RETAMA MANOR NURSING CENTER/SAN ANTONIO WEST

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 1 meal (noon meal) for resident #55 in that:<BR/>The dietary staff failed to identify discrepancies between the meal tickets and the plated meals.<BR/>The DM did not verify the accuracy of resident #55's meal against the meal ticket.<BR/>The Nurses failed confirm that the meals matched the resident #55's meal ticket prior to serving the resident.<BR/>This deficient practice could affect 1 resident who received the pureed meal from the kitchen by contributing asphyxiation, dissatisfaction, poor intake, and/or weight loss. <BR/>Findings include:<BR/>Record review of admission Record printed 10/25/2022 revealed Resident #55 was a [AGE] year-old female with an initial admission date of 1/25/2021 diagnosed with oropharyngeal phase dysphagia [disordered swallowing that can allow food or liquid to enter the lungs causing respiratory distress, damage to lung tissue or infection]. <BR/>Record Review of annual MDS (Minimum Data Set) date 9/25/2022 revealed Resident #55 required mechanically altered diet ( .change in texture of food or liquids e.g., pureed food .). Section V Care Area Assessment, prior assessment, indicated as 7/09/2022 indicated BIMS (Brief Interview for Mental Status) Summary Score as 15, indicative of intact cognition. <BR/>Record review of Resident #55's Care Plan, initiated on 01/25/2021, revised on 4/7/2022, revealed a focus area of nutrition problem with the following interventions: dysphagia level 2 mechanically altered texture; regular liquid consistency; provide and serve diet as ordered. <BR/>Record review of Order Summary Report printed 10/25/2022 revealed Resident #55 had dietary orders for consistent carbohydrate diet; dysphagia level 2, mechanically altered texture; regular consistency, no salt on trays with a start date of 10/18/2022. <BR/>Record review of Meal Tray tag dated 10/25/2022 for Resident #55 revealed instructions for pureed Chicken Posole Stew with Hominy - Pureed Corn Tortilla (6) - #16 Scp [scoop]. <BR/>Record Review of Task: Amount of Meal Eaten for Resident #55 revealed, 76% - 100% of noon meal eaten on 10/25/2022. <BR/>In an interview on 10/25/2022 at 12:38 PM Resident #55 stated the food served does not match the cards on the tray. Resident #55 stated this happened frequently, several times a week at random times. Resident #55 stated she still had not received her lunch tray as of yet, was hungry and ready to eat. <BR/>In an observation and interview on 10/25/2022 at 1:35 PM, Resident #55 had a whole 6-inch corn tortilla served with her meal tray. Resident #55 stated she frequently receives items she knows she cannot handle. Resident #55 stated she does not eat the whole corn tortilla as it is too tough for her. Resident #55 stated she just puts it to the side. Resident #55 stated, she did not want to make a fuss, as staff are trying, and I don't want to send my tray back because I don't want to wait any later to be able to eat! [See Form 6339 Photographic Evidence, P1.]<BR/>In an interview on 10/25/2022 at 1:40 PM, CNA C stated her responsibility was to ensure the correct resident received their tray in a timely manner after the nurse inspected it. CNA C stated that she is also expected to set up the tray for the residents as needed. CNA C stated at times she is required to assist the residents if they are not able to independently feed self. CNA C stated she was not sure if she was the aide that presented the tray to Resident #55 today. <BR/>In an interview on 10/25/2022 at 1:45 PM, ADON B stated that the Residents meal trays are reviewed and compared to the meal tray tag for accuracy. ADON B stated this included making sure the texture and liquid consistency were correct; along with any specialty items such as fortified items or magic cup ice creams. ADON B stated trays were also inspected to ensure that adaptive equipment was provided for the Residents' who required it. ADON B stated, Oh, Okay and then walked away from this surveyor when advised that a resident with instructions for pureed texture was served a whole corn tortilla. <BR/>In an interview on 10/26/2022 at 1:55 PM, the ADM asked this surveyor which resident was served the whole corn tortilla. The ADM stated the meal tags needed to be followed for resident safety.

**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 receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 3 of 8 (Resident #67, #5 and #45 ) residents in that:<BR/>1. Resident #67 had a pressure ulcer on her heel and was not observed offloading her heels. <BR/>2. Resident #5 had a pressure ulcer on her heel and was not observed offloading her heels. <BR/>3. Resident #45 was not turned every 2 hours by staff. <BR/>This could affect all residents with pressure ulcers and could result in wounds not healing. <BR/>The Finding were: <BR/>1.Record review of Resident # 67's admission Record dated 1/27/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), and disorder of skin. <BR/>Record review of Resident # 67's consolidated physician orders for January 2025 was documented offloading boots to promote wound healing every shift for wound healing and had an unstageable to right heel paint with betadine daily as needed or sound healing if soiled or removed and every shift for wound healing.<BR/>Record review of Resident # 67's Quarterly MDS dated 10/22//2024 was documented her BIMS score was 15 out of 15 (cognitively intact). Resident #67's Quarterly MDS Skin condition was documented resident at risk for developing pressure ulcers/injuries).<BR/>Record review of Resident #67's Annual MDS dated [DATE] was documented she was a risk for developing pressure ulcers, and unstageable pressure ulcer. <BR/>Record review of Resident # 67's care plan dated 1/30/2025 was documented potential for pressure ulcer development related to disease process, interventions wear heel protectors while in bed. <BR/>Record review of Resident #67's wound care assessment dated [DATE] was documented she had a right heel, unstageable pressure injury, clean with betadine daily open to air and offloading boot and elevate.<BR/>Observation on 1/26/2025 at 2:14 PM in Resident #67's room revealed she was laying down on her bed, with no offloading boots on her heels.<BR/>Observation on 1/27/2025 at 1:11 PM in Resident #67's room revealed she was sitting on her w/c with no offloading boots on her heels.<BR/>Observation on 1/28/2025 at 11:30 AM in Resident #67's room revealed she was lying in bed over her, and her feet/heels were not offloaded. <BR/>Interview on 1/28/2205 at 11:32 AM with LVN AB, wound care nurse, in Resident #67's room stated she did not have her offloading booties on the resident to offload her heels while in bed. LVN AB stated it was important to offload Resident #67's heels to prevent infection and wound getting worse. LVN AB stated Resident #67 had an unstageable wound on her right heel, and treatment was betadine and leave open to air.<BR/>2. Record review of Resident #5's admission Record dated 1/29/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), cognitive communications disorder, difficulty walking, need for assistance with personal care, dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, that interferes with daily life and activities), and had lack of coordination. <BR/>Record review of Resident #5's consolidated physician orders for January 2025 was documented to offloading boots every shift for prevention of breakdown.<BR/>Record review of Resident #5's significant change MDS dated [DATE] was documented her BIMS score was 13 out of 15 (cognitively intact), she was at risk for developing pressure ulcers/injuries, and she required use of manual wheelchair.<BR/>Record review of Resident #5's care plan dated 12/12/2024 was documented pressure ulcer or potential for pressure ulcer development related to disease process. Resident #5's goal was to have intact skin, free of redness, blisters or decollation by/through review dated. Resident #5s interventions was to have skin assessments as ordered, and treatments as ordered. Resident #5 had skin integrity non pressure related to excoriation to sacrum.<BR/>Observation on 1/28/2025 at 11:50 AM with Resident #5 was lying in bed, with no heel protectors on. <BR/>Interview on 1/28/2025 at 11:54 AM with CNA H stated she took Resident # 5 back to bed, changed her, but did not put her heel protector booties on. The she left to do another task. <BR/>Interview on 1/28/2025 at 12:04 PM with ADM and DON, they stated they would educate staff on the concerns with residents receiving treatment for pressure ulcers, such as heel protectors. <BR/>3. Record review of Resident #45's admission Record was dated 1/28/2025 she was admitted on [DATE], re-admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body, muscle weakness, need assistance with personal care, and adult failure to thrive. <BR/>Record review of Resident #45's consolidated physician orders for January 2025 documented were resident to be turned every 2 hours.<BR/>Record review of Resident #45's Significant change MDS dated [DATE] documented her BIMS score was 3 out of 15 (severely impaired),.Resident #45 had upper extremity impairment on both sides lower extremity impairment on one side, she was dependent on oral care, showers, dressing, personal hygiene, she was always incontinent, she used a wheelchair to mobilize in the facility, and required a feeding tube to eat. <BR/>Record review of Resident #45's care plan dated 1/24/2025 documented she had pressure ulcer or potential for pressure ulcer development related to disease process, immobility, and stroke. Resident #45's interventions were needing assistance to turn/reposition at least every 2 hours, more often as needed, or requested. <BR/>Observation on 1/26/2025 at 2:24 PM Resident #45 was laying in her bed on her right side.<BR/>Observation on 1/26/2025 at 4:27 PM Resident #45 was laying in her bed on her right side. <BR/>Interview on 1/26/2025 at 4:32 PM LVN J stated Resident #45 had not been moved/turned in bed. <BR/>Observation on 1/28/2025 at 9:34 AM Resident # 45 revealed she was on laying on her back. <BR/>Observation on 1/28/2025 at 11:46 AM Resident # 45 revealed she was on laying on her back. <BR/>Interview on 1/28/2025 at 11:49 AM LVN Z stated Resident # 45 was laying on her back. LVN Z stated residents were supposed to be repositioned every 2 hours. LVN Z stated she was not sure why the CNA's have not repositioned Resident # 45. LVN Z stated she would reposition Resident # 45 now. <BR/>Interview on 1/28/225 at 12:28 PM the MDS/LVN stated residents that were bed bound, should be repositioned at least every 2 hours and as needed. <BR/>Interview on 1/28/2025 at 12:04 PM the ADM and DON, stated they would educate staff on the concerns with repositioning residents while in bed. The DON stated she expected staff turn and reposition bed bound resident every 2 hours. <BR/>Record review of policy, repositioning dated May 2013 documented, The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individual care plan for repositioning, to promote comfort for all bed or chair bound resident and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Preperation-1. Review the residents care plan to evaluate for any special needs of the resident. General Gudiliens-1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. <BR/>Record review of policy, Prevention of Pressure Injuries dated April 2020 was documented The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation -Review the residents care plan and identify the risk factors as well as the intervention designed to reduce or eliminate those considered modifiable. Skin Assessment- 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADL and full skin assessment weekly c. reposition resident as indicated on care plan. Prevention -skin care 6. Do not rub to otherwise cause friction on skin that is at risk for pressure injuries. Mobily/Repositioning -1. Reposition all resident with or at risk of pressure injuries on an individualized schedule. 2 .provided support devise and assistance 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 effective pest control program so that it was free of pests and rodents for 1 of 7 residents (Resident #1) reviewed for pest control program. The facility failed to ensure Resident #1 was not found with maggots in his right stage 3 heel wound on 10/16/25. Resident #1 refused an ER referral when the maggots were found and was sent to the emergency room a day after the maggots were discovered. An IJ was identified on 10/23/25. The IJ template was provided to the facility on [DATE] at 3:25 p.m. While the IJ was removed on 10/25/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility's need to monitor the implementation and effectiveness of its Plan of Removal. This failure could place residents at risk of experiencing a diminished quality of life, infections and/or death. The findings include: Record review of Resident #1's face sheet, dated 10/21/25, reflected a 32 -year-old male who was admitted to the facility on [DATE] and discharged AMA on 10/20/2025. Resident #1 had diagnoses which included: osteophyte, right foot (bone spur) ,osteophyte (a bony outgrowth) right ankle and left foot and ankle, pressure ulcer to left buttock stage 3, pressure ulcer left hip stage 3, paraplegia (loss of impairment in both lower limes), amputation at level between elbow and wrist, open wound of lower back and pelvis, pressure ulcer to left buttock stage 3, pressure ulcer of right buttock stage 4, and pressure ulcer right heel stage 3. The RP was listed as the resident. Record review of Resident#1's admission MDS, dated [DATE], reflected a BIMS score of 12, indicative of moderate impairment in cognition. The ADLs for: B/B was catheter for blader; bowel was incontinent. Transfer was total assistance; and bed mobility was supervision. Assistive device was listed as motorized W/C. ROM was documented as impairment to lower body. Record review of Resident #1's skin assessment on admissions, dated 10/3/25, reflected a right heel pressure ulcer with measurements of 3.5 x5.5x08 full thickness stage 3 20% slough (puss) serosanguinous (mix of blood and serum) and drainage. Record review of Resident #1's NP A' skin assessment on 10/13/25 of the right heel reflected the following measurements: 3.5 Length by 5.5 Width by 0.8 Depth.Record review of Resident #1's CP, dated 10/16/25, reflected .Reports of having live maggots in his right heel wounds. Interventions listed in the CP included: education to the residents, MD notified, sent to ER on [DATE] for any treatment, and daily wound treatment and weekly skin assessments. The CP documented to notify the physician as needed when resident refused wound care.Record review of Resident #1's physician orders, dated 10/15/25, read: . Wound care to right heel stage 3 pressure injury, cleanse with normal saline, pat dry, apply medihoney, (calcium) alginate, cover with dry dressing daily. Record review of Resident #1's Nurse Note, dated 10/16/25 at 6:00 a.m., authored by RN A, reflected: Multiple wounds with purulent drainage. Record review of Resident #1's SBAR note, dated 10/16/25 at 9:23 p.m., authored by LVN D, reflected .Wound to right heel is noted with live maggots falling from wound site. Resident is noted with history of refusing wound care and non-compliance of staying outdoors in wheelchair for long periods of time. Wound site is cleaned and wound care provided. [MD call center] on call notified of finding and recommendation to send to ED for eval (evaluation) and treatment.Record review of Resident #1's SBAR noted, dated 10/17/25 at 12:17 p.m., authored by the DON, reflected .maggots noted to patient wounds on feet [right heel] .wound care provided. persuaded patient to go to hospital with education of the outcome if not getting treatment for maggots in his wounds [right heel] . [arrived at hospital at 2:44 p.m.] Record review of Resident #1's Nurse Note, dated 10/17/22 at 12:22 p.m., authored by the DON, reflected .Resident (#1) stated ' I know my body and I don't really need to go to the hospital, I'm used to having maggots and they come whenever [I] skip wound care, I should have told y'all that happens.' Record review of Resident #1's Hospital records reflected Resident #1 was sent to the hospital for refusing care and now has maggots on 10/17/25. Record review of Resident #1's AMA sheet, dated 10/20/25, reflected the signed resident sheet with 3 witnesses present (DON, LVN C and RN K). Reason for AMA: resident wanted to be independent.Observation on 10/22/25 at 10:20 a.m., revealed some flies in Resident #2's room while observing wound care given to Resident #2 by LVN C. [flies in the room had the potential of landing on the resident's wound or laying eggs throughout the room and later infecting the resident's wounds] Observation of Resident #1's room on 10/22/25 at approximately 12:15 p.m. reflected that the screen was not fully adjusted to the frame, potentially allowing for flies/gnats to enter. There were no flies or gnats observed. During an interview on 10/21/25 at 12:30 p.m., the DON stated: Resident #1 was discovered with maggots tohis right wound heel on 10/16/25 by LVN D. The DON stated the timeline was as follows: ---10/2/25-resident was admitted with 9 pressure ulcers to include stage 3 to the right heel. No maggots were present in the wounds. MD Orders for daily wound care.---10/3/25- to 10/13/25 daily wound care done.---10/14/25 skin assessment: no change to wounds and no maggots in any wound.---10/15/25-resident refused wound care all day. ---10/16/25 during the day shift (6:00 a.m. to 2:00 p.m.) resident refused wound care.---10/16/25 at 9:23 p.m. maggots were observed by LVN D in the right heel dressing. The resident refused to go to the ER. LVN D attempted to remove the maggots.---10/17/25 at 6:00 a.m. resident refused wound care.---10/17/25 around 8:30 a.m., Resident accepted wound care from the DON and maggots were again found in the right heel. MD was again notified and order given to send resident to the ER for an assessment.---10/17/25-DON convinced resident to be assessed at the ER and DON accompanied the resident.---10/17/25-ER note: [Right] lower extremity with a lateral [well] healing ulcer, no maggots. discharged to facility in a stable condition.---10/20/25- wound care given by NP PP in the morning. Resident signed out AMA around 2:00PM [MD had given new orders for IV daptomycin (wound infection) and Levaquin (wound infection) prior to the resident going out AMA.] During an interview on 10/21/25 at 4:26 PM, the DON stated Resident #1 received daily wound care and was seen by the NP [A] Wound Nurse Weekly but had a history of refusing wound care. The DON stated NP PP was aware Resident #1 at times refused wound care. During an interview on 10/22/25 at 9:55 AM, the DON stated Resident #1's right heel wound was covered when the resident was up and about based on observations by nursing staff to include the DON. During an interview on 10/22/25 at 10:04 a.m., the DON stated the resident 's dressing was clean and dry except on 10/16/25 at 6:00 a.m., when the dressing was soiled and the resident refused wound care. The DON stated maggots were discovered on 10/16/25 around 8:30 a.m. and cleaned by the DON and LVN C (wound nurse) were present. The DON added, she saw 3-4 maggots on the right heel. The DON stated the resident still had maggots on 10/17/25 around 9:00 a.m. located on the right heel and the toe of the right foot (no wound); and several maggots on the right foot. The DON stated, other staff who saw the maggots were the Administrator on the wound (right heel) and LVN C on the bed. During an interview on 10/22/2025 at 10:20 a.m., LVN C stated while doing wound care to Resident #2, she observed some flies in the resident's room. LVN C stated, He is really messy with food, and he [NAME] on food and spills it everywhere, so he does get flies sometimes. We try to clean it up quickly, but there's never been any infestation or anything. During a telephone interview on 10/22/25 at 11:05 a.m., NP PP stated rubbing could kill the maggot eggs on a wound. NP PP stated heat, and the smell of dry blood could lead to flies laying eggs on a resident and develop into maggots within 8-20 hours. NP PP stated Resident #1 had the habit of going out on pass and refusing wound care. NP PP stated there were no issues with the wound care given to residents by facility nursing staff. NP PP stated Resident #1 skipping wound care for 2 days or more could result in maggots being present. NP PP stated she never saw maggots in the resident's wounds, but the resident could be infected with maggots given his habit of refusing care and spending hours outside the facility in the heat. During an interview on 10/22/25 at 11:15 a.m., the Administrator stated the last pest control spraying was done on 10/10/25 and the next spraying was scheduled for every two weeks (10/24/25). The Administrator stated the Pest Company sprayed all the common interior areas and exterior for occasional insects; no issues noted on the spraying on 10/10/25. During a telephone interview on 10/22/25 at 12:07 p.m., the MD stated the skipping of wound care could lead to maggots developing within 8-12 hours especially if the wound was soaked, there was heat, and the dressing was uncovered. The MD added some cleansing wound care solutions could kill maggots. The MD stated there were standing orders when the resident missed wound care. The MD stated she first became aware of the maggots when reported on 10/16/25 by LVN D. During a telephone interview on 10/22/25 at 3:25 p.m., the Pest Control Vendor stated flies were controlled by checking for room sanitation, checking dumpsters, and spraying. The Vendor added, flies could be controlled by fly lights [not present in the facility] and wiping down surfaces with special liquids. The Vendor stated he had not seen an infestation of flies in the facility, but flies could be present in the facility from doors opening. During an interview on 10/22/25 at 3:35 p.m., the Administrator stated the facility had not identified a fly problem. The Administrator stated no fly lights had been installed in the facility to include the kitchen, and no request had been made to the pest control vendor for special spraying and wiping down surfaces for fly prevention. During an interview on 10/22/25 at 5:08 p.m., LVNC stated: when Resident #1 allowed wound care per physician orders was completed. LVN C stated she saw no issues with the wound care provided by other nursing staff. LVN stated she never saw maggots in Resident#1's wounds. On 10/17/25 while assisting the DON, LVN C stated she saw maggots on the resident's bed on 10/17/25 and removed the maggots from the bed. During an interview on 10/22/25 at 6:02 p.m., the Administrator stated she saw a few maggots on the resident's heel on 10/17/25 at 9:30 a.m. The Administrator stated the DON cleaned the maggots and disposed of them. During a joint interview on 10/22/25 at 6:15 p.m., the Administrator and DON stated the sheets were removed on 10/17/25 and Resident #1's room was cleaned and sanitized/bleached. The DON did not know whether the sheets were changed, and room cleaned on the 10/16/25 night shift when LVN D saw maggots. During a telephone interview on 10/22/25 at 6:24 p.m., LVN D stated, he saw maggots on Resident #1's right heel on 10/16/25 around 9:30 p.m. and called the MD for guidance. LVN D stated the MD gave an order to send the resident to the ER for an assessment; but the resident refused to go to the ER. LVN D stated he could not remember whether the sheets were changed, and the room cleaned and sanitized/bleached. During an interview on 10/23/25 at 9:12 a.m., the Housekeeping Manager stated: housekeeping was not on done the night of 10/16/25 when LVN D saw maggots on Resident#1 heel wound. The Housekeeping manager stated Resident #1's room was not cleaned or bleached or the linen changed because no housekeeping staff were on duty the night of 10/16/25. The Housekeeping Manager stated she assumed nursing staff at night was responsible for housekeeping. The Housekeeping Manager started around 2:00-3:00 p.m. on 10/17/25 housekeeping services were provided to Resident #1's which included: cleaned, sanitized and bleached; and linen was changed. The Housekeeping Manager stated the linen was discarded; no maggots were seen. The Housekeeping Manager stated housekeeping services were provided again when the DON saw maggots in the afternoon on 10/16/25. The Housekeeping Manager stated the effective method for maggot control was deep surface cleaning, bleaching, and discarding affective linen and materials. During a telephone interview on 10/23/25 at 1:30 p.m., LVN D (night nurse) stated: he only focused on wound care for the right heel where the maggots were present. LVN D stated he only visually looked at the other wounds and saw no maggots. LVN D stated he saw the maggots on 10/16/25 around 9:30 p.m. LVN D stated he had not seen maggots in the resident's wounds in the past. LNV D stated Resident #1's gown was changed and there was a brief change. LVN D stated there was no linen changed, and he was not aware of the room being cleaned and sanitized. During a telephone interview on 10/24/25 at 10:30 a.m., LVN D stated: the resident had a right heel pressure ulcer at admissions (10/2/25). LVN D stated there were no maggots on the 9 PU sites upon admission. LVN D stated, the skin condition was awful at admissions. The resident was total assistance for transfer. LVN D stated there were no flies or gnats in the room where the assessment was conducted on 10/16/25 at 9:23 p.m. of the right heel with maggots. LVN D stated the right heel dressing was intact the days he saw the resident. LVN D stated the dressings to the right heel were sometimes moist, and the resident sometimes refused care. LVN D stated Resident #1 was always outside in a gown and would have blankets on the motorized W/C. LVN D stated the resident enjoyed spending time outside. LVN D stated he called the MD around shift change after seeing the maggots. Record review of pest control logs reflected pest control visit on 10/10/25 with no noted issues. Record review of facility's grievance log for the past 90 days (August-October 2025) reflected no grievances involving pests. Record review of the facility's Cleaning and Disinfection of Environment Surfaces policy, dated revised June 2009, read, .Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Pathogens Standard. Record review of the facility's Pest Control policy, dated revised May 2008, read, .Our facility shall maintain an effective pest control program.to ensure that the building is kept free of insects and rodents. This was determined to be an Immediate Jeopardy (IJ) on 10/23/25 at 3:25 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 10/23/25 at 3:25 p.m. The following Plan of Removal submitted by the facility was accepted on 10/24/25 at 12:43 a.m. [Facility] respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on 10/23/2025. Plan submitted on 10/23/2025 at 6:30pm The facility allegedly failed to maintain an effective pest control program so that it is free of pests and rodents. On 10/16/25, Resident #1 was found with maggots in his right stage 4 heel wound. On 10/16/2025, when maggots were discovered in Resident #1's heel wound, the Director of Nursing (DON) and LVN C. immediately cleansed the wound per wound protocol. Resident #1's room [was] thoroughly cleaned and sanitized in accordance with the facility's cleaning and disinfection policy.Observation of Resident #1's room at approximately 12:15 p.m. on 10/22/25 revealed the screen was not fully adjusted to the frame, potentially allowing for flies/gnats to enter. However, no flies or gnats were observed. Observation of Resident #1's room at approximately 12:15 p.m. on 10/22/25 revealed the screen was not Fully adjusted to the frame, potentially allowing for flies/gnats to enter. However, no flies or gnats were observed. Surveyor and Administrator confirmed that the window was sealed appropriately, and that the screen's previous misalignment would not [allow] any insects or pests to enter the facility. A facility-wide environmental inspection was completed on 10/22/2025 by the Maintenance Director to ensure all windows, screens, and entry points were intact and secure. No issues noted. Observation on 10/22/25 at 10:20 a.m.flies were observed in Resident #2's room while observing wound care given to Resident #2 by LVN C. [Not Resident #1] During an interview on 10/22/2025 at 10:20 AM, LVN C stated while doing wound care to Resident #2, she observed some flies in the resident's room. LVN C stated, He is really messy with food, and he [NAME] on food and spills it everywhere, so he does get flies sometimes. We try to clean it up quickly, but there's never been any infestation or anything. Record review of pest control logs reflected pest control visit on 10/10/25 with no noted issues. During interview on 10/22/25 at 3:25 p.m., [Pest] Control Vendor stated flies were controlled by checking for room sanitation, checking dumpsters, and spraying. He said flies could be controlled by fly lights [not present in the facility] and wiping down surfaces with special liquids [not sure if done at the facility]. Record review of facility's Pest Control policy, dated revised May 2008, reflected, .Our facility shall maintain an effective pest control program.to ensure that the building is kept free of insects and rodents The Administrator confirmed the facility currently utilizes three fly zap lights as part of its pest control prevention program. These devices are strategically located at the facility entrance, kitchen area, and along A Hall and B Hall to minimize insect activity. In addition, the facility employs three high-velocity door fans, positioned at the E Hall exit, B Hall exit, and kitchen exit, to deter flying insects from entering the building. On 10/22/2025, the Administrator contacted Pest Control and placed an order for three additional fly zap lights to further enhance pest prevention coverage throughout the facility. The Zap lights were delivered and installed on 10/23/2025 by Pest Prevention Technician [.] in the following locations. B Hall Dining Room, C Hall Dining Room and E Hall dining room. The effectiveness of the newly installed Zap Lights will be monitored utilizing the environmental daily check list. The Housekeeping Supervisor and Maintenance Director and or designee will be responsible for Zap Light Effectiveness. On 10/23/2025 the Pest Prevention Technician assisted the facility utilized the wipe down method in rooms of residents with treatment orders. This method entails wiping down surfaces and walls. Observation of Resident #1's room at approximately 12:15 p.m. on 10/22/25 revealed the screen was not fully adjusted to the frame, potentially allowing flies/gnats to enter. However, no flies or gnats were observed. Surveyor and Administrator confirmed that the window was sealed appropriately, and that the screen's previous misalignment would not allow any insects or pests to enter the facility. A facility-wide environmental inspection was completed on 10/22/2025 by the Maintenance Director to ensure all windows, screens, and entry points were intact and secure. No issues noted Observation on 10/22/25 at 10:20 a.m., revealed some flies in Resident #2's room while observing wound care given to Resident #2 by LVN C. [Note-this is part of the facility's POR]During an interview on 10/22/2025 at 10:20 AM, LVN C stated while doing wound care to Resident #2, she observed some flies in the resident's room. LVN C stated, He is really messy with food, and he [NAME] on food and spills it everywhere, so he does get flies sometimes. We try to clean it up quickly, but there's never been any infestation or anything. Record review of pest control logs show pest control visit on 10/10/25 with no noted issues. [Note-this is part of the facility's POR]During interview on 10/22/25 at 3:25 p.m., the Pest Control Vendor stated flies were controlled by checking for room sanitation, checking dumpsters, and spraying. He said that flies could be controlled by fly lights [not present in the facility] and wiping down surfaces with special liquids [not sure if done at the facility].[Note-this is part of the facility's POR] Record review of the facility's Pest Control policy, dated revised May 2008, reflected, .Our facility shall maintain an effective pest control program.to ensure that the building is kept free of insects and rodents. [Note-this is part of the facility's POR] The Administrator confirmed that the facility currently utilizes three fly zap lights as part of its pest control prevention program. These devices are strategically located at the facility entrance, kitchen area, and along A Hall and B Hall to minimize insect activity. In addition, the facility employs three high-velocity door fans, positioned at the E Hall exit, B Hall exit, and kitchen exit, to deter flying insects from entering the building.Residents with the potential to be affected by the alleged deficient practice: A comprehensive skin and wound audit was completed for all residents with pressure injuries on 10/23/25 by the nurse managers to ensure no other residents were affected. No other maggots or pests were found. This assessment was documented in a progress note. No other issues were discovered. All Staff were in serviced on the facilities Pest Control Program. The training was completed on 10/23/25 and was conducted by the Administrator and Director of Nurses. Resident identified to have been affected by the alleged deficient practice: On 10/16/2025, after providing additional education and multiple attempts to encourage compliance with medical care, Resident #1 agreed to be transported to the emergency room for further evaluation and treatment. The Director of Nursing (DON) personally accompanied the resident to the hospital. Prior to transfer, the DON, Administrator, Social Worker, Treatment Nurse, Charge Nurse, and Certified Nursing Assistant (CNA) were all involved in efforts to educate and persuade the resident regarding the importance of receiving medical attention. Resident stated, I get maggots when I refuse care, and I had them before coming here. Resident was [educated] on multiple occasions by providers. Progress notes [input] on 10/9, 10/13, 10/14 and 10/20. Care Plan on 10/15 also references history of refusal of care. Systemic Measures:[all staff]Training provided to all staff on the Pest Control Policy and protocols for pest prevention, environmental inspection, and staff reporting. This was completed on 10/23/25. 100% completed. This was completed by the Administrator and Director of Nurses. [Housekeeping]Training provided to all staff on the cleanliness of resident rooms to ensure rooms remain as free as possible of items that may attract pests. The staff [were] educated on cleaning procedures in the event pest are identified. Housekeeping Cart is available in E hall housekeeping closet for after-hour [use]. This was completed on 10/23/25. 100% completed. This was completed by the Administrator and Director of Nurses. The facility increased pest control vendor visits from biweekly to weekly and added three additional fly light installations in key areas. Weekly vendor visits initiated on 10/22/25 for 4 weeks. The three additional Zap Lights were installed on 10/23/25 by by Pest Prevention Technician. Maintenance initiated a weekly environmental inspection log for all window seals, screens, and potential pest entry points. This will be completed by the Maintenance Director and [/] or designee. The facility began utilizing this log on 10/23/25. Environmental Services implemented a daily cleaning checklist focusing on food debris and sanitation in resident rooms and dining areas. This will be conducted by the Housekeeping Supervisor and or [/] designee. The facility began utilizing this log on 10/23/25. Nurses received re-education on wound care refusal documentation, physician notification, and resident education procedures. 100% completed. The training was completed on 10/23/2025 and was conducted by the Director of Nurses. Quality Assurance Performance Improvement: On 10/23/2025 the Quality Assessment and Assurance Committee members to include, the Medical Director, Administrator, and Director of Nursing, District Director of Clinical Services and Division VP of Operations met to review and approve this plan. The facility will review the pest control log daily for any pest control issues. The Admin/ DON/designee will review and observe. In addition, the Admin/DON/designee will complete 5 observations per week. If any pest control issues or deficient practices are discovered the Admin/ DON/designee will provide additional training [for] staff. Training to include. Pretest, Inservice, Post Test and Return Demonstration. The results of the Admin/ Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction:10/23/2025 Monitoring of the POR included the following: Observation and interview on 10/24/25 at 4:30 p.m. Housekeeping Staff GG was observed involved in the deep cleaning of the facility wall edges. Housekeeping Staff GG stated she was instructed on the wipe down method by the Pest Control vendor. Also, Housekeeping Staff GG stated she did deep cleaning and wall frame rubbing down of rooms where residents had orders for pressure ulcer wound care; the room assignments were given by the Housekeeping Manager. Observation on 10/24/25 from 4:25 p.m. to 4:35 p.m., of all window screens reflected no holes and properly fitted to the window frames. Also, windows of 6 residents receiving wound care were sealed. During an observation on 10/24/25 from 5:00 p.m. to 5:10 p.m., of the facility reflected, there were three fly zap lights as part of its pest control prevention program present. These devices were strategically located at the facility entrance, kitchen area, and along A Hall and B Hall to minimize insect activity. The facility employed three high-velocity door fans, positioned at the E Hall exit, B Hall exit, and kitchen exit, to deter flying insects from entering the building During an observation on 10/25/25 at 11:00 a.m. revealed 6 fly zaps were all working. During an interview on 10/24/25 at 1:25 p.m., RN G stated she attended in-service on Pest Control policy and the highlights were to report any insects or rodents found anywhere in the facility through the system TELS. RN G stated Prevention included keeping the residents clean and food out of the room. During an interview on 10/24/25 at 1:32 p.m., LVN H stated the highlights of the in-service included: increased pest control spray and install fly lights. LVN H stated Environmental inspection involved checking on hoarding of food by residents. LVN H stated Reporting involved making an entry in TELS and notifying the Administrator. During an interview on 10/24/25 at 1:41 p.m., RN K stated the training highlighted to prevent insects and rodents by checking for cleanliness of rooms and food in the room. RN K stated Prevention also included changing of linen. RN K stated Reporting involved notifying the to the Administrator and documenting in TELS. During an interview on 10/24/25 at 1:56 p.m., CNA N stated the training included: prevention of pests by fly lights and fans blowing out. CNA N stated the environment was to be kept clean During an interview on 10/24/25 at 2:04 p.m. CNA O stated: prevention of pests included the use of zap lights. Prevent CNA O stated food was to be discarded in trash cans and rooms kept clean. CNA O stated to report any COC to Nursing staff. During an interview on 10/24/25 at 2:07 p.m., CNA P stated: prevention of pests involved by keeping areas Cleaned and keep residents bathed. CNA P stated to Report to nurse and Administration any room changes. During an interview on 10/24/25 at 2:10 p.m., LVN Q stated prevention involved keeping the area clean, the residents clean and take out trash. LVN Q state Reporting involved documenting in TELS. During an interview on 10/24/25 at 2:25 p.m., Staff R (Social Worker) stated the highlights were: prevention by cleanliness and Resident rooms should not have leftover food. Staff R stated, Report by documenting in the maintenance binder and notify management.,During an interview on 10/24/25 at 2:27 p.m., Staff S (Rehab) stated: highlights of the training involved shutting windows and keeping rooms cleaned. Staff S stated residents were to be kept clean and received incontinent Care; and report any COC on wounds to nursing staff. During an interview on 10/24/25 at 2:30 p.m., Staff T (Maintenance) stated prevention training included: maintain the facility and seal any openings in screens or windows. Staff T stated Notify nursing staff if insects or rodents were seen in the facility and document in the maintenance log. During an interview on 10/24/24 at 2:35 p.m. the Maintenance Director stated he received no W/O to seal windows or screens during the time of the incident on 10/16-10/17/25. The Maintenance Director added prior to the incident the facility did not have fly lights. During an interview on 10/24/25 at 2:38 p.m. Staff U (Kitchen) stated: highlights of the training included to keep kitchen and facility clean and practice hygiene; and Report W/O to management. During an interview on 10/24/25 at 2:39 p.m. Staff V (kitchen) stated: prevention of pests through cleaning and checking; and Reporting of pests through W/O. During an interview on 10/24/25 at 2:40 p.m. Staff W (kitchen) stated training involved keep the kitchen clean and the facility and throw out trash and inspect dumpsters. Staff W stated Report to the administrative staff about any issues with insects. During an interview on 10/24/25 at 2:41 p.m. Staff X (kitchen) stated: in-service stressed to keep the facility and kitchen clean as a prevention measure against pests. Staff X stated to check on the appearance of residents.and Report immediately if insects were on ceiling lights During an interview on 10/24/25 at 1:42 p.m., LVN I stated the highlights of training included: prevention through spraying and keeping rooms clean. LVN I stated Reporting involved to report to the DON and put in the maintenance log. During an interview on 10/24/25 at 1:43 p.m., CNA J stated the highlights were: check rooms for food and drinks. CNA J stated the environment involved to make sure it was kept clean. CNA J stated Reporting to the charge nurse and any COC and to document. During an interview on 10/24/25 at 1:52 p.m., CNA L stated the highlights of training included: prevention by keeping the facility clean. CNA L stated Check that residents were bathed as a prevention measure. CNA L stated to Report to housekeeping and the Administrator any room change. During an interview on 10/24/25 at 1:54 p.m., CNA M stated the training emphasized prevention of pests by having the resident cleaned and showered; and ensuring trash was removed. CNA M stated Report on TELS and report to DON and COC. During an interview on 10/24/25 at 2:50 p.m., Staff Y (Rehab) stated highlights of training included: cleanliness in rooms and no clutter and no food. Staff Y stated check on resident odors and cleanliness as prevention. Staff Y added to Check on wound dressings; and inform the nursing staff if the residents appear dirty and unkempt. During an interview on 10/24/25 at 2:51 p.m., Staff Z (Rehab) stated: prevention of pests included rooms needed cleaning and windows sealed; and Residents should be clean and kept clean. Staff Z stated Report issues to the nursing staff. During an interview on 10/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 4 residents (Resident #2 and Resident #3) reviewed for clinical records.1. The facility failed to ensure Resident #2's output was documented in his medical record on 6/9/25 and 6/19/25. 2. The facility failed to ensure Resident #3's output was documented in his medical record on 6/9/25 and 6/19/25. 3. The facility failed to ensure Resident #3's complete VS were documented in his medical record on 6/29/25. This failure could place residents at risk of not receiving the care and services needed. Findings included: 1.Record review of Resident #2's admission Record, dated 7/1/25, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood) , Chronic Kidney Disease (condition in which kidneys are damaged and cannot filter blood) , Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar) , and Neuromuscular Dysfunction of the Bladder (lack bladder control due to a brain, spinal cord or nerve problem) . Record review of Resident #2's Care Plan, revised 1/12/25, revealed: [Resident #2] has suprapubic Catheter.Record Output qshift [sic]. Record review of Resident #2's June MAR, dated 7/3/25, revealed .Record Output every shift. was blank for 6/9/25 and 6/19/25, 10:00 pm - 6:00 am shift. Record review of Resident #2's Progress Notes from 6/9/25 to 6/19/25 did not reveal notes regarding Resident #2's output. During an interview with Resident #2 on 7/3/25 at 1:22 pm, Resident #2 said his catheter drainage bag was emptied 3 times a day without fail. 2. Record review of Resident #3's admission Record, dated 7/1/25, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Multiple Sclerosis (disease that damages the nervous system) . Record review of Resident #3's Care Plan, revised 5/28/25, revealed: [Resident #3] has suprapubic Catheter.Monitor and document intake and output. Record review of Resident #3's June MAR, dated 7/3/25, revealed .Record Output every shift. was blank for 6/9/25 and 6/19/25, 10:00 pm - 6:00 am shift. Record review of Resident #3's Progress Notes from 6/9/25 to 6/19/25 did not reveal notes regarding Resident #3's output. During an interview with Resident #3 on 7/1/25 at 1:23 pm, Resident #3 said the staff emptied his catheter drainage bag whenever they wanted. Telephone interview attempted on 7/2/25 at 2:00 pm with LVN A was unsuccessful. Telephone interview attempted on 7/2/25 at 3:37 pm with LVN B was unsuccessful. Telephone interview attempted on 7/3/25 at 1:58 pm with CNA C was unsuccessful. Telephone interview attempted on 7/3/25 at 2:02 pm with LVN B was unsuccessful. 3. Record review of Resident #3's Change in Condition Evaluation, dated 6/29/25, revealed the resident had a fever. Further review of the evaluation revealed: .Are these the most recent vital signs taken after the change in condition occurred? Yes, the Vital Signs Evaluation section reflected Resident #3's blood pressure was 132/76, dated 6/29/25; pulse was 67, dated 6/17/25; respiratory rate was 20, dated 6/23/25; and temperature was 97.6, dated 6/23/25. Record review of Resident #3's Progress Notes for 6/29/25 did not reveal notes regarding Resident #3's vital signs. During a telephone interview with Resident #3 on 7/2/25 at 11:44 am, Resident #3 said that RN E did assess his VS on 6/29/25 before he left to the hospital. During a telephone interview on 7/2/25 at 10:52 am, RN E said he assessed Resident #3 on 6/29/25 before he left to the hospital. RN E further stated the assessment included a complete set of vital signs: temperature, pulse, respiratory rate, and blood pressure, which were all within normal limits. RN E said he was sure he documented the vital signs in Resident #3's record. During an interview on 7/3/25 at 1:08 pm, the DON said she expected nurses to document all resident assessments, including vital signs, in the residents' record. The DON further stated documentation of assessments was important for follow up, so that changes in condition could be identified, adding that nurses coming in during the following shift may not receive pertinent information. During an interview on 7/3/25 at 3:00 pm, the Administrator said she expected nurses to use their judgement to decide what needed to be documented. The Administrator further stated she expected assessments, including vital signs, to be documented according to the facility's policy. Record review of the facility's policy, Charting and Documentation, Qtr 3, 2018, revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record: a. Objective observations.c. Treatments or services performed.7. Documentation of procedures and treatments should include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment.Record review of the facility's policy, Charting and Documentation, Qtr 2, 2020, revealed: .2. In addition, the nurse shall review and document/report the following baseline information, as applicable: a. Vital signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, with adequate and comfortable lighting levels in all areas; for 2 of 8 residents (Residents #18 and #37) reviewed for adequate lighting in the dining room. <BR/>On 1/26/2026 at noon and ongoing until 1/30/2025 the facility's dining rooms had malfunctioning fluorescent lamps and fixtures, which residents #18 and #37 had stated they wished for better lighting during their meals. <BR/>These failures could negatively impact residents' morale and overall sense of self-esteem. <BR/>The findings included:<BR/>A record review of Resident #18's admission record dated 1/30/2025 revealed an admission date of 9/2/2021 with diagnosis which included dysphagia (difficulty swallowing), anxiety, and bipolar disorder (a serious mental illness characterized by extreme mood swings.)<BR/>A record review of Resident #18's quarterly MDS assessment dated [DATE] revealed Resident #18 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. Further review revealed Resident #18 could usually understand others, could make herself understood, had adequate vision and hearing. Resident #18 was assessed with the ability to use suitable utensils to bring food and / or liquid to her mouth and swallow food and / or liquid once the meal was placed before her. During the assessment Resident #18 stated she sometimes felt lonely and isolated. Resident #18 was assessed with the need to use a wheelchair and could ambulate with the wheelchair. Resident #18 was assessed as medically complex with anemia (eating a healthy diet might prevent some forms of anemia), and malnutrition.<BR/>A record review of Resident #18's care plan dated 1/30/2025 revealed, Resident at risk for nutritional problem r/t vitamin D def sic(deficiency), HTN (high blood pressure), CHF (heart failure), CKD (kidney disease) and obese status . Monitor/document/report to MD PRN (as needed) for s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing<BR/>to eat, appears concerned during meals. Date Initiated: 08/26/2022 Provide and serve diet as ordered. <BR/>A record review of Resident #18's physicians' orders dated 1/30/2025 revealed the physician prescribed for Resident #18 to receive mirtazapine (an antidepressant - often prescribed off-label as an appetite stimulant to aid in weight gain for certain populations) 15mg at bedtime for a poor appetite.<BR/>A record review of Resident #37's admission record dated 1/30/2025 revealed an admission date of 5/5/2017 with diagnoses which included bilateral cataracts (both eyes - a condition affecting the eye that causes clouding of the lens. A gradual progression of vision problem, eventually, if not treated, may result in vision loss), depression, and dysphagia (difficulty swallowing). <BR/>A record review of Resident #37's quarterly MDS assessment dated [DATE] revealed Resident #37 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. Further review revealed Resident #37 could usually make herself understood and could understand others. Resident #37 was assessed with symptoms of little interest or pleasure in doing things? . feeling down, depressed, or hopeless? . yes 2-6 days .over the last 2 weeks Resident #37 was assessed with the ability to use suitable utensils to bring food and / or liquid to her mouth and swallow food and / or liquid once the meal was placed before her. Resident #18 was assessed as medically complex with a diagnosis of malnutrition.<BR/>During an observation and interview on 1/26/2025 at 12:08 PM Resident #18 and #37 were seated together at one of the dining room tables. The dining room was 1 of 2 which were adjacent to one another. The fluorescent light fixture directly above Resident #18's and #37's table was not illuminated and caused for a dimly lighted area within the dining room. Further observation revealed 4 out of approximately 9 fixtures were not illuminated in the dining rooms. Resident #18 and #37 stated the lights had not worked, for some time now . we don't know how long. Residents #18 and stated she felt a little down and she wished the lights worked and stated, I wish I could see what I am eating. Resident #37 stated, the dark makes me feel down. I would like more light . I want to see my food.<BR/>During an observation on 1/26/2025 at 12:08 to 12:45 PM the facility's dining rooms had flickering fluorescent lamps due to staff attempting to illuminate the malfunctioning lamps. Admissions coordinator stated the lights were now working because he turned on and off the switches. Observation at the time revealed the malfunctioning lights were illuminated only to malfunction again. The operations manager stated the electrical contractor would be called to repair the malfunctioning lamps. <BR/>Continued daily intermittent observations from 1/26/2025 to 1/30/2025 revealed the dining rooms continued with malfunctioning lamps. <BR/>A record review of the facility's policy titled Residents Rights dated February 2021 revealed, Policy Statement<BR/>Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>a. <BR/>a dignified existence;<BR/>b. <BR/>be treated with respect, kindness, and dignity; <BR/>

Based on observation, interview, and record review the facility failed to provide each resident that receives food from the kitchen, food that is palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for safe and appetizing temperatures: The breakfast meal served on 8/15/25 did not have the required holding temperatures for the last meal trayed served from the kitchen. This failure could lead to a diminished quality of life and expose residents to food borne pathogens and illness. The findings included: Observation on 8/15/25 from 8:05 AM to 8:40 AM of kitchen reflected that the steam table did not operate. The staff attempted to heat the food by adding hot water to the steam table or keeping food items longer in the oven. Observation of food temperatures of food items on the steam table reflected the following readings[breakfast meal]: readings were taken by [NAME] A with temperatures taken at 8:07 AM (initial) and test tray temperature at 8:50 AM: Oatmeal 110 F to (not taken; no more oatmeal) Eggs 159 F (initial) to 92 F (test tray) Sausage 122F to 79 F Puree Sausage 88F to 81 F Puree Eggs 89F to 78F Mechanical Soft Eggs 120F to 80F Mechanical Soft Sausage 97F to 80F Puree Bread 71F to 70FRemarks: 3 residents did not eat form the kitchen (PEG) [Observation and interview on 8/18/25 at 8:45 AM, of kitchen reflected that the steam table was still not working. Observation further reflected the breakfast food from the oven or stove top was placed in a roaster with hot water and then transferred to a plate. During an interview on 8/15/25 at 8:15 AM, [NAME] A stated the steam table was not working since Tuesday 8/12/25. [NAME] A stated the food was cold on the steam table and served cold food to the residents. [NAME] A stated efforts were made to keep the food hot by regulation at 165 F at steam table and 135 F when served. [NAME] A stated methods used to keep the food hot was to transfer the hot food from the oven or stove on the non-working steam table and putting hot water in the steam table. [NAME] A stated from the start of the food cycle the breakfast meal met temperatures and the temperatures were recorded on the temperature log sheet; but the food quickly lost its hot temperature. [NAME] A stated she was not aware of any resident complaining of foodborne illnesses from the cold food. During telephone interview on 8/15/25 at 8:20 AM, the Ombudsman stated that residents had complained to her about the cold food served in the facility for the past two to three days (8/12/25-8/15/25) During an interview on 8/15/25 at 8:25 AM, the FSS stated the steam table was not working since Tuesday (8/12/25) and the facility made efforts to repair the steam table without success. The FSS stated cold foods were served to the residents because the facility hoped that the steam table could be repaired in a short time. The FSS stated measures taken to keep the food hot included pouring hot water into the non-working steam table and holding foods in the oven or stove top until ready to be transferred to the steam table. During a joint interview on 8/15/25 at 9:45 AM, with the Administrator and DON, the Administrator stated the steam table had not worked since Tuesday (8/12/25) and a new steam table purchased order was made on 8/14/25.[Record review of purchased order was verified.] The Administrator stated that the efforts made included to repair the steam by two different vendors; and heating from the stove, and hot water added to non-working steam table. The Administrator stated a menu review was done on 8/12/25, and decision was made not to serve cold foods as the menu substitute. The Administrator stated the facility considered catering the food and did not contract for catering. The Administrator stated the dietician was present on Wednesday (8/13/25) and did not share any recommendation. The DON stated there had been no foodborne illnesses resulting from the cold food. The Administrator stated given the surveyor's entrance and the steam table had not been replaced, her plan was to either serve cold plates or cater until a working steam table was in present in the kitchen During an interview on 8/15/25 at 10:53 AM, the DON stated that by nursing practice and as the IP the facility should not have served cold eggs and sausages for breakfast on 8/15/25 because of the risk of bacteria build up and food borne illnesses to residents. The DON stated as the IP that she preferred not to answer the question why she did not advise the facility not to serve cold foods to the residents from 8/12/25 to 8/15/25. The DON stated that no resident suffered food borne illnesses from the cold food. During telephone interview on 8/15/25 at 11:10 AM, the Dietician stated she last visited the facility on Wednesday (8/13/25) and became aware of the non-working steam table. The Dietician stated cold food should not be served to residents because of the danger of food borne illnesses. The Dietician stated she took the temperature of the lunch meal on 8/13/25 and the temperatures met regulation. The Dietician stated she recommended to the facility to place boiling water in the non-working steam table and hold hot foods on the stove or oven until the meal was to be served from the steam table. The Dietician stated the facility did not inform her that the food was cold on Thursday (8/14/25) and the Friday (8/15/25) breakfast meals. The Dietician stated on 8/15/25 [arrival of surveyor] she again became aware of the issue of cold foods and made the recommendations to serve a cold lunch and buy roasters or thermal plates until the steam table was delivered. The Dietician stated catering was her last option. Record review of facility's Temperature Log dated 8/15/25 reflected that the food cooked met the minimum temperature of 165F before placed on the non-working steam table. Record review of the facility's 14-day menu for Week 3 reflected the breakfast menu for 8/15/25 included: eggs. cheese taco, and sausage. Record review of facility's list dated 8/15/25 of residents on tube feeding reflected that 3 residents did not eat from the kitchen. Record review of facility's 24 report dated 8/15/25 reflected no residents with food borne illnesses. Record review of facility's Food Preparation and Service dated 2001 read, .The 'danger zone' for food temperature is between 41 'F' and 135 'F'. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: <BR/>1. In a refrigerator, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date.<BR/>2. The facility's documents Three Compartment Sink Log and Milk Refrigerator Temperature Log for January 2025 reflected no entries were documented January 22-January 24. <BR/>3. Dietary Aide AG had a facial piercing and parts of her hair exposed while working in the kitchen. <BR/>These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. <BR/>The findings were:<BR/>1. <BR/>During observation on 01/26/25 at 10:52 AM, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. <BR/>During an interview on 01/26/25 at 01:03 PM, the CDM revealed the salad bags and the bag of ham in the refrigerator did not have a discard date, so he threw these foods away to ensure foods from the kitchen were safe to eat. He further revealed he was not aware of who did this and he oversaw this process. <BR/>2. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Milk Refrigerator Temperature Log for January 2025 reflected no temperatures were documented January 22-January 24 in the AM and PM. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Three Compartment Sink Log for January 2025 reflected no wash temperatures or PPM were documented January 22-January 24 in the AM and PM. <BR/>During an interview with [NAME] AF, during initial kitchen tour on 01/26/25 at 10:52 AM, she revealed there were missing days on the Milk Refrigerator Temperature Log and the Three Compartment Sink Log.<BR/>During an interview on 01/26/25 at 01:03 PM, the CDM confirmed Milk Refrigerator Temperature Log, dated January 2025, and Three Compartment Sink Log, dated January 2025, had no entries documented January 22- January 24 in the AM and PM. The CDM revealed it was important to follow the dishwashing guidelines to kill germs. He revealed he trusted his AM staff members checked temperatures, but he was unaware about his PM staff. He further revealed the log had blank spaces and he expected these logs to be filled completely. He revealed these deficiencies could cause food borne illnesses.<BR/>3. <BR/>During an interview and observation on 01/26/25 at 01:03 PM, it was observed that Dietary Aide AG, while preparing for lunch on 01/26/25, had a facial piercing (located on her bottom lip) and her hair net did not cover the bottom half of her hair. The CDM revealed he had to work on training about dress code with the kitchen staff as there were issues with them following the dress code, but he was going to start the training soon.<BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed it was important to label and date food products to make sure they were serving food safely. The RD further revealed that completing logs in the kitchen, like temperatures and dishwashing logs, prevented food borne illness.<BR/>Record review of facility's policy Food Preparation and Service, revised November 2022, reflected Food Preparation, Cooking, and Holding Time/Temperatures . 1. The danger zone for food temperatures is above 41 *F and below 135 *F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Food Distribution and Service . 1. Proper hot and cold temperatures are maintained during food distribution and service . 8. Food and nutrition services staff wear hair restraints (hair net) so that hair does not contact food. 9 . Jewelry is worn minimally, and hand jewelry is covered with gloves . 15. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.<BR/>Record review of facility's policy Refrigerators and Freezers, revised November 2022, reflected 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures . 4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . 7. All food is appropriately dated to ensure proper rotation by expiration dates . Use by dates are completed with expiration dates on all prepared food in refrigerators . 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-303 Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry .<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-302.12 Food Storage Containers, Identified with Common Name of Food . working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT . shall be identified with the common name of the FOOD.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-307 Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-5 Limitation of Growth of Organisms of Public Health Concern 3-501 Temperature and Time Control 3-501.12 Time/Temperature Control for Safety Food, Slacking . (A) Under refrigeration that maintains the FOOD temperature at 5*C (41*F) or less . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES .

Based on observation, interview, and record review the facility failed to maintain dietary equipment that was in safe operation condition for 1 of 1 kitchen reviewed for steam table operation. The steam table was not operating. This failure could place residents who ate meals from the kitchen at risk for spread of infections, food contamination, and food borne illnessThe findings included: Observation on 8/15/25 from 8:05 AM to 8:40 AM of kitchen reflected that the steam table did operate. The staff attempted to heat the food by adding hot water to the steam table or keeping food items longer in the oven. Observation of food temperatures of food items on the steam table reflected hot foods were in the danger zone. During an interview on 8/15/25 at 8:15 AM, [NAME] A stated the steam table was not operating since Tuesday 8/12/25. [NAME] A stated that the food was cold on the steam table and served cold to the residents. [NAME] A stated efforts that were made to keep the food hot by regulation, 165 F at steam table and 135F when served by keeping the food on the stove until transferred to the steam table and putting hot water in the steam table. The [NAME] stated from the start of the food cycle the breakfast meal met temperatures and the temperatures were recorded on the temperature log sheet. However, [NAME] A stated that the hot food on the steam table rapidly dropped in temperature and served cold to residents. [NAME] A stated she was not aware of any resident complaining of foodborne illnesses from the cold food. During an interview on 8/15/25 at 8:25 AM, the FSS stated that the steam table was not operating since Tuesday (8/12/25) and the facility had made efforts to repair the steam table without success. The FSS stated cold foods were served to the residents because the facility hoped that the steam table could be repaired in a short time by 8/13/25. The FSS stated measures taken to keep the food hot included pouring hot water into the non-working steam table and holding foods in the oven or stove top until ready to be transferred to the steam table. During a joint interview on 8/15/25 at 9:45 AM, with the Administrator and DON, the Administrator stated the steam table has not operating since Tuesday (8/12/25) and a new steam table purchased order was made on 8/14/25. The Administrator stated that the efforts made included to repair the steam by two different vendors; and heating from the stove, and hot water added to steam table. The Administrator stated a menu review was done, and decision was made not to serve cold foods. The DON stated there had been no foodborne illnesses resulting from the cold food served from the non-operating steam table. During telephone interview on 8/15/25 at 11:10 AM, the Dietician stated that she visited the facility on Wednesday (8/13/25) and became aware of the non-operating steam table. The Dietician stated she recommended to the facility to place boiling water in the non-working steam table and hold hot foods on the stove or oven until the meal was to be served from the non-operating steam table. Observation and interview on 8/18/25 at 8:45 AM, of kitchen reflected that the steam table was still not operating. Observation further reflected the breakfast food was served off the stove top and was placed in a roaster with hot water and then transferred to a plate. [The latter option for cooking foods was made by the facility's dietician]. Surveyor Test tray of a regular meal (eggs, sausage, and waffles) reflected the holding temperature was within regulation. [NAME] A stated that if a resident complained of cold food the microwave was available to re-heat the food. [NAME] A stated she expected the arrival of the steam table this week. During an interview on 8/18/25 at 9:25 AM, the Administrator stated the arrival of the steam was expected this Wednesday 8/20/25. The Administrator stated the facility would employ the options of serving cold foods or using the roaster until the arrival of an operating steam table. Record review of facility's invoice undated reflected the purchase of a steam table. Record review of facility's policies did not reflect a policy on maintaining essential equipment to include kitchen equipment in operation condition. [Surveyor on 8/15/25 at 8:00 AM requested from the Administrator a policy on maintaining essential equipment. At exit on 8/18/25 at 3:00 PM, the Administrator had not provided the surveyor with a policy on maintaining essential equipment.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 4 residents (Resident #2 and Resident #3) reviewed for clinical records.1. The facility failed to ensure Resident #2's output was documented in his medical record on 6/9/25 and 6/19/25. 2. The facility failed to ensure Resident #3's output was documented in his medical record on 6/9/25 and 6/19/25. 3. The facility failed to ensure Resident #3's complete VS were documented in his medical record on 6/29/25. This failure could place residents at risk of not receiving the care and services needed. Findings included: 1.Record review of Resident #2's admission Record, dated 7/1/25, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood) , Chronic Kidney Disease (condition in which kidneys are damaged and cannot filter blood) , Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar) , and Neuromuscular Dysfunction of the Bladder (lack bladder control due to a brain, spinal cord or nerve problem) . Record review of Resident #2's Care Plan, revised 1/12/25, revealed: [Resident #2] has suprapubic Catheter.Record Output qshift [sic]. Record review of Resident #2's June MAR, dated 7/3/25, revealed .Record Output every shift. was blank for 6/9/25 and 6/19/25, 10:00 pm - 6:00 am shift. Record review of Resident #2's Progress Notes from 6/9/25 to 6/19/25 did not reveal notes regarding Resident #2's output. During an interview with Resident #2 on 7/3/25 at 1:22 pm, Resident #2 said his catheter drainage bag was emptied 3 times a day without fail. 2. Record review of Resident #3's admission Record, dated 7/1/25, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Multiple Sclerosis (disease that damages the nervous system) . Record review of Resident #3's Care Plan, revised 5/28/25, revealed: [Resident #3] has suprapubic Catheter.Monitor and document intake and output. Record review of Resident #3's June MAR, dated 7/3/25, revealed .Record Output every shift. was blank for 6/9/25 and 6/19/25, 10:00 pm - 6:00 am shift. Record review of Resident #3's Progress Notes from 6/9/25 to 6/19/25 did not reveal notes regarding Resident #3's output. During an interview with Resident #3 on 7/1/25 at 1:23 pm, Resident #3 said the staff emptied his catheter drainage bag whenever they wanted. Telephone interview attempted on 7/2/25 at 2:00 pm with LVN A was unsuccessful. Telephone interview attempted on 7/2/25 at 3:37 pm with LVN B was unsuccessful. Telephone interview attempted on 7/3/25 at 1:58 pm with CNA C was unsuccessful. Telephone interview attempted on 7/3/25 at 2:02 pm with LVN B was unsuccessful. 3. Record review of Resident #3's Change in Condition Evaluation, dated 6/29/25, revealed the resident had a fever. Further review of the evaluation revealed: .Are these the most recent vital signs taken after the change in condition occurred? Yes, the Vital Signs Evaluation section reflected Resident #3's blood pressure was 132/76, dated 6/29/25; pulse was 67, dated 6/17/25; respiratory rate was 20, dated 6/23/25; and temperature was 97.6, dated 6/23/25. Record review of Resident #3's Progress Notes for 6/29/25 did not reveal notes regarding Resident #3's vital signs. During a telephone interview with Resident #3 on 7/2/25 at 11:44 am, Resident #3 said that RN E did assess his VS on 6/29/25 before he left to the hospital. During a telephone interview on 7/2/25 at 10:52 am, RN E said he assessed Resident #3 on 6/29/25 before he left to the hospital. RN E further stated the assessment included a complete set of vital signs: temperature, pulse, respiratory rate, and blood pressure, which were all within normal limits. RN E said he was sure he documented the vital signs in Resident #3's record. During an interview on 7/3/25 at 1:08 pm, the DON said she expected nurses to document all resident assessments, including vital signs, in the residents' record. The DON further stated documentation of assessments was important for follow up, so that changes in condition could be identified, adding that nurses coming in during the following shift may not receive pertinent information. During an interview on 7/3/25 at 3:00 pm, the Administrator said she expected nurses to use their judgement to decide what needed to be documented. The Administrator further stated she expected assessments, including vital signs, to be documented according to the facility's policy. Record review of the facility's policy, Charting and Documentation, Qtr 3, 2018, revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record: a. Objective observations.c. Treatments or services performed.7. Documentation of procedures and treatments should include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment.Record review of the facility's policy, Charting and Documentation, Qtr 2, 2020, revealed: .2. In addition, the nurse shall review and document/report the following baseline information, as applicable: a. Vital signs.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: <BR/>1. In a refrigerator, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date.<BR/>2. The facility's documents Three Compartment Sink Log and Milk Refrigerator Temperature Log for January 2025 reflected no entries were documented January 22-January 24. <BR/>3. Dietary Aide AG had a facial piercing and parts of her hair exposed while working in the kitchen. <BR/>These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. <BR/>The findings were:<BR/>1. <BR/>During observation on 01/26/25 at 10:52 AM, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. <BR/>During an interview on 01/26/25 at 01:03 PM, the CDM revealed the salad bags and the bag of ham in the refrigerator did not have a discard date, so he threw these foods away to ensure foods from the kitchen were safe to eat. He further revealed he was not aware of who did this and he oversaw this process. <BR/>2. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Milk Refrigerator Temperature Log for January 2025 reflected no temperatures were documented January 22-January 24 in the AM and PM. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Three Compartment Sink Log for January 2025 reflected no wash temperatures or PPM were documented January 22-January 24 in the AM and PM. <BR/>During an interview with [NAME] AF, during initial kitchen tour on 01/26/25 at 10:52 AM, she revealed there were missing days on the Milk Refrigerator Temperature Log and the Three Compartment Sink Log.<BR/>During an interview on 01/26/25 at 01:03 PM, the CDM confirmed Milk Refrigerator Temperature Log, dated January 2025, and Three Compartment Sink Log, dated January 2025, had no entries documented January 22- January 24 in the AM and PM. The CDM revealed it was important to follow the dishwashing guidelines to kill germs. He revealed he trusted his AM staff members checked temperatures, but he was unaware about his PM staff. He further revealed the log had blank spaces and he expected these logs to be filled completely. He revealed these deficiencies could cause food borne illnesses.<BR/>3. <BR/>During an interview and observation on 01/26/25 at 01:03 PM, it was observed that Dietary Aide AG, while preparing for lunch on 01/26/25, had a facial piercing (located on her bottom lip) and her hair net did not cover the bottom half of her hair. The CDM revealed he had to work on training about dress code with the kitchen staff as there were issues with them following the dress code, but he was going to start the training soon.<BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed it was important to label and date food products to make sure they were serving food safely. The RD further revealed that completing logs in the kitchen, like temperatures and dishwashing logs, prevented food borne illness.<BR/>Record review of facility's policy Food Preparation and Service, revised November 2022, reflected Food Preparation, Cooking, and Holding Time/Temperatures . 1. The danger zone for food temperatures is above 41 *F and below 135 *F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Food Distribution and Service . 1. Proper hot and cold temperatures are maintained during food distribution and service . 8. Food and nutrition services staff wear hair restraints (hair net) so that hair does not contact food. 9 . Jewelry is worn minimally, and hand jewelry is covered with gloves . 15. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.<BR/>Record review of facility's policy Refrigerators and Freezers, revised November 2022, reflected 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures . 4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . 7. All food is appropriately dated to ensure proper rotation by expiration dates . Use by dates are completed with expiration dates on all prepared food in refrigerators . 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-303 Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry .<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-302.12 Food Storage Containers, Identified with Common Name of Food . working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT . shall be identified with the common name of the FOOD.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-307 Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-5 Limitation of Growth of Organisms of Public Health Concern 3-501 Temperature and Time Control 3-501.12 Time/Temperature Control for Safety Food, Slacking . (A) Under refrigeration that maintains the FOOD temperature at 5*C (41*F) or less . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 secured yard reviewed for safety.<BR/>1.Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had a section of chain link fence a section of the chain link fencing was detached from the top rail and leaning down.<BR/>2. Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash. <BR/> These failures could place residents at risk for elopement and/or fire risks.<BR/>The findings included:<BR/>A record review of Resident #24's admission record dated 1/30/2025 revealed an admission date of 12/17/2024 with diagnoses which included tobacco use, lack of coordination, and muscle weakness.<BR/>A record review of Resident #24's quarterly MDS assessment dated [DATE] revealed Resident #24 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 12 which indicated intact cognition. Resident #24 was assessed with difficulty hearing and poor vision and used glasses. Resident #24 was assessed an elopement / wander risk and was supported for safety with a wander guard anklet. <BR/>A record review of Resident #24's care plan dated 1/30/2025 revealed, At risk for elopement /wandering as evidenced by Disoriented to place, Impaired safety awareness, wanders aimlessly Date Initiated: 12/19/2024. Device: Alarm: Check via Electronic Machine Every Day Date Initiated: 12/20/2024. Device: Alarm: Visually Check Every Shift Wander guard on Right Ankle every shift for Wonder Guard. The resident has, impaired visual function r/t Disease Process . Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. STCP: At risk for smoking related injury related to: supervised smoking . observe him/her for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management Date Initiated: 12/18/2024 <BR/>A record review of Resident #24's physicians' orders dated 1/30/2025 revealed the physician prescribed, for her elopement / wander risk, a wander guard anklet and to have the anklet checked daily. <BR/>A record review of Resident #55's admission record revealed an admission date of 2/4/2021 with diagnoses which included corneal ulcer of the right eye, generalized anxiety disorder, dementia with behavioral disturbance. <BR/>A record review of Resident #55's annual MDS assessment dated [DATE] revealed Resident #55 was an [AGE] year-old male admitted for long term care and resided in the MCU. Resident #55 was assessed with a BIMS score of 00 which indicated severe cognitive impairment as evidenced by his inability to participate in the assessment. <BR/>A record review of Resident #55's care plan dated 1/28/2025 revealed, (Resident #61) is an elopement risk/wanderer Continues placement on Memory Care at this time. is a smoker . Instruct (Resident #55) about the facility policy on smoking: locations, times, safety concerns . has a behavioral concern of increased agitation physical and verbal aggression with the possibility of throwing things . Staff to redirect resident to other activities . Intervene as needed to ensure resident safety <BR/>A record review of Resident #83's admission record dated 1/30/2025 revealed an admission date of 11/4/2024 with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a cluster of symptoms, not an illness. It's sometimes described as losing touch with reality), mood disturbance, and anxiety. Further review revealed Resident #83 resided in the MCU.<BR/>A record review of Resident #83's admission MDS assessment dated [DATE] revealed Resident #83 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. Resident #83 was reviewed for the 6 days prior to the assessment and Resident #83 was assessed with a history of behavioral symptoms, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) . behavior of this type occurred 1 to 3 days. verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . behavior of this type occurred 1 to 3 days. impact on others? Put others at significant risk for physical injury? Yes Further review revealed resident #83 was six foot tall and weighed 179 lbs. <BR/>A record review of Resident #83's care plan dated 1/29/2025 revealed, (Resident #83) has mood problem r/t Admission, agitation and anxiety from resident to staff root cause: Resident attempting to get out of memory care unit . is a safe smoker Date Initiated: 11/07/2024 . Patient educated to appropriate smoking areas Date Initiated: 11/07/2024 If safety becomes a concern involve IDT team and resident for reevaluation of smoking needs <BR/>During an observation and interview on 1/26/2025 at 11:30 AM revealed the facility's secured back yard / smoking patio. The patio presented with 2 red fire rated trash cans and 1 large plastic 30-gallon trash can with a plastic liner. The patio was supervised by the Admissions Coordinator and Residents #2, #24, #55, and #83 were among the 9 residents at the patio. Further observation revealed the residents were smoking cigarettes. Observation of the 30-gallon trash can revealed paper, plastic, and can trash among cigarette butts. Observations of the 2 red fire rated cigarette butt trash cans revealed more than 100 cigarette butts among plastic and paper trash. Further review revealed the yard was enclosed by a combination of 5 - 6-foot-tall wooden privacy fencing and metal galvanized chain link fencing. A section of the chain link fencing was detached from the top rail and leaning down. The Admissions coordinator stated Resident #25 was a wander risk and Residents #55 and #83 were also wander risk and resided in the secured MCU (memory Care Unit.) The Admissions coordinator stated the 30-gallon trash can had paper, plastic, and can trash among cigarette butts, the 2 red fire rated cigarette butt trash cans had more than 100 cigarette butts among plastic and paper trash, and a section of the chain link fencing was detached from the top rail and leaning down. The Admissions coordinator stated the cans had signage stating only cigarette butt trash was allowed in the cans, and the regular trash can should not have any cigarette butts. The Admissions coordinator stated the risk was a potential fire. <BR/>Daily intermittent observations, from 1/26/2025 to 1/30/2025 , revealed the facility's secured backyard and smoking patio yard had a section of chain link fence missing and had a regular trash can filled with trash and cigarette butts, several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash.<BR/>During an interview on 1/27/2025 at 10:02 AM the operations manager stated she was unaware of the secured backyard and smoking patio yard had a section of chain link fence missing and had a regular trash can filled with trash and cigarette butts, and several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash. <BR/> A record review of the facility's policy titled Smoking Policy - Residents dated October 2023, revealed, Policy Statement<BR/>This facility has established and maintains safe resident smoking practices.<BR/>Policy Interpretation and Implementation . 5. <BR/>Metal containers, with self-closing cover devices, are available in smoking areas. 6. <BR/>Ashtrays are emptied only into designated receptacles. <BR/>A policy for a safe environment was requested of the Administrator on 1/30/2025 and as of 2/7/2025 had not been provided. A policy on smoking was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain documentation that an alleged violation was thoroughly investigated for 1 of 8 PIRs reviewed that involved (Resident #1 and Resident #2) for facility compliance to prevent further abuse from resident to resident altercations.<BR/>The former Administrator A failed to investigate a resident to resident altercation (Resident #1 threw a cup and hit Resident #2 in the back of the head) that occurred on 07/21/2024.<BR/>This failure could place residents at risk for abuse from altercations and could place the residents at risk of harm. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/6/2025 revealed a 56yr old male admitted to the facility on [DATE] with diagnoses that included: epilepsy, encephalopathy, opioid abuse, bipolar disorder, etoh (alcohol) abuse, and blindness of left eye. <BR/>Record review of Resident #1's Care Plan dated 11/16/2024 revealed he was PASRR+ for developmental disorder, behavioral complex -physically and verbally abusive yelling and cursing. <BR/>Record review of Resident #1's QMDS dated [DATE] revealed he had a BIMS score of 14. <BR/>Record review of Resident #2's face sheet dated 1/10/2025 revealed a 64yr old male admitted to the facility on [DATE] with diagnoses that included: DM2 with neuropathy, bipolar disorder, major depressive disorder, HTN. He was discharged to home on 9/5/2024. <BR/>Record review of Resident #2's QMDS dated [DATE] revealed a BIMS score of 15. <BR/>Record review of Resident #2's Baseline Care Plan dated 4/22/2024 revealed impaired visual function related to cataracts, falls related psychotropics, inappropriate behaviors with staff and other residents, behaviors defecating in plastic bags from trash can in room, resistive with care (refuse medication). <BR/>During an interview and observation 1/06/2025 at 1:27PM Resident #1was sitting on the side of his bed, his room was clean and free of clutter, no foul odors. His left eye was blind, but he was able to see out of his right eye. He was alert and oriented x3. Resident #1 said when he had the altercation on 7/23/2024, he had come into the room and his roommate did not like the way he cleaned around his area because he liked for it to be clean, so they started arguing and pushing one another and he threw a coffee cup at his roommate. He said he did not know if he was coming towards him since he was blind in one eye and he thought he needed to defend himself. He said staff were there right away to help them. He said when he was moved to another room, he did not have any other issues, he felt safe, and his care was good.<BR/>During an interview on 1/8/2025 at 3:23PM CNA I said Resident #1 would hear people talking or think he heard people talk and would believe they would be talking about him, and he would respond with defensive verbal aggression. He said there was a resident that would mumble, and he would think that the resident was talking about him, but the resident would just mumble, not directed at anyone.<BR/>During an interview on 1/9/2025 at 10:35AM the AIT said she was not able to locate the PIR for intake # 519537. She said she understood the importance of the PIR being done, being sent to TULIP, and being available, but she was not at the facility until December and did not know anything about the incident's existence. The AIT said she made several attempts to contact Administrator A to inquire about the missing PIR, but she did not answer her calls. <BR/>During an interview on 1/10/2025 at 8:30AM the AIT said she was not able to locate the PIR for the intake# 519537. She said she had been at the facility since December 2024 and she searched the files that were in the office and in medical records. She said she reached out to the Administrator A who did not return her call. <BR/>Record review of in-service titled Reporting Resident to Resident Altercations dated 12/19/2024 revealed 17 employees received the in-service.<BR/>Record review of the facilit's5 policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy statement stated: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and Implementation #8 stated: Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 8 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that:<BR/>1. Resident #1 was an elopement risk and provided interventions to include a wander guard and checks to ensure proper placement. On 5/25/24 Resident #1 removed his wander guard and eloped from the facility. <BR/>2. Resident #2 was an elopement risk with interventions to include structured activity to distract from wandering. On 6/6/24, Resident #2 eloped from the facility. <BR/>The noncompliance was identified as a PNC. The PNC IJ began on 5/25/2024 and ended on 6/6/2024. The facility had corrected the non-compliance before the survey began. <BR/>This failure could place residents at risk for serious harm, disability, or death.<BR/>The findings included: <BR/>Observations 1/8/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. <BR/>Observation on 1/9/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. <BR/>Observation on 1/10/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. <BR/>1. Record review of Resident #1's admission Record dated 1/7/2025 revealed he was admitted on [DATE] with diagnoses of vascular dementia ( type of dementia that occurs when blood vessels in the brain are damaged, reducing blood flow and oxygen supply), epilepsy ( chronic brain disorder that causes seizures, which are brief episodes of involuntary movement.), language deficits, unsteady on feet, anxiety, major depressive disorder, and psychotic disorder with hallucinations (severe mental illnesses that can cause hallucinations and delusions). Record review of Resident #1's admission Record revealed he was discharged on 7/19/24.<BR/>Record review of Resident #1's consolidated physician orders for January 2025 revealed he had an order for wander guard dated 7/2/2024, device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering.<BR/>Record review of Resident #1's MAR (medications administration record) revealed device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering and monitoring every 15 minutes.<BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 4 (severely impaired cognition), epilepsy, behaviors of rejecting care and has a walker. After elopement the new interventions for Resident #1 was placed on q 15 minutes, visited by psychological MD and moved to a secure unit.<BR/>Record review of Resident #1's care plan (initiated 6/12/23 and prior to 5/25/24 incident) revealed he was at risk for elopement with interventions including Assess for distress; Contact family to sit with resident or deescalate situation; Device alarm change every 90 days; Visual check wander guard to left wrist q shift due to elopement risk; Wander guard check via electronic check every day due to elopement risk; Encourage resident to stay in common areas of building for observation if needed; Provide resident with safe place to wander if necessary. Following the elopement on 5/25/24, new intervention for Resident #1 was Monitor resident closely for signs/symptoms of increased wandering and desire to keep walking. New interventions were Resident #1: Resident will be monitored every 15 minutes until evaluated by psych on 5/29/24 (5/28/24); Redirect patient from doors (5/28/24); Involve patient in decision making regarding daily choices (5/28/24); Involve patient in preferred activities (5/28/24); Assess for risk of elopement per living center policy (5/28/24); Use wander guard placed on right ankle (6/11/24); Wander guard place on bottom of wheelchair seat as tolerated (7/12/24). <BR/>Record review of Resident #1's Wandering assessment dated [DATE] revealed he was forgetful/short attention span, mobility was independent, known wanderer/history of wandering and had a wander guard- scored a 12.0- high risk. <BR/>Record review of Resident #1's head to toe assessment dated [DATE] revealed no skin issues. <BR/>Record review of Resident #1's Pain assessment dated [DATE] revealed he was resistant to care/medication aggressiveness/physically or verbally abusive and had no pain. <BR/>Record review of Resident #1's progress note Interdisciplinary Team dated 5/25/2025 revealed elopement, due to Resident #1's diagnosis of dementia and baseline cognitive status resident #1 is a poor decision maker with poor impulse control resident can ambulate and likes to walk and venture around facility. Resident #1 stated he was trying to take a walk with no distress or agitations noted prior to exiting. intervention were abuse/neglect in service, and elopement in services. The MD and family were notified by DON, ADON, MDS staff. <BR/>Record review of Resident #1 psychological consult dated 5/2/2024 stated he was oriented to person, time, impaired to place and was to assess Resident #1's safety and comfort with no concerns of any type. <BR/>Record review of intake 506765, on 5/25/24 at 5:45 PM revealed, Resident #1 left the building. An off-duty staff member informed the facility the resident was seen outside. The resident was found at a bus station (less than a mile away) stating he was going to work. Staff were able to get the resident to come back to the facility. Resident #1's responsible party, ADM, DON, ADON and physician were notified. Record review of intake 506765 had a provider investigation and staff were in-serviced on abuse/neglect, elopement. Record of in-services was completed by all staff on 5/26/2024.<BR/>Record review of Resident #1's intake, on 5/26/24 at 7:30 PM revealed, Resident #1 attempted to leave the building, and his wander guard sounded. Staff responded to the alarm and found resident outside of the facility. They were able to redirect him back inside, and there were no injuries. <BR/>2. Record Resident #2's admission Record dated 1/8/2025 revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), major depressive disorder (a serious mental illness that causes a persistent low mood, loss of interest, and other symptoms that can affect daily life), cognitive communication deficit, dementia (a general term for a group of diseases that cause severe memory and thinking loss), and asthma (a chronic lung disease that causes inflammation and tightening of the muscles around the airways.). <BR/>Record review of Resident #2's physician orders dated 6/7/2024 for resident to wear a wander guard at all times due to elopement risk. visual check wander guard to right ankle every shift due to elopement risk. Record review of Mar (medication administration record revealed this was completed. <BR/>Record review of Resident #2's optional state assessment MDS dated [DATE] revealed she had a BIMS score of 5 out of 15 (severely impaired), she mobilized with walker. Record review of quarterly MDS dated [DATE] revealed she had a wander/elopement alarm. <BR/>Record review of Resident #2's care plan (initiated 10/10/18 and prior to 6/6/24 incident) revealed she was at risk for elopement with interventions including Distract resident from wandering by offering structured activities; Wander guard alarm: Change every 90 days and as needed. New intervention was Resident #2: Check placement and function of safety monitoring device every shift; Visual check wander guard to right ankle every shift due to elopement risk (6/10/24); Wander guard check via electronic machine every day due to elopement risk (6/10/24).<BR/>Record review of intake # 509407, Per facility self-report, on 6/6/24 between 4 and 5 PM, Resident #2 had family visiting and was attending an activity. The resident's [family member]informed staff she was missing. Resident #2 was found down the street in front of a church (less than a mile away) and said she was looking for her [family member]. The temperature was 93 that day. Resident #2 was given a head-to-toe assessment upon return to the facility and was sent to the ER for further assessment. Resident #2's ER paperwork revealed heat exhaustion, unspecified, and no other injury. She returned to the facility the same night.<BR/>Record review of Resident #2's Elopement Risk assessment dated [DATE] revealed she scored an 8-high risk and care plan was initiated/updated to reflect interventions. <BR/>Record review of Resident #2's 6/6/2024 and 6/12/2024 Head to toe Assessment revealed no injuries. <BR/>Record review of in-services dated on 6/6/2024 revealed in was on Abuse/Neglect/Explotation, Elopement, Front door, and Resident Rights with all staff. <BR/>Observation on 1/9/2025 at 2:25 PM revealed Resident #2 had her wander guard on her ankle. <BR/>Interview on 1/7/25at 1:14 PM with LVN F stated they kept a binder of residents that were wander/elopement for staff to check, but most staff know which resident have wandering behaviors. Resident #1 would sundown at night and be more confused. Staff monitored him, but she was not sure how he eloped out of facility. LVN F stated she was not sure how Resident #2 eloped, maybe a family member let her out. LVN F stated no other residents had eloped. Staff try to re-direct residents that wander towards the exits, now they have a staff person near the front door. <BR/>Interview with previous DON G stated #1 was found at the bus stop and not sure how he left the facility and was not gone more than 15-20 minutes. The previous DON G stated they started the elopement protocol to find Resident #1, he was not injured when they found him. Resident #1 was discharged to another facility that could be more appropriate for his aggressive behaviors and a secure unit. The previous DON G stated Resident #2 had left the building and the family had alerted them, the staff started the elopement protocol, they found Resident #2 less than a mile, at a church. The previous DON G stated they conducted a head to toe and decided to take her to the local clinic, she had heat exhaustion with no other injuries. The previous DON G stated her new interventions was a wander guard bracelet to wear in her ankle. Resident #2 had not had any previous elopements. The previous DON G stated she did conduct in-services with all staff for elopement.<BR/>Interview 1/8/2025 at 11:19 AM with the previous Maintenance supervisor H stated he found Resident #1 at the church nearby. He was trained on the elopement protocol. Maintenance supervisor H stated Resident #2 had no injuries and offered her water due to a warm day. Maintenance supervisor H stated he tested the wander guard monitors frequently and documented <BR/>Interview 1/9/2025 at 1:46 PM with the previous Administrator A stated Resident #1 was aggressive, so they worked with family/Ombudsman to get him transferred to a safe facility, since it was not safe for him at this facility. The Administrator stated she had reported the elopements to the STATE and trained staff on elopements. Administrator A stated there were new interventions in place for Resident #1 and #2. The new interventions for Resident #1 was to transfer him to a secure unit q 15 minute checks, and psychological MD visit Intervention for Resident #2 was a wander guard.<BR/>Interview 1/8/2025 AT 1:32 pm with Resident #2's family stated Resident #2 was found in 30-45 minutes and they took her to the local clinic for evaluation, she was dehydrated. The Family stated the facility acted immediately to Resident #2 missing, she had dementia and felt safer with her wander guard.<BR/>Interview 1/10/2025 at 4:29 PM with the medical director stated she was aware of the elopements and facility discussed in AD Hoc meeting. <BR/>Record review of in-services dated 5/26/2024 on Wandering/Elopement, Abuse/Neglect protocol/door alarm/ Resident Rights were completed with all staff.<BR/>Record review of check operations of door monitoring and resident, and test for doors and locks dated the week of 5/27/2024 and 6/7/2024. <BR/>Record review of Policy Wandering and Elopement dated 2019 revealed the facility will identify residents who are a t risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. <BR/>Policy Interpretation and Implementation<BR/>l. <BR/>If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.<BR/>2. <BR/>If an employee observes a resident leaving the premises, he/she should:<BR/>a. <BR/>attempt to prevent the resident from leaving in a courteous manner;<BR/>b. <BR/>get help from other staff members in the immediate vicinity, if necessary; and<BR/>c. <BR/>instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.<BR/>3. <BR/>If a resident is missing, initiate the elopement/missing resident emergency procedure:<BR/>a. <BR/>Determine if the resident is out on an authorized leave or pass;<BR/>b. <BR/>If the resident was not authorized to leave, initiate a search of the building(s) and premises; and<BR/>c. <BR/>If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.).<BR/>4. <BR/>When the resident returns to the facility, the director of nursing services or charge nurse shall:<BR/>a. <BR/>examine the resident for injuries;<BR/>b. <BR/>contact the attending physician and report findings and conditions of the resident;<BR/>c. <BR/>notify the resident's legal representative (sponsor);<BR/>d. <BR/>notify search teams that the resident has been located;<BR/>e. <BR/>complete and file an incident report; and<BR/>f <BR/>document relevant information in the resident's medical record.<BR/>Record review of the Policy Wander guard (no date) revealed: <BR/>Identification: Identify residents who are at risk of wandering<BR/>Consent: Obtain consent from residents, family members.<BR/>Monitoring: Regularly check on residents to ensure they are safe<BR/>Response Facility Protocol: Staff is to respond to alarms immediately.<BR/>Ensure resident is Safe.<BR/>Redirect Resident to safe environment.<BR/>Maintenance: Ensure the monitoring system works properly, even during power outages<BR/>Wander guard devices<BR/>Wristbands: Electronic bracelets<BR/>Door controllers: Devices that monitor doors and send alerts if they are opened without authorization were completed, before surveyor entered the facility.<BR/>The AIT-Administrator was notified on 1/10/25 at 4 PM, an PNC IJ situation had been identified due to the above failures. The PNC IJ template was given to the administrator on 1/10/24 at 4 PM.<BR/>Problem: IJ F689 Free of Accidents/Hazards/Supervision/Devices called on 1/10/2025. <BR/>Interventions:<BR/>Interviews with staff total was 35 all staff were in serviced on Elopement/Wandering, Abuse/Neglect, Door Alarms and to check resident devices (wander guards every shift) and understood the elopement protocol. <BR/>Interviews on 1/8/2025 at 1:21 PM-5pm and 1/9/2025 at 1 PM-6 PM. Scheduled shift were 6-2 PM, 2-10 PM. 10pm-6 AM.<BR/>1. CNA J, <BR/>2. LVN F <BR/>3. CNA K <BR/>4. CNA L<BR/>5. CNA M<BR/>6. LVN N<BR/>7. CNA O<BR/>8. CNA P<BR/>9. CNA Q<BR/>10. CMA R<BR/>11. MDS<BR/>12. LVN S<BR/>13. LVN T<BR/>14. DOR (director of rehabilitation) <BR/>15. CNA U<BR/>16. CNA V<BR/>17. ADON<BR/>18. Maintenance Director<BR/>19. CNA Y<BR/>20. CNA Z<BR/>21. CNA AA<BR/>22. CNA BB <BR/>23. RN CC<BR/>24. CNA DD<BR/>25. LVN EE<BR/>26. CNAFF<BR/>27. [NAME] GG<BR/>28. Dietary HH<BR/>29. Hsk II<BR/>30. Hsk JJ<BR/>31. HSK KK<BR/>32. Laundry LL<BR/>Record review of the facility Elopement Binder had 7 current residents for wandering behavior, it contained face sheet and care plans for wandering. <BR/>Observations on 1/10/2025 at 10am of residents in the elopement binder were checked for wander guard and were randomly checked at the door alarm throughout the day. <BR/>Observations and interview with the Maintenance Supervisor on 1/9/25 at 745 am-8:05 am stated he began employment in October at the facility; he stated that all of the facility doors were alarmed but the front door and the exit door for C-hall needed more attention for better security and are working properly now; the Maintenance Director stated that he checks all facility exit doors for security purposes twice a day-at the beginning of his shift and the end of his shift; all of the facility exit doors were observed by Surveyor with the Maintenance Director as noted:<BR/>Facility Front door-alarmed and working<BR/>D-hall exit door-alarmed and working; the Maintenance Director stated that a new mag lock was installed and he will provide paperwork for Surveyor<BR/>E-hall-exit door at the end of the hallway was alarmed and worked; door in lounge on hallway was alarmed and opened to outside open smoking area with two locked gates that were checked and secure.<BR/>A-hall-the door leads to a small courtyard area and was alarmed; the MD stated that the alarm is turned off and back on when he enters for the day and leaves at night and stays on during the w/c; the door stays locked without the alarm being on; the MD stated that the door stays alarmed on the w/e.<BR/>B-Hall- the exit door was alarmed; the MD stated he plans to purchase another mag lock for this door; he stated that he had been also turning this alarm on/off during his work hours to allow for multiple deliveries thru out the day and the door stays locked; Surveyor suggested that he keep this door alarmed at all times.<BR/>C-Hall-exit door alarmed and working.

Based on observation, interviews and record reviews, the facility's governing body failed to designate a person to exercise the administrator's authority when the facility did not have an administrator and secure a licensed nursing home administrator within 30 days.<BR/>The facility terminated Licensed Administrator A on 11/08/2024; hired Employee B, who was not a licensed administrator 24 days later and served in the capacity of the administrator for 39 days.<BR/>This failure could result in a decrease in the quality of care provided to the residents that could result in potential minimal harm to the resident.<BR/>The findings were:<BR/>Record review of the All Staff Active Listing, dated 1/4/2025, revealed Employee B was listed as the Administrator with a hire date of 12/02/2024.<BR/>Record review of an Application for Employment, signed digitally by Employee B on 12/13/24, revealed she applied for the Administrator position, had previously worked at another nursing home as an AIT, did not list the school she attended and did not indicate she was a Licensed Nursing Facility Administrator. <BR/>Record review of the Administrator Job Description, signed by Employee B on 12/02/2024, revealed under Education and Experience requirement was Active NHA [Nursing Home Administrator] License.<BR/>Record review of an email dated 12/11/24 from Texas Health & Human Services Long Term Care Regulation, Licensing & Credentialling to Employee B revealed she received authorization to proceed with registration for the Licensed Nursing Home Administrator exam.<BR/>In an entrance conference on 01/04/2025 at 8:57 a.m., Employee B stated she was an AIT.<BR/>In a further interview on 01/04/2025 at 9:05 a.m., Employee B stated her title was Operations Manager and the Administrator of the facility was Administrator C who was in the facility daily to monitor and assist Employee B. <BR/>Interview and observation on 01/04/2025 at 11:42 a.m., Administrator C, who had her name badge on that indicated she worked at Nursing Home D, stated her administrator's license was over Nursing Home D, not this facility; she was in the facility once or twice a week for a few hours to oversee what AIT Employee B did in the facility, and would come to the facility when HHSC surveyors were present. <BR/>Interview on 01/04/2025 at 12:37 p.m., Employee B stated she would take the licensed administrator's test at the end of January 2025, pulled out her phone to look at and stated the test was on 01/23/2025.<BR/>Interview on 01/05/2025 at 11:56 a.m., the HR Employee stated the previous Administrator A's last day she worked in the facility was 11/08/2024 and provided Administrator A's employee file.<BR/>Record review of Administrator A's employee file revealed her date of hire was 08/01/2022, was involuntarily terminated on 11/08/2024, and her Texas Nursing Home Administrator License was effective from 03/11/2021 to 03/22/2025.<BR/>Interview on 01/05/2025 from 3:37 p.m. to 3:59 p.m., the facility's South Texas President [Regional Director] stated he has covered the facility since March 2024. He said Administrator A's last day in the facility was the date the HR Employee provided the surveyor. The South Texas President stated he was aware there was a 30-day grace period to fill the administrator position. He said when Employee B was interviewed, they were aware she was not a licensed administrator, but Employee B was what they were looking for regarding to fitting in with the facility and knew there would be another lull of 30 days before she was licensed. He stated Employee B would take the administrator license test in January 2025; and she was being overseen by Administrator C. The South Texas President stated he could not say that residents would be harmed with an unlicensed administrator to manage the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 2 of 8 residents (Resident #18 and Resident #56) observed for resident rights.<BR/>1. <BR/>The facility failed to ensure all residents were served at one table before serving the other tables, allowing all residents to eat at the same time at their respective tables.<BR/>2. <BR/>Residents were served a fried chicken patty instead of fried chicken for 01/26/25 lunch meal.<BR/>3. <BR/>Residents struggled to cut their fried chicken patty with a fork. <BR/>These failures could place residents at risk of not being treated with dignity and respect. <BR/>Findings included:<BR/>Resident # 18<BR/>Record review of Resident #18's admission Record, dated 01/26/25, reflected Resident #18 was an [AGE] year-old initially admitted on [DATE]. It reflected Resident #18 had diagnoses to include dysphagia (difficulty in swallowing), lack of coordination, muscle weakness, cognitive communication deficit, and dementia (group of symptoms affecting memory, thinking and social abilities. <BR/>Record review of Resident #18's quarterly MDS assessment, dated 10/16/24, reflected Resident #18 had a BIMS of 15 out of 15, indicating intact cognition. <BR/>Record review of Resident #18's Lunch-Day 15 lunch meal tray ticket, dated 01/28/25, reflected menu to include Fried Chicken.<BR/>Resident #56<BR/>Record review of Resident #56's admission Record, dated 01/26/25, reflected Resident #56 was a [AGE] year-old initially admitted on [DATE]. It reflected Resident #56 had diagnoses to include depression, anxiety, lack of coordination, pain, and dementia (group of symptoms affecting memory, thinking and social abilities. <BR/>Record review of Resident #56's quarterly MDS assessment, dated 12/06/24, reflected Resident #56 had a BIMS of 07 out of 15, indicating severe cognitive impairment. <BR/>Record review of Resident #56's Lunch-Day 15 lunch meal tray ticket, dated 01/28/25, reflected menu to include Fried Chicken.<BR/>During an interview and observation on 01/26/25 at 12:27 PM, Resident #18 was sitting with another resident. Resident #18 revealed she had not received her lunch meal tray yet. The other resident sitting with Resident #18 was observed to be done with her lunch meal. Resident #18 revealed the other resident always got her meal first and Resident #18 was always waiting on her meal. Resident #18 revealed I want my meal and it bothered her that she still did not have her lunch meal tray. <BR/>During an interview and observation on 01/26/25 at 12:32 PM, Resident #56 revealed he received a chicken patty but wanted fried chicken as was reflected on his meal tray ticket. He revealed the chicken patty was half burnt, showing the bottom side of his chicken patty appeared to have the color black on some parts. He further revealed the chicken patty was too hard and it would take half a day to cut. Resident #56 was observed cutting his chicken patty with a fork. <BR/>During an interview and observation on 01/26/25 at 12:35 PM, Resident #18 revealed she can't eat the chicken patty that was served for 01/26/25 lunch. She revealed it was too hard and she could not cut it with her fork. She further revealed they did not receive any knives, so they had to cut their food with either a fork or a spoon. Resident #18 picked up the chicken patty and hit it on her plate, emphasizing how hard the chicken patty was and she needed a knife to cut her foods. Resident #18 revealed she had to ask for an alternative because she was not going to eat the chicken patty.<BR/>During an interview on 01/26/25 at 12:52 PM, the ADM and DON revealed the facility did not have any knives provided for residents to eat their meals due to safety concerns because they had a lot of residents with behavioral issues. <BR/>During an interview on 01/28/25 at 04:35 PM, the CDM revealed there were no substitution logs for this month (January 2025). He further revealed they used the substitution log in case they were not able to order what was needed for the menus. The CDM revealed they could not order the fried chicken that was reflected on the 01/26/25 lunch menu. <BR/>During an interview on 01/28/25 at 06:39 PM, the DON revealed he was not aware if residents at each table should be served first before the next, but it made sense when it could affect the residents' eating. <BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed she did not have to sign a substitution log for January 2025. The RD revealed the facility needed to be following the menus and the CDM was working on getting the ordering down. The RD revealed the facility needed to get a substitution log so the RD can make sure it was an acceptable substitution. The RD revealed the facility did not have knives because several residents had behavioral issues, however she understood from the resident's standpoint, it would be difficult for residents to cut foods as needed. <BR/>During an interview on 01/30/25 at 03:15 PM , CNA F revealed some of the residents get upset if they were not served what was on the menu. He revealed it was important to serve all the residents at one table first before moving onto the next table so they could eat together, because residents had feelings and could feel bad. <BR/>Record review of the facility's policy Resident Rights, revised February 2021, reflected Employees shall treat all residents with kindness, respect, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, with adequate and comfortable lighting levels in all areas; for 2 of 8 residents (Residents #18 and #37) reviewed for adequate lighting in the dining room. <BR/>On 1/26/2026 at noon and ongoing until 1/30/2025 the facility's dining rooms had malfunctioning fluorescent lamps and fixtures, which residents #18 and #37 had stated they wished for better lighting during their meals. <BR/>These failures could negatively impact residents' morale and overall sense of self-esteem. <BR/>The findings included:<BR/>A record review of Resident #18's admission record dated 1/30/2025 revealed an admission date of 9/2/2021 with diagnosis which included dysphagia (difficulty swallowing), anxiety, and bipolar disorder (a serious mental illness characterized by extreme mood swings.)<BR/>A record review of Resident #18's quarterly MDS assessment dated [DATE] revealed Resident #18 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. Further review revealed Resident #18 could usually understand others, could make herself understood, had adequate vision and hearing. Resident #18 was assessed with the ability to use suitable utensils to bring food and / or liquid to her mouth and swallow food and / or liquid once the meal was placed before her. During the assessment Resident #18 stated she sometimes felt lonely and isolated. Resident #18 was assessed with the need to use a wheelchair and could ambulate with the wheelchair. Resident #18 was assessed as medically complex with anemia (eating a healthy diet might prevent some forms of anemia), and malnutrition.<BR/>A record review of Resident #18's care plan dated 1/30/2025 revealed, Resident at risk for nutritional problem r/t vitamin D def sic(deficiency), HTN (high blood pressure), CHF (heart failure), CKD (kidney disease) and obese status . Monitor/document/report to MD PRN (as needed) for s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing<BR/>to eat, appears concerned during meals. Date Initiated: 08/26/2022 Provide and serve diet as ordered. <BR/>A record review of Resident #18's physicians' orders dated 1/30/2025 revealed the physician prescribed for Resident #18 to receive mirtazapine (an antidepressant - often prescribed off-label as an appetite stimulant to aid in weight gain for certain populations) 15mg at bedtime for a poor appetite.<BR/>A record review of Resident #37's admission record dated 1/30/2025 revealed an admission date of 5/5/2017 with diagnoses which included bilateral cataracts (both eyes - a condition affecting the eye that causes clouding of the lens. A gradual progression of vision problem, eventually, if not treated, may result in vision loss), depression, and dysphagia (difficulty swallowing). <BR/>A record review of Resident #37's quarterly MDS assessment dated [DATE] revealed Resident #37 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. Further review revealed Resident #37 could usually make herself understood and could understand others. Resident #37 was assessed with symptoms of little interest or pleasure in doing things? . feeling down, depressed, or hopeless? . yes 2-6 days .over the last 2 weeks Resident #37 was assessed with the ability to use suitable utensils to bring food and / or liquid to her mouth and swallow food and / or liquid once the meal was placed before her. Resident #18 was assessed as medically complex with a diagnosis of malnutrition.<BR/>During an observation and interview on 1/26/2025 at 12:08 PM Resident #18 and #37 were seated together at one of the dining room tables. The dining room was 1 of 2 which were adjacent to one another. The fluorescent light fixture directly above Resident #18's and #37's table was not illuminated and caused for a dimly lighted area within the dining room. Further observation revealed 4 out of approximately 9 fixtures were not illuminated in the dining rooms. Resident #18 and #37 stated the lights had not worked, for some time now . we don't know how long. Residents #18 and stated she felt a little down and she wished the lights worked and stated, I wish I could see what I am eating. Resident #37 stated, the dark makes me feel down. I would like more light . I want to see my food.<BR/>During an observation on 1/26/2025 at 12:08 to 12:45 PM the facility's dining rooms had flickering fluorescent lamps due to staff attempting to illuminate the malfunctioning lamps. Admissions coordinator stated the lights were now working because he turned on and off the switches. Observation at the time revealed the malfunctioning lights were illuminated only to malfunction again. The operations manager stated the electrical contractor would be called to repair the malfunctioning lamps. <BR/>Continued daily intermittent observations from 1/26/2025 to 1/30/2025 revealed the dining rooms continued with malfunctioning lamps. <BR/>A record review of the facility's policy titled Residents Rights dated February 2021 revealed, Policy Statement<BR/>Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>a. <BR/>a dignified existence;<BR/>b. <BR/>be treated with respect, kindness, and dignity; <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure and provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 5 of 8 (Residents #5, #22, #45, #67, #79) residents in that:<BR/>1.Resident #5 stayed in bed and had not observed activities program and activity assessment was not up to date. <BR/>2.Resident #22 she called bingo/loteria (Mexican bingo) and tried to get some activities for the other residents, since we don't have a full time Activity Director, since November 2024. The Activity Assessment was not up to date. <BR/>3. Resident #45 was bed bound resident with no in room activities. Activity assessment was blank.<BR/>4.Resident #67 had activities to do. The Activity Assessment was not up to date. <BR/>5. The Activity Calendar did not match the Activity for that hour in the facility.<BR/>6. Resident #79 stayed in bed and did not have his choice of activity (watching TV) set up. <BR/>These failures could place residents at risk of boredom, increased behaviors, and decrease quality of life. <BR/>The Findings were:<BR/>1.Record review of Resident #5's admission Record dated 1/29/2025 documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of cognitive communications disorder and lack of coordination. <BR/>Record review of Resident #5's consolidated physician orders for January 2025 was documented she may participate in activities as tolerated.<BR/>Record review of Resident #5's significant change MDS dated [DATE] documented her BIMS score was 13 out of 15 (cognitively intact). She wore corrective lenses and, sometimes requires someone to help to read instructions or other written material form doctor or pharmacy. Activities important for her to have books, newspaper, magazines music, around animals, do her favorite activities, go outside to get fresh air when weather is good, and participate in religions activities. She required use of manual wheelchair.<BR/>Record review of Resident #5's care plan dated 12/12/2024 was documented will encourage/assist with environmental acclimation and encourage socialization, recreational activity participation, room personalization, and routine development, Encourage activity/exercises and activity tolerance and ambulation.<BR/>Record review of Resident #5's Activity assessment dated [DATE] documented at Admission, she was able to read and write, likes to participate in religious activities, music, trips, wheeling outdoors, TV, conversing, and preferred activity in own room. <BR/>Observation on 1/26/2025 at 3:02 PM in Resident #5's room revealed she was lying in bed with covers over her and watching television. no other in room activity.<BR/>Observation on 1/27/2025 at 2:01 PM in Resident #5's room revealed was lying in bed covered with blankets and watching television. no other in room activity. <BR/>Observation on 1/28/2025 at 11:14 AM in Resident #5's room revealed was lying in bed covered with blankets and watching television. no other in room activity.9<BR/>Observation on 1/29/2025 at 2:52 PM in Resident #5's room revealed was lying in bed covered with blankets and watching television. no other in room activity.<BR/>Interview on 1/28/202 at 11:15 AM with Resident #5 stated she no staff come to conduct in room activities with her and she only watches television. <BR/>2.Record review of Resident #22's admission Record dated 1/29/2025 documented she was admitted on [DATE], re-admitted on [DATE] with muscle spasm, mild cognitive impairment, generalized anxiety, bipolar (a chronic mental health condition characterized by extreme shifts in mood, energy, and activity levels), and lack of coordination.<BR/>Record review of Resident #22's consolidated physician orders for January 2025 was documented she may participate in activities as tolerated.<BR/>Record review of Resident #22's Quarterly MDS dated [DATE] documented her BIMS score was 15 out of 15 (cognitively intact), no devices needed to ambulate, and had pain occasionally. <BR/>Record review of Resident #22's Quarterly MDS dated [DATE] documented activity-very important to listen to music, be around animals, keep up with news, do things with group of people, go outside to get fresh air when the weather is good, participate in religious activities. <BR/>Record review of Resident #22's care plan dated 1/22/2025 was documented she was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits due to forgetfulness and needs reminders, she prefers activities such as gardening, cooking and music. Record review of the Care plan was documented for her behaviors her interventions was staff to redirect resident to other activities, and for her muscle spasm intervention was to participate in daily activities. <BR/>Record review of Resident #22's Activity assessment dated [DATE] was documented she walked daily to group activities, she engages in trivia table games, board games, outing, church, pet therapy, music and entertainment assist with passing out activities. <BR/>Interview on 1/27/2025 at 2:35 PM Resident #22 stated the facility had not had an Activity Director for a few months and the prior Activity Director comes when she can. Resident #22 stated she announced Bingo and some vendors come for activity program but were not at facility all day. Resident #22 stated she tried to gather resident for Activities, so it would not be boring. She stated they do not have a structured Activity program at the facility. Resident #22 stated the vendors for Activities come for an hour a day.<BR/>3.Record review of Resident #45's admission Record was dated 1/28/2025 she was admitted on [DATE], re-admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body, , dementia) (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, that interferes with daily life and activities), muscle weakness, cognitive communication deficit, need assistance with personal care, and adult failure to thrive. <BR/>Record review of Resident #45's consolidated physician orders for January 2025 was documented she may participate in activities as tolerated.<BR/>Record review of Resident #45's Significant change MDS dated [DATE] was documented her BIMS score was 3 out of 15 (severely impaired), had ability to understand, very important for activities was to have books, to listen to music, be around animals, keep up with news, do things with group of people, go outside to get fresh air when the weather was good, and participate in religious activities. Resident #45 was documented she had upper extremity impairment on both sides' lower extremity impairment on one side, she was dependent on oral care, showers, dressing, personal hygiene, she was always incontinent, she used a wheelchair to mobilize in the facility, and required a feeding tube to eat. <BR/>Record review of Resident #45's care plan dated 1/24/2025 was documented she is dependent on staff for activities, cognition stimulation, social interaction related to cognitive deficits .Interventions she required assistance with activity functions and encourage activity exercises.<BR/>Record review of Resident #45's Activity assessment dated [DATE] was blank.<BR/>Observation and an attempted interview on 1/26/2025 at 2:21 PM Resident # 45 was sleeping in bed, covered by sheet, no music or TV on. Resident #45 was not interviewable.<BR/>Observation on 1/26/2025 at 4:24 PM Resident # 45 was sleeping in bed, covered by sheet, no music or TV on. <BR/>Observations on 1/27/2025 at 5:02 PM Resident # 45 was sleeping in bed, covered by sheet, no music or TV on. <BR/>Observation on 1/28/25 at 9:34 AM Resident # 45 revealed she awake, was on laying on her back, no music or TV on. <BR/>Observation on 1/29/2025 at 10:53 AM in Resident #45's room revealed she was laying down with a blanket on her, no TV or music.<BR/>4.Record review of Resident # 67's admission Record dated 1/27/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of muscle weakness, pain, lack of coordination, need for assistance with personal care, and cognitive communication deficit.<BR/>Record review of Resident # 67's consolidated physician orders for January 2025 was documented she may participate in activities as tolerated.<BR/>Record review of Resident # 67's Quarterly MDS dated 10/22//2024 was documented her BIMS score was 15 out of 15 (cognitively intact). <BR/>Record review of Resident #67's Annual MDS dated [DATE] was documented was very important to listen to music, do things with group of people, to do her favorite activity, and participate in religious activities. <BR/>Record review of Resident # 67's care plan dated 1/30/2025 was documented for Activity-will encourage/assist with environmental acclimation and encourage socialization, recreational activity participation, room personalization, and routine development, encourage activities.<BR/>Record review of Resident # 67's Activity assessment dated [DATE] was documented Quarterly she uses wheelchair to attend activities, she attends and participates in all group activities, social outings, music entertainment, yard games, board games, church, and crafts. <BR/>Observation on 1/26/2025 at 1:55 PM Resident #67's was laying down on her bed watching TV.<BR/>Interview on 1/26/2025 at 1:57 PM Resident #67 stated the Activity Director was not here anymore, so residents did not have any activities, just watch tv, no church today (Sunday), no activities today and it was different now. Resident #67 stated she used to like to do art and crafts, paint, and crafts for Holidays. Resident #67 stated they had not had an Activity Director for 2-3 months. <BR/>Observation on 1/27/2025 at 1:11 PM Resident #67 was sitting on w/c and was watching TV.<BR/>Observation on 1/28/2025 at 11:30 AM Resident #67 was sitting on w/c and was watching TV and looking outside her window.<BR/>Observation on 01/29/25 at 10:20 AM Resident #67's was sitting in her w/c in the main dining room/activity room revealed she was watching TV. <BR/>Interview on 1/29/2025 at 10:24 AM Resident #67 stated no arts and crafts today, and the activity calendar was not correct. <BR/>5. Record Review of the Large Activity Calendar that was posted in the area of the main dining room/Activity room revealed the following:<BR/>*1/28/2025 at 10:00 AM Daily Stretches<BR/>*1/28/2025 at 4:30 PM Hand hygiene. <BR/>*1/29/2025 at 10:00 AM Arts and crafts.<BR/>*1/30/2025 at Bingo<BR/>Observation on 1/28/25 at 10:17 AM in the dining room revealed residents' activity was loteria and Resident #22 was in charge.<BR/>Observation on 1/28/2025 at 4:33 PM in main dining area no hand hygiene activity.<BR/>Observation on 1/29/2025 at 10:22 AM in the dining area no arts and crafts in main Dining Room/Activity room.<BR/>Interview on 1/29/2025 at 10:23 AM with SW confirmed the residents were not doing arts and crafts right now and they are watching TV. The SW stated all staff pitch in for resident activities, 2 vendors come visit daily, and responded they come for a while. The SW stated they did not have a lot of activities; they have no activity director, and an Activity Director has been hired and started [DATE]th.<BR/>Observations on 1/30/2025 at 10:30 AM in main dining area no bingo. <BR/>6. Record review of Resident #79's admission Record, dated 01/27/25, reflected Resident #79 was a [AGE] year-old initially admitted on [DATE]. It reflected Resident #79 had diagnoses to include acquired absence of right leg above knee, expressive language disorder, anxiety disorder, and depression. <BR/>Record review of Resident #79's quarterly MDS assessment, dated 12/14/24, reflected Resident #79 had a BIMS of 08 out of 15, indicating moderate cognitive impairment. <BR/>Record review of Resident #79's care plan, last reviewed 01/03/25, reflected focus At risk for falls related to surgical incisions Right BKA .medication diuretic, pain, hypotension with intervention Activity Programming-exercises, TV programs, revised 09/16/24.<BR/>During an interview and observation on 01/26/25 at 03:57 PM, Resident #79 revealed he wanted to watch TV because he was bored in his room. Resident #79 was observed to only have his radio playing and he had no other activities to do in his room. He revealed he would like to watch TV because he was stuck in bed. <BR/>During an interview and observation on 01/28/25 at 09:20AM, Resident #79 revealed he was bored and wanted to watch television. He further revealed he was told the remote did not work so they did not put the television on for him. It was observed Resident #79's TV was not on. <BR/>During an interview and observation on 01/30/25 at 11:09 AM, Resident #79 revealed he wanted to read a newspaper or something because he did not get to do any activities. He further revealed he has had no help with turning his television on. It was observed Resident #79's TV was not on. <BR/>During an interview on 01/30/25 at 03:03 PM, CNA F revealed Resident #79's TV was not working. CNA F revealed he put Resident #79 in front of the TV in the public area at times. CNA F further revealed he had never seen Resident #79's TV on and assumed the TV was not working. CNA F further revealed the TV would help residents to stimulate their mind, especially for resident with psychological issues. <BR/>During an observation and interview on 01/30/25 at 03:40 PM, CNA F revealed the TV was working and he borrowed a remote from another resident to turn on Resident #79's TV.<BR/>Interview on 1/26/2025 at 5:30PM with prn Activity Director (prior/prn Activity Director) stated she was prn (as needed) Activity Director and comes in and does activities with Residents when she can. The prior/prn Activity Director stated she calls different vendors from her house and comes to facility to do some activities, when she can.<BR/>Interview on 1/27/2025 at 4:07 PM with Ombudsman AC stated the previous Activity Director left in November 20024. <BR/>Interview on 1/272025 at 2:45 PM with Resident Council group stated they use to vote on council to see which restaurant they wanted to go to each month. The Resident Council group stated they do not go to restaurants anymore, since they do not have anyone to take them. Resident #22 stated she announced on intercom bingo/loteria and some vendors come but only were at the facility for 1 hour. Residents stated they had to figure out what to do as an activity for the day and felt like we are in limbo. Residents stated they color, paint, and form small group to do board games and etc. <BR/>Interview on 1/30/2025 at 10:46 AM with ADM discussed the concern with no Activity Director, in room activities, have not observed activities that match the activity calendar, requested activity calendar for this month. No response. ADM stated no full-time Activity Director and were looking to hire one soon. ADM did not provide the in-room activity calendar before we exited and the Activity policy. <BR/>Record review of the job description for Director of Activities (no date) was documented The primary purpose of the position is to plan, organize, and direct a program of activities which provide opportunities for entertainment, exercise, relaxation, and expression and fulfills basic psychology, social and spiritual needs which will be available to all residents of the facility while delivering on the facilities values of wellness, compassion, customer experience and company results. Maintain all activity related records required by regulations and Medical Records Department-activity assessment, progress notes and discharge summary. Activity Calendar Duties include, plan, develop, organize, implement, evaluate and direct the activity programs of the facility, oversee day t day activities of resident in the facility.<BR/>Record review of the admission policy (no date) was documented, exhibit 2 items and services included in the daily Medicaid rate-Activities, participation in a group setting and on an individual basis, as selected by the resident.

**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 receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 3 of 8 (Resident #67, #5 and #45 ) residents in that:<BR/>1. Resident #67 had a pressure ulcer on her heel and was not observed offloading her heels. <BR/>2. Resident #5 had a pressure ulcer on her heel and was not observed offloading her heels. <BR/>3. Resident #45 was not turned every 2 hours by staff. <BR/>This could affect all residents with pressure ulcers and could result in wounds not healing. <BR/>The Finding were: <BR/>1.Record review of Resident # 67's admission Record dated 1/27/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), and disorder of skin. <BR/>Record review of Resident # 67's consolidated physician orders for January 2025 was documented offloading boots to promote wound healing every shift for wound healing and had an unstageable to right heel paint with betadine daily as needed or sound healing if soiled or removed and every shift for wound healing.<BR/>Record review of Resident # 67's Quarterly MDS dated 10/22//2024 was documented her BIMS score was 15 out of 15 (cognitively intact). Resident #67's Quarterly MDS Skin condition was documented resident at risk for developing pressure ulcers/injuries).<BR/>Record review of Resident #67's Annual MDS dated [DATE] was documented she was a risk for developing pressure ulcers, and unstageable pressure ulcer. <BR/>Record review of Resident # 67's care plan dated 1/30/2025 was documented potential for pressure ulcer development related to disease process, interventions wear heel protectors while in bed. <BR/>Record review of Resident #67's wound care assessment dated [DATE] was documented she had a right heel, unstageable pressure injury, clean with betadine daily open to air and offloading boot and elevate.<BR/>Observation on 1/26/2025 at 2:14 PM in Resident #67's room revealed she was laying down on her bed, with no offloading boots on her heels.<BR/>Observation on 1/27/2025 at 1:11 PM in Resident #67's room revealed she was sitting on her w/c with no offloading boots on her heels.<BR/>Observation on 1/28/2025 at 11:30 AM in Resident #67's room revealed she was lying in bed over her, and her feet/heels were not offloaded. <BR/>Interview on 1/28/2205 at 11:32 AM with LVN AB, wound care nurse, in Resident #67's room stated she did not have her offloading booties on the resident to offload her heels while in bed. LVN AB stated it was important to offload Resident #67's heels to prevent infection and wound getting worse. LVN AB stated Resident #67 had an unstageable wound on her right heel, and treatment was betadine and leave open to air.<BR/>2. Record review of Resident #5's admission Record dated 1/29/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), cognitive communications disorder, difficulty walking, need for assistance with personal care, dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, that interferes with daily life and activities), and had lack of coordination. <BR/>Record review of Resident #5's consolidated physician orders for January 2025 was documented to offloading boots every shift for prevention of breakdown.<BR/>Record review of Resident #5's significant change MDS dated [DATE] was documented her BIMS score was 13 out of 15 (cognitively intact), she was at risk for developing pressure ulcers/injuries, and she required use of manual wheelchair.<BR/>Record review of Resident #5's care plan dated 12/12/2024 was documented pressure ulcer or potential for pressure ulcer development related to disease process. Resident #5's goal was to have intact skin, free of redness, blisters or decollation by/through review dated. Resident #5s interventions was to have skin assessments as ordered, and treatments as ordered. Resident #5 had skin integrity non pressure related to excoriation to sacrum.<BR/>Observation on 1/28/2025 at 11:50 AM with Resident #5 was lying in bed, with no heel protectors on. <BR/>Interview on 1/28/2025 at 11:54 AM with CNA H stated she took Resident # 5 back to bed, changed her, but did not put her heel protector booties on. The she left to do another task. <BR/>Interview on 1/28/2025 at 12:04 PM with ADM and DON, they stated they would educate staff on the concerns with residents receiving treatment for pressure ulcers, such as heel protectors. <BR/>3. Record review of Resident #45's admission Record was dated 1/28/2025 she was admitted on [DATE], re-admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body, muscle weakness, need assistance with personal care, and adult failure to thrive. <BR/>Record review of Resident #45's consolidated physician orders for January 2025 documented were resident to be turned every 2 hours.<BR/>Record review of Resident #45's Significant change MDS dated [DATE] documented her BIMS score was 3 out of 15 (severely impaired),.Resident #45 had upper extremity impairment on both sides lower extremity impairment on one side, she was dependent on oral care, showers, dressing, personal hygiene, she was always incontinent, she used a wheelchair to mobilize in the facility, and required a feeding tube to eat. <BR/>Record review of Resident #45's care plan dated 1/24/2025 documented she had pressure ulcer or potential for pressure ulcer development related to disease process, immobility, and stroke. Resident #45's interventions were needing assistance to turn/reposition at least every 2 hours, more often as needed, or requested. <BR/>Observation on 1/26/2025 at 2:24 PM Resident #45 was laying in her bed on her right side.<BR/>Observation on 1/26/2025 at 4:27 PM Resident #45 was laying in her bed on her right side. <BR/>Interview on 1/26/2025 at 4:32 PM LVN J stated Resident #45 had not been moved/turned in bed. <BR/>Observation on 1/28/2025 at 9:34 AM Resident # 45 revealed she was on laying on her back. <BR/>Observation on 1/28/2025 at 11:46 AM Resident # 45 revealed she was on laying on her back. <BR/>Interview on 1/28/2025 at 11:49 AM LVN Z stated Resident # 45 was laying on her back. LVN Z stated residents were supposed to be repositioned every 2 hours. LVN Z stated she was not sure why the CNA's have not repositioned Resident # 45. LVN Z stated she would reposition Resident # 45 now. <BR/>Interview on 1/28/225 at 12:28 PM the MDS/LVN stated residents that were bed bound, should be repositioned at least every 2 hours and as needed. <BR/>Interview on 1/28/2025 at 12:04 PM the ADM and DON, stated they would educate staff on the concerns with repositioning residents while in bed. The DON stated she expected staff turn and reposition bed bound resident every 2 hours. <BR/>Record review of policy, repositioning dated May 2013 documented, The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individual care plan for repositioning, to promote comfort for all bed or chair bound resident and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Preperation-1. Review the residents care plan to evaluate for any special needs of the resident. General Gudiliens-1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. <BR/>Record review of policy, Prevention of Pressure Injuries dated April 2020 was documented The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation -Review the residents care plan and identify the risk factors as well as the intervention designed to reduce or eliminate those considered modifiable. Skin Assessment- 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADL and full skin assessment weekly c. reposition resident as indicated on care plan. Prevention -skin care 6. Do not rub to otherwise cause friction on skin that is at risk for pressure injuries. Mobily/Repositioning -1. Reposition all resident with or at risk of pressure injuries on an individualized schedule. 2 .provided support devise and assistance as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 8 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that:<BR/>1. Resident #1 was an elopement risk and provided interventions to include a wander guard and checks to ensure proper placement. On 5/25/24 Resident #1 removed his wander guard and eloped from the facility. <BR/>2. Resident #2 was an elopement risk with interventions to include structured activity to distract from wandering. On 6/6/24, Resident #2 eloped from the facility. <BR/>The noncompliance was identified as a PNC. The PNC IJ began on 5/25/2024 and ended on 6/6/2024. The facility had corrected the non-compliance before the survey began. <BR/>This failure could place residents at risk for serious harm, disability, or death.<BR/>The findings included: <BR/>Observations 1/8/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. <BR/>Observation on 1/9/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. <BR/>Observation on 1/10/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. <BR/>1. Record review of Resident #1's admission Record dated 1/7/2025 revealed he was admitted on [DATE] with diagnoses of vascular dementia ( type of dementia that occurs when blood vessels in the brain are damaged, reducing blood flow and oxygen supply), epilepsy ( chronic brain disorder that causes seizures, which are brief episodes of involuntary movement.), language deficits, unsteady on feet, anxiety, major depressive disorder, and psychotic disorder with hallucinations (severe mental illnesses that can cause hallucinations and delusions). Record review of Resident #1's admission Record revealed he was discharged on 7/19/24.<BR/>Record review of Resident #1's consolidated physician orders for January 2025 revealed he had an order for wander guard dated 7/2/2024, device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering.<BR/>Record review of Resident #1's MAR (medications administration record) revealed device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering and monitoring every 15 minutes.<BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 4 (severely impaired cognition), epilepsy, behaviors of rejecting care and has a walker. After elopement the new interventions for Resident #1 was placed on q 15 minutes, visited by psychological MD and moved to a secure unit.<BR/>Record review of Resident #1's care plan (initiated 6/12/23 and prior to 5/25/24 incident) revealed he was at risk for elopement with interventions including Assess for distress; Contact family to sit with resident or deescalate situation; Device alarm change every 90 days; Visual check wander guard to left wrist q shift due to elopement risk; Wander guard check via electronic check every day due to elopement risk; Encourage resident to stay in common areas of building for observation if needed; Provide resident with safe place to wander if necessary. Following the elopement on 5/25/24, new intervention for Resident #1 was Monitor resident closely for signs/symptoms of increased wandering and desire to keep walking. New interventions were Resident #1: Resident will be monitored every 15 minutes until evaluated by psych on 5/29/24 (5/28/24); Redirect patient from doors (5/28/24); Involve patient in decision making regarding daily choices (5/28/24); Involve patient in preferred activities (5/28/24); Assess for risk of elopement per living center policy (5/28/24); Use wander guard placed on right ankle (6/11/24); Wander guard place on bottom of wheelchair seat as tolerated (7/12/24). <BR/>Record review of Resident #1's Wandering assessment dated [DATE] revealed he was forgetful/short attention span, mobility was independent, known wanderer/history of wandering and had a wander guard- scored a 12.0- high risk. <BR/>Record review of Resident #1's head to toe assessment dated [DATE] revealed no skin issues. <BR/>Record review of Resident #1's Pain assessment dated [DATE] revealed he was resistant to care/medication aggressiveness/physically or verbally abusive and had no pain. <BR/>Record review of Resident #1's progress note Interdisciplinary Team dated 5/25/2025 revealed elopement, due to Resident #1's diagnosis of dementia and baseline cognitive status resident #1 is a poor decision maker with poor impulse control resident can ambulate and likes to walk and venture around facility. Resident #1 stated he was trying to take a walk with no distress or agitations noted prior to exiting. intervention were abuse/neglect in service, and elopement in services. The MD and family were notified by DON, ADON, MDS staff. <BR/>Record review of Resident #1 psychological consult dated 5/2/2024 stated he was oriented to person, time, impaired to place and was to assess Resident #1's safety and comfort with no concerns of any type. <BR/>Record review of intake 506765, on 5/25/24 at 5:45 PM revealed, Resident #1 left the building. An off-duty staff member informed the facility the resident was seen outside. The resident was found at a bus station (less than a mile away) stating he was going to work. Staff were able to get the resident to come back to the facility. Resident #1's responsible party, ADM, DON, ADON and physician were notified. Record review of intake 506765 had a provider investigation and staff were in-serviced on abuse/neglect, elopement. Record of in-services was completed by all staff on 5/26/2024.<BR/>Record review of Resident #1's intake, on 5/26/24 at 7:30 PM revealed, Resident #1 attempted to leave the building, and his wander guard sounded. Staff responded to the alarm and found resident outside of the facility. They were able to redirect him back inside, and there were no injuries. <BR/>2. Record Resident #2's admission Record dated 1/8/2025 revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), major depressive disorder (a serious mental illness that causes a persistent low mood, loss of interest, and other symptoms that can affect daily life), cognitive communication deficit, dementia (a general term for a group of diseases that cause severe memory and thinking loss), and asthma (a chronic lung disease that causes inflammation and tightening of the muscles around the airways.). <BR/>Record review of Resident #2's physician orders dated 6/7/2024 for resident to wear a wander guard at all times due to elopement risk. visual check wander guard to right ankle every shift due to elopement risk. Record review of Mar (medication administration record revealed this was completed. <BR/>Record review of Resident #2's optional state assessment MDS dated [DATE] revealed she had a BIMS score of 5 out of 15 (severely impaired), she mobilized with walker. Record review of quarterly MDS dated [DATE] revealed she had a wander/elopement alarm. <BR/>Record review of Resident #2's care plan (initiated 10/10/18 and prior to 6/6/24 incident) revealed she was at risk for elopement with interventions including Distract resident from wandering by offering structured activities; Wander guard alarm: Change every 90 days and as needed. New intervention was Resident #2: Check placement and function of safety monitoring device every shift; Visual check wander guard to right ankle every shift due to elopement risk (6/10/24); Wander guard check via electronic machine every day due to elopement risk (6/10/24).<BR/>Record review of intake # 509407, Per facility self-report, on 6/6/24 between 4 and 5 PM, Resident #2 had family visiting and was attending an activity. The resident's [family member]informed staff she was missing. Resident #2 was found down the street in front of a church (less than a mile away) and said she was looking for her [family member]. The temperature was 93 that day. Resident #2 was given a head-to-toe assessment upon return to the facility and was sent to the ER for further assessment. Resident #2's ER paperwork revealed heat exhaustion, unspecified, and no other injury. She returned to the facility the same night.<BR/>Record review of Resident #2's Elopement Risk assessment dated [DATE] revealed she scored an 8-high risk and care plan was initiated/updated to reflect interventions. <BR/>Record review of Resident #2's 6/6/2024 and 6/12/2024 Head to toe Assessment revealed no injuries. <BR/>Record review of in-services dated on 6/6/2024 revealed in was on Abuse/Neglect/Explotation, Elopement, Front door, and Resident Rights with all staff. <BR/>Observation on 1/9/2025 at 2:25 PM revealed Resident #2 had her wander guard on her ankle. <BR/>Interview on 1/7/25at 1:14 PM with LVN F stated they kept a binder of residents that were wander/elopement for staff to check, but most staff know which resident have wandering behaviors. Resident #1 would sundown at night and be more confused. Staff monitored him, but she was not sure how he eloped out of facility. LVN F stated she was not sure how Resident #2 eloped, maybe a family member let her out. LVN F stated no other residents had eloped. Staff try to re-direct residents that wander towards the exits, now they have a staff person near the front door. <BR/>Interview with previous DON G stated #1 was found at the bus stop and not sure how he left the facility and was not gone more than 15-20 minutes. The previous DON G stated they started the elopement protocol to find Resident #1, he was not injured when they found him. Resident #1 was discharged to another facility that could be more appropriate for his aggressive behaviors and a secure unit. The previous DON G stated Resident #2 had left the building and the family had alerted them, the staff started the elopement protocol, they found Resident #2 less than a mile, at a church. The previous DON G stated they conducted a head to toe and decided to take her to the local clinic, she had heat exhaustion with no other injuries. The previous DON G stated her new interventions was a wander guard bracelet to wear in her ankle. Resident #2 had not had any previous elopements. The previous DON G stated she did conduct in-services with all staff for elopement.<BR/>Interview 1/8/2025 at 11:19 AM with the previous Maintenance supervisor H stated he found Resident #1 at the church nearby. He was trained on the elopement protocol. Maintenance supervisor H stated Resident #2 had no injuries and offered her water due to a warm day. Maintenance supervisor H stated he tested the wander guard monitors frequently and documented <BR/>Interview 1/9/2025 at 1:46 PM with the previous Administrator A stated Resident #1 was aggressive, so they worked with family/Ombudsman to get him transferred to a safe facility, since it was not safe for him at this facility. The Administrator stated she had reported the elopements to the STATE and trained staff on elopements. Administrator A stated there were new interventions in place for Resident #1 and #2. The new interventions for Resident #1 was to transfer him to a secure unit q 15 minute checks, and psychological MD visit Intervention for Resident #2 was a wander guard.<BR/>Interview 1/8/2025 AT 1:32 pm with Resident #2's family stated Resident #2 was found in 30-45 minutes and they took her to the local clinic for evaluation, she was dehydrated. The Family stated the facility acted immediately to Resident #2 missing, she had dementia and felt safer with her wander guard.<BR/>Interview 1/10/2025 at 4:29 PM with the medical director stated she was aware of the elopements and facility discussed in AD Hoc meeting. <BR/>Record review of in-services dated 5/26/2024 on Wandering/Elopement, Abuse/Neglect protocol/door alarm/ Resident Rights were completed with all staff.<BR/>Record review of check operations of door monitoring and resident, and test for doors and locks dated the week of 5/27/2024 and 6/7/2024. <BR/>Record review of Policy Wandering and Elopement dated 2019 revealed the facility will identify residents who are a t risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. <BR/>Policy Interpretation and Implementation<BR/>l. <BR/>If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.<BR/>2. <BR/>If an employee observes a resident leaving the premises, he/she should:<BR/>a. <BR/>attempt to prevent the resident from leaving in a courteous manner;<BR/>b. <BR/>get help from other staff members in the immediate vicinity, if necessary; and<BR/>c. <BR/>instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.<BR/>3. <BR/>If a resident is missing, initiate the elopement/missing resident emergency procedure:<BR/>a. <BR/>Determine if the resident is out on an authorized leave or pass;<BR/>b. <BR/>If the resident was not authorized to leave, initiate a search of the building(s) and premises; and<BR/>c. <BR/>If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.).<BR/>4. <BR/>When the resident returns to the facility, the director of nursing services or charge nurse shall:<BR/>a. <BR/>examine the resident for injuries;<BR/>b. <BR/>contact the attending physician and report findings and conditions of the resident;<BR/>c. <BR/>notify the resident's legal representative (sponsor);<BR/>d. <BR/>notify search teams that the resident has been located;<BR/>e. <BR/>complete and file an incident report; and<BR/>f <BR/>document relevant information in the resident's medical record.<BR/>Record review of the Policy Wander guard (no date) revealed: <BR/>Identification: Identify residents who are at risk of wandering<BR/>Consent: Obtain consent from residents, family members.<BR/>Monitoring: Regularly check on residents to ensure they are safe<BR/>Response Facility Protocol: Staff is to respond to alarms immediately.<BR/>Ensure resident is Safe.<BR/>Redirect Resident to safe environment.<BR/>Maintenance: Ensure the monitoring system works properly, even during power outages<BR/>Wander guard devices<BR/>Wristbands: Electronic bracelets<BR/>Door controllers: Devices that monitor doors and send alerts if they are opened without authorization were completed, before surveyor entered the facility.<BR/>The AIT-Administrator was notified on 1/10/25 at 4 PM, an PNC IJ situation had been identified due to the above failures. The PNC IJ template was given to the administrator on 1/10/24 at 4 PM.<BR/>Problem: IJ F689 Free of Accidents/Hazards/Supervision/Devices called on 1/10/2025. <BR/>Interventions:<BR/>Interviews with staff total was 35 all staff were in serviced on Elopement/Wandering, Abuse/Neglect, Door Alarms and to check resident devices (wander guards every shift) and understood the elopement protocol. <BR/>Interviews on 1/8/2025 at 1:21 PM-5pm and 1/9/2025 at 1 PM-6 PM. Scheduled shift were 6-2 PM, 2-10 PM. 10pm-6 AM.<BR/>1. CNA J, <BR/>2. LVN F <BR/>3. CNA K <BR/>4. CNA L<BR/>5. CNA M<BR/>6. LVN N<BR/>7. CNA O<BR/>8. CNA P<BR/>9. CNA Q<BR/>10. CMA R<BR/>11. MDS<BR/>12. LVN S<BR/>13. LVN T<BR/>14. DOR (director of rehabilitation) <BR/>15. CNA U<BR/>16. CNA V<BR/>17. ADON<BR/>18. Maintenance Director<BR/>19. CNA Y<BR/>20. CNA Z<BR/>21. CNA AA<BR/>22. CNA BB <BR/>23. RN CC<BR/>24. CNA DD<BR/>25. LVN EE<BR/>26. CNAFF<BR/>27. [NAME] GG<BR/>28. Dietary HH<BR/>29. Hsk II<BR/>30. Hsk JJ<BR/>31. HSK KK<BR/>32. Laundry LL<BR/>Record review of the facility Elopement Binder had 7 current residents for wandering behavior, it contained face sheet and care plans for wandering. <BR/>Observations on 1/10/2025 at 10am of residents in the elopement binder were checked for wander guard and were randomly checked at the door alarm throughout the day. <BR/>Observations and interview with the Maintenance Supervisor on 1/9/25 at 745 am-8:05 am stated he began employment in October at the facility; he stated that all of the facility doors were alarmed but the front door and the exit door for C-hall needed more attention for better security and are working properly now; the Maintenance Director stated that he checks all facility exit doors for security purposes twice a day-at the beginning of his shift and the end of his shift; all of the facility exit doors were observed by Surveyor with the Maintenance Director as noted:<BR/>Facility Front door-alarmed and working<BR/>D-hall exit door-alarmed and working; the Maintenance Director stated that a new mag lock was installed and he will provide paperwork for Surveyor<BR/>E-hall-exit door at the end of the hallway was alarmed and worked; door in lounge on hallway was alarmed and opened to outside open smoking area with two locked gates that were checked and secure.<BR/>A-hall-the door leads to a small courtyard area and was alarmed; the MD stated that the alarm is turned off and back on when he enters for the day and leaves at night and stays on during the w/c; the door stays locked without the alarm being on; the MD stated that the door stays alarmed on the w/e.<BR/>B-Hall- the exit door was alarmed; the MD stated he plans to purchase another mag lock for this door; he stated that he had been also turning this alarm on/off during his work hours to allow for multiple deliveries thru out the day and the door stays locked; Surveyor suggested that he keep this door alarmed at all times.<BR/>C-Hall-exit door alarmed and working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 8 residents (Resident #71) reviewed for nutrition.<BR/>The facility failed to follow Resident #71's care plan for weighing Resident #71 weekly and failed to follow the facility's policy for weight assessment and intervention when Resident #71 had a significant weight loss. <BR/>These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #71's admission Record, dated 01/26/25, reflected Resident #71 was a [AGE] year-old initially admitted on [DATE]. It reflected Resident #71 had diagnoses to include depression, vitamin D deficiency, dysphagia, deficiency of other vitamins, vitamin B12 deficiency, iron deficiency, and pressure ulcer of other site (stage 3). <BR/>Record review of Resident #71's quarterly MDS assessment, dated 11/17/24, reflected Resident #71 had a BIMS score of 15 out of 15, indicating intact cognition. <BR/>Record review of Resident #71's care plan reflected [Resident #71] at risk for nutritional problem or potential nutritional problem r/t pressure ulcer, revised 01/06/25 with interventions to include Continue weekly weights, dated 11/01/24, and RD to evaluate and make diet change recommendations PRN., dated 08/09/24. <BR/>Record review of Resident #71's weight history, accessed 01/26/25, reflected no weight for January 2025, weight for 12/23/24 (192 pounds), and weight for 12/17/24 (203.9 pounds). This reflected a weight loss of 11.9 pounds (-5.8%) in 6 days, indicating a significant weight loss. <BR/>Record review of Resident #71's weight summary, accessed 01/29/25, reflected 12/03/24 weight (203 pounds) and 01/06/25 weight (193 pounds). This reflected a weight loss of 10 pounds (-4.9%) in 1 month, indicating a significant weight loss.<BR/>Record review of the nutritional assessments in PCC reflected no nutritional assessments done in December 2024 or January 2025 for Resident #71. <BR/>During an interview on 01/26/25 at 12:05 PM, Resident #71 revealed he had weight loss but felt like he was back to around 205 pounds. He revealed he would like to stay at 205 pounds and did not want to lose any weight. <BR/>During an interview on 01/29/25 at 10:35 AM, Doctor AA revealed he expected the facility to contact the Registered Dietitian about weight loss and he would follow RD recommendations for residents with weight loss. <BR/>During an interview on 01/29/25 at 12:25 PM, LVN AB revealed Resident #71 had no nutritional interventions in the past 3 months. She revealed the last nutritional intervention for Resident #71 was 10/17/24. <BR/>During an interview on 01/29/25 at 04:10 PM, the RD revealed LVN AB and her spoke about Resident #71 on Monday 01/27/25. She revealed 2 of the 3 wounds for Resident #71 were intact and 1 of 3 was stable. She revealed Resident #71 needed extra protein and calories for wound healing. She revealed residents were assessed when they had significant weight loss. The RD confirmed there was a weight loss between December and January of 10 pounds, but Resident #71's weight was stable for the last 3 weeks in December. The RD revealed there was a significant weight loss for one month and she did not do a significant weight note for him. The RD revealed they had tried different nutritional interventions with no success, but further revealed she could try more interventions like have the CDM visit Resident #71 for a preference update. <BR/>Record Review of the facility's policy Weight Assessment and Intervention, revised March 2022, reflected Weight Assessment 2. Weights are recorded in each unit's weight record chart and in the individual's medical record . 4. The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. 1 month-5% weight loss is significant .Care Planning 1. Care planning for weight loss or impaired nutrition is a multidisciplinary effort . Interventions 1. Interventions for undesirable weight loss are based on careful consideration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 25 medication administration opportunities with 4 errors resulting in a 16% medication error rate, for 1 of 8 residents (Resident #62) reviewed for medication administration.<BR/>1. <BR/>Medication Aide E administered Resident #62 his medication doxazosin (a medication to treat high blood pressure) 1 hour and 28 minutes late and his hydralazine (a medication to treat high blood pressure), carvedilol (used to treat heart failure with high blood pressure), and furosemide (used to treat swelling due to heart failure) late by 58 minutes. <BR/>These failures placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings included:<BR/>A record review of Resident #62's admission record dated 1/30/2025 revealed an admission date of 5/25/2022 with diagnoses which included hypertensive chronic kidney disease with end stage kidney disease (kidney disease complicated by high blood pressure, a person at this stage would need a kidney transplant or dialysis to stay alive.) <BR/>A record review of Resident #62's discharge assessment - return anticipated MDS dated [DATE] revealed Resident #62 was a [AGE] year-old male admitted for support with dialysis off-site therapy (a treatment for individuals whose kidneys are failing, by mechanical filtering waste and excess fluid from the blood.) <BR/>A record review of Resident #62's care plan dated 1/30/2025 revealed, Potential for complications r/t Renal Failure with dialysis . Medications as ordered by physician . Potential for altered tissue perfusion r/t Hypertension . Medications as ordered. Date Initiated: 05/21/2023 <BR/>A record review of Resident #62's physicians orders dated January 2025 revealed the physician prescribed for Resident #62 to receive the following medications:<BR/>Doxazosin an oral Tablet, 4mg, give 1 tablet by mouth one time a day at 7:30 AM for high blood pressure.<BR/>Hydralazine an oral Tablet, 50mg, give 1 tablet by mouth two times a day, at 8:00 AM and again at 4:00 PM, for high blood pressure. <BR/>Carvedilol an oral Tablet, 12.5mg, give 1 tablet by mouth two times a day at 8:00 AM and again at 4:00 PM for high blood pressure.<BR/>Furosemide an oral Tablet, 80mg, give 1 tablet by mouth two times a day at 8:00 AM and again at 4:00 PM for swelling.<BR/>During an observation and interview on 1/28/2025 at 9:49 AM revealed MA E preparing and administering medications for residents within the facility. Further review revealed MA E's computer electronic medical record display which demonstrated her assigned residents highlighted in red. MA E stated she was late administering medications. MA E stated her direct supervisor was the DON and she had not reported the late medication administration. Continued observation revealed she continued to administer medications to residents.<BR/>During an observation on 1/28/2025 at 9:58 AM revealed Medication Aide E (MA E) prepared and administered Resident #62's medications, to include:<BR/>Doxazosin an oral Tablet, 4mg, scheduled for administration at 7:30 AM late by 1 hour and 28 minutes. <BR/>Hydralazine an oral Tablet, 50mg, scheduled for administration at 8:00 AM late by 58 minutes.<BR/>Carvedilol an oral Tablet, 12.5mg, scheduled for administration at 8:00 AM late by 58 minutes.<BR/>Furosemide an oral Tablet, 80mg, scheduled for administration at 8:00 AM late by 58 minutes.<BR/>During a joint interview on 1/29/2025 at 4:04 PM with the operations manager and the DON, the DON stated the expectation was for the medications to be administered within 1 hour of the prescribed time. The DON stated his expectation was for MA E to have reported the potential late medication administration and MA E had not reported the late medication administration. <BR/>A policy regarding medication administration was requested from the administrator on 1/28/2025 at 10:00 AM and as of 1/30/2025 was not provided; however, a policy titled Documentation of Medication Administration was provided. A record review of the policy revealed no policy for timely medication administration. <BR/>A record review of the Institute for Safe Medication Practices website titled ISMP Acute Care Guidelines for Timely Administration of Scheduled Medication ismp-hosp-temp-MASTER.qxd accessed 2/4/2025 revealed, Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time.

Based on observation, interview, and record review, the facility failed to follow menus for 1 of 2 resident meals (dinner meal on 01/28/25) reviewed for menus in that:<BR/>The facility failed to follow the menu for residents on soft bite sized and minced moist diets for the dinner meal on 01/28/25.<BR/>This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.<BR/>The findings included: <BR/>Record review of Week 3 Menu reflected Tuesday (Day 17) Dinner included Tomato Basil Soup and Pimento Cheese Sandwich. <BR/>Record review of the recipes for Pimento Cheese Sandwich, undated, for the textures minced and moist and soft bite sized reflected recipe directions to include Grind 2 slice of bread 4-6 seconds to mince. Place prepared bread crumbs in a bowl and spray with vegetable pan spray until a more cohesive texture is achieved. Divide the prepared bread crumbs placing half of the crumbs as the first layer. Top with the #8 dip pimento cheese. Top with the other half of the minced prepared bread crumbs.<BR/>Record review of the recipes for Tomato Basil Soup, undated, for the textures minced and moist and soft bite sized reflected the soup should have been pureed. <BR/>During an observation of 01/28/25 dinner sample meal tray at 05:15 PM, the dinner for soft bite sized and minced and moist had a full pimiento cheese sandwich and a non-pureed tomato basil soup. <BR/>During an interview on 01/28/25 at 05:24PM, RN K revealed the nursing staff oversaw checking the meal trays after they left the kitchen, to ensure they were the foods listed on the tray ticket. She revealed if there was a discrepancy, they would go to the kitchen to let them know. RN K revealed she questioned if a sandwich was okay for soft and bite sized and was told okay. <BR/>During an interview on 01/29/25 at 11:45 AM, the CDM revealed they did not puree the tomato basil soup to its proper consistency. He further revealed the pimento cheese sandwich was not ground according to the recipe. He revealed it was important to follow the diet textures because residents could choke.<BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed residents should not be getting regular sandwiches if on minced and moist or soft and bite sized diets. The RD revealed if a resident received a sandwich on these diets, it was a choking hazard. The RD revealed the speech therapist and her educated on these textures. She revealed this in-service was done with nursing and dietary staff about 6 months ago. She further revealed she needed to do another in-service because it has been a long time and there had been a lot of new staff, nursing and dietary. <BR/>During an interview on 01/30/25 at 03:11 PM, CNA F revealed when the food trays came out of the kitchen, if the tray ticket was different, he would tell the nurse and then dietary. He further revealed soft bite sized diet was chopped up and he was familiar with the minced and moist texture. He revealed sandwiches should be chopped up. He further revealed a resident could choke if they were served a diet with a different texture than what they could have. <BR/>During an interview on 01/30/25 at 03:50 PM, [NAME] AD and [NAME] AE revealed soft bite sized and minced and moist diet were new diets they were following in the kitchen. [NAME] AE revealed he did not follow the recipes for soft bite sized and minced and moist diet on 01/28/25 dinner and did not know the food textures. They further revealed it was important to follow recipes for the residents' safety. <BR/>During an interview on 01/28/25 at 06:39 PM, the DON revealed it was important to serve diets as prescribed to avoid any choking hazards. The DON revealed the nursing staff was trained on these diet textures, but he could not recall when this training was. <BR/>Record review of facility's policy, undated, Standardized Recipes reflected, Standardized recipes shall be developed and used in the preparation of foods.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: <BR/>1. In a refrigerator, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date.<BR/>2. The facility's documents Three Compartment Sink Log and Milk Refrigerator Temperature Log for January 2025 reflected no entries were documented January 22-January 24. <BR/>3. Dietary Aide AG had a facial piercing and parts of her hair exposed while working in the kitchen. <BR/>These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. <BR/>The findings were:<BR/>1. <BR/>During observation on 01/26/25 at 10:52 AM, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. <BR/>During an interview on 01/26/25 at 01:03 PM, the CDM revealed the salad bags and the bag of ham in the refrigerator did not have a discard date, so he threw these foods away to ensure foods from the kitchen were safe to eat. He further revealed he was not aware of who did this and he oversaw this process. <BR/>2. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Milk Refrigerator Temperature Log for January 2025 reflected no temperatures were documented January 22-January 24 in the AM and PM. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Three Compartment Sink Log for January 2025 reflected no wash temperatures or PPM were documented January 22-January 24 in the AM and PM. <BR/>During an interview with [NAME] AF, during initial kitchen tour on 01/26/25 at 10:52 AM, she revealed there were missing days on the Milk Refrigerator Temperature Log and the Three Compartment Sink Log.<BR/>During an interview on 01/26/25 at 01:03 PM, the CDM confirmed Milk Refrigerator Temperature Log, dated January 2025, and Three Compartment Sink Log, dated January 2025, had no entries documented January 22- January 24 in the AM and PM. The CDM revealed it was important to follow the dishwashing guidelines to kill germs. He revealed he trusted his AM staff members checked temperatures, but he was unaware about his PM staff. He further revealed the log had blank spaces and he expected these logs to be filled completely. He revealed these deficiencies could cause food borne illnesses.<BR/>3. <BR/>During an interview and observation on 01/26/25 at 01:03 PM, it was observed that Dietary Aide AG, while preparing for lunch on 01/26/25, had a facial piercing (located on her bottom lip) and her hair net did not cover the bottom half of her hair. The CDM revealed he had to work on training about dress code with the kitchen staff as there were issues with them following the dress code, but he was going to start the training soon.<BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed it was important to label and date food products to make sure they were serving food safely. The RD further revealed that completing logs in the kitchen, like temperatures and dishwashing logs, prevented food borne illness.<BR/>Record review of facility's policy Food Preparation and Service, revised November 2022, reflected Food Preparation, Cooking, and Holding Time/Temperatures . 1. The danger zone for food temperatures is above 41 *F and below 135 *F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Food Distribution and Service . 1. Proper hot and cold temperatures are maintained during food distribution and service . 8. Food and nutrition services staff wear hair restraints (hair net) so that hair does not contact food. 9 . Jewelry is worn minimally, and hand jewelry is covered with gloves . 15. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.<BR/>Record review of facility's policy Refrigerators and Freezers, revised November 2022, reflected 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures . 4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . 7. All food is appropriately dated to ensure proper rotation by expiration dates . Use by dates are completed with expiration dates on all prepared food in refrigerators . 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-303 Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry .<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-302.12 Food Storage Containers, Identified with Common Name of Food . working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT . shall be identified with the common name of the FOOD.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-307 Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-5 Limitation of Growth of Organisms of Public Health Concern 3-501 Temperature and Time Control 3-501.12 Time/Temperature Control for Safety Food, Slacking . (A) Under refrigeration that maintains the FOOD temperature at 5*C (41*F) or less . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews 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; Standard and transmission-based precautions to be followed to prevent spread of infections; for 3 of 8 residents (Residents #45 and #69) and 3 of 3 staff (MA E, DON, LVN J) reviewed for infection prevention with Enhanced Barrier Precautions.<BR/>1. <BR/>Resident #69 was diagnosed with a urinary tract infection (UTI), assessed with the need for infection prevention enhanced barrier precautions (EBP), and on 1/26/2025 at 11:52 AM the DON wore 1 glove for personal protective equipment (PPE) while attempting to administer an intravenous access for Resident #69. <BR/>2. <BR/>Resident #69 was diagnosed with a urinary tract infection (UTI), assessed with the need for infection prevention enhanced barrier precautions, and on 1/28/2025 at 9:36 AM Medication Aide E (MA E) did not wear PPE while administering medications to Resident #69.<BR/>3. <BR/>Resident #45 was prescribed a gastric tube (g-tube; a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine), assessed with a need for infection prevention enhanced barrier precautions, and on 1/28/2025 did not wear EBP PPE and administered medications via Resident #45's g-tube. <BR/>These failures could place residents at risk for harm by cross contamination infections.<BR/>The findings included:<BR/>1.<BR/>A record review of Resident #69's admission record dated 1/30/2025 revealed an admission date of 7/7/2023 with diagnosis which included a urinary tract infection. <BR/>A record review of Resident #69's quarterly MDS assessment dated [DATE] revealed Resident #69 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 3 out a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #69's care plan dated 1/30/2025 revealed, Urinary Tract Infection, potential or actual r/t Diagnosis of BPH, Diagnosis of Urinary retention, Use of indwelling catheter dx (diagnosis) ESBL UTI (extended spectrum beta-lactamase urinary tract infection. ESBL-producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections), Date Initiated: 01/22/2025 . Antibiotic per MD (medical doctor) order x 5days. Date Initiated: 01/26/2025 <BR/>A record review of Resident #69's physicians orders dated 1/26/2025 revealed the physician prescribed for Resident #69 to receive meropenem (an intravenous antibiotic used to treat a variety of bacterial infections) Intravenous Solution, Use 500mg intravenously every 6 hours for ESBL UTI <BR/>During an observation and interview on 1/26/2025 at 11:52 AM revealed Resident #69's room which presented with EBP signage and a PPE supply cabinet at the room entry. Further observation revealed the DON in Resident #69's room, attempting to start an intravenous (IV) access. Further review revealed the DON wore a glove on his right hand as the lone PPE. The DON stated Resident #69 was diagnosed with a UTI and was prescribed intravenous antibiotics, He (Resident #69) had a midline (an intravenous access) he pulled it out and he is refusing the IV. <BR/>2.<BR/>During an observation and interview on 1/28/2025 at 9:36 AM revealed Medication Aide E was in Resident #69's room and had administered medication to Resident #69. MA E stated Resident #69 was diagnosed with a UTI and had a need for infection control EBP's and had PPE supplies as well as signage at his room entry. MA E stated she should have worn EBP PPE and had not. <BR/>3.<BR/>A record review of Resident #45's admission record, dated 12/25/2024, revealed an admission date of 1/3/2025 with diagnoses which included dysphagia following cerebral infarction (difficulty swallowing after a stroke), hypertension (high blood pressure), and diabetes type 2 (the inability for the body's cell to absorb blood sugar resulting in high levels of blood sugar with disease complications, e.g., blindness.)<BR/>A record review of Resident #45's quarterly MDS assessment dated [DATE] revealed Resident #45 was a [AGE] year-old female admitted for long term care with difficulty swallowing and supported with enteral feeding and medications via a g-tube.<BR/>A record review of Resident #45's care plan dated 1/30/2025 revealed, Enhanced barrier precautions r/t an indwelling medical device Specify: Peg tube Date Initiated: 01/04/2025 . [NAME] gown and gloves during high-contact personal care activities Date Initiated: 01/04/2025.<BR/>During an observation on 1/28/2025 at 5:32 PM revealed Resident #45's room entry presented with EBP signage and a PPE supply cabinet. Observations revealed LVN J prepared and administered medications to Resident #45 via her g-tube while LVN J wore gloves as PPE without a gown. LVN J stated she forgot to wear the gown and stated she should have worn a gown and gloves per the EBP protocol .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 secured yard reviewed for safety.<BR/>1.Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had a section of chain link fence a section of the chain link fencing was detached from the top rail and leaning down.<BR/>2. Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash. <BR/> These failures could place residents at risk for elopement and/or fire risks.<BR/>The findings included:<BR/>A record review of Resident #24's admission record dated 1/30/2025 revealed an admission date of 12/17/2024 with diagnoses which included tobacco use, lack of coordination, and muscle weakness.<BR/>A record review of Resident #24's quarterly MDS assessment dated [DATE] revealed Resident #24 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 12 which indicated intact cognition. Resident #24 was assessed with difficulty hearing and poor vision and used glasses. Resident #24 was assessed an elopement / wander risk and was supported for safety with a wander guard anklet. <BR/>A record review of Resident #24's care plan dated 1/30/2025 revealed, At risk for elopement /wandering as evidenced by Disoriented to place, Impaired safety awareness, wanders aimlessly Date Initiated: 12/19/2024. Device: Alarm: Check via Electronic Machine Every Day Date Initiated: 12/20/2024. Device: Alarm: Visually Check Every Shift Wander guard on Right Ankle every shift for Wonder Guard. The resident has, impaired visual function r/t Disease Process . Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. STCP: At risk for smoking related injury related to: supervised smoking . observe him/her for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management Date Initiated: 12/18/2024 <BR/>A record review of Resident #24's physicians' orders dated 1/30/2025 revealed the physician prescribed, for her elopement / wander risk, a wander guard anklet and to have the anklet checked daily. <BR/>A record review of Resident #55's admission record revealed an admission date of 2/4/2021 with diagnoses which included corneal ulcer of the right eye, generalized anxiety disorder, dementia with behavioral disturbance. <BR/>A record review of Resident #55's annual MDS assessment dated [DATE] revealed Resident #55 was an [AGE] year-old male admitted for long term care and resided in the MCU. Resident #55 was assessed with a BIMS score of 00 which indicated severe cognitive impairment as evidenced by his inability to participate in the assessment. <BR/>A record review of Resident #55's care plan dated 1/28/2025 revealed, (Resident #61) is an elopement risk/wanderer Continues placement on Memory Care at this time. is a smoker . Instruct (Resident #55) about the facility policy on smoking: locations, times, safety concerns . has a behavioral concern of increased agitation physical and verbal aggression with the possibility of throwing things . Staff to redirect resident to other activities . Intervene as needed to ensure resident safety <BR/>A record review of Resident #83's admission record dated 1/30/2025 revealed an admission date of 11/4/2024 with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a cluster of symptoms, not an illness. It's sometimes described as losing touch with reality), mood disturbance, and anxiety. Further review revealed Resident #83 resided in the MCU.<BR/>A record review of Resident #83's admission MDS assessment dated [DATE] revealed Resident #83 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. Resident #83 was reviewed for the 6 days prior to the assessment and Resident #83 was assessed with a history of behavioral symptoms, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) . behavior of this type occurred 1 to 3 days. verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . behavior of this type occurred 1 to 3 days. impact on others? Put others at significant risk for physical injury? Yes Further review revealed resident #83 was six foot tall and weighed 179 lbs. <BR/>A record review of Resident #83's care plan dated 1/29/2025 revealed, (Resident #83) has mood problem r/t Admission, agitation and anxiety from resident to staff root cause: Resident attempting to get out of memory care unit . is a safe smoker Date Initiated: 11/07/2024 . Patient educated to appropriate smoking areas Date Initiated: 11/07/2024 If safety becomes a concern involve IDT team and resident for reevaluation of smoking needs <BR/>During an observation and interview on 1/26/2025 at 11:30 AM revealed the facility's secured back yard / smoking patio. The patio presented with 2 red fire rated trash cans and 1 large plastic 30-gallon trash can with a plastic liner. The patio was supervised by the Admissions Coordinator and Residents #2, #24, #55, and #83 were among the 9 residents at the patio. Further observation revealed the residents were smoking cigarettes. Observation of the 30-gallon trash can revealed paper, plastic, and can trash among cigarette butts. Observations of the 2 red fire rated cigarette butt trash cans revealed more than 100 cigarette butts among plastic and paper trash. Further review revealed the yard was enclosed by a combination of 5 - 6-foot-tall wooden privacy fencing and metal galvanized chain link fencing. A section of the chain link fencing was detached from the top rail and leaning down. The Admissions coordinator stated Resident #25 was a wander risk and Residents #55 and #83 were also wander risk and resided in the secured MCU (memory Care Unit.) The Admissions coordinator stated the 30-gallon trash can had paper, plastic, and can trash among cigarette butts, the 2 red fire rated cigarette butt trash cans had more than 100 cigarette butts among plastic and paper trash, and a section of the chain link fencing was detached from the top rail and leaning down. The Admissions coordinator stated the cans had signage stating only cigarette butt trash was allowed in the cans, and the regular trash can should not have any cigarette butts. The Admissions coordinator stated the risk was a potential fire. <BR/>Daily intermittent observations, from 1/26/2025 to 1/30/2025 , revealed the facility's secured backyard and smoking patio yard had a section of chain link fence missing and had a regular trash can filled with trash and cigarette butts, several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash.<BR/>During an interview on 1/27/2025 at 10:02 AM the operations manager stated she was unaware of the secured backyard and smoking patio yard had a section of chain link fence missing and had a regular trash can filled with trash and cigarette butts, and several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash. <BR/> A record review of the facility's policy titled Smoking Policy - Residents dated October 2023, revealed, Policy Statement<BR/>This facility has established and maintains safe resident smoking practices.<BR/>Policy Interpretation and Implementation . 5. <BR/>Metal containers, with self-closing cover devices, are available in smoking areas. 6. <BR/>Ashtrays are emptied only into designated receptacles. <BR/>A policy for a safe environment was requested of the Administrator on 1/30/2025 and as of 2/7/2025 had not been provided. A policy on smoking was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 8 of 16 residents (Residents #5, 20, #27, #38, #68, #69, #81, and #85) reviewed for pharmacy services.<BR/>1. On [DATE] Medication Aide E administered late medications to Resident #20 at 10:49 AM:<BR/>a. Acetaminophen 325mg, (Tylenol) late by 1 hour and 49 minutes.<BR/>b. Levetiracetam 500mg (a medication to treat seizures) late by 1 hour and 49 minutes. <BR/>2. On [DATE] Medication Aide E administered late medications to Resident #27 at 9:20 AM:<BR/>a. Carvedilol 12.5mg (used to treat high blood pressure) late by 20 minutes.<BR/>b. Divalproex 125mg (used to treat schizophrenia) late by 20 minutes.<BR/>3. On [DATE] Medication Aide E administered late medications to Resident #38 at 10:51 AM:<BR/>a. Famotidine 20mg (used to reduce stomach acid) late by 1 hour and 51 minutes.<BR/>b. Docusate (a stool softener) 100mg late by 1 hour and 51 minutes.<BR/>c. Lamotrigine 100mg (used to prevent seizures) late by 1 hour and 51 minutes.<BR/>d. Sodium chloride 1gr (salt used to treat muscle weakness) late by 51 minutes. <BR/>4. On [DATE] Medication Aide E administered late medications to Resident #68 at 10:23 AM:<BR/>a. Metformin 1000mg (used to treat diabetes) late by 1 hour and 23 minutes.<BR/>5. On [DATE] Medication Aide E administered late medications to Resident #69 at 9:45 AM:<BR/>a. Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) late by 45 minutes.<BR/>6. An inspection on [DATE] of the facility's treatment nurse medication cart revealed expired insulins for Residents #5, #81, and #85 as evidenced by the following:<BR/>a. Resident #5's liraglutide (an anti-diabetic medication used to treat type 2 diabetes, and chronic obesity) subcutaneous (under the skin) solution pen-injector was stored unrefrigerated, and available for administration, in the cart and was expired by 19 days. <BR/>b. Resident #81's 3 injection vials of insulin lispro 100u/ml, were available for administration, stored unrefrigerated, unlabeled with an expiration date, and were expired by as much as 59 days.<BR/>c. Resident #85's 1 injection vial of insulin lispro 100u/ml, was available for administration, stored unrefrigerated, labeled with an expiration date of 12/20, and was expired by 45 days.<BR/>These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. <BR/>The findings included:<BR/>During an observation and interview on [DATE] at 9:49 AM revealed MA E preparing and administering medications for residents within the facility. Further review revealed MA E's computer electronic medical record display demonstrated MA E's assigned residents were highlighted in red. MA E stated she was late administering medications, specifically for Residents #20, 27, #38, #68, and #69. MA E stated her direct supervisor was the DON and she had not reported the late medication administration. Continued observation revealed she continued to administer medications to residents.<BR/>1. A record review of Resident #20's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included vascular dementia (parts of the brain are damaged due to a stroke) and convulsions (an electrical storm in the brain AKA seizures.) <BR/>A record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 was a [AGE] year-old male admitted for long term care and assessed a BIMS score of 5 out of a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #20's care plan dated [DATE] revealed, (Resident #20) has a seizure disorder r/t (related to) Stroke Date Initiated: [DATE] . Give medications as ordered. Observe/document for effectiveness and side effects. <BR/>A record review of Resident #20's physicians' orders revealed the physician prescribed for Resident #20 to receive levetiracetam 500mg twice a day at 8:00 AM and at 4:00 PM and acetaminophen 325mg three times a day at 8:00 AM, noon, and at 4:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], administered Resident #20 his acetaminophen 325mg and his levetiracetam 500mg at 10:49 AM late by 1 hour and 49 minutes.<BR/>2. A record review of Resident #27's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included hypertension (high blood pressure) and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others.)<BR/>A record review of Resident #27's Quarterly MDS assessment dated [DATE] revealed Resident #27 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. <BR/>A record review of Resident #27's care plan dated [DATE] revealed, (Resident #27) has Hx (history) of hallucinations. (Resident #27) states that this voice tells him bad things, including not to smoke, tells him he is overweight. Mr. Rico calls this voice/voices the devil . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #27's physicians orders dated [DATE] revealed the physician prescribed for Resident #27 to receive carvedilol 12.5mg and divalproex 125mg twice a day at 8:00 AM and again at 4:00 PM.<BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], administered Resident #27 his carvedilol 12.5mg and divalproex 125mg at 9:20 AM late by 20 minutes.<BR/>3. A record review of Resident #38's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures. Seizures are uncontrolled bursts of electrical activities that change sensations, behaviors, awareness, and muscle movements), Gastroesophageal reflux disease (AKA GERD, occurs when stomach acid frequently flows back into the esophagus, leading to irritation and discomfort), constipation, and muscle weakness. <BR/>A record review of Resident #38's Quarterly MDS assessment dated [DATE] revealed Resident #38 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. <BR/>A record review of Resident #38's care plan dated [DATE] revealed, (Resident #38) has behavioral concern of insisting medications be given at a certain time and becoming angry when medications are not being given exactly when requested. (Resident #38) has been made aware of and<BR/>educated on medication administration window . <BR/>A record review of Resident #38's physicians' orders dated [DATE] revealed the physician prescribed for Resident #38 to receive famotidine 20mg and docusate 100mg twice a day at 8:00 AM and again at 4:00 PM. Lamotrigine 100mg at 8:00 AM and again at 6:00 PM. Sodium chloride 1gr twice a day at 9:00 AM and again at 5:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 10:51 AM, administered Resident #38 his famotidine 20mg, docusate 100mg, lamotrigine 100mg late by 1 hour and 51 minutes and sodium chloride 1gr late by 51 minutes.<BR/>4. A record review of Resident #68's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included diabetes type 2. <BR/>A record review of Resident #68's quarterly MDS assessment dated [DATE] revealed Resident #68 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #68's care plan dated [DATE] revealed, (Resident #68) has impaired cognitive function/dementia or impaired thought processes r/t Dementia, Disease Process diabetes, . Administer meds as ordered. Date Initiated: [DATE] <BR/>A record review of Resident #68's physicians' orders dated [DATE] revealed the physician prescribed for Resident #68 to receive metformin 1000mg twice a day at 8:00 Am and again at 4:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 10:23 AM, administered Resident #68 his Metformin 1000mg late by 1 hour and 23 minutes.<BR/>5. A record review of Resident #69's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included a urinary tract infection. <BR/>A record review of Resident #69's quarterly MDS assessment dated [DATE] revealed Resident #69 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 3 out a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #69's care plan date [DATE] revealed, Urinary Tract Infection, potential or actual r/t Diagnosis of BPH, Diagnosis of Urinary retention, Use of indwelling catheter dx (diagnosis) ESBL UTI (extended spectrum beta-lactamase urinary tract infection. ESBL-producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections), Date Initiated: [DATE] . Antibiotic per MD (medical doctor) order x 5days. Date Initiated: [DATE] <BR/>A record review of Resident #69's physicians orders dated [DATE] revealed the physician prescribed for Resident #69 to receive Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) twice a day at 8:00 AM and again at 8:00 PM.<BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 9:45 AM, administered Resident #69 his Bactrim 800mg / 160mg late by 45 minutes.<BR/>During a joint interview on [DATE] at 4:04 PM with the operations manager and the DON, the DON stated the expectation was for the medications to be administered with in 1 hour of the prescribed time. The DON stated his expectation was for MA E to have reported the potential late medication administration and MA E had not reported the late medication administration. <BR/>6. A record review of Resident #5's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included type II diabetes (a long-term condition which results in too much sugar circulating in the blood. High blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.)<BR/>A record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care and assessed with a memory problem, Moderately impaired - decisions poor; cues / supervision required <BR/>A record review of Resident #5's care plan dated [DATE] revealed, Alteration in Blood Glucose due to hyper/hypoglycemia dx. DMII, . Date Initiated: [DATE] . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #5's physicians' orders dated [DATE] revealed the physician prescribed for Resident#5 to receive liraglutide 18mg/3ml, 1.2mg injected under the skin daily at 8:00 AM. <BR/>During an observation and interview on [DATE] at 10:30 AM revealed LVN Z attending the nurse treatment cart on the facility's D-hall and was preparing to administer insulins prior to the noon meal. LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed an insulin injection pen for Resident #5. The pen was labeled, liraglutide injection (Resident #5) 18mg/3ml, . date opened [DATE] .exp. [DATE] . discard pen 30 days after first use LVN Z stated she would not use the insulin pen because it was expired and would immediately discard the injection pen. <BR/>A record review of Resident #81's admission record dated [DATE] revealed an admission date of [DATE] with diagnosis which included type II diabetes.<BR/>A record review Resident #81's quarterly MDS assessment dated [DATE] revealed Resident #81 was a [AGE] year-old female assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #81's care plan dated [DATE] revealed, Potential for complication hypo hyperglycemia r/t DMII. Date Initiated: [DATE] . Medications/blood sugar check as ordered and as needed. Date Initiated: [DATE] <BR/>A record review of Resident #81's physicians' orders dated [DATE] revealed the physician prescribed for Resident #81 to receive insulin lispro 4 times a day at 6:30 AM, 11:30 AM, 4:30 PM, and at 8:00 PM, insulin lispro 100u/ml inject per sliding scale: if 0-150 = 0; 151 - 250 = 2; . 301-400 = 14 . subcutaneously before meals and at bedtime for diabetes <BR/>A record review of Resident #85's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes. <BR/>A record review of Resident #85's quarterly MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted for long term care and assessed with a memory care problem, Severely impaired - never / rarely made decisions <BR/>A record review of Resident #85's physicians' orders dated [DATE] revealed the physician prescribed for Resident #85 to receive insulin lispro three times a day at 6:30 AM, 11:30 AM, and at 4:30 PM, (insulin lispro) subcutaneously solution pen injector 100u/ml inject 10 unit subcutaneously before meals for diabetes <BR/>During an observation and interview on [DATE] at 10:30 AM LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed a plastic bag which contained 4 insulin injection pen refill vials. The bag was labeled, (Resident #81) (the facility) (insulin lispro) 100u/ml cartridge qty: 15, [DATE] . refrigerate Observation of the 4 vials revealed:<BR/>1. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #81's name, dated with an open date of [DATE], observed 2/3's full.<BR/>2. 3ml glass vial insulin lispro 100u/3ml labeled (Resident #81) [DATE] observed full.<BR/>3. 3ml glass vial insulin lispro 100u/3ml unlabeled with a resident's name, dated with an open date 12/20 (no year), observed full.<BR/>4. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #85's name, undated, no open date noted, observed &frac12; full. <BR/>LVN Z stated the vials were stored unrefrigerated, in a bag labeled Resident #81, however, LVN Z could not state who the insulin vials were intended for and could not state the date the vials were unrefrigerated. LVN Z stated she would discard the vials because they were unsafe to use.<BR/>During an interview on [DATE] at 1:10 PM the DON stated the expectations and trainings for nurses who administer insulin was for the insulin to be labeled with an opened date and a dispose of date, to include a use span of 28 days. The DON stated all insulins older than 28 days and or unlabeled insulins should be discarded. The DON stated the risk for harm would be residents may not receive the therapeutic effects of their prescribed medications. <BR/>A policy regarding medication administration was requested on [DATE] at 10:00 AM and as of [DATE] was not provided; however, a policy titled Documentation of Medication Administration was provided. A record review of the policy revealed no policy for timely medication administration. <BR/>A record review of the Institute for Safe Medication Practices website titled ISMP Acute Care Guidelines for Timely Administration of Scheduled Medication ismp-hosp-temp-MASTER.qxd accessed [DATE] revealed, Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time. <BR/>A record review of the lirglutide manufactures website titled, Victoza (liraglutide) injection, Important Information accessed [DATE], https://www.victoza.com/faq.html, revealed, Instructions for Use? You can use your Victoza pen for up to 30 days after you use it the first time. First Time Use for Each New Pen. How should I store Victoza?<BR/>Before use:<BR/>o Store your new, unused Victoza pen in the refrigerator between 36&ordm;F to 46&ordm;F (2&ordm;C to 8&ordm;C).<BR/>o If Victoza is stored outside of refrigeration (by mistake) prior to first use, it should be used or thrown away within 30 days.<BR/>Pen in use:<BR/>o Use a Victoza pen for only 30 days. Throw away a used Victoza pen 30 days after you start using it, even if some medicine is left in the pen.<BR/>o Store your Victoza pen at room temperature between 59&ordm;F to 86&ordm;F (15&ordm;C to 30&ordm;C), or in a refrigerator between 36&ordm;F to 46&ordm;F (2&deg;C to 8&deg;C).<BR/>A record review of the insulin lispro manufactures website titled bing.com/ck/a?!&&p=88304c2b6b2aae023b9ebee38f5cae217a125895e1f0391c2809d0dd502d8becJmltdHM9MTc0MDA5NjAwMA&ptn=3&ver=2&hsh=4&fclid=1aed91e9-b39d-6b39-1288-8473b27c6a4d&psq=lispro+kwikpen+instructions&u=a1aHR0cHM6Ly9waS5saWxseS5jb20vdXMvaHVtYWxvZy1rd2lrcGVuLXVtLnBkZg&ntb=1, accessed [DATE], revealed, INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) <BR/>(insulin lispro) injection, for subcutaneous use revealed, Do not use past the expiration date printed on the Label or for more than 28 days after you first start using. Store unused insulin in the refrigerator at 36&deg;F to 46&deg;F (2&deg;C to 8&deg;C).<BR/>o Do not freeze your insulin. Do not use if it has been frozen.<BR/>o Unused insulin may be used until the expiration date printed on the Label, if it has been kept in the refrigerator.<BR/>In-use:<BR/>o Store the insulin you are currently using at room temperature [up to 86&deg;F (30&deg;C)]. Keep away from heat and light.<BR/>o Throw away the HUMALOG insulin you are using after 28 days, even if it still has insulin left in it.<BR/>A record review of the facility's policy titled, Medication Labeling and Storage dated February 2023, revealed, The facility stores all medications and biologicals and locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to the keys. Policy interpretation and implementation: medication storage; . compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trains or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. H residence medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. medication labeling; labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration, and appropriate instructions and precautions. multi dose vials that have been opened or accessed (for example needle punctured) are gated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Multi dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for dialysis.<BR/>1. <BR/>The facility failed to ensure Resident #1 had a complete set of vital signs assessed prior to leaving for dialysis on (8) occasions. <BR/>2. <BR/>The facility failed to ensure Resident #1 had a complete set of vital signs and access site assessed upon returning to the facility after dialysis on (9) occasions. <BR/>These deficient practices could affect residents who receive dialysis treatments at risk for inadequate care and/or decline in health.<BR/>Findings included: <BR/>1. Record review of Resident #1's admission Record, dated 12/5/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic Kidney Failure (condition in which kidneys are unable to filter waste from blood), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), ESRD (kidneys can longer function due to permanent damage), and Hypertension (high blood pressure).<BR/>Record review of Resident #1's Care Plan , initiated 9/4/24, revealed: CKD with Dialysis .Assess shunt for any redness, swelling, or pain .Take to dialysis as scheduled .<BR/>Record review of Resident #1's Order Summary, dated 11/28/24, revealed an order for dialysis treatment, dated 9/18/24. Further review revealed Monday, Wednesday, Friday dialysis at 11:30 am.<BR/>Record review of Resident #1's Dialysis Pre & Post Assessment, completed by LVN E, revealed the Dialysis Pre-Evaluation were not complete on the following dates: 10/2/24, 10/7/24, 10/11/24, 10/14/24, 10/18/24, 10/23/24, 10/28/24, and 11/13/24. Further review revealed LVN E documented vital signs from previous dates on the mentioned dates. <BR/>Record review of Resident #1's Progress notes revealed: <BR/>10/2/24 - there was no pre dialysis assessment documented. <BR/>10/14/24 - there was no pre dialysis assessment documented. <BR/>10/18/24 - there was no pre dialysis assessment documented. <BR/>10/28/24 - there was no pre dialysis assessment documented. <BR/>11/13/24 - there was no pre dialysis assessment documented. <BR/>Record review of Resident #1's Dialysis Pre & Post Assessment, completed by LVN E, revealed the Dialysis Post-Evaluation was not complete on 10/2/24, 10/7/24, 10/11/24, 10/14/24, 10/16/24, 10/18/24, 10/23/24, 10/28/24, and 11/13/24. <BR/>Record review of Resident #1's Progress notes revealed: <BR/>10/2/24 - there was no post dialysis assessment documented. <BR/>10/11/24 - there was no post dialysis assessment documented.<BR/>10/23/24 - there was no post dialysis assessment documented. <BR/>10/28/24 - there was no post dialysis assessment documented. <BR/>11/13/24 - there was no post dialysis assessment documented. <BR/>During an interview on 12/2/24 at 2:26 pm, Resident #1 said he did not remember if he was assessed prior to going to dialysis. <BR/>During an interview on 12/5/24 at 2:09 pm, the DON said she expected that residents be assessed on the same day of dialysis, 30 minutes - 1 hour before the residents were transported to the dialysis center. The DON further stated the residents were to be assessed once they returned from dialysis as well to ensure the residents were stable. The DON said the pre/post assessments included how the resident looked, their cognition, if they had shortness of breath, any complaints, a complete set of vital signs (T, P, R, BP, and O2 sat), assessment of the dialysis access site, and a comparison to the dialysis center assessment after the residents returned from dialysis. The DON said the resident may be unstable prior to dialysis or may become unstable after dialysis so it was important to have the complete assessment before and after dialysis. <BR/>Attempts to interview LVN E on 12/5/24 at 5:15 pm and 12/6/24 at 10:06 am were unsuccessful. <BR/>During an interview on 12/6/24 at 3:04 pm, RN H said he expected residents to be assessed on the same day of dialysis prior to be transported to the dialysis center. RN H further stated staff could not use assessments from previous days because the facility needed a baseline to know whether the resident was stable or not before they left for the dialysis center, the resident should not be sent to dialysis with a low BP. RN H said the pre/post dialysis assessments includes respiration, BP, HR, O2 sat, and temperature every time the residents went to dialysis, along with the access site for bleeding and signs of infection. RN H further stated if the assessments were not competed or not documented, the facility would be unable to know if the residents were stable. <BR/>During an interview on 12/6/24 at 3:58 pm, the DON said she was not aware LVN E used assessments from previous dates on the above-mentioned assessments because she did not review pre/post dialysis assessments unless they were triggered by the UDA (User Defined Assessment), which only triggered if the assessments were not within normal limits. <BR/>Record review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, revealed: . Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews 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; Standard and transmission-based precautions to be followed to prevent spread of infections; for 3 of 8 residents (Residents #45 and #69) and 3 of 3 staff (MA E, DON, LVN J) reviewed for infection prevention with Enhanced Barrier Precautions.<BR/>1. <BR/>Resident #69 was diagnosed with a urinary tract infection (UTI), assessed with the need for infection prevention enhanced barrier precautions (EBP), and on 1/26/2025 at 11:52 AM the DON wore 1 glove for personal protective equipment (PPE) while attempting to administer an intravenous access for Resident #69. <BR/>2. <BR/>Resident #69 was diagnosed with a urinary tract infection (UTI), assessed with the need for infection prevention enhanced barrier precautions, and on 1/28/2025 at 9:36 AM Medication Aide E (MA E) did not wear PPE while administering medications to Resident #69.<BR/>3. <BR/>Resident #45 was prescribed a gastric tube (g-tube; a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine), assessed with a need for infection prevention enhanced barrier precautions, and on 1/28/2025 did not wear EBP PPE and administered medications via Resident #45's g-tube. <BR/>These failures could place residents at risk for harm by cross contamination infections.<BR/>The findings included:<BR/>1.<BR/>A record review of Resident #69's admission record dated 1/30/2025 revealed an admission date of 7/7/2023 with diagnosis which included a urinary tract infection. <BR/>A record review of Resident #69's quarterly MDS assessment dated [DATE] revealed Resident #69 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 3 out a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #69's care plan dated 1/30/2025 revealed, Urinary Tract Infection, potential or actual r/t Diagnosis of BPH, Diagnosis of Urinary retention, Use of indwelling catheter dx (diagnosis) ESBL UTI (extended spectrum beta-lactamase urinary tract infection. ESBL-producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections), Date Initiated: 01/22/2025 . Antibiotic per MD (medical doctor) order x 5days. Date Initiated: 01/26/2025 <BR/>A record review of Resident #69's physicians orders dated 1/26/2025 revealed the physician prescribed for Resident #69 to receive meropenem (an intravenous antibiotic used to treat a variety of bacterial infections) Intravenous Solution, Use 500mg intravenously every 6 hours for ESBL UTI <BR/>During an observation and interview on 1/26/2025 at 11:52 AM revealed Resident #69's room which presented with EBP signage and a PPE supply cabinet at the room entry. Further observation revealed the DON in Resident #69's room, attempting to start an intravenous (IV) access. Further review revealed the DON wore a glove on his right hand as the lone PPE. The DON stated Resident #69 was diagnosed with a UTI and was prescribed intravenous antibiotics, He (Resident #69) had a midline (an intravenous access) he pulled it out and he is refusing the IV. <BR/>2.<BR/>During an observation and interview on 1/28/2025 at 9:36 AM revealed Medication Aide E was in Resident #69's room and had administered medication to Resident #69. MA E stated Resident #69 was diagnosed with a UTI and had a need for infection control EBP's and had PPE supplies as well as signage at his room entry. MA E stated she should have worn EBP PPE and had not. <BR/>3.<BR/>A record review of Resident #45's admission record, dated 12/25/2024, revealed an admission date of 1/3/2025 with diagnoses which included dysphagia following cerebral infarction (difficulty swallowing after a stroke), hypertension (high blood pressure), and diabetes type 2 (the inability for the body's cell to absorb blood sugar resulting in high levels of blood sugar with disease complications, e.g., blindness.)<BR/>A record review of Resident #45's quarterly MDS assessment dated [DATE] revealed Resident #45 was a [AGE] year-old female admitted for long term care with difficulty swallowing and supported with enteral feeding and medications via a g-tube.<BR/>A record review of Resident #45's care plan dated 1/30/2025 revealed, Enhanced barrier precautions r/t an indwelling medical device Specify: Peg tube Date Initiated: 01/04/2025 . [NAME] gown and gloves during high-contact personal care activities Date Initiated: 01/04/2025.<BR/>During an observation on 1/28/2025 at 5:32 PM revealed Resident #45's room entry presented with EBP signage and a PPE supply cabinet. Observations revealed LVN J prepared and administered medications to Resident #45 via her g-tube while LVN J wore gloves as PPE without a gown. LVN J stated she forgot to wear the gown and stated she should have worn a gown and gloves per the EBP protocol .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 4 residents reviewed for resident rights. <BR/>The facility failed to notify Resident #1's physician of her change of condition on 8/08/2024 when an injury of unknown origin developed into a hematoma [collection of blood outside of a blood vessel where it does not belong, may result in swelling, discoloration and warmth] at the back of her head. Resident #1 was subsequently sent out to the hospital on 8/09/2024 . <BR/>This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. <BR/>The findings included: <BR/>Record review of the admission Record, printed 8/10/2023, reflected Resident #1 was a [AGE] year-old female originally admitted on [DATE]. <BR/>Record review of the quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS summary score of four, indicative of severe cognitive impairment. Under section GG - Functional Abilities and Goals, Resident #1 was coded as having used a walker and a wheelchair for mobility; partial/moderate assistance for ambulation of 10 feet, 50 feet with two turns, ambulation of 150 feet, and transfers of all types. Resident #1's primary medical condition category that best described reason for admission was coded as medically complex conditions related to type 2 diabetes mellitus [chronic condition where the body either doesn't make enough insulin or doesn't respond to it effectively; leading to high blood sugar levels which can cause symptoms like tiredness, hunger, thirst and increased urination]. Other active diagnoses included non-Alzheimer's dementia [group of symptoms affecting memory, thinking and social abilities, marked by a severe decline in cognitive functions to the extent that it interferes with the person's daily life], fracture, [broken bone] history of falling, generalized muscle weakness, difficulty in walking, other lack of coordination. <BR/>Record review of the Care Plan reflected Resident #1 had a focus area of: at risk for falls related to gait/balance problems, osteopenia, and chondrocalcinosis[also known as pseudogout, buildup of inflammatory particulates in the joint], history of falls, initiated on 9/14/2024 with an actual fall on 7/09/2024; with the following associated interventions: encourage Resident #1 to ask for assistance initiated 7/06/2024; pad on bedside table and bedframe with pool noodle, initiated 6/28/2024; resident to use PVC [a strong, synthetic plastic] low bed initiated on 4/08/2024. Other focus area included: visually impaired, initiated on 9/25/2023 with the revision on 2/22/2024. Additional focus area included: Complex Behavioral Care Plan - sits self on floor and scooting on floor, initiated 12/01/2023, with a revision on 8/09/2024. Focus area: at risk for complications related to anticoagulant or antiplatelet medication, initiated on 8/06/2024; with the following associated interventions: observed for signs and symptoms of bleeding i.e., bruising with a date initiated of 8/06/2024. Focus areas of complications related to recent [September 2023] brain bleed, history of fall prior to admission initiated on 9/14/2023; with the following associated interventions: monitor for signs and symptoms of brain bleed e.g., irritability, restlessness, initiated 9/28/2023. Focus area: complications related to .fractures 9/28/2023, initiated on 9/21/2024, with a revision on 6/15/2024. Focus area: risk for spontaneous fractures as resident has osteopenia/chondrocalcinosis initiated on 10/09/2023, with a revision on 10/10/2023. <BR/>Record review of Order Summary Report, printed 8/10/2024, reflected Resident #1 had physician's orders for aspirin 81 mg by mouth in the morning, with a start date of 8/06/2024. <BR/>Record review of Progress Note dated 8/08/2024 at 8:27 AM, authored by LVN C reflected Resident #1 had a laceration to left eyebrow and its course of treatment.<BR/>Record review of Progress Note dated 8/08/2024 at 1:49 PM, authored by Treatment Nurse, reflected Resident #1 had laceration above left eye and its course of treatment. <BR/>Record review of Progress Note dated 8/08/2023 at 3:51 PM, authored by DOR, reflected assessment of furniture in Resident #1's room. <BR/>Record review of Progress Note dated 8/08/2024 at 7:29 PM, authored by LVN A reflected Resident #1 was non-compliant with any medication or interventions. <BR/>Record review of Progress Note dated 8/09/2024 at 1:44 PM, authored by LVN C, reflected Resident #1 sent out to local emergency room for reddish purple hematoma to left side of back of head. <BR/>In an interview on 8/10/2024 at 12:35 PM, the ADM stated, she had first heard of Resident #1's injury was during morning meeting on Friday 8/09/2024 around 9:00 AM, although the injury was discovered sometime during the afternoon of Thursday 8/08/2024 by the DOR who reported it to LVN A. ADM stated LVN A told her that he did not report the change in condition, which was the development of a bump to the back of Resident #1's head, because it was associated with a previous injury, which was a laceration to her left eyebrow. The ADM stated, in consultation with the DON, she requested the Treatment Nurse immediately assess Resident #1 on Friday 8/09/2024. The ADM stated, upon confirmation of the bump to the back of Resident #1's head, by the Treatment Nurse, that the decision was made to send Resident #1 out via EMS for further evaluation and treatment. <BR/>In an interview on 8/10/2024 at 2:00 PM, the DON stated she first learned of Resident #1's injury during morning meeting on Friday 8/09/2024 at around 9:00 AM. The DON stated that the development of the bump on the back of the head was first noted by the DOR on the afternoon of Thursday 8/08/2024. The DON stated she was told the DOR reported it to the nurse assigned that area [subsequently identified as LVN A]. <BR/>In an interview on 8/10/2024 at 2:40 PM, the DOR stated on Thursday 8/09/2024 she had gone to Hall A, a secured unit within the facility, to work with another resident and noted that Resident #1 was agitated and not her normal self. The DOR stated that in an effort to calm Resident #1 she was speaking to her softly and stroking her hair. The DOR stated that was when she noted a bump on the left back side of Resident #1s head. The DOR stated she was not sure what time it was, only that it was in the afternoon, after shift change at 2:00 PM on Thursday 8/09/2024. The DOR stated she informed the nurse assigned to Hall A of the bump to the back of Resident #1's head. [Who was subsequently identified as LVN A.]<BR/>In an interview on 8/10/2024 at 3:40 PM, LVN A stated that the off going nurse told him at shift change report on Thursday 8/08/2024 [approximately 2:00 PM] that Resident #1 had a laceration to left eyebrow due to an unwitnessed incident. LVN A stated shortly thereafter he assessed Resident #1 and did not note any other injury. LVN A stated that later that afternoon [8/08/2024] a female member of the rehabilitation staff alerted him to the development of the bump to the back of Resident #1's head [subsequently identified as the DOR]. LVN A stated he the re-assessed and confirmed the bump to the back of Resident #1's head and reported it to the DON, and the ADM on Thursday 8/08/2024. LVN A stated he placed a call to the on-call physician services but did not receive a call back before to the end of his shift. LVN A stated he documented the information on the 24-Hour Report/Change of Condition Report. LVN A stated that he notified Resident #1's family member of the change of condition. LVN A stated that the family member was Spanish only speaking but had someone on their end that translated during the call. <BR/>Record review of the 24-Hour Report/Change of Condition Report, dated 8/08/2024, reflected Resident #1's laceration to left eyebrow but did not include documentation of the bump to the back of the head. <BR/>[Attempted interview with family member and physician but did not receive a call back prior to exit on 8/10/2024.]<BR/>In an interview on 8/10/2024 at 4:08 PM, the Treatment Nurse stated she assessed Resident #1 on Thursday 8/08/2024 due to the injury of unknown origin resulting in a laceration to the left eyebrow. The Treatment Nurse stated she did a complete head-to-toe assessment and did not find any additional injuries or areas of redness on Resident #1. The Treatment Nurse stated she believed the bump to the back of Resident #1's head developed over time and after her assessment. The Treatment Nurse stated she was not sure of the exact time of the assessment, but it would have been some time on the 6am-2pm shift, and she believed it was around midday. <BR/>In an interview on 8/10/2024 at 4:29 PM, The Maintenance Director stated he had a text message exchange with the DON dated 8/08/2024 at 6:12 PM, in which he was directed to swap Resident #1's current regular bed, to a PVC, stationary low bed. <BR/>In an interview on 8/10/2024 at 4:51 PM, with on-call physician group RN B, stated that there were no documented notes related to Resident #1 on Thursday 8/08/2024. RN B stated their expectation was those calls be documented at every point of contact for clarity and continuity of care. RN B stated the first documented notes indicating a call was made to the on-call physician group was on Friday 8/09/2024 at 11:51 AM, when the facility staff [subsequently identified as LVN C] informed the on-call physician group that Resident #1 needed to be sent out for further evaluation and treatment related to a hematoma to the back of her head. <BR/>In an interview on 8/10/2024 at 5:02 PM, LVN A reiterated that he was told by someone in the Rehabilitation department, that Resident #1 had a bump to the back of her head on 8/08/2024, but he was not sure of her name or title. LVN A stated he did call the number for the on-call physician group but did not get a call back before the end of his shift. LVN A stated when he informed the DON of the bump to the back of Resident #1's head, she gave him instructions to get a low bed with out wheels for Resident #1 as a safety precaution. <BR/>In an interview on 8/10/2024 at 5:10 PM, the DON stated that she was not informed Thursday 8/08/2024 that Resident #1 had additional injuries beyond the laceration to the eyebrow. The DON stated that it was not until she was reviewing the 24-Hour Report/Change of Condition Report, dated 8/08/2024, in preparation for the morning meeting on Friday 8/09/2024 that she read the information regarding the bump to Resident #1's head. It was at this point on Friday 8/09/2024 approximate 9:00 AM, that she and the ADM requested the Treatment Nurse assess Resident #1. <BR/>In an interview on 8/10/2024 at 5:25 PM, the DON stated her expectation was that staff document assessment findings in the EHR timely and notify the physician or the on-call physician regarding change of conditions. The DON stated that the development of a bump to the back of the head was a significant change of condition and should have been reported immediately to the physician. The DON stated that if the physician did not call back promptly, a follow up call should be placed. The DON stated it was important to report change of condition in order not to delay care and provide treatments in a timely manner. <BR/>Record review of Change in a Resident's Condition or Status policy, revised February 2021, reflected: 1. The nurse will notify the residents attending physician or physician on call when there has been a(an): a. accident or incident . b. discovery of injuries of an unknown source .d. significant change in the resident's physical/emotional/mental condition .2. Significant change of condition is a major decline or improvement .a. will not normally resolve itself with out intervention by staff. <BR/>Record review of In-Service, dated 8/09/2024, included topics of New Hire/Agency Check Off List that included phone number contacts of key personnel; Reporting and Notification; Abuse and Neglect - Clinical Protocol policy revised March 2018. In-Service signed by 31 interdisciplinary staff members ranging from nursing (RNs, LVNs and CNA) staff; habilitation therapy (DOR, physical and occupational assistants) staff, dietary staff, laundry and housekeeping service staff.

**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 receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 3 of 8 (Resident #67, #5 and #45 ) residents in that:<BR/>1. Resident #67 had a pressure ulcer on her heel and was not observed offloading her heels. <BR/>2. Resident #5 had a pressure ulcer on her heel and was not observed offloading her heels. <BR/>3. Resident #45 was not turned every 2 hours by staff. <BR/>This could affect all residents with pressure ulcers and could result in wounds not healing. <BR/>The Finding were: <BR/>1.Record review of Resident # 67's admission Record dated 1/27/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), and disorder of skin. <BR/>Record review of Resident # 67's consolidated physician orders for January 2025 was documented offloading boots to promote wound healing every shift for wound healing and had an unstageable to right heel paint with betadine daily as needed or sound healing if soiled or removed and every shift for wound healing.<BR/>Record review of Resident # 67's Quarterly MDS dated 10/22//2024 was documented her BIMS score was 15 out of 15 (cognitively intact). Resident #67's Quarterly MDS Skin condition was documented resident at risk for developing pressure ulcers/injuries).<BR/>Record review of Resident #67's Annual MDS dated [DATE] was documented she was a risk for developing pressure ulcers, and unstageable pressure ulcer. <BR/>Record review of Resident # 67's care plan dated 1/30/2025 was documented potential for pressure ulcer development related to disease process, interventions wear heel protectors while in bed. <BR/>Record review of Resident #67's wound care assessment dated [DATE] was documented she had a right heel, unstageable pressure injury, clean with betadine daily open to air and offloading boot and elevate.<BR/>Observation on 1/26/2025 at 2:14 PM in Resident #67's room revealed she was laying down on her bed, with no offloading boots on her heels.<BR/>Observation on 1/27/2025 at 1:11 PM in Resident #67's room revealed she was sitting on her w/c with no offloading boots on her heels.<BR/>Observation on 1/28/2025 at 11:30 AM in Resident #67's room revealed she was lying in bed over her, and her feet/heels were not offloaded. <BR/>Interview on 1/28/2205 at 11:32 AM with LVN AB, wound care nurse, in Resident #67's room stated she did not have her offloading booties on the resident to offload her heels while in bed. LVN AB stated it was important to offload Resident #67's heels to prevent infection and wound getting worse. LVN AB stated Resident #67 had an unstageable wound on her right heel, and treatment was betadine and leave open to air.<BR/>2. Record review of Resident #5's admission Record dated 1/29/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), cognitive communications disorder, difficulty walking, need for assistance with personal care, dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, that interferes with daily life and activities), and had lack of coordination. <BR/>Record review of Resident #5's consolidated physician orders for January 2025 was documented to offloading boots every shift for prevention of breakdown.<BR/>Record review of Resident #5's significant change MDS dated [DATE] was documented her BIMS score was 13 out of 15 (cognitively intact), she was at risk for developing pressure ulcers/injuries, and she required use of manual wheelchair.<BR/>Record review of Resident #5's care plan dated 12/12/2024 was documented pressure ulcer or potential for pressure ulcer development related to disease process. Resident #5's goal was to have intact skin, free of redness, blisters or decollation by/through review dated. Resident #5s interventions was to have skin assessments as ordered, and treatments as ordered. Resident #5 had skin integrity non pressure related to excoriation to sacrum.<BR/>Observation on 1/28/2025 at 11:50 AM with Resident #5 was lying in bed, with no heel protectors on. <BR/>Interview on 1/28/2025 at 11:54 AM with CNA H stated she took Resident # 5 back to bed, changed her, but did not put her heel protector booties on. The she left to do another task. <BR/>Interview on 1/28/2025 at 12:04 PM with ADM and DON, they stated they would educate staff on the concerns with residents receiving treatment for pressure ulcers, such as heel protectors. <BR/>3. Record review of Resident #45's admission Record was dated 1/28/2025 she was admitted on [DATE], re-admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body, muscle weakness, need assistance with personal care, and adult failure to thrive. <BR/>Record review of Resident #45's consolidated physician orders for January 2025 documented were resident to be turned every 2 hours.<BR/>Record review of Resident #45's Significant change MDS dated [DATE] documented her BIMS score was 3 out of 15 (severely impaired),.Resident #45 had upper extremity impairment on both sides lower extremity impairment on one side, she was dependent on oral care, showers, dressing, personal hygiene, she was always incontinent, she used a wheelchair to mobilize in the facility, and required a feeding tube to eat. <BR/>Record review of Resident #45's care plan dated 1/24/2025 documented she had pressure ulcer or potential for pressure ulcer development related to disease process, immobility, and stroke. Resident #45's interventions were needing assistance to turn/reposition at least every 2 hours, more often as needed, or requested. <BR/>Observation on 1/26/2025 at 2:24 PM Resident #45 was laying in her bed on her right side.<BR/>Observation on 1/26/2025 at 4:27 PM Resident #45 was laying in her bed on her right side. <BR/>Interview on 1/26/2025 at 4:32 PM LVN J stated Resident #45 had not been moved/turned in bed. <BR/>Observation on 1/28/2025 at 9:34 AM Resident # 45 revealed she was on laying on her back. <BR/>Observation on 1/28/2025 at 11:46 AM Resident # 45 revealed she was on laying on her back. <BR/>Interview on 1/28/2025 at 11:49 AM LVN Z stated Resident # 45 was laying on her back. LVN Z stated residents were supposed to be repositioned every 2 hours. LVN Z stated she was not sure why the CNA's have not repositioned Resident # 45. LVN Z stated she would reposition Resident # 45 now. <BR/>Interview on 1/28/225 at 12:28 PM the MDS/LVN stated residents that were bed bound, should be repositioned at least every 2 hours and as needed. <BR/>Interview on 1/28/2025 at 12:04 PM the ADM and DON, stated they would educate staff on the concerns with repositioning residents while in bed. The DON stated she expected staff turn and reposition bed bound resident every 2 hours. <BR/>Record review of policy, repositioning dated May 2013 documented, The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individual care plan for repositioning, to promote comfort for all bed or chair bound resident and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Preperation-1. Review the residents care plan to evaluate for any special needs of the resident. General Gudiliens-1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. <BR/>Record review of policy, Prevention of Pressure Injuries dated April 2020 was documented The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation -Review the residents care plan and identify the risk factors as well as the intervention designed to reduce or eliminate those considered modifiable. Skin Assessment- 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADL and full skin assessment weekly c. reposition resident as indicated on care plan. Prevention -skin care 6. Do not rub to otherwise cause friction on skin that is at risk for pressure injuries. Mobily/Repositioning -1. Reposition all resident with or at risk of pressure injuries on an individualized schedule. 2 .provided support devise and assistance as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #1) of 3 residents reviewed for enteral feeds, in that: <BR/>The facility failed to ensure Resident #1's doctor's orders of administering water, before initiating feeding, were being followed. <BR/>This failure could place residents at risk of not receiving the proper hydration requirements prescribed by the physician. <BR/>The findings included:<BR/>Record Review of Resident #1's admission record, dated 08/31/24, reflected a [AGE] year-old female initially admitted [DATE] with diagnoses to include dysphagia (difficulty in swallowing) following cerebral infarction (stroke) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). <BR/>Record Review of Resident #1's significant change in status MDS assessment, dated 07/22/24, reflected Resident #1 was inappropriate for a BIMS score evaluation and had short and long-term memory problems. It further reflected Resident #1 had a feeding tube while not a resident and while a resident. <BR/>Record Review of Resident #1's doctor's orders, dated 08/31/24, reflected Enteral feed order every 6 hours Give Glucerna 1.5 bolus 237ml and Enteral Feed Order every shift Flush with 100 mLs H2O before/after meds total 200ml, before initiating feeding or when there is an interruption of feeding to maintain Tube Patency., with start date 07/18/24. <BR/>Record review of Resident #1's care plan, dated 08/31/24, reflected {Resident #1] requires tube feeding r/t dysphagia, swallowing problem, initiated 07/02/24, with intervention Enteral feed order every 6 hours Give Glucerna 1.5 bolus 237ml, initiated 07/03/24, and Enteral Feed Order every shift Flush with 100 mLs H2O before/after meds total 200ml, before initiating feeding or when there is an interruption of feeding to maintain Tube Patency., initiated 07/18/24.<BR/>During an interview and observation on 09/01/24 at 01:15 PM, LPN F was administering a bolus feeding to Resident #1 and did not administer 100ml water flush before giving a bolus feeding as prescribed . She revealed she typically does administer 100mls of water before Resident #1's bolus feeding, but she was nervous. She further revealed it was important to administer water before flushes to make sure the tube was clear. <BR/>During an interview on 09/01/24 at 03:55 PM, the DON revealed she spoke with LPN F and LPN F shared deficiencies she performed while administering a bolus feeding to Resident #1 to include not administering 100ml water flush before administering the enteral formula per doctor's orders. After LPN F told the DON about her mistakes with Resident #1's enteral feeding, the DON revealed she educated LPN F on the policy for enteral nutrition. <BR/>Record Review of the facility's policy, revised November 2018, Enteral Tube Feeding via Syringe (Bolus), reflected The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally . Preparation: 1. Verify that there is a physician's order for this procedure . Steps in the procedure: 9. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .<BR/>Record Review of the facility's policy, revised November 2018, Enteral Nutrition, reflected, 3. The dietitian, with input from the provider and nurse: d. Calculated fluids to be provided . 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian .5. Some examples of potential benefits for using a feeding tube include: a. Addressing malnutrition and dehydration; b. Promoting wound healing; and/or c. Allowing a resident to gain strength that may allow him or her to return to oral nutrition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 3 residents (Resident #1) by 1 of 1 nurse (LPN F) reviewed for competent staff, in that:<BR/>LPN F failed to provide water flushes for enteral nutrition before enteral formula was administered as ordered for Resident #1.<BR/>This failure could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in a decline in health. <BR/>The findings included: <BR/>Record Review of Resident #1's admission record, dated 08/31/24, reflected a [AGE] year-old female initially admitted [DATE] with diagnoses to include dysphagia (difficulty in swallowing) following cerebral infarction (stroke) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). <BR/>Record Review of Resident #1's significant change in status MDS assessment, dated 07/22/24, reflected Resident #1 was inappropriate for a BIMS score evaluation and had short and long-term memory problems. It further reflected Resident #1 had a feeding tube while not a resident and while a resident. <BR/>Record Review of Resident #1's doctor's orders, dated 08/31/24, reflected Enteral feed order every 6 hours Give Glucerna 1.5 bolus 237ml and Enteral Feed Order every shift Flush with 100 mLs H2O before/after meds total 200ml, before initiating feeding or when there is an interruption of feeding to maintain Tube Patency., with start date 07/18/24. <BR/>Record review of Resident #1's care plan, dated 08/31/24, reflected {Resident #1] requires tube feeding r/t dysphagia, swallowing problem, initiated 07/02/24, with intervention Enteral feed order every 6 hours Give Glucerna 1.5 bolus 237ml, initiated 07/03/24, and Enteral Feed Order every shift Flush with 100 mLs H2O before/after meds total 200ml, before initiating feeding or when there is an interruption of feeding to maintain Tube Patency., initiated 07/18/24.<BR/>During an interview and observation on 09/01/24 at 01:15 PM, LPN F was administering a bolus feeding to Resident #1 and did not administer 100ml water flush before giving a bolus feeding as prescribed . She revealed she typically does administer 100mls of water before Resident #1's bolus feeding, but she was nervous. She further revealed it was important to administer water before flushes to make sure the tube is clear. <BR/>During an interview on 09/01/24 at 03:55 PM, the DON revealed she spoke with LPN F and LPN F shared deficiencies she performed while administering a bolus feeding to Resident #1 to include not administering 100ml water flush before administering the enteral formula per doctor's orders . After LPN F told the DON about her mistakes with Resident #1's enteral feeding, the DON revealed she educated LPN F on the policy for enteral nutrition. The DON further revealed she could not find signed and completed Enteral nutrition competency paperwork for LPN F, however, the facility followed the guidelines specified in the facility's policy for enteral nutrition. The DON revealed she had been working as the DON for about a month, oversaw required training being done, and had plans to train the entire staff on required competencies in September 2024. She further revealed the nursing staff received their trainings upon hire, annually, and as needed. <BR/>Record Review of the facility's policy, revised November 2018, Enteral Tube Feeding via Syringe (Bolus), reflected The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally . Preparation: 1. Verify that there is a physician's order for this procedure . Steps in the procedure: 9. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .<BR/>Record Review of the facility's policy, revised November 2018, Enteral Nutrition, reflected, 3. The dietitian, with input from the provider and nurse: d. Calculated fluids to be provided . 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian .5. Some examples of potential benefits for using a feeding tube include: a. Addressing malnutrition and dehydration; b. Promoting wound healing; and/or c. Allowing a resident to gain strength that may allow him or her to return to oral nutrition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 4 residents reviewed for resident rights. <BR/>The facility failed to notify Resident #1's physician of her change of condition on 8/08/2024 when an injury of unknown origin developed into a hematoma [collection of blood outside of a blood vessel where it does not belong, may result in swelling, discoloration and warmth] at the back of her head. Resident #1 was subsequently sent out to the hospital on 8/09/2024 . <BR/>This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. <BR/>The findings included: <BR/>Record review of the admission Record, printed 8/10/2023, reflected Resident #1 was a [AGE] year-old female originally admitted on [DATE]. <BR/>Record review of the quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS summary score of four, indicative of severe cognitive impairment. Under section GG - Functional Abilities and Goals, Resident #1 was coded as having used a walker and a wheelchair for mobility; partial/moderate assistance for ambulation of 10 feet, 50 feet with two turns, ambulation of 150 feet, and transfers of all types. Resident #1's primary medical condition category that best described reason for admission was coded as medically complex conditions related to type 2 diabetes mellitus [chronic condition where the body either doesn't make enough insulin or doesn't respond to it effectively; leading to high blood sugar levels which can cause symptoms like tiredness, hunger, thirst and increased urination]. Other active diagnoses included non-Alzheimer's dementia [group of symptoms affecting memory, thinking and social abilities, marked by a severe decline in cognitive functions to the extent that it interferes with the person's daily life], fracture, [broken bone] history of falling, generalized muscle weakness, difficulty in walking, other lack of coordination. <BR/>Record review of the Care Plan reflected Resident #1 had a focus area of: at risk for falls related to gait/balance problems, osteopenia, and chondrocalcinosis[also known as pseudogout, buildup of inflammatory particulates in the joint], history of falls, initiated on 9/14/2024 with an actual fall on 7/09/2024; with the following associated interventions: encourage Resident #1 to ask for assistance initiated 7/06/2024; pad on bedside table and bedframe with pool noodle, initiated 6/28/2024; resident to use PVC [a strong, synthetic plastic] low bed initiated on 4/08/2024. Other focus area included: visually impaired, initiated on 9/25/2023 with the revision on 2/22/2024. Additional focus area included: Complex Behavioral Care Plan - sits self on floor and scooting on floor, initiated 12/01/2023, with a revision on 8/09/2024. Focus area: at risk for complications related to anticoagulant or antiplatelet medication, initiated on 8/06/2024; with the following associated interventions: observed for signs and symptoms of bleeding i.e., bruising with a date initiated of 8/06/2024. Focus areas of complications related to recent [September 2023] brain bleed, history of fall prior to admission initiated on 9/14/2023; with the following associated interventions: monitor for signs and symptoms of brain bleed e.g., irritability, restlessness, initiated 9/28/2023. Focus area: complications related to .fractures 9/28/2023, initiated on 9/21/2024, with a revision on 6/15/2024. Focus area: risk for spontaneous fractures as resident has osteopenia/chondrocalcinosis initiated on 10/09/2023, with a revision on 10/10/2023. <BR/>Record review of Order Summary Report, printed 8/10/2024, reflected Resident #1 had physician's orders for aspirin 81 mg by mouth in the morning, with a start date of 8/06/2024. <BR/>Record review of Progress Note dated 8/08/2024 at 8:27 AM, authored by LVN C reflected Resident #1 had a laceration to left eyebrow and its course of treatment.<BR/>Record review of Progress Note dated 8/08/2024 at 1:49 PM, authored by Treatment Nurse, reflected Resident #1 had laceration above left eye and its course of treatment. <BR/>Record review of Progress Note dated 8/08/2023 at 3:51 PM, authored by DOR, reflected assessment of furniture in Resident #1's room. <BR/>Record review of Progress Note dated 8/08/2024 at 7:29 PM, authored by LVN A reflected Resident #1 was non-compliant with any medication or interventions. <BR/>Record review of Progress Note dated 8/09/2024 at 1:44 PM, authored by LVN C, reflected Resident #1 sent out to local emergency room for reddish purple hematoma to left side of back of head. <BR/>In an interview on 8/10/2024 at 12:35 PM, the ADM stated, she had first heard of Resident #1's injury was during morning meeting on Friday 8/09/2024 around 9:00 AM, although the injury was discovered sometime during the afternoon of Thursday 8/08/2024 by the DOR who reported it to LVN A. ADM stated LVN A told her that he did not report the change in condition, which was the development of a bump to the back of Resident #1's head, because it was associated with a previous injury, which was a laceration to her left eyebrow. The ADM stated, in consultation with the DON, she requested the Treatment Nurse immediately assess Resident #1 on Friday 8/09/2024. The ADM stated, upon confirmation of the bump to the back of Resident #1's head, by the Treatment Nurse, that the decision was made to send Resident #1 out via EMS for further evaluation and treatment. <BR/>In an interview on 8/10/2024 at 2:00 PM, the DON stated she first learned of Resident #1's injury during morning meeting on Friday 8/09/2024 at around 9:00 AM. The DON stated that the development of the bump on the back of the head was first noted by the DOR on the afternoon of Thursday 8/08/2024. The DON stated she was told the DOR reported it to the nurse assigned that area [subsequently identified as LVN A]. <BR/>In an interview on 8/10/2024 at 2:40 PM, the DOR stated on Thursday 8/09/2024 she had gone to Hall A, a secured unit within the facility, to work with another resident and noted that Resident #1 was agitated and not her normal self. The DOR stated that in an effort to calm Resident #1 she was speaking to her softly and stroking her hair. The DOR stated that was when she noted a bump on the left back side of Resident #1s head. The DOR stated she was not sure what time it was, only that it was in the afternoon, after shift change at 2:00 PM on Thursday 8/09/2024. The DOR stated she informed the nurse assigned to Hall A of the bump to the back of Resident #1's head. [Who was subsequently identified as LVN A.]<BR/>In an interview on 8/10/2024 at 3:40 PM, LVN A stated that the off going nurse told him at shift change report on Thursday 8/08/2024 [approximately 2:00 PM] that Resident #1 had a laceration to left eyebrow due to an unwitnessed incident. LVN A stated shortly thereafter he assessed Resident #1 and did not note any other injury. LVN A stated that later that afternoon [8/08/2024] a female member of the rehabilitation staff alerted him to the development of the bump to the back of Resident #1's head [subsequently identified as the DOR]. LVN A stated he the re-assessed and confirmed the bump to the back of Resident #1's head and reported it to the DON, and the ADM on Thursday 8/08/2024. LVN A stated he placed a call to the on-call physician services but did not receive a call back before to the end of his shift. LVN A stated he documented the information on the 24-Hour Report/Change of Condition Report. LVN A stated that he notified Resident #1's family member of the change of condition. LVN A stated that the family member was Spanish only speaking but had someone on their end that translated during the call. <BR/>Record review of the 24-Hour Report/Change of Condition Report, dated 8/08/2024, reflected Resident #1's laceration to left eyebrow but did not include documentation of the bump to the back of the head. <BR/>[Attempted interview with family member and physician but did not receive a call back prior to exit on 8/10/2024.]<BR/>In an interview on 8/10/2024 at 4:08 PM, the Treatment Nurse stated she assessed Resident #1 on Thursday 8/08/2024 due to the injury of unknown origin resulting in a laceration to the left eyebrow. The Treatment Nurse stated she did a complete head-to-toe assessment and did not find any additional injuries or areas of redness on Resident #1. The Treatment Nurse stated she believed the bump to the back of Resident #1's head developed over time and after her assessment. The Treatment Nurse stated she was not sure of the exact time of the assessment, but it would have been some time on the 6am-2pm shift, and she believed it was around midday. <BR/>In an interview on 8/10/2024 at 4:29 PM, The Maintenance Director stated he had a text message exchange with the DON dated 8/08/2024 at 6:12 PM, in which he was directed to swap Resident #1's current regular bed, to a PVC, stationary low bed. <BR/>In an interview on 8/10/2024 at 4:51 PM, with on-call physician group RN B, stated that there were no documented notes related to Resident #1 on Thursday 8/08/2024. RN B stated their expectation was those calls be documented at every point of contact for clarity and continuity of care. RN B stated the first documented notes indicating a call was made to the on-call physician group was on Friday 8/09/2024 at 11:51 AM, when the facility staff [subsequently identified as LVN C] informed the on-call physician group that Resident #1 needed to be sent out for further evaluation and treatment related to a hematoma to the back of her head. <BR/>In an interview on 8/10/2024 at 5:02 PM, LVN A reiterated that he was told by someone in the Rehabilitation department, that Resident #1 had a bump to the back of her head on 8/08/2024, but he was not sure of her name or title. LVN A stated he did call the number for the on-call physician group but did not get a call back before the end of his shift. LVN A stated when he informed the DON of the bump to the back of Resident #1's head, she gave him instructions to get a low bed with out wheels for Resident #1 as a safety precaution. <BR/>In an interview on 8/10/2024 at 5:10 PM, the DON stated that she was not informed Thursday 8/08/2024 that Resident #1 had additional injuries beyond the laceration to the eyebrow. The DON stated that it was not until she was reviewing the 24-Hour Report/Change of Condition Report, dated 8/08/2024, in preparation for the morning meeting on Friday 8/09/2024 that she read the information regarding the bump to Resident #1's head. It was at this point on Friday 8/09/2024 approximate 9:00 AM, that she and the ADM requested the Treatment Nurse assess Resident #1. <BR/>In an interview on 8/10/2024 at 5:25 PM, the DON stated her expectation was that staff document assessment findings in the EHR timely and notify the physician or the on-call physician regarding change of conditions. The DON stated that the development of a bump to the back of the head was a significant change of condition and should have been reported immediately to the physician. The DON stated that if the physician did not call back promptly, a follow up call should be placed. The DON stated it was important to report change of condition in order not to delay care and provide treatments in a timely manner. <BR/>Record review of Change in a Resident's Condition or Status policy, revised February 2021, reflected: 1. The nurse will notify the residents attending physician or physician on call when there has been a(an): a. accident or incident . b. discovery of injuries of an unknown source .d. significant change in the resident's physical/emotional/mental condition .2. Significant change of condition is a major decline or improvement .a. will not normally resolve itself with out intervention by staff. <BR/>Record review of In-Service, dated 8/09/2024, included topics of New Hire/Agency Check Off List that included phone number contacts of key personnel; Reporting and Notification; Abuse and Neglect - Clinical Protocol policy revised March 2018. In-Service signed by 31 interdisciplinary staff members ranging from nursing (RNs, LVNs and CNA) staff; habilitation therapy (DOR, physical and occupational assistants) staff, dietary staff, laundry and housekeeping service staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 8 of 16 residents (Residents #5, 20, #27, #38, #68, #69, #81, and #85) reviewed for pharmacy services.<BR/>1. On [DATE] Medication Aide E administered late medications to Resident #20 at 10:49 AM:<BR/>a. Acetaminophen 325mg, (Tylenol) late by 1 hour and 49 minutes.<BR/>b. Levetiracetam 500mg (a medication to treat seizures) late by 1 hour and 49 minutes. <BR/>2. On [DATE] Medication Aide E administered late medications to Resident #27 at 9:20 AM:<BR/>a. Carvedilol 12.5mg (used to treat high blood pressure) late by 20 minutes.<BR/>b. Divalproex 125mg (used to treat schizophrenia) late by 20 minutes.<BR/>3. On [DATE] Medication Aide E administered late medications to Resident #38 at 10:51 AM:<BR/>a. Famotidine 20mg (used to reduce stomach acid) late by 1 hour and 51 minutes.<BR/>b. Docusate (a stool softener) 100mg late by 1 hour and 51 minutes.<BR/>c. Lamotrigine 100mg (used to prevent seizures) late by 1 hour and 51 minutes.<BR/>d. Sodium chloride 1gr (salt used to treat muscle weakness) late by 51 minutes. <BR/>4. On [DATE] Medication Aide E administered late medications to Resident #68 at 10:23 AM:<BR/>a. Metformin 1000mg (used to treat diabetes) late by 1 hour and 23 minutes.<BR/>5. On [DATE] Medication Aide E administered late medications to Resident #69 at 9:45 AM:<BR/>a. Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) late by 45 minutes.<BR/>6. An inspection on [DATE] of the facility's treatment nurse medication cart revealed expired insulins for Residents #5, #81, and #85 as evidenced by the following:<BR/>a. Resident #5's liraglutide (an anti-diabetic medication used to treat type 2 diabetes, and chronic obesity) subcutaneous (under the skin) solution pen-injector was stored unrefrigerated, and available for administration, in the cart and was expired by 19 days. <BR/>b. Resident #81's 3 injection vials of insulin lispro 100u/ml, were available for administration, stored unrefrigerated, unlabeled with an expiration date, and were expired by as much as 59 days.<BR/>c. Resident #85's 1 injection vial of insulin lispro 100u/ml, was available for administration, stored unrefrigerated, labeled with an expiration date of 12/20, and was expired by 45 days.<BR/>These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. <BR/>The findings included:<BR/>During an observation and interview on [DATE] at 9:49 AM revealed MA E preparing and administering medications for residents within the facility. Further review revealed MA E's computer electronic medical record display demonstrated MA E's assigned residents were highlighted in red. MA E stated she was late administering medications, specifically for Residents #20, 27, #38, #68, and #69. MA E stated her direct supervisor was the DON and she had not reported the late medication administration. Continued observation revealed she continued to administer medications to residents.<BR/>1. A record review of Resident #20's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included vascular dementia (parts of the brain are damaged due to a stroke) and convulsions (an electrical storm in the brain AKA seizures.) <BR/>A record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 was a [AGE] year-old male admitted for long term care and assessed a BIMS score of 5 out of a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #20's care plan dated [DATE] revealed, (Resident #20) has a seizure disorder r/t (related to) Stroke Date Initiated: [DATE] . Give medications as ordered. Observe/document for effectiveness and side effects. <BR/>A record review of Resident #20's physicians' orders revealed the physician prescribed for Resident #20 to receive levetiracetam 500mg twice a day at 8:00 AM and at 4:00 PM and acetaminophen 325mg three times a day at 8:00 AM, noon, and at 4:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], administered Resident #20 his acetaminophen 325mg and his levetiracetam 500mg at 10:49 AM late by 1 hour and 49 minutes.<BR/>2. A record review of Resident #27's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included hypertension (high blood pressure) and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others.)<BR/>A record review of Resident #27's Quarterly MDS assessment dated [DATE] revealed Resident #27 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. <BR/>A record review of Resident #27's care plan dated [DATE] revealed, (Resident #27) has Hx (history) of hallucinations. (Resident #27) states that this voice tells him bad things, including not to smoke, tells him he is overweight. Mr. Rico calls this voice/voices the devil . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #27's physicians orders dated [DATE] revealed the physician prescribed for Resident #27 to receive carvedilol 12.5mg and divalproex 125mg twice a day at 8:00 AM and again at 4:00 PM.<BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], administered Resident #27 his carvedilol 12.5mg and divalproex 125mg at 9:20 AM late by 20 minutes.<BR/>3. A record review of Resident #38's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures. Seizures are uncontrolled bursts of electrical activities that change sensations, behaviors, awareness, and muscle movements), Gastroesophageal reflux disease (AKA GERD, occurs when stomach acid frequently flows back into the esophagus, leading to irritation and discomfort), constipation, and muscle weakness. <BR/>A record review of Resident #38's Quarterly MDS assessment dated [DATE] revealed Resident #38 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. <BR/>A record review of Resident #38's care plan dated [DATE] revealed, (Resident #38) has behavioral concern of insisting medications be given at a certain time and becoming angry when medications are not being given exactly when requested. (Resident #38) has been made aware of and<BR/>educated on medication administration window . <BR/>A record review of Resident #38's physicians' orders dated [DATE] revealed the physician prescribed for Resident #38 to receive famotidine 20mg and docusate 100mg twice a day at 8:00 AM and again at 4:00 PM. Lamotrigine 100mg at 8:00 AM and again at 6:00 PM. Sodium chloride 1gr twice a day at 9:00 AM and again at 5:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 10:51 AM, administered Resident #38 his famotidine 20mg, docusate 100mg, lamotrigine 100mg late by 1 hour and 51 minutes and sodium chloride 1gr late by 51 minutes.<BR/>4. A record review of Resident #68's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included diabetes type 2. <BR/>A record review of Resident #68's quarterly MDS assessment dated [DATE] revealed Resident #68 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #68's care plan dated [DATE] revealed, (Resident #68) has impaired cognitive function/dementia or impaired thought processes r/t Dementia, Disease Process diabetes, . Administer meds as ordered. Date Initiated: [DATE] <BR/>A record review of Resident #68's physicians' orders dated [DATE] revealed the physician prescribed for Resident #68 to receive metformin 1000mg twice a day at 8:00 Am and again at 4:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 10:23 AM, administered Resident #68 his Metformin 1000mg late by 1 hour and 23 minutes.<BR/>5. A record review of Resident #69's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included a urinary tract infection. <BR/>A record review of Resident #69's quarterly MDS assessment dated [DATE] revealed Resident #69 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 3 out a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #69's care plan date [DATE] revealed, Urinary Tract Infection, potential or actual r/t Diagnosis of BPH, Diagnosis of Urinary retention, Use of indwelling catheter dx (diagnosis) ESBL UTI (extended spectrum beta-lactamase urinary tract infection. ESBL-producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections), Date Initiated: [DATE] . Antibiotic per MD (medical doctor) order x 5days. Date Initiated: [DATE] <BR/>A record review of Resident #69's physicians orders dated [DATE] revealed the physician prescribed for Resident #69 to receive Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) twice a day at 8:00 AM and again at 8:00 PM.<BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 9:45 AM, administered Resident #69 his Bactrim 800mg / 160mg late by 45 minutes.<BR/>During a joint interview on [DATE] at 4:04 PM with the operations manager and the DON, the DON stated the expectation was for the medications to be administered with in 1 hour of the prescribed time. The DON stated his expectation was for MA E to have reported the potential late medication administration and MA E had not reported the late medication administration. <BR/>6. A record review of Resident #5's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included type II diabetes (a long-term condition which results in too much sugar circulating in the blood. High blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.)<BR/>A record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care and assessed with a memory problem, Moderately impaired - decisions poor; cues / supervision required <BR/>A record review of Resident #5's care plan dated [DATE] revealed, Alteration in Blood Glucose due to hyper/hypoglycemia dx. DMII, . Date Initiated: [DATE] . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #5's physicians' orders dated [DATE] revealed the physician prescribed for Resident#5 to receive liraglutide 18mg/3ml, 1.2mg injected under the skin daily at 8:00 AM. <BR/>During an observation and interview on [DATE] at 10:30 AM revealed LVN Z attending the nurse treatment cart on the facility's D-hall and was preparing to administer insulins prior to the noon meal. LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed an insulin injection pen for Resident #5. The pen was labeled, liraglutide injection (Resident #5) 18mg/3ml, . date opened [DATE] .exp. [DATE] . discard pen 30 days after first use LVN Z stated she would not use the insulin pen because it was expired and would immediately discard the injection pen. <BR/>A record review of Resident #81's admission record dated [DATE] revealed an admission date of [DATE] with diagnosis which included type II diabetes.<BR/>A record review Resident #81's quarterly MDS assessment dated [DATE] revealed Resident #81 was a [AGE] year-old female assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #81's care plan dated [DATE] revealed, Potential for complication hypo hyperglycemia r/t DMII. Date Initiated: [DATE] . Medications/blood sugar check as ordered and as needed. Date Initiated: [DATE] <BR/>A record review of Resident #81's physicians' orders dated [DATE] revealed the physician prescribed for Resident #81 to receive insulin lispro 4 times a day at 6:30 AM, 11:30 AM, 4:30 PM, and at 8:00 PM, insulin lispro 100u/ml inject per sliding scale: if 0-150 = 0; 151 - 250 = 2; . 301-400 = 14 . subcutaneously before meals and at bedtime for diabetes <BR/>A record review of Resident #85's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes. <BR/>A record review of Resident #85's quarterly MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted for long term care and assessed with a memory care problem, Severely impaired - never / rarely made decisions <BR/>A record review of Resident #85's physicians' orders dated [DATE] revealed the physician prescribed for Resident #85 to receive insulin lispro three times a day at 6:30 AM, 11:30 AM, and at 4:30 PM, (insulin lispro) subcutaneously solution pen injector 100u/ml inject 10 unit subcutaneously before meals for diabetes <BR/>During an observation and interview on [DATE] at 10:30 AM LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed a plastic bag which contained 4 insulin injection pen refill vials. The bag was labeled, (Resident #81) (the facility) (insulin lispro) 100u/ml cartridge qty: 15, [DATE] . refrigerate Observation of the 4 vials revealed:<BR/>1. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #81's name, dated with an open date of [DATE], observed 2/3's full.<BR/>2. 3ml glass vial insulin lispro 100u/3ml labeled (Resident #81) [DATE] observed full.<BR/>3. 3ml glass vial insulin lispro 100u/3ml unlabeled with a resident's name, dated with an open date 12/20 (no year), observed full.<BR/>4. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #85's name, undated, no open date noted, observed &frac12; full. <BR/>LVN Z stated the vials were stored unrefrigerated, in a bag labeled Resident #81, however, LVN Z could not state who the insulin vials were intended for and could not state the date the vials were unrefrigerated. LVN Z stated she would discard the vials because they were unsafe to use.<BR/>During an interview on [DATE] at 1:10 PM the DON stated the expectations and trainings for nurses who administer insulin was for the insulin to be labeled with an opened date and a dispose of date, to include a use span of 28 days. The DON stated all insulins older than 28 days and or unlabeled insulins should be discarded. The DON stated the risk for harm would be residents may not receive the therapeutic effects of their prescribed medications. <BR/>A policy regarding medication administration was requested on [DATE] at 10:00 AM and as of [DATE] was not provided; however, a policy titled Documentation of Medication Administration was provided. A record review of the policy revealed no policy for timely medication administration. <BR/>A record review of the Institute for Safe Medication Practices website titled ISMP Acute Care Guidelines for Timely Administration of Scheduled Medication ismp-hosp-temp-MASTER.qxd accessed [DATE] revealed, Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time. <BR/>A record review of the lirglutide manufactures website titled, Victoza (liraglutide) injection, Important Information accessed [DATE], https://www.victoza.com/faq.html, revealed, Instructions for Use? You can use your Victoza pen for up to 30 days after you use it the first time. First Time Use for Each New Pen. How should I store Victoza?<BR/>Before use:<BR/>o Store your new, unused Victoza pen in the refrigerator between 36&ordm;F to 46&ordm;F (2&ordm;C to 8&ordm;C).<BR/>o If Victoza is stored outside of refrigeration (by mistake) prior to first use, it should be used or thrown away within 30 days.<BR/>Pen in use:<BR/>o Use a Victoza pen for only 30 days. Throw away a used Victoza pen 30 days after you start using it, even if some medicine is left in the pen.<BR/>o Store your Victoza pen at room temperature between 59&ordm;F to 86&ordm;F (15&ordm;C to 30&ordm;C), or in a refrigerator between 36&ordm;F to 46&ordm;F (2&deg;C to 8&deg;C).<BR/>A record review of the insulin lispro manufactures website titled bing.com/ck/a?!&&p=88304c2b6b2aae023b9ebee38f5cae217a125895e1f0391c2809d0dd502d8becJmltdHM9MTc0MDA5NjAwMA&ptn=3&ver=2&hsh=4&fclid=1aed91e9-b39d-6b39-1288-8473b27c6a4d&psq=lispro+kwikpen+instructions&u=a1aHR0cHM6Ly9waS5saWxseS5jb20vdXMvaHVtYWxvZy1rd2lrcGVuLXVtLnBkZg&ntb=1, accessed [DATE], revealed, INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) <BR/>(insulin lispro) injection, for subcutaneous use revealed, Do not use past the expiration date printed on the Label or for more than 28 days after you first start using. Store unused insulin in the refrigerator at 36&deg;F to 46&deg;F (2&deg;C to 8&deg;C).<BR/>o Do not freeze your insulin. Do not use if it has been frozen.<BR/>o Unused insulin may be used until the expiration date printed on the Label, if it has been kept in the refrigerator.<BR/>In-use:<BR/>o Store the insulin you are currently using at room temperature [up to 86&deg;F (30&deg;C)]. Keep away from heat and light.<BR/>o Throw away the HUMALOG insulin you are using after 28 days, even if it still has insulin left in it.<BR/>A record review of the facility's policy titled, Medication Labeling and Storage dated February 2023, revealed, The facility stores all medications and biologicals and locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to the keys. Policy interpretation and implementation: medication storage; . compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trains or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. H residence medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. medication labeling; labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration, and appropriate instructions and precautions. multi dose vials that have been opened or accessed (for example needle punctured) are gated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Multi dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #61) reviewed for quality of care in that: <BR/>Resident #61 did not receive a neurologist appointment as ordered after a standalone seizure event occurring on or about 5/13/2023. <BR/>This failure could affect residents who receive care from the facility and place them at risk for worsening conditions.<BR/>The findings were:<BR/>Record review of Resident #61's face sheet, dated 12/14/23, reflected a [AGE] year-old male resident who was initially admitted to the facility on [DATE], with diagnoses of Cerebral Infarction [damage to tissues in the brain due to a loss of oxygen to the area], gastro-esophageal reflux disease without esophagitis [stomach acid repeatedly flowing back into the tube connecting your mouth and stomach without inflaming the esophagus], and hyperlipidemia [high concentration of fats in the blood]. Resident #61's primary care physician was reflected as being also the facility's medical director. <BR/>Record review of Resident #61's Quarterly MDS, dated [DATE], reflected Resident #61 had a BIMS of 12, signifying moderate cognitive impairment.<BR/>Record review of Resident #61's care plan, undated , obtained 12/15/23, reflected the following problem area: Potential for complications r/t Seizure Disorder. This problem area had the following intervention: Refer to neurologist. Dx: Seizure. <BR/>Record review of Resident #61's orders, obtained 12/15/23, reflected Resident #61 had the following order with a start date of 5/13/23: Refer to neurologist. Dx: Seizure every shift D/C once appointment has been made.<BR/>Record review of Resident #61's progress notes between 5/13/2023 and 12/15/2023 reflected no indication of any other seizure events, apart from the seizure event detailed on 5/13/23. Record review of the progress note detailing the seizure event on 5/13/2023 reflected that Resident #61's father alerted a staff member of the resident having a seizure, and Resident #61 was assessed by nursing staff and sent to a local hospital. <BR/>An Interview with Resident #61 was attempted on 12/12/2023 at 1:45 PM, the resident was unable to be interviewed due to diagnosis of Aphasia [a language disorder that affects a persons ability to communicate]. <BR/>During an interview on 12/15/2023 at 10:05 AM, the Administrator stated that the facility had been unable to secure an appointment with a neurologist due to problems they were having with the resident's insurance. The Administrator stated that the Medical Director and residents doctor were aware and the Medical Director was attempting to use her resources in the community to get Resident #61 an appointment with a neurologist. The Administrator stated that there was not documentation in the resident's medical records of attempts to make neurologist appointments. The Administrator stated the resident had not had any other seizure activity since 5/13/2023.<BR/>During an interview on 12/15/2023 at 11:00 AM, the DON stated that she was made aware of the failure on 12/15/2023 by the Administrator, and that previously the task of scheduling appointments and following up was the responsibility of Unit Managers. The DON stated that the position of Unit Managers does not exist anymore, and that the staff who were in those positions were no longer at the facility. The DON stated the resident had not had any seizure activity since 5/13/2023. The DON stated the risks to residents could include worsening conditions, complications, as well as potentially missing medication changes.<BR/>Phone interview attempt on 12/15/2023 at 10:27 AM with the Medical Director was unsucessful. A phone call was made to the Medical Director, and a voicemail was left after the call was not answered. <BR/>Record review of a facility policy, undated, titled, Referrals, Social Services revealed Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by a physician.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: <BR/>1. In a refrigerator, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date.<BR/>2. The facility's documents Three Compartment Sink Log and Milk Refrigerator Temperature Log for January 2025 reflected no entries were documented January 22-January 24. <BR/>3. Dietary Aide AG had a facial piercing and parts of her hair exposed while working in the kitchen. <BR/>These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. <BR/>The findings were:<BR/>1. <BR/>During observation on 01/26/25 at 10:52 AM, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. <BR/>During an interview on 01/26/25 at 01:03 PM, the CDM revealed the salad bags and the bag of ham in the refrigerator did not have a discard date, so he threw these foods away to ensure foods from the kitchen were safe to eat. He further revealed he was not aware of who did this and he oversaw this process. <BR/>2. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Milk Refrigerator Temperature Log for January 2025 reflected no temperatures were documented January 22-January 24 in the AM and PM. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Three Compartment Sink Log for January 2025 reflected no wash temperatures or PPM were documented January 22-January 24 in the AM and PM. <BR/>During an interview with [NAME] AF, during initial kitchen tour on 01/26/25 at 10:52 AM, she revealed there were missing days on the Milk Refrigerator Temperature Log and the Three Compartment Sink Log.<BR/>During an interview on 01/26/25 at 01:03 PM, the CDM confirmed Milk Refrigerator Temperature Log, dated January 2025, and Three Compartment Sink Log, dated January 2025, had no entries documented January 22- January 24 in the AM and PM. The CDM revealed it was important to follow the dishwashing guidelines to kill germs. He revealed he trusted his AM staff members checked temperatures, but he was unaware about his PM staff. He further revealed the log had blank spaces and he expected these logs to be filled completely. He revealed these deficiencies could cause food borne illnesses.<BR/>3. <BR/>During an interview and observation on 01/26/25 at 01:03 PM, it was observed that Dietary Aide AG, while preparing for lunch on 01/26/25, had a facial piercing (located on her bottom lip) and her hair net did not cover the bottom half of her hair. The CDM revealed he had to work on training about dress code with the kitchen staff as there were issues with them following the dress code, but he was going to start the training soon.<BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed it was important to label and date food products to make sure they were serving food safely. The RD further revealed that completing logs in the kitchen, like temperatures and dishwashing logs, prevented food borne illness.<BR/>Record review of facility's policy Food Preparation and Service, revised November 2022, reflected Food Preparation, Cooking, and Holding Time/Temperatures . 1. The danger zone for food temperatures is above 41 *F and below 135 *F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Food Distribution and Service . 1. Proper hot and cold temperatures are maintained during food distribution and service . 8. Food and nutrition services staff wear hair restraints (hair net) so that hair does not contact food. 9 . Jewelry is worn minimally, and hand jewelry is covered with gloves . 15. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.<BR/>Record review of facility's policy Refrigerators and Freezers, revised November 2022, reflected 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures . 4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . 7. All food is appropriately dated to ensure proper rotation by expiration dates . Use by dates are completed with expiration dates on all prepared food in refrigerators . 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-303 Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry .<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-302.12 Food Storage Containers, Identified with Common Name of Food . working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT . shall be identified with the common name of the FOOD.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-307 Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-5 Limitation of Growth of Organisms of Public Health Concern 3-501 Temperature and Time Control 3-501.12 Time/Temperature Control for Safety Food, Slacking . (A) Under refrigeration that maintains the FOOD temperature at 5*C (41*F) or less . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 1 of 5 residents (Resident #4) reviewed for accommodations of needs in that:<BR/>Resident #4's call light was clipped out of reach onto his privacy curtain.<BR/>This deficient practice could place residents at risk of not receiving care or attention needed.<BR/>The findings were:<BR/>Record review of Resident #4's face sheet, dated 10/27/23, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, bullous disorder [a rare skin condition that causes large, fluid-filled blisters], unspecified, muscle weakness (generalized), contracture [a fixed tightening of muscle or tendons], right hand, and stiffness of right hip, not elsewhere classified.<BR/>Record review of Resident #4's Quarterly MDS, dated [DATE], revealed Resident #4 had a BIMS of 9, signifying moderate cognitive impairment. Further record review of this MDS, item G0300. Functional Limitation in Range of Motion, revealed Resident #4 had impairment to both upper extremities and both lower extremities. <BR/>Record review of Resident #4's care plan, dated 10/27/23, revealed the following problem area last revised on 8/24/23: [Resident #4] is at risk for falls r/t [related to] gait/balance problems, vision/hearing problems . 8/23/23 fall. Further record review of this document revealed the following interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation and interview on 10/27/23 at 11:13 a.m. revealed Resident #4 was seen lying in bed. Resident #4 was awake, alert, and his upper limbs were contracted. Resident #4's call light was clipped to his privacy curtain at the head of bed and was out of reach. Resident #4 stated he was able to use his call light and he did not know where his call light was.<BR/>During an interview on 10/27/23 at 11:18 a.m., LVN A stated a resident's call light should be next to the resident. LVN A confirmed Resident #4's call light was clipped onto privacy curtain and state the call light should not be on the privacy curtain. LVN A stated she was not sure how Resident #4's call light became clipped to the privacy curtain.<BR/>During an interview on 10/27/23 at 11:55 a.m., the interim DON stated a resident's call light should be on a resident's bed if a resident is in bed. The interim DON stated it was important to ensure a resident's call light was within reach to avoid falls, for safety, for emergencies, and any needs a resident may have. The interim DON confirmed the resident's call light should not be clipped to the curtain. When asked if the facility had a quality assurance process to ensure a resident's call light was in place, the interim DON stated the facility had hallway ambassadors, which were certain administrative staff who were assigned to round on different units to ensure a resident had anything needed, a resident had no clutter in the room, and to observe for any maintenance issues. <BR/>Record review of a facility policy titled, Answering the Call Light, dated July 2023, revealed the following: ensure that the call light is accessible to the resident when in bed.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: <BR/>1. In a refrigerator, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date.<BR/>2. The facility's documents Three Compartment Sink Log and Milk Refrigerator Temperature Log for January 2025 reflected no entries were documented January 22-January 24. <BR/>3. Dietary Aide AG had a facial piercing and parts of her hair exposed while working in the kitchen. <BR/>These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. <BR/>The findings were:<BR/>1. <BR/>During observation on 01/26/25 at 10:52 AM, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. <BR/>During an interview on 01/26/25 at 01:03 PM, the CDM revealed the salad bags and the bag of ham in the refrigerator did not have a discard date, so he threw these foods away to ensure foods from the kitchen were safe to eat. He further revealed he was not aware of who did this and he oversaw this process. <BR/>2. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Milk Refrigerator Temperature Log for January 2025 reflected no temperatures were documented January 22-January 24 in the AM and PM. <BR/>Record review, during initial kitchen tour on 01/26/25 at 10:52 AM, of facility's document, Three Compartment Sink Log for January 2025 reflected no wash temperatures or PPM were documented January 22-January 24 in the AM and PM. <BR/>During an interview with [NAME] AF, during initial kitchen tour on 01/26/25 at 10:52 AM, she revealed there were missing days on the Milk Refrigerator Temperature Log and the Three Compartment Sink Log.<BR/>During an interview on 01/26/25 at 01:03 PM, the CDM confirmed Milk Refrigerator Temperature Log, dated January 2025, and Three Compartment Sink Log, dated January 2025, had no entries documented January 22- January 24 in the AM and PM. The CDM revealed it was important to follow the dishwashing guidelines to kill germs. He revealed he trusted his AM staff members checked temperatures, but he was unaware about his PM staff. He further revealed the log had blank spaces and he expected these logs to be filled completely. He revealed these deficiencies could cause food borne illnesses.<BR/>3. <BR/>During an interview and observation on 01/26/25 at 01:03 PM, it was observed that Dietary Aide AG, while preparing for lunch on 01/26/25, had a facial piercing (located on her bottom lip) and her hair net did not cover the bottom half of her hair. The CDM revealed he had to work on training about dress code with the kitchen staff as there were issues with them following the dress code, but he was going to start the training soon.<BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed it was important to label and date food products to make sure they were serving food safely. The RD further revealed that completing logs in the kitchen, like temperatures and dishwashing logs, prevented food borne illness.<BR/>Record review of facility's policy Food Preparation and Service, revised November 2022, reflected Food Preparation, Cooking, and Holding Time/Temperatures . 1. The danger zone for food temperatures is above 41 *F and below 135 *F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Food Distribution and Service . 1. Proper hot and cold temperatures are maintained during food distribution and service . 8. Food and nutrition services staff wear hair restraints (hair net) so that hair does not contact food. 9 . Jewelry is worn minimally, and hand jewelry is covered with gloves . 15. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.<BR/>Record review of facility's policy Refrigerators and Freezers, revised November 2022, reflected 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures . 4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . 7. All food is appropriately dated to ensure proper rotation by expiration dates . Use by dates are completed with expiration dates on all prepared food in refrigerators . 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-303 Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry .<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 2-302.12 Food Storage Containers, Identified with Common Name of Food . working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT . shall be identified with the common name of the FOOD.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-307 Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.<BR/>Record Review of U.S. Food and Drug Administration's 2022 Food Code reflected, 3-5 Limitation of Growth of Organisms of Public Health Concern 3-501 Temperature and Time Control 3-501.12 Time/Temperature Control for Safety Food, Slacking . (A) Under refrigeration that maintains the FOOD temperature at 5*C (41*F) or less . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure a MDS was electronically completed and transmitted to the CMS System within 14 days after completion for 32 of 75 residents reviewed for closed records. <BR/>The facility failed to transmit quarterly MDS assessments for residents #1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #14, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, #27, #28, #29, #33, #35, #39, #40, and #47 as of 10/27/2022. <BR/>The facility failed to transmit discharge MDS assessments for residents #31 and #34 as of 10/17/2022.<BR/>This failure affected 2 discharged residents and could place an additional 30 current residents at risk of not having their assessments transmitted timely.<BR/>Findings included:<BR/>1. Record review of admission Record printed 10/27/2022 revealed Resident #1 was a [AGE] year-old male with an initial admission date of 9/11/2020 diagnosed with acute respiratory failure.<BR/>Record review of Resident #1's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>2. Record review of admission Record printed 10/27/2022 revealed Resident #2 was a [AGE] year-old male with an initial admission date of 1/29/2018 diagnosed with schizoaffective disorder, bipolar type.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>3. Record review of admission Record printed 10/27/2022 revealed Resident #3 was an [AGE] year-old female with an initial admission date of 9/2/2021 diagnosed with acute diastolic (congestive) heart failure, retention of urine, unspecified.<BR/>Record review of Resident #3's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>4. Record review of admission Record printed 10/27/2022 revealed Resident #4 was a [AGE] year-old male with an initial admission date of 6/9/2017 diagnosed with schizoaffective disorder, multi-system degeneration of the autonomic nervous system.<BR/>Record review of Resident #4's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>5. Record review of admission Record printed 10/27/2022 revealed Resident #6 was a [AGE] year-old female with an initial admission date of 4/1/2021 diagnosed with type 2 diabetes mellitus without complications and acute cystitis without hematuria.<BR/>Record review of Resident #6's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>6. Record review of admission Record printed 10/27/2022 revealed Resident #7 was an [AGE] year-old female with an initial admission date of 2/18/2016 diagnosed with Alzheimer's disease.<BR/>Record review of Resident #7's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>7. Record review of admission Record printed 10/27/2022 revealed Resident #8 was a [AGE] year-old male with an initial admission date of 1/1/2020 diagnosed with essential (primary) hypertension.<BR/>Record review of Resident #8's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>8. Record review of admission Record printed 10/27/2022 revealed Resident #9 was an [AGE] year-old female with an initial admission date of 5/10/2021 diagnosed with Alzheimer's disease.<BR/>Record review of Resident #9's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>9. Record review of admission Record printed 10/27/2022 revealed Resident #10 was a [AGE] year-old male with an initial admission date of 5/25/2022 diagnosed with type 2 diabetes mellitus with diabetic neuropathy.<BR/>Record review of Resident #10's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>10. Record review of admission Record printed 10/27/2022 revealed Resident #11 was a [AGE] year-old male with an initial admission date of 1/13/2019 diagnosed with epilepsy.<BR/>Record review of Resident #11's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>11. Record review of admission Record printed 10/27/2022 revealed Resident #12 was a [AGE] year-old male with an initial admission date of 1/6/2010 diagnosed with Parkinson's disease.<BR/>Record review of Resident #12's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>12. Record review of admission Record printed 10/27/2022 revealed Resident #14 was a [AGE] year-old female with an initial admission date of 6/15/2017 diagnosed with hyperlipidemia and schizophrenia.<BR/>Record review of Resident #14's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>13. Record review of admission Record printed 10/27/2022 revealed Resident #16 was a [AGE] year-old male with an initial admission date of 5/11/2022 diagnosed with acute prostatitis.<BR/>Record review of Resident #16's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>14. Record review of admission Record printed 10/27/2022 revealed Resident #17 was a [AGE] year-old female with an initial admission date of 2/28/2022 diagnosed with non-st elevation (nstemi) myocardial infarction.<BR/>Record review of Resident #17's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>15. Record review of admission Record printed 10/27/2022 revealed Resident #18 was a [AGE] year-old male with an initial admission date of 7/22/2004 diagnosed with cerebrovascular disease.<BR/>Record review of Resident #18's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>16. Record review of admission Record printed 10/27/2022 revealed Resident #19 was a [AGE] year-old female with an initial admission date of 8/24/2017 diagnosed with major depressive disorder, single episode, severe with psychotic features.<BR/>Record review of Resident #19's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>17. Record review of admission Record printed 10/27/2022 revealed Resident #20 was a [AGE] year-old female with an initial admission date of 12/8/2017 diagnosed with type 2 diabetes mellitus without complications, acessential (primary) hypertension.<BR/>Record review of Resident #20's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>18. Record review of admission Record printed 10/27/2022 revealed Resident #22 was a [AGE] year-old male with an initial admission date of 12/17/2021 diagnosed with hypo-osmolality and hyponatremia.<BR/>Record review of Resident #22's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>19. Record review of admission Record printed 10/27/2022 revealed Resident #23 was a [AGE] year-old female with an initial admission date of 2/18/2016 diagnosed with end stage renal disease.<BR/>Record review of Resident #23's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>20. Record review of admission Record printed 10/27/2022 revealed Resident #24 was a [AGE] year-old female with an initial admission date of 3/13/2017 diagnosed with carcinoma in situ of left breast.<BR/>Record review of Resident #24's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>21. Record review of admission Record printed 10/27/2022 revealed Resident #25 was a [AGE] year-old female with an initial admission date of 6/21/2017 diagnosed with dementia, psychotic disturbance, mood disturbance, and anxiety.<BR/>Record review of Resident #25's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>22. Record review of admission Record printed 10/27/2022 revealed Resident #26 was a [AGE] year-old female with an initial admission date of 10/6/2021 diagnosed with effusion, left ankle.<BR/>Record review of Resident #26's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>23. Record review of admission Record printed 10/27/2022 revealed Resident #27 was a [AGE] year-old female with an initial admission date of 5/3/2013 diagnosed with major depressive disorder, single episode, severe with psychotic features.<BR/>Record review of Resident #27's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>24. Record review of admission Record printed 10/27/2022 revealed Resident #28 was an [AGE] year-old male with an initial admission date of 6/18/2014 diagnosed with vascular dementia.<BR/>Record review of Resident #28's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>25. Record review of admission Record printed 10/27/2022 revealed Resident #29 was a [AGE] year-old male with an initial admission date of 6/17/2022 diagnosed with unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia.<BR/>Record review of Resident #29's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>26. Record review of admission Record printed 10/27/2022 revealed Resident #31 was an [AGE] year-old male with an initial admission date of 3/21/2022 diagnosed with displaced midcervical fracture of left femur. Resident #31 was discharged to Acute care hospital: Southwest General hospital on 9/24/2022<BR/>Record review of Resident #31's discharge MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>27. Record review of admission Record printed 10/27/2022 revealed Resident #33 was a [AGE] year-old female with an initial admission date of 1/10/2022 diagnosed with vascular dementia.<BR/>Record review of Resident #33's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>28. Record review of admission Record printed 10/27/2022 revealed Resident #34 was a [AGE] year-old male with an initial admission date of 4/18/2011 diagnosed with quadriplegia. Resident #34 was discharged to Acute care hospital: Baptist Medical Center - San [NAME] Downtown on 8/7/2022<BR/>Record review of Resident #34's discharge MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>29. Record review of admission Record printed 10/27/2022 revealed Resident #35 was a [AGE] year-old male with an initial admission date of 8/18/2021 diagnosed with unspecified mood [affective] disorder, bipolar disorder, unspecified.<BR/>Record review of Resident #35's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>30. Record review of admission Record printed 10/27/2022 revealed Resident #39 was a [AGE] year-old male with an initial admission date of 12/16/2021 diagnosed with type 2 diabetes mellitus with hyperglycemia.<BR/>Record review of Resident #39's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>31. Record review of admission Record printed 10/27/2022 revealed Resident #40 was a [AGE] year-old male with an initial admission date of 4/7/2017 diagnosed with cerebral infarction due to embolism of the right anterior cerebral artery.<BR/>Record review of Resident #40's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>32. Record review of admission Record printed 10/27/2022 revealed Resident #47 was a [AGE] year-old male with an initial admission date of 3/1/2022 diagnosed with embolism and thrombosis of superficial veins of left lower extremity.<BR/>Record review of Resident #47's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDSC's electronic transmittal log.<BR/>During an interview on 10/27/2022 at 4:45 PM with the MDSC I revealed that the MDS for 32 of 32 residents were export ready but not accepted by CMS. The MDSC I stated that the MDS Resource Manager at corporate instructed her not to transmit the MDS updates until they received a Medic-Aid ID from CMS. <BR/>Record review of the facility MDS Transmittal Policy on 10/27/2022 at 05:16 PM revealed instructions to follow Omnibus Budget Reconciliation Act (OBRA) and Resident Assessment Instrument (RAI) guidelines.<BR/>In an interview on 10/27/2022 at 6:00 PM, the MDS Resource Manager stated that MDS updates were not accepted by CMS because the facility did yet have the MPI/Medic-Aid number under the new company name.<BR/>In an interview on 10/27/2022 at 6:06 PM, he Administrator stated that I know she [MDSC I] was getting them [MDS updates] down in a timely manner, but we couldn't submit them due to not having the MPI/Medic-Aid number under the new company name.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 8 of 16 residents (Residents #5, 20, #27, #38, #68, #69, #81, and #85) reviewed for pharmacy services.<BR/>1. On [DATE] Medication Aide E administered late medications to Resident #20 at 10:49 AM:<BR/>a. Acetaminophen 325mg, (Tylenol) late by 1 hour and 49 minutes.<BR/>b. Levetiracetam 500mg (a medication to treat seizures) late by 1 hour and 49 minutes. <BR/>2. On [DATE] Medication Aide E administered late medications to Resident #27 at 9:20 AM:<BR/>a. Carvedilol 12.5mg (used to treat high blood pressure) late by 20 minutes.<BR/>b. Divalproex 125mg (used to treat schizophrenia) late by 20 minutes.<BR/>3. On [DATE] Medication Aide E administered late medications to Resident #38 at 10:51 AM:<BR/>a. Famotidine 20mg (used to reduce stomach acid) late by 1 hour and 51 minutes.<BR/>b. Docusate (a stool softener) 100mg late by 1 hour and 51 minutes.<BR/>c. Lamotrigine 100mg (used to prevent seizures) late by 1 hour and 51 minutes.<BR/>d. Sodium chloride 1gr (salt used to treat muscle weakness) late by 51 minutes. <BR/>4. On [DATE] Medication Aide E administered late medications to Resident #68 at 10:23 AM:<BR/>a. Metformin 1000mg (used to treat diabetes) late by 1 hour and 23 minutes.<BR/>5. On [DATE] Medication Aide E administered late medications to Resident #69 at 9:45 AM:<BR/>a. Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) late by 45 minutes.<BR/>6. An inspection on [DATE] of the facility's treatment nurse medication cart revealed expired insulins for Residents #5, #81, and #85 as evidenced by the following:<BR/>a. Resident #5's liraglutide (an anti-diabetic medication used to treat type 2 diabetes, and chronic obesity) subcutaneous (under the skin) solution pen-injector was stored unrefrigerated, and available for administration, in the cart and was expired by 19 days. <BR/>b. Resident #81's 3 injection vials of insulin lispro 100u/ml, were available for administration, stored unrefrigerated, unlabeled with an expiration date, and were expired by as much as 59 days.<BR/>c. Resident #85's 1 injection vial of insulin lispro 100u/ml, was available for administration, stored unrefrigerated, labeled with an expiration date of 12/20, and was expired by 45 days.<BR/>These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. <BR/>The findings included:<BR/>During an observation and interview on [DATE] at 9:49 AM revealed MA E preparing and administering medications for residents within the facility. Further review revealed MA E's computer electronic medical record display demonstrated MA E's assigned residents were highlighted in red. MA E stated she was late administering medications, specifically for Residents #20, 27, #38, #68, and #69. MA E stated her direct supervisor was the DON and she had not reported the late medication administration. Continued observation revealed she continued to administer medications to residents.<BR/>1. A record review of Resident #20's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included vascular dementia (parts of the brain are damaged due to a stroke) and convulsions (an electrical storm in the brain AKA seizures.) <BR/>A record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 was a [AGE] year-old male admitted for long term care and assessed a BIMS score of 5 out of a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #20's care plan dated [DATE] revealed, (Resident #20) has a seizure disorder r/t (related to) Stroke Date Initiated: [DATE] . Give medications as ordered. Observe/document for effectiveness and side effects. <BR/>A record review of Resident #20's physicians' orders revealed the physician prescribed for Resident #20 to receive levetiracetam 500mg twice a day at 8:00 AM and at 4:00 PM and acetaminophen 325mg three times a day at 8:00 AM, noon, and at 4:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], administered Resident #20 his acetaminophen 325mg and his levetiracetam 500mg at 10:49 AM late by 1 hour and 49 minutes.<BR/>2. A record review of Resident #27's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included hypertension (high blood pressure) and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others.)<BR/>A record review of Resident #27's Quarterly MDS assessment dated [DATE] revealed Resident #27 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. <BR/>A record review of Resident #27's care plan dated [DATE] revealed, (Resident #27) has Hx (history) of hallucinations. (Resident #27) states that this voice tells him bad things, including not to smoke, tells him he is overweight. Mr. Rico calls this voice/voices the devil . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #27's physicians orders dated [DATE] revealed the physician prescribed for Resident #27 to receive carvedilol 12.5mg and divalproex 125mg twice a day at 8:00 AM and again at 4:00 PM.<BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], administered Resident #27 his carvedilol 12.5mg and divalproex 125mg at 9:20 AM late by 20 minutes.<BR/>3. A record review of Resident #38's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures. Seizures are uncontrolled bursts of electrical activities that change sensations, behaviors, awareness, and muscle movements), Gastroesophageal reflux disease (AKA GERD, occurs when stomach acid frequently flows back into the esophagus, leading to irritation and discomfort), constipation, and muscle weakness. <BR/>A record review of Resident #38's Quarterly MDS assessment dated [DATE] revealed Resident #38 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition. <BR/>A record review of Resident #38's care plan dated [DATE] revealed, (Resident #38) has behavioral concern of insisting medications be given at a certain time and becoming angry when medications are not being given exactly when requested. (Resident #38) has been made aware of and<BR/>educated on medication administration window . <BR/>A record review of Resident #38's physicians' orders dated [DATE] revealed the physician prescribed for Resident #38 to receive famotidine 20mg and docusate 100mg twice a day at 8:00 AM and again at 4:00 PM. Lamotrigine 100mg at 8:00 AM and again at 6:00 PM. Sodium chloride 1gr twice a day at 9:00 AM and again at 5:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 10:51 AM, administered Resident #38 his famotidine 20mg, docusate 100mg, lamotrigine 100mg late by 1 hour and 51 minutes and sodium chloride 1gr late by 51 minutes.<BR/>4. A record review of Resident #68's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included diabetes type 2. <BR/>A record review of Resident #68's quarterly MDS assessment dated [DATE] revealed Resident #68 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #68's care plan dated [DATE] revealed, (Resident #68) has impaired cognitive function/dementia or impaired thought processes r/t Dementia, Disease Process diabetes, . Administer meds as ordered. Date Initiated: [DATE] <BR/>A record review of Resident #68's physicians' orders dated [DATE] revealed the physician prescribed for Resident #68 to receive metformin 1000mg twice a day at 8:00 Am and again at 4:00 PM. <BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 10:23 AM, administered Resident #68 his Metformin 1000mg late by 1 hour and 23 minutes.<BR/>5. A record review of Resident #69's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included a urinary tract infection. <BR/>A record review of Resident #69's quarterly MDS assessment dated [DATE] revealed Resident #69 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 3 out a possible 15 which indicated severely impaired cognition. <BR/>A record review of Resident #69's care plan date [DATE] revealed, Urinary Tract Infection, potential or actual r/t Diagnosis of BPH, Diagnosis of Urinary retention, Use of indwelling catheter dx (diagnosis) ESBL UTI (extended spectrum beta-lactamase urinary tract infection. ESBL-producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections), Date Initiated: [DATE] . Antibiotic per MD (medical doctor) order x 5days. Date Initiated: [DATE] <BR/>A record review of Resident #69's physicians orders dated [DATE] revealed the physician prescribed for Resident #69 to receive Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) twice a day at 8:00 AM and again at 8:00 PM.<BR/>A record review of the facility's Medication Admin Audit Report dated [DATE] revealed MA E, on [DATE], at 9:45 AM, administered Resident #69 his Bactrim 800mg / 160mg late by 45 minutes.<BR/>During a joint interview on [DATE] at 4:04 PM with the operations manager and the DON, the DON stated the expectation was for the medications to be administered with in 1 hour of the prescribed time. The DON stated his expectation was for MA E to have reported the potential late medication administration and MA E had not reported the late medication administration. <BR/>6. A record review of Resident #5's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included type II diabetes (a long-term condition which results in too much sugar circulating in the blood. High blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.)<BR/>A record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care and assessed with a memory problem, Moderately impaired - decisions poor; cues / supervision required <BR/>A record review of Resident #5's care plan dated [DATE] revealed, Alteration in Blood Glucose due to hyper/hypoglycemia dx. DMII, . Date Initiated: [DATE] . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #5's physicians' orders dated [DATE] revealed the physician prescribed for Resident#5 to receive liraglutide 18mg/3ml, 1.2mg injected under the skin daily at 8:00 AM. <BR/>During an observation and interview on [DATE] at 10:30 AM revealed LVN Z attending the nurse treatment cart on the facility's D-hall and was preparing to administer insulins prior to the noon meal. LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed an insulin injection pen for Resident #5. The pen was labeled, liraglutide injection (Resident #5) 18mg/3ml, . date opened [DATE] .exp. [DATE] . discard pen 30 days after first use LVN Z stated she would not use the insulin pen because it was expired and would immediately discard the injection pen. <BR/>A record review of Resident #81's admission record dated [DATE] revealed an admission date of [DATE] with diagnosis which included type II diabetes.<BR/>A record review Resident #81's quarterly MDS assessment dated [DATE] revealed Resident #81 was a [AGE] year-old female assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #81's care plan dated [DATE] revealed, Potential for complication hypo hyperglycemia r/t DMII. Date Initiated: [DATE] . Medications/blood sugar check as ordered and as needed. Date Initiated: [DATE] <BR/>A record review of Resident #81's physicians' orders dated [DATE] revealed the physician prescribed for Resident #81 to receive insulin lispro 4 times a day at 6:30 AM, 11:30 AM, 4:30 PM, and at 8:00 PM, insulin lispro 100u/ml inject per sliding scale: if 0-150 = 0; 151 - 250 = 2; . 301-400 = 14 . subcutaneously before meals and at bedtime for diabetes <BR/>A record review of Resident #85's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes. <BR/>A record review of Resident #85's quarterly MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted for long term care and assessed with a memory care problem, Severely impaired - never / rarely made decisions <BR/>A record review of Resident #85's physicians' orders dated [DATE] revealed the physician prescribed for Resident #85 to receive insulin lispro three times a day at 6:30 AM, 11:30 AM, and at 4:30 PM, (insulin lispro) subcutaneously solution pen injector 100u/ml inject 10 unit subcutaneously before meals for diabetes <BR/>During an observation and interview on [DATE] at 10:30 AM LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed a plastic bag which contained 4 insulin injection pen refill vials. The bag was labeled, (Resident #81) (the facility) (insulin lispro) 100u/ml cartridge qty: 15, [DATE] . refrigerate Observation of the 4 vials revealed:<BR/>1. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #81's name, dated with an open date of [DATE], observed 2/3's full.<BR/>2. 3ml glass vial insulin lispro 100u/3ml labeled (Resident #81) [DATE] observed full.<BR/>3. 3ml glass vial insulin lispro 100u/3ml unlabeled with a resident's name, dated with an open date 12/20 (no year), observed full.<BR/>4. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #85's name, undated, no open date noted, observed &frac12; full. <BR/>LVN Z stated the vials were stored unrefrigerated, in a bag labeled Resident #81, however, LVN Z could not state who the insulin vials were intended for and could not state the date the vials were unrefrigerated. LVN Z stated she would discard the vials because they were unsafe to use.<BR/>During an interview on [DATE] at 1:10 PM the DON stated the expectations and trainings for nurses who administer insulin was for the insulin to be labeled with an opened date and a dispose of date, to include a use span of 28 days. The DON stated all insulins older than 28 days and or unlabeled insulins should be discarded. The DON stated the risk for harm would be residents may not receive the therapeutic effects of their prescribed medications. <BR/>A policy regarding medication administration was requested on [DATE] at 10:00 AM and as of [DATE] was not provided; however, a policy titled Documentation of Medication Administration was provided. A record review of the policy revealed no policy for timely medication administration. <BR/>A record review of the Institute for Safe Medication Practices website titled ISMP Acute Care Guidelines for Timely Administration of Scheduled Medication ismp-hosp-temp-MASTER.qxd accessed [DATE] revealed, Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time. <BR/>A record review of the lirglutide manufactures website titled, Victoza (liraglutide) injection, Important Information accessed [DATE], https://www.victoza.com/faq.html, revealed, Instructions for Use? You can use your Victoza pen for up to 30 days after you use it the first time. First Time Use for Each New Pen. How should I store Victoza?<BR/>Before use:<BR/>o Store your new, unused Victoza pen in the refrigerator between 36&ordm;F to 46&ordm;F (2&ordm;C to 8&ordm;C).<BR/>o If Victoza is stored outside of refrigeration (by mistake) prior to first use, it should be used or thrown away within 30 days.<BR/>Pen in use:<BR/>o Use a Victoza pen for only 30 days. Throw away a used Victoza pen 30 days after you start using it, even if some medicine is left in the pen.<BR/>o Store your Victoza pen at room temperature between 59&ordm;F to 86&ordm;F (15&ordm;C to 30&ordm;C), or in a refrigerator between 36&ordm;F to 46&ordm;F (2&deg;C to 8&deg;C).<BR/>A record review of the insulin lispro manufactures website titled bing.com/ck/a?!&&p=88304c2b6b2aae023b9ebee38f5cae217a125895e1f0391c2809d0dd502d8becJmltdHM9MTc0MDA5NjAwMA&ptn=3&ver=2&hsh=4&fclid=1aed91e9-b39d-6b39-1288-8473b27c6a4d&psq=lispro+kwikpen+instructions&u=a1aHR0cHM6Ly9waS5saWxseS5jb20vdXMvaHVtYWxvZy1rd2lrcGVuLXVtLnBkZg&ntb=1, accessed [DATE], revealed, INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) <BR/>(insulin lispro) injection, for subcutaneous use revealed, Do not use past the expiration date printed on the Label or for more than 28 days after you first start using. Store unused insulin in the refrigerator at 36&deg;F to 46&deg;F (2&deg;C to 8&deg;C).<BR/>o Do not freeze your insulin. Do not use if it has been frozen.<BR/>o Unused insulin may be used until the expiration date printed on the Label, if it has been kept in the refrigerator.<BR/>In-use:<BR/>o Store the insulin you are currently using at room temperature [up to 86&deg;F (30&deg;C)]. Keep away from heat and light.<BR/>o Throw away the HUMALOG insulin you are using after 28 days, even if it still has insulin left in it.<BR/>A record review of the facility's policy titled, Medication Labeling and Storage dated February 2023, revealed, The facility stores all medications and biologicals and locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to the keys. Policy interpretation and implementation: medication storage; . compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trains or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. H residence medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. medication labeling; labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration, and appropriate instructions and precautions. multi dose vials that have been opened or accessed (for example needle punctured) are gated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Multi dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

Based on observation, interview, and record review, the facility failed to follow menus for 1 of 2 resident meals (dinner meal on 01/28/25) reviewed for menus in that:<BR/>The facility failed to follow the menu for residents on soft bite sized and minced moist diets for the dinner meal on 01/28/25.<BR/>This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.<BR/>The findings included: <BR/>Record review of Week 3 Menu reflected Tuesday (Day 17) Dinner included Tomato Basil Soup and Pimento Cheese Sandwich. <BR/>Record review of the recipes for Pimento Cheese Sandwich, undated, for the textures minced and moist and soft bite sized reflected recipe directions to include Grind 2 slice of bread 4-6 seconds to mince. Place prepared bread crumbs in a bowl and spray with vegetable pan spray until a more cohesive texture is achieved. Divide the prepared bread crumbs placing half of the crumbs as the first layer. Top with the #8 dip pimento cheese. Top with the other half of the minced prepared bread crumbs.<BR/>Record review of the recipes for Tomato Basil Soup, undated, for the textures minced and moist and soft bite sized reflected the soup should have been pureed. <BR/>During an observation of 01/28/25 dinner sample meal tray at 05:15 PM, the dinner for soft bite sized and minced and moist had a full pimiento cheese sandwich and a non-pureed tomato basil soup. <BR/>During an interview on 01/28/25 at 05:24PM, RN K revealed the nursing staff oversaw checking the meal trays after they left the kitchen, to ensure they were the foods listed on the tray ticket. She revealed if there was a discrepancy, they would go to the kitchen to let them know. RN K revealed she questioned if a sandwich was okay for soft and bite sized and was told okay. <BR/>During an interview on 01/29/25 at 11:45 AM, the CDM revealed they did not puree the tomato basil soup to its proper consistency. He further revealed the pimento cheese sandwich was not ground according to the recipe. He revealed it was important to follow the diet textures because residents could choke.<BR/>During an interview on 01/29/25 at 04:31 PM, the RD revealed residents should not be getting regular sandwiches if on minced and moist or soft and bite sized diets. The RD revealed if a resident received a sandwich on these diets, it was a choking hazard. The RD revealed the speech therapist and her educated on these textures. She revealed this in-service was done with nursing and dietary staff about 6 months ago. She further revealed she needed to do another in-service because it has been a long time and there had been a lot of new staff, nursing and dietary. <BR/>During an interview on 01/30/25 at 03:11 PM, CNA F revealed when the food trays came out of the kitchen, if the tray ticket was different, he would tell the nurse and then dietary. He further revealed soft bite sized diet was chopped up and he was familiar with the minced and moist texture. He revealed sandwiches should be chopped up. He further revealed a resident could choke if they were served a diet with a different texture than what they could have. <BR/>During an interview on 01/30/25 at 03:50 PM, [NAME] AD and [NAME] AE revealed soft bite sized and minced and moist diet were new diets they were following in the kitchen. [NAME] AE revealed he did not follow the recipes for soft bite sized and minced and moist diet on 01/28/25 dinner and did not know the food textures. They further revealed it was important to follow recipes for the residents' safety. <BR/>During an interview on 01/28/25 at 06:39 PM, the DON revealed it was important to serve diets as prescribed to avoid any choking hazards. The DON revealed the nursing staff was trained on these diet textures, but he could not recall when this training was. <BR/>Record review of facility's policy, undated, Standardized Recipes reflected, Standardized recipes shall be developed and used in the preparation of foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 1 meal (noon meal) for resident #55 in that:<BR/>The dietary staff failed to identify discrepancies between the meal tickets and the plated meals.<BR/>The DM did not verify the accuracy of resident #55's meal against the meal ticket.<BR/>The Nurses failed confirm that the meals matched the resident #55's meal ticket prior to serving the resident.<BR/>This deficient practice could affect 1 resident who received the pureed meal from the kitchen by contributing asphyxiation, dissatisfaction, poor intake, and/or weight loss. <BR/>Findings include:<BR/>Record review of admission Record printed 10/25/2022 revealed Resident #55 was a [AGE] year-old female with an initial admission date of 1/25/2021 diagnosed with oropharyngeal phase dysphagia [disordered swallowing that can allow food or liquid to enter the lungs causing respiratory distress, damage to lung tissue or infection]. <BR/>Record Review of annual MDS (Minimum Data Set) date 9/25/2022 revealed Resident #55 required mechanically altered diet ( .change in texture of food or liquids e.g., pureed food .). Section V Care Area Assessment, prior assessment, indicated as 7/09/2022 indicated BIMS (Brief Interview for Mental Status) Summary Score as 15, indicative of intact cognition. <BR/>Record review of Resident #55's Care Plan, initiated on 01/25/2021, revised on 4/7/2022, revealed a focus area of nutrition problem with the following interventions: dysphagia level 2 mechanically altered texture; regular liquid consistency; provide and serve diet as ordered. <BR/>Record review of Order Summary Report printed 10/25/2022 revealed Resident #55 had dietary orders for consistent carbohydrate diet; dysphagia level 2, mechanically altered texture; regular consistency, no salt on trays with a start date of 10/18/2022. <BR/>Record review of Meal Tray tag dated 10/25/2022 for Resident #55 revealed instructions for pureed Chicken Posole Stew with Hominy - Pureed Corn Tortilla (6) - #16 Scp [scoop]. <BR/>Record Review of Task: Amount of Meal Eaten for Resident #55 revealed, 76% - 100% of noon meal eaten on 10/25/2022. <BR/>In an interview on 10/25/2022 at 12:38 PM Resident #55 stated the food served does not match the cards on the tray. Resident #55 stated this happened frequently, several times a week at random times. Resident #55 stated she still had not received her lunch tray as of yet, was hungry and ready to eat. <BR/>In an observation and interview on 10/25/2022 at 1:35 PM, Resident #55 had a whole 6-inch corn tortilla served with her meal tray. Resident #55 stated she frequently receives items she knows she cannot handle. Resident #55 stated she does not eat the whole corn tortilla as it is too tough for her. Resident #55 stated she just puts it to the side. Resident #55 stated, she did not want to make a fuss, as staff are trying, and I don't want to send my tray back because I don't want to wait any later to be able to eat! [See Form 6339 Photographic Evidence, P1.]<BR/>In an interview on 10/25/2022 at 1:40 PM, CNA C stated her responsibility was to ensure the correct resident received their tray in a timely manner after the nurse inspected it. CNA C stated that she is also expected to set up the tray for the residents as needed. CNA C stated at times she is required to assist the residents if they are not able to independently feed self. CNA C stated she was not sure if she was the aide that presented the tray to Resident #55 today. <BR/>In an interview on 10/25/2022 at 1:45 PM, ADON B stated that the Residents meal trays are reviewed and compared to the meal tray tag for accuracy. ADON B stated this included making sure the texture and liquid consistency were correct; along with any specialty items such as fortified items or magic cup ice creams. ADON B stated trays were also inspected to ensure that adaptive equipment was provided for the Residents' who required it. ADON B stated, Oh, Okay and then walked away from this surveyor when advised that a resident with instructions for pureed texture was served a whole corn tortilla. <BR/>In an interview on 10/26/2022 at 1:55 PM, the ADM asked this surveyor which resident was served the whole corn tortilla. The ADM stated the meal tags needed to be followed for resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 3 of 9 (room [ROOM NUMBER], #47 and resident #76) incidences of privacy concerns in that:<BR/>1. LVN J did not knock on rooms [ROOM NUMBERS] before entering rooms. <BR/>2. LVN Z left her computer open with resident#76's personal information. <BR/>This could affect and result in resident privacy being violated. <BR/>The Findings were:<BR/>1. Observation on 1/26/2025 at 10:33 AM LVN J went into room [ROOM NUMBER] and did not knock on the door before entering room. <BR/>Observation on 1/26/25 at 10:00 AM LVN J went into room [ROOM NUMBER] and did not knock on the door before entering room. <BR/>Interview on 1/26/25 at 10:38 AM with LVN J stated she did not knock on the 2 doors, and she should have knocked before she entered. <BR/>2. Observation on 1/26/2025 at 12:11 PM to 12:19 PM revealed LVN Z had her computer screen open revealing Resident #76's confidentiality information . (residents picture, resident name, vitals, age, id number, and medications to be provided). <BR/>Interview on 1/26/2025 at 1:48 PM with LVN Z stated she forgot to turn the monitor screen off and got busy checking resident lunch trays.<BR/>Interview on 1/28/2025 at 12:04 PM with ADM and DON, did discuss and stated they will educate staff on the concerns with knocking on the door, and staff leaving the computer screen open to residents' personal information. No other response was provided.<BR/>Record review of policy, Dignity dated February 2021 Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 7. Staff are expected to knock and request permission before entering resident's rooms. <BR/>Record review of policy, Confidentiality of Information and Personal Privacy dated October 2017 was documented Our Facility will protect and safeguard resident confidentiality and personal privacy. 1. The facility will safeguard the persona privacy and confidentiality of all resident personal and medical records. 4. access to resident personal and medical records will be limited to authorized staff and business associates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 nurse medication carts reviewed for security and supervision and for 3 of 8 residents (Residents #5, #81, and #85) reviewed for safe storage of insulins. <BR/>1. On [DATE] at 6:06 PM LVN J attended the nurse medication cart on the facility's D-hall and left the medication cart unsupervised and unlocked for 7 minutes while she left and provided care for a Resident. LVN J was out of line-of-sight with the nurse medication cart. <BR/>2. An inspection on [DATE] of the facility's treatment nurse medication cart revealed expired insulins for Residents #5, #81, and #85 as evidenced by the following:<BR/>a. Resident #5's liraglutide (an anti-diabetic medication used to treat type 2 diabetes, and chronic obesity) subcutaneous (under the skin) solution pen-injector was stored unrefrigerated, and available for administration, in the cart and was expired by 19 days. <BR/>b. Resident #81's 3 injection vials of insulin lispro 100u/ml, were available for administration, stored unrefrigerated, unlabeled with an expiration date, and were expired by as much as 59 days.<BR/>c. Resident #85's 1 injection vial of insulin lispro 100u/ml, was available for administration, stored unrefrigerated, labeled with an expiration date of 12/20, and was expired by 45 days.<BR/>These failures could place residents at risk for harm by not receiving the therapeutic effects of their insulins. <BR/>The findings included:<BR/>During an observation and interview on [DATE] at 6:06 PM revealed LVN J attended the nurse medication cart on the facility's D-hall and left the medication cart unsupervised and unlocked for 7 minutes while she left and provided care for a Resident. LVN J was out of line-of-sight with the nurse medication cart. Further observation revealed LVN J to return to the cart on [DATE] at 6:13 PM and stated she had left the cart unlocked and apologized as she locked the cart. <BR/>1. A record review of Resident #5's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included type II diabetes (a long-term condition which results in too much sugar circulating in the blood. High blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.)<BR/>A record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care and assessed with a memory problem, Moderately impaired - decisions poor; cues / supervision required <BR/>A record review of Resident #5's care plan dated [DATE] revealed, Alteration in Blood Glucose due to hyper/hypoglycemia dx. DMII, . Date Initiated: [DATE] . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #5's physicians' orders dated [DATE] revealed the physician prescribed for Resident#5 to receive liraglutide 18mg/3ml, 1.2mg injected under the skin daily at 8:00 AM. <BR/>During an observation and interview on [DATE] at 10:30 AM revealed LVN Z attending the nurse treatment cart on the facility's D-hall and was preparing to administer insulins prior to the noon meal. LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed an insulin injection pen for Resident #5. The pen was labeled, liraglutide injection (Resident #5) 18mg/3ml, . date opened [DATE] .exp. [DATE] . discard pen 30 days after first use LVN Z stated she would not use the insulin pen because it was expired and would immediately discard the injection pen. <BR/>2. A record review of Resident #81's admission record dated [DATE] revealed an admission date of [DATE] with diagnosis which included type II diabetes.<BR/>A record review Resident #81's quarterly MDS assessment dated [DATE] revealed Resident #81 was a [AGE] year-old female assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #81's care plan dated [DATE] revealed, Potential for complication hypo hyperglycemia r/t DMII. Date Initiated: [DATE] . Medications/blood sugar check as ordered and as needed. Date Initiated: [DATE] <BR/>A record review of Resident #81's physicians' orders dated [DATE] revealed the physician prescribed for Resident #81 to receive insulin lispro 4 times a day at 6:30 AM, 11:30 AM, 4:30 PM, and at 8:00 PM, insulin lispro 100u/ml inject per sliding scale: if 0-150 = 0; 151 - 250 = 2; . 301-400 = 14 . subcutaneously before meals and at bedtime for diabetes <BR/>3. A record review of Resident #85's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes. <BR/>A record review of Resident #85's quarterly MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted for long term care and assessed with a memory care problem, Severely impaired - never / rarely made decisions <BR/>A record review of Resident #85's physicians' orders dated [DATE] revealed the physician prescribed for Resident #85 to receive insulin lispro three times a day at 6:30 AM, 11:30 AM, and at 4:30 PM, (insulin lispro) subcutaneously solution pen injector 100u/ml inject 10 unit subcutaneously before meals for diabetes <BR/>During an observation and interview on [DATE] at 10:30 AM LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed a plastic bag which contained 4 insulin injection pen refill vials. The bag was labeled, (Resident #81) (the facility) (insulin lispro) 100u/ml cartridge qty: 15, [DATE] . refrigerate Observation of the 4 vials revealed:<BR/>1. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #81's name, dated with an open date of [DATE], observed 2/3's full.<BR/>2. 3ml glass vial insulin lispro 100u/3ml labeled (Resident #81) [DATE] observed full.<BR/>3. 3ml glass vial insulin lispro 100u/3ml unlabeled with a resident's name, dated with an open date 12/20 (no year), observed full.<BR/>4. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #85's name, undated, no open date noted, observed &frac12; full. <BR/>LVN Z stated the vials were stored unrefrigerated, in a bag labeled Resident #81, however, LVN Z could not state who the insulin vials were intended for and could not state the date the vials were unrefrigerated. LVN Z stated she would discard the vials because they were unsafe to use. <BR/>During an interview on [DATE] at 1:10 PM the DON stated the expectations and trainings for nurses who administer medications to residents was for the medication cart to be locked anytime the nurse was away from the cart. The DON stated it was the individual nurse's responsibility to lock the cart anytime they left the cart unattended. <BR/>A record review of the facility's policy titled, Medication Labeling and Storage dated February 2023, revealed, The facility stores all medications and biologicals and locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to the keys. Policy interpretation and implementation: medication storage; . compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trains or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. H residence medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. medication labeling; labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration, and appropriate instructions and precautions. multi dose vials that have been opened or accessed (for example needle punctured) are gated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Multi dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to protect the residents right to be free from physical abuse by Resident #83 and #55, for 3 of 13 residents (Residents #55, #61, and #83) reviewed for physical abuse and neglect.<BR/>1. On 1/11/2025 on or about 11:00 AM Resident #61 was physically battered by Resident #83, to include a face punch, his hair pulled, and drug by his foot across the floor. <BR/>2. On 4/9/2024 Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another.<BR/>3. On 4/22/2024 Resident #61 was punched in the nose by Resident #55. <BR/>4. On 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. <BR/>An IJ was identified on 1/29/2025. The IJ template was provided to the facility on 1/29/2025 at 3:15 PM. While the IJ was removed on 1/30/2025 at 9:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm.<BR/>These failures placed residents at risk for physical abuse.<BR/>The findings included:<BR/>1. Resident #61<BR/>A record review of Resident #61's admission record dated 1/27/2025, revealed an admission date of 1/2/2024 with diagnoses which included dementia with moderate agitation (a group of symptoms affecting memory, thinking and social abilities. further review revealed Resident #61 resided in the facility's secured Memory Care Unit (MCU).<BR/>A record review of Resident #61's annual MDS assessment dated [DATE] revealed Resident #61 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 4 out of a possible 15 which indicated severely impaired cognition. Resident #61 was reviewed for the 6 days prior to the assessment and Resident #61 was assessed with a history of wandering, has the Resident wandered? Behavior of this type occurred 1 to 3 days. does the wandering place the Resident at significant risk of getting to a potentially dangerous place? Yes Resident #61 was diagnosed with cataracts (a gradual progression of vision problem, eventually, if not treated, may result in vision loss.) Further review revealed Resident #61 was 5 foot and 5 inches tall and weighed 129 lbs.<BR/>A record review of Resident #61's care plan dated 1/29/2025 revealed, Behavioral Complex Care Plan Physically Abusive Behavior, Socially Inappropriate Behavior, Wandering, verbally abusive and/or resisting care.<BR/>12/24/24 pacing back/forth ready to go to work attempted to go out-door pushing bar. 1/11/25 Another Resident (Resident #83) entered this Res room. Staff heard yelling other resident was found dragging (Resident #61) by the hair as per CNA, then that resident began to drag Resident (#61) by the legs . revision 1/16/2025 . Resident move to different room. Date Initiated: 01/14/2025 Refer to behavioral health Date Initiated: 08/13/2024 Revision on: 8/14/2024 Separate Residents. Date Initiated: 01/11/2025 . Resident #61 uses anti-anxiety medications r/t agitation. Resident #61 is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor every shift for safety <BR/>A record review of Resident #61's physicians orders, dated 6/10/2024, revealed the physician prescribed for staff to have Frequent monitoring throughout the shift staff to attempt to anticipate some of residents needs as tolerated. <BR/>A record review of Incident reports indicated the following:<BR/>A record review of the facility's incident report dated 4/9/2024 revealed Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another. Further review of the report revealed the previous administrator and the previous DON had been notified. <BR/>A record review of the facility's incident report dated 4/22/2024 revealed the previous DON documented Resident #61 was punched in the nose by Resident #55. Resident #61 was presented to the nurse with a bloody nose after exiting Resident #55's room. Resident #61 took the nurse to Resident #55 room and stated, this is the bathroom, and he won't let me use it. He hit my nose. Resident #55 stated, He came in here to take a shit. I told him to get out. He peed in the corner, so I hit him on the nose.<BR/>A record review of the facility's incident report dated 8/12/2024 revealed the LVN C documented on 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. Resident #55 stated, I hit him because he came into my room.<BR/>Resident # 83<BR/>A record review of Resident #83's admission record dated 1/30/2025 revealed an admission date of 11/4/2024 with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a cluster of symptoms, not an illness. It's sometimes described as losing touch with reality), mood disturbance, and anxiety. Further review revealed Resident #83 resided in the MCU.<BR/>A record review of Resident #83's admission MDS assessment dated [DATE] revealed Resident #83 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. Resident #83 was reviewed for the 6 days prior to the assessment and Resident #83 was assessed with a history of behavioral symptoms, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) . behavior of this type occurred 1 to 3 days. verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . behavior of this type occurred 1 to 3 days. impact on others? Put others at significant risk for physical injury? Yes Further review revealed resident #83 was six foot tall and weighed 179 lbs. <BR/>A record review of Resident #83's care plan dated 1/29/2025 revealed, <BR/>Behavioral Complex Care Plan Physically Abusive Behavior, Verbally Abusive Behavior 1/1/25 noted standing in doorway of another resident, both residents with raised voices. 1/11/25 Another Resident went into his room this resident. This resident is kept separated from other resident and redirected as necessary Date Initiated: 11/06/2024 Revision on: 01/28/2025 . Look for alternative placement. Date Initiated: 01/14/2025 Residents were separated. Date Initiated: 01/01/2025 Staff to explain cares to resident prior to and during process of cares. Date Initiated: 11/07/2024 Revision on: 11/14/2024 <BR/>A record review of Resident #61's provider investigation report dated 1/20/2024 revealed the operations manager documented an incident on 1/11/2025 at 11:00 AM, where Resident #83 physically battered Resident #61. The operations manager documented Resident #83 as the perpetrator and identified CNA A and RN S as witnesses. The operations manager documented, Resident was hit by another Resident, dragging by his hair and his leg per CNA. Resident stated he accidentally walked into wrong room. after interviewing staff and Resident(s) it was found Resident wandered into wrong room and was the cause of the altercation and we moved residents' room to avoid future issues. (Resident #61) is extensive supervision and needs constant redirection due to dementia diagnosis <BR/>During an observation and interview on 01/26/25 at 3:55 PM revealed the MCU where Resident # 61 was asleep in room [ROOM NUMBER] (which was not his assigned room.) CNA A was the only staff in the MCU. CNA A was alerted by the surveyor that Resident #61 was not in his assigned bedroom. CNA A discovered Resident #61 in another bedroom and redirected him to his bedroom. CNA A stated on 1/11/2025 at 11:00 AM she heard screams from the end of the hall and ran to the sounds and witnessed Resident #83 in his room and had Resident #61 by his hair and was dragging him to the floor. CNA A attempted to separate them but Resident #83 was a large man and CNA A was herself threatened so she ran down the hall, exited the MCU to gather emergency assistance, and upon her return to the MCU, she witnessed Resident #83 had Resident #61 by his foot and drug him out of Resident #83's room and into the hallway. CNA A stated, I am often alone in the MCU, the nurse works this MCU and another hall outside of the MCU. CNA A stated Resident #83 was very aware of his room and becomes violent when anyone was in his room. Resident #61 was very confused and often goes into different rooms and Resident #83 becomes aggressive towards Resident #61.<BR/>During an interview on 1/30/2025 at 5:35 PM RN S stated she was a nurse who worked at the facility as needed and could work the MCU during the 10P-6A shift. RN S stated she had received the in-service for the MCU which included the addition of 2 CNAs would staff the MCU. RN S stated she appreciated the addition of 2 CNAs for the MCU since she was on duty on 1/22/2025 at 11:00 AM when Resident #61 was battered by Resident #83 and CNA A had to leave the residents and the MCU to alert her to the resident-to-resident abuse. RN S stated she was on the adjacent hall providing care when CNA A exited the MCU and called out for help in the MCU. RN S stated she ran after CNA A and entered the MCU to the end of the hall to Resident #83's bedroom and witnessed Resident #83 dragging Resident #63 by his legs out of the room into the hall. RN S stated the residents were separated for safety and assessed head to toe, no injuries were assessed for Resident #83, and Resident #61 was assessed with a right cheek redness, slight swelling, and discoloration. The physician received a report and Resident #61 was supported with x-rays which revealed no deep injuries. RNS stated residents were monitored frequently and ultimately Resident #61 was relocated to a bedroom away from Resident #83's bedroom. <BR/>During an interview on 1/27/2025 at 4:05 Resident #61's emergency contact stated Resident #61 was a full code and would often visit him. Resident #61's emergency contact stated she often observed the MCU was staffed by 1CNA and 1 nurse and was not aware the nurse would leave the MCU to care for residents outside of the MCU. Resident #61's emergency contact stated she received a report from Resident #61's Representative that Resident #61 was punched in the face by Resident #83 but was not aware Resident #61 was left alone with Resident #83 while the CNA left to get help. <BR/>During a joint interview on 1/28/2025 at 11:47 AM Resident #61's representative and emergency contact stated they had not received a full report for the Resident-to-Resident aggression on 1/11/2025 when Resident #61 wandered into a different bedroom, I only knew that another Resident had hit Resident #61 in the face and he had received x-rays. Resident #61's representative and emergency contact stated they were unaware the MCU was staffed by one CNA and were unaware Resident #61 was left alone while Resident #83 was beating Resident #61, (Resident #61) is profoundly confused and needs redirection to his bedroom . he often goes to lay down . and needs to be monitored for safety and never left alone <BR/>During a joint interview on 1/28/2025 at 8:55 AM the DON and the operations manager stated the facility operates 3 shifts: 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00 AM to include the MCU. The operations manager stated she investigated an incident of Resident-to-Resident aggression between Resident #61 and Resident #83 on 1/11/2024 at 11:00 AM when CNA A witnessed Resident #83 pulled Resident #61 out of his room when Resident #61 wandered into the bedroom. The DON stated currently 13 residents resided in the MCU to include Residents #61 and Resident #83. The DON stated the MCU was staffed by 1 CNA and 1 nurse during every shift. The DON stated the nurse was also assigned another set of residents to care for outside of the MCU and stated, she would leave the MCU to care for residents in the C hall. The administrator stated the facility provided for Resident #61's safety, post the aggression incident, by moving Resident #61 to a different bedroom away from Resident #83 and continued with the 1 CNA to monitor and redirect the MCU residents. The operations manager and the DON stated the IDT met Monday - Friday mornings and they were responsible for leading the meeting. The DON and the operations manager stated the previous day's care was reviewed and the team would be responsible for developing and implementing any further care to keep residents healthy and safety. The operations manager stated on 1/13/2025 the IDT met and decided to move Resident #61 to a different bedroom and continue with the level of supervision for the MCU. <BR/>During an interview on 01/28/2025 at 3:00 PM, the MDS nurse stated she was responsible for updating Residents care plans to include Resident #61's care plan on 01/14/2025. The MDS nurse stated the IDT met during the morning meeting on 01/13/2025 and again on 01/14/2025 and reviewed the aggression incident on 01/11/2025 for Residents #61 and #83 and decided to add interventions for Resident #61 to be moved to a different bedroom and for Resident #83 to be safely discharged to another facility. The MDS nurse stated residents in the MCU had a history of Resident-to-Resident physical aggression and prior to the 01/13/2025 and 01/14/2025 meetings, there were no interventions for monitoring for wandering safety for residents #61 and #83 to include the history of physical aggression between the two. <BR/>Resident #55<BR/>A record review of Resident #55's admission record revealed an admission date of 2/4/2021 with diagnoses which included corneal ulcer of the right eye, generalized anxiety disorder, dementia with behavioral disturbance. <BR/>A record review of Resident #55's annual MDS assessment dated [DATE] revealed Resident #55 was a [AGE] year-old male admitted for long term care and resided in the MCU. Resident #55 was assessed with a BIMS score of 00 which indicated severe cognitive impairment as evidenced by his inability to participate in the assessment. <BR/>A record review of Resident #55's care plan dated 1/28/2025 revealed, (Resident #55) has a behavioral concern of increased agitation physical and verbal aggression with the possibility of throwing things. 1/8/25: yelled and cursed at SW Date Initiated: 12/22/2022 Revision on: 01/09/2025 Intervene as needed to ensure resident safety. Date Initiated: 12/22/2022 Leave additional activities to keep resident engaged. (psych provider) eval/tx for psychological services. Refer to behavioral health. Date Initiated: 08/13/2024 Revision on: 08/13/2024 . Staff to redirect resident to other activities Date Initiated: 12/22/2022 Revision on: 12/22/2022<BR/>2. <BR/>During an interview and observation on 01/26/25 at 4:00 PM revealed LVN C entered the MCU and to exit the MCU and attended residents in the C-hall. LVN C stated she was assigned to work the MCU and the c-hall (rooms 34-46) which were located outside of the MCU. LVN C stated the MCU was also staffed by 1 CNA, who would stay in the MCU. <BR/>During an observation and interview on 1/27/2025 at 3:32 PM revealed CNA B exited the MCU, continued observation revealed the MCU was unattended. At 3:54 PM revealed CNA B returned to the MCU. CNA B stated he was the only staff in the MCU and had left the MCU briefly to return a meal tray to the kitchen. CNA B stated he was the CNA for the MCU and there was no nurse until 4:30 PM. CNA B stated the current nurse on duty was the DON and he was not in the MCU. CNA B stated if a Resident had aggression, he would be by himself, he would attempt to separate residents and then leave the MCU to go get help. CNA B stated if a Resident was discovered unresponsive, he would have to leave the unit to ask for help because he would not know who was a full code and/or a DNR. CNA B stated it was routine to be by himself due to the routine schedule which had a nurse to work 2 halls to include the MCU. CNA B stated his concern for aggressive and confused residents was for Resident #61 and Resident #83 history of physical aggression.<BR/>During an interview with DON and Administrator on 01/28/2025 at 4:10 PM, their plan for keeping residents safe was for staff to monitor wandering residents, separate aggressive residents, and leave the memory care unit to call for help.<BR/>A record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, revealed, Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.<BR/>The Administrator was notified on 1/29/2025 at 3:15 PM an IJ was identified on 1/29/2025 due to the above failures. The IJ template was provided to the facility on 1/29/2025 at 3:15 PM and was accepted on 1/30/2025 at 9:00 PM. <BR/>Plan of removal <BR/>Date 1/29/2025 (the Facility)<BR/>PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY<BR/>To Whom it May Concern, <BR/>Summary of details which leads to outcomes. <BR/>On 1/29/2025 sic(1/26/2025) annual survey was initiated at (The Facility). On 1/29/2025, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to residents' health.<BR/>The notification of the alleged immediate jeopardy states as follows:<BR/>F600 Abuse and Neglect<BR/>The facility neglected to have measures in place to keep residents in the memory care unit free from abuse.<BR/>Problem <BR/>On 01/11/2025 at 11 AM, Resident #61 wandered into Resident #83's room on the memory care unit. Resident #83 punched Resident #61 in the face, pulled Resident #61's hair, and dragged Resident #61 across the floor by his foot.<BR/>Immediate Corrections Implemented for Removal of Immediate Jeopardy.<BR/>Once the facility was made aware of the deficient practice, the Director of Nursing/ designee immediately ensured a second team member would be staffed in the memory care unit as of 1/28/2025. <BR/>The facility Director of Nursing/designee completed a 100% in-service for nursing staff over ensuring two staff members need to be in the memory care unit at all times, that one staff member needs to remain in memory care unit in the case of emergencies, and utilization of walkie talkies to promote communication between unit and general population. Walkie Talkies will be held by nursing staff member, as emergency communication back up, in the unit and the second by the licensed nurse that is floating between two units.<BR/>Identification of Others:<BR/>Residents identified at risk for deficient practice are the resident population residing in the memory care unit. <BR/>Systemic Changes<BR/>The Director of Nursing/ designee initiated immediate education with all licensed/certified nursing staff over staffing requirements for memory care unit, that one facility staff member needs to remain in memory care unit in the case of emergencies, and utilization of walkie talkies to promote communication between unit and general population. These educations are at 100% completion as of 1/28/2025. Staff who are on leave or off-site have been notified and provided education via phone call. <BR/>The Director of Nursing /designee initiated immediate education, by neuropsychologist, with all licensed/certified nursing staff over managing difficult behaviors, de-escalation strategies, and wandering/elopement on 1/29/2025. This education will be at 100% completion by 1/29/2025. Staff who are on leave or off-site have been notified and provided education via phone call. <BR/>The Director of Nursing/designee initiated immediate education with all facility staff over the Abuse, Neglect, Exploitation or Misappropriation Prevention Program on 1/29/2025. Staff who are on leave or off-site have been notified and provided education via phone call. <BR/>Administrator/designee will conduct monthly all-staff meetings, beginning on 2/12/25, during monthly in-service a specific aspect of behavioral care will be addressed: focus on de-escalation of behaviors, behavior management, wandering, dementia care and activities.<BR/>All education and training was sic(were) started on 1/28/2025 and will continue until all nursing staff have received training prior to the start of their work shift. <BR/>The facility Director of Nursing, Corporate Clinical Director and Administrator met on 1/28/2025 to evaluate the facility's staffing schedules and requirements regarding the memory care unit and general population. <BR/>All residents have access to behavioral health services. Residents with increased behaviors are identified by staff and provided with comprehensive behavioral health services to include medication management, counseling services, cognitive behavioral therapy, and neuropsych sic(neuropsychic) therapy.<BR/>The Director of nursing/designee will complete education and training with all licensed/certified nursing staff and newly hired licensed/certified nursing staff over facility's memory care unit staffing requirement. The education will be provided by DON or designee and be kept in the employees' HR file. <BR/>The Director of nursing/designee will complete Preferences for Activity and Leisure (PAL) Cards for all residents in the memory care unit to assist in managing challenging behaviors and de-escalation strategies such as providing triggers, providing comfort and familiarity, offering calming strategies, encouraging positive redirection, supporting non-verbal communication, building trust and rapport, etc. By integrating PAL Cards into daily care, staff can proactively prevent agitation and respond effectively when challenging behaviors arise, fostering a person-centered care environment. PAL Cards will be completed for all residents in memory care unit by 1/29/2025. All nursing staff will receive education on purpose and utilization of PAL Cards by 1/29/2025. <BR/>The Administrator, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by 1/29/2025 to review and address concerns related to the deficient practices identified in F600. Monitoring will include a system to ensure deficient practice is prevented and residents in the memory care unit will have sufficient supervision. The monitoring and oversight system will gather measurable data for review of patterns or trending. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. <BR/>Monitoring <BR/>The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all residents especially in the memory care unit are under appropriate supervision. This monitoring system will begin 1/29/2025. All concerns identified during the monitoring process will be addressed timely and staffing will be adjusted appropriately. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 3 months for this plan of correction. The administrator will be responsible for monitoring DON compliance with the system weekly. System compliance will be documented and discussed. <BR/>Administrator/designee will monitor use of walkie talkies every shift x 7 days then random audit daily x 3 months. Sign out log will be completed every shift to validate staff responsible for carrying and utilization of walkie talkies.<BR/>The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by 1/29/2025 to review and address concerns related to the deficient practices identified in F600, to include monitoring of PAL card use and compliance with utilization and updating as appropriate. <BR/>Clinical Director of Operations will in-service Admin and DON over deficient practice F600 Abuse and Neglect on 1/29/2025. Monitoring will be conducted weekly for 4 weeks to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. <BR/>Social Services/designee will attend daily meeting Monday - Friday to be made aware of any newly identified behaviors or concerns. Social Services/designee will assure necessary notification to behavioral health services are in place or make necessary appointments to have residents in need seen as soon as possible.<BR/>The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented.<BR/>Ad Hoc QAPI meeting will be held on 1/29/2025 with the Medical Director, Administrator and Director of Nursing to review and validate the plan of removal. <BR/>Involvement of Medical Director <BR/>The Director of Nursing notified the facility's Medical Director, of the Immediate Jeopardy tag on 1/29/2025.<BR/>The Administrator will be responsible for implementation of ensuring the adequate process regarding staffing requirements for increased supervision and minimize to support accident management. The new process/systems were initiated on 1/29/2025. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 1/29/2025.<BR/>Plan of Removal Verification <BR/>Intermittent observations on 1/26/2025, 1/27/2025, 1/28/2025, and 1/29/2025 from 8:00 AM to 10:00 PM revealed 13 residents resided in the MCU to include residents #55, #61, and #83.<BR/>During an observation and interview on 1/29/2025 at 1:30 PM it was revealed that CNA D and MA E were staffing the MCU. MA E and CNA D stated they were assigned to the MCU and if they needed help, they would stay in the MCU and call via the 2-way radios provided. MA E stated LVN C had the radio while she was out of the MCU providing care for other residents.<BR/>Observation on 1/30/2025 at 5:25 PM in the memory care unit had 2 CNA's and 1 nurse/CNA. <BR/>Observation and interview on 1/30/2024 at 5:26 PM revealed LVN R had the other walkie talkie and could use to communicate with the CNAs in the MCU.<BR/>Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B stated if one leaves the MCU, they can use the walkie talkie for emergency as well. Dr. x<BR/>During an observation on 1/29/2025 at 10:40 AM revealed Dr. X provided the in-service topic Understanding Dementia to staff in the facility's living room.<BR/>During an interview on 01/29/25 at 11:09 AM, Dr. X revealed he conducted an in-service to the facility staff on helping residents with dementia. He revealed some interventions he taught to include getting to know residents, getting to know their triggers, and adjusting resident care accordingly.<BR/>Record review of in-service/sign in sheet, dated 1/29/2025, reflected in-service topic Understanding Dementia with Facilitator Dr. X. further review revealed 54-staff signed the document. <BR/>Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B stated if one leaves the MCU can use the walkie talkie for emergency as well. <BR/>During an interview on 1/30/2025 5:29/2025 the DON stated he would hold an all-staff monthly meeting, beginning 2/12/2025, to cover aspects of behavioral care with a focus on de-escalation of behaviors, behavior management, wandering, dementia care and activities.<BR/>During an interview on 1/30/2025 at 5:38 PM the DON stated all the in-services have been completed for all staff and stated any staff who had not received the in service i.e., new staff, no one would be able to accept a work shift until they received the in service. <BR/>During an interview on 01/30/25 at 07:00 PM, the Administrator revealed he informed the DON will ensure 2 CNAs will be always staffed back in MCU. They revealed when a staff member did not come in as scheduled, they would make sure to fill this position in. They further revealed they were actively hiring and searching for new staff members to be adequately staffed. <BR/>Record reviews of facility schedules, from 1/26/2025 to 1/30/2025, revealed the following staff usually worked the following shifts: <BR/>6:00 AM - 2:00 PM <BR/>LVNs RNs:<BR/>DON<BR/>ADON<BR/>LVN C<BR/>CNAs:<BR/>CNA G<BR/>CNA F<BR/>CNA A<BR/>MA E<BR/>CNA H<BR/>CNA I<BR/>2:00 PM - 10:00 PM<BR/>LVN J<BR/>RN K<BR/>LVN L<BR/>LVN W<BR/>CNAs <BR/>CNA B<BR/>CNA M<BR/>CNA N<BR/>CNA O<BR/>CNA P<BR/>CNA Q<BR/>10:00 PM to 6:00 AM <BR/>Nurses<BR/>LVN R<BR/>RN S<BR/>CNAs<BR/>CNA T<BR/>CNA U<BR/>During an observation on 1/30/2025 at 1:55 PM of the MCU revealed CNA B and CNA U staffed the MCU. It was observed CNA B had on his person the 2-way radio and RN K had the other 2-way radio while she documented at the nurse's station located outside of the MCU. <BR/>Record review of Resident - to Resident Altercations (2022) and unmanageable residents (2010) policy, in- service, dated 1/11/2025, indicated there is to be 2 CNA's on A hall at all times. If there is an emergency, 1 aide needs to always stay with the resident /residents, while the other aide goes to help, there will be a walkie talkie to communicate with A hall nurse and A hall CNAs in case of emergency. The Walkie talkie needs to always stay with the employee during their shift. Walkie talkies will be checked every shift to ensure they are working properly. There will be a walkie talkie log to be initialed by nurses and CNA documenting they are working properly every shift signed by 53 staff, to include CNA A, CNA B, LVN C, CNA D, and MA E.<BR/>A record review of the facility's in- service dated 1/29/2025 titled Abuse and Neglect had 89 staff signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E.<BR/>A record review of the facility's in- service dated 1/29/2025 titled Understanding Dementia had 44 staff signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E.<BR/>A record review of the facility's in-service dated 1/29/2025 titled PAL (preference for activity and leisure) had 28 staff signatures.<BR/>Observation on 1/30/2025 at 7:03 PM revealed the MCU nurse station where the PAL (preference for activity and leisure) binder was located. The PAL (preference for activity and leisure) binder reve[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 (Resident #5) residents in that:<BR/>Resident #5's code status in chart did not match the care plan.<BR/>This failure could affect residents by not having their end of life met. <BR/>The Findings were:<BR/>Record review of Resident #5's admission Record dated 1/29/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), cognitive communications disorder. Further review revealed the resident had an advanced directive of DNR. <BR/>Record review of Resident #5's consolidated physician orders for January 2025 documented an order for full code (resuscitate).<BR/>Record review of Resident #5's significant change MDS dated [DATE] was documented her BIMS score was 13 out of 15 (cognitively intact).<BR/>Record review of Resident #5's psychosocial assessment dated [DATE] was documented she was a full code. <BR/>Record review of Resident #5's care plan dated 12/12/2024 was documented she was a DNR. Interventions were following facility protocol for identification of code status, and review code status quarterly.<BR/>Interview on 1/27/2025 at 2:01 PM with Resident #5 stated she wanted to be a Full Code. <BR/>Interview on 1/29/2025 at 12:24 PM with SW revealed she was hired on 11/2/2024 and confirmed Resident #5's the care plan did not match her order or admission Record. The SW stated she will check with the nurses to put in resident order. The SW stated she would ask the residents upon admission and quarterly assessments about their advanced directives. <BR/>Record review of Policy for care plan, Comprehensive Person-Centered dated March 2022 was documented, The Comprehensive Care Plan: includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident highest practicable physical, mental, and psychosocial wellbeing, Include the resident stated goals upon admission and desired outcomes.

**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 receives appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #50) reviewed for incontinent care in that: <BR/>While providing incontinent care for Resident #50, CNA D did not clean Resident #50's meatus (duct by which urine is conveyed) working outward. <BR/>This deficient practice could place residents at risk for infection and skin breakdown due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident # 50's face sheet dated 12/14/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory. [Schizophrenia] is a severe mental illness that affects how a person thinks, feels, and behaves, and [ Depressive disorder] is a mood disorder that causes a persistent feeling of sadness and loss of interest. <BR/>Record review of Resident # 50's Quarterly MDS dated [DATE], revealed Resident #15 had a BIMS score of 15, which indicated no cognitive Impairment. <BR/>Resident #50 was indicated to frequently be incontinent of bladder and bowel and needed limited to extensive assistance with his activities of daily living. <BR/>Review of Resident # 50's care plan dated 6/17/22, revealed a problem of Bladder Incontinence with interventions clean peri area with each incontinence episode. <BR/>Observation on 12/14/23 at 9:34 a.m. revealed that while providing incontinent care for Resident #50, CNA D did not wipe the peri area, starting with the meatus ( duct by which urine is conveyed ) and working outward. <BR/>During an interview on 12/14/2023 at 9:52 a.m. CNA D revealed that he was nervous and forgot to wipe the peri area, starting with the meatus ( duct by which urine is conveyed) and working outward. CNA D stated he should have wiped the peri area, starting with the meatus ( duct by which urine is conveyed) and working outward. CNA D said he had received incontinence care training within the last year. <BR/>Review of annual skills check for CNA D revealed CNA D passed competency for Perineal care/incontinent care on 04/18/2023.<BR/>During an interview with the DON on 12/14/2023 at 10:28 a.m., the DON stated that during the incontinent care of a male resident, Staff should wipe the peri area, starting with the meatus ( duct by which urine is conveyed) and working outward. The DON said she was doing annual incontinence care annual skills checks but did not do spot checks during the year. The DON stated that if staff performed peri care deviating from policy, residents risked possible urinary infections. <BR/>Review of facility policy, titled Perineal care, dated 2023, revealed Wipe Peri area male starting with the urethra and working outward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 nurse medication carts reviewed for security and supervision and for 3 of 8 residents (Residents #5, #81, and #85) reviewed for safe storage of insulins. <BR/>1. On [DATE] at 6:06 PM LVN J attended the nurse medication cart on the facility's D-hall and left the medication cart unsupervised and unlocked for 7 minutes while she left and provided care for a Resident. LVN J was out of line-of-sight with the nurse medication cart. <BR/>2. An inspection on [DATE] of the facility's treatment nurse medication cart revealed expired insulins for Residents #5, #81, and #85 as evidenced by the following:<BR/>a. Resident #5's liraglutide (an anti-diabetic medication used to treat type 2 diabetes, and chronic obesity) subcutaneous (under the skin) solution pen-injector was stored unrefrigerated, and available for administration, in the cart and was expired by 19 days. <BR/>b. Resident #81's 3 injection vials of insulin lispro 100u/ml, were available for administration, stored unrefrigerated, unlabeled with an expiration date, and were expired by as much as 59 days.<BR/>c. Resident #85's 1 injection vial of insulin lispro 100u/ml, was available for administration, stored unrefrigerated, labeled with an expiration date of 12/20, and was expired by 45 days.<BR/>These failures could place residents at risk for harm by not receiving the therapeutic effects of their insulins. <BR/>The findings included:<BR/>During an observation and interview on [DATE] at 6:06 PM revealed LVN J attended the nurse medication cart on the facility's D-hall and left the medication cart unsupervised and unlocked for 7 minutes while she left and provided care for a Resident. LVN J was out of line-of-sight with the nurse medication cart. Further observation revealed LVN J to return to the cart on [DATE] at 6:13 PM and stated she had left the cart unlocked and apologized as she locked the cart. <BR/>1. A record review of Resident #5's admission record dated [DATE], revealed an admission date of [DATE] with diagnoses which included type II diabetes (a long-term condition which results in too much sugar circulating in the blood. High blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.)<BR/>A record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care and assessed with a memory problem, Moderately impaired - decisions poor; cues / supervision required <BR/>A record review of Resident #5's care plan dated [DATE] revealed, Alteration in Blood Glucose due to hyper/hypoglycemia dx. DMII, . Date Initiated: [DATE] . Administer medications as ordered Date Initiated: [DATE] <BR/>A record review of Resident #5's physicians' orders dated [DATE] revealed the physician prescribed for Resident#5 to receive liraglutide 18mg/3ml, 1.2mg injected under the skin daily at 8:00 AM. <BR/>During an observation and interview on [DATE] at 10:30 AM revealed LVN Z attending the nurse treatment cart on the facility's D-hall and was preparing to administer insulins prior to the noon meal. LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed an insulin injection pen for Resident #5. The pen was labeled, liraglutide injection (Resident #5) 18mg/3ml, . date opened [DATE] .exp. [DATE] . discard pen 30 days after first use LVN Z stated she would not use the insulin pen because it was expired and would immediately discard the injection pen. <BR/>2. A record review of Resident #81's admission record dated [DATE] revealed an admission date of [DATE] with diagnosis which included type II diabetes.<BR/>A record review Resident #81's quarterly MDS assessment dated [DATE] revealed Resident #81 was a [AGE] year-old female assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #81's care plan dated [DATE] revealed, Potential for complication hypo hyperglycemia r/t DMII. Date Initiated: [DATE] . Medications/blood sugar check as ordered and as needed. Date Initiated: [DATE] <BR/>A record review of Resident #81's physicians' orders dated [DATE] revealed the physician prescribed for Resident #81 to receive insulin lispro 4 times a day at 6:30 AM, 11:30 AM, 4:30 PM, and at 8:00 PM, insulin lispro 100u/ml inject per sliding scale: if 0-150 = 0; 151 - 250 = 2; . 301-400 = 14 . subcutaneously before meals and at bedtime for diabetes <BR/>3. A record review of Resident #85's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes. <BR/>A record review of Resident #85's quarterly MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted for long term care and assessed with a memory care problem, Severely impaired - never / rarely made decisions <BR/>A record review of Resident #85's physicians' orders dated [DATE] revealed the physician prescribed for Resident #85 to receive insulin lispro three times a day at 6:30 AM, 11:30 AM, and at 4:30 PM, (insulin lispro) subcutaneously solution pen injector 100u/ml inject 10 unit subcutaneously before meals for diabetes <BR/>During an observation and interview on [DATE] at 10:30 AM LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed a plastic bag which contained 4 insulin injection pen refill vials. The bag was labeled, (Resident #81) (the facility) (insulin lispro) 100u/ml cartridge qty: 15, [DATE] . refrigerate Observation of the 4 vials revealed:<BR/>1. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #81's name, dated with an open date of [DATE], observed 2/3's full.<BR/>2. 3ml glass vial insulin lispro 100u/3ml labeled (Resident #81) [DATE] observed full.<BR/>3. 3ml glass vial insulin lispro 100u/3ml unlabeled with a resident's name, dated with an open date 12/20 (no year), observed full.<BR/>4. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #85's name, undated, no open date noted, observed &frac12; full. <BR/>LVN Z stated the vials were stored unrefrigerated, in a bag labeled Resident #81, however, LVN Z could not state who the insulin vials were intended for and could not state the date the vials were unrefrigerated. LVN Z stated she would discard the vials because they were unsafe to use. <BR/>During an interview on [DATE] at 1:10 PM the DON stated the expectations and trainings for nurses who administer medications to residents was for the medication cart to be locked anytime the nurse was away from the cart. The DON stated it was the individual nurse's responsibility to lock the cart anytime they left the cart unattended. <BR/>A record review of the facility's policy titled, Medication Labeling and Storage dated February 2023, revealed, The facility stores all medications and biologicals and locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to the keys. Policy interpretation and implementation: medication storage; . compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trains or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. H residence medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. medication labeling; labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration, and appropriate instructions and precautions. multi dose vials that have been opened or accessed (for example needle punctured) are gated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Multi dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 (Resident #5) residents in that:<BR/>Resident #5's code status in chart did not match the care plan.<BR/>This failure could affect residents by not having their end of life met. <BR/>The Findings were:<BR/>Record review of Resident #5's admission Record dated 1/29/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), cognitive communications disorder. Further review revealed the resident had an advanced directive of DNR. <BR/>Record review of Resident #5's consolidated physician orders for January 2025 documented an order for full code (resuscitate).<BR/>Record review of Resident #5's significant change MDS dated [DATE] was documented her BIMS score was 13 out of 15 (cognitively intact).<BR/>Record review of Resident #5's psychosocial assessment dated [DATE] was documented she was a full code. <BR/>Record review of Resident #5's care plan dated 12/12/2024 was documented she was a DNR. Interventions were following facility protocol for identification of code status, and review code status quarterly.<BR/>Interview on 1/27/2025 at 2:01 PM with Resident #5 stated she wanted to be a Full Code. <BR/>Interview on 1/29/2025 at 12:24 PM with SW revealed she was hired on 11/2/2024 and confirmed Resident #5's the care plan did not match her order or admission Record. The SW stated she will check with the nurses to put in resident order. The SW stated she would ask the residents upon admission and quarterly assessments about their advanced directives. <BR/>Record review of Policy for care plan, Comprehensive Person-Centered dated March 2022 was documented, The Comprehensive Care Plan: includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident highest practicable physical, mental, and psychosocial wellbeing, Include the resident stated goals upon admission and desired outcomes.

Based on observations, interviews and record review the facility failed to ensure the activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who- Is licensed or registered, if applicable, by the State in which practicing; and has completed a training course approved by the State for 1 of 1 facility in that:<BR/>Operations Manager stated no full time Activity Director. No full time Activity Director since November 2024.<BR/>This failure could result residents not having activities while residing in the facility. <BR/>The Findings were:<BR/>Interview on 1/26/2025 at 5:30PM with prn Activity Director (prn Activity Director) stated she was prn (as needed) Activity Director an comes in and does activities with Residents when she can. The prn Activity Director stated she calls different vendors from her house and comes to facility to do some activities, when she can.<BR/>Interviews with the Resident Council stated they did not have an Activity Director and they try to figure out what to do for the day. Resident council stated they left us in limbo with no Activity Director. <BR/>Interview on 1/27/2025 at 2:35 PM Resident #22 stated the facility had not had an Activity Director for a few months and the prior Activity Director comes when she can. Resident #22 stated she announces Bingo and some vendors come for activity program but were not at facility all day. Resident #22 stated she tries to gather resident for Activities, so it won't be boring and do not have a structured Activity program at the facility. Resident #22 stated the vendors for Activities come for an hour a day.<BR/>Interview on 1/27/2025 at 4:07 PM with Ombudsman AC stated the previous Activity Director left in November 2024. <BR/>Interview on 1/27/2025 at 5 PM the Operations Manager stated they did not have a full time Activity Director and was in the process of hiring an Activity Director. The Operations manager stated they had not had an Activity Director for a few months. <BR/>Interview on 1/29/2025 at 3:14 PM CNA F stated the prior Activity Director had not been full time since November 2024. CNA F stated since the Activity Director had not been at the facility, it had not been the same, some residents gather themselves to play bingo, watch TV, color and church group comes and vendors come to visit for a few hours a day. <BR/>Record review of the job description for Director of Activities (no date) was documented The primary purpose of the position is to plan, organize, and direct a program of activities which provide opportunities for entertainment, exercise, relaxation, and expression and fulfills basic psychology, social and spiritual needs which will be available to all residents of the facility while delivering on the facilities values of wellness, compassion, customer experience and company results. Maintain all activity related records required by regulations and Medical Records Department-activity assessment, progress notes and discharge summary. Activity Calendar Duties include, plan, develop, organize, implement, evaluate and direct the activity programs of the facility, oversee day to day activities of resident in the facility.<BR/>Record review of the admission policy (no date) was documented, exhibit 2 items and services included in the daily Medicaid Rate-Activities, participation in a group setting and on an individual basis, as selected by the resident.