>8:39 AM - Nursing staff at ER bedside to give report on patient. ER nurse stated they would have to continue to restrain her and give her some medication in order to do a proper exam. At bedside, no outward sign of injury or c/o pain noticed. unable to contact family members on file as there is no working number. PCP notified of incident.<BR/>Record review of the facility's Provider Investigation Report, completed by the Assistant Administrator on 06/16/25, reflected the following:<BR/>Incident date: 06/09/2025, Time of Incident: 07:45 AM <BR/>Resident noted by staff to not be in room and window broken. Perimeter search completed and [Police Department] police notified. <BR/>Assessment Date 06/09/25; Time: 08:15 AM; <BR/>Resident assessed and no apparent injuries noted. <BR/>Perimeter search and [Police Department] police notified.<BR/>Physician [name], notified. <BR/>Family [name], notified. <BR/>Safe surveys completed. <BR/>Staff in-service on Elopement procedures. <BR/>Entire facility check to ensure all residents accounted for.<BR/>Investigation Summary: Resident noted by nursing staff to not be in room or on south memory community. Resident room noted with broken window. Perimeter search completed and [Police Department] located resident after resident noted missing and transported resident to [hospital] ER for psychiatric evaluation. Staff interview state resident was currently on every 15 minute checks and when checked resident not in room and window broken. Staff state perimeter check completed and when not able to locate during perimeter check [police department] police were notified. Staff interview stat resident had no attempted to leave memory unit prior to this incident. Resident placed on q 15 minute checks due to pacing and wandering in and out of other resident rooms. Chat review reflects resident referred to psych service for behavioral and medication management. <BR/>Provider Action Taken Post-Investigation: <BR/>Resident care plan to be updated upon return from hospital. All staff in-service on Elopement procedures. Window alarms ordered for memory care windows. Resident elopement risk assessments updated. Care plans reviewed and updated for elopement risk residents. QAPI meeting conducted with Medical Director to review elopement protocols and action plan.<BR/>Record review of CNA C statement, dated 06/09/25 at 9:00 AM, reflected: Summoned resident for breakfast and noticed she was missing from her room and window was broken notified charge nurse immediately and assisted in search for resident. <BR/>Record review of LVN A statement, dated 06/09/25 at 9:00AM reflected: CNA notified nurse that resident was missing from room and window was broken. We immediately contacted DON/admin and began search on unit and grounds. Admin assisted with search effort and 911 called; last time seen: 7:30, summoned for breakfast 0745, called DON/ED 0746, began search 0746, called 911 0800, police located resident 0815, staff/admin 0820, 0839 [Police} police restrained resident and escorted to [hospital] for further evaluation and treatment. <BR/>Interview on 06/18/25 at 11:27 AM, CNA B revealed she worked the day Resident #1 eloped from the facility. She stated she was not the CNA assigned to Resident #1. She stated she could not recall the exact time, but she observed Resident #1 standing by her room door and then she closed the door. She stated Resident #1 was on q15 minutes checks and LVN A was completing them. She stated from what she was told Resident #1 was last seen at 7:30 AM in her room, then at 7:45 AM CNA C went to inform Resident #1 it was time for breakfast and that is when they realize she was gone. She stated Resident #1 broke the window and jumped the fence. She stated they called Code Green and initiated a search inside and outside the facility and notified the police department. She stated Resident #1 was found by the police department, unknown where she found. She stated prior to Resident #1's elopement, the resident was placed on 1:1 supervision and then q15 minute checks because Resident #1 was having behaviors and pacing up and down. She stated they were in-serviced on abuse, neglect, and elopement. She stated the facility added alarms to all residents' windows. <BR/>An attempt was made to contact LVN A on 06/18/25 at 11:55 AM by phone; however, there was no answer.<BR/>Interview on 06/18/25 at 2:05 PM, the DON revealed Resident #1 eloped from the facility on 06/09/25. She stated she received a call from LVN A at 7:46 AM and informed her Resident #1 had broken the window from her room. She stated they initiated a search inside and outside the facility. She stated the police was notified and they were able to locate Resident #1 about .5 miles from the facility. She stated Resident #1 was a fast walker, when she was found she had no injuries; however, resident was having behaviors and the police decided to take her to the hospital for further evaluation. She stated prior to Resident #1 elopement, resident was not exit-seeking; however, she was pacing the hall and wandering into residents' rooms. She stated Resident #1 had history of eloping at home. She stated since Resident #1 was wandering into residents' room and pacing the hall, as an intervention, they placed Resident #1 on 1:1 supervision and then she was doing better and placed Resident #1 on q15 minute checks. She stated staff were completing q15 minutes checks when Resident #1 eloped, the last time she was observed was at 7:30 AM and then noticed she was gone at 7:45 AM. She stated all staff were in-serviced on abuse and neglect, and elopement. She stated alarms were also added to both North and South memory care unit and they also implemented resident logs which have to be completed before a resident was taken off the unit either for a visit or therapy session.<BR/>Interview on 06/18/25 at 3:26 PM, the Administrator revealed he had arrived at the facility when he was informed Resident #1 had broken her room window and eloped. He stated the staff had initiated a search inside and outside facility grounds. He stated the police were notified, and the police was able to locate Resident #1 about 5 minutes from the facility. He stated he went to the scene were Resident #1 was located, he stated resident was having behaviors and was transported to the hospital for further evaluation. He stated prior to Resident #1's elopement, they had interventions in place due to Resident #1 having behaviors and refusing medications. He stated Resident #1 was placed on 1:1 and then q15 minute checks due to the resident pacing the halls and wandering into residents' rooms. He stated when Resident #1 eloped, staff were still completing q15 minute checks on Resident #1. He stated they in-serviced all staff on abuse and neglect and elopement. He stated they added alarms to all windows in the memory care unit. The Administrator stated Resident #1 had not returned to the facility since incident. <BR/>Interview on 06/19/25 at 10:16 AM, CNA C revealed she was the CNA assigned to Resident #1 when she eloped. She stated the last time she observed Resident #1 was around 6:15 AM in her room. She stated Resident #1 was on q15 minutes check and LVN A was completing them while she was assisting other residents with getting them up for the day. She stated when it was time for breakfast, she went to Resident #1's room and that was when she noticed Resident #1 was not in the room and the window was broken. She stated she notified LVN A and they began a search for Resident #1. She stated she was in-serviced on abuse and neglect, and elopement. <BR/>Record review of facility Elopement Management policy, revised 05/02/25, reflected the following: <BR/>An immediate investigation and search will be conducted if a resident is considered missing. The resident will be located and returned to a safe environment within standard practice guidelines.<BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 06/18/23 at 4:45 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 06/18/25 at 6:35 PM.<BR/>The facility took the following actions to correct the non-compliance prior to the abbreviated survey:<BR/>Record review revealed an elopement assessment were reviewed and completed on residents on 06/09/25. <BR/>Record review of safe surveys completed by the facility on 06/09/25 with five residents reflected there were no issues noted.<BR/>Record review of the facility's South Memory Unit Elopement binder located at the nurses' station reflected the binder contained pictures of residents, who were elopement risk, and contained information regarding the residents.<BR/>Record review of the facility's Resident Log on North and South Memory Unit reflected residents were being signed out when taken off unit for therapy sessions. <BR/>Observation on 06/18/25 at 11:34 AM revealed all windows in the South Memory Unit had an alarm. Alarms were loud enough to be heard throughout the unit. <BR/>Record review of the following in-services dated 06/09/2025 reflected all facility staff were in-serviced on abuse, neglect, elopement, missing person, and Code [NAME] for elopements/missing persons. The in-services were conducted and signed by all facility staff.<BR/>Interviews on 06/18/25 from 11:22 AM through 06/19/25 at 3:30 PM with CNA B, CNA C, LVN D, CNA E, Wound Care Nurse F, MDS Coordinator G, MDS Coordinator H, CNA I, CNA J, CMA K, CNA L, CNA M, [NAME] K. Physical Therapy O, CNA P, Floor Tech Q, Housekeeping R, Housekeeping Supervisor S, LVN/Coordinator T, LVN U, CNA V, CNA W, RN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, CNA EE, CNA FF, CNA GG, CNA HH, Activity Assistant, and the Assistant Administrator revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize missing person/elopement policy, missing/elopement code, abuse and neglect, completing head counts before and after shift change and alarms added to all windows in the memory care unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #100) reviewed for enteral nutrition.<BR/>The facility failed to follow Resident #100's physician orders for enteral feeding.<BR/>These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.<BR/>Findings included:<BR/>Record review of Resident #100's face sheet dated 06/19/25 reflected the resident was [AGE] year-old male admitted on [DATE]. <BR/>Record review of Resident #100's Quarterly MDS dated [DATE] reflected the resident had severe cognitive impairment with a BIMS score of 00. Resident #100 required supervision or touching assistance with eating. The assessment reflected Resident #100's diagnosis included Anemia (lack of healthy red blood cells), Diabetes Mellitus (high blood sugar), Alzheimer's Disease (gradual decline in memory, thinking, and behavior), Malnutrition (imbalance of nutrients the body needs and what it actually received). Resident #100 utilized a feeding tube, mechanically altered diet, and therapeutic diet while a resident at the facility. <BR/>Record review of Resident #100's undated care plan reflected the following: <BR/>Resident #100 had Altered Nutritional Status related to Dysphagia/Swallowing difficulty, limited mobility, and risk of malnutrition as evidenced by: Diet: Consistency - Puree - Level 4, Crushed medication, Diet: Liquids-Nectar/Mildly thick, Jevity 1.2 Cal 0.06 gram-1.2 kcal 65 ml/hr. X 9 hrs. GOAL: Resident will be comfortable with food and fluids provided. Snacks between meals as preference on a daily basis. Interventions included Dietitian referral as indicated. Monitor oral intake of food and fluid. Provide snacks between meals as preferred. <BR/>Altered Nutritional Status: Enteral Feeding Monitor related to Jevity 1.2 Cal 0.06 gram-1.2 Kcal 65ml/hr. X 9 hrs. Evidenced by Peg-tub Dressing every noc shift (10PM-6AM). Peg-tub Flush 30 Cubic centimeter PEG Tube every shift. Peg-Tube Residual Cubic centimeter Feeding Tube every shift. Peg-tube Flush 200 Cubic centimeter G-tube every 4 hours. GOAL: Resident will have no signs or symptoms of aspiration over the next 90 days. Interventions included keep the head of the resident's bed at 30 degree and 45 degrees after bolus feeding. Monitor labs when available. Monitor tolerance of tube feeding. Monitor weight monthly/weekly. Provide family support/education regarding palliative nutrition and hydration care. Provide water flush as ordered. Provide water flush at med pass per nursing policy. <BR/>Record review of Resident #100's physician orders included the following: <BR/>Glucerna 1.5 Cal 0.08 gram-1.5 Kcal/mL oral liquid (nutritional tx. Glucose intolerance, lactose-free, soy/fiber) 237 Milliliter PEG Tube every 4 hours once Osmolite 1.5 is available discontinue Glucerna 1.5 and restart previous Osmolite 1.5 orders. Diagnosis: unspecified severe protein-calorie malnutrition. Start date 04/23/25.<BR/>Record review of Resident #100's April 2025, MAR reflected Resident #100 had not been administered Glucerna 1.5 on April 24, 2025, at 01:00 AM, 05:00 AM and April 25, 2025, at 01:00 AM. <BR/>Observation on 06/18/24 at 12:38 PM of Resident #100 revealed him in the dining room assisted with puree diet. <BR/>Interview by phone on 06/19/25 at 11:20 AM with LVN LL revealed she worked overnight shift with Resident #100. LVN LL stated Resident #100 was on 20 hours of continuous tube feedings with Osomilte, 200 flush of water every 4 hours. LVN LL stated she received a new order to substitute Jevity until Osomilte formula came in. LVN LL was asked to confirm if the alternative formula was for Jevity or Glucerna, she replied I do not recall the order being for Glucerna, I am really good about completing my feedings over night, I never miss. LVN LL stated she did not recall Resident #100 missing any feedings, there was only one resident that was on Glucerna and Resident #100 was not one of them. LVN LL was asked about Resident #100 MAR dated 04/24/25 with two missed feedings and 04/25/25 with one missed feeding on her shift, LVN LL stated she did not know why there would be any missed feedings. LVN LL stated when residents miss their feedings it placed them at risk of losing weight. LVN LL stated she was responsible for following physician orders to ensure resident's feedings were administered. <BR/>Interview on 06/19/25 at 12:20 PM with RN X revealed he was working with Resident #100, RN X stated Resident #100 was on continuous feeding with puree diet pleasure foods. Upon review of Resident #100's April 2025 MAR he expressed there were two missed feedings on April 24, 2025 and one missed feeding on April 25, 2025 as indicated by the red X. RN X stated he was not able to review any progress notes on these days that indicated a reason for the missed feedings. According to RN X, the nurse that was on duty those days were responsible for ensuring Resident #100 completed his feedings. RN X stated not doing so placed him at risk of losing weight and malnutrition. <BR/>Interview and record review on 06/19/25 at 2:30 PM with DON revealed Resident #100 is on continuous feeding by tube feeding 20 hours a day, 200 flushes with water every 4 hours. The DON stated Resident #100 is doing really well with no concerns of weight loss. Upon record review, the DON stated she confirmed the red x's indicated missed feedings for Resident #100 on 04/24/25 at 1:00 AM and 5:00 AM, and 04/25/25 at 1:00 AM. The DON stated she was able to review any notes on missed feedings in the clinical record. The DON stated nurses on duty with Resident #100 were expected to record the orders as they come in and follow them, if orders are placed on hold there should be documentation. The DON stated not following the orders or holding the orders without documentation placed Resident #100 at risk of weight loss. <BR/>Record review of the facility's Physician Orders policy revised 01/10/23, reflected:<BR/>The qualified nursing personnel will take and implement telephone orders according to the Practice Guidelines. Immediate electronic entry is recommended; however, manual orders may be required in instances .<BR/>Procedure:<BR/>1. Enter Resident's last name and first name, attending physician's name, date, resident number, and community's name.<BR/>2. Record the actual order received from the physician.<BR/>3. The nurse taking the order signs full signature (first initial, last name, and title) in the signature of Nurse Receiving Order box. Enter the time the order was received and check appropriate box (a.m. or p.m.). Telephone and verbal orders are immediately recorded on resident's medical record.<BR/>4. After initiating the steps to carry out the physician's written order (I.e., entering it on the medication sheet, placing order with pharmacy, etc.), the nurse countersigns and dates the order with full signature in the Signature of Nurse Noting Order box.<BR/>5. Telephone orders must be entered into the HER as soon as possible.<BR/>6. A licensed nurse will confirm manual/paper order has been entered into the HER.<BR/>7. Send copy of the Physician's Order(s) to the pharmacy. This provides backup to your verbal communication with the pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of COVID-19 for 1 of 2 (Resident # 2) residents and 3 of 5 (CNA B, CNA C, and Med Aide D) staff reviewed for infection control. <BR/>The facility failed to ensure CNA B, CNA C, and Med Aide D were wearing appropriate PPE and following infection control practices during care of residents positive with COVID-19. The staff subsequently entered rooms of residents who were negative for COVID-19 and did not perform hand hygiene during meal service.<BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>These failures could place residents at risk of exposure of Covid-19 virus which could result in serious illness, hospitalization, and/or death. <BR/>Findings included: <BR/>Record review of Resident # 2's face sheet, dated 12/23/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Record review Resident # 2's consolidated orders, dated 12/23/22, revealed she had a diagnosis of COVID-19.<BR/>Review of the Resident Census Roster dated 12/20/22 revealed as of 12/20/22 two residents (including Resident # 2) were positive for COVID-19 and Resident # 2 was assigned to RM [ROOM NUMBER]. <BR/>Review of Admission/Discharge log revealed Resident # 2 went to the hospital on [DATE] and returned to the facility on [DATE].<BR/>Review of Isolation list revealed Resident # 2 was placed on isolation upon return to the facility on [DATE] because she tested positive for COVID-19 while at the hospital. <BR/>Interview with Resident # 2's family representative on 12/20/22 at 8:54 AM revealed there was a camera in Resident # 2's room. <BR/>Review of video footage on 12/20/22 at 9:15 AM revealed CNA A and an unknown agency staff were at bedside of Resident # 2 to perform incontinent care at 4:40 AM that morning. Both staff wore a N95 mask and gloves. No eye protection or gowns were noted. CNA A wore two N95 masks with the top strap of both masks behind her head, while the bottom straps of both masks hung underneath her chin.<BR/>Review of the staff schedule dated 12/19/22 revealed CNA A was assigned to 23 residents on 12/19/22 10PM-6AM shift, including Residents #2 and #3. The schedule also revealed 2 agency aides had worked on that shift as well.<BR/>Interview via telephone with CNA A on 12/21/22 at 7:07 AM revealed she did not know the name of the aide that helped her change Resident # 2 in the morning on 12/20/22. When asked what the appropriate PPE was for entering a covid-19 positive room, CNA A stated gown, gloves, face shield and mask.<BR/>Interview with Staffing Coordinator on 12/20/22 at 3:30 PM revealed she did not have access to the phone numbers of the staff sent to her from the agency company with whom the facility had a contract. <BR/>Observation on 12/20/22 at 5:56 PM revealed CNA B entered Resident # 2's room to answer the call light. CNA B was wearing an N95 and a face shield. He did not wear a gown.<BR/>Review of video footage of Resident # 2's room from 12/20/22 at 5:56 PM when CNA B answered the call light revealed CNA B reached over without gloves, grabbed the resident with both hands and pulled her over so that she was positioned in the center of the bed. The video footage revealed hand hygiene was not performed while CNA B was in the room. <BR/>Observation on 12/20/22 at 5:58 PM revealed CNA B exited Resident # 2's room pushed his face shield up to his forehead leaving the face shield at an angle and pulled his N95 down below his chin and turned around to speak with the resident from the doorway. No hand hygiene was performed. <BR/>Observation on 12/20/22 at 6:02 PM to 6:14 PM revealed CNA B in a COVID-19 negative room delivering dinner meals. CNA B exited the COVID-19 negative room and proceeded to the beverage cart on the hallway. CNA B picked up drinking cups by the rim and lined them up on the cart, grabbed pitchers of water and iced tea and poured drinks into the respective cups. CNA C then grabbed those same beverage pitchers to pour drinks that were delivered to other residents as well. CNA B delivered resident meals and beverages, and helped residents get set up to eat in four covid negative resident rooms. Each room housed two residents each (8 residents total). CNA B used hand sanitizer only once upon exit of one of the four rooms.<BR/>Observation on 12/20/22 at 6:15 PM revealed CNA C and the kitchen server pushed the beverage and hot food cart down to the other side of the 100 hall to continue serving meals to covid negative residents (the same cart CNA B had touched to deliver food to residents after entering Resident #2's room). <BR/>Interview via telephone on 12/21/22 at 12:36 PM with CNA B revealed he recalled entering Resident # 2's room without a gown during the evening shift on 12/20/22. CNA B stated there were gowns available in the gray container outside the resident's room and stated he could not explain why he did not wear a gown before entering the room. He stated he had been in-serviced recently on the need to wear N95, face shield and gown to enter a covid positive room. He stated handwashing was covered in the recent in-services. CNA B stated entering a covid positive room without proper PPE and then entering a covid negative room could increase the chances of getting other residents sick or contamination of other things. <BR/>Review of video footage revealed on 12/20/22 at 7:13 PM Med aide D entered Resident # 2's room with medications and a cup. Med aide D wore gloves, N95 mask and goggles. He was not wearing a gown.<BR/>Observation on 12/20/22 at 7:30 PM revealed Med aide D entered a covid negative room to administer medications to both residents in that room.<BR/>In an interview on 12/21/22 at 4:10 PM Med aide D revealed he gave Resident # 2 her medications first for the 7PM medication pass on 12/20/22. Med aide D stated after Resident # 2, he gave meds to two residents on the same side of the hall as Resident # 2, and then gave meds to the residents on the A side of 100 hall as most of the residents on that hall had 7PM meds ordered. Med aide D stated it escaped his mind to use the gown when he administered meds to Resident # 2 on 12/20/22. He stated the risk for entering covid negative rooms after not wearing appropriate PPE in a covid positive room was transmission of covid-19. <BR/>Record review of the Coronavirus Management Plan Texas Phase 2 & 3, which the facility was using as their policy, dated 11/03/22, revealed COVID Positive Unit .Personnel who enter the room will wear N95 respirators. In addition, staff should wear a gown, gloves, and face shield or goggles.<BR/>Review of the CDC Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-10) Pandemic, dated 09/23/22, reflected HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>On 12/21/22 at 1:11 PM the Assistant Administrator, DON and Regional Director of Operations were notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>The facility's Plan of Removal was accepted on 12/22/22 at 12:14 PM and reflected the following: [name of the facility]<BR/>PLAN OF REMOVAL<BR/>FOR <BR/>IMMEDIATE JEOPARDY on 12/21/22<BR/>To Whom it May Concern,<BR/>Infection Control<BR/>F880- The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. <BR/>Identify residents who could be affected<BR/>All residents have the potential to be affected by this alleged proficient practice<BR/>Problem<BR/>Staff members were seen providing care for a COVID positive resident without wearing appropriate PPE and/or wearing PPE in an inappropriate manner.<BR/>Staff members were seen not performing hand hygiene after entering a COVID positive resident's room and when passing meal trays to residents.<BR/>Action Taken <BR/>Infection Control<BR/>&cent; <BR/>ICP will re-educate Director of Nursing and Assistant Director of Nursing on company's infection control policy related to Covid 19 by end of day on 12/22/2022.<BR/>&cent; <BR/>Use of alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer<BR/>&cent; <BR/>Donning/Doffing of proper PPE for N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms<BR/>&cent; <BR/>ICP is responsible for monitoring the education of the Director of Nursing and the Assistant Director of Nursing on company's infection control policy related to Covid 19<BR/>Hand Hygiene and Competency<BR/>&cent; <BR/>Staff in-servicing on alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer with competency conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or Designee include staff handwashing and when to use hand sanitizer. <BR/>&cent; <BR/>Competencies consist of review of necessary steps and 100 % accuracy on return demonstration.<BR/>&cent; <BR/>Inservicing was implemented on 12/21/2022. All staff to be included in training. Training to be completed by 12/23/22. Staff not physically in community to receive their education in person prior to their next shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their next shift. <BR/>&cent; <BR/>Monitoring will begin 12/22/2022 and will be conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or designee to observe and document hand hygiene compliance twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>PPE and Competency<BR/>&cent; <BR/>ICP, Director of Nursing, Assistant Director of Nursing, and Designee in-serviced all staff on what PPE to wear to include type of mask i.e. N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms <BR/>&cent; <BR/>All staff will be in-serviced in person prior to working their shift. Training to be completed by 12/23/22 Those not physically in community will receive their education in-service in person prior to working their shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration prior to working their next shift. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their first shift. <BR/>&cent; <BR/>Monitoring began 12/22/2022 and will be done by ICP, Director of Nursing, Assistant Director of Nursing, or designee through random questioning on PPE and hand hygiene to ensure knowledge has been retained on various eight hour shifts to begin 12/22/2022. <BR/>&cent; <BR/>Director of Nursing or designee is rounding twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance ensuring proper infection control practices are in place through observation and questioning. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>On 12/22/22 to 12/23/22 the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by:<BR/>Review of the facility's in-service and competency testing records revealed:<BR/>1.The DON's name was listed as the facilitator of the in-services. The in-service topic was Infection Control, Covid-19 with an emphasis on hand hygiene and donning/doffing PPE.<BR/>2.As of 12/23/22 at 4:40 PM a total of 132 staff employed at the facility had been in-serviced and passed the hand hygiene and PPE competency.<BR/>Observations conducted from 12/22/22 at 10:55 AM to 5:00 PM on 12/23/22 revealed staff were donning and doffing PPE appropriately upon entrance and exit of covid-19 positive rooms. <BR/>Interviews conducted on 12/23/22 from 9:48 AM to 5:30 PM with staff from all three shifts(LVN E, Med aide F, CNA G, CNA H, CNA I, CNA J, COTA, ST Assistant Director, LVN K, Housekeeper L, Environmental Director, Laundry aide, Dietary cook M, Dietary cook N, PT O, CNA P, RN Q, CNA R, LVN S, CNA T, LVN U, LVN V, Housekeeper Z, LVN W, RN X, CNA Y, and Rehab tech), revealed staff were knowledgeable about what PPE was required to enter a COVID-19 positive room and why hand hygiene was important after doffing to prevent the spread of infection. The staff stated they had to watch videos on hand hygiene and PPE and had to perform a skills test.<BR/>In an interview with the ADON on 12/23/22 at 4:56 PM it was revealed that utilizing PPE and performing hand hygiene was the way to ensure COVID-19 was not being spread when going from a positive room to a negative room. The ADON stated charge nurses, direct supervisors and everyone was in charge of going behind staff to ensure they followed infection control protocols. They could make rounds and address any issues at that time. The ADON stated an IJ was identified because the staff were not following the proper PPE and hand hygiene protocols, thereby placing residents at risk. The ADON stated the facility was going to implement ongoing monitoring, monitoring tools and schedules to ensure proper infection control measures were followed. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated an IJ was identified because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated she understood why this was identified as an IJ because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview on 12/23/22 at 5:48 PM, the Assistant Administrator stated an IJ was identified because of the failure of staff to wear the proper PPE, going in and out of resident rooms that were covid positive and negative in addition to concerns with handwashing and sanitizing. She stated all this could lead to potential harm or spread of infections and diseases. <BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four (Residents #1, #2, #3 and #4) of four residents reviewed for physician services.<BR/>The facility failed to ensure Residents #1, #2, #3 and #4 were seen by their attending physician at least once every 60 days. The attending physician's extender was completing all visits for the residents, not alternating visits with the physician. <BR/>The failure could place residents at an increased risk of not receiving appropriate and adequate medical care and a lack of oversight by the physician, which could place the residents at risk of harm and health decline. <BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet dated 03/26/25 reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of hypertensive chronic kidney disease (occurs when high blood pressure damages the kidneys, leading to impaired kidney function and potentially end-stage renal disease), intervertebral disc degeneration (a condition where the discs between vertebrae in the spine break down or wear down, potentially causing pain, numbness, and weakness), osteoarthritis in right knee (degenerative joint disease), mixed hyperlipidemia (a condition where multiple types of lipids (fats) in the blood are elevated above normal levels), morbid (severe) obesity, overactive bladder, constipation, and allergic rhinitis. Resident #1's face sheet reflected MD A was listed as her attending physician. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 03, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00 which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She required partial/moderate assistance from staff for her ADL's and was incontinent of bowel and bladder. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 was administered three at-risk drugs-an antipsychotic, an antidepressant and a diuretic (medication that helps reduce fluid build-up). <BR/>Record review of Resident #1's care plan initiated on 10/02/23 and last updated 01/14/25 reflected the following problem/issues: 1) Psychotropic drug use related to schizophrenia, 2) Impaired physical mobility due to stroke and 3) Dementia, dysphagia (difficulty swallowing) and inability to communicate.<BR/>Record review of Resident #1's March 2025 Physician Orders reflected she was prescribed the current labs and medications while under MD A's medical care: TSH, CBC, CMP and lipid profile every 12 months in October (start date 10/04/23), montelukast 10 mg once every evening (start date 10/02/23), omeprazole 40 mg once a day (start date 08/15/24), oxybutynin 40 mg once a day (start date 10/03/23), simvastatin 20 mg once at bedtime (start date 10/02/23), duloxetine 20 mg at bedtime (start fate 10/02/23), risperidone 2 mg two tablets at bedtime (start date 10/17/24), loratadine 10 mg once a day (start day 11/25/23), Lisinopril 40 mg once a day-hole if SPB less than 110 and DBP less than 60 (start date 10/02/23), Mucinex 600 mg ER twice a day every 12 hours (start date 08/15/24), Ingrezza 40 mg once at bedtime (start date 03/05/25), furosemide 40 mg once a day (start date 11/05/23), fluticasone propionate 50 mcg/actuation nasal spray one in each nostril once a day (start date 10/03/23), fenofibrate nano crystallized 145 mg once at bedtime (start date 10/02/23) and donepezil 10 mg two tablets at bedtime (start date 11/08/24). <BR/>Record review of Resident #1's clinical chart reflected no evidence of any visit by a physician in the past 12 months from 03/01/24 through 03/26/25. <BR/>Review of Resident #1's clinical chart revealed the following physician extender visits by NP B since 03/01/2024: 03/08/24, 04/07/24, 05/07/24, 06/04/24, 07/04/24, 08/09/24, 09/04/24, 10/08/24 (NH annual History and Physical Exam), 11/03/24, 12/03/24, 01/02/25 and 02/05/25. <BR/>2. Record review of Resident #2's face sheet dated 03/26/25 reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of paraplegia (the inability to voluntarily move the lower parts of the body), vitamin D deficiency, constipation, essential (primary) hypertension (a condition where the force of blood against the artery walls is consistently too high, potentially damaging the heart, brain, and other organs), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal or nerve problems) , gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus) and chronic pain due to trauma. Resident #2's face sheet reflected MD A was listed as her attending physician.<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderate cognitive impairment. Resident #2 had fluctuating behaviors of inattention and disorganized thinking and sometimes experienced social isolation. She had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. Resident #2 required physical assistance of staff for her ADL's, had an indwelling catheter and was frequently incontinent of bowel. She used a wheelchair for mobility and had no range of motion issues. Resident #2 had no indicators of pain and had no falls since the last MDS assessment. Resident #2 was administered three at-risk drugs: an antipsychotic, an antidepressant, an opioid and an anticonvulsant. <BR/>Record review of Resident #2's care plan initiated 01/21/21 and last revised 03/07/25 reflected the following problems/issues: 1) Use of Xanax due to anxiety, restlessness and fidgeting; 2) History of depression and use of multiple antidepressants, 3) Acute pain from trauma due to paraplegia and spinal cord injury, 4) Use of antihypertensive medications due to elevated blood pressure, 5) Impaired physical mobility and self-care deficits and use of a F oley catheter. <BR/>Record review of Resident #2's March 2025 Physician Orders reflected she was prescribed the current labs and medications while under MD A's medical care: TSH, CMP, CBC and lipid profile every 12 months (start date 12/16/24), duloxetine 20 mg twice a day (start 03/07/25), escitalopram 10 mg 1 &frac12; tablet at bedtime to equal 15 mg (start date 03/07/25), lamotrigine 100 mg twice a day (start date 01/17/25), Uzedy 200 mg/0.56 ml subcutaneously once a month on the 27th (start date 10/25/24) and sennosides 8.6 mg-docusate sodium 50 mg twice a day (start date 03/11/21).<BR/>Record review of Resident #2's clinical chart reflected no evidence of any visit by a physician in the past 12 months from 03/01/24 through 03/26/25. <BR/>Review of Resident #2's clinical chart revealed the following physician extender visits by NP B since 03/01/2024: 03/04/24, 04/03/24, 05/07/24, 05/24/24, 06/06/24, 07/06/24, 08/11/24, 09/06/24, 10/06/24, 11/05/24, 12/23/24, 01/14/25 and 02/05/25. <BR/>3. Record review of Resident #3's face sheet dated 03/26/25 reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of senile degeneration of brain (also known as dementia, is a group of conditions that cause a decline in cognitive function and memory and is a progressive and irreversible process that typically occurs in older adults), sequelae of cerebral infarction (also known as an ischemic stroke, is the death of brain tissue (cerebral infarct) due to a lack of blood flow (ischemia) caused by a blockage or narrowing of blood vessels in the brain), chronic kidney disease-stage 3 (a gradual progressive loss of kidney function leading to a buildup of waste and fluid in the body), major depressive disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, impacting daily functioning), hyperlipidemia (a condition characterized by elevated levels of lipids (fats) in the blood which can increase the risk of heart disease and stroke), Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), neuromuscular dysfunction of bladder (a condition where bladder control is lost due to problems with the brain, spinal cord, or nerves that control bladder function, leading to difficulties in emptying or holding urine) and pain. Resident #3'w face sheet reflected MD A was listed as her attending physician.<BR/>Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severe cognitive impairment and a mood score of 00 which indicated no negative mood issues. Resident #3 had no potential indicators of psychosis, no physical or verbal behavioral symptoms, no rejection or care and no wandering behaviors, fluctuating behaviors of inattention and disorganized thinking and sometimes experienced social isolation. She had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. Resident #3 required extensive physical assistance of staff for her ADL's and was incontinent of bowel and bladder. She used a wheelchair for mobility and had no range of motion issues. Resident #3 had no indicators of pain and had no falls since the last MDS assessment. Resident #3 received physical and occupational therapy during her last assessment period. <BR/>Record review of Resident #3's care plan dated 09/07/24 reflected the following problems/issues: 1) Poor balance, 2) Problems with elimination (bowel/bladder), 3) Dysphagia and chewing difficulty, and 4) Pain. <BR/>Record review of Resident #3's March 2025 Physician Orders reflected she was prescribed the current labs and medications while under MD A's medical care: TSH, CMP, CBC labs every 12 months (start date 09/27/24), Depakote valproic acid every three months (start 12/27/24), mirtazapine 15 mg 0.5mg at bedtime (start date 02/14/25), divalproex 125 mg twice a day (start date 02/21/25), bupropion ER on ce a day (start date 02/12/25), Myrbetriq 50 mg ER on ce a day (start date 09/27/24), atorvastatin 40 mg once a day (start 09/27/24), aspirin 81 mg once a day (start date 09/27/24) and amlodipine 10 mg once a day (hold if SBP less than 110 and DBP less than 60) (start date 09/27/24).<BR/>Record review of Resident #3's clinical chart reflected no evidence of any visit by a physician since her admission on [DATE]. <BR/>Review of Resident #3's clinical chart revealed the following physician extender visits by NP B since her admission on [DATE]: 09/28/25, 10/14/24, 11/09/24, 12/07/24, 01/02/25 and 02/01/25. <BR/>4. Record review of Resident #4's face sheet dated 03/26/25 reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), diarrhea, pruritus (itching), allergic rhinitis, hypertension, constipation, long term (current) use of anticoagulants, schizophrenia (a chronic mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), thyrotoxicosis (excessive thyroid hormone levels in the bloodstream) and pain. Resident #4's face sheet reflected MD A was listed as her attending physician.<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #4 had signs/symptoms of delirium which included fluctuating inattention and disorganized thinking and her mood score was a 00 which indicated no negative mood issues. Resident #4 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She required limited supervision/assistance from staff for her ADL's and was continent of bowel and occasionally incontinent of bladder. Resident #4 had no indicators of pain and had no falls since the last MDS assessment. Resident #4 was administered five at-risk drugs-an antipsychotic, an antidepressant, an anticoagulant (a medication to prevent or reduce blood clotting), a diuretic and an anticonvulsant. Resident #4 also received hospice care and occupational therapy during the last assessment period. <BR/>Record review of Resident #4's care plan 02/27/25 reflected the following problems/issues: 1) Atrial fibrillation (abnormal heart rhythm) and use of anti-coagulants, 2) Use of anticonvulsant, antidepressant and opioid therapy, 3) Renal disease (gradual loss of kidney function) and constipation, 4) Skin breakdown and wound care, 5) Pain and hospice care related to a terminal diagnosis. <BR/>Record review of Resident #4's March 2025 Physician Orders reflected she was prescribed the current medications while under MD A's medical care: rivaroxaban 15 mg once every evening (start date 02/27/25), olanzapine 5 mg at bedtime (start date 02/27/25), duloxetine 20 mg once a day (start date 02/27/25), divalproex 125 mcg two capsules twice a day (start date 02/27/25), tramadol 50 mg every six hours as needed (start date 02/27/25), thiamine 50 mg once a day (start date 02/27/25), midodrine 5 mg three times a day as needed- administer for SBP less than 90 (start date 02/27/25), trazadone 150 mg once at bedtime (start date 02/27/25), hydroxyzine 10 mg once a day (start date 02/27/25), folic acid 1 mg once a day (start date 02/27/25), docusate sodium 100 mg twice a day (start date 02/27/25), amlodipine 5 mg once a day-hold if SBP greater than 110 and hold if DBP greater than 60 (Start date 02/27/25) and methimazole 5 mg once a day (start date 02/27/25). <BR/>Record review of Resident #4's clinical chart reflected no evidence of any visit by a physician for the past 12 months (03/01/24 through 03/26/25). <BR/>5. An interview with MD A on 03/26/25 at 1:34 PM revealed he did not have any documented evidence that he completed face to face visits for Residents #1, #2, #3 and #4. MD A stated he usually did rounds with his nurse practitioner and gave him instructions on what changes to make to treatment. He stated his office was across the street from the facility and if the nursing staff needed him to see a resident in person, he would go and see them. MD A stated, I would say I am falling behind on writing notes; I delegate that to the nurse practitioner. MD A stated he understood the CMS regulations related to face-to-face physician visits, but again stated, I am falling behind. MD A stated he had one physician extender, NP B. He stated it was important for the attending physician to see their assigned resident, for good medical service. For Resident #1, MD A stated she had degenerative arthritis and he was planning on seeing her later in the day (03/26/25) because she needed a steroid shot and ultrasound to do a knee injection. He stated he would complete his physician face to face visit with her at that time. <BR/>An interview with the Administrator on 03/26/25 at 4:30 PM revealed there was no facility policy related to physician visits and they followed the CMS/HHSC regulatory language.<BR/>A follow up interview with the Administrator on 03/28/25 at 10:11 AM revealed after investigator intervention, MD A saw Resident #1 on 03/27/25 at his office and provided her a knee injection the resident had been waiting to receive for knee discomfort. The Administrator provided MD A's physician documentation for the visit. <BR/>6. Record review of the facility's signed July 2014 Medical Director Agreement with MD A reflected in part, .3. Duties of Physician- a. Physician Leadership (i) Assist the Facility in ensuring that residents and patients have appropriate physician coverage and ensure the provision of physician and health care practitioner services; 3.2 Physician shall perform the Services in a timely and professional manner and in conformity with the highest standards of procedure and ethics. Physician shall comply with Facility's policies and procedures and medical staff bylaws, including, without limitation, those relating to conduct, standards of medical care and record compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #3) of four residents reviewed for pharmacy services.<BR/>The facility failed to administer Resident #3, who had a diagnosis of dementia, with her morning medications on 03/26/25 and 03/27/25. Both the medication aide and nurse acknowledged they were busy and did not attempt to give them to her again after one refusal. As a result, Resident #3 missed eight different medications both days, including blood pressure readings related to blood pressure medication, as well as two supplements. <BR/>The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 03/26/25 reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of senile degeneration of brain (also known as dementia, is a group of conditions that cause a decline in cognitive function and memory and is a progressive and irreversible process that typically occurs in older adults), sequelae of cerebral infarction (also known as an ischemic stroke, is the death of brain tissue (cerebral infarct) due to a lack of blood flow (ischemia) caused by a blockage or narrowing of blood vessels in the brain), chronic kidney disease-stage 3 (a gradual progressive loss of kidney function leading to a buildup of waste and fluid in the body), major depressive disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, impacting daily functioning), hyperlipidemia (a condition characterized by elevated levels of lipids (fats) in the blood which can increase the risk of heart disease and stroke), Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), neuromuscular dysfunction of bladder (a condition where bladder control is lost due to problems with the brain, spinal cord, or nerves that control bladder function, leading to difficulties in emptying or holding urine) and pain. <BR/>Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severe cognitive impairment and a mood score of 00 which indicated no negative mood issues. Resident #3 had no potential indicators of psychosis, no physical or verbal behavioral symptoms, no rejection or care and no wandering behaviors. <BR/>Record review of Resident #3's care plan dated 09/07/24 reflected the following problems/issues: 1) Poor balance, 2) Problems with elimination (bowel/bladder), 3) Dysphagia (difficulty swallowing) and chewing difficulty, and 4) Pain. The interventions for her prescribed medications were to administer medications as ordered. <BR/>Record review of Resident #3's March 2025 Physician Orders reflected she was prescribed: mirtazapine 15 mg 0.5mg at bedtime (antidepressant-start date 02/14/25), divalproex 125 mg twice a day (anticonvulsant-start date 02/21/25), bupropion ER on ce a day (antidepressant-start date 02/12/25), Myrbetriq 50 mg ER on ce a day (treats overactive bladder-start date 09/27/24), atorvastatin 40 mg once a day for cholesterol (start 09/27/24), megestrol 5ml by mouth once a day for dementia (start date 02/21/25), aspirin 81 mg once a day (start date 09/27/24), amlodipine 10 mg once a day (blood pressure-hold if SBP less than 110 and DBP less than 60) (start date 09/27/24), polyethylene glycol 17 grams once a day in eight ounces of fluid (start date 12/17/25), 2.0 Cal Med Pass supplement 60 ml four times a day with medication pass for adult failure to thrive (start 12/17/24).<BR/>Record review of Resident #3's March 2025 MAR reflected she was not administered the following medications on 03/26/25 and 03/27/25 on the morning shift: amlodipine, aspirin, atorvastatin (including no blood pressure recordings), bupropion, multivitamin, divalproex, megestrol, Myrbetriq, polyethylene glycol and med pass supplement. The MAR for the missed med administrations was initialed by MA D as resident refusals. <BR/>Record review of Resident #3's nursing progress notes revealed no entry for 03/26/25 and 03/27/25 to document the nurse was notified of the medication refusals, why the medication was not given, nor what was done after the resident refused to take the medication and if the doctor was notified. <BR/>An interview with LVN C on 03/26/25 at 12:47 PM revealed if a medication aide could not administer a medication for whatever reason, then the medication would show on the MAR as not given and the med aide had to tell the charge nurse, then that charge nurse had to document and follow up on it. He said if a medication was not able to be given after three attempts, including for resident refusals, the nurse had to contact the doctor. LVN C stated he liked to notify the doctor after the first refusal especially if it was a high-risk medication, Just to put it on the doctor's radar in case it becomes an issue. <BR/>An interview with the DON on 03/26/25 at 2:18 PM revealed she did not have an ADON working in the facility, so she had been responsible for all the DON duties and the ADON's duties. In response to Resident #3's medication not being given for two days on the morning shift and documented as refusals, the DON stated, We need to figure out why med aides are clicking not given on these MARs. Maybe they are just going too fast and not clicking the correct reason is why it was not given. <BR/>An interview with MA D on 03/28/25 at 1:05 PM revealed she was the person who did the med administration pass for Resident #3 on 03/26/25 and 03/27/25 in the morning. She stated Resident #3 did not take the medication when offered both those days and spit it out. MA D stated in the mornings, sometimes Resident #3 refused to let the med aide take her blood pressure and would move her arms around to where she could not get an accurate reading on the machine. MA D stated that with the medications, she crushed them and put them in applesauce but Resident #3 would spit it out. MA D stated, If she is feisty, she will not accept. MA D stated when that happened, she was supposed to let the charge nurse know that an attempt was made and refused. MA D stated there was one other medication aide in the facility who passed medications on the other halls and in the mornings, they had to have their own routine due to the number of medications that had to be administered. MA D stated she typically started administering medications around 6:30 AM-7AM and tried to be finished by 10:00 AM. MA D stated, I have to keep moving. If someone refuses, I got to keep going because I have other meds to give. MA D stated again that her job was to report medication refusals to the charge nurse and it was on the charge nurse to chart it, call the doctor and follow up and decide what to do. <BR/>An interview with MA E on 03/28/25 at 1:14 PM revealed she had administered Resident #3's medications that morning (03/28/25) with no issues. She stated sometimes when Resident #3 was mad, she would refuse to let the med aide take her blood pressure and give her medications, but not every day. MA E stated when Resident #3 refused the blood pressure, she would tell her that her family member really wanted her to stay healthy and would like it, and she would normally comply. MA E stated Resident #3 liked sweet things, so when she crushed her medications , she put them in applesauce with a little bit of jelly. MA E said if Resident #3 did refuse her medications during a med pass, the med aide had to document it in the e-chart and then notify the nurse and both of them would try together to encourage the resident to take them. MA E stated it was important for Resident #3 to take her medications as ordered because she needed the blood pressure medication due to her running high at times, and there was another medication to help her calm down and not stress or feel frustrated. <BR/>An interview with LVN F on 03/28/25 at 2:00 PM revealed she was the charge nurse for Resident #3 and stated MA D did notify her about the medication refusals. LVN F stated, I was busy, but typically we have to document if they refuse. She stated if the resident continued to refuse for a couple of days, which was not typical, then the NP was notified. LVN F stated, As a nurse, I am supposed to document that the med aide tried to administer meds but the patient didn't want them. LVN F stated when that happened, she would normally go to the resident's room and try to encourage them but at the end of the day, it was their right. She said for the past two mornings (03/26/25 and 03/27/25), she did not try to get Resident #3 to take her medications when she was notified of the refusals. LVN F stated, At the time when the med aide let me know [03/26/25], I was in the middle of doing ten things at once. I would have gone in there normally under regular circumstances to try to get her to take it but I was very busy and not able to go in. Same thing yesterday [03/27/25]. Last couple of weeks we have been slammed and busy.<BR/>An interview with the DON on 03/28/25 at 3:03 PM revealed LVN F was a newer nurse and although she was a good nurse, it was just a mistake and she and she had already begun in-serving the nursing staff. The DON stated her expectation was that when notified of medication refusals, the nurse should notify the physician after two medication refusals. <BR/>Record review of the facility's policy titled, Medication Administration Guidelines, dated January 2024 reflected, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Procedures .2. Obtain and record any vital signs as necessary prior to medication administration .Documentation .2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the MAR for that dosage is initialed and circled .If two consecutive doses of a vital medications are withheld or refused, the physician is notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident's drug regimen must be free from unnecessary drugs, without adequate indications for its use for two (Residents #1 and #2) of four residents reviewed for psychotropic medications.<BR/>The facility failed to ensure Residents #1 and #2 were not prescribed Austedo (a prescription medicine used to treat involuntary movements in adults with tardive dyskinesia (movement disorder characterized by involuntary movements) or Huntington's disease (an illness that causes nerve cells in the brain to decay over time and affects a person's movement, thinking ability, mental health) without adequate indications for its use. <BR/>The failure could affect residents by placing them at risk for possible adverse side effects, a decreased quality of life and continued use of possible unnecessary medications.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet dated 03/26/25 reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of hypertensive chronic kidney disease (occurs when high blood pressure damages the kidneys, leading to impaired kidney function and potentially end-stage renal disease), intervertebral disc degeneration (a condition where the discs between vertebrae in the spine break down or wear down, potentially causing pain, numbness, and weakness) osteoarthritis in right knee (degenerative joint disease), mixed hyperlipidemia (a condition where multiple types of lipids (fats) in the blood are elevated above normal levels), morbid (severe) obesity, overactive bladder, constipation, and allergic rhinitis. Resident #1's face sheet reflected MD A was listed as her attending physician. Resident #1 did not have any diagnoses of mental illness or EPS (involuntary movements and other motor disturbances that can occur as a side effect of certain medications, particularly antipsychotic drugs) and tardive dyskinesia (a chronic movement disorder that can develop as a side effect of long-term use of certain medications, primarily antipsychotic drugs). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 03, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00 which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. Resident #1 was administered three at-risk drugs-an antipsychotic, an antidepressant and a diuretic (medicines that increase the amount of urine you produce).<BR/>Record review of Resident #1's care plan initiated on 10/02/23 and last updated 01/14/25 reflected the following problem/issues: 1) Psychotropic drug use related to schizophrenia, 2) Impaired physical mobility due to stroke and 3) Dementia, dysphagia (difficulty swallowing) and inability to communicate.<BR/>Record review of Resident #1's AIMS assessments dated 01/16/24, 04/17/24, 08/20/24 and 02/20/25 each reflected an assessed score of 0, which indicated no evidence of tardive dyskinesia. The AIMS assessment evaluated and observed for facial and oral movements, extremity movements and trunk movements.<BR/>Record review of Resident #1's Psychiatric Periodic Evaluation dated 09/13/24 and completed by the PMHNP reflected she was being seen for a monthly routine follow-up evaluation visit due to an original referral from MD A for psychotropic management, intermittent agitation and spontaneous psychosis. The evaluation also indicated she presented as actively delusional, with intermittent anxiety and restlessness. The PMHNP documented, Patient is also noted with involuntary tremors likely due to prolonged use of psychotropics. Upon review, will start patient on Austedo 12 mg XR to target extrapyramidal movements (involuntary movements without one's control) and increase Risperdal to 2mg two tablets for schizophrenia .will monitor closely. The PMHNP's AIMS assessment section in the evaluation reflected Resident #1 had facial and oral movements and upper extremity movements. Prior visits from the PMHNP on 03/28/24, 07/22/24 and 08/12/24 reflected no issues with Resident #1's movements. <BR/>Record review of Resident #1's March 2025 Physician Orders reflected she was prescribed the following medications related to her mental/cognitive diagnoses: duloxetine 20 mg at bedtime (antidepressant-start date 10/02/23), risperidone 2 mg two tablets at bedtime (anti-psychotic-start date 10/17/24), Austedo XR 36 mg once at bedtime for schizophrenia (start date 09/13/25, end date 03/26/25).<BR/>Record review of Resident #1's March 2025 MAR reflected she was administered Austedo 17 times from 03/01/25 through 03/28/25 before it was discontinued. <BR/>Record review of Resident #1's nursing progress notes from 03/01/24 to 09/13/24 (prior to being prescribed Austedo), revealed no mention of the resident having any issues with uncontrolled movements. <BR/>An observation and interview with Resident #1 on 03/26/25 at 12:20 PM revealed she was eating lunch and was not observed to have any movements or tremors. Due to her limited cognition, she was unable to provide insight on the medication and its use. <BR/>An interview with the DON on 03/26/25 at 2:18 PM revealed a representative from the company that made the medication Austedo came to give a presentation to nursing management in July/August 2024 and let them know what the medication could be used for. The DON stated after that presentation, the staff noticed some pill rolling (a type of tremor associated with Parkinson's disease named for the way it looks, where a person appears to be rolling a pill or small object between their thumb and index finger) that Resident #1 was doing, Nothing more, it was small, nothing with her limbs or large movements. The DON stated because of that, the decision was made to try her on the medication the representative from Austedo had presented on. However, after Resident #1 was on the medication, the representative left his position and it became complicated to get the medication and it was costly. As a result, the PMHNP decided to use a different medication instead.<BR/>2. Record review of Resident #2's face sheet dated 03/26/25 the resident was a [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of paraplegia, vitamin D deficiency, constipation, essential (primary) hypertension, neuromuscular dysfunction of bladder, gastro-esophageal reflux disease and chronic pain due to trauma. Resident #2's face sheet reflected MD A was listed as her attending physician.<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderate cognitive impairment. Resident #2 had fluctuating behaviors of inattention and disorganized thinking and sometimes experienced social isolation. She had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. Resident #2 required physical assistance of staff for her ADLs, had an indwelling catheter and was frequently incontinent of bowel. She used a wheelchair for mobility and had no range of motion issues. Resident #2 had no indicators of pain and had no falls since the last MDS assessment. Resident #2 was administered three at-risk drugs: an antipsychotic, an antidepressant, an opioid and an anticonvulsant. <BR/>Record review of Resident #2's care plan initiated 01/21/21 and last revised 03/07/25 reflected the following problems/issues: 1) Use of Xanax due to anxiety, restlessness and fidgeting; 2) History of depression and use of multiple antidepressants, 3) Acute pain from trauma due to paraplegia and spinal cord injury, 4) Use of antihypertensive medications due to elevated blood pressure, 5) Impaired physical mobility and self-care deficits and use of a Foley catheter. <BR/>Record review of Resident #2's AIMS assessments dated 01/16/24, 04/23/24 and 03/26/25 each reflected an assessed score of 0, which indicated no evidence of tardive dyskinesia. The AIMS assessment evaluated and observed for facial and oral movements, extremity movements and trunk movements.<BR/>Record review of Resident #1's Psychiatric Periodic Evaluation dated 10/25/24 and completed by the PMHNP reflected she was being seen for a monthly routine follow-up evaluation visit due to an original referral from MD A for reports of resistance to care and a medication check. The PMHNP's AIMS assessment section reflected Resident #2 had no abnormal facial or oral movements, no abnormal extremity movements and no abnormal trunk movements. The PMHNP documented, Patient is presenting with increased tremors, around the mouth, and trunk movement, suggestive of tardive dyskinesia due to prolonged use of anti-psychotics .start patient on Austedo.<BR/>Record review of Resident #2's March 2025 Physician Orders reflected she was prescribed the following medications related to her mental/cognitive diagnoses: Austedo XR once at bedtime for drug-induced subacute dyskinesia (start date 11/03/24, end date 03/28/25), duloxetine 20 mg twice a day for anxiety (anti-depressant-start 03/07/25), escitalopram 10 mg 1 &frac12; tablet at bedtime to equal 15 mg for depression (antipsychotic-start date 03/07/25), lamotrigine 100 mg twice a day for schizoaffective disorder (antiepileptic-start date 01/17/25) and Uzedy 200 mg/0.56 ml subcutaneously once a month on the 27th for schizoaffective disorder (antipsychotic-start date 10/25/24).<BR/>Record review of Resident #2's March 2025 MAR reflected she was administered Austedo 19 times from 03/01/25 through 03/27/25 before it was discontinued.<BR/>Record review of Resident #1's nursing progress notes from 03/01/24 to 09/01/24 (prior to being prescribed Austedo), revealed no mention of the resident having any issues with uncontrolled movements.<BR/>An interview and observation with Resident #2 on 03/28/25 at 12:45 PM revealed she was sitting in her wheelchair outside her room softly bobbing her head. Resident #2 said that she tended to [NAME] her head when she was feeling anxiety and if she tried to stop while she was feeling anxious, it could make her feel worse inside her head. She said it did not bother her and helped her relax. Resident #2 stated she was not aware she had been prescribed and was taking the medication Austedo for movement issues. Resident #2 said her movements were not uncontrolled, it was just a way to calm down. Resident #2 stated she had been taking Risperdal injections but did not think they were causing her any side effects with movements or tremors. <BR/>An interview with the DON on 03/28/25 at 11:00 AM revealed Resident #2 used to rock back and forth a while back but got it under control. <BR/>3. An interview with LVN C on 03/26/25 at 12:47 PM revealed he was the charge nurse for Residents #1 and #2 and from his observations, neither had any movement issues he was aware of. He was not aware of the medication Austedo both residents were prescribed or what it was for. <BR/>An interview with the PMHNP on 03/28/25 at 10:13 AM revealed residents who were prescribed antipsychotic medications for a long period of time could develop side effects from prolonged use, such as tremors, rocking, buccal (mouth/cheek) movements, tardive dyskinesia. He stated Austedo was a medication that decreased the side effects of movements which could be difficult for patients. The PMHNP stated he determined the need for Resident #1 and Resident #2 to be prescribed Austedo based off his clinical observations he made during his visits. The PMHNP stated Austedo was very expensive and costly and the pharmacy wanted a pre-authorization every time, which could be hard to get, which was why it was discontinued and another brand was prescribed. The PMHNP stated Resident #2's movements had improved but he was going to prescribe her a new medication called Ingrezza because she was rocking slowly when he saw her earlier in the morning on 03/28/25. He stated, I think it can exhaust the patient.<BR/>4. Record review of the facility policy titled, Abnormal Involuntary Movement Scale (AIMS) Evaluations, effective 01/12/18 reflected, To formally evaluate residents for whom dopamine blocking medications have been prescribed to identify symptoms that may indicate the presence of Tardive Dyskinesia .Tardive Dyskinesia: A neurologic disorder characterized by abnormal involuntary movements which may occur as an undesired effect of dopamine blocking medications .7. Only a physician or physician extender shall make a diagnosis of the presence of Tardive Dyskinesia. When such a diagnosis is made, the interdisciplinary team shall work with the resident and family to determine the most appropriate course of treatment, considering both the effects of Tardive Dyskinesia and the patient's psychiatric condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident has a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of five residents (Resident #1) reviewed for care plans.<BR/>The facility failed to follow Resident #1's care plan intervention of lowering the bed and the use of half bedrails due to fall risk.<BR/>This failure could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing.<BR/>Findings included:<BR/>Record review of Resident #1's electronic face sheet printed on 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included but not limited to Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach. This can cause pain, difficulty in swallowing or chest pain.)<BR/>Record review of the annual MDS dated [DATE] did not indicate a BIMS score. Section GG Functional Abilities reflected Resident #1 required substantial/maximum assistance with transfers and sit to stand. Resident #1 was not coded for falls on the MDS.<BR/>Record review of Resident#1's service plan last reviewed 12/11/2024 revealed Resident #1 was a fall risk with interventions to include call light within reach and &frac12; bed rail use.<BR/>Observation on 03/08/2025 at 11:05 AM of Resident #1's bed revealed it was not in the lowest position, the fall mat was leaning against the wall and the bed rails were down. <BR/>Observation on 03/08/2025 at 3:09 PM of Resident #1 revealed she was in bed sleeping. The bed was not in the lowest position, the bed rails were not raised, and a fall mat was not on the floor. <BR/>Interview on 03/08/2025 at 11:15 AM with LVN A revealed Resident #1's fall mat should have been down and the bed rail should have been up on one side. LVN A stated she was not sure why the fall mat was not down, bed not in lowest position and rail not up. LVN A stated anyone who entered the room should have ensured fall interventions were in place.<BR/>Interview on 03/08/2025 at 11:53 AM with CNA B revealed he had not been in Resident #1's room since around 9:00 AM when he attempted to feed her. He stated he forgot to lower the bed and put the fall mat down when he left the room. CNA B stated he was not aware of what the risk would be if interventions were not followed.<BR/>Interview on 03/08/2025 at 1:30 PM with the Director of Nursing revealed Resident #1 was a fall risk and should have had the bed in the lowest position and the fall mat on the floor on one side of the bed and the bed rail up on the other side of the bed. The Director of Nursing stated all staff should ensure fall interventions were in place each time they enter the room. The Director of Nursing stated the risk of not ensuring interventions were in place would be the resident could fall and get hurt.<BR/>Record review of the facility's Comprehensive Care plan policy, revised 02/12/2020, reflected: Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**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 abuse for one of six residents (Resident #6) reviewed for abuse.<BR/>The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 punched and then pushed her on 02/05/25 located on a secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury.<BR/>The noncompliance was identified as PNC. The IJ began on 02/05/25 and ended on 02/05/25. The facility had corrected the noncompliance before the survey began.<BR/>This failure placed residents at risk for abuse.<BR/>Findings included: <BR/>Record review of Resident #6's face sheet, dated 02/26/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE].<BR/>Record review of Resident #6's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her diagnoses included hip fracture, anxiety disorder, and other orthopedic condition. The MDS indicated she had no behaviors of any kind and that she utilized a wheelchair. <BR/>Record review of Resident #6's care plan, updated 01/13/25, reflected she was a fall risk.<BR/>Record review of Resident #6's Nurses Notes reflected the following: <BR/>- Resident noted standing up off from couch when another resident pushed her, and she went down landing on her sacral area resident removed from area made safe during assessment resident screaming and protecting right leg and hip area prn apap given dr [Physician Z] called 911 called DON preset and aware family called and message left resident transferred to [Hospital Y] for evaluation. Written on 02/05/25 by LVN X.<BR/>- 1830; Met with [Resident #6's RP] in person to discuss fall and injury. She was made aware, per investigation, fellow resident pushed her as she was standing from sofa, she lost her balance and fell landing on her buttocks. [Resident #6] complained of pain to her right hip and thigh area, could not recall event or how she landed on floor. [Resident #6's RP] informed resident was sent to ER at [Hospital Y] due to c/o pain and inability to bear weight on right leg . written on 02/05/25 by the DON.<BR/>- Resident returned from [Hospital Y] via stretcher and EMT with oxygen therapy at 2L/min via nasal cannula at 1810. Resident diagnosed with subcapital fracture of the right femoral neck. Resident surgical wound is clean and dry, with no signs of infection . Written by RN W on 02/08/25.<BR/>Record review of Resident #6's hospital records reflected the following: Hospital Course: patient got into physical altercation with another resident, they pushed to this patient [sic] to the ground when she landed on her bottom, she developed severe pain in the right hip, presented to the ER where she was found to have right neck femur fracture, s/p surgery 02/06 .Active Problems: Closed fracture of neck of right femur .<BR/>Observation and interview on 02/26/25 at 1:40 PM with Resident #6 revealed she was sitting on the couch in the common area. Resident #6 had her wheelchair next to her and said she was doing okay. Resident #6 said she was not in any pain and felt safe in the facility. Resident #6 said she never had a fall or had anyone push her in the facility before. <BR/>Attempted phone interview on 02/26/25 at 1:57 PM with Resident #6's RP was unsuccessful as they did not answer or call back. <BR/>Record review of Resident #7's face sheet, dated 02/26/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #7's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 07, indicating severe cognitive impairment. Her diagnoses included other neurological conditions, Alzheimer's disease, and anxiety disorder. Her MDS indicated she did not have any behaviors towards anyone. <BR/>Record review of Resident #7's care plan, updated 04/08/25, did not reflect or include anything about her behaviors.<BR/>Record review of Resident #7's Nurses Notes reflected the following: <BR/>- Resident very disruptive and verbally aggressive with other residents, walked over to sofa and pushed another resident unprovoked and then went directly to her room. Dose not recall incident but is paranoid that fellow residents are taking her belongings. DON notified and gave directive to contact PCP for order to send resident to [Hospital S] for eval and treatment, message left with [Resident #7's RP] NO ANSWER WHEN CALLED, [NP N] contacted, order received to send out for eval. Resident placed on 1:1 monitoring until transferred to [Hospital S]. written on 02/05/25 by the DON.<BR/>- Resident return from [Hospital S] via EMT at 10:19. Resident is alert, appears calm and cooperative at this time. DON and family member notified. Plan of care continues. Written on 02/05/25 by the DON.<BR/>Record review of Resident #7's Psychiatric Periodic Evaluation, dated 02/07/25, reflected the following: .[Resident #7] is seen today per staff request due to reports of increased anxiety, compulsivity, restlessness, and for psychotropics management. Resident is sitting up in the common area, she is calm at the moment and denying any pain or discomfort. Aspiration of reports of recent mood swing, agitation, and restlessness reported by nursing staff, patient started crying, and reports that people are 'getting to her face'. She reports mood swing, and spontaneous anxiety and agitation. Chart reviewed, medication profile reviewed, she is on the following psychotropics with no noticeable adverse effects: Aricept 10mg po daily for dementia, Levothyroxine 100 mcg for hypothyroidism, Cymbalta 20 mg p.o. twice daily for depression/anxiety lamotrigine 25 mg p.o. twice for mood regulation, and Atarax 25 mg po daily for anxiety. Due to reports of mood swing, and spontaneous combativeness, will increase lamotrigine and monitor closely. Nursing staff notified.<BR/>Observation and interview on 02/26/25 at 1:42 PM with Resident #7 revealed she was sitting on a different couch in the common area. Resident #7 said she was doing okay and sometimes argued with others, but she never got into a fight with anyone or pushed anyone down. Resident #7 said she felt safe in the facility. <BR/>Attempted phone interview on 02/26/25 at 1:55 PM with Resident #7's RP was unsuccessful as they did not answer or call back. <BR/>Interview on the phone on 02/26/25 at 12:15 PM with CNA V revealed Resident #7 had a tendency to go off and always think someone was in her room. CNA V said she was down the hall making up a resident's bed when Resident #7 was upset at another resident saying things like she's going to jail and I'm going to kill her. CNA V said Resident #7 was not referring to Resident #6 at this time, but she de-escalated the situation and sat Resident #7 down on the couch. CNA V said she turned around and started to walk to the nurse's station when Resident #6 asked to go to the bathroom and stood up to get off the couch. CNA V said Resident #7 went over to Resident #6, punched her, then pushed her to the ground. CNA V said she ran over to the residents and asked Resident #7 why she did that and noticed Resident #7 was still trying to go after Resident #6 who was on the ground. CNA V said everything happened so fast but she was trying to get Resident #7 away from the situation and have her go to her room. CNA V said Resident #6 went to the hospital that night and did not come back for a few days and had a hip fracture. CNA V said Resident #7 was more alert than other residents on the secured unit because one of her triggers was when residents went down the hall who did not have rooms down there. CNA V said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. <BR/>Interview on the phone on 02/26/25 at 12:43 PM with CNA U revealed it was after a meal one day (02/05/25), Resident #7 said that Resident #6 went to her room and stole something and then there was a lot of commotion. CNA U said she went towards Residents #6 and #7 to divide them up because Resident #7 had punched Resident #6 and then pushed her down to the ground. CNA U said she told Resident #7 not to do that and to let staff handle the situation but Resident #6 was already on the ground. CNA U said she was not working on the secured unit at the time but had just stopped by to drop something off. CNA U said she thought Resident #6 was injured when she said her head was hurting and she could not walk. CNA U said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on 02/26/25 at 1:34 PM with LVN X revealed Resident #6 was a sweet lady and Resident #7 was very nasty with her mouth and bossy. LVN X said on 02/05/25, Resident #7 was amped up for whatever reason and staff were not sure why. LVN X said Resident #6 was getting off the couch while talking to Resident #7 when Resident #7 pushed Resident #6. LVN X said she did not witness what happened but heard about it from another aide. LVN X said when Resident #6 was on the ground she called 911 and sent her to the hospital. LVN X said during her assessment while checking Resident #6's range of motion, she yelled when assessing her right side. LVN X said after the incident happened, the NP came to see Resident #7 and adjusted her medications which seems to have worked because she's been extremely pleasant and calm ever since. LVN X said she's never seen Resident #7 be physically aggressive towards others, only verbally aggressive. LVN X said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on 02/26/25 at 1:43 PM with CNA T revealed she was leaving the shower room and heard Resident #7 talking loudly and arguing about something when she hauled off and hit Resident #6 who fell down. CNA T said Resident #7 did not have any injuries from this situation but Resident #6 did because she was grabbing her leg and crying and saying her leg was hurting. CNA T said Resident #6 was sent to the hospital afterwards. CNA T said Resident #7 yells at others when she thought someone was stealing her clothes, but no one was. CNA T said she had never seen Resident #7 be physically aggressive towards anyone before this. CNA T said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on the phone on 02/26/25 at 2:14 PM with NP O revealed Resident #7 she had episodes of psychosis based on her thinking people were taking her things from her room. NP O said Resident #7 was very paranoid and had mood swings with agitation, so she was eventually moved to the all-female secured unit. NP O said he was informed Resident #7 was involved in a resident-to-resident altercation, so he went to assess her and review her medications. NP O said based on the assessment, he thought she needed mood stabilizers, so he added those to her orders. NP O said since then, Resident #7 was more stable and engaged in activities that she's participating more in. NP O said he was not aware of any other physical altercation Resident #7 was involved in. NP O said Resident #7 was now more redirectable.<BR/>Interview on 02/26/25 at 3:19 PM with the DON revealed the day the incident occurred, LVN X was here and came to get the DON because she was concerned about Resident #6's leg. The DON said she was told that Resident #6 was trying to stand and Resident #7 pushed her, causing Resident #6 to lose her balance and fall in a squatting position since she's so tall. The DON said Resident #6 fell on her bottom and complained of her leg hurting. The DON said she was worried Resident #6 had a fracture from the incident. The DON said Resident #7 had walked away from the situation and went to her room but was clueless about what had just happened. The DON said Resident #7 was put on one-to-one care until she was sent to [Hospital S] where she was evaluated and sent back to the facility the same day. The DON said Resident #7 was also seen by the NP who adjusted her meds and she had been quiet ever since. The DON said Resident #7 had a behavior of thinking someone was stealing her clothes and would get upset but never became violent with anyone. The DON said she was not told that Resident #7 had first punched Resident #6 before pushing her down. The DON said after the situation happened, staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents. <BR/>Interview on 02/26/25 at 4:01 PM with the Administrator revealed he was the abuse coordinator for the whole campus, but he had an Administrator's Assistant who was also the abuse coordinator for the South building where Residents #6 and #7 were. The Administrator said he understood that Resident #6 stood up from the sofa and Resident #7 pushed her causing her to fall to the ground when she started to complain of pain. The Administrator said Resident #6 was sent out to have x-rays done which showed she had a fracture. The Administrator said all staff were responsible for monitoring resident's and their behaviors to ensure they were not getting into an altercation with each other. The Administrator said several things could happen to residents if they were to get into an altercation with each other such as harm. The Administrator said because of the resident's diagnoses a lot of times they did not remember what they did or who they did something to. <BR/>Interview on 02/26/25 at 4:17 PM with the Administrator's Assistant revealed based on what she heard and through her investigation, Resident #7 was the aggressor towards Resident #6. The Administrator's Assistant said Resident #6 was on the couch and as she was getting up, Resident #7 pushed her causing her to fall to the ground. The Administrator's Assistant said the charge nurse did an assessment on Resident #6 and found that she was complaining of pain, so she was sent to the hospital. The Administrator's Assistant said at the hospital, x-rays were done where it was found she had a fracture which required surgery to repair it. The Administrator's Assistant said there had not been any other instances of physical aggression from Resident #7 before this. The Administrator's Assistant said she was also the abuse coordinator for the facility and staff were to report any instance or allegation of abuse to her. The Administrator's Assistant said all residents have the right to be free from abuse in the facility. The Administrator's Assistant said she was not told that Resident #7 punched Resident #6 in the face. The Administrator's Assistant said staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents.<BR/>Record review of a provider investigation report reflected the following information:<BR/>Investigation Summary: On 2/5/25, a resident-to-resident altercation occurred between [Resident #6] and [Resident #7], both residing in the South Memory Community. The incident occurred when [Resident #7], who was loudly fussing, accused [Resident #6] of entering her room. As [Resident #6] attempted to rise from the couch in the dining room, [Resident #7] pushed [Resident #6], causing [Resident #6] to fall to the floor and land on her sacral area. Nursing staff were present and immediately intervened, separating the residents. A head-to-toe assessment was conducted for both residents by the charge nurse, [LVN X]. [Resident #6] complained of right hip pain, held her right leg, and was unable to bear weight on it. Although no visible injuries were noted and vital signs stable. Pain medication was administered and [Resident #6] was sent to the ER for further evaluation and treatment. [Resident #7], [sic] no adverse effect and injuries noted, vital signs stable. Placed on 1:1 supervision pending a transfer to [Hospital S]. Notifications made to Family, [Resident #6's RP and Resident #7's RP] notified. [Physician R and Physician Q] notified. Interview and statements collected from witnesses present attached. Social worker conducted safety survey, noting no concerns. Staff in-service [sic] resident to resident altercation, resident behaviors, resident 1:1, abuse and neglect. <BR/>[Resident #6] was admitted to the hospital and underwent surgery for a right hip repair. She returned to the facility on 2/8/25 with new order for Tylenol 3 and a follow-up appointment scheduled with [Physician P] on 2/20/25 at 11:30 AM. She is currently alert and resting in bed. [Resident #7] was placed on 1:1 supervision pending a transfer to [Hospital S]. On 2/5/25, [Resident #7] was evaluated by [Hospital S] and cleared to return to the facility the same day. Q15-minute checks were conducted for 72 hours per facility. [Resident #7] is currently cooperative and participating in normal activities without further incidents.<BR/>Record review of resident safe surveys revealed 5 were completed with residents on 02/05/25 with no additional findings of any other abuse in the facility. <BR/>Record review of an in-service, dated 02/05/25, reflected staff were in-serviced regarding abuse, falls, resident monitoring, injury of unknown origin, and resident-to-resident altercation. <BR/>Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 02/12/20, reflected: Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property.<BR/>The Administrator was notified on 03/12/25 at 10:00 AM that a past non-compliance IJ situation had been identified due to the above failures.<BR/>It was determined this failure placed Resident #6 in an IJ situation on 02/05/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of five residents (Resident #1) reviewed for misappropriation of property.<BR/>The facility failed to prevent the ADON from taking two morphine pills prescribed for Resident #1 on 02/24/25.<BR/>This failure could place residents at risk of pain and failure to achieve therapeutic effects intended by the physician. <BR/>The noncompliance was identified as past noncompliance that began on 02/24/25 and ended on 02/24/25. The facility had corrected the noncompliance before the surveyor entered. No Plan of Correction required. <BR/>Findings included:<BR/>Record review of Resident #1's undated Face Sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included lung cancer, brain cancer, and high blood pressure.<BR/>Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 8 indicating he was moderately cognitively impaired. His Function Status indicated he needed limited assistance with his ADLs. <BR/>Record review of Resident #1's care plan, dated 02/19/25, reflected he had anxiety and depression, he had pain that was treated with morphine in pill and liquid forms, and he was a fall risk. <BR/>Record review of Resident #1's physician orders reflected an order dated 02/18/25 Morphine 15 mg ER, one tablet twice a day for pain<BR/>Interview on 02/26/25 at 12:04 PM with the DON revealed Resident #1 had been admitted from hospice at home with a bottle of Morphine 15 mg extended release tablets, as well as liquid morphine. The morphine pills were counted and a count sheet was created indicating he started with 9 pills. The DON stated the physician's order was 1 pill twice a day. The DON stated on 02/24/25 on the 6:00 AM-2:00 PM shift the ADON notified LVN A there was a change in Resident #1's medications, the morphine pills were discontinued and the resident was to only receive the liquid morphine. The ADON took the pills and the corresponding count sheet to her office. <BR/>The DON stated on the 2:00 PM-10:00 PM shift on 02/24/25 Resident #1's MAR indicated he was due for a morphine pill and there were none on the cart. The ADON was contacted about the order, and she brought the pills back out with a new count sheet that started with three pills. The resident was medicated, but staff thought there were pills missing. The DON was contacted the morning of 02/25/25 about their concern. The DON reviewed the order and determined Resident #1 should have had 5 pills the previous night, not 3. The count sheet should not have been a new one, it should have been the original sheet with all the previous doses documented. The DON contacted the ADON who brought in the original count sheet. The original count sheet had the numbers altered to indicate the resident had admitted with 7 pills instead of 9 pills. The ADON was currently suspended pending an investigation.<BR/>The DON stated the resident did not miss any doses of his morphine pills, and his hospice nurse brought a refill of pills in a pill pack form instead of loose pills in a bottle. <BR/>Interview on 02/26/25 at 1:15 PM with LVN A revealed the ADON came to her on 02/24/25 and stated there were no orders from hospice for any of Resident #1's medications. The ADON removed the morphine pills as well as the liquid morphine from her cart. LVN A stated the ADON brought the liquid morphine back to her within about an hour, but not the pills. LVN A stated the count at 2:00 PM was not off because the pills and the count sheet were not on the cart. <BR/>Attempts were made on 02/26/25 at 1:30 PM and 2:00 PM to interview the the ADON by phone, but the attempts were unsuccessful. <BR/>Record review of the facility's Abuse, Neglect, and Exploitation, and Misappropriation of Resident Property, dated 02/12/20, reflected the following:<BR/>The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.<BR/>Misappropriation: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had a right to be treated with respect and dignity for 1 of 3 residents (Resident #189) reviewed for dignity. <BR/>The facility failed to ensure Resident #189's catheter urine collection bag had a privacy cover.<BR/>This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. <BR/>Findings included: <BR/>Record review of Resident #189's face Sheet, dated 12/11/24, reflected the resident was a [AGE] year-old male who was admitted on [DATE]. <BR/>Review of Resident #189's MDS dated [DATE] reflected the resident's cognition was moderately impaired with a BIMS score of 07. Active diagnosis included Indwelling catheter (including suprapubic catheter and nephrostomy tube), ostomy, cancer, hypertension, benign prostatic hyperplasia, renal insufficiency, obstructive uropathy, diabetes mellitus, fractures, and stroke. Section GG reflected resident required partial/moderate assistance with toileting hygiene and toilet transfers. Section H indicated indwelling catheter. <BR/>Review of Resident #189's care plan dated 12/11/24 reflected resident at risk for problems with elimination related to history of urinary tract infection. Goals included residents' elimination status will be maintained or improved over the next 90 days. Decrease in number of incontinent episodes by implementation of a scheduled toileting program over the next 90 days. Interventions included Monitor signs for symptoms of urinary tract infection. Observe pattern of incontinence, and initiate toileting schedule or prompted voiding if indicated. Uses brief. Resident with urinary catheter related to anatomical or functional diagnosis. Goal included resident will be free complications of indwelling catheter over the next 90 days. Interventions included care/changing of urinary catheter as ordered. Confer with physician regarding the continued need of urinary catheter, consider the risks and benefits of continuing the long-term use of an indwelling urinary catheter and remove it as soon as possible if indicated. Monitor urine appearance, amount, odor, clarity. <BR/>Record review of Resident #189's order summary report dated 12/11/24 reflected the resident had an order for:<BR/>1. Foley Catheter 16 Fr (CATHETER) 1 Urethral every shift Bulb size 10cc ***PROVIDE CATHETER CARE, MONITOR FOR SECURITY STRAP AND PRIVACY BAG PLACEMENT*** <BR/>2. Catheter as Needed CLOGGED /DISLODGED Change foley catheter (change drainage bag with catheter change) CDC recommendation: Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised <BR/>3. Catheter every shift Assess for bladder distention, small frequent voids, dribbling, resident complaint of bladder feeling full. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding, if present notify MD.<BR/>Observation and interview on 12/08/24 at 2:07 PM revealed Resident #189's catheter bag was laying on the floor on the side of the bed without a privacy bag. Resident #189 stated he knew his catheter bag did not have a privacy bag; however, he was usually in his room most of the time. Resident #189 stated he felt uncomfortable with his catheter revealing the contents of his urine especially when he had visitors. <BR/>Observation and interview on 12/10/24 at 2:37 PM revealed Resident #189's catheter bag did not have a privacy bag. <BR/>Observation and interview on 12/11/24 at 2:07 PM revealed Resident #189's catheter bag was laying on the floor on the side of the bed without a privacy bag. <BR/>Observation and interview on 12/11/24 at 2:15 PM with LVN K revealed Resident #189 was usually in bed, in his room most of the day so his catheter bag was rarely seen by the community. LVN K stated it was important to have a privacy bag to protect his dignity, and that any nursing staff could place a privacy bag. <BR/>Interview on 12/11/24 at 2:20 PM with ADON C revealed she was not aware Resident #189 was without a privacy cover, and she stated catheter bags should be covered at all times for privacy. ADON C stated all nursing staff were responsible for ensuring urine collection bags were covered and not on the floor at all times. <BR/>Interview on 07/25/24 at 6:00 PM with DON revealed she was not notified by the that Resident #189's catheter was found without a privacy bag and was on the floor. The DON stated all catheter bags were to be covered with a privacy bag to protect resident privacy and dignity. The DON stated her expectation was for all nursing staff to ensure catheter bags were covered and hanging properly to allow the fluid to drain properly by flow of gravity. <BR/>Record review of the facility's Care and Removal of an Indwelling Catheter policy, dated 01/12/20, reflected: <BR/>Staff will provide care of an indwelling catheter in accordance with standard practice guidelines. Evaluate the need for catheter care, provide privacy, and assist resident to a comfortable position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**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, the comprehensive person-centered care plan, and the resident's choices to meet each resident's physical mental and psychosocial needs for one (Resident #6) of seven residents reviewed for quality of care.<BR/>The facility failed to ensure Resident # 6 received medications according to physician orders for pain management when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 was in pain for three days before being sent to the hospital.<BR/>This failure placed residents at risk of unrelieved pain and discomfort.<BR/>An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM.<BR/>Findings included: <BR/>Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on 11/07/2022. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome.<BR/>Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined.<BR/>Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell. Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected.<BR/>Review of the Incident Report dated 11/04/22 reflected Resident # 6 was involved in a witnessed altercation with a fall and had pain upon movement at a level four on a scale of 1-10. <BR/>Review of Resident #6's Physician's Orders reflected the only pain ordered for Resident # 6 was 500 mg of Naproxen. One tablet was to be given twice per day as needed for Mild pain on a scale of 1-3. This Naproxen medication was to be given with food and the diagnosis for this medication was central pain syndrome.<BR/>Review of the Medication Administration Record (MAR) in the electronic medical record on 01/12/23 for Resident #6 revealed she had pain at a level six to her left hip on 11/06/22 in the evening. The MAR also revealed Naproxen was not administered to Resident # 6 from 11/4/22 through 11/7/22. The MAR reflected that no pain medication was given to Resident #6 during that time frame. <BR/>Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out.<BR/>Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport.<BR/>Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell. LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation.<BR/>Review of the Witness Statement dated 11/08/22 reflected CNA AF witnessed the incident with Resident # 6 and notified LVN S immediately. CNA AF's written statement indicated, Resident #6, continued to have symptoms of pain to her left hip and decreased mobility on 11/5/22 and 11/6/22, I notified the charge nurse and resident remained in bed on those dates.<BR/>Interview on 12/22/22 at 10:20 AM with LVN S revealed the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. In a later interview on 01/12/23 at 10:09 AM LVN S stated she gave Resident #6 pain medication after she fell on [DATE]. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. A later phone Interview on 01/12/23 at 3:01 PM with LVN S revealed she attributed not documenting the administration of the Naproxen to the adrenaline of the whole issue.<BR/>Interview on 01/12/23 at 11:27 AM with CNA AF stated Resident # 6 was able to walk to the dining room on 11/4/22 after the fall with no problem after LVN S did all the assessments. CNA AF stated that on 11/5/22 Resident # 6 was no longer getting up, could not walk and was screaming of pain. CNA AF stated that Resident #6 was able to walk before the fall, although if the staff would let her, she would lay in bed all day. <BR/>In an interview on 01/12/23 at 12:45 PM the ADON stated she checked their system and did not find any documentation of pain medication given to Resident #6, however she spoke with LVN S who stated she gave Resident # 6 Naproxen. <BR/>Interview on 12/22/22 at 3:38 PM with Resident # 6's Primary Contact listed on Face Sheet stated Resident #6 was diagnosed with left hip fracture and had surgery where her socket was removed. The primary contact stated the resident was still in pain and was at another (different) facility and had to go on hospice after the surgery. The Primary contact stated Resident #6 used to walk and now she stayed in a fetal position in bed because she was in too much pain. <BR/>Interview on 01/12/23 at 5:30 PM DON stated if a Resident has had a fall, their pain should be treated. DON stated that if pain medication was not adequate, the staff should contact the doctor to get something stronger so that the resident is not in distress. DON stated If the stronger medication does not help, the resident should be sent to the hospital. DON also stated that in the nursing world if it was not documented, it was not done. <BR/>Review of the facility's Pain Management and Basic Comfort Measures policy, revised 01/12/20, revealed, .Provide pain medication as prescribed by an authorized prescriber . Consult with family members, other health care providers for assistance with pain management techniques . Observe for unresolved pain and address per physician's orders . Record pain management techniques in the record. <BR/>The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023.<BR/>The facility implemented the following interventions to address non-compliance:<BR/>Review of the facility's one on one in-service (training) titled Fall prevention, Xray ordering process, family communication, dated 11/07/22 with LVN included: pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. <BR/>Review of the facility's In-Service for all nursing staff on falls with injury dated 11/8/22, included pain management. <BR/>Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. <BR/>In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. In a later interview on 1/13/23 at 3:01 PM LVN S stated the Unit Manager discussed with her about the fall process and stressed the importance of documenting administration of medication because if it is documented it means it was not done. The Unit Manager pointed out to her that she needed to call the doctor for a stronger medication since the Naproxen was only for pain on a scale of 1-3. LVN S stated she has since had to call the doctor for stronger pain meds for a different patient with a similar issue. <BR/>Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for pain management, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff had been in-serviced on these topics. The nurses also were aware that if there was not a medication to cover the pain level indicated, that they should call the doctor to get another order. <BR/>Observations from 12/20/22 at 7:40 PM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13).<BR/>Interviews with Residents with PRN pain management on 01/12/23 revealed they got medication when requested and they were not in any pain (Resident #'s 11, 12 and 13).<BR/>Review of the MAR for Residents with PRN pain management revealed pain assessments were completed and pain medications administered as ordered for Resident #'s 11, 12, 13, 15, 16, 17 and 18.<BR/>Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON.<BR/>In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and DON were following up to check what was done to address the pain scale on the incident reports. The ADON and DON were monitoring pain meds and ensuring they had meds ordered that covered all numbers on the pain scale. The DON stated for example that if a Resident only had pain medication coverage for pain level of 1-3, the facility would call the doctor to get a medication to cover a higher level of pain. DON stated the IDT team met daily to review each fall and to ensure follow up from each department as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Residents #189) reviewed for urine incontinence/catheters. <BR/>The facility failed to ensure Resident #189's catheter urine collection bag was kept off the floor.<BR/>This failure placed residents at risk of urinary tract infection.<BR/>Findings included: <BR/>Record review of Resident #189's face Sheet, dated 12/11/24, reflected the resident was a [AGE] year-old male who was admitted on [DATE]. <BR/>Record review of Resident #189's MDS dated [DATE] reflected the resident's cognition was moderately impaired with a BIMS score of 07. Active diagnosis included Indwelling catheter (including suprapubic catheter and nephrostomy tube), ostomy, cancer, hypertension, benign prostatic hyperplasia, renal insufficiency, obstructive uropathy, diabetes mellitus, fractures, and stroke. Section GG reflected resident required partial/moderate assistance with toileting hygiene and toilet transfers. Section H indicated indwelling catheter. <BR/>Record review of Resident #189's care plan dated 12/11/24 reflected resident at risk for problems with elimination related to history of urinary tract infection. Goals included residents' elimination status will be maintained or improved over the next 90 days. Decrease in number of incontinent episodes by implementation of a scheduled toileting program over the next 90 days. Interventions included Monitor signs for symptoms of urinary tract infection. Observe pattern of incontinence, and initiate toileting schedule or prompted voiding if indicated. Uses brief. Resident with urinary catheter related to anatomical or functional diagnosis. Goal included resident will be free complications of indwelling catheter over the next 90 days. Interventions included care/changing of urinary catheter as ordered. Confer with physician regarding the continued need of urinary catheter, consider the risks and benefits of continuing the long-term use of an indwelling urinary catheter and remove it as soon as possible if indicated. Monitor urine appearance, amount, odor, clarity. <BR/>Record review of Resident #189's order summary report dated 12/11/24 reflected the resident had an order for:<BR/>1. Foley Catheter 16 Fr (CATHETER) 1 Urethral every shift Bulb size 10cc ***PROVIDE CATHETER CARE, MONITOR FOR SECURITY STRAP AND PRIVACY BAG PLACEMENT*** <BR/>2. Catheter as Needed CLOGGED /DISLODGED Change foley catheter (change drainage bag with catheter change) CDC recommendation: Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised <BR/>3. Catheter every shift Assess for bladder distention, small frequent voids, dribbling, resident complaint of bladder feeling full. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding, if present notify MD.<BR/>Observation and interview on 12/08/24 at 2:07 PM revealed Resident #189's catheter bag was laying on the floor on the side of the bed. Resident #189 revealed at times he can feel the catheter pulling but could not tell if it was from the bag being on the floor. <BR/>Observation and interview on 12/10/24 at 2:37 PM revealed Resident #189's catheter bag was laying on flat in bed with urine in the line near the insertion cite. Resident #189's catheter bag was tangled with both his nephrostomy tubes. Resident #189 stated he felt pressure and felt like he could not urinate. LVN G observed the urine collection bag on Resident #189's bed. LVN G stated the resident catheter bag should be hung at the lowest part of the bed, not doing so placed resident at risk of urine flowing backwards causing pain or discomfort to the resident. LVN G stated it was the responsibility of all nursing staff to ensure his catheter bag was placed properly in a hanging position, not laying flat. <BR/>Observation and interview on 12/11/24 at 2:07 PM revealed Resident #189's catheter bag was laying on the floor on the side of the bed. Resident #189 stated he was not aware his catheter bag was on the floor. Resident #189 stated he was not aware of whom his aide or nurse was, that it had been a while since he had last seen staff. <BR/>Observation and interview on 12/11/24 at 2:15 PM with LVN K revealed it was the responsibility of all nursing staff to ensure all catheter bags were hanging on the lowest part of the resident's bed. LVN K entered Resident 189's room to reveal his catheter bag on the floor. LVN K stated having the catheter bag on the floor left resident at risk of infection and contamination. LVN K stated the aide was good about assisting residents with picking the catheter up off the floor; however, she could not do it while picking up trays from the rooms. <BR/>Interview on 12/11/24 at 2:20 PM with ADON C revealed she was not aware Resident #189's urine collection bag was observed the floor several times. ADON C stated resident catheter bags should not be on the floor but hung low to allow for gravity to work, not doing so placed residents at risk of infection and bacteria. ADON C stated all nursing staff were responsible for ensuring urine collection bags were not on the floor at all times. <BR/>Interview on 07/25/24 at 6:00 PM with DON revealed she was not notified by the that Resident #189's catheter was found on the floor. The DON stated her expectation was for all nursing staff to ensure catheter bags were hanging properly to allow the fluid to drain properly by flow of gravity. The DON stated if not residents were placed at risk of decline in health, possible infection and leaking. DON further stated phyician orders were expected to be followed, ADONs and floor nurses were responsible to ensure physician orders were being followed.<BR/>Record review of the facility's Care and Removal of an Indwelling Catheter policy, dated 01/12/20, reflected: <BR/>Staff will provide care of an indwelling catheter in accordance with standard practice guidelines. Evaluate the need for catheter care, provide privacy, and assist resident to a comfortable position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared and served according to the resident's assessment, plan of care, and in a form designed to meet the resident's needs for 1 (lunch on 12/10/24) of 3 meals reviewed for resident's needs.<BR/>The facility failed to follow Resident #29's physician's order for pureed consistency food and nectar thickened liquids for the lunch meal on 12/10/24. <BR/>This failure could place residents at risk of decreased food intake, weight loss and an increased risk of aspiration.<BR/>Findings include:<BR/>Review of Resident #29's face sheet, dated 12/11/24, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Review of Resident #29's Quarterly MDS Assessment, dated 10/31/24, reflected he had a BIMS score of 05, indicating severe cognitive impairment. His diagnoses included pneumonia (an infection that inflames the air sacs in one or both lungs), Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA) or stroke (occurs when something blocks blood supply to part of the brain), and seizure disorder or epilepsy (a long-term brain condition where a person has repeated seizures). He also had complaints of difficulty or pain with swallowing and had a mechanically altered diet while a resident. <BR/>Review of Resident #29's Consolidated Order, dated 12/11/24, reflected the following: Diet: Consistency- Puree .Diet: Liquids- Nectar/Mildly thick .<BR/>Review of Resident #29's Care plan, initiated on 11/04/24, reflected the following: Care Area/Problem: Altered Nutritional Status, Evidence By: Therapeutic diet .Diet: Consistency- Puree .Diet: Liquids- Nectar/Mildly Thick .<BR/>Review of Resident #29's meal ticket for Lunch- Day 10 reflected the following: Diet: Large Portion, Texture: Pureed Level 4, Liquid: Mildly Thick(2)/Nectar .Menu: Pureed Meatball Sub on Bun, Pureed Steamed Broccoli, Pureed Boston Cream Pie, Coffee or Tea- Nectar/Mild Thick (2), Water-Nectar/Mild Thick (2).<BR/>Review of Resident #29's Nurses Note reflected the following: <BR/>-On 12/10/24 ADON C wrote: At lunch time this resident consumed 1 potato chip and about half a glass of thin liquids. Items removed, tea replaced with thickened apple juice. No coughing noted education done with the resident and dietary manager notified to do education with there [sic] staff. The patient states I'm ok, I knew I wasn't supposed to have it, but I just ate one. [sic] No acute distress noted. [NP O] notified of the same, received new orders to do speech evaluation and treat and monitoring for any coughing and if occur obtain stat chest X-ray [sic].<BR/>Observation on 12/10/24 at 12:50 PM of Resident #29 revealed he was sitting at a table in the dining room in his wheelchair. Resident #29 had a plate in front of him with food that was a pureed consistency. Resident #29 had a bowl of whole potato chips served to him by a woman passing by. Resident #29 was observed taking a whole potato chip from the bowl and eating it. (The surveyor found a staff from the nursing department and informed them that Resident #29 was eating whole potato chips but was ordered a pureed diet.) The potato chips were removed from Resident #29 by a member of the nursing department. <BR/>Interview on 12/10/24 at 12:53 PM with [NAME] N revealed she was passing whole potato chips to residents in the dining room and gave Resident #29 a bowl of whole potato chips. [NAME] N said she was told to only give the whole potato chips to any resident with a sub sandwich and thought Resident #29 had one on his plate. [NAME] N said she did not see that Resident #29 had a plate of pureed food and not a whole sub sandwich in front of him. <BR/>Observation on 12/10/24 at 1:00 PM of Resident #29 revealed he was telling Nutrition Aide L that he was missing his cake from his meal.<BR/>Observation on 12/10/24 at 1:05 PM revealed Resident #29 had a whole piece of cake in front of him and he was attempting to take a bite of it. (The surveyor intervened and told someone from the nursing department that Resident #29 had a whole piece of cake, and they took it away from him before he could eat any of it.) The Dietitian brought Resident #29 a bowl of pureed cake to eat. <BR/>Observation on 12/10/24 at 1:06 PM revealed Resident #29 had a cup of mostly drank tea in a glass in front of him; the tea was not thickened. The Dietitian took the tea away saying, It was not nectar thick and another staff member brought Resident #29 nectar thickened juice for him to drink. <BR/>Interview on 12/10/24 at 2:04 PM with the DM, Dietitian, and Assistant Administrator revealed he was not sure what happened or why Resident #29 was served whole potato chips as they should not have been available to him. The DM said the person who passed the whole potato chips to Resident #29 should have recognized that he was ordered a pureed diet and not to give him whole potato chips. The DM said he was not sure why Resident #29 was served whole cake. The Dietitian said all staff should have seen the resident with pureed food and provided him with the pureed cake instead. The DM said the kitchen had thickened liquids readily available, so he was not sure why Resident #29 was given thin liquids instead today during lunch. The DM said the staff member passing liquids out should have known what the resident required. The DM said the purpose of providing residents with their ordered diet was to prevent them from aspirating (when contents such as food, drink, saliva or vomit enters the lungs) and choking which could ultimately kill someone even if it was an accident. The DM said each person in the dining room was responsible for looking at a resident's meal ticket to ensure they were provided the correct diet for food and drinks. The DM said he counted on the nursing department to catch any mistakes made by the dietary department. <BR/>Review of the facility's policy, revised 02/06/24, and titled Menus reflected the following: Nutrition Services will provide a nourishing, palatable, well-balanced meal that observes the nutritional requirements, special dietary needs, preferences, and allergies of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area and to ensure call light cord was accessible for 1 of 35 residents (Resident #130) reviewed for call light access. <BR/>The facility did not adequately equip Resident #130's room with a call light cord to allow the resident to call for assistance.<BR/>This failure could place residents at risk of not being able to call for assistance when needed. <BR/>Findings included:<BR/>Review of Resident #130's Face sheet, dated 12/10/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. <BR/>Review of Resident #130's quarterly MDS assessment, dated 10/27/24, reflected he had diagnoses of hypertension (high blood pressure) and hemiplegia (paralysis on one side of the body) and hemiparesis (one-side muscle weakness). His brief interview for mental status assessment was unable to be completed due to the resident was rarely/never understood. The MDS further indicated Resident #130 was partial/moderate assistance from staff. <BR/>Review of Resident #130's care plan, updated on 09/17/24, reflected Problem: Fall Risk: [Resident #130] has the potential for falls related to cognitive status. Goal: [Resident #130] Resident at Risk for Falls resident safety will be maintained over the next 90 days. Interventions: Keep call light and most frequently used personal items within reach. <BR/>Observation and interview on 12/08/24 at 11:08 AM revealed Residents #130 lying in bed. Observation further revealed no call light cord for Bed A (Resident #130). Interview with Resident #130's revealed he had no call light cord and could not explain for how long he did not have a call light. Resident #130 stated he pushed his call light at times for help, but he was able to ambulate to the nurse's station. <BR/>Observation and interview on 12/09/24 at 8:18 AM with CNA H revealed Resident#130 did not have a call light cord. She stated she was the CNA assigned to Resident #130. She stated every resident should have a call light cord in their room and within reach. CNA H stated she was not aware Resident #130 did not have a call light cord and she had not noticed during the rounds. She stated in case of a missing call light staff was supposed to document on the maintenance logbook and report to the Maintenance Director. She stated it was all staff's responsibility to check for call rights while performing the 2 hourly rounds. She stated the potential risk of not having a call light would be residents not being able to ask for help. She stated she had done training on call lights checking and answering.She was not asked on type of assitance she offered to resident #130.<BR/>Interview on 12/09/24 at 8:24 AM with LVN F revealed he was the nurse assigned to Resident #130. LVN F stated he had not noticed Resident #130 did not had a call light cord until it was pointed out today (12/09/24). He stated the potential risk would be residents would be unable to call for assistance. He stated staff was supposed to document on maintenance logbook and notify the maintenance director in case of missing call light or call that are not functioning.<BR/>Interview on 12/09/24 at 8:28 AM with the ADON revealed each resident should have a call light cord in their room and within reach. It was all staff's responsibility to check and ensure residents have the call light within reach and they have call light in their rooms. She stated she was unaware Resident #130 did not have a call light. She stated the risk of not having a call light would be not getting help and needs not being met. Observed the ADON review the maintenance logbook and stated there had not been any requests for call lights documented.<BR/>Interview on 12/10/24 at 2:08 PM with the Maintenance Director revealed each resident should have a call light in their room. He stated he was unaware Resident #130 did not have a call light until on12/09/24. The Maintenance Director stated he had a maintenance logbook on each nurse's station, and they were checked daily by the maintenance department and there was no documentation of call light missing and those that were reported were already replaced. He stated he had not had any requests for call lights. <BR/>Interview on 12/11/24 11:12 AM with the DON revealed each resident should have a call light in their room and within reach and functioning. She stated she was unaware Resident #130 did not have a call light. She stated she expected the staff to document on maintenance logbook so that the call light was replaced if not functioning. She stated the risk of not having a call light in place and functioning would be safety.<BR/>Review of the facility's Call Lights Answering policy, dated 01/19/23, reflected:<BR/>The staff will provide an environment that helps meet the needs of the resident by answering call lights appropriately.<BR/> .7. When leaving the room, be sure the call light is placed within the resident's reach. The policy did not address room being equipped with a functioning call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of five resident (Resident #81) reviewed for nutrition.<BR/>The facility failed to ensure Resident #81 maintained acceptable parameters of nutritional status and provide timely interventions as demonstrated by Resident #81 experiencing a 15.51% weight loss in 30 days from October to November. Resident #81 had not continued to lose weight from November to December, however. <BR/>This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization. <BR/>Findings included: <BR/>Review of Resident #81's face sheet, dated 12/10/24, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Review of Resident #81's admission MDS Assessment, dated 10/03/24, reflected she did not have a BIMS score calculated (a term used to screen and identify a resident's cognition) Her active diagnoses included stroke (when blood flow to a part of the brain is interrupted, leading to brain cell death), Alzheimer's Disease (a type of brain disorder that causes problems with memory, thinking and behavior), and Depression (characterized by persistent feelings of sadness and loss of interest in activities once enjoyed). Her functional abilities included needing partial/moderate assistance with eating and no indication of weight loss was noted. Her MDS indicated she was on a therapeutic diet. <BR/>Review of Resident #81's Consolidated Orders for December 2024 reflected the following: <BR/>-as of 12/09/24, Daily Multivitamin-Minerals tablet, 1 tablet by mouth 1 time per day<BR/>-as of 12/09/24, 2.0 Cal Med Pass Supplement () 60 Milliliters by mouth 4 times per day with medication pass [sic]<BR/>Review of Resident #81's Care Plan, initiated 09/27/24, reflected the following: <BR/>Care Area/Problem: Altered Nutritional Status, Evidenced by: Diet: Consistency- Regular .Interventions: Monitor oral intake of food and fluid .<BR/>Review of Resident #81's electronic health record revealed under the weights tab of her chart was the following dates and weights: <BR/>-10/03/24 <BR/>149.6 pounds<BR/>-11/4/24 <BR/>89.6 pounds <BR/>Review of Resident #81's Nurses Note from 11/26/24 reflected the following: LVN Q wrote During breakfast, resident noted to be pocketing food. 25% of meal consumed. NP notified.<BR/>Interview on 12/09/24 at 11:27 AM on the phone with Resident #81's RP revealed he knew her eating habits could not be helped because she was on antipsychotics due to her dementia. Resident #81's RP said a long time ago, a doctor had explained to him that eventually she would not be able to eat on her own due to her conditions so other family members went to the facility to make sure she was assisted with her meals and encouraged to eat. Resident #81's RP said other family members who visit the resident daily have noticed her weight loss and communicated that with him.<BR/>Interview on 12/10/24 at 4:28 PM on the phone with Physician P revealed he needed a few minutes to review Resident #81's chart before answering the surveyor's questions. Physician P said after reviewing Resident #81's chart her weight loss was related to sarcopenia (the loss of muscle mass specifically related to aging. It's normal to lose some muscle mass as you age) which was unavoidable but there were things the facility could put in place to slow the weight loss down. Physician P said he was not aware that Resident #81 had a decrease in appetite or was pocketing food and that he normally would be notified of those things so he could put interventions in place. Physician P said more than likely, Resident #81 was going to lose weight regardless of what interventions were put in place though. <BR/>Observation and interview on 12/09/24 at 12:00 PM with Resident #81 revealed she was in the dining room sitting in a wheelchair with a family member seated next to her. Resident #81's family member had brought a protein shake with her from outside of the facility and was encouraging the resident to drink some of it. Resident #81 could be heard and seen refusing to drink the protein shake initially but eventually did accept some of it. When Resident #81 received her meal tray, the resident said she was cautious of the food and said it was terrible and that she did not want to eat any of it. Resident #81's family member was seen attempting to assist the resident with eating some of the food from the plate and once the resident had the food in her mouth, she was seen pushing it to the sides of her mouth and holding the food in her cheek. Resident #81 was seen not swallowing or attempting to chew the food. The surveyor asked Resident #81 if she wanted something different like a soup, sandwich, or salad and Resident #81 said no and that she was cautious of all the foods and that she did not believe the food was good. <BR/>Interview on 12/09/24 at 1:00 PM with LVN B revealed she was new to the secured unit and to Resident #81, but she had noticed the resident pocketing food and not eating as much while she had been caring for her. LVN B said the family brought in shakes for Resident #81 to drink. LVN B said she was not sure if Resident #81 had lost weight or not and was not sure if the NP or Physician had been notified of these things. <BR/>Interview on 12/10/24 at 10:05 AM with CNA A revealed she worked PRN and was newer to the secured unit. CNA A said it was normal for Resident #81 to not eat a lot, even if staff tried to assist her with eating. CNA A said Resident #81's family member was trying to help her eat yesterday (12/09/24) but she was refusing. CNA A said sometimes Resident #81 would eat and sometimes she would not; but when she did not she was offered a shake . CNA A said sometimes she would drink the shake but sometimes she did not, it depended on how she was feeling that day. <BR/>Interview on 12/10/24 at 2:04 PM with the Dietitian revealed she saw the 89.6 pounds weight entered into Resident #81's chart but wanted to get another weight for her because it did not seem right. The Dietitian said Resident #81 was put on her radar last month due to the weight and was not sure why a new weight was not provided to her by the ADON or DON. The Dietitian said she was not sure why the weight was not followed up on over a month ago. The Dietitian said she did not believe Resident #81 had lost that much weight and could not pull up additional information in the system at this time to provide more information. The Dietitian said she would look into it and follow-up at a later time. <BR/>Interview on 12/10/24 at 2:52 PM with ADON D revealed the 89.6 pounds weight in Resident #81's chart was not right. ADON D said she only received the weights for each resident and entered the information; she was not aware that the new weight indicated such a significant weight loss. ADON D said she worked the memory care unit last week and saw that Resident #81 had a decline and decrease in appetite. ADON D said she sat at the table with Resident #81 and tried to help her to eat but she did not eat. ADON D said normally when staff noticed a resident had a decrease in appetite they would notify the doctor. ADON D said since this was only the first time she saw Resident #81 had a decrease in appetite she wanted to wait and see if it was going to be a pattern or not. ADON D said Resident #81 also had family with her at mealtimes and even the family could not get the resident to eat the meal in front of her. <BR/>Interview on 12/10/24 at 3:08 PM with ADON C said she was not aware that Resident #81 had lost weight, was pocketing food, or had loss of appetite. ADON C said normally staff would share their concerns they had with her to see what interventions need to be put in place and would notify the family and doctor about their concerns. ADON C said she was not sure why nothing had been done to address Resident #81's weight loss or to see if the 89.6 pounds was an accurate weight. <BR/>Observation on 12/10/24 at 3:14 PM of Resident #81 being weighed in her wheelchair with a scale revealed she weighed 166.2 pounds. Resident #81 was taken back to her room and placed in bed, while the Infection Preventionist and Staffing Coordinator brought her wheelchair back to the scale to be weighed at 3:18 PM. The wheelchair weighed 39.6 pounds. This meant that Resident #81 weighed 126.6 pounds. [This reflected a 15.51%, or 22.8 pounds, weight loss since admission, 09/27/24.]<BR/>Interview on 12/10/24 at 4:38 PM with the DON revealed she had paper copies of all residents' weights for November and December 2024. The DON showed for November 2024 next to Resident #81's name was 89.6 crossed out and 126 written next to it. The DON showed for December 2024 next to Resident #81's name was 126.4 x2 written next to it. The DON explained that Resident #81 was confused with a different resident when being weighed and that was why there was a weight discrepancy in her chart, and why the 89.6 lbs was added instead of the 126.4 lbs weight that should have been entered for her November weight. The DON said even with the 126.4 pounds, it indicated Resident #81 had weight loss from admission that had not been addressed. The DON said she knew Resident #81's appetite was going down, but she was not aware the resident was pocketing her food. The DON said Resident #81 was in the other building's secured unit and was not eating as much so she was moved to the other building's secured unit for less stimulation and seemed to be doing better. The DON said both the Physician and Dietitian could see weights in a resident's chart when they came to review care for the resident. The DON said weights were reviewed every week by the nursing department as well, but she was not sure why no one had noticed the weight discrepancy. The DON said if the nursing staff noticed Resident #81 pocketing food or having a hard time swallowing, they could put in a referral to speech therapy to see if their diet consistency needed to be changed or a swallow study needed to happen. The DON said if Resident #81 had an appetite change or was not eating the same it would be the same process, but that the Physician should be notified as well. The DON said lots of things could happen to a resident who was losing weight due to an appetite change or pocketing food; that the outcome depended on their disease process. <BR/>Review of the facility's policy revised 01/12/20, and titled Weight Monitoring reflected: 2. Monthly: b) Unplanned and undesired weigh variance will be evaluated for significance utilizing the Resident Assessment Instrument Guidelines and will be reweighed according to the RAI guidelines are as followed: i. 5% in thirty (30) days, ii. 7.5% in ninety (90) days, iii. 10% in one hundred-eighty (180) days .e) If the monthly weight gain or loss shows significance as indicated in (b) above, the resident is reweighed within twenty-four (24) hours to assure accuracy of weight. f) if the reweigh identifies there is an actual weight gain or loss according to RAI guidelines outlined in (b), the resident/family, physician and Registered Dietician are notified via phone, the Registered Dietician via email. The date of such notification is documented in the nurse's notes in the HER. g) The Registered Dietitian reviews the resident's nutritional status and makes recommendations for interventions in the nutritional therapy assessment if significant weight change is noted. h) Significant, unplanned changes in weights are reviewed at the Standards of Care Committee meeting. The Committee will also identify any gradual weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for six (Residents #2, #3, #4 #5 #6 and #7) of six residents reviewed for safe clean homelike environment.<BR/>1. The facility failed to ensure Residents #2, and #3 did not have soiled briefs in the trash cans in their rooms. <BR/>2. The facility failed to ensure Residents #2, #4, and #5 had clean privacy curtains in their rooms. <BR/>3. The facility failed to ensure the ceiling vents Resident #5, #6 and #7's rooms were clean.<BR/>These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment.<BR/>Findings included: <BR/>1. Review of Resident #2's Face Sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral ischemia (common mechanism of acute brain injury that results from impaired blood flow to the brain).<BR/>Review of Resident #2's MDS assessment, dated 03/18/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment. <BR/>Observation and interview on 04/18/24 at 11:10 AM with Resident #2 in her room revealed the resident was on her bed. A soiled brief with fecal matter observed in the trash can. Some dried brown stains were observed on the resident's privacy curtain. Resident#2 stated the brief was changed during wound care by the nurse, but she was not aware it was put in the trash can. She stated her curtain was all stained, and she did not like the way it looked. She stated she would like somebody to wash it.<BR/>2. Review of Resident 3's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included hypertension (high blood pressure) and obesity (excessive fat deposits that can impair health)<BR/>Review of Resident #3's MDS assessment, dated 03/19/24, revealed the resident had a BIMS score of 15 indicating cognitive intact.<BR/>Observation and interview on 04/18/24 at 11:10 AM with Resident #2 in her room revealed resident was on her bed. A soiled brief was observed in the trash can. The resident revealed she had changed herself in the morning when she was preparing to go for therapy. She stated she decided to put the brief in the trash can by the door, because if she kept it in the trash can in the bathroom the CNAs did not empty it and would leave it for the housekeepers. <BR/>3. Review of Resident #5's face sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).<BR/>Review of Resident #5's MDS assessment, dated 04/02/24, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. <BR/>Observation on 04/18/24 at 12:01 PM with Resident #5 in her room in the memory care unit revealed the ceiling vent was dusty, and there were black marks on the ceiling around the vent opening. <BR/>4. Review of Resident #6's Face Sheet, dated 04/18/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and Unilateral primary osteoarthritis, left knee (a condition in which the natural cushioning between joints cartilage wears away). <BR/>Review of Resident #6's MDS assessment, dated 03/28/2024, revealed the resident had a BIMS score of 03 indicating severe cognitive impairment.<BR/>Observation on 04/18/24 at 12:09 PM revealed Resident #6's room on the memory care unit had a privacy curtain with brown stains, and the vents in the room were dusty with black marks on the ceiling round the ventilation opening. <BR/>5. Review of Resident #4's Face Sheet, dated 04/18/24, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE].The resident's diagnoses included Unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and hypertension (high blood pressure).<BR/>Review of Resident #4's MDS assessment, dated 03/28/2024, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. <BR/>Observation on 04/18/24 at 12:30 PM of Resident #4's room in the memory care unit revealed the privacy curtain in the room had brown stains. <BR/>6. Review of Resident #7's face sheet, dated 04/18/24, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #7's diagnoses included Chronic systolic (congestive) heart failure (a condition in which the left ventricle of your heart was weak) and Muscle weakness (happens when full effort doesn't produce a normal muscle contraction or movement).<BR/>Review of Resident #7's MDS assessment, dated 03/25/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment.<BR/>Observation and interview on 04/18/24 at 1:09 PM in Resident #7's room revealed he pointed out that the ceiling vent was dusty and there were black marks on the ducts. He stated his expectation was the housekeepers should have wiped the ducts when cleaning the room, and they did not. Resident #7 stated he felt if action was not taken the dust might continue to accumulate, and it might affect him in the future. <BR/>Observation and interview with CNA C, who was assigned to Residents #2 and #3, on 04/18/24 at 11:15 AM revealed there were soiled briefs in the trash cans in both residents' rooms and a stained privacy curtain for Resident #2. She stated she had been to both rooms earlier, and she did not see the briefs in the trash cans. She stated briefs were not supposed to be left in the room after incontinence care. She stated they should be put in a plastic bag and put in the barrel outside the rooms on the hallway. She stated she was aware if the curtains were dirty or stained, she should notify the housekeepers, but she had not noticed the stains. She stated leaving soiled briefs in the room could cause contamination. She stated she had done training on incontinence care.<BR/>Observation and interview with LVN A on 4/18/24 at 11:38 AM, revealed he was the one who provided incontinence care to Resident #2 during wound care. He stated he was in a hurry to go and observe breakfast in the dining room and that was how he left the soiled brief in the trash can. LVN stated he was aware he was not supposed to leave a soiled brief in the trash can. He stated he was supposed to put it on plastic bag and then put it in the barrel outside the room on the hallway. He stated he had not checked on Resident #3's room but revealed staff had been leaving soiled briefs in the trash cans, and they needed to be trained on the importance of not leaving soiled briefs in the trash can. He stated the risk of leaving soiled briefs in the room was contamination. He stated he had done an in-service on incontinence care and disposal of soiled briefs.<BR/>Observation and interview with CNA D, who was assigned to Residents #4, #5, and #6, on 04/18/24 at 12:11 PM revealed she had observed the privacy curtains were stained. CNA D revealed she was aware if curtains were dirty or stained, she should notify housekeeping, but she had not because she was busy.<BR/>Observation and interview with Housekeeper I on 04/18/24 at 1:12 PM revealed the rooms vents were dusty. He stated it was his responsibility and other housekeepers to clean the vent ducts as they cleaned the rooms. He stated he was supposed to let the maintenance department know in case they were dirty for cleaning. Housekeeper I, stated the vents do not look good. He stated there was no schedule for dusting, they were supposed to dust daily as they clean the rooms, but he has not dusted the vents for some time, and he did not have any reason for not dusting. He stated it was also the housekeepers' responsibility to check on curtains. If they were dirty, they should notify maintenance to remove them, so they could be taken to the laundry to be washed. He stated the risk of having dusty vents was that it could affect resident with allergies and also residents were entitled to a clean and safe homelike environment.<BR/>Interview with Maintenance Director on 04/18/24 at 2:47 PM revealed he had one of his staff who was responsible for ensuring the curtains and the ventilation ducts were clean. He stated the vents were supposed to be removed cleansed and painted at times and other times they only required dusting. He stated he did not like how the ceiling vents looked. He stated he did not manage to see the curtains, but he was informed three privacy curtains were stained, and they were removed by his assistant. He stated he would take full responsibility for the vents and curtains being dirty, and he would be working closely with the staff to ensure they were cleansed. He stated the risk of the ceiling vents being dusty was that if they blew on residents they could be affected, especially those allergic to dust. He also stated residents were entitled to clean and safe environment.<BR/>Interview with Assistant Maintenance Director on 04/18/24 at 3:00 PM revealed he was responsible for the curtains and air vents with help from the housekeepers, but there was no schedule of when to clean them. He stated he did go to the rooms to check how they looked, and he was notified by the director they did not look good. He stated he was notified of the stained curtains, and he saw three were stained. He stated he had to remove them for the housekeepers to wash them. He stated he did not have any reason why the vents and curtains were dirty. He stated residents were entitled to a clean and safe environment. He stated he was notified by the housekeepers if they needed to be changed or washed.<BR/>Interview with the DON on 04/18/24 at 3:44 PM revealed her expectation was that staff performing incontinence care should put soiled briefs in a plastic bag, get them out of the room, and dispose of them in the barrels outside the room. She stated they should not leave soiled briefs in the room to prevent contamination and to control odors. The DON stated she had provided an in-service on incontinence care. <BR/>Review of the facility's Resident Room Cleaning policy dated November 2021 reflected: <BR/>PURPOSE: To provide a clean, attractive, and safe environment for residents, visitors, and staff. <BR/> .K. Heater/ A/C Unit - wipe top and all sides, check top vents for accumulation of dust or debris; remove built-up dirt under the unit, sweep, and damp mop. <BR/>J. Windows - clean window tracks and check curtains/blinds for soiling. Report any soiled blinds or curtains to the Housekeeping Supervisor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for six (Residents #2, #3, #4 #5 #6 and #7) of six residents reviewed for safe clean homelike environment.<BR/>1. The facility failed to ensure Residents #2, and #3 did not have soiled briefs in the trash cans in their rooms. <BR/>2. The facility failed to ensure Residents #2, #4, and #5 had clean privacy curtains in their rooms. <BR/>3. The facility failed to ensure the ceiling vents Resident #5, #6 and #7's rooms were clean.<BR/>These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment.<BR/>Findings included: <BR/>1. Review of Resident #2's Face Sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral ischemia (common mechanism of acute brain injury that results from impaired blood flow to the brain).<BR/>Review of Resident #2's MDS assessment, dated 03/18/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment. <BR/>Observation and interview on 04/18/24 at 11:10 AM with Resident #2 in her room revealed the resident was on her bed. A soiled brief with fecal matter observed in the trash can. Some dried brown stains were observed on the resident's privacy curtain. Resident#2 stated the brief was changed during wound care by the nurse, but she was not aware it was put in the trash can. She stated her curtain was all stained, and she did not like the way it looked. She stated she would like somebody to wash it.<BR/>2. Review of Resident 3's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included hypertension (high blood pressure) and obesity (excessive fat deposits that can impair health)<BR/>Review of Resident #3's MDS assessment, dated 03/19/24, revealed the resident had a BIMS score of 15 indicating cognitive intact.<BR/>Observation and interview on 04/18/24 at 11:10 AM with Resident #2 in her room revealed resident was on her bed. A soiled brief was observed in the trash can. The resident revealed she had changed herself in the morning when she was preparing to go for therapy. She stated she decided to put the brief in the trash can by the door, because if she kept it in the trash can in the bathroom the CNAs did not empty it and would leave it for the housekeepers. <BR/>3. Review of Resident #5's face sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).<BR/>Review of Resident #5's MDS assessment, dated 04/02/24, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. <BR/>Observation on 04/18/24 at 12:01 PM with Resident #5 in her room in the memory care unit revealed the ceiling vent was dusty, and there were black marks on the ceiling around the vent opening. <BR/>4. Review of Resident #6's Face Sheet, dated 04/18/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and Unilateral primary osteoarthritis, left knee (a condition in which the natural cushioning between joints cartilage wears away). <BR/>Review of Resident #6's MDS assessment, dated 03/28/2024, revealed the resident had a BIMS score of 03 indicating severe cognitive impairment.<BR/>Observation on 04/18/24 at 12:09 PM revealed Resident #6's room on the memory care unit had a privacy curtain with brown stains, and the vents in the room were dusty with black marks on the ceiling round the ventilation opening. <BR/>5. Review of Resident #4's Face Sheet, dated 04/18/24, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE].The resident's diagnoses included Unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and hypertension (high blood pressure).<BR/>Review of Resident #4's MDS assessment, dated 03/28/2024, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. <BR/>Observation on 04/18/24 at 12:30 PM of Resident #4's room in the memory care unit revealed the privacy curtain in the room had brown stains. <BR/>6. Review of Resident #7's face sheet, dated 04/18/24, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #7's diagnoses included Chronic systolic (congestive) heart failure (a condition in which the left ventricle of your heart was weak) and Muscle weakness (happens when full effort doesn't produce a normal muscle contraction or movement).<BR/>Review of Resident #7's MDS assessment, dated 03/25/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment.<BR/>Observation and interview on 04/18/24 at 1:09 PM in Resident #7's room revealed he pointed out that the ceiling vent was dusty and there were black marks on the ducts. He stated his expectation was the housekeepers should have wiped the ducts when cleaning the room, and they did not. Resident #7 stated he felt if action was not taken the dust might continue to accumulate, and it might affect him in the future. <BR/>Observation and interview with CNA C, who was assigned to Residents #2 and #3, on 04/18/24 at 11:15 AM revealed there were soiled briefs in the trash cans in both residents' rooms and a stained privacy curtain for Resident #2. She stated she had been to both rooms earlier, and she did not see the briefs in the trash cans. She stated briefs were not supposed to be left in the room after incontinence care. She stated they should be put in a plastic bag and put in the barrel outside the rooms on the hallway. She stated she was aware if the curtains were dirty or stained, she should notify the housekeepers, but she had not noticed the stains. She stated leaving soiled briefs in the room could cause contamination. She stated she had done training on incontinence care.<BR/>Observation and interview with LVN A on 4/18/24 at 11:38 AM, revealed he was the one who provided incontinence care to Resident #2 during wound care. He stated he was in a hurry to go and observe breakfast in the dining room and that was how he left the soiled brief in the trash can. LVN stated he was aware he was not supposed to leave a soiled brief in the trash can. He stated he was supposed to put it on plastic bag and then put it in the barrel outside the room on the hallway. He stated he had not checked on Resident #3's room but revealed staff had been leaving soiled briefs in the trash cans, and they needed to be trained on the importance of not leaving soiled briefs in the trash can. He stated the risk of leaving soiled briefs in the room was contamination. He stated he had done an in-service on incontinence care and disposal of soiled briefs.<BR/>Observation and interview with CNA D, who was assigned to Residents #4, #5, and #6, on 04/18/24 at 12:11 PM revealed she had observed the privacy curtains were stained. CNA D revealed she was aware if curtains were dirty or stained, she should notify housekeeping, but she had not because she was busy.<BR/>Observation and interview with Housekeeper I on 04/18/24 at 1:12 PM revealed the rooms vents were dusty. He stated it was his responsibility and other housekeepers to clean the vent ducts as they cleaned the rooms. He stated he was supposed to let the maintenance department know in case they were dirty for cleaning. Housekeeper I, stated the vents do not look good. He stated there was no schedule for dusting, they were supposed to dust daily as they clean the rooms, but he has not dusted the vents for some time, and he did not have any reason for not dusting. He stated it was also the housekeepers' responsibility to check on curtains. If they were dirty, they should notify maintenance to remove them, so they could be taken to the laundry to be washed. He stated the risk of having dusty vents was that it could affect resident with allergies and also residents were entitled to a clean and safe homelike environment.<BR/>Interview with Maintenance Director on 04/18/24 at 2:47 PM revealed he had one of his staff who was responsible for ensuring the curtains and the ventilation ducts were clean. He stated the vents were supposed to be removed cleansed and painted at times and other times they only required dusting. He stated he did not like how the ceiling vents looked. He stated he did not manage to see the curtains, but he was informed three privacy curtains were stained, and they were removed by his assistant. He stated he would take full responsibility for the vents and curtains being dirty, and he would be working closely with the staff to ensure they were cleansed. He stated the risk of the ceiling vents being dusty was that if they blew on residents they could be affected, especially those allergic to dust. He also stated residents were entitled to clean and safe environment.<BR/>Interview with Assistant Maintenance Director on 04/18/24 at 3:00 PM revealed he was responsible for the curtains and air vents with help from the housekeepers, but there was no schedule of when to clean them. He stated he did go to the rooms to check how they looked, and he was notified by the director they did not look good. He stated he was notified of the stained curtains, and he saw three were stained. He stated he had to remove them for the housekeepers to wash them. He stated he did not have any reason why the vents and curtains were dirty. He stated residents were entitled to a clean and safe environment. He stated he was notified by the housekeepers if they needed to be changed or washed.<BR/>Interview with the DON on 04/18/24 at 3:44 PM revealed her expectation was that staff performing incontinence care should put soiled briefs in a plastic bag, get them out of the room, and dispose of them in the barrels outside the room. She stated they should not leave soiled briefs in the room to prevent contamination and to control odors. The DON stated she had provided an in-service on incontinence care. <BR/>Review of the facility's Resident Room Cleaning policy dated November 2021 reflected: <BR/>PURPOSE: To provide a clean, attractive, and safe environment for residents, visitors, and staff. <BR/> .K. Heater/ A/C Unit - wipe top and all sides, check top vents for accumulation of dust or debris; remove built-up dirt under the unit, sweep, and damp mop. <BR/>J. Windows - clean window tracks and check curtains/blinds for soiling. Report any soiled blinds or curtains to the Housekeeping Supervisor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #2 and #5) of 2 residents reviewed for pressure ulcer treatment.<BR/>The facility failed to ensure Resident #2 and #5 received wound care according to physician orders.<BR/>This failure could place the resident at risk of worsening wounds.<BR/>Findings included:<BR/>1. Review of Resident #5's face sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).<BR/>Review of Resident #5's MDS assessment, dated 04/02/2024, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment and Resident #5 was at risk of developing pressure ulcers/injuries.<BR/>Review of Resident #5's care plan, dated 04/10/24, indicated skin breakdown: At risk for/actual skin, Cleanse Wound every am shift (6am-2pm). Cleanse Wound as Needed as Needed Dislodged. She was care planned for open area will be healed over the next 90 days. Interventions: Treatments and dressings as ordered per physician.<BR/>Review of Resident #5's physician orders revealed the following wound care orders, dated 04/10/24, reflected the following orders: <BR/>Cleanse Wound every am shift (6am-2pm) WOUND OF THE RIGHT BUTTOCK: Cleanse with normal saline or wound cleanser pat dry. Apply mupirocin topical 2% and Santyl. Cover with a dry dressing daily.<BR/>Cleanse Wound as Needed Dislodged WOUND OF THE RIGHT BUTTOCK: Cleanse with normal saline or wound cleanser, pat dry. Apply mupirocin topical 2% and Santyl. Cover with a dry dressing as needed. <BR/>Review of Resident #5's Treatment Record for April 2024 indicated wound care was not provided on 04/17/24 and 04/18/24.<BR/>Observation on 04/18/24 at 12:10 PM with CNA D revealed Resident #5 had a dressing on her coccyx dated 04/16/24. <BR/>Observation and interview on 04/18/24 at 3:05 PM with LVN E, who was the Wound Care Nurse, revealed she was not responsible for performing wound care on the North Side. She stated the floor nurses were responsible for their residents since the wound care nurse was off duty. She assessed the resident and confirmed the dressing was dated 04/16/23. She stated failure to follow the doctor's orders could result in the wound getting worse and getting infected. She then prepared and disinfected the table, put supplies together, and she changed the resident's wound dressing.<BR/>Interview on 04/18/24 at 5:20 PM with LVN B revealed she was not aware Resident #5's wound care was not performed by the 6:00 AM-2:00 PM shift, and the nurse had not told her during shift change. LVN B stated failure to perform wound care as indicated could worsen the wound and slow the healing. <BR/>2. Review of Resident #2's Face sheet, dated, 04/18/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral ischemic (common mechanism of acute brain injury that results from impaired blood flow to the brain).<BR/>Review of Resident #2's MDS assessment, dated 03/18/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment. Her Skin Conditions indicated she was at risk of developing pressure ulcers/injuries. Resident has open lesion.<BR/>Review of Resident #2's care plan, dated 02/20/24, indicated skin breakdown: At risk for/actual skin, cleanse wound as needed if dislodged. She was care planned for open area will be healed over the next 90 days. Interventions: Treatments and dressings as ordered per physician. <BR/>Review of Resident #2's physician orders revealed the following wound care orders, dated 04/03/24:<BR/>Cleanse Wound every am shift (6am-2pm) NON-PRESSURE WOUND OF THE LEFT BUTTOCK: Cleanse wound with NS/WC, pat dry. Apply anapest and collagen sheet, then cover with a dry dressing daily. <BR/>Review of Resident #2's Treatment Record for April 2024 indicated wound care was provided on 04/19/24 and 04/20/24. <BR/>Observation on 04/21/24 at 11:25 AM with LVN A revealed him performing wound care. He washed his hands and put on gloves. He disinfected the table and let to dry. He removed the gloves and washed his hands. He explained the procedure to Resident #2. He put supplies together, washed his hands, put on gloves, and explained the procedure to Resident #2. He unfastened the resident's brief, and Resident #2's wound dressing was dated 04/18/24. He removed the old dressing, doffed his gloves, washed his hands, and put on new gloves. LVN A then cleansed the wound, patted it dry, doffed his gloves, washed his hands, and put on new gloves. The wound was healing with no signs of infection. LVN A next applied anapest, collagen sheet then covered the wound with a dry dressing. He then doffed his gloves and washed his hands. <BR/>Interview on 04/21/24 at 11:35 AM with LVN A revealed the dressing was dated 04/18/24. He stated he was responsible for performing wound care on 04/19/24 and 04/20/24, and he had not managed to perform wound care for all residents because there were many. He stated Resident #2's wound care was supposed to be done daily on the 6:00 AM-2:00 PM shift. He stated the risk of not performing wound care as per the doctor's order was that it could lead to the wound worsening. He stated he did not understand how he signed the treatment administration record as wound care was performed while it was not performed. He stated he understood signing without performing wound care could make the resident miss the treatment as per physicians' orders and could worsen the wound. <BR/>Interview on 04/21/24 at 11:38 AM with the DON revealed the nursing staff knew they had to follow physician orders as they were written. The DON stated the facility had a Wound Care Nurse, but she was out. She stated they had requested for nurses on the floor to perform wound care on their halls. Staff nurses were responsible for wound care when the Wound Care Nurse was not available. The DON stated she was not aware that nurses were not performing wound care and were signing treatment administration records before administering care. She stated she would perform a wound sweep on all residents and ensure all the wounds were taken care of. She stated failure to follow the doctors' orders could result in the wounds worsening. She stated she was responsible for ensuring wound care was being provided. She stated she was responsible for monitoring that wound care was being provided.<BR/>Interview on 04/22/24 at 11:40 AM with LVN N revealed she worked the 6:00 AM-2:00 PM shift with Resident #5. She stated she was aware the resident's wound care was supposed to be done, but the resident refused. She stated she had not notified the on-coming nurse, and she had not notified the management or documented in the progress notes. She stated failure to perform wound care as indicated could result in the the wound getting worse or getting infected. She stated she was also supposed to let the doctor know about the refusal.<BR/>Review of the facility's current policy dated July 2018 titled, Treatment of Wounds: Dressing Changes-Performing reflected:<BR/> . 1. Review orders and treatments and gather supplies. <BR/>2. Follow standard precautions and infection control methods depending on the appropriate<BR/>type of transmission-based precautions.<BR/> .4. Ensure all wound dressing products are completely removed with each dressing change if present

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one of three residents (Resident #3) reviewed for oxygen.<BR/>The facility failed to ensure Resident #3's oxygen concentrator and nasal cannula was dated, labeled, and changed on a weekly basis. The facility failed to ensure Resident #3's oxygen delivered as ordered by physician at 2 liters per minute. <BR/>This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection.<BR/>Findings included:<BR/>Review of Resident #3's admission Record dated 02/23/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included low back pain, Hypoxemia (an abnormally low level of oxygen in the blood), chronic pain due to trauma, elevated blood-pressure reading with diagnosis of high blood pressure, anemia (reduced ability to carry oxygen), shortness of breath, dehydration, hypokalemia (low blood potassium levels), difficulty walking.<BR/>Review of Resident #3's quarterly MDS assessment, dated 02/12/24, revealed a BIMS score of 8, indicating moderate cognitive impairment. Her MDS indicated she received oxygen therapy while a resident. <BR/>Review of Resident #3's baseline care plan dated with onset of 08/02/23 revealed Resident #3 had issues with breathing patterns. Goal: Resident #3 will demonstrate an effective respiratory rate, depth, and pattern. Intervention: Adjust head of bed and body positioning to assist ease of respirations, Administer medications, respiratory treatments, and oxygen as ordered, administer nebulizer treatments as ordered, monitor lung sounds, pallor, cough, and character of sputum, monitor respiratory rate, depth, and effort, notify medical doctor and family of any change of condition. <BR/>Record review of Resident #3's orders dated 08/02/23 revealed:<BR/>Oxygen at 2 liters per minutes delivered by nasal cannula, every shift, Oxygen saturation check, if Oxygen saturation less than 90 percent notify medical doctor. <BR/>Oxygen, every Sunday on every night shift (10:00 PM-6:00 AM) Change and label oxygen tubing and humidifier bottle and clean concentrator filter weekly. <BR/>Record review of Resident #3's electronic medication and treatment record revealed:<BR/>Orders to change and label oxygen tubing and humidifier bottle and clean concentrator filter was completed on 02/04/24, 02/11/24, 02/18/24. <BR/>Orders to check oxygen saturation every shift was completed daily starting from 02/01/24 - 02/23/24 morning shift, all readings above 90 percent. <BR/>Observation and interview on 02/21/24 at 10:47 AM with Resident #3 revealed she had constant use of oxygen. Resident #3 stated she had issues with breathing, pain, anxiety and required oxygen to help her breath and calm down. Resident #3 stated staff was not changing out her oxygen bottle or tube, and she could not recall the last time staff had come in to check the oxygen level or the humidifier on the oxygen machine before today. Observation of Resident #3 revealed she was not wearing the tubing., She stated staff had just came in to check the machine. Observation of Resident's nasal cannula revealed it was not labeled or dated and water bottle concentrator was empty, not labeled or dated, delivered 2.5 liters per minute. Observation revealed staff entered the room to change out the tubing and humidifier and left the room when she observed surveyor in the room. <BR/>Interview on 02/21/24 at 11:28 AM with LVN A revealed she entered the room to change out Resident #3's nasal cannula and water bottle because she did a round to check and noticed it had not been changed. LVN A stated the tubing and water bottle should be changed out on the overnight shift every Sunday. LVN A stated the nursing staff was responsible for changing both the tubing and water bottle. LVN A stated both the tubing and water bottle should be labeled and dated. According to LVN A, Resident #3's machine should be running at 2 liters. LVN A stated she was not sure of any risk to Resident #3 not having her tubing changed weekly or her water bottle checked often because Resident #3 hardly wore the tubing and frequently took it off.<BR/>Interview on 02/21/24 at 11:40 AM with CNA B revealed she was working today with Resident #3; CAN B stated she had entered the room a couple times during the morning. CNA B stated she often saw Resident #3 with her tubing in her nose but has not seen her having a hard time breathing. CNA B stated when she completed care she did not notice that the water bottle on the oxygen machine was empty, but if she did, she would have notified the nurse. <BR/>Interview on 02/23/24 at 11:10 AM with ADON revealed nursing staff on the overnight shift were responsible to change out humidifiers and tubing every Sunday on the 10:00 PM-6:00 AM shift. ADON stated nursing staff should be monitoring oxygen every shift, therefore if the water bottle was empty, it should have been changed out at that time it was found empty. ADON stated Resident #3 had orders to have 2 liters per minute, and she was not aware Resident #3 was using the machine at 2.5 liters. ADON stated it was expectation to have tubing and humidifiers dated and labeled, and nurses should be following physician orders to change, label, date and monitor according to the orders. According to ADON, Resident #3 should be only on 2 liters. ADON stated using oxygen at 2 liters per minute does not require water, only when you use at 3 liters but there could be a risk of respiratory problems. ADON stated ADON's were responsible for checking to ensure nursing staff were changing out the tubing and oxygen weekly. <BR/>Interview on 02/23/24 at 12:21 PM with DON revealed nursing staff was responsible for ensuring to follow physician orders when it came to Resident #3's oxygen use. DON stated she expected the tubing and humidifier to be changed, labeled, and dated weekly. DON stated the humidifier was just for comfort, there was no risk to Resident #3 if there was not water present. DON stated Resident #3 did not wear her tubing all the time; however, nursing staff needed to always follow orders. <BR/>Record review of facility's Applying an Oxygen Delivery Device policy, revised 01/12/20, reflected:<BR/>Standard of Practice: Staff will apply oxygen delivery devices in accordance with standard practice guidelines. <BR/>Procedure: <BR/>Identify the resident.<BR/>Validate physician orders.<BR/>Validate peripheral capillary oxygen saturation. <BR/>Attach oxygen delivery device as required.<BR/>Attach humidified oxygen source if required, nasal cannula. <BR/>Verify setting on the flowmeter and oxygen source and the prescribed flow rate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received proper treatment and assist the resident in making appointments for 1 of 1 resident (Resident #116) whose records were reviewed for vision services in that:<BR/>Nursing staff failed to ensure that Resident #116 was scheduled for an ophthalmologist appointment since July 2023. <BR/>This failure could affect residents and contribute to a decline in vision.<BR/>Findings included:<BR/>Review of Resident #116's face sheet, dated 11/08/23, revealed the resident was initially admitted to the facility on [DATE] with diagnoses to include cerebral infarction and chronic diastolic congestive heart failure.<BR/>Review of Resident #116's Consolidated Order dated 10/21/23 revealed Resident #116 had a diagnosis of Unspecified Glaucoma.<BR/>Review of Resident #1's quarterly MDS, dated [DATE], revealed the resident had severe cognitive impairment with a BIMS score of 6.<BR/>Review of Resident #1's nurse's note, dated 07/19/23, reflected in part: Called [name of optometry clinic] to schedule surgery for removal of cataracts, and they stated that they were referring her to [name of hospital] with [name of doctor], and once the referral process has been completed then someone from [name of hospital] would be giving her a call. Informed resident of this and she would need to ensure that she answers the phone to get appointment set up. Resident verbalized an understanding. Called residents family member to inform her of follow up status, but no answer and unable to LM.<BR/>Interview on 11/06/23 at 12:28 PM with Resident #116 revealed Resident #116 had difficulty seeing due to her poor eyesight. Resident #116 stated the facility was supposed to make a follow-up appointment for her about her cataracts and glaucoma with an ophthalmologist, following her 07/19/23 appointment, but the facility failed to schedule an appointment and transport for her. This was supposed to have been after her appointment on 07/19/23.<BR/>Interview and record review on 11/7/2023 at 9:31 AM with the Social Worker revealed she scheduled the appointments for residents for vision. Review of Resident #116's mobile vision note dated 08/22/23 reflected: Vision MDS Code: Impaired. [Name of Company] was provided by [Physician]. The Social Worker revealed she did not schedule any referral appointments for Resident #116.<BR/>Interview on 11/08/23 at 5:10 PM with the DON revealed the last notes for Resident #116 she saw were in July 2023. The DON stated the staff member responsible for ensuring referrals were completed and residents were seen by those physicians was the DON of the building the resident lived in. The DON stated the previous DON was responsible for Resident #116's referral. The previous DON's last day was 11/01/23, and he had failed to ensure a referral and transport to an ophthalmologist was scheduled for Resident #116. The current DON was acting as an interim DON over the South building as well as her current position as DON of the North building on the facility's campus. She assumed this role when the previous DON of the South building resigned. <BR/>Review of the facility's Resident's Right: Clinical Operations Policy policy, revised August 2022, reflected: The staff will abide by and protect resident rights in accordance with state and federal guidelines. Procedure: Staff will abide by resident rights as outlined within CMS State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities (Rev. 11-22-17) In the Event a resident rights issue is observed or alleged, staff will report the issue to the Administrator. The Administrator will pursue appropriate action regarding the alleged issue regarding resident rights, which may include but are not limited to1. Social Service Referral .

**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 proper treatment and care to maintain good foot health for 1 of 36 residents (Resident #146) reviewed for foot care.<BR/>The facility did not ensure Resident #146 received toenail care. <BR/>This failure could place residents at risk for not receiving foot care which is consistent with professional standards of practice. <BR/>Findings included:<BR/>Record review of the face sheet, dated 11/08/23, revealed Resident #146 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of secondary hypertension (high blood pressure), cerebral infarction (disrupted blood flow to the brain), central pain syndrome. <BR/>Record review of Resident #146's MDS, dated [DATE], revealed resident BIMS score was 00, indicative of severe cognitive impairment. The MDS revealed Resident #146 had no behaviors or rejection of care. The MDS revealed Resident #146 required substantial/maximal assistance when putting on/taking off footwear. <BR/>Record review of the comprehensive care plan, revised on 09/20/23, reflected: Generalize weakness Goal: Resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90days. Interventions: Encourage resident o complete as much self-care as possible independently or with minimal assist. Provide assistance with self-care as needed. Care plan did no address fingernails or toenails.<BR/>Record review of Resident #146's physician orders revealed Podiatrist Consult for long thick toenails with PVD Date started 10/13/22. <BR/>Record review of Resident #146 podiatrist notes revealed the last time the podiatrist visited and saw the resident was on 06/13/23. Podiatric Diagnosis: Onychomycosis (nail fungus) and PVD (Peripheral vascular disease - poor blood flow). The podiatrist notes revealed seen at request for treatment of mycotic nail in presence of PVD. <BR/>Observation on 11/06/23 at 10:44 AM revealed Resident #146 was sitting on his bed. Observed Resident #146's bilateral lower extremities with grown tall nails. Resident #146 was not a good historian and was unable to answer questions. <BR/>Observation and interview on 11/06/23 at 11:15 AM revealed Resident #146 walking on the hallway with no socks on. Observed Resident #146 bilateral lower extremities with grown tall nails. Resident #146 was not a good historian, resident stated his toenails were cut; however, resident's toenails were approximately an inch long. Resident #146 unable to answer further questions. <BR/>Interview on 11/08/23 at 12:46 PM with CNA J revealed she was the CNA assigned to Resident #146. She stated CNAs were not responsible for cutting residents fingernails or toenails. She stated it was the responsibility of the nurses to cut residents fingernails and toenails. She stated when they observed residents' nails being long, they will notify the nurse on duty. She stated she had observed Resident #146 toenails. She stated the resident toenails were long. She stated she could not recall if she had notified the nurse about it.<BR/>Interview on 11/08/23 at 12:48 PM with LVN K revealed he was the nurse for Resident #146. He stated the CNAs were responsible to notify the nurses regarding residents' toenails and the nurses would notify the Social Worker to request a podiatry appointment. LVN K stated he had not observed Resident #146's toenails and had not been notified by the CNA's regarding Resident #146 toenails. LVN K stated the podiatrist last visit was in October 2023, could not recall of the exact date. He stated he could not recall if Resident #146 was seen by the podiatrist. <BR/>Interview on 11/08/23 at 1:00 PM with Social Worker revealed he was responsible for scheduling podiatry appointments. He stated podiatry only comes when they request it. He stated the nurses on duty would notify him of which residents need podiatry services. He stated when he has enough residents who need podiatry, he would schedule podiatry appointment. He stated enough residents would be about 10 residents. He stated when the Podiatrist comes, he would provide the Podiatrist with a census list and the Podiatrist would see all the residents in both buildings. He stated the last time the Podiatrist visited was 06/12/23 and 10/18/23. Social Worker stated he had not been notified regarding Resident #146 needing podiatry. He stated Resident #146 was on the census list on October 18th; however, he was unsure if resident refuse service from podiatry. <BR/>Interview on 11/08/23 at 1:23 PM with the ADON revealed the nurses were responsible for cutting residents fingernails and toenails unless the residents were diabetic or had something acute. The ADON stated nail care was monitored by performing rounds. She stated the Social Worker was responsible for scheduling podiatry. The ADON stated the last time podiatry visited was on 10/19/23, they usually come for 2-3 days to complete both buildings. The ADON stated she was unsure if Resident #146 was seen last month; however, resident should had been seen by podiatry. The ADON stated when podiatry comes, they would get podiatry notes on the residents that were seen. She stated risk not providing nail care could cause infection control. <BR/>Interview on 11/08/23 at 3:24 PM with the DON revealed her expectations were for residents' fingernails and toenails to be completed by her staff unless the residents were diabetic. She stated the nurses on duty would notify the Social Worker of residents who need podiatry and the Social Worker would send the referral. The DON stated the Podiatrist comes every 60 days and would see all the residents in both buildings. The DON stated the last time Podiatry visited was last month on 10/18/23. She stated Resident #146 was seen by the Podiatrist. The DON stated no staff have notified her regarding Resident #146 toenails. She stated the risk of not providing foot care and toenail care could cause skin breakdown, infections such as nail fungus. <BR/>A request of 10/18/23 Podiatry Notes was requested from the ADON and DON; however, it was not provided prior to exit, or documentation of Resident #146 refusing service care. <BR/>Review of the facility's Foot and Toenail Care, Routine policy, revised 02/12/20, reflected: Residents will be provided routine foot and toenail care within the professional scope of practice for CNAs, LVN/LPNs and RNs as dictated per state guidelines and in accordance with standard practice. The skill of toenail trimming of residents with diabetes, peripheral vascular disease/peripheral arterial disease (PVD/PAD), or circulatory compromise cannot be delegated to Certified Nursing Assistants (CNAs) and unlicensed personnel. CNAs should report special considerations, breaks in skin, redness, numbness, swelling and pain. CNAs shall be trained in accordance with professional practice guidelines prior to performing foot and toenail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #3) of four residents reviewed for pharmacy services.<BR/>The facility failed to administer Resident #3, who had a diagnosis of dementia, with her morning medications on 03/26/25 and 03/27/25. Both the medication aide and nurse acknowledged they were busy and did not attempt to give them to her again after one refusal. As a result, Resident #3 missed eight different medications both days, including blood pressure readings related to blood pressure medication, as well as two supplements. <BR/>The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 03/26/25 reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] with active diagnoses of senile degeneration of brain (also known as dementia, is a group of conditions that cause a decline in cognitive function and memory and is a progressive and irreversible process that typically occurs in older adults), sequelae of cerebral infarction (also known as an ischemic stroke, is the death of brain tissue (cerebral infarct) due to a lack of blood flow (ischemia) caused by a blockage or narrowing of blood vessels in the brain), chronic kidney disease-stage 3 (a gradual progressive loss of kidney function leading to a buildup of waste and fluid in the body), major depressive disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, impacting daily functioning), hyperlipidemia (a condition characterized by elevated levels of lipids (fats) in the blood which can increase the risk of heart disease and stroke), Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), neuromuscular dysfunction of bladder (a condition where bladder control is lost due to problems with the brain, spinal cord, or nerves that control bladder function, leading to difficulties in emptying or holding urine) and pain. <BR/>Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severe cognitive impairment and a mood score of 00 which indicated no negative mood issues. Resident #3 had no potential indicators of psychosis, no physical or verbal behavioral symptoms, no rejection or care and no wandering behaviors. <BR/>Record review of Resident #3's care plan dated 09/07/24 reflected the following problems/issues: 1) Poor balance, 2) Problems with elimination (bowel/bladder), 3) Dysphagia (difficulty swallowing) and chewing difficulty, and 4) Pain. The interventions for her prescribed medications were to administer medications as ordered. <BR/>Record review of Resident #3's March 2025 Physician Orders reflected she was prescribed: mirtazapine 15 mg 0.5mg at bedtime (antidepressant-start date 02/14/25), divalproex 125 mg twice a day (anticonvulsant-start date 02/21/25), bupropion ER on ce a day (antidepressant-start date 02/12/25), Myrbetriq 50 mg ER on ce a day (treats overactive bladder-start date 09/27/24), atorvastatin 40 mg once a day for cholesterol (start 09/27/24), megestrol 5ml by mouth once a day for dementia (start date 02/21/25), aspirin 81 mg once a day (start date 09/27/24), amlodipine 10 mg once a day (blood pressure-hold if SBP less than 110 and DBP less than 60) (start date 09/27/24), polyethylene glycol 17 grams once a day in eight ounces of fluid (start date 12/17/25), 2.0 Cal Med Pass supplement 60 ml four times a day with medication pass for adult failure to thrive (start 12/17/24).<BR/>Record review of Resident #3's March 2025 MAR reflected she was not administered the following medications on 03/26/25 and 03/27/25 on the morning shift: amlodipine, aspirin, atorvastatin (including no blood pressure recordings), bupropion, multivitamin, divalproex, megestrol, Myrbetriq, polyethylene glycol and med pass supplement. The MAR for the missed med administrations was initialed by MA D as resident refusals. <BR/>Record review of Resident #3's nursing progress notes revealed no entry for 03/26/25 and 03/27/25 to document the nurse was notified of the medication refusals, why the medication was not given, nor what was done after the resident refused to take the medication and if the doctor was notified. <BR/>An interview with LVN C on 03/26/25 at 12:47 PM revealed if a medication aide could not administer a medication for whatever reason, then the medication would show on the MAR as not given and the med aide had to tell the charge nurse, then that charge nurse had to document and follow up on it. He said if a medication was not able to be given after three attempts, including for resident refusals, the nurse had to contact the doctor. LVN C stated he liked to notify the doctor after the first refusal especially if it was a high-risk medication, Just to put it on the doctor's radar in case it becomes an issue. <BR/>An interview with the DON on 03/26/25 at 2:18 PM revealed she did not have an ADON working in the facility, so she had been responsible for all the DON duties and the ADON's duties. In response to Resident #3's medication not being given for two days on the morning shift and documented as refusals, the DON stated, We need to figure out why med aides are clicking not given on these MARs. Maybe they are just going too fast and not clicking the correct reason is why it was not given. <BR/>An interview with MA D on 03/28/25 at 1:05 PM revealed she was the person who did the med administration pass for Resident #3 on 03/26/25 and 03/27/25 in the morning. She stated Resident #3 did not take the medication when offered both those days and spit it out. MA D stated in the mornings, sometimes Resident #3 refused to let the med aide take her blood pressure and would move her arms around to where she could not get an accurate reading on the machine. MA D stated that with the medications, she crushed them and put them in applesauce but Resident #3 would spit it out. MA D stated, If she is feisty, she will not accept. MA D stated when that happened, she was supposed to let the charge nurse know that an attempt was made and refused. MA D stated there was one other medication aide in the facility who passed medications on the other halls and in the mornings, they had to have their own routine due to the number of medications that had to be administered. MA D stated she typically started administering medications around 6:30 AM-7AM and tried to be finished by 10:00 AM. MA D stated, I have to keep moving. If someone refuses, I got to keep going because I have other meds to give. MA D stated again that her job was to report medication refusals to the charge nurse and it was on the charge nurse to chart it, call the doctor and follow up and decide what to do. <BR/>An interview with MA E on 03/28/25 at 1:14 PM revealed she had administered Resident #3's medications that morning (03/28/25) with no issues. She stated sometimes when Resident #3 was mad, she would refuse to let the med aide take her blood pressure and give her medications, but not every day. MA E stated when Resident #3 refused the blood pressure, she would tell her that her family member really wanted her to stay healthy and would like it, and she would normally comply. MA E stated Resident #3 liked sweet things, so when she crushed her medications , she put them in applesauce with a little bit of jelly. MA E said if Resident #3 did refuse her medications during a med pass, the med aide had to document it in the e-chart and then notify the nurse and both of them would try together to encourage the resident to take them. MA E stated it was important for Resident #3 to take her medications as ordered because she needed the blood pressure medication due to her running high at times, and there was another medication to help her calm down and not stress or feel frustrated. <BR/>An interview with LVN F on 03/28/25 at 2:00 PM revealed she was the charge nurse for Resident #3 and stated MA D did notify her about the medication refusals. LVN F stated, I was busy, but typically we have to document if they refuse. She stated if the resident continued to refuse for a couple of days, which was not typical, then the NP was notified. LVN F stated, As a nurse, I am supposed to document that the med aide tried to administer meds but the patient didn't want them. LVN F stated when that happened, she would normally go to the resident's room and try to encourage them but at the end of the day, it was their right. She said for the past two mornings (03/26/25 and 03/27/25), she did not try to get Resident #3 to take her medications when she was notified of the refusals. LVN F stated, At the time when the med aide let me know [03/26/25], I was in the middle of doing ten things at once. I would have gone in there normally under regular circumstances to try to get her to take it but I was very busy and not able to go in. Same thing yesterday [03/27/25]. Last couple of weeks we have been slammed and busy.<BR/>An interview with the DON on 03/28/25 at 3:03 PM revealed LVN F was a newer nurse and although she was a good nurse, it was just a mistake and she and she had already begun in-serving the nursing staff. The DON stated her expectation was that when notified of medication refusals, the nurse should notify the physician after two medication refusals. <BR/>Record review of the facility's policy titled, Medication Administration Guidelines, dated January 2024 reflected, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Procedures .2. Obtain and record any vital signs as necessary prior to medication administration .Documentation .2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the MAR for that dosage is initialed and circled .If two consecutive doses of a vital medications are withheld or refused, the physician is notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to self-determination for 2 of 7 residents (Residents #55, and #173) reviewed for self-determination in that:<BR/>1. CNAs failed to change Resident #55's bed linen, leaving her with no bed sheets. <BR/>2. Dietary staff were rude in their interactions with Resident #173 when discussing her food choices. <BR/>These failures could place residents at risk of decreased feelings of self-worth. <BR/>Findings included:<BR/>Review of Resident #55's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, speech impairment, seizures, and obesity. <BR/>Review of Resident # 55's quarterly MDS assessment, dated 08/21/23, revealed a BIMS score of 8, indicating she was moderately cognitively impaired. Her Functional Status indicated she required extensive assistance with most of her ADLs. <BR/>Review of Resident #55's care plan, dated 10/25/23, revealed she had a speech deficit related to her stroke, mobility impairment related to her stroke, and a self-care deficit. <BR/>Interview on 11/06/23 at 11:44 AM Resident #55 stated her bed linen were not changed very often, maybe once or twice a week. Staff do not bring fresh water and ice unless they were asked to do so. Her current pitcher of water was from the previous evening and had no ice left in it. <BR/>Observation and interview on 11/07/23 at 8:49 AM revealed Resident #55 had no fitted sheet under her, she was lying directly on her mattress. Resident #55 stated her linen had been changed the previous evening and was told there were no more fitted sheets. <BR/>Observation on 11/08/23 at 9:32 AM revealed Resident #55 remained directly on her mattress with no fitted sheet under her. Resident #55 stated no one had ever brought in linen the previous day. <BR/>Interview on 11/08/23 at 9:38 AM CNA F stated she had not been to Resident #55's room except to pass her breakfast tray. CNA F stated she did not notice the resident had no bedding under her. but she would address it immediately. <BR/>Interview on 11/08/23 at 9:40 AM LVN G stated she had been made aware Resident #55 needing a fitted sheet and it had been addressed. LVN G stated the risk of leaving a resident directly on the mattress without a sheet to protect them was skin breakdown and discomfort. <BR/>Review of Resident #173's undated admission Record revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses that included UTI, emphysema, morbid obesity, diabetes, and dementia. <BR/>Review of Resident #173's quarterly MDS assessment, dated 10/05/23, revealed a BIMS score of 9 indicating she was moderately cognitively impaired. Her Functional Status indicated she required minimal assistance with her ADLs. <BR/>Review of Resident #173's care plan, dated 09/26/23, revealed she had a cognitive, hearing, and visual impairment, and she was a fall risk due to mobility impairment. <BR/>Interview on 11/06/23 at 1:52 PM, Resident #173 stated she had limited food that she could eat because of medical problems. Resident #173 stated she had tried to discuss it with the dietary staff but had been yelled at and felt belittled, so she no longer tried. Resident #173 stated she would ask for an alternative if she could not eat what was brought to her. <BR/>Interview on 11/07/23 at 3:35 PM, the DON stated she had investigated Resident #173's complaint and discovered the resident had met with the Dietary Manger, the resident stated she felt afraid of the Dietary Manager at that moment, feeling they would be retaliatory. The DON stated if the resident had felt fear in that moment, that was abuse as far as she was concerned. The DON stated the Dietary Manager had been suspended pending an investigation. The DON stated the Dietary Manager had a heavy accent and that might have lead to the misunderstanding, but she would counsel the Dietary Manager. The DON stated she expected all of the staff to speak to, and treat, the residents with the utmost respect at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for six (Residents #2, #3, #4 #5 #6 and #7) of six residents reviewed for safe clean homelike environment.<BR/>1. The facility failed to ensure Residents #2, and #3 did not have soiled briefs in the trash cans in their rooms. <BR/>2. The facility failed to ensure Residents #2, #4, and #5 had clean privacy curtains in their rooms. <BR/>3. The facility failed to ensure the ceiling vents Resident #5, #6 and #7's rooms were clean.<BR/>These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment.<BR/>Findings included: <BR/>1. Review of Resident #2's Face Sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral ischemia (common mechanism of acute brain injury that results from impaired blood flow to the brain).<BR/>Review of Resident #2's MDS assessment, dated 03/18/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment. <BR/>Observation and interview on 04/18/24 at 11:10 AM with Resident #2 in her room revealed the resident was on her bed. A soiled brief with fecal matter observed in the trash can. Some dried brown stains were observed on the resident's privacy curtain. Resident#2 stated the brief was changed during wound care by the nurse, but she was not aware it was put in the trash can. She stated her curtain was all stained, and she did not like the way it looked. She stated she would like somebody to wash it.<BR/>2. Review of Resident 3's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included hypertension (high blood pressure) and obesity (excessive fat deposits that can impair health)<BR/>Review of Resident #3's MDS assessment, dated 03/19/24, revealed the resident had a BIMS score of 15 indicating cognitive intact.<BR/>Observation and interview on 04/18/24 at 11:10 AM with Resident #2 in her room revealed resident was on her bed. A soiled brief was observed in the trash can. The resident revealed she had changed herself in the morning when she was preparing to go for therapy. She stated she decided to put the brief in the trash can by the door, because if she kept it in the trash can in the bathroom the CNAs did not empty it and would leave it for the housekeepers. <BR/>3. Review of Resident #5's face sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).<BR/>Review of Resident #5's MDS assessment, dated 04/02/24, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. <BR/>Observation on 04/18/24 at 12:01 PM with Resident #5 in her room in the memory care unit revealed the ceiling vent was dusty, and there were black marks on the ceiling around the vent opening. <BR/>4. Review of Resident #6's Face Sheet, dated 04/18/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and Unilateral primary osteoarthritis, left knee (a condition in which the natural cushioning between joints cartilage wears away). <BR/>Review of Resident #6's MDS assessment, dated 03/28/2024, revealed the resident had a BIMS score of 03 indicating severe cognitive impairment.<BR/>Observation on 04/18/24 at 12:09 PM revealed Resident #6's room on the memory care unit had a privacy curtain with brown stains, and the vents in the room were dusty with black marks on the ceiling round the ventilation opening. <BR/>5. Review of Resident #4's Face Sheet, dated 04/18/24, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE].The resident's diagnoses included Unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and hypertension (high blood pressure).<BR/>Review of Resident #4's MDS assessment, dated 03/28/2024, revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. <BR/>Observation on 04/18/24 at 12:30 PM of Resident #4's room in the memory care unit revealed the privacy curtain in the room had brown stains. <BR/>6. Review of Resident #7's face sheet, dated 04/18/24, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #7's diagnoses included Chronic systolic (congestive) heart failure (a condition in which the left ventricle of your heart was weak) and Muscle weakness (happens when full effort doesn't produce a normal muscle contraction or movement).<BR/>Review of Resident #7's MDS assessment, dated 03/25/24, revealed the resident had a BIMS score of 10 indicating moderate cognitive impairment.<BR/>Observation and interview on 04/18/24 at 1:09 PM in Resident #7's room revealed he pointed out that the ceiling vent was dusty and there were black marks on the ducts. He stated his expectation was the housekeepers should have wiped the ducts when cleaning the room, and they did not. Resident #7 stated he felt if action was not taken the dust might continue to accumulate, and it might affect him in the future. <BR/>Observation and interview with CNA C, who was assigned to Residents #2 and #3, on 04/18/24 at 11:15 AM revealed there were soiled briefs in the trash cans in both residents' rooms and a stained privacy curtain for Resident #2. She stated she had been to both rooms earlier, and she did not see the briefs in the trash cans. She stated briefs were not supposed to be left in the room after incontinence care. She stated they should be put in a plastic bag and put in the barrel outside the rooms on the hallway. She stated she was aware if the curtains were dirty or stained, she should notify the housekeepers, but she had not noticed the stains. She stated leaving soiled briefs in the room could cause contamination. She stated she had done training on incontinence care.<BR/>Observation and interview with LVN A on 4/18/24 at 11:38 AM, revealed he was the one who provided incontinence care to Resident #2 during wound care. He stated he was in a hurry to go and observe breakfast in the dining room and that was how he left the soiled brief in the trash can. LVN stated he was aware he was not supposed to leave a soiled brief in the trash can. He stated he was supposed to put it on plastic bag and then put it in the barrel outside the room on the hallway. He stated he had not checked on Resident #3's room but revealed staff had been leaving soiled briefs in the trash cans, and they needed to be trained on the importance of not leaving soiled briefs in the trash can. He stated the risk of leaving soiled briefs in the room was contamination. He stated he had done an in-service on incontinence care and disposal of soiled briefs.<BR/>Observation and interview with CNA D, who was assigned to Residents #4, #5, and #6, on 04/18/24 at 12:11 PM revealed she had observed the privacy curtains were stained. CNA D revealed she was aware if curtains were dirty or stained, she should notify housekeeping, but she had not because she was busy.<BR/>Observation and interview with Housekeeper I on 04/18/24 at 1:12 PM revealed the rooms vents were dusty. He stated it was his responsibility and other housekeepers to clean the vent ducts as they cleaned the rooms. He stated he was supposed to let the maintenance department know in case they were dirty for cleaning. Housekeeper I, stated the vents do not look good. He stated there was no schedule for dusting, they were supposed to dust daily as they clean the rooms, but he has not dusted the vents for some time, and he did not have any reason for not dusting. He stated it was also the housekeepers' responsibility to check on curtains. If they were dirty, they should notify maintenance to remove them, so they could be taken to the laundry to be washed. He stated the risk of having dusty vents was that it could affect resident with allergies and also residents were entitled to a clean and safe homelike environment.<BR/>Interview with Maintenance Director on 04/18/24 at 2:47 PM revealed he had one of his staff who was responsible for ensuring the curtains and the ventilation ducts were clean. He stated the vents were supposed to be removed cleansed and painted at times and other times they only required dusting. He stated he did not like how the ceiling vents looked. He stated he did not manage to see the curtains, but he was informed three privacy curtains were stained, and they were removed by his assistant. He stated he would take full responsibility for the vents and curtains being dirty, and he would be working closely with the staff to ensure they were cleansed. He stated the risk of the ceiling vents being dusty was that if they blew on residents they could be affected, especially those allergic to dust. He also stated residents were entitled to clean and safe environment.<BR/>Interview with Assistant Maintenance Director on 04/18/24 at 3:00 PM revealed he was responsible for the curtains and air vents with help from the housekeepers, but there was no schedule of when to clean them. He stated he did go to the rooms to check how they looked, and he was notified by the director they did not look good. He stated he was notified of the stained curtains, and he saw three were stained. He stated he had to remove them for the housekeepers to wash them. He stated he did not have any reason why the vents and curtains were dirty. He stated residents were entitled to a clean and safe environment. He stated he was notified by the housekeepers if they needed to be changed or washed.<BR/>Interview with the DON on 04/18/24 at 3:44 PM revealed her expectation was that staff performing incontinence care should put soiled briefs in a plastic bag, get them out of the room, and dispose of them in the barrels outside the room. She stated they should not leave soiled briefs in the room to prevent contamination and to control odors. The DON stated she had provided an in-service on incontinence care. <BR/>Review of the facility's Resident Room Cleaning policy dated November 2021 reflected: <BR/>PURPOSE: To provide a clean, attractive, and safe environment for residents, visitors, and staff. <BR/> .K. Heater/ A/C Unit - wipe top and all sides, check top vents for accumulation of dust or debris; remove built-up dirt under the unit, sweep, and damp mop. <BR/>J. Windows - clean window tracks and check curtains/blinds for soiling. Report any soiled blinds or curtains to the Housekeeping Supervisor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 5 residents (Resident #113) reviewed with limited range of motion. <BR/>The facility failed to ensure Resident #113 was receiving contracture management to treat their contracted hands. <BR/>This failure could place residents at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. <BR/>Findings included: <BR/>Review of Resident #113's face sheet, dated 11/08/23, revealed the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute kidney failure, severe sepsis (a life-threatening condition that occurs when an infection triggers a massive inflammatory response in the body, damaging vital organs), and diabetes. <BR/>Review of Resident #113's physician's orders, dated 11/08/23, reflected the following: Frequent visual checks every shift CARROT TO BILATERAL HANDS: as tolerated .remove device and inspect skin under device qshift, if s/s skin breakdown present do not reapply device and notify MD .as of 09/18/23.<BR/>Review of Resident #113's quarterly MDS Assessment, dated 08/10/23, reflected a BIMS score of 00 indicating the resident was unable to complete the interview. <BR/>Review of Resident #113's care plan, dated 04/10/23, reflected the following: Care Area/Problem: *Self Care Deficit [04/10/23 .] Decreased RT fingers ROM .Decreased LT fingers ROM .Goal: Resident will maintain or improve ROM over the next 90 days .<BR/>Observation and interview on 11/06/23 at 10:40 AM revealed Resident #113 in her bed in her room. She did not have carrots in either hand. Resident #113's hands were contracted to where her thumbs were folded into the palms of her hands and her fingers were closed around it. Resident #113 was not able to answer any questions or seem to recognize that questions were being asked. Resident #113 just stared blankly at the surveyor.<BR/>Observation on 11/07/23 at 2:40 PM revealed Resident #113 in her bed in her room. She did not have carrots in either hand.<BR/>Observation on 11/07/23 at 3:17 PM revealed Resident #113 in her bed. She did not have carrots in either hand.<BR/>Interview on 11/07/23 at 3:18 PM with CNA E revealed he was not familiar with Resident #113 because he had only been assigned to her hall today and had not worked with her before. CNA E said he did see that Resident #113 had contractures to both of her hands and described her hands as being closed and in a fist form. CNA E said he would have to ask the nurse if she was supposed to have anything in her hands or not but had not seen anything in her hands today (11/07/23). <BR/>Interview on 11/07/23 at 3:19 PM with LVN D revealed he was Resident #113's nurse and was familiar with her. LVN D said Resident #113 had contractures to both of her hands to where they were closed like a fist. LVN D said Resident #113 did not have any interventions to be put in place for her contractures such as carrots or hand towel rolls. LVN D said the purpose of having those interventions was to reduce the effect and pain caused by contractures. LVN D said it was the nurses responsibility to ensure interventions for contractures were put in place. LVN D said he would have to check and see if Resident #113 had an order for contracture intervention such as a carrot. LVN D said he checked Resident #113's orders and saw that she was supposed to have carrots in both of her hands to prevent the contractures from getting worse. LVN D said the risk to Resident #113 of not having her carrots was that her nails could start to dig into her skin and cause damage like a skin tear and could cause her to be in pain. <BR/>Interview on 11/08/23 at 11:02 AM with the DON revealed she was not sure if Resident #113 had contractures or not. The DON said the responsibility of ensuring contracture interventions were in place as ordered was on the CNA when providing ADL care to residents. The DON said the purpose of having an intervention for a contracture was to minimize them. The DON said the risk to the resident of not having the intervention in place was that it may cause contractures to get worse. <BR/>Review of the facility's Joint Mobility, Splinting, and Range of Motion policy, revised 02/12/20, reflected: The nursing staff will assist the resident with activities of daily living regarding joint mobility, splinting and range of motion using restorative and rehabilitative care techniques [sic].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision. <BR/>The facility failed to ensure Resident #1 who had a history of wandering and exit-seeking, was provided with adequate supervision to prevent her from eloping on 06/09/25. Resident #1 was found 5 minutes away from the facility by police and was transported to the hospital for evaluation due to the resident experiencing hallucinations and delusions. <BR/>The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/10/25. The facility had corrected the noncompliance before the survey began. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 06/18/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 06/05/25, reflected her diagnoses included unspecified dementia, severe, with other behavioral disturbance, schizophrenia, and delusional disorders. Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further revealed Section E - Behaviors indicated Resident #1 exhibited wandering behaviors. <BR/>Record review of Resident #1's care plan, dated 06/04/25, reflected: Care Area/Problem: Attempted to Elopement: Resident is Exit seeking, high elopement risk. Goal: Resident safety will be maintained over the next 90 days. Interventions: Assess for contributing sensory. Check resident location every 15 minutes. Maintain behavior log. Notify physician and family/responsible party. Remove resident from immediate situation to assure safety. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.<BR/>Record review of Resident #1's Resident Visual Monitoring dated 06/04/25-06/05/25 reflected Resident #1 was on 1:1 supervision. <BR/>Record review of Resident #1's Nurse Visual Check Individual Resident Monitoring dated 06/06/25 - 06/09/25 reflected Resident #1 was on 15 minutes checks.<BR/>Record review of Resident #1's progress notes dated 06/09/25 at 6:54 PM by LVN A reflected the following entries: <BR/>7:30 AM - in room dressed for the day<BR/>7:46 AM - CNA summoned resident to the dining room for breakfast and noted resident not in room and window broken. CNA notified nurse and I contacted DON and Administrator. Staff began searching unit and grounds. All other doors and courtyard exit found to be in locked position.<BR/>8:00 AM - unable to find resident in building or on grounds, contacted PD [Police Number] for missing resident. <BR/>8:15 AM [Police Department] police contacted nurse, [LVN A], LVN stating they have resident in custody.<BR/>8:20 AM - Administrator and nursing staff attempting to calm resident along with PD, but resident remained belligerent and psychotic. Currently, she is delusional and believes buzzards are raping her and nursing staff are putting a curse on her.<BR/>8:25 AM - Attempted to transport resident for further evaluation and care via facility van without success.<BR/>8:39 AM - [Police Department] PD unable to coax resident in car or ambulance and were forced to restrain resident with handcuffs for everyone's safety and then transported to [Hospital] for further evaluation and treatment.<BR/>8:39 AM - Nursing staff at ER bedside to give report on patient. ER nurse stated they would have to continue to restrain her and give her some medication in order to do a proper exam. At bedside, no outward sign of injury or c/o pain noticed. unable to contact family members on file as there is no working number. PCP notified of incident.<BR/>Record review of the facility's Provider Investigation Report, completed by the Assistant Administrator on 06/16/25, reflected the following:<BR/>Incident date: 06/09/2025, Time of Incident: 07:45 AM <BR/>Resident noted by staff to not be in room and window broken. Perimeter search completed and [Police Department] police notified. <BR/>Assessment Date 06/09/25; Time: 08:15 AM; <BR/>Resident assessed and no apparent injuries noted. <BR/>Perimeter search and [Police Department] police notified.<BR/>Physician [name], notified. <BR/>Family [name], notified. <BR/>Safe surveys completed. <BR/>Staff in-service on Elopement procedures. <BR/>Entire facility check to ensure all residents accounted for.<BR/>Investigation Summary: Resident noted by nursing staff to not be in room or on south memory community. Resident room noted with broken window. Perimeter search completed and [Police Department] located resident after resident noted missing and transported resident to [hospital] ER for psychiatric evaluation. Staff interview state resident was currently on every 15 minute checks and when checked resident not in room and window broken. Staff state perimeter check completed and when not able to locate during perimeter check [police department] police were notified. Staff interview stat resident had no attempted to leave memory unit prior to this incident. Resident placed on q 15 minute checks due to pacing and wandering in and out of other resident rooms. Chat review reflects resident referred to psych service for behavioral and medication management. <BR/>Provider Action Taken Post-Investigation: <BR/>Resident care plan to be updated upon return from hospital. All staff in-service on Elopement procedures. Window alarms ordered for memory care windows. Resident elopement risk assessments updated. Care plans reviewed and updated for elopement risk residents. QAPI meeting conducted with Medical Director to review elopement protocols and action plan.<BR/>Record review of CNA C statement, dated 06/09/25 at 9:00 AM, reflected: Summoned resident for breakfast and noticed she was missing from her room and window was broken notified charge nurse immediately and assisted in search for resident. <BR/>Record review of LVN A statement, dated 06/09/25 at 9:00AM reflected: CNA notified nurse that resident was missing from room and window was broken. We immediately contacted DON/admin and began search on unit and grounds. Admin assisted with search effort and 911 called; last time seen: 7:30, summoned for breakfast 0745, called DON/ED 0746, began search 0746, called 911 0800, police located resident 0815, staff/admin 0820, 0839 [Police} police restrained resident and escorted to [hospital] for further evaluation and treatment. <BR/>Interview on 06/18/25 at 11:27 AM, CNA B revealed she worked the day Resident #1 eloped from the facility. She stated she was not the CNA assigned to Resident #1. She stated she could not recall the exact time, but she observed Resident #1 standing by her room door and then she closed the door. She stated Resident #1 was on q15 minutes checks and LVN A was completing them. She stated from what she was told Resident #1 was last seen at 7:30 AM in her room, then at 7:45 AM CNA C went to inform Resident #1 it was time for breakfast and that is when they realize she was gone. She stated Resident #1 broke the window and jumped the fence. She stated they called Code Green and initiated a search inside and outside the facility and notified the police department. She stated Resident #1 was found by the police department, unknown where she found. She stated prior to Resident #1's elopement, the resident was placed on 1:1 supervision and then q15 minute checks because Resident #1 was having behaviors and pacing up and down. She stated they were in-serviced on abuse, neglect, and elopement. She stated the facility added alarms to all residents' windows. <BR/>An attempt was made to contact LVN A on 06/18/25 at 11:55 AM by phone; however, there was no answer.<BR/>Interview on 06/18/25 at 2:05 PM, the DON revealed Resident #1 eloped from the facility on 06/09/25. She stated she received a call from LVN A at 7:46 AM and informed her Resident #1 had broken the window from her room. She stated they initiated a search inside and outside the facility. She stated the police was notified and they were able to locate Resident #1 about .5 miles from the facility. She stated Resident #1 was a fast walker, when she was found she had no injuries; however, resident was having behaviors and the police decided to take her to the hospital for further evaluation. She stated prior to Resident #1 elopement, resident was not exit-seeking; however, she was pacing the hall and wandering into residents' rooms. She stated Resident #1 had history of eloping at home. She stated since Resident #1 was wandering into residents' room and pacing the hall, as an intervention, they placed Resident #1 on 1:1 supervision and then she was doing better and placed Resident #1 on q15 minute checks. She stated staff were completing q15 minutes checks when Resident #1 eloped, the last time she was observed was at 7:30 AM and then noticed she was gone at 7:45 AM. She stated all staff were in-serviced on abuse and neglect, and elopement. She stated alarms were also added to both North and South memory care unit and they also implemented resident logs which have to be completed before a resident was taken off the unit either for a visit or therapy session.<BR/>Interview on 06/18/25 at 3:26 PM, the Administrator revealed he had arrived at the facility when he was informed Resident #1 had broken her room window and eloped. He stated the staff had initiated a search inside and outside facility grounds. He stated the police were notified, and the police was able to locate Resident #1 about 5 minutes from the facility. He stated he went to the scene were Resident #1 was located, he stated resident was having behaviors and was transported to the hospital for further evaluation. He stated prior to Resident #1's elopement, they had interventions in place due to Resident #1 having behaviors and refusing medications. He stated Resident #1 was placed on 1:1 and then q15 minute checks due to the resident pacing the halls and wandering into residents' rooms. He stated when Resident #1 eloped, staff were still completing q15 minute checks on Resident #1. He stated they in-serviced all staff on abuse and neglect and elopement. He stated they added alarms to all windows in the memory care unit. The Administrator stated Resident #1 had not returned to the facility since incident. <BR/>Interview on 06/19/25 at 10:16 AM, CNA C revealed she was the CNA assigned to Resident #1 when she eloped. She stated the last time she observed Resident #1 was around 6:15 AM in her room. She stated Resident #1 was on q15 minutes check and LVN A was completing them while she was assisting other residents with getting them up for the day. She stated when it was time for breakfast, she went to Resident #1's room and that was when she noticed Resident #1 was not in the room and the window was broken. She stated she notified LVN A and they began a search for Resident #1. She stated she was in-serviced on abuse and neglect, and elopement. <BR/>Record review of facility Elopement Management policy, revised 05/02/25, reflected the following: <BR/>An immediate investigation and search will be conducted if a resident is considered missing. The resident will be located and returned to a safe environment within standard practice guidelines.<BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 06/18/23 at 4:45 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 06/18/25 at 6:35 PM.<BR/>The facility took the following actions to correct the non-compliance prior to the abbreviated survey:<BR/>Record review revealed an elopement assessment were reviewed and completed on residents on 06/09/25. <BR/>Record review of safe surveys completed by the facility on 06/09/25 with five residents reflected there were no issues noted.<BR/>Record review of the facility's South Memory Unit Elopement binder located at the nurses' station reflected the binder contained pictures of residents, who were elopement risk, and contained information regarding the residents.<BR/>Record review of the facility's Resident Log on North and South Memory Unit reflected residents were being signed out when taken off unit for therapy sessions. <BR/>Observation on 06/18/25 at 11:34 AM revealed all windows in the South Memory Unit had an alarm. Alarms were loud enough to be heard throughout the unit. <BR/>Record review of the following in-services dated 06/09/2025 reflected all facility staff were in-serviced on abuse, neglect, elopement, missing person, and Code [NAME] for elopements/missing persons. The in-services were conducted and signed by all facility staff.<BR/>Interviews on 06/18/25 from 11:22 AM through 06/19/25 at 3:30 PM with CNA B, CNA C, LVN D, CNA E, Wound Care Nurse F, MDS Coordinator G, MDS Coordinator H, CNA I, CNA J, CMA K, CNA L, CNA M, [NAME] K. Physical Therapy O, CNA P, Floor Tech Q, Housekeeping R, Housekeeping Supervisor S, LVN/Coordinator T, LVN U, CNA V, CNA W, RN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, CNA EE, CNA FF, CNA GG, CNA HH, Activity Assistant, and the Assistant Administrator revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize missing person/elopement policy, missing/elopement code, abuse and neglect, completing head counts before and after shift change and alarms added to all windows in the memory care unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #113) reviewed for clinical records. <BR/>The facility failed to ensure staff accurately documented on Resident #113's MAR on 11/07/23. <BR/>This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records.<BR/>Findings included:<BR/>Review of Resident #113's face sheet, dated 11/08/23, revealed th resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute kidney failure, severe sepsis (a life-threatening condition that occurs when an infection triggers a massive inflammatory response in the body, damaging vital organs), and diabetes. <BR/>Review of Resident #113's physician's orders, dated 11/08/23, reflected the following: Frequent visual checks every shift CARROT TO BILATERAL HANDS: as tolerated ***remove device and inspect skin under device qshift, if s/s skin breakdown present do not reapply device and notify MD*** as of 09/18/23.<BR/>Review of Resident #113's quarterly MDS Assessment, dated 08/10/23, reflected a BIMS score of 00 indicating the resident was unable to complete the interview. <BR/>Review of Resident #113's care plan, dated 04/10/23, reflected the following: Care Area/Problem: *Self Care Deficit [04/10/23 .] Decreased RT fingers ROM Decreased LT fingers ROM .Goal: Resident will maintain or improve ROM over the next 90 days <BR/>Observation and interview on 11/06/23 at 10:40 AM revealed Resident #113 in her bed in her room. She did not have carrots in either hand. Resident #113's hands were contracted to where her thumbs were folded into the palms of her hands and her fingers were closed around it. Resident #113 was not able to answer any questions or seem to recognize that questions were being asked. Resident #113 just stared blankly at the surveyor.<BR/>Observation on 11/07/23 at 2:40 PM revealed Resident #113 in her bed in her room. She did not have carrots in either hand.<BR/>Observation on 11/07/23 at 3:17 PM revealed Resident #113 in her bed. She did not have carrots in either hand.<BR/>Review of Resident #113's November 2023 MAR revealed an O for on was documented for the day shift on 11/07/23 for the following order: Frequent visual checks every shift CARROT TO BILATERAL HANDS: as tolerated .remove device and inspect skin under device qshift, if s/s skin breakdown present do not reapply device and notify MD <BR/>Interview on 11/07/23 at 3:19 PM with LVN D revealed he was Resident #113's nurse and was familiar with her. LVN D said he checked Resident #113's orders and saw that she was supposed to have carrots in both of her hands to prevent the contractures from getting worse. LVN D said he did check off on Resident #113's MAR today (11/07/23) that she had the carrots in her hands, ut she actually did not. LVN D said he must have overlooked it when he was charting.<BR/>Interview on 11/08/23 at 11:02 AM with the DON revealed she was not sure if Resident #113 had contractures or not. The DON said she expected staff to document accurately on the resident's MAR. The DON said LVN D should not have documented on Resident #113's MAR that she had the carrots in her hand if they were not actually in her hands. The DON said the purpose of documenting accurately was to make sure orders were completed correctly. The DON said it was the nurse's responsibility for that shift and providing that treatment, medication, or service to document accurately on a resident's MAR. The DON said the risk to the resident was that if staff documented it was provided when it was not it could make it appear that the intervention was not working because it was never provided. <BR/>Review of the facility's policy, revised 01/12/20, and titled Documentation- Clinical reflected: Documentation of the clinical assessment of the resident will be recorded in accordance with state specific regulations, other regulatory bodies as indicated and the practice guideline in the EHR [sic].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident's representative was notified when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. <BR/>The RP/family was not notified when of Resident #1 who was not capable of making decisions was discovered with a new wound on 09/22/23 denying the RP/family the opportunity to participate in the resident's treatment options. <BR/>This failure could place residents at risk of not having the RP/family aware, informed of and/or participating in treatment options.<BR/>Findings included: <BR/>Review of Resident #1's closed clinical records revealed a quarterly MDS assessment dated [DATE]. The MDS assessment reflected the resident was a [AGE] year-old female admitted to the facility 07/05/23. Diagnoses included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertensive heart disease heart problems that occur because of high blood pressure), and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The MDS assessment reflected Resident #1's BIMS score was 0 indicating severe cognitive impairment. The assessment reflected the resident's skin problems included Open lesion(s) other than ulcers, rashes, cuts, and Moisture Associated Skin Damage. Additionally, the resident used a wheelchair for mobility, was always incontinent of bowel/bladder, required extensive physical assistance of two people for bed mobility/transfers and extensive physical assistance of one person for dressing, eating and hygiene.<BR/>Review of Resident #1's comprehensive care plan dated 08/31/23 revealed the problem of risk for and actual impaired skin integrity was addressed. <BR/>Review of nurse's notes dated 09/22/23 documented by LVN A revealed Resident #1 was noted with a new wound to the right middle finger. Orders were received to treat with triple antibiotic ointment. There was no documentation the RP/family was notified of the new wound. <BR/>Review of Resident #1's weekly wound assessments dated September and October 2023 revealed the first documented assessment of the finger wound was 09/26/23 four days after discovery. The assessment dated [DATE] reflected the resident was assessed with a 0.2 by 0.2-centimeter (length by width) area of dried fibrinous exudate (scab) to the right hand/finger that was facility acquired on 09/22/23. Treatment with triple antibiotic ointment continued. According to the assessment a notification was made on 09/26/23, but there was no documentation as to who was notified.<BR/>Interview on 11/10/23 at 10:09 a.m. the TN stated he never spoke to Resident #1's family about the finger wound. <BR/>During an interview on 11/13/23 at 1:26 p.m. the TN stated he notified Resident #1's family about the resident's finger wound on 09/26/23 during his initial assessment of the wound. <BR/>Interview on 11/10/23 at 1:12 LVN A stated she was not able to recall what Resident #1's finger wound looked like on 09/22/23, but thought it looked infected.<BR/>Interview on 11/10/23 at 12:21 p.m. Resident #1's RP stated they noticed a Band-Aid on the resident's finger in August 2003 but was never informed of why the Band-Aid was in place . They stated facility staff never informed them of any wound or problems with the resident's finger until 10/23/23.<BR/>Interview on 11/13/23 at 10:55 a.m. LVN A stated she did not notify Resident #1's RP/family on 09/22/23 when the resident was noted with a wound to the finger. The nurse stated she thought it was close to the end of her shift and she was rushing. LVN A stated the RP/family should be notified for any changes in a resident's condition to include a newly discovered wound and she just forgot to do so.<BR/>Interview on 11/13/23 at 9:30 a.m. the DON stated the facility had initiated in-service training on 11/10/23 for nursing staff related to changes in condition, wounds, and notifications. <BR/>Interview on 11/13/23 at 3:13 p.m. the DON stated it was important to notify the RP/family of any changes in a resident's condition to include the discovery of a new wound because the RP/family should be aware to allow them to be part of the resident's plan of care. She stated the facility's P/P related to acute changes in condition include the discovery of new wounds. <BR/>Review of the facility's P/P revised 01/18/18 related to change in condition revealed the resident's family, guardians, or other appropriate people should be notified when there was a significant change in condition. The P/P defined an acute change of condition as a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important was defined as a deviation that, without intervention, might result in complications or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately for 1 of 3 residents (Resident #1) reviewed for abuse reporting.<BR/>The facility failed to ensure LVN A reported an allegation of sexual abuse involving Resident #1. <BR/>This failure could place residents at risk for not having allegations of abuse reported. <BR/>Findings included:<BR/>1. Review of Resident #1's face sheet, dated 11/07/23, reflected the resident was a [AGE] year-old female. Her diagnoses included a sexually transmitted disease and dementia. <BR/>Review of Resident #1's MDS assessment, dated 09/07/23, reflected she admitted to the facility on [DATE]. The resident's cognitive status was moderately impaired. She had no behaviors. Her diagnoses included traumatic brain dysfunction and depression. <BR/>Review of Resident #1's Care Plan, dated 10/25/23, reflected she had a care plan for dementia, elopement, physical aggression, and sexually transmitted disease. <BR/>There were no care plans for sexual activity. <BR/>A phone interview on 11/04/23 at 11:05 AM with LVN A revealed she told the Surveyor an allegation of abuse. She said in the main building of the facility she was concerned that residents in the male/female memory care unit were being forced into sexual activities with other residents. She said she did not know the names of the residents. She said the staff in the memory care unit were in the area where the residents were being forced into sexual interactions. She said she was also concerned because Resident #1 had a sexually transmitted disease, and it was well known that Resident #1 had sexual encounters with residents and those residents could have been exposed to. LVN A said she did not report the allegation to the facility. She said she did not have names of residents, dates, times, or names of staff involved. She said it was a conversation she overheard but could not remember when or who it was she overheard. LVN A said she reported it to the Surveyor because she felt it was something that needed to be looked into, but she did not want to get involved and had no plans to report the allegation of abuse to the facility. She said she regretted telling the Surveyor because she did not want to get involved. LVN A said she did not do anything to protect the residents from the abuse but that she discussed it with LVN F. LVN A said any sexual activity would be sexual abuse because the residents in the memory care unit could not consent, but she would not report it. <BR/>An interview on 11/04/23 at 10:55 AM with the DON and Administrator revealed there were no allegations of sexual abuse with the male/female memory care unit reported to them. They said Resident #1 was not sexually active and was moved to the all-female unit because she would stand next to the exit door to see the keypad to try to elope . They said that all allegations of sexual abuse had to be reported and investigated. The Administrator said he was going to self-report and investigate the allegation of sexual abuse that the Surveyor reported to him. <BR/>An observation of the male/female secure unit on 11/07/23 at 11:30 am revealed residents were ambulating in the hall and day room. Residents were seated in chairs and couches. There was no inappropriate touching or sexual activity observed. <BR/>An interview on 11/04/23 at 11:35 AM with LVN B revealed there were no residents in the male/female unit who were sexually active. She said Resident #1 never displayed sexual behaviors. LVN B said if she observed or heard about an allegation of abuse, she would report it to the Abuse Coordinator. <BR/>An interview on 11/04/23 at 11:40 am with LVN C revealed there were no residents in the male/female unit who were sexually active. She said Resident #1 never displayed sexual behaviors. LVN C said if she observed or heard about an allegation of abuse, she would report it to the Abuse Coordinator.<BR/>An interview on 11/04/23 at 11:45 am with CNA D revealed there were no residents in the male/female unit who were sexually active. She said some residents would hold hands. CNA D said if she observed or heard about an allegation of abuse, she would report it to the Abuse Coordinator.<BR/>An interview and observation on 11/04/23 at 2:05 PM with Resident #1 revealed she was in the female only memory care unit. She was lying in bed. The resident sat up when the Surveyor entered. The resident said she was doing well and watching TV. The resident was confused, but indicated she was doing ok.<BR/>An interview on 11/04/23 at 2:20 PM with LVN E revealed Resident #1 did not have any sexual behaviors and none of the memory care residents were sexually active. She said if she saw or heard an allegation of abuse she would intervene and report it. <BR/>An interview on 11/04/23 at 2:35 PM with LVN F revealed she was not aware of any allegations of sexual abuse with the memory care residents. She said she worked with Resident #1 and the resident did not have a history of any sexual activity. LVN F said she would report any allegation of abuse she heard or observed to the abuse coordinator. She said she never talked with any staff concerning an allegation of sexual abuse with residents. <BR/>An interview on 11/04/23 at 2:45 PM with the ADON revealed she was not aware of any allegations of sexual activity in either memory care unit. She said Resident #1 did not have a history of sexual activity. The ADON said if she heard or observed an allegation of sexual abuse she would report it. <BR/>An interview on 11/04/23 at 3:00 PM with the Administrator and DON revealed LVN A was working. The Surveyor notified them of the allegation of abuse made by LVN A. They said they were not aware of any allegations of sexual abuse. The Administrator said he would need to report the allegation and conduct a facility investigation. The Administrator said LVN A would be suspended pending investigation. <BR/>An interview on 11/04/23 at 3:40 PM with the DON revealed LVN A was hired in 2021 and had no disciplinary actions related to failure to report. The DON said the facility did on-going in-services for abuse and neglect reporting. She said the most recent in-service was completed in October 2023. She said staff knew who to report to and that the phone number for Abuse Coordinator was posted. <BR/>Record review of an in-service on the Abuse, Neglect, and Misappropriation of Property policy, dated 09/18/23, reflected it was signed by LVN A. <BR/>Review of the Facility Policy and Procedure, Abuse, Neglect and Exploitation and Misappropriation of Resident Property, 02/12/20, reflected:<BR/>Purpose<BR/>The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation, and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one (Resident #1) of five residents reviewed for resident rights.<BR/>The facility failed to ensure Dietary Aide B treated Resident #1 with respect and dignity in her interaction with him on 09/15/23 to which Resident #2 was a witness to. <BR/>This failure led to the residents having feelings of being worried or scared. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 10/12/23, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/03/23. His diagnoses included chronic obstructive pulmonary disease (a persistent respiratory symptoms like progressive breathlessness and cough) and morbid obesity. <BR/>Review of Resident #1's significant change in status MDS Assessment, dated 08/28/23, reflected he had a BIMS of 07, indicating moderate cognitive impairment. <BR/>Review of Resident #2's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure) and hyperlipidemia (high cholesterol). <BR/>Review of Resident #2's quarterly MDS Assessment, dated 08/04/23, reflected he had a BIMS of 14, indicating the resident was cognitively intact. <BR/>Review of the Provider Investigation Report for Incident Intake ID 451901 reflected under the description of the allegation was the following: Resident [#1] states that he was using profanities in the south dining room and the dietary employee told him not to talk that way and stated she was going to take him to his room if he continues. Resident states that employee is unprofessional and should not talk to him that way. Further review revealed under the investigation summary was the following: Resident [#1] states that while he was in the dining room taking [sic] with another resident he started using profanities. Resident [#1] states that he was told by the dining employee that he cannot talk that way in the dining room. He stated employee told him that he would be removed from the dining room if he continued to use profanities in front of the other residents .Employee [Dietary Aide B] denied allegation. Employee [Dietary Aide B] states that she was in the dining room and asked resident to stop using loud profanities in front of other residents.<BR/>In an observation and interview on 10/11/23 beginning at 11:40 AM with Resident #2 revealed he was in his room sitting in a wheelchair. Resident #2 said that a while back he was sitting in the dining room around the corner from his room during the lunch meal service with Resident #1. Resident #2 said he was not sure who the staff was in the dining room with them, but she was from the kitchen staff. Resident #2 said Resident #1 said something to himself or the table of residents and the kitchen staff person probably thought he said something about her or the food. Resident #2 said the kitchen staff got upset and both Resident #1 and the staff member started arguing with each other. Resident #2 said he could not remember everything that was said but did remember her saying that she was going to get her boyfriend up to the facility to whip his butt. Resident #2 said this statement made him worried because he was not sure if she was serious about that or not. Resident #2 said he was especially worried about it because there was not a staff member who sat at the front of the building to watch people coming into the building. <BR/>In an interview on 10/12/23 at 2:03 PM with CNA C revealed she was walking through the dining room one day when she saw Resident #1 and Dietary Aide B verbally going back and forth with each other arguing. CNA C said she was not sure who started the argument or what it was about and was trying to intervene before it escalated. CNA C said she overheard Dietary Aide B tell Resident #1 she was going to get her husband on him. CNA C told Dietary Aide B she could not speak to Resident #1 that way and asked Resident #1 if she could take him away from the dining room and back to his room to which he agreed. <BR/>Attempted interviews via phone on 10/11/23 at 1:17 PM and 1:35 PM with Dietary Aide B were unsuccessful. <BR/>Review of an interview statement from Dietary Aide B, dated 09/20/23, reflected under the interviewer's observations/comments reflected the following: I was preparing meal plates in the dining room on 09/15/23 for lunch. During meal service overheard resident call me a 'bitch' I told the resident note [sic] to speak to me that way and to show me respect. Resident continued to yell profanities at me. I walked away and notified my supervisor [sic].<BR/>In an interview on 10/12/23 at 2:41 PM with the Dietary Manager revealed Dietary Aide B came to her and said Resident #1 was using profane language against her in the dining room. The Dietary Manager said she reported this to the Administrator and Dietary Aide B was suspended pending the investigation of what occurred. She stated since the incident happened in the other building and that was also where Resident #1 lived, when Dietary Aide B was unsuspended, she was only allowed to work in the North Building. She stated she was never told anyone that Dietary Aide B had allegedly threatened Resident #1. The Dietary Manager stated she expected staff to not respond to residents in a verbal way and to notify management if there was a situation arising to that level again. <BR/>In an interview on 10/12/23 at 11:46 AM with the ADON revealed Resident #1 made an allegation of staff being verbally mean to him, and she completed the staff interviews regarding the situation. The ADON said during the interviews no one had reported to her that Dietary Aide B made a threat towards Resident #1. <BR/>In an interview on 10/12/23 at 12:21 PM with DON D revealed he expected residents to be treated with privacy and dignity and expected staff to respond to residents in a professional and calm manner. <BR/>In an interview on 10/12/23 at 12:58 PM with DON E revealed Resident #1 came and told her what happened between him and Dietary Aide B. DON E said Resident #1 told her he said something along the lines of ain't that a bitch while in the dining room and Dietary Aide B misunderstood and thought Resident #1 had called her that name. DON E said Dietary Aide B responded by saying that Resident #1 could not talk like that, or he would have to go to his room . DON E said she was told that Resident #1 and Dietary Aide B went back and forth arguing because Resident #1 felt like Dietary Aide B could not make him leave the area. DON E said she took this as an allegation of abuse, so she stopped Resident #1 from continuing the story, and went to get the Administrator who was the Abuse Coordinator. DON E said she was told that Dietary Aide B said she would tell her husband about the situation but had not heard anything about an alleged threat made. DON E said Dietary Aide B was suspended immediately pending the investigation.<BR/>In an interview on 10/12/23 at 2:09 PM with the Administrator revealed he was the Abuse Coordinator and was responsible for reporting and investigating allegations of abuse. The Administrator said he heard from Resident #1 that he had an issue with Dietary Aide B when she did not like that, he was using profanity in the dining room. The Administrator said Resident #1 was talking to his friend and said the word bitch and Dietary Aide B thought Resident #1 was calling her that name. The Administrator said Dietary Aide B told Resident #1 that he could not talk that way in the dining room and that she would remove him if he continued to speak that way . The Administrator said he was never told about the alleged threat made by Dietary Aide B. The Administrator said staff should not respond to residents and enter into a verbal argument with them and instead should leave and report the situation to him.<BR/>Review of the facility's Exercise of Rights policy, dated 2011, reflected: .5. Our facility will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident has a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of five residents (Resident #1) reviewed for care plans.<BR/>The facility failed to follow Resident #1's care plan intervention of lowering the bed and the use of half bedrails due to fall risk.<BR/>This failure could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing.<BR/>Findings included:<BR/>Record review of Resident #1's electronic face sheet printed on 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included but not limited to Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach. This can cause pain, difficulty in swallowing or chest pain.)<BR/>Record review of the annual MDS dated [DATE] did not indicate a BIMS score. Section GG Functional Abilities reflected Resident #1 required substantial/maximum assistance with transfers and sit to stand. Resident #1 was not coded for falls on the MDS.<BR/>Record review of Resident#1's service plan last reviewed 12/11/2024 revealed Resident #1 was a fall risk with interventions to include call light within reach and &frac12; bed rail use.<BR/>Observation on 03/08/2025 at 11:05 AM of Resident #1's bed revealed it was not in the lowest position, the fall mat was leaning against the wall and the bed rails were down. <BR/>Observation on 03/08/2025 at 3:09 PM of Resident #1 revealed she was in bed sleeping. The bed was not in the lowest position, the bed rails were not raised, and a fall mat was not on the floor. <BR/>Interview on 03/08/2025 at 11:15 AM with LVN A revealed Resident #1's fall mat should have been down and the bed rail should have been up on one side. LVN A stated she was not sure why the fall mat was not down, bed not in lowest position and rail not up. LVN A stated anyone who entered the room should have ensured fall interventions were in place.<BR/>Interview on 03/08/2025 at 11:53 AM with CNA B revealed he had not been in Resident #1's room since around 9:00 AM when he attempted to feed her. He stated he forgot to lower the bed and put the fall mat down when he left the room. CNA B stated he was not aware of what the risk would be if interventions were not followed.<BR/>Interview on 03/08/2025 at 1:30 PM with the Director of Nursing revealed Resident #1 was a fall risk and should have had the bed in the lowest position and the fall mat on the floor on one side of the bed and the bed rail up on the other side of the bed. The Director of Nursing stated all staff should ensure fall interventions were in place each time they enter the room. The Director of Nursing stated the risk of not ensuring interventions were in place would be the resident could fall and get hurt.<BR/>Record review of the facility's Comprehensive Care plan policy, revised 02/12/2020, reflected: Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident care policies were implemented for parenteral fluids based on current professional standards of practice for the preparation, insertion, administration, maintenance, and discontinuance of the IV as well as prevention of infection at the site to the extent possible for 1 of 3 residents (Resident #2)<BR/> reviewed for PICC line dressing change. (PICC- peripherally inserted central catheter-a thin, soft, long tube that is inserted into a vein into the arm, leg, or neck).<BR/>The facility failed to ensure Resident #2 received dressing changes to the PICC line every 7 days as ordered by the physician. <BR/>This failure could place residents at risk of unidentified skin issues and risk of infection . <BR/>Findings include: <BR/>Record review of Resident #2 face sheet, dated 01/18/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Arthritis due to right knee bacteria, Chronic kidney disease and Sepsis. <BR/>Review of Resident #2's MDS dated [DATE] revealed a BIMS of 13, indicating cognitively intact. Resident #2 required extensive for ADLs. He required the assistance of one person assist. Resident #2 required IV feeding while being a resident at the facility.<BR/>Record review of Resident #2's care plan, dated 01/18/23, revealed he required IV Therapy via A PICC line. The facility would assess the catheter site for signs and symptoms of infection. Catheter site dressing change as ordered , onset 12/14/22.<BR/>Review of the physician order dated 01/18/23 revealed an order for Resident #2 PICC Line dressing change, Every Tuesday on every am shift (6am-2pm) or when it becomes, damp, loose, soiled of the patient develops problems at the site that requires further inspection, start date 12/13/21.<BR/>Record review of Resident #2's progress notes dated 01/01/23 to 01/18/23 revealed the dressing change for the PICC line was completed on 01/05/23.<BR/>Record review of Resident #2 MAR/TAR, dated 01/18/22, revealed Resident #2 received dressing changes to the PICC line on 01/03/23, 01/10/23 and 01/17/23.<BR/>Observation on 01/18/23 at 1:48 PM revealed the PICC line dressing was dated 01/05/23 for Resident #2 .<BR/>An interview with Resident #2 on 01/18/23 at 1:50 pm revealed no concern regarding pain.<BR/>Observation and interview on 01/18/23 with the DON at 2:13 PM, inside of Resident #2's room, revealed Resident #2's PICC line dressing was last changed on 01/05/23, according to the date on the bandage. She revealed there was no signs or symptoms of infection noted for Resident #2. The site was not painful for Resident #2 . The DON asked Resident #2 while observing the site.<BR/>Further interview with the DON on 01/18/23 at 2:20 PM revealed after reviewing the physician orders for Resident #2 the dressing change for the PICC line must be completed every 7 Tuesday. The orders also revealed a PRN order to change the dressing as needed if soiled or loosen. The charge nurses were responsible for changing the dressing as ordered. There was no reason why the dressing change had not been completed since 01/05/23. She had not been made aware Resident #2 had refused dressing changes. The DON stated no one had informed her of any concerns of the dressing changes not being completed as ordered. The nurses were required to follow the physician orders. The DON stated it was important for Resident #2 to have the dressing changes and not changing the dressing had the potential of infection.<BR/>An interview with the Attending Physician on 01/18/23 at 2:43 PM revealed he was not aware of the dressing changes for the PICC line not being completed as ordered. The Attending Physician stated the dressing change must be completed to prevent infection.<BR/>An interview with LVN D on 01/18/23 at 2:50 PM revealed Resident #2 had an order for dressing changes to the PICC line site, schedule for every Tuesday or PRN . LVN D revealed he had documented on 01/03/23 and 01/10/23 he completed the dressing change, though he had not completed the dressing change on 01/10/23. He had not completed the dressing change on 01/10/23 because the dressing change had recently been completed and it looked good. LVN D stated the dressing must be completed as ordered to prevent infection. <BR/>Record review of the facility's Dressing change for Vascular access devices policy, dated 08/21, revealed .1. Short peripheral catheter dressings are changed every 7 days or when the integrity of the dressing is compromised. Change the dressing if moisture, drainage, or blood is present or for further assessment if infection is suspected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**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, the comprehensive person-centered care plan, and the resident's choices to meet each resident's physical mental and psychosocial needs for one (Resident #6) of seven residents reviewed for quality of care.<BR/>The facility failed to ensure Resident # 6 received medications according to physician orders for pain management when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 was in pain for three days before being sent to the hospital.<BR/>This failure placed residents at risk of unrelieved pain and discomfort.<BR/>An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM.<BR/>Findings included: <BR/>Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on 11/07/2022. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome.<BR/>Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined.<BR/>Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell. Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected.<BR/>Review of the Incident Report dated 11/04/22 reflected Resident # 6 was involved in a witnessed altercation with a fall and had pain upon movement at a level four on a scale of 1-10. <BR/>Review of Resident #6's Physician's Orders reflected the only pain ordered for Resident # 6 was 500 mg of Naproxen. One tablet was to be given twice per day as needed for Mild pain on a scale of 1-3. This Naproxen medication was to be given with food and the diagnosis for this medication was central pain syndrome.<BR/>Review of the Medication Administration Record (MAR) in the electronic medical record on 01/12/23 for Resident #6 revealed she had pain at a level six to her left hip on 11/06/22 in the evening. The MAR also revealed Naproxen was not administered to Resident # 6 from 11/4/22 through 11/7/22. The MAR reflected that no pain medication was given to Resident #6 during that time frame. <BR/>Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out.<BR/>Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport.<BR/>Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell. LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation.<BR/>Review of the Witness Statement dated 11/08/22 reflected CNA AF witnessed the incident with Resident # 6 and notified LVN S immediately. CNA AF's written statement indicated, Resident #6, continued to have symptoms of pain to her left hip and decreased mobility on 11/5/22 and 11/6/22, I notified the charge nurse and resident remained in bed on those dates.<BR/>Interview on 12/22/22 at 10:20 AM with LVN S revealed the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. In a later interview on 01/12/23 at 10:09 AM LVN S stated she gave Resident #6 pain medication after she fell on [DATE]. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. A later phone Interview on 01/12/23 at 3:01 PM with LVN S revealed she attributed not documenting the administration of the Naproxen to the adrenaline of the whole issue.<BR/>Interview on 01/12/23 at 11:27 AM with CNA AF stated Resident # 6 was able to walk to the dining room on 11/4/22 after the fall with no problem after LVN S did all the assessments. CNA AF stated that on 11/5/22 Resident # 6 was no longer getting up, could not walk and was screaming of pain. CNA AF stated that Resident #6 was able to walk before the fall, although if the staff would let her, she would lay in bed all day. <BR/>In an interview on 01/12/23 at 12:45 PM the ADON stated she checked their system and did not find any documentation of pain medication given to Resident #6, however she spoke with LVN S who stated she gave Resident # 6 Naproxen. <BR/>Interview on 12/22/22 at 3:38 PM with Resident # 6's Primary Contact listed on Face Sheet stated Resident #6 was diagnosed with left hip fracture and had surgery where her socket was removed. The primary contact stated the resident was still in pain and was at another (different) facility and had to go on hospice after the surgery. The Primary contact stated Resident #6 used to walk and now she stayed in a fetal position in bed because she was in too much pain. <BR/>Interview on 01/12/23 at 5:30 PM DON stated if a Resident has had a fall, their pain should be treated. DON stated that if pain medication was not adequate, the staff should contact the doctor to get something stronger so that the resident is not in distress. DON stated If the stronger medication does not help, the resident should be sent to the hospital. DON also stated that in the nursing world if it was not documented, it was not done. <BR/>Review of the facility's Pain Management and Basic Comfort Measures policy, revised 01/12/20, revealed, .Provide pain medication as prescribed by an authorized prescriber . Consult with family members, other health care providers for assistance with pain management techniques . Observe for unresolved pain and address per physician's orders . Record pain management techniques in the record. <BR/>The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023.<BR/>The facility implemented the following interventions to address non-compliance:<BR/>Review of the facility's one on one in-service (training) titled Fall prevention, Xray ordering process, family communication, dated 11/07/22 with LVN included: pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. <BR/>Review of the facility's In-Service for all nursing staff on falls with injury dated 11/8/22, included pain management. <BR/>Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. <BR/>In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. In a later interview on 1/13/23 at 3:01 PM LVN S stated the Unit Manager discussed with her about the fall process and stressed the importance of documenting administration of medication because if it is documented it means it was not done. The Unit Manager pointed out to her that she needed to call the doctor for a stronger medication since the Naproxen was only for pain on a scale of 1-3. LVN S stated she has since had to call the doctor for stronger pain meds for a different patient with a similar issue. <BR/>Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for pain management, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff had been in-serviced on these topics. The nurses also were aware that if there was not a medication to cover the pain level indicated, that they should call the doctor to get another order. <BR/>Observations from 12/20/22 at 7:40 PM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13).<BR/>Interviews with Residents with PRN pain management on 01/12/23 revealed they got medication when requested and they were not in any pain (Resident #'s 11, 12 and 13).<BR/>Review of the MAR for Residents with PRN pain management revealed pain assessments were completed and pain medications administered as ordered for Resident #'s 11, 12, 13, 15, 16, 17 and 18.<BR/>Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON.<BR/>In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and DON were following up to check what was done to address the pain scale on the incident reports. The ADON and DON were monitoring pain meds and ensuring they had meds ordered that covered all numbers on the pain scale. The DON stated for example that if a Resident only had pain medication coverage for pain level of 1-3, the facility would call the doctor to get a medication to cover a higher level of pain. DON stated the IDT team met daily to review each fall and to ensure follow up from each department as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical procedures for notification of the ordering physician for one (Resident #6) of five residents reviewed for diagnostic services.<BR/>The facility did not ensure diagnostic services were provided for Resident #6 as ordered when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 remained at the facility for three days before being sent to the hospital where the x-rays were obtained.<BR/>These failures could place residents at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering.<BR/>An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM.<BR/>Findings included: <BR/>Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on 11/07/2022. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome.<BR/>Review of Resident # 6's Care Plan dated 12/23/22 revealed a 'fall care plan was in place with the following intervention added on 11/04/22, Assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc.<BR/>Review of 24-hour report dated 11/4/22 reflected a comment written by LVN S, resident was pushed down by another resident, exhibited pain in left hip call Dr and ordered x-ray.<BR/>Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined.<BR/>Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out.<BR/>Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport.<BR/>Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell. Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected.<BR/>Review of facility's Provider Investigation Report dated 11/15/22 revealed Resident # 6 was pushed by another resident on 11/08/22 which resulted in a witnessed fall. Resident # 6 was assessed and complained of pain to left lower leg. Further review of the report indicated the resident was sent to ER for further evaluation where x-rays revealed a fracture to the left hip. This report reflected the incident occurred on 11/8/22 even though it occurred on 11/4/22. The facility was informed of Resident # 6's x-ray results on 11/8/22 after sending her to the hospital on [DATE]. The facility in-serviced (trained) staff on abuse, neglect, resident to resident behaviors, fall with injury and x-ray ordering on 11/8/22.<BR/>Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell. LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation.<BR/>Interview and record review on 12/20/22 beginning at 7:53 AM with LVN AA revealed a one-time left hip x-ray (2 views) was ordered for Resident # 6 on Friday 11/04/22. A Stat x-ray with the same views was ordered for Resident # 6 on Sunday 11/06/22. LVN AA stated he did not know why the x-rays were not done. LVN AA stated after reviewing the record that it was LVN S that entered the x-ray orders. LVN AA stated that it was the doctor and not the LVN that determined the type of x-ray that was ordered, whether stat or regular. LVN AA stated that normal practice was if someone had a fall and was in pain, to get an order from the doctor, enter the order into the system and then call it into the x-ray company. <BR/>Interview on 12/22/22 at 10:20 AM with LVN S stated she entered an x-ray order after Resident # 6 fell on [DATE]. LVN S stated she had some time off in between the two x-ray orders on 11/04/22 and 11/06/22. LVN S stated the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. <BR/>Interview on 01/12/23 at 10:09 AM with LVN S revealed at the time of the fall LVN S did not know she had to call the x-ray company after entering the order in the facility's electronic medical record. LVN S stated she did not call the company on 11/4/22, however she stated she called them on 11/06/22. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. <BR/>Interview via telephone on 12/22/22 at 11:22 AM with NP AD revealed the x-ray company typically obtained the x-ray the same day it was ordered whether he ordered a stat x-ray or not. He stated that when x-ray orders came in, the facility was supposed to informed him right away. NP AD stated if an x-ray revealed a fracture, it would be an immediate transfer to the ER. NP AD stated with a fall on 11/4/22, if the staff called him on 11/6/22 he would have told them if an x-ray was not done within the hour, that the Resident should be sent out to the hospital. When informed Resident # 6 was not sent out until 11/7/22 after falling on 11/4/22, NP AD was surprised at the length of time that had elapsed, NP AD stated he did not know what happened, and stated that he always answered his phone. <BR/>Interview on 12/22/22 at 3:38 PM with Resident # 6's primary contact listed on Resident # 6's Face Sheet on revealed Resident was diagnosed with left hip fracture and had surgery where her socket was removed. She stated the resident was still in pain and was at another facility and had to go on hospice after the surgery. She stated Resident #6 used to walk and now she stayed in the fetal position in bed because she was in too much pain. <BR/>Interview on 12/22/22 beginning at 5:02 PM with the Assistant Administrator and DON revealed LVN S should have called the x-ray company to find out the estimated time of arrival of the x-ray company. They stated LVN S thought that when she entered the order in the facility's electronic medical record platform, that it automatically went to the x-ray company, but there was actually an additional step. DON stated The facility needed to fax the company and then the company would call to confirm. The Assistant Administrator stated that after the incident she told LVN U, the Unit Manager to educate LVN S on the process of x-ray ordering. The Assistant Administrator stated x-ray ordering should have been part of LVN S's new hire training process. The DON stated the LVN that worked 2-10 PM shift on 11/06/22 should have sent Resident # 6 out to the hospital when it was realized that the x-ray was not obtained in the time frame (3-4 hr span of time) provided by the nurse practitioner. The DON stated she understood the danger of having a long-time lapse before being sent to the hospital after a fall. She stated if a person was normally ambulatory and then that changes, they should have an x-ray and often those patients need to be sent out to the hospital for further evaluation. <BR/>In a later interview on 01/12/23 at 12:01 PM with the DON and ADON, it was clarified that staff could either enter the x-ray order in the online portal of the x-ray company or call them on the phone to communicate the x-ray order. <BR/>The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023. <BR/>The facility implemented the following interventions to address non-compliance:<BR/>Review of the facility's In-Service (training) dated 11/07/22 reflected LVN U, the Unit Manager provided one on one training to LVNS S titled Fall prevention, Xray ordering process, family communication, included pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. <BR/>Review of the facility's in-service dated 11/8/22 reflected training for all nursing staff on Falls with Injury, included instructions on ordering x-rays from the x-ray company. <BR/>Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. <BR/>In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. LVN S stated she was given instructions on the entering the x-ray orders on the online portal of the x-ray company and on calling the company on the phone to get confirmation that the order was received.<BR/>Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for ensuring x-ray orders were carried out, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff stated they had been in-serviced on these topics. <BR/>Observations from 12/20/22 at 7:40 AM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13).<BR/>Review of facility Fall Incidents between November 2022 and December 2022, aside from Resident # 6, reflected facility residents with a fall were sent out to the hospital in a timely manner when a change of condition was identified for Resident #'s 4, 8, 9 and 10.<BR/>Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON.<BR/>In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and the DON were following up to check that x-rays were completed if ordered. DON stated the IDT Team met daily to review each fall and to ensure follow up from each department as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of COVID-19 for 1 of 2 (Resident # 2) residents and 3 of 5 (CNA B, CNA C, and Med Aide D) staff reviewed for infection control. <BR/>The facility failed to ensure CNA B, CNA C, and Med Aide D were wearing appropriate PPE and following infection control practices during care of residents positive with COVID-19. The staff subsequently entered rooms of residents who were negative for COVID-19 and did not perform hand hygiene during meal service.<BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>These failures could place residents at risk of exposure of Covid-19 virus which could result in serious illness, hospitalization, and/or death. <BR/>Findings included: <BR/>Record review of Resident # 2's face sheet, dated 12/23/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Record review Resident # 2's consolidated orders, dated 12/23/22, revealed she had a diagnosis of COVID-19.<BR/>Review of the Resident Census Roster dated 12/20/22 revealed as of 12/20/22 two residents (including Resident # 2) were positive for COVID-19 and Resident # 2 was assigned to RM [ROOM NUMBER]. <BR/>Review of Admission/Discharge log revealed Resident # 2 went to the hospital on [DATE] and returned to the facility on [DATE].<BR/>Review of Isolation list revealed Resident # 2 was placed on isolation upon return to the facility on [DATE] because she tested positive for COVID-19 while at the hospital. <BR/>Interview with Resident # 2's family representative on 12/20/22 at 8:54 AM revealed there was a camera in Resident # 2's room. <BR/>Review of video footage on 12/20/22 at 9:15 AM revealed CNA A and an unknown agency staff were at bedside of Resident # 2 to perform incontinent care at 4:40 AM that morning. Both staff wore a N95 mask and gloves. No eye protection or gowns were noted. CNA A wore two N95 masks with the top strap of both masks behind her head, while the bottom straps of both masks hung underneath her chin.<BR/>Review of the staff schedule dated 12/19/22 revealed CNA A was assigned to 23 residents on 12/19/22 10PM-6AM shift, including Residents #2 and #3. The schedule also revealed 2 agency aides had worked on that shift as well.<BR/>Interview via telephone with CNA A on 12/21/22 at 7:07 AM revealed she did not know the name of the aide that helped her change Resident # 2 in the morning on 12/20/22. When asked what the appropriate PPE was for entering a covid-19 positive room, CNA A stated gown, gloves, face shield and mask.<BR/>Interview with Staffing Coordinator on 12/20/22 at 3:30 PM revealed she did not have access to the phone numbers of the staff sent to her from the agency company with whom the facility had a contract. <BR/>Observation on 12/20/22 at 5:56 PM revealed CNA B entered Resident # 2's room to answer the call light. CNA B was wearing an N95 and a face shield. He did not wear a gown.<BR/>Review of video footage of Resident # 2's room from 12/20/22 at 5:56 PM when CNA B answered the call light revealed CNA B reached over without gloves, grabbed the resident with both hands and pulled her over so that she was positioned in the center of the bed. The video footage revealed hand hygiene was not performed while CNA B was in the room. <BR/>Observation on 12/20/22 at 5:58 PM revealed CNA B exited Resident # 2's room pushed his face shield up to his forehead leaving the face shield at an angle and pulled his N95 down below his chin and turned around to speak with the resident from the doorway. No hand hygiene was performed. <BR/>Observation on 12/20/22 at 6:02 PM to 6:14 PM revealed CNA B in a COVID-19 negative room delivering dinner meals. CNA B exited the COVID-19 negative room and proceeded to the beverage cart on the hallway. CNA B picked up drinking cups by the rim and lined them up on the cart, grabbed pitchers of water and iced tea and poured drinks into the respective cups. CNA C then grabbed those same beverage pitchers to pour drinks that were delivered to other residents as well. CNA B delivered resident meals and beverages, and helped residents get set up to eat in four covid negative resident rooms. Each room housed two residents each (8 residents total). CNA B used hand sanitizer only once upon exit of one of the four rooms.<BR/>Observation on 12/20/22 at 6:15 PM revealed CNA C and the kitchen server pushed the beverage and hot food cart down to the other side of the 100 hall to continue serving meals to covid negative residents (the same cart CNA B had touched to deliver food to residents after entering Resident #2's room). <BR/>Interview via telephone on 12/21/22 at 12:36 PM with CNA B revealed he recalled entering Resident # 2's room without a gown during the evening shift on 12/20/22. CNA B stated there were gowns available in the gray container outside the resident's room and stated he could not explain why he did not wear a gown before entering the room. He stated he had been in-serviced recently on the need to wear N95, face shield and gown to enter a covid positive room. He stated handwashing was covered in the recent in-services. CNA B stated entering a covid positive room without proper PPE and then entering a covid negative room could increase the chances of getting other residents sick or contamination of other things. <BR/>Review of video footage revealed on 12/20/22 at 7:13 PM Med aide D entered Resident # 2's room with medications and a cup. Med aide D wore gloves, N95 mask and goggles. He was not wearing a gown.<BR/>Observation on 12/20/22 at 7:30 PM revealed Med aide D entered a covid negative room to administer medications to both residents in that room.<BR/>In an interview on 12/21/22 at 4:10 PM Med aide D revealed he gave Resident # 2 her medications first for the 7PM medication pass on 12/20/22. Med aide D stated after Resident # 2, he gave meds to two residents on the same side of the hall as Resident # 2, and then gave meds to the residents on the A side of 100 hall as most of the residents on that hall had 7PM meds ordered. Med aide D stated it escaped his mind to use the gown when he administered meds to Resident # 2 on 12/20/22. He stated the risk for entering covid negative rooms after not wearing appropriate PPE in a covid positive room was transmission of covid-19. <BR/>Record review of the Coronavirus Management Plan Texas Phase 2 & 3, which the facility was using as their policy, dated 11/03/22, revealed COVID Positive Unit .Personnel who enter the room will wear N95 respirators. In addition, staff should wear a gown, gloves, and face shield or goggles.<BR/>Review of the CDC Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-10) Pandemic, dated 09/23/22, reflected HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>On 12/21/22 at 1:11 PM the Assistant Administrator, DON and Regional Director of Operations were notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>The facility's Plan of Removal was accepted on 12/22/22 at 12:14 PM and reflected the following: [name of the facility]<BR/>PLAN OF REMOVAL<BR/>FOR <BR/>IMMEDIATE JEOPARDY on 12/21/22<BR/>To Whom it May Concern,<BR/>Infection Control<BR/>F880- The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. <BR/>Identify residents who could be affected<BR/>All residents have the potential to be affected by this alleged proficient practice<BR/>Problem<BR/>Staff members were seen providing care for a COVID positive resident without wearing appropriate PPE and/or wearing PPE in an inappropriate manner.<BR/>Staff members were seen not performing hand hygiene after entering a COVID positive resident's room and when passing meal trays to residents.<BR/>Action Taken <BR/>Infection Control<BR/>&cent; <BR/>ICP will re-educate Director of Nursing and Assistant Director of Nursing on company's infection control policy related to Covid 19 by end of day on 12/22/2022.<BR/>&cent; <BR/>Use of alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer<BR/>&cent; <BR/>Donning/Doffing of proper PPE for N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms<BR/>&cent; <BR/>ICP is responsible for monitoring the education of the Director of Nursing and the Assistant Director of Nursing on company's infection control policy related to Covid 19<BR/>Hand Hygiene and Competency<BR/>&cent; <BR/>Staff in-servicing on alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer with competency conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or Designee include staff handwashing and when to use hand sanitizer. <BR/>&cent; <BR/>Competencies consist of review of necessary steps and 100 % accuracy on return demonstration.<BR/>&cent; <BR/>Inservicing was implemented on 12/21/2022. All staff to be included in training. Training to be completed by 12/23/22. Staff not physically in community to receive their education in person prior to their next shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their next shift. <BR/>&cent; <BR/>Monitoring will begin 12/22/2022 and will be conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or designee to observe and document hand hygiene compliance twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>PPE and Competency<BR/>&cent; <BR/>ICP, Director of Nursing, Assistant Director of Nursing, and Designee in-serviced all staff on what PPE to wear to include type of mask i.e. N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms <BR/>&cent; <BR/>All staff will be in-serviced in person prior to working their shift. Training to be completed by 12/23/22 Those not physically in community will receive their education in-service in person prior to working their shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration prior to working their next shift. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their first shift. <BR/>&cent; <BR/>Monitoring began 12/22/2022 and will be done by ICP, Director of Nursing, Assistant Director of Nursing, or designee through random questioning on PPE and hand hygiene to ensure knowledge has been retained on various eight hour shifts to begin 12/22/2022. <BR/>&cent; <BR/>Director of Nursing or designee is rounding twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance ensuring proper infection control practices are in place through observation and questioning. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>On 12/22/22 to 12/23/22 the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by:<BR/>Review of the facility's in-service and competency testing records revealed:<BR/>1.The DON's name was listed as the facilitator of the in-services. The in-service topic was Infection Control, Covid-19 with an emphasis on hand hygiene and donning/doffing PPE.<BR/>2.As of 12/23/22 at 4:40 PM a total of 132 staff employed at the facility had been in-serviced and passed the hand hygiene and PPE competency.<BR/>Observations conducted from 12/22/22 at 10:55 AM to 5:00 PM on 12/23/22 revealed staff were donning and doffing PPE appropriately upon entrance and exit of covid-19 positive rooms. <BR/>Interviews conducted on 12/23/22 from 9:48 AM to 5:30 PM with staff from all three shifts(LVN E, Med aide F, CNA G, CNA H, CNA I, CNA J, COTA, ST Assistant Director, LVN K, Housekeeper L, Environmental Director, Laundry aide, Dietary cook M, Dietary cook N, PT O, CNA P, RN Q, CNA R, LVN S, CNA T, LVN U, LVN V, Housekeeper Z, LVN W, RN X, CNA Y, and Rehab tech), revealed staff were knowledgeable about what PPE was required to enter a COVID-19 positive room and why hand hygiene was important after doffing to prevent the spread of infection. The staff stated they had to watch videos on hand hygiene and PPE and had to perform a skills test.<BR/>In an interview with the ADON on 12/23/22 at 4:56 PM it was revealed that utilizing PPE and performing hand hygiene was the way to ensure COVID-19 was not being spread when going from a positive room to a negative room. The ADON stated charge nurses, direct supervisors and everyone was in charge of going behind staff to ensure they followed infection control protocols. They could make rounds and address any issues at that time. The ADON stated an IJ was identified because the staff were not following the proper PPE and hand hygiene protocols, thereby placing residents at risk. The ADON stated the facility was going to implement ongoing monitoring, monitoring tools and schedules to ensure proper infection control measures were followed. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated an IJ was identified because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated she understood why this was identified as an IJ because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview on 12/23/22 at 5:48 PM, the Assistant Administrator stated an IJ was identified because of the failure of staff to wear the proper PPE, going in and out of resident rooms that were covid positive and negative in addition to concerns with handwashing and sanitizing. She stated all this could lead to potential harm or spread of infections and diseases. <BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of COVID-19 for 1 of 2 (Resident # 2) residents and 3 of 5 (CNA B, CNA C, and Med Aide D) staff reviewed for infection control. <BR/>The facility failed to ensure CNA B, CNA C, and Med Aide D were wearing appropriate PPE and following infection control practices during care of residents positive with COVID-19. The staff subsequently entered rooms of residents who were negative for COVID-19 and did not perform hand hygiene during meal service.<BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>These failures could place residents at risk of exposure of Covid-19 virus which could result in serious illness, hospitalization, and/or death. <BR/>Findings included: <BR/>Record review of Resident # 2's face sheet, dated 12/23/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Record review Resident # 2's consolidated orders, dated 12/23/22, revealed she had a diagnosis of COVID-19.<BR/>Review of the Resident Census Roster dated 12/20/22 revealed as of 12/20/22 two residents (including Resident # 2) were positive for COVID-19 and Resident # 2 was assigned to RM [ROOM NUMBER]. <BR/>Review of Admission/Discharge log revealed Resident # 2 went to the hospital on [DATE] and returned to the facility on [DATE].<BR/>Review of Isolation list revealed Resident # 2 was placed on isolation upon return to the facility on [DATE] because she tested positive for COVID-19 while at the hospital. <BR/>Interview with Resident # 2's family representative on 12/20/22 at 8:54 AM revealed there was a camera in Resident # 2's room. <BR/>Review of video footage on 12/20/22 at 9:15 AM revealed CNA A and an unknown agency staff were at bedside of Resident # 2 to perform incontinent care at 4:40 AM that morning. Both staff wore a N95 mask and gloves. No eye protection or gowns were noted. CNA A wore two N95 masks with the top strap of both masks behind her head, while the bottom straps of both masks hung underneath her chin.<BR/>Review of the staff schedule dated 12/19/22 revealed CNA A was assigned to 23 residents on 12/19/22 10PM-6AM shift, including Residents #2 and #3. The schedule also revealed 2 agency aides had worked on that shift as well.<BR/>Interview via telephone with CNA A on 12/21/22 at 7:07 AM revealed she did not know the name of the aide that helped her change Resident # 2 in the morning on 12/20/22. When asked what the appropriate PPE was for entering a covid-19 positive room, CNA A stated gown, gloves, face shield and mask.<BR/>Interview with Staffing Coordinator on 12/20/22 at 3:30 PM revealed she did not have access to the phone numbers of the staff sent to her from the agency company with whom the facility had a contract. <BR/>Observation on 12/20/22 at 5:56 PM revealed CNA B entered Resident # 2's room to answer the call light. CNA B was wearing an N95 and a face shield. He did not wear a gown.<BR/>Review of video footage of Resident # 2's room from 12/20/22 at 5:56 PM when CNA B answered the call light revealed CNA B reached over without gloves, grabbed the resident with both hands and pulled her over so that she was positioned in the center of the bed. The video footage revealed hand hygiene was not performed while CNA B was in the room. <BR/>Observation on 12/20/22 at 5:58 PM revealed CNA B exited Resident # 2's room pushed his face shield up to his forehead leaving the face shield at an angle and pulled his N95 down below his chin and turned around to speak with the resident from the doorway. No hand hygiene was performed. <BR/>Observation on 12/20/22 at 6:02 PM to 6:14 PM revealed CNA B in a COVID-19 negative room delivering dinner meals. CNA B exited the COVID-19 negative room and proceeded to the beverage cart on the hallway. CNA B picked up drinking cups by the rim and lined them up on the cart, grabbed pitchers of water and iced tea and poured drinks into the respective cups. CNA C then grabbed those same beverage pitchers to pour drinks that were delivered to other residents as well. CNA B delivered resident meals and beverages, and helped residents get set up to eat in four covid negative resident rooms. Each room housed two residents each (8 residents total). CNA B used hand sanitizer only once upon exit of one of the four rooms.<BR/>Observation on 12/20/22 at 6:15 PM revealed CNA C and the kitchen server pushed the beverage and hot food cart down to the other side of the 100 hall to continue serving meals to covid negative residents (the same cart CNA B had touched to deliver food to residents after entering Resident #2's room). <BR/>Interview via telephone on 12/21/22 at 12:36 PM with CNA B revealed he recalled entering Resident # 2's room without a gown during the evening shift on 12/20/22. CNA B stated there were gowns available in the gray container outside the resident's room and stated he could not explain why he did not wear a gown before entering the room. He stated he had been in-serviced recently on the need to wear N95, face shield and gown to enter a covid positive room. He stated handwashing was covered in the recent in-services. CNA B stated entering a covid positive room without proper PPE and then entering a covid negative room could increase the chances of getting other residents sick or contamination of other things. <BR/>Review of video footage revealed on 12/20/22 at 7:13 PM Med aide D entered Resident # 2's room with medications and a cup. Med aide D wore gloves, N95 mask and goggles. He was not wearing a gown.<BR/>Observation on 12/20/22 at 7:30 PM revealed Med aide D entered a covid negative room to administer medications to both residents in that room.<BR/>In an interview on 12/21/22 at 4:10 PM Med aide D revealed he gave Resident # 2 her medications first for the 7PM medication pass on 12/20/22. Med aide D stated after Resident # 2, he gave meds to two residents on the same side of the hall as Resident # 2, and then gave meds to the residents on the A side of 100 hall as most of the residents on that hall had 7PM meds ordered. Med aide D stated it escaped his mind to use the gown when he administered meds to Resident # 2 on 12/20/22. He stated the risk for entering covid negative rooms after not wearing appropriate PPE in a covid positive room was transmission of covid-19. <BR/>Record review of the Coronavirus Management Plan Texas Phase 2 & 3, which the facility was using as their policy, dated 11/03/22, revealed COVID Positive Unit .Personnel who enter the room will wear N95 respirators. In addition, staff should wear a gown, gloves, and face shield or goggles.<BR/>Review of the CDC Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-10) Pandemic, dated 09/23/22, reflected HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>On 12/21/22 at 1:11 PM the Assistant Administrator, DON and Regional Director of Operations were notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM.<BR/>The facility's Plan of Removal was accepted on 12/22/22 at 12:14 PM and reflected the following: [name of the facility]<BR/>PLAN OF REMOVAL<BR/>FOR <BR/>IMMEDIATE JEOPARDY on 12/21/22<BR/>To Whom it May Concern,<BR/>Infection Control<BR/>F880- The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. <BR/>Identify residents who could be affected<BR/>All residents have the potential to be affected by this alleged proficient practice<BR/>Problem<BR/>Staff members were seen providing care for a COVID positive resident without wearing appropriate PPE and/or wearing PPE in an inappropriate manner.<BR/>Staff members were seen not performing hand hygiene after entering a COVID positive resident's room and when passing meal trays to residents.<BR/>Action Taken <BR/>Infection Control<BR/>&cent; <BR/>ICP will re-educate Director of Nursing and Assistant Director of Nursing on company's infection control policy related to Covid 19 by end of day on 12/22/2022.<BR/>&cent; <BR/>Use of alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer<BR/>&cent; <BR/>Donning/Doffing of proper PPE for N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms<BR/>&cent; <BR/>ICP is responsible for monitoring the education of the Director of Nursing and the Assistant Director of Nursing on company's infection control policy related to Covid 19<BR/>Hand Hygiene and Competency<BR/>&cent; <BR/>Staff in-servicing on alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer with competency conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or Designee include staff handwashing and when to use hand sanitizer. <BR/>&cent; <BR/>Competencies consist of review of necessary steps and 100 % accuracy on return demonstration.<BR/>&cent; <BR/>Inservicing was implemented on 12/21/2022. All staff to be included in training. Training to be completed by 12/23/22. Staff not physically in community to receive their education in person prior to their next shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their next shift. <BR/>&cent; <BR/>Monitoring will begin 12/22/2022 and will be conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or designee to observe and document hand hygiene compliance twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>PPE and Competency<BR/>&cent; <BR/>ICP, Director of Nursing, Assistant Director of Nursing, and Designee in-serviced all staff on what PPE to wear to include type of mask i.e. N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms <BR/>&cent; <BR/>All staff will be in-serviced in person prior to working their shift. Training to be completed by 12/23/22 Those not physically in community will receive their education in-service in person prior to working their shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration prior to working their next shift. <BR/>&cent; <BR/>This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their first shift. <BR/>&cent; <BR/>Monitoring began 12/22/2022 and will be done by ICP, Director of Nursing, Assistant Director of Nursing, or designee through random questioning on PPE and hand hygiene to ensure knowledge has been retained on various eight hour shifts to begin 12/22/2022. <BR/>&cent; <BR/>Director of Nursing or designee is rounding twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance ensuring proper infection control practices are in place through observation and questioning. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given.<BR/>On 12/22/22 to 12/23/22 the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by:<BR/>Review of the facility's in-service and competency testing records revealed:<BR/>1.The DON's name was listed as the facilitator of the in-services. The in-service topic was Infection Control, Covid-19 with an emphasis on hand hygiene and donning/doffing PPE.<BR/>2.As of 12/23/22 at 4:40 PM a total of 132 staff employed at the facility had been in-serviced and passed the hand hygiene and PPE competency.<BR/>Observations conducted from 12/22/22 at 10:55 AM to 5:00 PM on 12/23/22 revealed staff were donning and doffing PPE appropriately upon entrance and exit of covid-19 positive rooms. <BR/>Interviews conducted on 12/23/22 from 9:48 AM to 5:30 PM with staff from all three shifts(LVN E, Med aide F, CNA G, CNA H, CNA I, CNA J, COTA, ST Assistant Director, LVN K, Housekeeper L, Environmental Director, Laundry aide, Dietary cook M, Dietary cook N, PT O, CNA P, RN Q, CNA R, LVN S, CNA T, LVN U, LVN V, Housekeeper Z, LVN W, RN X, CNA Y, and Rehab tech), revealed staff were knowledgeable about what PPE was required to enter a COVID-19 positive room and why hand hygiene was important after doffing to prevent the spread of infection. The staff stated they had to watch videos on hand hygiene and PPE and had to perform a skills test.<BR/>In an interview with the ADON on 12/23/22 at 4:56 PM it was revealed that utilizing PPE and performing hand hygiene was the way to ensure COVID-19 was not being spread when going from a positive room to a negative room. The ADON stated charge nurses, direct supervisors and everyone was in charge of going behind staff to ensure they followed infection control protocols. They could make rounds and address any issues at that time. The ADON stated an IJ was identified because the staff were not following the proper PPE and hand hygiene protocols, thereby placing residents at risk. The ADON stated the facility was going to implement ongoing monitoring, monitoring tools and schedules to ensure proper infection control measures were followed. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated an IJ was identified because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview with the DON on 12/22/22 at 8:39 AM she stated she understood why this was identified as an IJ because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. <BR/>In an interview on 12/23/22 at 5:48 PM, the Assistant Administrator stated an IJ was identified because of the failure of staff to wear the proper PPE, going in and out of resident rooms that were covid positive and negative in addition to concerns with handwashing and sanitizing. She stated all this could lead to potential harm or spread of infections and diseases. <BR/>An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Medication Cart #1) of three medication carts reviewed.<BR/>MA B failed to ensure Medication Cart #1 was locked when unattended on 08/27/24. <BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>In an observation on 08/27/24 at 10:23 AM, Medication Cart #1 was observed unlocked and unattended near the one of the main entrances of the facility. There were two staff members at the nurses' station but walked away after a couple of minutes. There were four residents in wheelchairs in the immediate area. Another resident wheeled himself into the building from outside while the cart was unlocked and unattended. LVN A was observed coming from an office area behind the nurses' station. The office did not have any windows. LVN A stated Medication Cart #1 belonged to MA B. He stated she was down the hall, and he would go get her. MA B was observed as she walked toward Medication Cart #1 at 10:31 AM. <BR/>In an interview on 08/27/24 at 10:31 AM, MA B stated she could not say why she left the cart unlocked and unattended. She stated she last used Medication Cart #1 right before 10:00 AM. She stated the cart was used for the 100 hall and the hall across from the 100 hall. MA B stated she would usually take the cart with her down the halls when she used it and would return the medication cart to the entrance area once she was done using it. MA B stated the risk of leaving the mediation cart unlocked when unattended was anyone could get medication from the cart. <BR/>In an interview on 08/27/24 at 2:20 PM, the DON stated all staff who worked with medications had been trained on keeping the medication carts locked when unattended. The DON stated the risk of an unlocked and unattended medication cart was residents could get the medications. In the same interview, the Administrator stated the medications carts should always be locked when staff step away from it. The Administrator stated the risk was anyone could get to the medications. <BR/>Record review of the facility's policy titled, Medication Administration General Guidelines, dated January 2024, reflected the following:<BR/> .17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 of 5 (Resident # 4 , # 5, #21 and #22) residents reviewed for ADL care.<BR/>1. The facility failed to ensure Resident #21 was provided showers as scheduled and personal hygiene based on the resident's preference.<BR/>2. The facility failed to ensure Resident #22 was provided showers as scheduled.<BR/>3. The facility failed to ensure Resident # 4, and Resident # 5 had their ADL needs met in a timely manner.<BR/>These failures could place residents at risk of not receiving personal care services and a decreased quality of life.<BR/>Findings included:<BR/>Resident #21<BR/>Record review of Resident #21's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia, end stage renal disease, metabolic encephalopathy, and muscle wasting and atrophy. <BR/>Record review of Resident #21's admission MDS dated [DATE], revealed a BIMS of 9, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #21 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, extensive assistance of two staff for transfers, and was total dependence on one staff for bathing. <BR/>Record review of Resident #21's care plan, dated 10/15/2022, revealed Self care deficit with goal of resident will maintain or improve self-care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Encourage resident to complete as much self care as possible independently or with minimal assist, Prefers bath in AM, Provide assistance with self care as needed. Review of the care plan did not indicate Resident #21 had refused any care.<BR/>Record review of Resident #21's ADL sheet dated 10/17/2022 to 12/20/2022, revealed the last shower that was documented was on 11/11/2022. <BR/>Observation and interview on 12/21/2022 at 9:52 am revealed Resident #21 was lying in bed eating breakfast. When asked if he received his showers or bed baths, Resident #21 stated if he had one complaint that would be it. Resident #21 stated he liked to be clean and dress nice, and once or twice he has gone 2-3 days without water touching him. Resident #21 stated he was told by staff he could ask for a shower or bath but he would not receive one. Resident #21 stated he told the nurse or the tech on an unknown date that he would like to bathe or shower and stay clean. Resident #21 stated he did not know when his shower days were scheduled. Resident #21 stated staff told him he could request a shower but when he did, staff would not provide him with a shower.<BR/>Interview on 12/21/2022 at 11:03 am with CNA P revealed she has worked at the facility for 3 years and normally worked 700 hall. She stated CNA's are responsible to give showers to residents. She stated the shower schedule was even numbered rooms on Monday, Wednesday, and Friday and the odd numbered rooms were Tuesday, Thursday, and Saturday. She stated the 6 am to 2 pm shift showered the A beds and the 2 pm to 10 pm shift showered the B beds. She stated if a resident refused their shower, she would try again later and if they still refused, she would tell the nurse and document the refusal. She stated when CNA's completed showers they were documented as given. She stated she was about to shower Resident #21 when surveyor requested to speak with her. She stated Resident #21's shower was actually B bed shower (2 pm to 10 pm shift) but she was going to do everybody's shower. She stated she just asked him today because she had extra time. <BR/>Observation and interview on 12/22/2022 at 4:43 pm, revealed Resident #21 lying in bed wearing a blue t shirt which appeared to have crumbs or flakes on the chest/chin area. Resident #21 was observed to have stubble on chin, cheeks and above the lip. When asked if he received his shower, Resident #21 stated he got the first one yesterday (12/21/2022) in a long time but he felt so good. Resident #21 stated he was going to get another one tomorrow. Resident #21 stated the last time he had a shower before 12/21/22 was 4-5 days before that. Resident #21 stated he wanted his face to be shaved and said it had been about a week since the aides had last shaved him. <BR/>Observation and interview on 12/23/2022 at 4:15 pm, revealed Resident #21 was lying in bed and was observed to be wearing the same blue t shirt as yesterday (12/22/2022). There appeared to be crumbs or flakes on the shirt on the chest area. Resident #21 was observed to have stubble on his face the same as the previous day. Resident #21 stated he did not get a shower today and stated whenever the staff came back into the room, he was going to ask for a soapy towel to wash himself. Resident #21 stated he had no skin breakdown. Resident #21 stated he liked to be shaved every 3-4 days. <BR/>Resident #22 <BR/>Record review of Resident #22's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/02/2022. Resident #22's diagnoses included encephalopathy, unspecified intracranial injury without loss of consciousness, displaced comminuted fracture of shaft of right femur, and heart failure. <BR/>Record review of Resident#22's of the 5-day MDS revealed a BIMS of 13, which indicated the resident's cognition was intact. Record review of Resident#22's discharge MDS dated [DATE], revealed Resident #22 required limited assistance with transfer and dressing, extensive assistance with toilet use and personal hygiene, and physical help in part of bathing activity.<BR/>Record review of Resident #22's care plan, dated 09/05/2022, revealed Self care deficit with goal that resident will maintain or improve self care area of dressing, grooming hygiene and bathing over the next 90 days with interventions that included Prefer Bath in PM and Provide assistance with self care as needed. Review of the care plan did not indicate Resident #22 had refused any care. <BR/>Record review on 12/21/2022 of Resident #22's ADL sheet dated, 08/03/2022 to 10/01/2022, revealed no entries for bathing. <BR/>Record review of the provider investigation report dated 10/07/2022 revealed Resident #22 reported that he was not receiving his showers as requested and that was neglect. <BR/>Record review of the investigation summary revealed the ADON had interviewed staff about Resident #22's showers and the staff had reported that showers were given, and at times the resident would request showers on nonscheduled days or would refuse. <BR/>Interview on 12/23/2022 at 3:37 pm, the ADON stated CNA's are responsible for giving residents showers. She stated the schedule is per room per shift and even rooms are Monday, Wednesday, Friday and odd are Tuesday, Thursday, Saturday with A bed 6 am to 2 pm shift and B Bed 2 pm to 10 pm shift. She stated the facility has ongoing education with CNA's but have not had any issues with showers or bed baths. She stated the risk to residents if they do not get showers/ADL care was skin integrity and infection control. When asked how it would make the resident feel to not get a shower, she stated she could not say how they feel or not feel. She stated Resident #21's shower schedule was Monday, Wednesday, Friday 6 am to 2 pm and the resident wanted a shower everyday and only the times he wanted, he never complained on his shower days that he was not getting a shower, he complained that he was not getting a shower on his off days. <BR/>Interview on 12/23/2022 at 5:33 pm, the ADON stated she had just got off the phone with IT and said that the bathing task was unassigned and that was why it was not showing but they would be showing now. She stated with agency aides sometimes they cannot document so they are looking at doing a soft file where the aide can chart it on paper and staff can later put it in the system. She stated she was going to in-service the nurses about assigning the aides in the system. The ADON provided ADL sheets for Residents #21 and #22. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #21 reflected Resident #21 had no entry for the following dates on his scheduled shower days: 11/07/2022, 11/09/2022, 11/25/2022, 12/02/2022, 12/09/2022, 12/14/2022, 12/12/2022, and 12/19/2022. <BR/>Review of ADL sheets dated 12/23/2022 for Resident #22 reflected Resident #22 had no entry on his scheduled shower days for 09/12/2022 and 09/16/2022. <BR/>Record review of facility policy titled, Bathing (not partial or complete Bed bath) effective 01/12/2018, revised 02/12/2020 reflected the procedure for showers and included, in part: Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan .tasks commonly completed during the bathing process: inspect skin, especially those what are showing redness or signs of breakdown .record the procedure in the record .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record.<BR/>Resident # 4 <BR/>Record review of Resident # 4's face sheet, dated 11/29/22, revealed she was a [AGE] year-old who admitted to the facility on [DATE]. Resident # 4's diagnoses included long term (current) use of antibiotics, edema, overactive bladder, osteoarthritis, non-pressure chronic ulcer of right heel and ankle.<BR/>Record review of Resident # 4's MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident # 4's care plan, dated 11/29/22, revealed resident was incontinent, was an extensive assist for transfers, used a wheelchair and staff was to provide assistance with self-care as needed.<BR/>Resident # 5<BR/>Record review of Resident # 5's face sheet dated 12/28/22 revealed a 70-yr-old male who admitted to the facility on [DATE]. Resident # 5's diagnoses included other specified metabolic disorders, acute kidney failure, personal history of transient ischemic attack, cerebral infarction and hypertension. <BR/>Observation on 12/20/22 at 7:49 AM revealed call light for Resident # 5 was triggered and CNA AE walked past his room without responding to the call light. <BR/>Interview on 12/20/22 at 7:50 AM with Resident # 5 revealed he triggered his call light six hours ago and no one came to answer it. <BR/>Interview on 12/20/22 at 7:53 AM with LVN AA who was on the hall passing meds revealed he was unsure if call light for Resident # 5 was triggered when he started his shift at 6AM that morning. When asked if he attempted to answer Resident # 5's call light when he saw that it was on, LVN AA stated he had not really noticed the light was on until he observed the surveyors enter the room.<BR/>Observation on 12/20/22 at 7:53 AM revealed call light for Resident # 4 was triggered. A member of the housekeeping staff was at the entrance of Resident # 4's Rm cleaning that area.<BR/>Observation on 12/20/22 at 7:58 AM revealed a male Janitor walked past still triggered call light for Resident # 5 without entering the room to see what Resident # 5 needed.<BR/>Observation on 12/20/22 at 8:00 AM revealed ICN AC walked down the hallway and passed the rooms of Resident # 4 and Resident # 5 without responding to the call lights. <BR/>Observation and interview on 12/20/22 at 8:04 AM revealed Resident # 4 was not wearing pants, was covered in a purple blanket with her legs exposed and bent over leaning off the bed. Resident #4 stated she pressed her call light a while ago because she wanted to get changed and dressed. As Resident # 4 was speaking urine began falling from resident onto the floor. <BR/>Interview on 12/20/22 at 8:07 AM with LVN AA revealed CNA AE was working with him, he was not sure exactly which room she was in at the moment, and he was unsure how many rooms CNA AE had to cover but he could find out.<BR/>Interview on 12/20/22 at 12:53 AM with ICN AC revealed that all staff were to answer call lights including house keeping staff. ICN AC stated if a staff member was not able to render the requested service, they were to leave he call light on and go report to an aide or a nurse. When asked why she did not answer two call lights that were triggered this morning when she passed by surveyors interviewing LVN AA, she stated she did not notice the call lights were triggered. This interview was witnessed by the Assistant Administrator. <BR/>Interview on 12/22/22 at 9:05 AM with Resident # 5 revealed it was typical for staff to ignore his call light from 10:30 PM to 7:30 AM. He stated there were 2 occasions when his urinal fell, and no one came. <BR/>Interview on 12/22/22 at 9:24 AM with Resident # 4 revealed that on 12/20/22 after surveyor visit it took about fifteen minutes for staff to come get her cleaned up. Resident # 4 sated the facility was shorthanded and could not keep enough staff. <BR/>Review of the facility's policy titled, Call lights - Answering, revised 02/12/20, indicated Respond to patients/resident's call lights and emergency lights in a timely manner.

**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, the comprehensive person-centered care plan, and the resident's choices to meet each resident's physical mental and psychosocial needs for one (Resident #6) of seven residents reviewed for quality of care.<BR/>The facility failed to ensure Resident # 6 received medications according to physician orders for pain management when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 was in pain for three days before being sent to the hospital.<BR/>This failure placed residents at risk of unrelieved pain and discomfort.<BR/>An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM.<BR/>Findings included: <BR/>Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on 11/07/2022. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome.<BR/>Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined.<BR/>Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell. Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected.<BR/>Review of the Incident Report dated 11/04/22 reflected Resident # 6 was involved in a witnessed altercation with a fall and had pain upon movement at a level four on a scale of 1-10. <BR/>Review of Resident #6's Physician's Orders reflected the only pain ordered for Resident # 6 was 500 mg of Naproxen. One tablet was to be given twice per day as needed for Mild pain on a scale of 1-3. This Naproxen medication was to be given with food and the diagnosis for this medication was central pain syndrome.<BR/>Review of the Medication Administration Record (MAR) in the electronic medical record on 01/12/23 for Resident #6 revealed she had pain at a level six to her left hip on 11/06/22 in the evening. The MAR also revealed Naproxen was not administered to Resident # 6 from 11/4/22 through 11/7/22. The MAR reflected that no pain medication was given to Resident #6 during that time frame. <BR/>Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out.<BR/>Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport.<BR/>Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell. LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation.<BR/>Review of the Witness Statement dated 11/08/22 reflected CNA AF witnessed the incident with Resident # 6 and notified LVN S immediately. CNA AF's written statement indicated, Resident #6, continued to have symptoms of pain to her left hip and decreased mobility on 11/5/22 and 11/6/22, I notified the charge nurse and resident remained in bed on those dates.<BR/>Interview on 12/22/22 at 10:20 AM with LVN S revealed the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. In a later interview on 01/12/23 at 10:09 AM LVN S stated she gave Resident #6 pain medication after she fell on [DATE]. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. A later phone Interview on 01/12/23 at 3:01 PM with LVN S revealed she attributed not documenting the administration of the Naproxen to the adrenaline of the whole issue.<BR/>Interview on 01/12/23 at 11:27 AM with CNA AF stated Resident # 6 was able to walk to the dining room on 11/4/22 after the fall with no problem after LVN S did all the assessments. CNA AF stated that on 11/5/22 Resident # 6 was no longer getting up, could not walk and was screaming of pain. CNA AF stated that Resident #6 was able to walk before the fall, although if the staff would let her, she would lay in bed all day. <BR/>In an interview on 01/12/23 at 12:45 PM the ADON stated she checked their system and did not find any documentation of pain medication given to Resident #6, however she spoke with LVN S who stated she gave Resident # 6 Naproxen. <BR/>Interview on 12/22/22 at 3:38 PM with Resident # 6's Primary Contact listed on Face Sheet stated Resident #6 was diagnosed with left hip fracture and had surgery where her socket was removed. The primary contact stated the resident was still in pain and was at another (different) facility and had to go on hospice after the surgery. The Primary contact stated Resident #6 used to walk and now she stayed in a fetal position in bed because she was in too much pain. <BR/>Interview on 01/12/23 at 5:30 PM DON stated if a Resident has had a fall, their pain should be treated. DON stated that if pain medication was not adequate, the staff should contact the doctor to get something stronger so that the resident is not in distress. DON stated If the stronger medication does not help, the resident should be sent to the hospital. DON also stated that in the nursing world if it was not documented, it was not done. <BR/>Review of the facility's Pain Management and Basic Comfort Measures policy, revised 01/12/20, revealed, .Provide pain medication as prescribed by an authorized prescriber . Consult with family members, other health care providers for assistance with pain management techniques . Observe for unresolved pain and address per physician's orders . Record pain management techniques in the record. <BR/>The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023.<BR/>The facility implemented the following interventions to address non-compliance:<BR/>Review of the facility's one on one in-service (training) titled Fall prevention, Xray ordering process, family communication, dated 11/07/22 with LVN included: pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. <BR/>Review of the facility's In-Service for all nursing staff on falls with injury dated 11/8/22, included pain management. <BR/>Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. <BR/>In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. In a later interview on 1/13/23 at 3:01 PM LVN S stated the Unit Manager discussed with her about the fall process and stressed the importance of documenting administration of medication because if it is documented it means it was not done. The Unit Manager pointed out to her that she needed to call the doctor for a stronger medication since the Naproxen was only for pain on a scale of 1-3. LVN S stated she has since had to call the doctor for stronger pain meds for a different patient with a similar issue. <BR/>Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for pain management, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff had been in-serviced on these topics. The nurses also were aware that if there was not a medication to cover the pain level indicated, that they should call the doctor to get another order. <BR/>Observations from 12/20/22 at 7:40 PM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13).<BR/>Interviews with Residents with PRN pain management on 01/12/23 revealed they got medication when requested and they were not in any pain (Resident #'s 11, 12 and 13).<BR/>Review of the MAR for Residents with PRN pain management revealed pain assessments were completed and pain medications administered as ordered for Resident #'s 11, 12, 13, 15, 16, 17 and 18.<BR/>Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON.<BR/>In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and DON were following up to check what was done to address the pain scale on the incident reports. The ADON and DON were monitoring pain meds and ensuring they had meds ordered that covered all numbers on the pain scale. The DON stated for example that if a Resident only had pain medication coverage for pain level of 1-3, the facility would call the doctor to get a medication to cover a higher level of pain. DON stated the IDT team met daily to review each fall and to ensure follow up from each department as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents were free of any significant medication errors for one of six residents (Resident #2) reviewed for pharmacy services. <BR/>The facility failed to administer Resident #2's cancer medication, Ibrance, as prescribed, which resulted in the resident missing four doses between 08/26/24 and 08/29/24.<BR/>This failure could place residents at risk of not achieving the therapeutic effects intended by the physician. <BR/>Findings included:<BR/>Record review of Resident #2's undated Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure, swelling of the legs, and breast cancer in 2019. <BR/>Record review of resident #2's quarterly MDS, dated 01/24//25, reflected a BIMS score of 8 indicating she mildly cognitively impaired. Her Functional Status indicated she required staff assistance with her ADLs. <BR/>Record review of Resident #2's care plan, dated 02/18/25, reflected she had anxiety and seizures, breast cancer to the left breast. <BR/>Record review of physician orders for Resident #2 reflected an order dated 08/08/24:<BR/>Ibrance 125 mg capsule (PALBOCICLIB) 1 capsule by mouth 1 time per day 21 Days. Ibrance 125 mg 1 tablet by mouth daily x 21 days, then off for 1 week, then resume for another 3 weeks <BR/>Dx: Malignant neoplasm of central portion of left female breast<BR/>Record review of Resident #2's MARs from August 2024 to December 2024 reflected the resident did not receive her Ibrance as ordered from 08/26/24-08/29/24.<BR/>Interview on 02/26/24 at 3:30 PM with the DON revealed there were some problems getting Resident #2's Ibrance delivered initially as it came from a specialty pharmacy, not their normal pharmacy. The DON stated there should be no reason the resident did not receive her Ibrance from August 26th through the 29th. The MAR indicated on the 27th (08/27/24) the resident was at a doctor's appointment, but the resident should have received her dose before she left or after she returned. The DON stated cancer medications like that were important to ensure all doses were given to maintain therapeutic blood levels. <BR/>Record review of the facility's Medication Administration policy, dated January 2024, reflected:<BR/> .Medications are administered as prescribed, in accordance with manufacturer's specifications, good nursing principles and practices .<BR/> .19. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the nurse returns to the missed residents to administer the medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for one (Resident #1) five reviewed for resident call system, in that:<BR/>Resident #1's call lights was on the floor and not within reach on 03/24/2025.<BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Record review of Resident #1's electronic face sheet printed on 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach. This can cause pain, difficulty in swallowing or chest pain.)<BR/>Record review of the annual MDS dated [DATE] did not indicate a BIMS score. Section GG Functional Abilities reflected Resident #1 required substantial/maximum assistance with transfers and sit to stand. <BR/>Record review of Resident#1's service plan last reviewed 12/11/2024 reflected Resident #1 was a fall risk with interventions to include call light within reach.<BR/>Observation and attempted interview on 03/08/2025 at 11:05 AM revealed the call button was on the floor and out of Resident #1's reach. Resident #1 was only able to answer yes or no questions. <BR/>Interview and observation on 03/08/2025 at 11:15 AM with LVN A revealed the call light should have been within reach. LVN A stated all staff should ensure call lights were within reach each time they entered a room. LVN A stated Resident #1 never used her call light however it should have been within reach.<BR/>Interview on 03/08/2025 at 11:53 AM with CNA B revealed he was last in Resident #1's room around 9:00 AM, and he thought the call light was within reach. CNA B stated he was not sure what the risk would be if the call light was not in reach. <BR/>Interview on 03/08/2025 at 12:22 PM with the Assistant Executive Director revealed when she was made aware of the call light not being in place, she stated, Those questions would be more suitable for the Director of Nursing. The interview was ended.<BR/>Interview on 03/08/2025 at 1:30 PM with the Director of Nursing revealed staff should have ensured call lights were within reach each time they entered a resident room. The Director of Nursing revealed the risk of not ensuring the call light was in place would be residents would not be able to reach staff if needed. <BR/>Record review of the facility's Resident Rights policy, dated 08/22/2020, reflected it did not address resident rights to reasonable accommodations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents were free of any significant medication errors for one of six residents (Resident #2) reviewed for pharmacy services. <BR/>The facility failed to administer Resident #2's cancer medication, Ibrance, as prescribed, which resulted in the resident missing four doses between 08/26/24 and 08/29/24.<BR/>This failure could place residents at risk of not achieving the therapeutic effects intended by the physician. <BR/>Findings included:<BR/>Record review of Resident #2's undated Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure, swelling of the legs, and breast cancer in 2019. <BR/>Record review of resident #2's quarterly MDS, dated 01/24//25, reflected a BIMS score of 8 indicating she mildly cognitively impaired. Her Functional Status indicated she required staff assistance with her ADLs. <BR/>Record review of Resident #2's care plan, dated 02/18/25, reflected she had anxiety and seizures, breast cancer to the left breast. <BR/>Record review of physician orders for Resident #2 reflected an order dated 08/08/24:<BR/>Ibrance 125 mg capsule (PALBOCICLIB) 1 capsule by mouth 1 time per day 21 Days. Ibrance 125 mg 1 tablet by mouth daily x 21 days, then off for 1 week, then resume for another 3 weeks <BR/>Dx: Malignant neoplasm of central portion of left female breast<BR/>Record review of Resident #2's MARs from August 2024 to December 2024 reflected the resident did not receive her Ibrance as ordered from 08/26/24-08/29/24.<BR/>Interview on 02/26/24 at 3:30 PM with the DON revealed there were some problems getting Resident #2's Ibrance delivered initially as it came from a specialty pharmacy, not their normal pharmacy. The DON stated there should be no reason the resident did not receive her Ibrance from August 26th through the 29th. The MAR indicated on the 27th (08/27/24) the resident was at a doctor's appointment, but the resident should have received her dose before she left or after she returned. The DON stated cancer medications like that were important to ensure all doses were given to maintain therapeutic blood levels. <BR/>Record review of the facility's Medication Administration policy, dated January 2024, reflected:<BR/> .Medications are administered as prescribed, in accordance with manufacturer's specifications, good nursing principles and practices .<BR/> .19. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the nurse returns to the missed residents to administer the medication .

**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 abuse for one of six residents (Resident #6) reviewed for abuse.<BR/>The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 punched and then pushed her on 02/05/25 located on a secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury.<BR/>The noncompliance was identified as PNC. The IJ began on 02/05/25 and ended on 02/05/25. The facility had corrected the noncompliance before the survey began.<BR/>This failure placed residents at risk for abuse.<BR/>Findings included: <BR/>Record review of Resident #6's face sheet, dated 02/26/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE].<BR/>Record review of Resident #6's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her diagnoses included hip fracture, anxiety disorder, and other orthopedic condition. The MDS indicated she had no behaviors of any kind and that she utilized a wheelchair. <BR/>Record review of Resident #6's care plan, updated 01/13/25, reflected she was a fall risk.<BR/>Record review of Resident #6's Nurses Notes reflected the following: <BR/>- Resident noted standing up off from couch when another resident pushed her, and she went down landing on her sacral area resident removed from area made safe during assessment resident screaming and protecting right leg and hip area prn apap given dr [Physician Z] called 911 called DON preset and aware family called and message left resident transferred to [Hospital Y] for evaluation. Written on 02/05/25 by LVN X.<BR/>- 1830; Met with [Resident #6's RP] in person to discuss fall and injury. She was made aware, per investigation, fellow resident pushed her as she was standing from sofa, she lost her balance and fell landing on her buttocks. [Resident #6] complained of pain to her right hip and thigh area, could not recall event or how she landed on floor. [Resident #6's RP] informed resident was sent to ER at [Hospital Y] due to c/o pain and inability to bear weight on right leg . written on 02/05/25 by the DON.<BR/>- Resident returned from [Hospital Y] via stretcher and EMT with oxygen therapy at 2L/min via nasal cannula at 1810. Resident diagnosed with subcapital fracture of the right femoral neck. Resident surgical wound is clean and dry, with no signs of infection . Written by RN W on 02/08/25.<BR/>Record review of Resident #6's hospital records reflected the following: Hospital Course: patient got into physical altercation with another resident, they pushed to this patient [sic] to the ground when she landed on her bottom, she developed severe pain in the right hip, presented to the ER where she was found to have right neck femur fracture, s/p surgery 02/06 .Active Problems: Closed fracture of neck of right femur .<BR/>Observation and interview on 02/26/25 at 1:40 PM with Resident #6 revealed she was sitting on the couch in the common area. Resident #6 had her wheelchair next to her and said she was doing okay. Resident #6 said she was not in any pain and felt safe in the facility. Resident #6 said she never had a fall or had anyone push her in the facility before. <BR/>Attempted phone interview on 02/26/25 at 1:57 PM with Resident #6's RP was unsuccessful as they did not answer or call back. <BR/>Record review of Resident #7's face sheet, dated 02/26/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #7's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 07, indicating severe cognitive impairment. Her diagnoses included other neurological conditions, Alzheimer's disease, and anxiety disorder. Her MDS indicated she did not have any behaviors towards anyone. <BR/>Record review of Resident #7's care plan, updated 04/08/25, did not reflect or include anything about her behaviors.<BR/>Record review of Resident #7's Nurses Notes reflected the following: <BR/>- Resident very disruptive and verbally aggressive with other residents, walked over to sofa and pushed another resident unprovoked and then went directly to her room. Dose not recall incident but is paranoid that fellow residents are taking her belongings. DON notified and gave directive to contact PCP for order to send resident to [Hospital S] for eval and treatment, message left with [Resident #7's RP] NO ANSWER WHEN CALLED, [NP N] contacted, order received to send out for eval. Resident placed on 1:1 monitoring until transferred to [Hospital S]. written on 02/05/25 by the DON.<BR/>- Resident return from [Hospital S] via EMT at 10:19. Resident is alert, appears calm and cooperative at this time. DON and family member notified. Plan of care continues. Written on 02/05/25 by the DON.<BR/>Record review of Resident #7's Psychiatric Periodic Evaluation, dated 02/07/25, reflected the following: .[Resident #7] is seen today per staff request due to reports of increased anxiety, compulsivity, restlessness, and for psychotropics management. Resident is sitting up in the common area, she is calm at the moment and denying any pain or discomfort. Aspiration of reports of recent mood swing, agitation, and restlessness reported by nursing staff, patient started crying, and reports that people are 'getting to her face'. She reports mood swing, and spontaneous anxiety and agitation. Chart reviewed, medication profile reviewed, she is on the following psychotropics with no noticeable adverse effects: Aricept 10mg po daily for dementia, Levothyroxine 100 mcg for hypothyroidism, Cymbalta 20 mg p.o. twice daily for depression/anxiety lamotrigine 25 mg p.o. twice for mood regulation, and Atarax 25 mg po daily for anxiety. Due to reports of mood swing, and spontaneous combativeness, will increase lamotrigine and monitor closely. Nursing staff notified.<BR/>Observation and interview on 02/26/25 at 1:42 PM with Resident #7 revealed she was sitting on a different couch in the common area. Resident #7 said she was doing okay and sometimes argued with others, but she never got into a fight with anyone or pushed anyone down. Resident #7 said she felt safe in the facility. <BR/>Attempted phone interview on 02/26/25 at 1:55 PM with Resident #7's RP was unsuccessful as they did not answer or call back. <BR/>Interview on the phone on 02/26/25 at 12:15 PM with CNA V revealed Resident #7 had a tendency to go off and always think someone was in her room. CNA V said she was down the hall making up a resident's bed when Resident #7 was upset at another resident saying things like she's going to jail and I'm going to kill her. CNA V said Resident #7 was not referring to Resident #6 at this time, but she de-escalated the situation and sat Resident #7 down on the couch. CNA V said she turned around and started to walk to the nurse's station when Resident #6 asked to go to the bathroom and stood up to get off the couch. CNA V said Resident #7 went over to Resident #6, punched her, then pushed her to the ground. CNA V said she ran over to the residents and asked Resident #7 why she did that and noticed Resident #7 was still trying to go after Resident #6 who was on the ground. CNA V said everything happened so fast but she was trying to get Resident #7 away from the situation and have her go to her room. CNA V said Resident #6 went to the hospital that night and did not come back for a few days and had a hip fracture. CNA V said Resident #7 was more alert than other residents on the secured unit because one of her triggers was when residents went down the hall who did not have rooms down there. CNA V said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. <BR/>Interview on the phone on 02/26/25 at 12:43 PM with CNA U revealed it was after a meal one day (02/05/25), Resident #7 said that Resident #6 went to her room and stole something and then there was a lot of commotion. CNA U said she went towards Residents #6 and #7 to divide them up because Resident #7 had punched Resident #6 and then pushed her down to the ground. CNA U said she told Resident #7 not to do that and to let staff handle the situation but Resident #6 was already on the ground. CNA U said she was not working on the secured unit at the time but had just stopped by to drop something off. CNA U said she thought Resident #6 was injured when she said her head was hurting and she could not walk. CNA U said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on 02/26/25 at 1:34 PM with LVN X revealed Resident #6 was a sweet lady and Resident #7 was very nasty with her mouth and bossy. LVN X said on 02/05/25, Resident #7 was amped up for whatever reason and staff were not sure why. LVN X said Resident #6 was getting off the couch while talking to Resident #7 when Resident #7 pushed Resident #6. LVN X said she did not witness what happened but heard about it from another aide. LVN X said when Resident #6 was on the ground she called 911 and sent her to the hospital. LVN X said during her assessment while checking Resident #6's range of motion, she yelled when assessing her right side. LVN X said after the incident happened, the NP came to see Resident #7 and adjusted her medications which seems to have worked because she's been extremely pleasant and calm ever since. LVN X said she's never seen Resident #7 be physically aggressive towards others, only verbally aggressive. LVN X said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on 02/26/25 at 1:43 PM with CNA T revealed she was leaving the shower room and heard Resident #7 talking loudly and arguing about something when she hauled off and hit Resident #6 who fell down. CNA T said Resident #7 did not have any injuries from this situation but Resident #6 did because she was grabbing her leg and crying and saying her leg was hurting. CNA T said Resident #6 was sent to the hospital afterwards. CNA T said Resident #7 yells at others when she thought someone was stealing her clothes, but no one was. CNA T said she had never seen Resident #7 be physically aggressive towards anyone before this. CNA T said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents.<BR/>Interview on the phone on 02/26/25 at 2:14 PM with NP O revealed Resident #7 she had episodes of psychosis based on her thinking people were taking her things from her room. NP O said Resident #7 was very paranoid and had mood swings with agitation, so she was eventually moved to the all-female secured unit. NP O said he was informed Resident #7 was involved in a resident-to-resident altercation, so he went to assess her and review her medications. NP O said based on the assessment, he thought she needed mood stabilizers, so he added those to her orders. NP O said since then, Resident #7 was more stable and engaged in activities that she's participating more in. NP O said he was not aware of any other physical altercation Resident #7 was involved in. NP O said Resident #7 was now more redirectable.<BR/>Interview on 02/26/25 at 3:19 PM with the DON revealed the day the incident occurred, LVN X was here and came to get the DON because she was concerned about Resident #6's leg. The DON said she was told that Resident #6 was trying to stand and Resident #7 pushed her, causing Resident #6 to lose her balance and fall in a squatting position since she's so tall. The DON said Resident #6 fell on her bottom and complained of her leg hurting. The DON said she was worried Resident #6 had a fracture from the incident. The DON said Resident #7 had walked away from the situation and went to her room but was clueless about what had just happened. The DON said Resident #7 was put on one-to-one care until she was sent to [Hospital S] where she was evaluated and sent back to the facility the same day. The DON said Resident #7 was also seen by the NP who adjusted her meds and she had been quiet ever since. The DON said Resident #7 had a behavior of thinking someone was stealing her clothes and would get upset but never became violent with anyone. The DON said she was not told that Resident #7 had first punched Resident #6 before pushing her down. The DON said after the situation happened, staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents. <BR/>Interview on 02/26/25 at 4:01 PM with the Administrator revealed he was the abuse coordinator for the whole campus, but he had an Administrator's Assistant who was also the abuse coordinator for the South building where Residents #6 and #7 were. The Administrator said he understood that Resident #6 stood up from the sofa and Resident #7 pushed her causing her to fall to the ground when she started to complain of pain. The Administrator said Resident #6 was sent out to have x-rays done which showed she had a fracture. The Administrator said all staff were responsible for monitoring resident's and their behaviors to ensure they were not getting into an altercation with each other. The Administrator said several things could happen to residents if they were to get into an altercation with each other such as harm. The Administrator said because of the resident's diagnoses a lot of times they did not remember what they did or who they did something to. <BR/>Interview on 02/26/25 at 4:17 PM with the Administrator's Assistant revealed based on what she heard and through her investigation, Resident #7 was the aggressor towards Resident #6. The Administrator's Assistant said Resident #6 was on the couch and as she was getting up, Resident #7 pushed her causing her to fall to the ground. The Administrator's Assistant said the charge nurse did an assessment on Resident #6 and found that she was complaining of pain, so she was sent to the hospital. The Administrator's Assistant said at the hospital, x-rays were done where it was found she had a fracture which required surgery to repair it. The Administrator's Assistant said there had not been any other instances of physical aggression from Resident #7 before this. The Administrator's Assistant said she was also the abuse coordinator for the facility and staff were to report any instance or allegation of abuse to her. The Administrator's Assistant said all residents have the right to be free from abuse in the facility. The Administrator's Assistant said she was not told that Resident #7 punched Resident #6 in the face. The Administrator's Assistant said staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents.<BR/>Record review of a provider investigation report reflected the following information:<BR/>Investigation Summary: On 2/5/25, a resident-to-resident altercation occurred between [Resident #6] and [Resident #7], both residing in the South Memory Community. The incident occurred when [Resident #7], who was loudly fussing, accused [Resident #6] of entering her room. As [Resident #6] attempted to rise from the couch in the dining room, [Resident #7] pushed [Resident #6], causing [Resident #6] to fall to the floor and land on her sacral area. Nursing staff were present and immediately intervened, separating the residents. A head-to-toe assessment was conducted for both residents by the charge nurse, [LVN X]. [Resident #6] complained of right hip pain, held her right leg, and was unable to bear weight on it. Although no visible injuries were noted and vital signs stable. Pain medication was administered and [Resident #6] was sent to the ER for further evaluation and treatment. [Resident #7], [sic] no adverse effect and injuries noted, vital signs stable. Placed on 1:1 supervision pending a transfer to [Hospital S]. Notifications made to Family, [Resident #6's RP and Resident #7's RP] notified. [Physician R and Physician Q] notified. Interview and statements collected from witnesses present attached. Social worker conducted safety survey, noting no concerns. Staff in-service [sic] resident to resident altercation, resident behaviors, resident 1:1, abuse and neglect. <BR/>[Resident #6] was admitted to the hospital and underwent surgery for a right hip repair. She returned to the facility on 2/8/25 with new order for Tylenol 3 and a follow-up appointment scheduled with [Physician P] on 2/20/25 at 11:30 AM. She is currently alert and resting in bed. [Resident #7] was placed on 1:1 supervision pending a transfer to [Hospital S]. On 2/5/25, [Resident #7] was evaluated by [Hospital S] and cleared to return to the facility the same day. Q15-minute checks were conducted for 72 hours per facility. [Resident #7] is currently cooperative and participating in normal activities without further incidents.<BR/>Record review of resident safe surveys revealed 5 were completed with residents on 02/05/25 with no additional findings of any other abuse in the facility. <BR/>Record review of an in-service, dated 02/05/25, reflected staff were in-serviced regarding abuse, falls, resident monitoring, injury of unknown origin, and resident-to-resident altercation. <BR/>Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 02/12/20, reflected: Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property.<BR/>The Administrator was notified on 03/12/25 at 10:00 AM that a past non-compliance IJ situation had been identified due to the above failures.<BR/>It was determined this failure placed Resident #6 in an IJ situation on 02/05/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for one (Resident #1) five reviewed for resident call system, in that:<BR/>Resident #1's call lights was on the floor and not within reach on 03/24/2025.<BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Record review of Resident #1's electronic face sheet printed on 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach. This can cause pain, difficulty in swallowing or chest pain.)<BR/>Record review of the annual MDS dated [DATE] did not indicate a BIMS score. Section GG Functional Abilities reflected Resident #1 required substantial/maximum assistance with transfers and sit to stand. <BR/>Record review of Resident#1's service plan last reviewed 12/11/2024 reflected Resident #1 was a fall risk with interventions to include call light within reach.<BR/>Observation and attempted interview on 03/08/2025 at 11:05 AM revealed the call button was on the floor and out of Resident #1's reach. Resident #1 was only able to answer yes or no questions. <BR/>Interview and observation on 03/08/2025 at 11:15 AM with LVN A revealed the call light should have been within reach. LVN A stated all staff should ensure call lights were within reach each time they entered a room. LVN A stated Resident #1 never used her call light however it should have been within reach.<BR/>Interview on 03/08/2025 at 11:53 AM with CNA B revealed he was last in Resident #1's room around 9:00 AM, and he thought the call light was within reach. CNA B stated he was not sure what the risk would be if the call light was not in reach. <BR/>Interview on 03/08/2025 at 12:22 PM with the Assistant Executive Director revealed when she was made aware of the call light not being in place, she stated, Those questions would be more suitable for the Director of Nursing. The interview was ended.<BR/>Interview on 03/08/2025 at 1:30 PM with the Director of Nursing revealed staff should have ensured call lights were within reach each time they entered a resident room. The Director of Nursing revealed the risk of not ensuring the call light was in place would be residents would not be able to reach staff if needed. <BR/>Record review of the facility's Resident Rights policy, dated 08/22/2020, reflected it did not address resident rights to reasonable accommodations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for one (Resident #1) five reviewed for resident call system, in that:<BR/>Resident #1's call lights was on the floor and not within reach on 03/24/2025.<BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Record review of Resident #1's electronic face sheet printed on 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach. This can cause pain, difficulty in swallowing or chest pain.)<BR/>Record review of the annual MDS dated [DATE] did not indicate a BIMS score. Section GG Functional Abilities reflected Resident #1 required substantial/maximum assistance with transfers and sit to stand. <BR/>Record review of Resident#1's service plan last reviewed 12/11/2024 reflected Resident #1 was a fall risk with interventions to include call light within reach.<BR/>Observation and attempted interview on 03/08/2025 at 11:05 AM revealed the call button was on the floor and out of Resident #1's reach. Resident #1 was only able to answer yes or no questions. <BR/>Interview and observation on 03/08/2025 at 11:15 AM with LVN A revealed the call light should have been within reach. LVN A stated all staff should ensure call lights were within reach each time they entered a room. LVN A stated Resident #1 never used her call light however it should have been within reach.<BR/>Interview on 03/08/2025 at 11:53 AM with CNA B revealed he was last in Resident #1's room around 9:00 AM, and he thought the call light was within reach. CNA B stated he was not sure what the risk would be if the call light was not in reach. <BR/>Interview on 03/08/2025 at 12:22 PM with the Assistant Executive Director revealed when she was made aware of the call light not being in place, she stated, Those questions would be more suitable for the Director of Nursing. The interview was ended.<BR/>Interview on 03/08/2025 at 1:30 PM with the Director of Nursing revealed staff should have ensured call lights were within reach each time they entered a resident room. The Director of Nursing revealed the risk of not ensuring the call light was in place would be residents would not be able to reach staff if needed. <BR/>Record review of the facility's Resident Rights policy, dated 08/22/2020, reflected it did not address resident rights to reasonable accommodations.

Based on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food safety in one of two of the facility's kitchens that served 114 of the facility's 205 residents. <BR/>The facility failed to date, label and seal food items in the dry storage area.<BR/>This failure could place residents at risk for contamination and food-borne illness. <BR/>Findings included:<BR/>An observation of the dry storage area on 09/20/22 at 8:46 AM revealed an undated bag of hamburger buns that were covered in plastic wrap, three undated bags of hamburger buns that had been previously opened and had a few buns remaining. One of the three bags had green mold on the bread that could be seen through the transparent bagging. There was also a previously opened bag of hot dog buns, sealed properly, yet undated. Additionally, one unopened bag of hot dog buns was observed with green mold throughout the transparent bag. <BR/>In an interview on 09/20/22 at 8:50 AM, the Nutrition Aide revealed it was facility policy to date the breads. She stated she was responsible for helping the Nutrition Services Director by dating items and going around to dispose of old food items. She stated that if a bread bag was opened, it should be dated and sealed well.<BR/>An observation in the dry storage area on 9/20/22 at 8:51 AM revealed a bag of salt undated and unsealed. Observation of a container of sugar was undated and mislabeled as spoons.<BR/>In an interview on 09/20/22 at 8:52 AM, the Nutrition aide revealed the salt bag should have been closed. She stated that some staff were negligent about closing the bag of salt properly. <BR/>In an interview on 09/22/22 at 10:08 AM, the Nutrition Services Director revealed if staff opened bread, they needed to seal it properly and date it. She stated dating and labeling was important to ensure proper food storage and avoid contamination. The Nutrition Services Director stated she transferred the salt into a bin and the sugar container had been labeled correctly. She stated it was important to label the bins correctly so that staff could identify the content and prevent cross contamination. <BR/>In an interview on 09/22/22 at 3:07 PM, the ED revealed all food should be labeled and dated when opened. The ED stated that all food items ought to be sealed. The ED stated that labeling was important so that the product could be properly identified. <BR/>Review of the facility's policy, Food Storge, dated 8/1/18, revealed, .Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened.<BR/>Review of the U.S. Public Health Service Food Code, dated 2017, reflected: <BR/> .3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. <BR/>(A) A food specified in 3-501.17(A) or (B) shall be discarded if it: <BR/>(2) Is in a container or package that does not bear a date or day; <BR/>(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .

Based on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food safety in one of two of the facility's kitchens that served 114 of the facility's 205 residents. <BR/>The facility failed to date, label and seal food items in the dry storage area.<BR/>This failure could place residents at risk for contamination and food-borne illness. <BR/>Findings included:<BR/>An observation of the dry storage area on 09/20/22 at 8:46 AM revealed an undated bag of hamburger buns that were covered in plastic wrap, three undated bags of hamburger buns that had been previously opened and had a few buns remaining. One of the three bags had green mold on the bread that could be seen through the transparent bagging. There was also a previously opened bag of hot dog buns, sealed properly, yet undated. Additionally, one unopened bag of hot dog buns was observed with green mold throughout the transparent bag. <BR/>In an interview on 09/20/22 at 8:50 AM, the Nutrition Aide revealed it was facility policy to date the breads. She stated she was responsible for helping the Nutrition Services Director by dating items and going around to dispose of old food items. She stated that if a bread bag was opened, it should be dated and sealed well.<BR/>An observation in the dry storage area on 9/20/22 at 8:51 AM revealed a bag of salt undated and unsealed. Observation of a container of sugar was undated and mislabeled as spoons.<BR/>In an interview on 09/20/22 at 8:52 AM, the Nutrition aide revealed the salt bag should have been closed. She stated that some staff were negligent about closing the bag of salt properly. <BR/>In an interview on 09/22/22 at 10:08 AM, the Nutrition Services Director revealed if staff opened bread, they needed to seal it properly and date it. She stated dating and labeling was important to ensure proper food storage and avoid contamination. The Nutrition Services Director stated she transferred the salt into a bin and the sugar container had been labeled correctly. She stated it was important to label the bins correctly so that staff could identify the content and prevent cross contamination. <BR/>In an interview on 09/22/22 at 3:07 PM, the ED revealed all food should be labeled and dated when opened. The ED stated that all food items ought to be sealed. The ED stated that labeling was important so that the product could be properly identified. <BR/>Review of the facility's policy, Food Storge, dated 8/1/18, revealed, .Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened.<BR/>Review of the U.S. Public Health Service Food Code, dated 2017, reflected: <BR/> .3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. <BR/>(A) A food specified in 3-501.17(A) or (B) shall be discarded if it: <BR/>(2) Is in a container or package that does not bear a date or day; <BR/>(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Medication Cart #1) of three medication carts reviewed.<BR/>MA B failed to ensure Medication Cart #1 was locked when unattended on 08/27/24. <BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. <BR/>Findings included:<BR/>In an observation on 08/27/24 at 10:23 AM, Medication Cart #1 was observed unlocked and unattended near the one of the main entrances of the facility. There were two staff members at the nurses' station but walked away after a couple of minutes. There were four residents in wheelchairs in the immediate area. Another resident wheeled himself into the building from outside while the cart was unlocked and unattended. LVN A was observed coming from an office area behind the nurses' station. The office did not have any windows. LVN A stated Medication Cart #1 belonged to MA B. He stated she was down the hall, and he would go get her. MA B was observed as she walked toward Medication Cart #1 at 10:31 AM. <BR/>In an interview on 08/27/24 at 10:31 AM, MA B stated she could not say why she left the cart unlocked and unattended. She stated she last used Medication Cart #1 right before 10:00 AM. She stated the cart was used for the 100 hall and the hall across from the 100 hall. MA B stated she would usually take the cart with her down the halls when she used it and would return the medication cart to the entrance area once she was done using it. MA B stated the risk of leaving the mediation cart unlocked when unattended was anyone could get medication from the cart. <BR/>In an interview on 08/27/24 at 2:20 PM, the DON stated all staff who worked with medications had been trained on keeping the medication carts locked when unattended. The DON stated the risk of an unlocked and unattended medication cart was residents could get the medications. In the same interview, the Administrator stated the medications carts should always be locked when staff step away from it. The Administrator stated the risk was anyone could get to the medications. <BR/>Record review of the facility's policy titled, Medication Administration General Guidelines, dated January 2024, reflected the following:<BR/> .17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked.