GOLDEN ACRES LIVING AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with accommodation of resident needs and preferences for 1 of 30 residents (Resident #255) reviewed for reasonable accommodation of needs.<BR/>The facility failed to ensure the call light system was within reach of the Resident #255 lying in bed.<BR/>This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers.<BR/>Findings included:<BR/>A record review of Resident #255's MDS assessment dated [DATE] reflected Resident #255 was a [AGE] year-old male with a BIMS score 03 of 15, indicating severe cognitive impairment. Resident #255 was admitted to the facility on [DATE] with the diagnoses of Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), seizures disorder, and depression. The review further reflected the resident was totally dependent on staff for the ADL's (activity of daily living).<BR/>A record review of Resident #255's Comprehensive Care Plan dated 10/28/24 reflected Focus. At risk for falls r/t dementia, seizures, and history of CVA. Goal. Will not sustain serious injury through the review date. Interventions. Be sure the call light is within reach and encourage to use it to call for assistance as needed. <BR/>Observation on 10/28/24 at 11:39 AM Resident#255 was lying in bed and trying to get up. Resident#255 stated he wanted to pee. Resident#255's call light was on top of the nightstand. Resident#255 could not reach the call light, this state surveyor pressed the resident call light, and LVN E entered the room to answer the call light. This state surveyor pointed to the call light on the nightstand. LVN E stated the call light was not within reach of Resident#255 and took the call light from the nightstand and placed it next to Resident#255 in the bed. LVN E called an aide to take Resident#255 to use the bathroom.<BR/>Interview on 10/28/24 at 11:41 AM LVN E stated the call light was not within reach of the Resident#255. LVN E stated the call light should be within residents reach at all times, and risk to the resident not getting help on time could be a fall and possible injury. LVN E stated it was the responsibility of all the staff to make sure the call light was within resident reach before exiting the room.<BR/>Interview on 10/30/2024 at 2:11 PM the DON stated all call lights needed to be always within reach of the resident. The DON stated the call light in the resident's bathroom should be next to the toilet and within resident use, even if the resident was lying in the floor. The DON stated the call light pull string should be going straight from the wall outlet down, and not hanging or intertwined on the fixtures. The DON stated the risk to the residents, if they cannot reach the call light, they could not call for help, and they will not get the help they needed.<BR/>Interview on 10/30/24 at 3:44 PM the Administrator stated all the call light pull strings in the secured unit had been fixed, and they were no longer too long and dragging on the floor. He stated the staff had been reeducated to report any issue with the call light system to the Maintenance Supervisor. The Administrator stated the risk to residents, if the call light was not within resident reach or did not work properly, the residents could not call for help. <BR/>Review of the facility policy titled policy/Procedure-Nursing services. Section: Routine Procedures- Subject: Call Light/Bell, revised 05/2007 revealed It is the policy of(to provide the resident a means of communication with nursing staff . 5. Place the call device within resident's reach before leaving room. If call light/bell defective, immediately report this information to the unit supervisor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #60, Resident 86, Resident #89, and Resident #114) of 8 residents reviewed for ADLs. <BR/>The facility failed to ensure:<BR/>1- Resident #60 had his fingernails trimmed and cleaned.<BR/>2- Resident #86 had her fingernails' bed cleaned.<BR/>3- Resident #89 had her fingernails trimmed.<BR/>4- Resident #114 had his fingernails trimmed and cleaned.<BR/>This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>1- Review of Resident #60's Quarterly MDS assessment dated [DATE] reflected Resident #60 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), contracture unspecified joint, muscle weakness, lack of coordination, and need for assistance with personal care. Resident #60's BIMS not assessed. Resident #60 required extensive assistance of one-person physical assistance with dressing, and personal hygiene.<BR/>Review of Resident #60's Comprehensive Care Plan, revised 01/18/23, reflected the following: Focus: Resident at risk for an ADL self-care performance deficit related to cerebral infarction and lack of coordination and weakness. Goal: will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene with supervision, independence, modified independence through the review date. Intervention: Personal hygiene: Requires total assistance with personal hygiene care. <BR/>An observation on 08/24/23 at 9:30 AM revealed Resident #60 was sitting in his wheelchair. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails on the left hand were chipped. Resident #60 stated he did not like his nails long. He stated he did not tell anybody about his nails. <BR/>2- Review of Resident #86's Quarterly MDS assessment, dated 08/01/2023, reflected Resident #86 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia, lack of coordination and type 2 diabetes mellitus. Resident #86 BIMS not assessed. Resident#86 required extensive assistance of one-person physical assistance with dressing, transfers, and personal hygiene.<BR/>Review of Resident #86's Comprehensive Care Plan revised 07/31/23 reflected the following: Focus: ADL self-care performance deficit related to decline in function, poor mobility, and weakness. Goal: the resident will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: Encourage to participate to the fullest extent possible with each interaction. <BR/>Observation on 08/24/23 at 9:35 AM revealed Resident #86 was laying in her bed. The nails' beds, on both hands, had dark brown color. Resident #86 was unable to answer questions.<BR/>3- Review of Resident #89's Comprehensive MDS assessment, dated 08/10/2023, reflected Resident #89 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included muscle weakness, lack of coordination, and physical debility (general weakness or feebleness that may be a result or an outcome of one or more medical condition). Resident #89 had a BIMS of 09 which indicated Resident #89's cognition was moderately altered. Resident#89 required extensive assistance of one-person physical assistance with dressing, and personal hygiene.<BR/>Review of Resident #89's Comprehensive Care Plan revised 03/09/23 reflected the following: Focus: resident#89 has an ADL self-care performance deficit r/t functional decline secondary to hypertension, and heart failure. Goal: Will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: Encourage to participate to the fullest extent possible with each interaction. <BR/>Observation and interview on 08/24/23 at 9:39 AM revealed Resident #89 was laying in her bed. The nails on both hands were approximately 0.7cm in length extending from the tip of her fingers. Resident #89 stated that she did not like her nails very long because they bother her. Resident #89 stated I have to tell them, if I don't keep asking, they would not do it.<BR/>4- Review of Resident #114's Quarterly MDS assessment, dated 07/04/2023, reflected Resident #114 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain [NAME] to problems with the blood vessels that supply it), muscle weakness, and lack of coordination. Resident #114 had a BIMS of 5 which indicated Resident #114's cognition was severely altered. Resident#114 required extensive assistance of one-person physical assistance with bed mobility, dressing, and personal hygiene.<BR/>Review of Resident #114's Comprehensive Care Plan revised 02/28/23 reflected the following: Focus: resident#114 has an ADL self-care performance deficit r/t weakness, poor safety awareness, cognitive impairment. Goal: Resident #114 will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: encourage to participate to the fullest extent possible with each interaction. <BR/>Observation on 08/24/23 at 9:45 AM revealed Resident #114 was laying in his bed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #114 was unable to answer questions.<BR/>Interview on 08/24/23 at 9:52 AM, CNA K stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA K stated she would clean Resident #86 fingernails and she would clean and trim Resident #89 and Resident#114's nails right then. <BR/>Interview on 08/24/23 at 10:00 AM, LVN J stated CNAs were responsible to clean and trim residents' nails during the showers. LVN J stated only nurses cut residents' nails if they were diabetic. LVN J stated no one notified her Resident #86, Resident #89, and Resident #114's nails were long and dirty, and she had not noticed the nails herself. LVN J stated Resident#86 was diabetic and she would clean her nails.<BR/>Interview on 08/24/23 at 11:26 AM, CNA I stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA I stated she would clean and trim Resident #60's fingernails.<BR/>Interview on 08/24/23 at 11:30 AM, LVN A stated CNAs were responsible to clean and trim residents' nails during the showers. LVN A stated only nurses cut residents' nails if they were diabetic. LVN A stated she had not noticed the nails of Resident #60. LVN A stated she would clean and trim his nails.<BR/>Interview on 08/24/23 4:46 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. The DON stated she was responsible to do routine rounds for monitoring. <BR/>Record review of the facility's policy titled ADL, Services to carry out, revised July 2013, reflected Procedures: . 2- If a resident is unable to carry out activity of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff .

Based on observations, interviews, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #104) of 2 residents reviewed for catheter care.<BR/>The facility failed to ensure CNA B kept Resident #104's urine catheter bag below the level of the bladder during incontinent care.<BR/>This failure could place residents at risk for urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #104's Quarterly MDS assessment, dated 10/09/24, reflected an admission date of 09/25/22. Resident #104 had a BIMS score of 09, meaning her cognition was moderately impaired. She required maximal assist with ADLs. Resident #104's active diagnoses included reflux uropathy (condition where urine flows backward from the bladder into the ureters and sometimes the kidneys), diabetes mellitus, and Alzheimer's disease.<BR/>Record review of Resident #104's care plan, dated 06/22/23, reflected . [Resident#104] has indwelling catheter . Goal: will show no sign/symptoms of urinary infection . Interventions included .Position catheter bag and tubing below the level of the bladder and away from entrance room door . <BR/>Review of Resident #104's Physician Orders Report dated 10/30/24 reflected, . Change foley catheter monthly on 15 day of each month . every shift starting on the 15th and ending on the 15th every month. With start date of 08/15/24.<BR/>Observation on 10/30/24 at 11:08 AM revealed CNA B , and CNA G entered Resident #104's room. Both staff performed hand hygiene, and donned gowns and gloves. CNA G uncovered Resident #104 and unfastened the resident's brief. CNA B cleaned Resident #104's front pubic area with wipes, using one wipe per stroke. CNA B placed Resident #104's urinary catheter drainage bag on the bed by the resident's feet. Both CNAs assisted the resident to turn on her right side. CNA B cleaned the resident's buttocks using peri-wipes, she removed and discarded the dirty brief, and she put a clean brief under the resident. Both CNAs assisted Resident #104 back on her back. Urine was observed backing up in the tubing back toward the resident's bladder. Both CNAs fastened the brief. CNA B hooked the urinary catheter drainage bag, back on the right side of the bed. CNA G covered Resident #104. Both CNA removed gloves and gowns, washed hands, and left the room.<BR/>In an interview on 10/30/24 at 12:06 PM, CNA B stated the urinary drainage bag was to be always kept below the resident's bladder. CNA B stated she knew better but she worried to pull the tubing. She stated by failing to keep the bag under the bladder level it would put the resident at risk for urinary tract infections. <BR/>In an interview with the DON on 10/30/24 at 02:30 PM she stated the catheter was to be maintained below the level of the bladder. She stated placing the drainage bag on the bed was not maintaining it below the bladder. She stated by not keeping it below the bladder urine could back up into the bladder and increase the risk of urinary tract infections. She stated she would do skills check on nursing staff and the ADON would do random checks to monitor staff.<BR/>Record review of CNA B's skills verification checklist dated 09/04/24 reflected she was competent in Peri-care-Foley catheter tubing care. <BR/>Record review of the facility's policy titled, Catheter Care, Indwelling, revised May 2017, reflected, .Purpose: To promote hygiene, comfort, and decrease risk of infection for catheterized residents . Procedure . 12. Keep tubing below level of bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 of 5 residents (#343) reviewed for respiratory care in that:<BR/>The facility failed to ensure Resident #343 nasal tubing and oxygen water container for her oxygen concentrators were dated. <BR/>These deficient practices could affect residents who received oxygen therapy and serve as a source of infection.<BR/>Findings included:<BR/>Record review of Resident #343 Face Sheet, dated 08/23/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included: Cerebral infarction (stroke), bacteremia (bacteria in the blood), pneumonia (infection of the lungs), Type 2 Diabetes Mellitus (changed in sugar levels of the blood) without complications, Acute chronic respiratory failure with hypoxia (not enough oxygen in your blood or too much).<BR/>Review of Resident #343 Quarterly MDS, dated [DATE] reflected a BIMS score of 9 indicating moderate cognitive impairment, oxygen use for respiratory disease, infection, and pneumonia. Resident required extensive assistance of two staff with bed mobility and toileting, transport and with ADLs.<BR/>Record review of Resident #343's MD orders dated 8/16/23 revealed change o2 tubing & humidifier bottle every night shift every Wednesday .Check oxygen levels every shift or as needed. 02 at 3L via nasal cannula every shift for oxygen related to Acute respiratory failure. There was no order for the change of nasal cannula.<BR/>Record review of Resident #343 Comprehensive Care Plan dated 08/16/23 revealed Resident #343 has an infection of respiratory tract pneumonia and interventions .Resident has oxygen therapy related to acute and chronic respiratory failure. On antibiotic therapy for infection bacteremia .ADL self-care performance deficit related to decline in function, poor gate and balance and weaknesses of bilateral leg .dependent on staff for cognitive stimulation related to limited physical limitation.<BR/>In an observation on 08/22/23 at 11:55 AM of Resident #343's nasal cannula tubing and oxygen concentrator bottle were not dated and labeled.<BR/>In an interview with Resident #343 on 08/22/23 at 11:55 AM she stated that she did not remember when the nurses changed her tubing. She said she was not having in complications breathing only nausea and decreased appetite. <BR/>In an interview on 08/22/23 at 12:05 PM with Resident #343's family member revealed she was not sure when the oxygen was administered, and that the resident had only been here for one week. She said she had not observed staff coming and checking the machine. <BR/>In an interview on 08/24/23 at 3:39 PM with the ADON revealed it was her expectation for staff to change tubing and oxygen water supplies and date them upon completion to communicate to all nursing staff that the task was completed and the to date when the tubing and fluid was changed, as overuse of tubing can lead to leaks and cuts, unsanitary and dryness from the lack of liquid causing great discomfort.<BR/>In an interview with the DON on 08/24/23 at 4:40 PM revealed she expects the nursing staff to date tubing to prevent infection prevention incidents and notify and document the change in equipment electronically. It is the responsibility of the charge nurse and ADON to conduct rounds and assess that the items have been changed and dated properly. <BR/>In an interview on 08/24/23 at 5:19 PM with the Administrator he stated that the nursing staff are expected to follow the policy and procedures for medical task and monitoring of equipment care assuring sanitation protocols were conducted to provide quality of care for all residents. <BR/>Record review of the facility's policy titled licensed Nurse Procedures .Oxygen Equipment dated oxygen, policy dated 05/2017 reflected: .Tubing and cannulas should be dated and replaced every 7 days according to the manufacturer recommendation, or as needed.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of three residents reviewed for infection control. <BR/>Housekeeper A failed to properly doff her PPE according to CDC guidelines when leaving Residents #2's room after cleaning it . <BR/>This failure placed residents at risk for the spread of infection.<BR/>Findings included:<BR/>Observation and Interview on 06/29/23 beginning at 11:40 AM of Housekeeper A entering a room which indicated isolation on the door and coming out of the room with the PPE on and getting a cleaning item off her cart and going back into the resident room. Housekeeper A then came out of the room with the PPE on disposed of the gown first, gloves and then the mask in the housekeeping cart and sanitized her hands. The housekeeping cart was kept near the room and did not enter another resident room. There was no staff, resident or visitor observed on the hall. Interview with Housekeeper A revealed she had worked in the facility for 1 month. Housekeeper A stated when she completed her cleaning in a quarantine room she would dispose of the PPE outside of the room and would put on new PPE before entering another room. Housekeeper A revealed she put the PPE in a trash bag and disposed of it outside the facility. <BR/>Interview on 06/29/23 at 3:30PM with the DON revealed she had worked in the facility for 9 years. She stated she was responsible for making sure all staff were properly trained on how to Donn(put on) and Doff( take off) PPE. The DON stated Housekeeper A is agency staff and each morning the agency staff are in - serviced on the infection control policy and procedure. The DON revealed staff are in serviced monthly and annually for infection control. She stated the risk of not correctly Doffing PPE that COVID could be spread throughout the building.<BR/>Record review of Resident #1's care plan date initiated 6/19/23 by DON revealed focus COVID positive with symptoms of coughing and generalized weakness. Interventions, activity as tolerated, droplet precautions per protocol, emphasize good hand washing techniques to all direct care staff, encourage coughing, deep breathing, encourage fluid intake, give anitpyretics as ordered.<BR/>Review of nursing note dated 06/19/23 completed by the DON revealed Resident was tested for COVID and result showed positive. She has[sic] shows signs ans symptoms of coughing and general malaise.<BR/>Review of nursing note dated 06/28/23 revealed Evaluation being completed due to confirmed COVID -19 diagnoses. Resident has transmisson based precautions maintained. Resident is in room alone due to active infection.<BR/> Review of the facility policy Infection control and prevention: emerging infectious disease: coronavirus 2019 dated 3/9/20 revealed HPC must receive training on and demonstrate an understanding of when to use PPE; what PPE is necessary how to properly don, use and doff PPE in a manner to prevent self-contamination: how to properly dispose of or disinfect and maintain PPE and the limitations of PPE. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. Gloves: remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns: Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (Resident #1) of five residents reviewed for residents' rights. <BR/>The facility failed to ensure temperatures in Resident#1's room, were not above not the acceptable range (81 degrees Fahrenheit) for resident safety and comfort.<BR/>These failures increase the risk of the residents experiencing decreased the comfort and affect the wellbeing of residents<BR/>Findings included:<BR/>Record review of the face sheet for Resident #1 revealed an 74- year- old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, chronic obstructive pulmonary disease ( a group of diseases that cause airflow blockage ad breathing-related problems), thrombocytopenia (a condition that occurs when the platelet count in your blood is too low), acute respiratory failure with hypercapnia(happens when you have too much carbon dioxide in your blood).<BR/>Review of the MDS completed 6/9/23 did not include a BIMS Score<BR/>Interview on 06/29/23 10:25AM with Resident #1 revealed she had lived in the facility for one year. Resident #1 stated the air was not working in her room and she informed the Maintenance Supervisor of the issue on 06/28/23 which was when the unit went out. Resident #1 was informed by Maintenance Supervisor that she would need to remove all items from in front of the air conditioner before it could be serviced. Resident #1 stated she did have the portable air conditioner which she had always had however with her main air conditioning unit not working, the portable air conditioner was not keeping the room cool. <BR/>Interview on 06/29/23 at 11:00AM with the Maintenance Supervisor stated the temperature of the rooms were taken only if the resident complained about the temperature of the room. The Maintenance Supervisor revealed Resident #1 complained to him on 6/28/23 about the air being broken in the room however no one had looked at the air yet due to the resident needing to move items from in front of the air conditioner. The Maintenance Supervisor stated he had not put in a work order for the air conditioner in Resident #1's room due to not assessing the air conditioner yet. The Maintenance Supervisor took the temperature of the room which was 83 degrees Fahrenheit. The Maintenance Supervisor stated the temperature in resident rooms should have been no warmer than 74 degrees. The Maintenance Supervisor stated when room temperatures were past 74 degrees Fahrenheit, there could have been a risk for health complications. <BR/>Interview on 06/29/23 at 3:30PM with the Administrator revealed he had spoken with the Maintenance Supervisor regarding fixing the air conditioner in Resident #'1 room today (6/29/23). The Administrator stated he had in- serviced the Maintenance Supervisor regarding completing and submitting work orders. The Administrator stated he would also investigate to determine why the work order was not complete when Resident #1 informed the Maintenance Supervisor about the air conditioner not working. The Administrator stated there was a risk of health conditions for residents when room temperatures rise above 81 degrees. The Administrator revealed it was the responsibility of the Maintenance Supervisor to ensure the Resident #1's air conditioner was working properly. The Administrator stated Resident #1 was asked on 6/29/23 if she wanted to move to another room until the air conditioner was fixed however Resident #1 refused and stated she was ok in her room.<BR/>Review of the facility policy Resident rights, policy number NARR01 dated revised 05/2007 did not discuss clean and comfortable living environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident representative for 1 of 4 residents (Resident #1) reviewed for changes in condition.<BR/>The facility failed to notify Resident # 1's family member of continued emesis and a subsequent order for Resident # 1 to be sent out to the hospital. <BR/>This deficient practice could result in denial of resident rights of family to be notified with any change of status. Failure to notify family members of significant change of status could affect any resident at risk for hospitalization.<BR/>Findings included:<BR/>Record review of Resident # 1's admission Record dated [DATE] revealed a 53- year-old male who admitted to the facility on [DATE] and expired on [DATE]. His diagnoses included chronic obstructive pulmonary disease (causes airflow blockage and breathing problems), Type 1 Diabetes (chronic condition in which the pancreas produces little or no insulin), Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar), Indeterminate colitis (chronic digestive disease), rheumatoid arthritis (immune system attacks healthy cells in body causing pain & swelling), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, Stage 3 chronic kidney disease, heart disease, myocardial infarction (heart attack), and legal blindness. <BR/>Record review of Resident # 1's Order Summary Report dated [DATE] revealed the resident had an order for DNR/Do Not Attempt Resuscitation with an order date oof [DATE]. Resident # 1 had PRN orders for both Meclizine and Ondansetron (AKA Zofran), for the treatment of nausea and vomiting. <BR/>Record review of Resident # 1's Progress Note dated [DATE] at 4:50 AM written by LVN B revealed, Resident put on call light and upon entering room he stated he had thrown up. Observed a small amount of emesis that was clear-brown tinged. Resident was administered Zofran 2 hours prior to episode. Resident stated he did not want to eat dinner because he felt nauseous since lunch time. Checked blood glucose and it was 144/DL. Resident vs was 130/70, 69 (HR), 97.0 (temp), Spo2 98%. No signs of distress. Will continue to monitor. Will report to oncoming staff.<BR/>Record review of Resident # 1's Progress Note dated [DATE] at 8:45 AM written by LVN A revealed, Entered resident room resident alert and oriented no episodes of nausea or vomiting noted. Blood sugar 272 at this time. Head of bed raised 90 degrees.<BR/>Record review of Resident # 1's Progress Note dated [DATE] at 11:30 AM written by LVN A revealed, Entered resident room, resident noted to have episode of vomiting. Light brown tinged emesis noted on resident alert and oriented. Resident states he vomited and doesn't feel good. PRN Ondansetron administered at this time. Will continue to monitor.<BR/>Record review of Resident # 1's Progress Note dated [DATE] at 11:41 AM written by LVN A revealed, Head to toe assessment completed on resident, resident in bed, head of bed raised 90 degrees. Resident alert and oriented xs3. Aware of situation and surroundings. No shortness of breath or labored breathing noted. Abdomen soft and non-distended resident last known bowel movement was [DATE]. NP [name] was present in the facility notified of resident having episode of vomiting and condition. Order given to send resident to ER for further evaluation.<BR/>Record review of Resident # 1's Progress Note dated [DATE] at 12:50 PM written by LVN A revealed, Entered resident room, resident noted to have no respirations. Unable to obtain vital signs. at this time. Resident has DNR code status order. NP [name] Called and notified of resident findings.<BR/>Record review of Resident # 1's Progress Note dated [DATE] at 2:02 PM written by RN C revealed, Resident lying supine in bed,pupils fixed and dilated,no chest movement noted,no pulse and no B/P,PRONOUNCED AT 13:45 PM.<BR/>The progress notes did not indicate that Resident # 1's family was notified of the continued emesis that prompted the NP to order for him to be transferred to the hospital for further evaluation. <BR/>An interview with Resident # 1's family member on [DATE] at 6:24 PM revealed the facility did not notify her that there was an order for Resident # 1 to be sent out to the hospital. She stated she was not contacted by the facility until 2pm on [DATE] when they called to inform her that Resident #1 had expired. <BR/>An interview with LVN A on [DATE] At 11:36 AM, revealed anything about labs or patient condition changing from their baseline would constitute calling the family to notify of a change in condition. LVN A stated that if he called a family, he would document it. LVN A stated on [DATE] Resident #1 was having nausea and vomiting, his vitals were normal. LVN A stated he informed the nurse practitioner who subsequently ordered for Resident # 1 to be sent to the hospital. LVN A stated he called for non-emergency transport because Resident # 1's vital signs were normal. LVN A stated after he called for transport, he went back to assess Resident #1 and found that he did not have vital signs or respirations. LVN A stated the emesis would constitute a change of condition. LVN A stated he remembered calling the family of Resident #1 or perhaps it was the nurse (LVN B) that worked before his shift started that day that informed the family of the emesis. <BR/>An interview with the DON on [DATE] at 12:06 PM revealed Resident # 1 always had emesis on an doff and that is why he had a PRN order for Zofran (a nausea medication). The DON stated one episode of emesis was not a change of condition for Resident #1; only continuous emesis with the color of ground coffee would be a change of condition. The DON stated the night nurse (LVN B) notified Resident # 1's family member that he was having emesis. The DON stated the documentation was not here, so there was an assumption that it was not done.<BR/>An interview with LVN B on [DATE] at 1:02 PM, revealed she did not see Resident # 1's emesis as a change in condition. If the emesis was coffee ground in color and it was a large amount, she would see it as severe and notify the physician and the family. LVN B stated Resident # 1 only had a small amount of emesis and it was clear mucous on her shift. LVN B stated she did not call Resident# 1's family. She stated while she was waiting to be relieved from her shift the morning of [DATE] Resident #1's family member called the facility, and she answered the phone. LVN B stated she spoke with the family member briefly, informed her about the small emesis and that Zofran was given, and told the family member that LVN A would call her back. <BR/>An interview with ADM on [DATE] at 1:51 PM revealed LVN A should be notifying and documenting in the notes. The ADM stated the facility talked to Resident # 1's family member, but it was not documented so the DON went back to document on [DATE]. The ADM stated there should have been a follow up call to the family when the NP said to send Resident #1 out. The ADM stated it was their procedure for the nurse to document and they had started in-servicing staff on documentation.<BR/>An interview with the NP on [DATE] at 9:38 AM revealed the nurse had informed her that Resident #1 had emesis but did not have shortness of breath, nor was in distress. When the emesis happened the second time in a short while, the NP stated she told the nurse to send him out for an ER evaluation because of his history of hospitalization due to colitis a few years ago. The NP stated depending on the condition, if the resident was alert, not in distress, and had no shortness of breath, the resident would be considered stable so non-emergency transport would be reasonable. She stated only if there were signs of distress would a 911 call be needed.<BR/>Record Review of facility's policy titled, Change of Condition Reporting, dated 5/2007, revealed, Acute Medical Change .3. The responsible party, POA, or guardian will be notified that there has been a change in the resident's condition and what steps are being taken .Routine Medical Change 7. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (Resident #1) of five residents reviewed for residents' rights. <BR/>The facility failed to ensure temperatures in Resident#1's room, were not above not the acceptable range (81 degrees Fahrenheit) for resident safety and comfort.<BR/>These failures increase the risk of the residents experiencing decreased the comfort and affect the wellbeing of residents<BR/>Findings included:<BR/>Record review of the face sheet for Resident #1 revealed an 74- year- old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, chronic obstructive pulmonary disease ( a group of diseases that cause airflow blockage ad breathing-related problems), thrombocytopenia (a condition that occurs when the platelet count in your blood is too low), acute respiratory failure with hypercapnia(happens when you have too much carbon dioxide in your blood).<BR/>Review of the MDS completed 6/9/23 did not include a BIMS Score<BR/>Interview on 06/29/23 10:25AM with Resident #1 revealed she had lived in the facility for one year. Resident #1 stated the air was not working in her room and she informed the Maintenance Supervisor of the issue on 06/28/23 which was when the unit went out. Resident #1 was informed by Maintenance Supervisor that she would need to remove all items from in front of the air conditioner before it could be serviced. Resident #1 stated she did have the portable air conditioner which she had always had however with her main air conditioning unit not working, the portable air conditioner was not keeping the room cool. <BR/>Interview on 06/29/23 at 11:00AM with the Maintenance Supervisor stated the temperature of the rooms were taken only if the resident complained about the temperature of the room. The Maintenance Supervisor revealed Resident #1 complained to him on 6/28/23 about the air being broken in the room however no one had looked at the air yet due to the resident needing to move items from in front of the air conditioner. The Maintenance Supervisor stated he had not put in a work order for the air conditioner in Resident #1's room due to not assessing the air conditioner yet. The Maintenance Supervisor took the temperature of the room which was 83 degrees Fahrenheit. The Maintenance Supervisor stated the temperature in resident rooms should have been no warmer than 74 degrees. The Maintenance Supervisor stated when room temperatures were past 74 degrees Fahrenheit, there could have been a risk for health complications. <BR/>Interview on 06/29/23 at 3:30PM with the Administrator revealed he had spoken with the Maintenance Supervisor regarding fixing the air conditioner in Resident #'1 room today (6/29/23). The Administrator stated he had in- serviced the Maintenance Supervisor regarding completing and submitting work orders. The Administrator stated he would also investigate to determine why the work order was not complete when Resident #1 informed the Maintenance Supervisor about the air conditioner not working. The Administrator stated there was a risk of health conditions for residents when room temperatures rise above 81 degrees. The Administrator revealed it was the responsibility of the Maintenance Supervisor to ensure the Resident #1's air conditioner was working properly. The Administrator stated Resident #1 was asked on 6/29/23 if she wanted to move to another room until the air conditioner was fixed however Resident #1 refused and stated she was ok in her room.<BR/>Review of the facility policy Resident rights, policy number NARR01 dated revised 05/2007 did not discuss clean and comfortable living environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #32) of three residents reviewed for care plans. <BR/>1. The facility failed to care plan significant weight loss of -16.4 pounds (- 7.5%) in 3 months that was triggered on 8/3/2023 for Resident #32.<BR/>This failure placed residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings included: <BR/>Review of MDS assessment dated [DATE] for Resident #32 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of Type 2 Diabetes Mellitus, Cognitive Communicative deficit, Muscle weakness, Unspecified Protein Calorie Malnutrition, Unspecified Non-Alzheimer's Dementia, Dysphagia (difficulty swallowing), Essential hypertension, Anxiety Disorder, Bipolar disorder. Resident # 32 required extensive assistance with toilet use and personal hygiene. The resident's height was 5 feet 4 inches, and weight was 176 pounds on 8/9/2023. Resident # 32 Ideal body weight was 130 pounds (+/-10%).<BR/>Interview with Resident # 32 on 08/22/23 at 2:12 PM revealed that he thinks he may have lost weight but was not sure about his usual body weight. <BR/>Observation of Resident # 32 on 08/23/23 at 09:15 AM, revealed Resident # 32 was eating breakfast in his room. Observation revealed Resident #32 ate about 60% of his breakfast.<BR/>Interview with CNA F on 8/23/23 at 1:19 PM revealed Resident #32 ate 60% of his lunch. CNA F stated he had not observed any weight loss on the resident. Interview with CNA F revealed Resident # 32 ate well at most times in his room. <BR/>Interview with LVN B on 08/23/23 at 1:30 PM revealed that Resident#32 ate well at most times. LVN B revealed she had seen new Dietitian notes for including house shakes on the resident. <BR/>Interview with Dietitian on 8/23/23 at 1:57 PM revealed that she was aware of the Resident # 32's weight loss and documented it on a progress note on 8/4/2023. The Dietitian stated she had interventions in place such as offering house supplements. Interview revealed weekly weights were usually done by the Director of Nursing (DON)/Restorative Nurse Assistant. The Dietitian stated weight loss was rapid and supplements were offered to begin immediate intervention. <BR/>Record Review of Dietitian progress note dated 8/23/23 for Resident #32 at 2 revealed the Dietitian documented on 8/4/2023 that Resident # 32 had significant weight loss of 12.9# (pounds) 6.8% X 1 month, 16.4# 7.5% X 3months, 25.7# 12.7% X 6 months. Resident #32 was on Low Concentrated sweet / thin liquid diet. Food intake documented as 50-100% with varying assistance needed. Review revealed the Dietitian recommended house supplement 4 oz twice a day to provide additional calories and protein. <BR/>Interview with Restorative Nurse Assistant on 08/23/23 at 02:11 PM revealed Resident #32 was changed to manual lift weights since he had change in condition around May. The Restorative Nurse Assistant stated Resident # 32could not stand for adequate time to take standing weight. Interview revealed the documented weights in the electronic health record (EHR) system were accurate. The Restorative Nurse Assistant stated Resident # 32 weighed around 200 pounds before the change in condition . The Restorative Nurse Assistant stated Resident # 32 was on weekly weights since 8/3/2023. <BR/>Interview with ADON G on 08/24/23 at 11:55 AM revealed the facility was aware of Resident #32's weight loss and interventions put in place by the Dietitian. ADON G also confirmed that resident # 32 was put on weekly weights by the Nursing team. <BR/>Interview with MDS LVN on 8/24/23 at 12:24 PM revealed acute care plans were entered by Nursing Staff and he could not comment on Weight loss Care plan intervention added on 8/24/23 by the DON. <BR/>Interview with CNA E on 08/24/23 at 2:30 PM revealed he was familiar with Resident # 32's care. He reported Resident # 32 usually ate in the room. Interview revealed Resident # 32 ate in the dining room since he had a pending dental visit. Per CNA E, Food intake was recorded on the intake and output record. CNA E stated that if he noticed any changes with Resident # 32's food intake, he would report it to the Nursing staff. <BR/>In an interview with LVN A on 08/24/23 at 02:35 PM, she stated she was an agency LVN and was familiar with the care of the Resident # 32. LVN A revealed weights were monitored weekly x 4 weeks for any significant weight loss. LVN A reported she was not sure if the resident had lost weight and needed to look at her EHR. LVN A noted Resident # 32 sometimes needed assistance with eating. Interview revealed staff would then assist Resident #32 with eating.<BR/>In an Interview with Director of Nursing (DON) on 8/24/23 at 3:32 PM, she stated resident # 32's weight loss was triggered on 8/3/23. The DON a revealed that ideally acute care plans should be documented within a week of the trigger being identified i.e., by 8/10/2023. When asked, what kind of intervention should the Care plan have for significant weight loss, the DON reported Dietitian to review, weekly weights, discussion in morning meetings, referral to physician as needed. The DON stated that the care plan for weight loss was updated on 8/24/2023 for Dietitian review and weekly weights. <BR/>Record review of Resident # 32's weights revealed: <BR/>8/24/2023 11:38 <BR/>173.9 pounds <BR/>8/17/2023 11:50 <BR/>171.3 pounds <BR/>8/14/2023 12:20 <BR/>174.4 pounds <BR/>8/9/2023 11:47 <BR/>176.0 pounds <BR/>8/3/2023 12:50 <BR/>176.0 pounds <BR/>7/8/2023 13:52 <BR/>188.9 pounds <BR/>6/8/2023 12:52 <BR/>195.0 pounds <BR/>5/10/2023 07:34 <BR/>192.4 pounds <BR/>Resident had weight loss of -16.4 pounds (-7.5%) significant weight loss in a period of three months. Record review and interviews revealed that interventions were in place for weight loss, however facility failed to document care plan for significant weight loss.<BR/>Record Review of the facility's policy for Nutrition Status Management revealed that facility will update and revise care plan as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #60, Resident 86, Resident #89, and Resident #114) of 8 residents reviewed for ADLs. <BR/>The facility failed to ensure:<BR/>1- Resident #60 had his fingernails trimmed and cleaned.<BR/>2- Resident #86 had her fingernails' bed cleaned.<BR/>3- Resident #89 had her fingernails trimmed.<BR/>4- Resident #114 had his fingernails trimmed and cleaned.<BR/>This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. <BR/>Findings include:<BR/>1- Review of Resident #60's Quarterly MDS assessment dated [DATE] reflected Resident #60 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), contracture unspecified joint, muscle weakness, lack of coordination, and need for assistance with personal care. Resident #60's BIMS not assessed. Resident #60 required extensive assistance of one-person physical assistance with dressing, and personal hygiene.<BR/>Review of Resident #60's Comprehensive Care Plan, revised 01/18/23, reflected the following: Focus: Resident at risk for an ADL self-care performance deficit related to cerebral infarction and lack of coordination and weakness. Goal: will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene with supervision, independence, modified independence through the review date. Intervention: Personal hygiene: Requires total assistance with personal hygiene care. <BR/>An observation on 08/24/23 at 9:30 AM revealed Resident #60 was sitting in his wheelchair. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails on the left hand were chipped. Resident #60 stated he did not like his nails long. He stated he did not tell anybody about his nails. <BR/>2- Review of Resident #86's Quarterly MDS assessment, dated 08/01/2023, reflected Resident #86 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia, lack of coordination and type 2 diabetes mellitus. Resident #86 BIMS not assessed. Resident#86 required extensive assistance of one-person physical assistance with dressing, transfers, and personal hygiene.<BR/>Review of Resident #86's Comprehensive Care Plan revised 07/31/23 reflected the following: Focus: ADL self-care performance deficit related to decline in function, poor mobility, and weakness. Goal: the resident will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: Encourage to participate to the fullest extent possible with each interaction. <BR/>Observation on 08/24/23 at 9:35 AM revealed Resident #86 was laying in her bed. The nails' beds, on both hands, had dark brown color. Resident #86 was unable to answer questions.<BR/>3- Review of Resident #89's Comprehensive MDS assessment, dated 08/10/2023, reflected Resident #89 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included muscle weakness, lack of coordination, and physical debility (general weakness or feebleness that may be a result or an outcome of one or more medical condition). Resident #89 had a BIMS of 09 which indicated Resident #89's cognition was moderately altered. Resident#89 required extensive assistance of one-person physical assistance with dressing, and personal hygiene.<BR/>Review of Resident #89's Comprehensive Care Plan revised 03/09/23 reflected the following: Focus: resident#89 has an ADL self-care performance deficit r/t functional decline secondary to hypertension, and heart failure. Goal: Will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: Encourage to participate to the fullest extent possible with each interaction. <BR/>Observation and interview on 08/24/23 at 9:39 AM revealed Resident #89 was laying in her bed. The nails on both hands were approximately 0.7cm in length extending from the tip of her fingers. Resident #89 stated that she did not like her nails very long because they bother her. Resident #89 stated I have to tell them, if I don't keep asking, they would not do it.<BR/>4- Review of Resident #114's Quarterly MDS assessment, dated 07/04/2023, reflected Resident #114 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain [NAME] to problems with the blood vessels that supply it), muscle weakness, and lack of coordination. Resident #114 had a BIMS of 5 which indicated Resident #114's cognition was severely altered. Resident#114 required extensive assistance of one-person physical assistance with bed mobility, dressing, and personal hygiene.<BR/>Review of Resident #114's Comprehensive Care Plan revised 02/28/23 reflected the following: Focus: resident#114 has an ADL self-care performance deficit r/t weakness, poor safety awareness, cognitive impairment. Goal: Resident #114 will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: encourage to participate to the fullest extent possible with each interaction. <BR/>Observation on 08/24/23 at 9:45 AM revealed Resident #114 was laying in his bed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #114 was unable to answer questions.<BR/>Interview on 08/24/23 at 9:52 AM, CNA K stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA K stated she would clean Resident #86 fingernails and she would clean and trim Resident #89 and Resident#114's nails right then. <BR/>Interview on 08/24/23 at 10:00 AM, LVN J stated CNAs were responsible to clean and trim residents' nails during the showers. LVN J stated only nurses cut residents' nails if they were diabetic. LVN J stated no one notified her Resident #86, Resident #89, and Resident #114's nails were long and dirty, and she had not noticed the nails herself. LVN J stated Resident#86 was diabetic and she would clean her nails.<BR/>Interview on 08/24/23 at 11:26 AM, CNA I stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA I stated she would clean and trim Resident #60's fingernails.<BR/>Interview on 08/24/23 at 11:30 AM, LVN A stated CNAs were responsible to clean and trim residents' nails during the showers. LVN A stated only nurses cut residents' nails if they were diabetic. LVN A stated she had not noticed the nails of Resident #60. LVN A stated she would clean and trim his nails.<BR/>Interview on 08/24/23 4:46 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. The DON stated she was responsible to do routine rounds for monitoring. <BR/>Record review of the facility's policy titled ADL, Services to carry out, revised July 2013, reflected Procedures: . 2- If a resident is unable to carry out activity of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 of 5 residents (#343) reviewed for respiratory care in that:<BR/>The facility failed to ensure Resident #343 nasal tubing and oxygen water container for her oxygen concentrators were dated. <BR/>These deficient practices could affect residents who received oxygen therapy and serve as a source of infection.<BR/>Findings included:<BR/>Record review of Resident #343 Face Sheet, dated 08/23/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included: Cerebral infarction (stroke), bacteremia (bacteria in the blood), pneumonia (infection of the lungs), Type 2 Diabetes Mellitus (changed in sugar levels of the blood) without complications, Acute chronic respiratory failure with hypoxia (not enough oxygen in your blood or too much).<BR/>Review of Resident #343 Quarterly MDS, dated [DATE] reflected a BIMS score of 9 indicating moderate cognitive impairment, oxygen use for respiratory disease, infection, and pneumonia. Resident required extensive assistance of two staff with bed mobility and toileting, transport and with ADLs.<BR/>Record review of Resident #343's MD orders dated 8/16/23 revealed change o2 tubing & humidifier bottle every night shift every Wednesday .Check oxygen levels every shift or as needed. 02 at 3L via nasal cannula every shift for oxygen related to Acute respiratory failure. There was no order for the change of nasal cannula.<BR/>Record review of Resident #343 Comprehensive Care Plan dated 08/16/23 revealed Resident #343 has an infection of respiratory tract pneumonia and interventions .Resident has oxygen therapy related to acute and chronic respiratory failure. On antibiotic therapy for infection bacteremia .ADL self-care performance deficit related to decline in function, poor gate and balance and weaknesses of bilateral leg .dependent on staff for cognitive stimulation related to limited physical limitation.<BR/>In an observation on 08/22/23 at 11:55 AM of Resident #343's nasal cannula tubing and oxygen concentrator bottle were not dated and labeled.<BR/>In an interview with Resident #343 on 08/22/23 at 11:55 AM she stated that she did not remember when the nurses changed her tubing. She said she was not having in complications breathing only nausea and decreased appetite. <BR/>In an interview on 08/22/23 at 12:05 PM with Resident #343's family member revealed she was not sure when the oxygen was administered, and that the resident had only been here for one week. She said she had not observed staff coming and checking the machine. <BR/>In an interview on 08/24/23 at 3:39 PM with the ADON revealed it was her expectation for staff to change tubing and oxygen water supplies and date them upon completion to communicate to all nursing staff that the task was completed and the to date when the tubing and fluid was changed, as overuse of tubing can lead to leaks and cuts, unsanitary and dryness from the lack of liquid causing great discomfort.<BR/>In an interview with the DON on 08/24/23 at 4:40 PM revealed she expects the nursing staff to date tubing to prevent infection prevention incidents and notify and document the change in equipment electronically. It is the responsibility of the charge nurse and ADON to conduct rounds and assess that the items have been changed and dated properly. <BR/>In an interview on 08/24/23 at 5:19 PM with the Administrator he stated that the nursing staff are expected to follow the policy and procedures for medical task and monitoring of equipment care assuring sanitation protocols were conducted to provide quality of care for all residents. <BR/>Record review of the facility's policy titled licensed Nurse Procedures .Oxygen Equipment dated oxygen, policy dated 05/2017 reflected: .Tubing and cannulas should be dated and replaced every 7 days according to the manufacturer recommendation, or as needed.

Based on observation and interview the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs in 1 (L400 Hall medication room) of 5 medication rooms reviewed for medication storage. <BR/>The narcotic lock box in the refrigerator of L400 Hall medication room was not locked. <BR/>This failure could result in drug diversion of controlled medications.<BR/>Findings included:<BR/>Observation on 06/22/2022 at 3:15p.m., of the medication room on the L400 Hall revealed the narcotic lock box in the refrigerator was secured to the refrigerator, but the box was not locked. The contents of the unlocked narcotic box included the following medications: <BR/>-ABH (Ativan, Benadryl, and Haldol) 1-25-1mg/ml gel, labeled as a compounded medication, for Resident #106. <BR/>-14 syringes of ABH gel were contained in a clear, labeled bag. <BR/>Interview with LVN A on 06/22/2022 at 3:15p.m., he stated the lock had been broken on the narcotic box in the refrigerator of the medication room on L400 Hall for about 1 month. LVN A said both he and the morning shift nurse told the maintenance people about this. He said he did not know if the ADON or the DON were aware of the issue. The LVN said he did not know why it had not been fixed. He said he communicated with maintenance through a computer message on a system used in the facility to communicate with other staff. He said he was sure the message was received because when you send it, they get it. LVN A said the unlocked narcotic box was not good, and said it was to be locked because the medications were controlled and could be stolen or disappear. He said it was the nurse's responsibility to make sure the narcotics are locked. He said the nurse's lock the door to the medication room and only the charge nurse had the key.<BR/>In an interview on 06/22/2022 at 2:44p.m., the ADON said she was not aware the narcotic box in the medication room refrigerator on the L400 Hall was not locked. She said no staff had reported a problem with the lock to her. The ADON said the importance of the narcotic box being locked was to prevent the medications from being stolen if someone were to get into the medication room, narcotic drug diversion. The ADON said a resident could get a hold of the medication if they got in the door of the medication room and wandered in.<BR/>In an interview on 06/22/22 at 3:02p.m., the DON said she was just made aware the lock on the narcotic box does in the medication room on the L400 Hall did not work. She said they were getting an order to fix it. The DON said the charge nurses on every shift were responsible for making sure the narcotic medications were securely locked. She said she did not know why the nurses did this and said in-services have been held regarding medication storage and narcotics being locked. The DON said her expectation was the nurse immediately notify the unit manager/ADON, and they were not available, then she should be notified of the issue of a broken lock. She said there was no reason why this should have been left this way. The DON said potential problems with the narcotic box being left unlocked included the medication could be lost, someone could get in there and take it, drug diversion, and staff wouldn't have medication for residents. <BR/>Record review of the facility's policy, Medication Access and Storage, dated 8/03/2021, revealed It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was treated with the respect and dignity and care for each resident in a manner that promoted the maintenance of her quality of life for one (Resident #11) of 5 residents reviewed for dignity.<BR/>The facility failed to provide dignity and respect for Resident #11 by ignoring her request to go toilet 3 times. <BR/>These failures could place residents in the facility at risk of feeling low self-worth and disrespected.<BR/>Findings included:<BR/>Record review of Resident #11's face sheet revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included: senile degeneration of brain not elsewhere classified (cognitive decline) Age related osteoporosis (weak bones), bone density disorder (low bone mass), bipolar disease (depression disorder) insomnia (difficulty sleeping).<BR/>Observation on 08/22/23 at 10:00 AM revealed Resident #11's ambulating in her wheelchair to the nurse station where there were 4 staff talking. She told MA-G that she needed to go to the restroom. MA G ignored her and continued to talk. Resident #11 then approached LVN-S, the charge nurse, and requested to be taken to the rest room. LVN-S told the resident that she had already been to the restroom. Resident approached surveyor and asked to be taken to the rest room. <BR/>In an interview on 08/22/23 at 10:15 AM with MA-G she stated that the resident was a two person assist by staff for toileting . Surveyor asked if other staff could assist, and she asked the aide to assist the resident. MA-G said residents have the right to be toileted upon request, yet someone had just taken the resident to the restroom . MA-G stated that she received on-boarding and regular in-service training on resident rights, abuse, and neglect. MA-G said that she was not able to assist resident as she was training a new medication aide at the time. <BR/>Interview on 08/24/23 at 2:39 PM with LVN S revealed that observed CNA D had recently taken the resident to the restroom approximately 5 minutes ago, son she did not need to go again. He said it was the resident's right to be taken to be toileted. He said failing to respond could lead to resident impaired well-being. He said failing to toilet resident's timely could lead to Urinary Tract Infection or other infections. LVN S stated he receives regular in-service training on resident rights, neglect, and abuse. <BR/>In an interview on 08/24/23 at 2:45 PM with CNA-D revealed that residents have the right to be taken to toilet upon request as this was their right and failing to take a resident could lead to infections.<BR/>In an interview on 08/24/23 at 3:39 PM with the ADON revealed it was her expectation for staff to respond to resident toileting and incontinent care upon request if they are not busy with another resident. She said falling to toilet residents could lead to a urinary tract infection.<BR/>In an interview on 08/24/23 at 4:40 PM with the DON revealed that she expects staff to respond to resident restroom request as this was their right and failing to do so can result in the resident's dignity be violated. She said that she along with nurse managers and lead nurses are responsible for conducting rounds and monitoring ADL care and resident needs and care, then will redirect and educate staff on observations of resident rights, dignity, and respect. She stated that this failure could lead to decreased self-worth, embarrassment, depression, and emotional wellness declines.<BR/>In an interview on 08/24/23 at 5:19 PM with the Administrator revealed it was his expectation for staff to assist resident's at their earliest opportunity, and if there were no care staff, contact the charge nurse. He said it would depend on the resident's behaviors and rather if they are incontinent . He said he was not a nurse and could not provided information on the medical side however it could affect the resident's self-worth and determination.<BR/>Record review of the facility's, Resident Rights, policy dated 11/2016 with a review date of 1/22 reflected: .1. it is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident,

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of three residents reviewed for infection control. <BR/>Housekeeper A failed to properly doff her PPE according to CDC guidelines when leaving Residents #2's room after cleaning it . <BR/>This failure placed residents at risk for the spread of infection.<BR/>Findings included:<BR/>Observation and Interview on 06/29/23 beginning at 11:40 AM of Housekeeper A entering a room which indicated isolation on the door and coming out of the room with the PPE on and getting a cleaning item off her cart and going back into the resident room. Housekeeper A then came out of the room with the PPE on disposed of the gown first, gloves and then the mask in the housekeeping cart and sanitized her hands. The housekeeping cart was kept near the room and did not enter another resident room. There was no staff, resident or visitor observed on the hall. Interview with Housekeeper A revealed she had worked in the facility for 1 month. Housekeeper A stated when she completed her cleaning in a quarantine room she would dispose of the PPE outside of the room and would put on new PPE before entering another room. Housekeeper A revealed she put the PPE in a trash bag and disposed of it outside the facility. <BR/>Interview on 06/29/23 at 3:30PM with the DON revealed she had worked in the facility for 9 years. She stated she was responsible for making sure all staff were properly trained on how to Donn(put on) and Doff( take off) PPE. The DON stated Housekeeper A is agency staff and each morning the agency staff are in - serviced on the infection control policy and procedure. The DON revealed staff are in serviced monthly and annually for infection control. She stated the risk of not correctly Doffing PPE that COVID could be spread throughout the building.<BR/>Record review of Resident #1's care plan date initiated 6/19/23 by DON revealed focus COVID positive with symptoms of coughing and generalized weakness. Interventions, activity as tolerated, droplet precautions per protocol, emphasize good hand washing techniques to all direct care staff, encourage coughing, deep breathing, encourage fluid intake, give anitpyretics as ordered.<BR/>Review of nursing note dated 06/19/23 completed by the DON revealed Resident was tested for COVID and result showed positive. She has[sic] shows signs ans symptoms of coughing and general malaise.<BR/>Review of nursing note dated 06/28/23 revealed Evaluation being completed due to confirmed COVID -19 diagnoses. Resident has transmisson based precautions maintained. Resident is in room alone due to active infection.<BR/> Review of the facility policy Infection control and prevention: emerging infectious disease: coronavirus 2019 dated 3/9/20 revealed HPC must receive training on and demonstrate an understanding of when to use PPE; what PPE is necessary how to properly don, use and doff PPE in a manner to prevent self-contamination: how to properly dispose of or disinfect and maintain PPE and the limitations of PPE. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. Gloves: remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns: Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (Resident #1) of five residents reviewed for residents' rights. <BR/>The facility failed to ensure temperatures in Resident#1's room, were not above not the acceptable range (81 degrees Fahrenheit) for resident safety and comfort.<BR/>These failures increase the risk of the residents experiencing decreased the comfort and affect the wellbeing of residents<BR/>Findings included:<BR/>Record review of the face sheet for Resident #1 revealed an 74- year- old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, chronic obstructive pulmonary disease ( a group of diseases that cause airflow blockage ad breathing-related problems), thrombocytopenia (a condition that occurs when the platelet count in your blood is too low), acute respiratory failure with hypercapnia(happens when you have too much carbon dioxide in your blood).<BR/>Review of the MDS completed 6/9/23 did not include a BIMS Score<BR/>Interview on 06/29/23 10:25AM with Resident #1 revealed she had lived in the facility for one year. Resident #1 stated the air was not working in her room and she informed the Maintenance Supervisor of the issue on 06/28/23 which was when the unit went out. Resident #1 was informed by Maintenance Supervisor that she would need to remove all items from in front of the air conditioner before it could be serviced. Resident #1 stated she did have the portable air conditioner which she had always had however with her main air conditioning unit not working, the portable air conditioner was not keeping the room cool. <BR/>Interview on 06/29/23 at 11:00AM with the Maintenance Supervisor stated the temperature of the rooms were taken only if the resident complained about the temperature of the room. The Maintenance Supervisor revealed Resident #1 complained to him on 6/28/23 about the air being broken in the room however no one had looked at the air yet due to the resident needing to move items from in front of the air conditioner. The Maintenance Supervisor stated he had not put in a work order for the air conditioner in Resident #1's room due to not assessing the air conditioner yet. The Maintenance Supervisor took the temperature of the room which was 83 degrees Fahrenheit. The Maintenance Supervisor stated the temperature in resident rooms should have been no warmer than 74 degrees. The Maintenance Supervisor stated when room temperatures were past 74 degrees Fahrenheit, there could have been a risk for health complications. <BR/>Interview on 06/29/23 at 3:30PM with the Administrator revealed he had spoken with the Maintenance Supervisor regarding fixing the air conditioner in Resident #'1 room today (6/29/23). The Administrator stated he had in- serviced the Maintenance Supervisor regarding completing and submitting work orders. The Administrator stated he would also investigate to determine why the work order was not complete when Resident #1 informed the Maintenance Supervisor about the air conditioner not working. The Administrator stated there was a risk of health conditions for residents when room temperatures rise above 81 degrees. The Administrator revealed it was the responsibility of the Maintenance Supervisor to ensure the Resident #1's air conditioner was working properly. The Administrator stated Resident #1 was asked on 6/29/23 if she wanted to move to another room until the air conditioner was fixed however Resident #1 refused and stated she was ok in her room.<BR/>Review of the facility policy Resident rights, policy number NARR01 dated revised 05/2007 did not discuss clean and comfortable living environment.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of three residents reviewed for infection control. <BR/>Housekeeper A failed to properly doff her PPE according to CDC guidelines when leaving Residents #2's room after cleaning it . <BR/>This failure placed residents at risk for the spread of infection.<BR/>Findings included:<BR/>Observation and Interview on 06/29/23 beginning at 11:40 AM of Housekeeper A entering a room which indicated isolation on the door and coming out of the room with the PPE on and getting a cleaning item off her cart and going back into the resident room. Housekeeper A then came out of the room with the PPE on disposed of the gown first, gloves and then the mask in the housekeeping cart and sanitized her hands. The housekeeping cart was kept near the room and did not enter another resident room. There was no staff, resident or visitor observed on the hall. Interview with Housekeeper A revealed she had worked in the facility for 1 month. Housekeeper A stated when she completed her cleaning in a quarantine room she would dispose of the PPE outside of the room and would put on new PPE before entering another room. Housekeeper A revealed she put the PPE in a trash bag and disposed of it outside the facility. <BR/>Interview on 06/29/23 at 3:30PM with the DON revealed she had worked in the facility for 9 years. She stated she was responsible for making sure all staff were properly trained on how to Donn(put on) and Doff( take off) PPE. The DON stated Housekeeper A is agency staff and each morning the agency staff are in - serviced on the infection control policy and procedure. The DON revealed staff are in serviced monthly and annually for infection control. She stated the risk of not correctly Doffing PPE that COVID could be spread throughout the building.<BR/>Record review of Resident #1's care plan date initiated 6/19/23 by DON revealed focus COVID positive with symptoms of coughing and generalized weakness. Interventions, activity as tolerated, droplet precautions per protocol, emphasize good hand washing techniques to all direct care staff, encourage coughing, deep breathing, encourage fluid intake, give anitpyretics as ordered.<BR/>Review of nursing note dated 06/19/23 completed by the DON revealed Resident was tested for COVID and result showed positive. She has[sic] shows signs ans symptoms of coughing and general malaise.<BR/>Review of nursing note dated 06/28/23 revealed Evaluation being completed due to confirmed COVID -19 diagnoses. Resident has transmisson based precautions maintained. Resident is in room alone due to active infection.<BR/> Review of the facility policy Infection control and prevention: emerging infectious disease: coronavirus 2019 dated 3/9/20 revealed HPC must receive training on and demonstrate an understanding of when to use PPE; what PPE is necessary how to properly don, use and doff PPE in a manner to prevent self-contamination: how to properly dispose of or disinfect and maintain PPE and the limitations of PPE. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. Gloves: remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns: Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area

Based on observation, interview, and record review, the facility failed to properly store food in accordance with the professional standards for food service safety in the facility's only kitchen reviewed for food storage.<BR/>The facility failed to ensure food items in the refrigerator were sealed, labeled and dated appropriately.<BR/>These failures could place residents at risk for food-borne illness and cross contamination. <BR/>Findings included:<BR/>1.) Observation of the kitchen's only walk-in freezer on 06/20/22 at 9:40AM revealed the following:<BR/>-Two packages of frozen French fries that were opened, unsealed, and undated with the date in which the food was to be used or discarded.<BR/>2.) Observation of the kitchen's only walk-in refrigerator on 06/20/22 at 9:48AM revealed the following:<BR/>-Two covered bowls containing liquid substances that had not been labeled or dated with the dates in which the substance was placed in either bowl.<BR/>-Two bricks of sliced cheese that were not dated with the date in which they were to be used or discarded.<BR/>-One box of undated, sliced tomatoes which had a fuzzy, grey-white substance covering most of the tomatoes.<BR/>During an interview with the Assistant Dietary Manager on 06/20/22 at 9:52AM, she stated the two packages of frozen French fries were improperly stored. She stated after the bags had been opened, they should have been re-sealed and dated with the date in which they were to be used or discarded. The Assistant Dietary Manager identified the two covered bowls containing liquid substances in the walk-in refrigerator as chicken broth. She stated the bowls of chicken should have been dated with the date(s) in which the broth was placed in the bowls. The Assistant Dietary Manager stated the two bricks of sliced cheese that should have been dated with the date in which they were to be used or discarded. The Assistant Dietary Manager stated the tomatoes appeared to be molded and should have been previously thrown away. The Assistant Dietary Manager stated the risk of having improperly stored foods included the potential of residents receiving spoiled foods and getting sick.<BR/>Review of the U.S. Public Health Service Food Code, dated 2017, reflected, 3-501.17 Food Establishment and if the Food is held for more than 24 hours, to indicate the date or day by which the Food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and:(1) The day the original container is opened in the Food establishment shall be counted as Day 1; and (2) The day or date marked by the Food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on Food safety. 3) Marking the date or day the original container is opened in a Food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Regulatory Authority upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (L200) of six halls reviewed for physical environment.<BR/>1. The facility failed to ensure resident room bathroom shared between L218 and L219 had working hot water and did not drip in bathroom sink.<BR/>2. The facility failed to ensure resident room bathroom shared between L216 and L217 did not drip from bathroom faucet.<BR/>3. The facility failed to ensure resident room [ROOM NUMBER]'s chiller did not have exposed wires underneath. <BR/>These failures could place facility at risk for unsanitary and hazardous living conditions.<BR/>Findings included:<BR/>1. Observations on 08/22/23 at 11:00 AM and 2:15 PM revealed bathroom sink faucet between resident rooms [ROOM NUMBERS] was dripping. The left faucet turned but no water came out.<BR/>Observation and Interview on 08/24/23 at 2:05 PM with Maintenance Assistant P revealed the bathroom sink between resident rooms [ROOM NUMBERS] shared bathroom had a left faucet which turned but no water came out and the faucet dripped. He stated he was not aware of the bathroom left faucet in between resident rooms [ROOM NUMBERS] not working which was where the hot water would come out. He stated it looked like it was turned off but Maintenance was unaware of it. <BR/>2. Observations on 08/22/23 at 10:58 AM and 2:13 PM revealed bathroom sink faucet between resident rooms [ROOM NUMBERS] was dripping from the faucet. <BR/>Interview on 08/22/23 at 2:16 PM revealed the Maintenance Director was not aware of the dripping faucets for two resident bathroom sinks. He stated he was not notified about them by facility staff.<BR/>Observation and Interview on 08/24/23 at 2:07 PM with Maintenance Assistant P revealed the bathroom sink between resident rooms [ROOM NUMBERS] shared bathroom had water dripping from the faucet when turned off.<BR/>Interview on 08/24/23 at 2:09 PM with RN O revealed she was not aware of any resident bathroom faucets dripping and she was unaware of the hot water faucet in shared bathroom between resident 218 and 219 not working.<BR/>Interview on 08/24/23 at 2:25 PM with CNA N revealed she was not aware of any issues with resident bathroom faucets dripping in resident rooms for 218/219 shared bathroom or 216/217 shared bathroom. She was not aware of the hot water faucet in shared resident bathroom [ROOM NUMBER]/219 not working. <BR/>3. Observations on 08/22/23 at11:04 AM and 2:17 PM revealed Resident room [ROOM NUMBER] had 5 wires (2 white colored, 2 yellow colored and 1 red colored wire) exposed under her room air chiller below the window. <BR/>Interview on 08/22/23 at 2:23 PM with Resident #74 revealed she did not recall any wires in her room or the faucet dripping in bathroom. She stated there was a guy who worked at facility and fixed any issues in her room. <BR/>Interview on 08/22/23 at 11:38 AM with LVN B stated she was not aware of the exposed wires under the room chiller in resident room [ROOM NUMBER]. <BR/>Interview on 08/22/23 at 2:18 PM with Maintenance Director revealed there was no cover under the air chiller in resident room but there should not be exposed wires underneath it. He stated they would put the exposed wires back inside. He stated he did have some residents but not on this hall who would pull the wires out so they were exposed. <BR/>Interview on 08/24/23 at 3:20 PM with Administrator revealed he expected facility staff to notify Maintenance about maintenance issues and nurses had access to initiate a maintenance order. <BR/>Review of facility's maintenance log for 07/01/23 to 08/24/23 reflected no maintenance orders for resident rooms or bathrooms for L216, L217, L218 and L219.<BR/>Review of facility's policy Plant Maintenance Program - Resident Areas revised December 2016 reflected The primary purpose of the plant maintenance program is to practice preventative maintenance that routinely monitors and maintains a functioning state of being within the plant instead of responding to inoperable and broken down systems.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 8%, based on3 errors out of 59 opportunities, which involved 2 of 6 residents (Resident # 76 and #105); and 2 of 3 staff (LVN D and CMA E) reviewed for medication errors.<BR/>CMA E crushed Guaifenesin Extended Release and Divalproex Delayed Release medications and administered them to Resident #76<BR/>LVN D administered Hydrochlorothiazide 100 mg instead of 50 mg, did not administer Coreg 3.125 mg and administered Oxcarbazepine 150 mg instead of 300 mg to Resident #105<BR/>This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.<BR/>Findings Included: <BR/>Resident #76<BR/>Observation of a medication pass on 06/21/22 at 09:40 AM, CMA E administer the following medications to Resident #76: <BR/>stool softener 100 mg 1 tablet, Tylenol 500 mg 1 tablet, <BR/>benztropine 0.5 mg 1 tablet, <BR/>divalproex DR (Delayed Release) 500 mg 1 tablet, <BR/>benzonatate 100 mg 1 capsule, and <BR/>guaifenesin 600 mg ER (Extended Release) 1 tablet and Multi-Vit with minerals 1 tablet. <BR/>CMA E crushed the medications and mixed with apple sauce and then administered to Resident #76. <BR/>Review of Resident #79 physician orders reflected an order for divalproex DR 500 mg 1 tablet and guaifenesin 600 mg ER 1 tablet by mouth. <BR/>In an interview with CMA E on 06/21/22 at 09:48 AM, CMA E stated she crushed the DR and ER because the resident could not swallow whole pills, and the staff had always crushed the medications. CMA E stated she knew not crush the medication because they would not be effective if they were crushed. She stated she crushed the medications because the resident could not swallow the medication whole. <BR/> In an interview with CMA E on 06/21/22 at 02:12 PM, she stated she informed the charge nurse and the supervisor of the ER and DR medications. The charge nurse informed the primary care provider, and the medication changes were made to capsule with direction to open the capsule.<BR/>Resident #105<BR/>Observation of a medication pass on 06/21/22 at 10:45 AM, LVN D administered the following medications to Resident #105 with the exception of Coreg 3.125mg: <BR/>-Oxcarbazepine 150 mg 1 tablet, <BR/>-Hydrocodone/APAP 7.5 mg-325 mg 1 tablet,<BR/>-Senna 8.6 mg 1 tablet, <BR/>-aspirin 81 mg adult low dose enteric coated 1 tablet, <BR/>-Multi-Vit with minerals 1 tablet, <BR/>-D3-5 (Cholecalciferol) 1 tablet, clopidogrel 75 mg 1 tablet, <BR/>-Stool softener 100 mg 1 tablet, <BR/>-Donepezil 5 mg 1 tablet, duloxetine 30 mg 1 capsule, <BR/>-Hydrochlorothiazide 50 mg 2 tablets, <BR/>-Probiotic 1 tablet, magnesium oxide 400 mg 1 tablet, <BR/>-Lisinopril 40 mg 1 tablet and <BR/>-Amlodipine 10 mg 1 tablet <BR/>Review of Resident #105's physician orders dated 06/22/22 reflected the following orders: <BR/>-Oxcarbazepine 300 mg,<BR/>-Hydrochlorothiazide 50 mg, and <BR/>-Coreg 3.125 mg. <BR/>Review of Resident #10's MAR on 6/22/22 indicated to administer the following medication to the resident:<BR/>-Oxcarbazepine 300 mg, <BR/>-Hydrochlorothiazide 50 mg, and <BR/>-Coreg 3.125 mg<BR/>In an interview on 06/21/22 at 01:45 PM, LVN D stated she was supposed to administer medications per the physician orders and follow the five rights of medication administration. LVN D stated not administering the right dose of medications and missing a prescribed medication could cause negative side effects like to elevated blood pressure. <BR/>In an interview on 06/22/22 at 01:33 PM, the DON revealed CMA E was not supposed to crush DR and ER medications because it will not be effective, she also stated CMA E should know better not to crush any medication that was enteric coated or extended release. The DON stated the staff was to follow the physician order and follow the five rights of medications administration. <BR/>Review of the facility policy revised 8/3/21, titled Medication Administration reflected, It is the policy of this facility that medications shall be administered as prescribed by the attending physician.2. Medications must be administered in accordance with the written orders of the attending physician. 11. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse must document the missed dose and reason in the MAR (medication administration record).

Based on observation, interview, and record review, the facility failed to properly store food in accordance with the professional standards for food service safety in the facility's only kitchen reviewed for food storage.<BR/>The facility failed to ensure food items in the refrigerator were sealed, labeled and dated appropriately.<BR/>These failures could place residents at risk for food-borne illness and cross contamination. <BR/>Findings included:<BR/>1.) Observation of the kitchen's only walk-in freezer on 06/20/22 at 9:40AM revealed the following:<BR/>-Two packages of frozen French fries that were opened, unsealed, and undated with the date in which the food was to be used or discarded.<BR/>2.) Observation of the kitchen's only walk-in refrigerator on 06/20/22 at 9:48AM revealed the following:<BR/>-Two covered bowls containing liquid substances that had not been labeled or dated with the dates in which the substance was placed in either bowl.<BR/>-Two bricks of sliced cheese that were not dated with the date in which they were to be used or discarded.<BR/>-One box of undated, sliced tomatoes which had a fuzzy, grey-white substance covering most of the tomatoes.<BR/>During an interview with the Assistant Dietary Manager on 06/20/22 at 9:52AM, she stated the two packages of frozen French fries were improperly stored. She stated after the bags had been opened, they should have been re-sealed and dated with the date in which they were to be used or discarded. The Assistant Dietary Manager identified the two covered bowls containing liquid substances in the walk-in refrigerator as chicken broth. She stated the bowls of chicken should have been dated with the date(s) in which the broth was placed in the bowls. The Assistant Dietary Manager stated the two bricks of sliced cheese that should have been dated with the date in which they were to be used or discarded. The Assistant Dietary Manager stated the tomatoes appeared to be molded and should have been previously thrown away. The Assistant Dietary Manager stated the risk of having improperly stored foods included the potential of residents receiving spoiled foods and getting sick.<BR/>Review of the U.S. Public Health Service Food Code, dated 2017, reflected, 3-501.17 Food Establishment and if the Food is held for more than 24 hours, to indicate the date or day by which the Food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and:(1) The day the original container is opened in the Food establishment shall be counted as Day 1; and (2) The day or date marked by the Food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on Food safety. 3) Marking the date or day the original container is opened in a Food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Regulatory Authority upon request.

Based on observation and interview the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs in 1 (L400 Hall medication room) of 5 medication rooms reviewed for medication storage. <BR/>The narcotic lock box in the refrigerator of L400 Hall medication room was not locked. <BR/>This failure could result in drug diversion of controlled medications.<BR/>Findings included:<BR/>Observation on 06/22/2022 at 3:15p.m., of the medication room on the L400 Hall revealed the narcotic lock box in the refrigerator was secured to the refrigerator, but the box was not locked. The contents of the unlocked narcotic box included the following medications: <BR/>-ABH (Ativan, Benadryl, and Haldol) 1-25-1mg/ml gel, labeled as a compounded medication, for Resident #106. <BR/>-14 syringes of ABH gel were contained in a clear, labeled bag. <BR/>Interview with LVN A on 06/22/2022 at 3:15p.m., he stated the lock had been broken on the narcotic box in the refrigerator of the medication room on L400 Hall for about 1 month. LVN A said both he and the morning shift nurse told the maintenance people about this. He said he did not know if the ADON or the DON were aware of the issue. The LVN said he did not know why it had not been fixed. He said he communicated with maintenance through a computer message on a system used in the facility to communicate with other staff. He said he was sure the message was received because when you send it, they get it. LVN A said the unlocked narcotic box was not good, and said it was to be locked because the medications were controlled and could be stolen or disappear. He said it was the nurse's responsibility to make sure the narcotics are locked. He said the nurse's lock the door to the medication room and only the charge nurse had the key.<BR/>In an interview on 06/22/2022 at 2:44p.m., the ADON said she was not aware the narcotic box in the medication room refrigerator on the L400 Hall was not locked. She said no staff had reported a problem with the lock to her. The ADON said the importance of the narcotic box being locked was to prevent the medications from being stolen if someone were to get into the medication room, narcotic drug diversion. The ADON said a resident could get a hold of the medication if they got in the door of the medication room and wandered in.<BR/>In an interview on 06/22/22 at 3:02p.m., the DON said she was just made aware the lock on the narcotic box does in the medication room on the L400 Hall did not work. She said they were getting an order to fix it. The DON said the charge nurses on every shift were responsible for making sure the narcotic medications were securely locked. She said she did not know why the nurses did this and said in-services have been held regarding medication storage and narcotics being locked. The DON said her expectation was the nurse immediately notify the unit manager/ADON, and they were not available, then she should be notified of the issue of a broken lock. She said there was no reason why this should have been left this way. The DON said potential problems with the narcotic box being left unlocked included the medication could be lost, someone could get in there and take it, drug diversion, and staff wouldn't have medication for residents. <BR/>Record review of the facility's policy, Medication Access and Storage, dated 8/03/2021, revealed It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose .

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 medication cart (medication aide cart Hall N1) of 6 medication carts reviewed for pharmacy services in that: <BR/>The facility failed to ensure medications in unsecure containers were immediately removed from stock.<BR/>This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.<BR/>Findings Included:<BR/>An observation on 08/23/2023 at 8:13 AM of the Medication Aide Cart Hall N1 revealed the blister pack for Resident #15's lorazepam 0.5 mg (milligrams) tablet (controlled medication used for anxiety) had 1 blister seal broken and the pill was still inside the broken blister. The blister pack for Resident #64's APAP/codeine 300-30 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister. <BR/>In an observation and interview on 08/23/23 at 8:17 AM, CMA L stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk of a damaged blister would be a potential for drug diversion. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, tow nurses should discard the medication. <BR/>Interview on 08/24/23 at 4:45 PM, the DON stated if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON and the DON were supposed to check the cart randomly.<BR/>Record review of the facility's policy Medication Access and Storage/Drug Destruction, revised July 2023 reflected the following: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident Room L320-A) of 9 residents' rooms reviewed for resident call system in that: <BR/>The facility failed to ensure Resident Room L320-A's call light was working properly and did not have exposed wires on the wall where call button cord was connected to the wall. <BR/>This failure could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity. <BR/>Findings included:<BR/>Review of Resident #23's face sheet dated 08/24/23 reflected Resident #23 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of malnutrition, diabetes, lack of coordination, abnormalities of gait and mobility and generalized muscle weakness. <BR/>Review of Resident #23's Quarterly MDS assessment dated [DATE] reflected Resident #23 had a BIMS of 15 indicating he was cognitively intact. He required supervision with ADLs and one person physical assistance with hygiene.<BR/>Observation and interview on 08/22/23 at 11:30 AM revealed Resident # 23's call button was not working in resident room L320. Call button cord connected to the wall had about a quarter size area showing 3 exposed wires coming out of the wall not covered. Resident #23 stated he thought the call button was working. He stated it had been working but did notice the wires showing. He stated he used call button for assistance.<BR/>Observation and Interview on 08/22/23 at 11:35 AM revealed CNA F pressed the call button but it was not working and did not light up at the wall indicating it was pressed. He stated he just noticed the exposed wires today when pressing call button just now. He was not aware of any issues with call buttons not working for residents. He stated Resident #23 did use his call light 2 days ago and it worked without issues. He stated he will notify Maintenance and nursing about it.<BR/>Interview on 08/22/23 at 11:38 AM with LVN B revealed she was the charge nurse for Resident #23. LVN B stated she was not aware of Resident #23's call light not working. She will make sure Maintenance is made aware of it and will get it working. LVN B was not aware of the exposed wires. She stated Resident #23 needed a call button working in his room to call for assistance when needed.<BR/>Interview on 08/22/23 at 11:50 AM the Administrator revealed he was not aware of any resident call lights not working and will ensure Maintenance follows up and gets it working for the resident. He stated residents should have a working call light.<BR/>Review of facility's policy Call light system outage procedure undated reflected If a call light does not work in a resident room the following steps must be taken Notify the Maintenance Department Implement 15 min room rounds.

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 facility reviewed for reporting.<BR/>The facility failed to report to the State Survey Agency when the facility was without power from 05/28/24 to 05/31/24.<BR/>This failure could place residents at risk for harm to include neglect and diminished quality of life.<BR/>Findings included:<BR/>In an observation on 05/31/24 at 9:30 AM the fire truck was observed leaving the facility.<BR/>In an interview on 05/31/24 at 9:32 AM the Front Desk Receptionist revealed the electricity turned on 15 minutes before surveyor entered. The Front Desk Receptionist revealed the electricity had been off since Tuesday because of the inclement weather.<BR/>In an interview on 06/03/24 at 11:15 AM, with the DON revealed the facility lost power on 05/28/24 and power returned on 05/31/24. The DON revealed the Administrator was responsible for reporting incidents to the state. The DON revealed the Administrator was absent, she is the next in charge to report incident to the state. The DON revealed management and staff were on the floor providing care for the residents and were very busy. The DON revealed that residents were not at any risk because the generator worked. <BR/>In an interview on 6/03/24 at 11:45 AM, with the Administrator revealed the facility lost power 05/28/24 to 05/31/24. The Administrator revealed he did not report the incident to the State Agency because his liaison stated as long as the generators were working the incident did not need to be reported to the state. The Administrator revealed he was responsible for reporting facility self-reported incidents. The Administrator revealed the staff monitored the residents constantly and the heat was at 80 degrees inside the facility during the power outage. <BR/>Record review of facility policy Nursing Administration-Section: Resident Rights-, Subject: Abuse prevention - Reporting and Investigating (revised November 2016) revealed the following in part:<BR/>All alleged violations will be reported via phone or in writing within 24 hours to the state Licensing Agency .<BR/>Record review of Long- Term Care Regulatory Provider Letter PL 19-17 dated 7/10/19 revealed the following:<BR/> .A NF must report to HHSC the following types of incidents in accordance with applicable state and federal requirement:<BR/> . emergency situation that pose a threat to resident health and safety Immediately, but not later than 24 hours after the incident occurs or is suspected .

Based on observation, interview, and record review, the facility failed to properly store food in accordance with the professional standards for food service safety in the facility's only kitchen reviewed for food storage.<BR/>The facility failed to ensure food items in the refrigerator were sealed, labeled and dated appropriately.<BR/>These failures could place residents at risk for food-borne illness and cross contamination. <BR/>Findings included:<BR/>1.) Observation of the kitchen's only walk-in freezer on 06/20/22 at 9:40AM revealed the following:<BR/>-Two packages of frozen French fries that were opened, unsealed, and undated with the date in which the food was to be used or discarded.<BR/>2.) Observation of the kitchen's only walk-in refrigerator on 06/20/22 at 9:48AM revealed the following:<BR/>-Two covered bowls containing liquid substances that had not been labeled or dated with the dates in which the substance was placed in either bowl.<BR/>-Two bricks of sliced cheese that were not dated with the date in which they were to be used or discarded.<BR/>-One box of undated, sliced tomatoes which had a fuzzy, grey-white substance covering most of the tomatoes.<BR/>During an interview with the Assistant Dietary Manager on 06/20/22 at 9:52AM, she stated the two packages of frozen French fries were improperly stored. She stated after the bags had been opened, they should have been re-sealed and dated with the date in which they were to be used or discarded. The Assistant Dietary Manager identified the two covered bowls containing liquid substances in the walk-in refrigerator as chicken broth. She stated the bowls of chicken should have been dated with the date(s) in which the broth was placed in the bowls. The Assistant Dietary Manager stated the two bricks of sliced cheese that should have been dated with the date in which they were to be used or discarded. The Assistant Dietary Manager stated the tomatoes appeared to be molded and should have been previously thrown away. The Assistant Dietary Manager stated the risk of having improperly stored foods included the potential of residents receiving spoiled foods and getting sick.<BR/>Review of the U.S. Public Health Service Food Code, dated 2017, reflected, 3-501.17 Food Establishment and if the Food is held for more than 24 hours, to indicate the date or day by which the Food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and:(1) The day the original container is opened in the Food establishment shall be counted as Day 1; and (2) The day or date marked by the Food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on Food safety. 3) Marking the date or day the original container is opened in a Food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Regulatory Authority upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident Room L320-A) of 9 residents' rooms reviewed for resident call system in that: <BR/>The facility failed to ensure Resident Room L320-A's call light was working properly and did not have exposed wires on the wall where call button cord was connected to the wall. <BR/>This failure could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity. <BR/>Findings included:<BR/>Review of Resident #23's face sheet dated 08/24/23 reflected Resident #23 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of malnutrition, diabetes, lack of coordination, abnormalities of gait and mobility and generalized muscle weakness. <BR/>Review of Resident #23's Quarterly MDS assessment dated [DATE] reflected Resident #23 had a BIMS of 15 indicating he was cognitively intact. He required supervision with ADLs and one person physical assistance with hygiene.<BR/>Observation and interview on 08/22/23 at 11:30 AM revealed Resident # 23's call button was not working in resident room L320. Call button cord connected to the wall had about a quarter size area showing 3 exposed wires coming out of the wall not covered. Resident #23 stated he thought the call button was working. He stated it had been working but did notice the wires showing. He stated he used call button for assistance.<BR/>Observation and Interview on 08/22/23 at 11:35 AM revealed CNA F pressed the call button but it was not working and did not light up at the wall indicating it was pressed. He stated he just noticed the exposed wires today when pressing call button just now. He was not aware of any issues with call buttons not working for residents. He stated Resident #23 did use his call light 2 days ago and it worked without issues. He stated he will notify Maintenance and nursing about it.<BR/>Interview on 08/22/23 at 11:38 AM with LVN B revealed she was the charge nurse for Resident #23. LVN B stated she was not aware of Resident #23's call light not working. She will make sure Maintenance is made aware of it and will get it working. LVN B was not aware of the exposed wires. She stated Resident #23 needed a call button working in his room to call for assistance when needed.<BR/>Interview on 08/22/23 at 11:50 AM the Administrator revealed he was not aware of any resident call lights not working and will ensure Maintenance follows up and gets it working for the resident. He stated residents should have a working call light.<BR/>Review of facility's policy Call light system outage procedure undated reflected If a call light does not work in a resident room the following steps must be taken Notify the Maintenance Department Implement 15 min room rounds.

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 facility reviewed for reporting.<BR/>The facility failed to report to the State Survey Agency when the facility was without power from 05/28/24 to 05/31/24.<BR/>This failure could place residents at risk for harm to include neglect and diminished quality of life.<BR/>Findings included:<BR/>In an observation on 05/31/24 at 9:30 AM the fire truck was observed leaving the facility.<BR/>In an interview on 05/31/24 at 9:32 AM the Front Desk Receptionist revealed the electricity turned on 15 minutes before surveyor entered. The Front Desk Receptionist revealed the electricity had been off since Tuesday because of the inclement weather.<BR/>In an interview on 06/03/24 at 11:15 AM, with the DON revealed the facility lost power on 05/28/24 and power returned on 05/31/24. The DON revealed the Administrator was responsible for reporting incidents to the state. The DON revealed the Administrator was absent, she is the next in charge to report incident to the state. The DON revealed management and staff were on the floor providing care for the residents and were very busy. The DON revealed that residents were not at any risk because the generator worked. <BR/>In an interview on 6/03/24 at 11:45 AM, with the Administrator revealed the facility lost power 05/28/24 to 05/31/24. The Administrator revealed he did not report the incident to the State Agency because his liaison stated as long as the generators were working the incident did not need to be reported to the state. The Administrator revealed he was responsible for reporting facility self-reported incidents. The Administrator revealed the staff monitored the residents constantly and the heat was at 80 degrees inside the facility during the power outage. <BR/>Record review of facility policy Nursing Administration-Section: Resident Rights-, Subject: Abuse prevention - Reporting and Investigating (revised November 2016) revealed the following in part:<BR/>All alleged violations will be reported via phone or in writing within 24 hours to the state Licensing Agency .<BR/>Record review of Long- Term Care Regulatory Provider Letter PL 19-17 dated 7/10/19 revealed the following:<BR/> .A NF must report to HHSC the following types of incidents in accordance with applicable state and federal requirement:<BR/> . emergency situation that pose a threat to resident health and safety Immediately, but not later than 24 hours after the incident occurs or is suspected .