MERIDIAN CARE MONTE VISTA

Based on observations, record reviews, and interviews, the facility failed to correct impairments during the inspection for 1 of 1 Fire Alarm System, inspected for regulatory requirements, failed to ensure outside areas, were maintained in good condition and kept free of conditions which constituted a fire or health hazard and failed to ensure the Emergency Preparedness Plan had been evaluated and updated annually. The Emergency Preparedness Plan was not updated at least annually. The Fire Alarm Control Panel was impaired indicating a low battery trouble signal. There were multiple trees on the back side of the facility leaning up against the roof which could constitute a fire hazard. These failures could affect the health and safety of residents dependent on staff to maintain the facility free of fire hazards, have a functioning alarm system and ensure staff were prepared to address emergency situations. Findings included:During an interview in the entrance conference, at 09:20 a.m. on 11/07/2025, the Administrator stated she was employed as the Administrator with the facility for one week. She stated she had not had the chance to review the Emergency Preparedness Plan. The Administrator stated the Emergency Preparedness Plan was not reviewed. When asked if she was aware of the Emergency Preparedness Plan binders being updated she stated she was not aware of the requirement. She understood as the Administrator she was responsible to review and update the Emergency Preparedness Plan at least annually. After further discussion the Administrator understood and agreed this could leave the staff unprepared during an emergency, causing confusion, a delay in evacuation, physical injuries, mental distress, and exposure to environmental conditions to the residents.Record review on 11/07/2025 of the Facility's Report, dated 11/07/2025, provided by the Administrator, revealed 52 residents resided in the facility with 17 resident's dependent on ventilators for maintaining oxygen levels.Record review on 11/07/2025 of the Emergency Preparedness Plan obtained from the Administrator reflected an emergency preparedness plan that had been reviewed, signed, and dated in 2005. There was no other documentation provided before exit to reflect a current review of their Emergency Preparedness Plan. Observation on 11/07/2025 at 10:39 A.M., revealed the fire alarm annunciator located near the Nurse Station had a trouble signal indicating Low Battery.During an interview on 11/07/2025, at the time of observation, the Maintenance Director confirmed and stated there was a trouble signal at the Fire Alarm Control Panel. He stated he was aware the Fire Alarm System had a trouble signal and stated it was due to an issue with the board. He stated he had two contractors come out and service the panel and one contractor stated the battery voltage was working properly. The other contractor stated it could be an issue with the board. He stated he would get a complete diagnosis of the issue and make any necessary repairs. The Maintenance Director stated that the low battery trouble signal will come and go periodically and that he developed a method to charge batteries onsite and swap them out if needed. He further stated he would contact the contractor and have them send the estimate for repairs as soon as possible so repairs can be started. The Maintenance Director stated if the Fire Alarm System did not function properly in the event of a fire it could allow the fire to spread to the rest of the building, harming residents. Record review on 11/07/2025 of the Inspection, Testing, and Maintenance sticker affixed to the Fire Alarm control panel, dated 09/10/2025, revealed a red service tag with a list of conditions/area: Fault in panel DC battery charge failure.Record review on 11/07/2025 of the Inspection, Testing, and Maintenance sticker affixed to the Fire Alarm control panel, dated 09/23/2025, revealed a white service tag with a list of services: replaced SD 2nd Floor, Lobby - Checked on battery charger voltage - 27V.During an observation outside inspection of the back side of the facility, it was noted there was vegetation growing over the roof of the building along with multiple dead fallen tree branches, dead brush, and dead leaves along the entirety of the rear adjacent to the smoking area.In an interview on 11/07/2025, at the time of observation, the Maintenance Director stated there were trees leaning against the building. The Maintenance Director stated the area adjacent to the smoking area was also surrounded by dead leaves and fallen tree branches. The Maintenance Director stated he was responsible for ensuring the grounds and maintaining compliance. He stated he was aware of the overgrown vegetation and tree branches; however, he was extremely busy with his workload. He stated he would get a vendor to ensure compliance was met with the outside grounds. He further stated if the facility grounds are not kept free of fire hazards it could place individuals at risk of a diminished quality of life and potential injuries

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 6 residents (Resident #1) whose records were reviewed for code status. Facility staff failed to follow emergency protocol, did not obtain an AED, did not obtain the crash cart, or continue CPR until EMS arrived after Resident #1, and who had a Full Code in place, was found unresponsive with no pulse or respirations. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk of not receiving life-saving measures, decline in health resulting in serious injury and or death. The findings included: Record review of Resident #1's face sheet, dated [DATE], reflected she was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with dependence on respirator [ventilator] status (patient requires mechanical ventilation to breathe independently due to respiratory failure), dependence on supplemental oxygen, paroxysmal atrial fibrillation (an episode of atrial fibrillation that results in uncoordinated movement of the atria), acute systolic (congestive) heart failure (heart's inability to pump blood effectively, leading to fluid buildup in the body), chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of respiratory symptoms characterized by obstructed airflow that makes it difficult to breathe) and cerebral infarction (occurs when a blood vessel in the brain is blocked, preventing oxygen and nutrients from reaching the brain tissue). Record review of Resident #1's care plan, close date [DATE], revealed the resident was full code status (a patient wishes to recieve all resuscitation efforts and life-saving measures during a medical emergency) and to being CPR after absence of vitals signs, call 911, call physician to notify, ensure staff are aware of code status through designated system, and full code order in chart. Record review of Resident #1's physician orders, dated [DATE], revealed an order for full code with start date of [DATE], and no end date. Record review of Resident #1's progress notes, dated [DATE], revealed:-A note Written by LVN C on [DATE] at 2:45 a.m. Patient was breathing while sleeping when this nurse got to her room to check on her. her vitals were WNL this was about an hour ago before she had an attack. the aids were doing their rounds when they found out she was not breathing, and the nurse was notified which they immediately started CPR on the patient and Ems was called. when they arrived, they tried to revive the patient to no avail she had passed on. Dr.notified.-A note written by RT E on [DATE] at 3:12 a.m. pt expired around 2300. CNA called me to check on patient because she looked pale. PT was unconscious. I checked her o2 sat and her exhaled tidal volumes. Her volumes were of 404 and she didnt have a pulse. We checked her code status and began CPR. During an observation on 8/225 at 1:08 p.m. the facility had an AED by the nurses' station which contained pads with an expiration date of [DATE]. The AED green light indicator, indicated it was in working order. There was a crash cart with various supplies including an Ambu bag (manual resuscitator is a handheld medical device used to provide positive pressure ventilation to patients who are not breathing). During an interview on [DATE] at 12:44 p.m. EMS F stated they were dispatched to a call for Resident #1 at 11:24 p.m. Upon arrival to the facility at 11:26 p.m. the patient was the only person in the room at 11:30 p.m., no care was being provided, and it did not appear that any care had been provided prior to their arrival. Resident #1 was found pulseless and apneic (not breathing). EMS F stated staff told them the resident was full code and did not have a DNR. EMS F stated there were no signs of lividity (bluish-purple discoloration of the skin that occurs after death) or rigor mortis. (stiffening of the body after death) EMS F stated they moved the resident from the bed to the floor and began CPR. EMS F stated the resident was found to be in asystole (absence of electrical activity in the heart). EMS F stated a medical director was contacted and advised to cease efforts and the time of death was 11:52 p.m. During an interview on [DATE] at 3:58 p.m. LVN D stated she was called to the 2nd floor of the building by CNA A and CNA B to check on Resident #1 because she was not breathing and could not find LVN C to help. LVN D stated she went to Resident #1's room, she found her not breathing, pulseless, and began CPR in the resident's bed while holding the phone with her cheek calling 911 and performing compressions. LVN D stated she instructed CNA B to go find the LVN C and CNA A to go find RT E. LVN D stated CNA A returned with RT E. LVN D stated she asked the aide and RT if the resident was full code, and both told her they did not know. LVN D stated RT E started to bag Resident #1 and CNA A took over compression while she left to go look up the resident's code status on the computer. LVN D stated she never returned to the room because EMS showed up while she was at the computer. LVN D stated she never instructed staff to obtain the AED but did ask for the crash cart however it was never obtained. LVN D stated she was CPR certified, and her certification was current. During an interview on [DATE] at 3:25 p.m. CNA A stated she and CNA B went to Resident #1's room to provide incontinent care during her rounds. CNA A stated she was unsure of the exact time this occured. CNA A stated she found the resident with her eyes closed and not responding. She stated they checked Resident #1's pulse and they could not find one. CNA A stated her and CNA B left the resident's room and started looking for LVN C, were not able to find her, and went down to the first floor and got LVN D to help instead. CNA A stated they returned to the Resident #1's room and LVN D started CPR. CNA A stated at some point the maintenance director came into the resident room and stated the resident was a DNR, and showed everyone a text from the ADON stating she was a DNR. CNA A stated the nurse then left the room to check the patient chart for code status and she took over compressions. CNA A stated she called 911 at 11:23 p.m. but was advised by the dispatcher that the nurse had already called, and EMS was in route to the nursing home, and she could hang up. CNA A stated she took over compressions then. CNA A stated RT E came into the room to take over and CNA A left to check the patient's chart for code status. CNA A stated she was CPR certified, and her certification was current. During an interview on [DATE] at 6:07 p.m. RT E stated she was called from the hallway to help with CPR for Resident #1. RT E stated she started bagging Resident #1 when the maintenance director came to the room and stated Resident #1 was DNR. RT E stated she put the resident back on her vent to respect her wishes in case she was DNR and returned to her computer to check the residents code status. RT E stated EMS arrived while she was at her computer, and she went into the room with EMS to assist with CPR. RT E stated she was CPR certified, and her certification was current. During an interview on [DATE] at 7:06 p.m. the DON stated she was informed on a group text that staff called 911 for Resident #1 on the night of [DATE]. The DON stated the primary way staff check a residents' code status is on the EHR. If the resident is full code they should initiate CPR. The DON stated anyone who is CPR certified can initiate CPR and call for help, have other staff obtain the AED and crash cart. The DON stated LVN D did leave the room to obtain the code status but other staff continued CPR to her knowledge. The DON stated she did not know if staff attempted to obtain the AED or crash cart. The DON stated you can do CPR in the resident bed but it is not ideal. The DON stated delayed or stopped CPR could cause prolonged oxygen deprivation to the brain leading to loss of brain activity. The DON stated she would expect staff to continue CPR until EMS arrived. During an interview on [DATE] at 7:27 p.m. the Administrator stated he was notified the resident had passed [DATE]. The administrator stated as far as he knew staff responded appropriately to the resident and there was nothing to report to the state. The Administrator stated when they looked at everything it looked like it was done correctly. Record review of the facility's policy titled Emergency Procedure Cardiopulmonary Resuscitation, dated 2018, stated 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless:a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; orb. there are obvious signs of irreversible death (e.g., rigor mortis).7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 9:11 p.m. The Administrator was notified and provided with the IJ template. The following Plan of Removal (POR) was accepted on [DATE] at 1:44 p.m. and indicated the following: The facility respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on [DATE]. Plan submitted on [DATE] at 1:20pm. Facility failed to provide timely emergency services and professional standards for CPR. - The facility failed to initiate CPR on Resident #1 who was found unresponsive on [DATE] around 11pm, not breathing, and with no pulse. On [DATE], around 11pm, Resident #1 was found unresponsive, not breathing, and with no pulse by CNA A and CNA B. CNAs A and B left Resident #1's room to locate the Charge Nurse for help. CNA A is CPR certified and did not initiate CPR on Resident #1 who was a full code. When LVN D arrived moments later, CPR was initiated. Staff did not obtain either the AED or crash cart. CPR remained in effect for several minutes until the time that staff reports they were notified by the ADON (who has remote access for PointClickCare log-in) that Resident #1 was a DNR. At this time, they stopped CPR and exited room. EMS arrived moments later and re-initiated CPR. Residents with the potential to be affected by the alleged deficient practice:On [DATE], The Facility completed an audit of Resident code status. Eighteen (18) Residents were confirmed as DNR and thirty-seven (37) Residents were confirmed as full code. Red dot visual aide for all DNR Residents was audited and confirmed accurate. DNR Binder with OOH DNRs was audited and found accurate. Staff in-servicing of all Charge Nurses and Respiratory Therapists was immediately initiated regarding how to confirm/verify code status prior to initiating CPR; location of code status is confirmed by using PointClickCare; where to find the DNR binder at nurses' station with copies of OOH DNRs, and to utilize the red dot visual reminder on Resident's door for DNR Residents. Resident identified to have been affected by the alleged deficient practice:- Resident #1, who was a full code, was identified as having been affected by the alleged deficient practice. Systemic Measures: Training Topics for timely emergency services and professional standards for CPR will be added to new-hire orientation: The Facility immediately added the training for providing timely emergency services and professional standards for CPR to all new hire education. (See training topics below.) Mock Codes: The Facility immediately implemented a mock code program in which random monthly mock codes will be called on all 3 shifts to ensure appropriate and timely response occurs from all staff. The first mock code was conducted by the DON on [DATE] on the 10p-6a shift. Code Status Audits: The Facility's DON and/or Designee will perform daily code status audits to ensure the OOH DNR is in the DNR binder and the red dot visual reminder is on the Resident's nameplate. The audit will be completed by pulling the Order Listing Report daily from PCC for review of any new/changed code status orders. If any new/changed orders exist, the DON and/or Designee will then ensure that any needed OOH DNRs are confirmed in the binder, and that any needed Red Dot visual aides are in place on the Resident's nameplate. Training: Will be completed by [DATE] as follows:a. Re-initiate staff in-servicing on CPR/code status to include the additional topics of any CPR certified staff member initiating CPR (if you are CPR certified and the Resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR); non-CPR certified staff member action (if you are not CPR certified, you must call 911 and follow the 911 operator's instruction until a CPR certified staff member arrives); Charge Nurse and/or Designee will be responsible for confirming any unclear code status; ensuring AED is placed on Resident during all codes; ensuring crash cart is brought to Resident's room during all codes; and to continue all CPR efforts until you have been relieved of this duty by EMS. All Facility staff will be included the aforementioned in-servicing. Inservice sign in sheet will be cross referenced with employee roster. Quality Assurance Performance Improvement: On [DATE], the Quality Assessment and Assurance Committee members to include the Medical Director, Administrator, and Director of Nursing, and the Regional Director of Clinical Services met to review and approve this plan. The Administrator and/or Designee will review any new-hire packets weekly for 3 months to ensure training on timely emergency services and professional standards for CPR has been completed. The Administrator and/or Designee will review the random monthly mock code sign-in sheets to ensure it is being completed at least monthly on all 3 shifts on a weekly basis for 3 months. The Administrator and/or Designee will review the code status audits weekly for 3 months. The results of the Administrator and/or Designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Plan of Removal Verification[DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and/or completed by: On [DATE] at 1:49 p.m. residents #1-#18 rooms were verified to have red dots next to their names. Record review on [DATE] of the 100 hall and 200 hall DNR binders contained DNRs for 18 residents and were available in the nurses station. Record review of order audit report, dated [DATE], revealed a list of all current residents' code status orders. Record review of order audit report, dated [DATE], revealed a list of 18 residents who's order for code status was DNR. Record review of a facility document titled DNR Audits-monitoring frequency-weekly x3 months, no date, revealed a log with a start date on the log of [DATE]-[DATE] for tracking completion of weekly DNR audits. Record review of facility document titled Timely Emergency Services and Professional Standards for CPR, no dated, stated scare providers for our Residents, we need to ensure that we always provide timely emergency services and professional standards for CPR. Key points to ensure this is achieved are: If you are CPR certified and the Resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Non-CPR certified staff members must call 911 and follow the 911 operator's instruction until a CPR certified staff member arrives. The Charge Nurse and/or Designee will be responsible for confirming any unclear code status. To determine a Resident's code status, you can look in the Resident's chart/orders in PCC or you can refer to the visual red dot aide. If you see a red dot on the resident's nameplate by the door it indicates the Resident is a DNR. Any Resident with a red dot on his/her nameplate is a DN R. If you are a CNA, you can also find the Resident's CPR status on the Resident's tab in the POC. To be able to perform effective compressions, you must either place the backboard from the crash cart under the Resident OR move the Resident to the floor. In any code situation, the crash cart and AED must be brought to the room and utilized. The AED should be placed on the Resident as soon as possible as it will guide the CPR process from that point forward. Once the CPR process is initiated, it cannot be stopped for any reason until EMS arrives and completely takes over. Record review of a log titled New Hire Training Emergency Services and Professional Standards for CPR, no date, monitor frequency- weekly x3 months, with a start date of [DATE] through [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated new hire orientation is given by HR, that would be included in the nursing portion of new hire orientation. The DON stated nursing management participated in new hire orientation. The DON stated orientation was usually on a set date of the week and management all had a time slot to present training material. The DON stated nurses have extra training they had to completed and the emergency training would be implemented for new hires. During an interview on [DATE] at 4:38 p.m. the ADON G stated they had a mock code the night of [DATE] and that morning. ADON G stated that morning she went into the room and put my call light to see how long staff would take. She was unresponsive by holding a sign that said she was unresponsive, full code, and laid in a patient bed. The ADON stated staff eventually figured out it was a mock code, grabbed the crash cart and AED, simulated compressions and calling 911. Record review of a document with Mock Code written at the top, and no date, showed on [DATE] 5 staff signatures that participated in the mock code. Another date of [DATE] showed 7 staff signatures participated in the mock code. Record review of a document titled Mock Code, no date, revealed a check list of questions asking if mock codes were conducted on all 3 shifts at least monthly? If not was this immediately corrected? And admin/designee signature and date. The start date was [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated herself and ADON G had done the mock codes on [DATE] during the night shift and on [DATE] during the morning shift. The DON stated they had a person pretending to be unconscious in an empty room, they pulled the call light, waited for someone to respond, and had a sign on that said I am not breathing. The DON stated then staff realized what was going on, they had them go through the steps and pretend to call 911, get the AED, get the crash cart, and get other staff. They had done the mock codes on both floor the 1st and the 2nd floor. The staff upstairs had done better probably due to most of the emergency codes they actually had were upstairs because it was where the vent unit was and they are used to emergency code situations. The DON stated the downstairs staff had parts of the code were easier for some and parts needed to be refreshed on. The DON stated they went through the scenario more than once and introduced new scenarios each time. During an interview on [DATE] at 4:40 p.m. ADON G stated she had assisted with chart audits. The ADON stated they have an order listing report which pulled all the resident orders from whatever time range they set. The ADON stated they would check the report daily. The ADON stated chart audits were a team effort between the ADONs and DON. The DON would check the current DNR binders to ensure they were up to date and located at the nurse's station. Record review of in-service, dated 8/1, reviewed topics of: advance directives-you must always verify code status on your residents prior to initiating/ not initiating CPR, look in PCC profile DNR/ full code this is priority, visual reminder with the red dot on the door of DNR patients, code book of nurses station with copies of OOH DNR. The in-service was signed by 54 direct care staff between [DATE]-[DATE] Record review of in-service, dated 8/2 and 8/3, reviewed topics of: CPR code status-who is there I code states in PCC, these are your active current physician orders. Residents who are DNR will have (red dot) on the name plate on their door and copy of OOH DNR in binder at nurses station. Once decision is made to initiate CPR and code status these verified, CPR certified staff will initiate CPR (chest compressions) and call for help. Either place patient on the floor or utilize backboard for effective CPR. Crash cart and AED brought to room and placed AED on patient following directions of ADD. Once CPR is initiated it is never stopped until EMS arrives and assumes care of patient fully taking over CPR/ ALS. If you are CPR certified and the resident DNR status is unclear CPR will be initiated until it is determined that there is a DNR on a physicians order not to administer CPR. If you are not CPR certified, you must call 911 and follow the 911 operator instructions until the CPR certified staff member arrives. The in-service was signed by 54 staff in person. Record review of a current employee list 2025 by department revealed there were 89 staff at the facility. 82 were in service in person or by phone. One staff was active duty and not available, 2 staff phones were disconnected, 3 did not answer, and 1 was on FLMA. Record review of in-service titled AED and Crash Cart, dated [DATE], revealed anytime you are performing CPR on a resident, you must ensure the AED and crash cart are obtained. The AED should be placed on the resident as soon as possible and the crash cart must be available. LVN D was in-service via phone by RN H. LVN D verbalized understanding of the above. 18 staff (CNA A, ADON G, LVN I, LVN J, RT K, LVN L, RT M, DOR N, DA O, FDS P, HR, MS, AD, HK Q, HKS, CNA R, COOK S, DA T, CAN U, and CNA V) were interviewed to include direct care staff, non-direct care staff, day shift, and night shift staff were on [DATE] between 3:26 p.m. and 5:24 p.m. All staff verbalized understanding the in-service training over CPR, code status, and emergency response. CPR certified staff were able to verbalize appropriate emergency response actions and non CPR certified staff were able to verbalize appropriate emergency response actions. All staff verbalized understanding of the code status systems. During an interview on [DATE] at 6:34 p.m. the DON stated she gave the in-service on [DATE], [DATE], and [DATE]. The DON stated she went over how to find resident code status that it is in the patient's profile in PCC. The DON stated she trained staff to ensure they gave effective CPR compressions on a hard surface with the back board or on the floor, utilized the AED and crash cart, the importance of initiating 911 for advanced life support, initiating CPR immediately, and not stopping till EMS comes in and takes over. The DON stated she trained on the red dot system; the red dot was a visual reminder of resident with DNR code status, and orders for DNR. The DON stated she was the one who places the dot by residents' names on the door, after she verified there is a valid DNR, and signed order. Record review of a log titled Quality Assessment and Assurance Committee, dated [DATE], revealed the DON, Medical Director, Administrator, and Regional nurse attended a meeting reviewing the POR for this IJ. During an interview on [DATE] at 7:03 p.m. Administrator stated they had a QA meeting on [DATE] where they went over the dos and Don'ts of a DNR or full code, if residents had the red dot you would not resuscitate, they would get help if you are not DNR code status, if there was not red dot net to the resident's name they can assume they were full code, and if non clinical staff of course they would not start CPR, they would call for help. The Administrator stated once staff arrived with a crash cart if you are not clinical you could step out or be on stand by for assistance. During an interview on [DATE] at 6:34 p.m. the DON stated they went over CPR if the code status was unknown, they would initiate CPR until they were confirmed DNR or until EMS arrived. Record review of a log titled New Hire Training Emergency Services and Professional Standards for CPR, no date, revealed a log to monitor frequency- weekly x3 months, with a start date of [DATE] through [DATE]. Record review of a document titled Mock Code, no date, revealed a check list asking if mock codes were conducted on all 3 shifts at least monthly? If not was this immediately corrected? And admin/designee signature and date. The start date was [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated they would complete the mock code and fill out the forms. Herself and the ADONs will perform the mock code or nursing management. Record review of a facility document titled DNR Audits-monitoring frequency-weekly x3 months revealed a log with a start date on the log of [DATE]-[DATE] to monitor if DNR audits were completed weekly for 3 months. During an interview on [DATE] at 7:03 p.m. Administrator stated he was going to oversee the binder with the logs, the DON and ADON were going to be doing the code status, and logs were for him to fill out based on the information they gave him. The Administrator stated he would say yes or no to them filling out the log and completing the task. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 7:19 p.m. While the IJ was removed on [DATE] at 7:19 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to promote and facilitate resident's self determination with support of resident choice and the right to refuse care for 1 of 4 (Resident #7) reviewed for resident rights.<BR/>Resident #7 was unable to refuse care without the threat of calling his family member.<BR/>This failure could affect the resident's psychosocial well-being and the ability to maintain highest level of independence.<BR/>The findings included: <BR/>Record review of Resident #7's face sheet dated 6/19/2025 revealed a [AGE] year-old male was admitted to the facility on [DATE] with the diagnoses: hypertension, chronic kidney disease, and coronary artery disease(narrowing or blockage of the artery leading to the heart).<BR/>Record review of Resident #7's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 indicative of cognition intact.<BR/>Record review of Resident #7's Care Plan dated 6/13/2025 revealed he was care planned per family member's request to be called with episodes of refusal of car with changing his clothing, obsessive-compulsive.<BR/>Interview on 6/19/2025 at 10:55AM Resident #7 said when he was told that his family member would be called because he refused to change his clothes, he made him feel sad and like he was not an adult. He said he did not refuse; he hesitated and then agreed to change his clothes. He said he felt like he was being threatened when they (staff) said they would call his family member when his family member was younger than him. Resident #7 said it made him feel sad because he did not want his family member to be mad at him and then he would not come to see him. He said he liked when his family member would come see him and he did not want him to be mad at him.<BR/>Interview on 5/19/2025 at 2:40PM the DON said with Resident #7, it was an issue with him not wanting to change his clothes and staff would tell him they would call his family member and staff had gotten used to telling him they would call his family member as a way to get him to do things. She said it was used as a threat and she said they had to be redirected not to say that to the resident. The DON said residents should not be threatened to do things because it was a violation of their rights to make choices and it could cause psycho-social harm to the resident.<BR/>Interview on 6/19/2025 at 4:40PM the Administrator said Resident #7's family member told them to call him and to inform Resident #7 that he would be called if he would refuse to change his clothes or refuse incontinent care. The Administrator said he told him they could not do that because he had the right to refuse and if he insisted, he, Resident #7's family member would be called in to the state because that would be considered abuse. The Administrator said threatening residents to comply with care was a violation of their rights and it could cause mental harm to the resident and diminish their desire to maintain their independence.<BR/>Interview on 6/20/2025 at 10:05AM CNA B said he told Resident #7 that he would help him change his clothes because he was wet. When he refused, he told him that the AD would call his family member.<BR/>Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 stated in part: Residents had the right to be free from abuse; Policy Interpretation and Implementation stated in part: <BR/>1. Protect residents from abuse by anyone but not limited to: facility staff, family members, legal representatives. <BR/>5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect the rights of residents to be free from misappropriation of property for 2 of 8 residents (Resident #5, Resident #6) reviewed for misappropriation of medication. <BR/>The facility failed to ensure Resident #5's and Resident #6's medications were secured and not diverted when delivered to the facility.<BR/>The noncompliance was identified as past noncompliance. The noncompliance began on [DATE] and ended on [DATE]. <BR/>This failure could place residents who receive pain medications at risk of diminished quality of life and distress.<BR/>The findings included:<BR/>Record review of Resident #5's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses: epilepsy, hypertension, joint derangement (a chronic condition that is a result of an underlying injury), and stiff man syndrome (autoimmune neurological disorder with muscle stiffness and painful spasms). He expired on [DATE] at the facility. <BR/>Record review of Resident #5's CP dated [DATE] revealed he was care planned for pain medication and epilepsy.<BR/>Record review of Resident #5's QMDS dated [DATE] revealed he had a BIMS score of 14, indicative of mild cognitive deficit.<BR/>Record review of Resident #5's electronic medication administration record for the month of February 2025 revealed he received the pain medication as needed, administered by LVN A.<BR/>Record review of Resident #5's physician orders dated [DATE] with an end date [DATE] revealed he had orders for Norco 10mg-325mg 1 tablet by mouth every 4 hours as needed for pain.<BR/>Record review of Resident #6's face sheet dated [DATE] revealed an [AGE] year-old male was admitted on [DATE] with the diagnoses: type 2 diabetes, encephalopathy (any disease or disorder that affects the brain's function or structure), quadriplegia (loss of function of all four limbs), and chronic kidney disease.<BR/>Record review of Resident #6's CP dated [DATE] revealed he was care planned for hospice with diagnosis of failure to thrive, diabetes, pain due to osteoarthritis and arteriosclerosis, and chronic wounds.<BR/>Record review of Resident #6's QMDS dated [DATE] revealed he had a BIMS score of 4, indicative of severe cognitive deficit.<BR/>Record review of Resident #6's physician orders revealed he had an order dated [DATE] for Norco 10mg-325mg to give 1 tablet by mouth every Tuesday and Thursday on day shift for pain. <BR/>Record review of Resident #6's eMAR for the month of February 2025 revealed the Norco was signed and administered only by LVN A.<BR/>Interview on [DATE] at 3:20PM the DON said the medication diversion occurred because the Residents #5 and <BR/>#6 received Norco scheduled and as needed, but Resident #5 hardly ever took the medication. She said Resident #6 was on hospice and his medication was ordered through their pharmacy. She said the reason it took so long for it to be discovered that LVN A was diverting medication was since Resident #5 rarely took his scheduled or his as needed pain medication, she would be the only person that would call in refills and the only person that received them from pharmacy. She called in refills for Resident #6's as needed Norco. She said an audit was done with the in-house pharmacy and the hospice pharmacy and they noticed there were several cards of Norco unaccounted for. The nurse was suspended and tested and was negative for Norco but positive for cocaine and she never returned to the facility. The DON said her license was referred to the BON. The DON said the process instituted was for the DON and the ADON to be notified by email when narcotics came in from pharmacy and they retrieved the invoice from the basket on the wall on the unit and checked the carts to ensure the medication was on the carts. She said an electronic signature was also done to keep track of who received the medications. She said the police were called as well. She said the residents involved in the diversion did not miss any medications because the medications were in the locked drawer, and they did not miss any if needed. She only called in refills and diverted them when delivered.<BR/>Interview on [DATE] at 4:40PM with the Administrator and DON, the DON said when medications would come in from pharmacy, she would receive an email. The Administrator said the DON and ADON would get the invoice that came with the medication and check for narcotics and then check the medication carts for the quantity and dosage medications.<BR/>Interview on [DATE] at 4:50PM LVN B said when narcotics come in from pharmacy, before the delivery person left, the medication had to be verified with the amount of medication, the dosage, and the resident's name. Before the medication was placed in the cart, 2 nurses had to verify the medication and with 2 signatures. <BR/>Interview on [DATE] at 4:55PM LVN C (agency) said when pharmacy delivered narcotics she would verify the amount of pills, the dosage, the resident name, the medication. The medication had to be verified by another nurse for 2 signatures and then placed in the lockbox on the medication cart.<BR/>Interview on [DATE] at 9:46AM LVN D (agency) said when pharmacy delivered narcotics, she would first check to make sure all the medications were accounted for (quantity of narcotic) according to the invoice before she signed to receive the medication from the driver; then she would check the medication dosage, order, and resident name with another nurse, both sign and if needed, make a narcotic count sheet and place the medication in the lockbox on the medication cart. <BR/>Observation on [DATE] at 12:10PM LVN E and LVN F did narcotic count on the 1st floor, with LVN F calling the name of the medication, resident's name, and the amount remaining in the bubble card. LVN E checked the cards as he called them and the count was correct, no missing medications.<BR/>Observation on [DATE] at 12:15PM LVN D (agency) and LVN G did narcotic count on the 2nd floor following the same process- calling the name and the remaining amount, while the agency nurse checked the card, no missing medications.<BR/>Interview on [DATE] at 12:26PM the DON said the PNC-drug diversion was identified on [DATE] and the nurse was suspended on [DATE] because they knew it was LVN A due to pharmacy audits. She was drug tested, tested positive for cocaine and she never returned and was ultimately terminated. The PNC was corrected on [DATE] and a full facility reconciliation for the narcotics was completed, without any missing medications. The DON said in-services were done immediately on abuse, neglect, and misappropriation of property, process of receiving medication from pharmacy, and narcotic count.<BR/>Record review of the in-service dated [DATE] titled Abuse, Neglect, Exploitation and Misappropriation and Preventionrevealed 81 out of 81 employees were in-serviced, including 3 out of 3 agency nurses.<BR/>Record review of the in-services dated [DATE] titled Process of Receiving Medications from Pharmacy revealed 24 out of 24 nurses were in-serviced and 3 out of 3 agency nurses were in-serviced for the process.<BR/>Record review of facility policy dated [DATE] titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.<BR/>Record review of facility policy dated [DATE] titled Accepting Delivery of Medications stated 1.All staff follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications are brought to the attention of the pharmacist and director of nursing services. Under Policy Interpretation and Implementation stated: 2. Before signing to accept the delivery, the nurse reconciles the medications in the package with the delivery ticket/order receipt. 4. A nurse signs the delivery ticket, indicating review and acceptance of the delivery, and keeps a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket is archived in a designated location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation result in serious bodily injury for 1 of 4 Residents (Resident #3) whose records were reviewed for abuse and neglect., in that;<BR/>The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #3 suffered a fracture to her left tibia (lower leg).<BR/>This deficient practice could affect any resident and could contribute to further abuse and neglect. <BR/>The findings were:<BR/>Record review of Resident #3's face sheet dated [DATE] revealed an admission date of [DATE] and a readmission date of [DATE] with diagnoses which included: moderate intellectual disabilities, autistic disorder, and unspecified fracture of upper end of tibia, initial encounter for closed fracture (break in one of the bones of the lower leg) ([DATE]). <BR/>Record review of Resident #3's Care Plan last reviewed/revised on [DATE] revealed the resident had a communication problem related to neurological symptoms, cognitive function, intellectual disability, autistic disorder with impaired thought processes, developmental delay, difficulty making decisions, impaired decision making and long-term memory loss and was able to voice some needs. Interventions included: Resident #3 needed staff to anticipate, meet her needs, and assist with all decision making. The care plan indicated Resident #3 said the word yes mainly. <BR/>Record review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 0 which indicated a severe cognitive impairment. The assessment revealed the resident had unclear speech, could sometimes make herself understood, and could sometimes understand others. The MDS assessment revealed Resident #3 required maximum assistance to total dependence with ADL care, was not able to ambulate and had total dependence on staff for transfers. <BR/>Record review of Resident #3's x-ray results (obtained by facility in facility) dated [DATE] revealed: an acute to early subacute transverse fracture of the left proximal tibial shift with diffuse osteopenia. (New to approximately 1 month old fracture to upper part of one of the bones in the lower left leg with demineralization of the bones which can result is bones that are brittle and break easily). <BR/>Record review of Resident #3's hospital records dated [DATE] revealed Resident #3 was a wheelchair and bedbound resident who resided in a LTC facility and presented to the hospital via EMS with a left proximal tibia fracture. The report revealed per outside x-ray done on [DATE] which revealed acute to early subacute transverse fracture of the proximal tibial shaft. Patient intellectually impaired due to birth defects (and) cannot give history. Resident admitted and treated for left tibia fracture .<BR/>Record review of TULIP on [DATE] revealed the facility had not self-reported Resident #3's fracture to the left tibia. <BR/>During an observation/interview of Resident #3 on [DATE] at 1:58 p.m. at a local hospital revealed the resident was awake and alert in a hospital bed watching cartoons on the television. Resident #3 had obvious facial, hand and foot abnormalities typical of someone with a chromosomal defect. She was pleasant with a childlike demeanor. Resident #3 answered yes/no questions with unknown accuracy. Resident #3 was able to give inconsistent word responses at times to simple questions. She was not able to state how she obtained the injury to her left leg. She was not able to answer the question of where she was or why she was there. She was not able to give detailed interview questions due to her cognitive status and additional details were unable to be elicited. <BR/>During an interview on [DATE] at 2:08 p.m., an RN at a local hospital stated Resident #3 had a chromosomal abnormality and was intellectually disabled. She stated the resident had arrived at the facility with a left leg brace and x-rays confirmed she had a fracture to the left tibia. The RN stated the facility had stated Resident #3 had broken her left leg by bumping it while getting in the facility van on an unknown date. She stated Resident #3 was not able to say what had happened to her due to her intellectual disability. She stated Resident #3 had not stated anything that could be understood other than crying for her momma. She stated Resident #3 had spinal stenosis and functional paraplegia and it was possible she was unable to feel when she was initially injured although she could feel pain when her leg was moved. <BR/>During an interview on [DATE] at 7:39 p.m., LVN C stated he worked as a charge nurse, treatment nurse and ADON. He stated on Monday ([DATE]) around 5:00 p.m., he was told by the DON that Resident #3 had a bruise to her left leg. He stated the DON asked him to assess Resident #3 because he does skin assessments and because he was the wound care nurse. He stated when he assessed Resident #3, he noticed she had edema (swelling) to her leg at baseline (typical for the resident). He stated there was slight redness that was warm to touch and painful and he noticed a big bruise to her left leg. LVN C stated the bruise was the whole shin area approximately 12 inches long and wrapped around the back of the left calf into the soft tissue. He stated the darkest part of the bruise was on the front. LVN C stated Resident #3 only complained of pain when he touched the front of the shin and not the calf. He stated when he moved the left leg the resident moaned and complained of pain by making facial grimaces and then verbally stated it hurt. LVN C stated he notified Resident #3's physician about the bruises and the redness and warmth, and he sent the physician a picture. LVN C stated the physician responded by ordering an x-ray. LVN C stated he had performed a skin assessment on Resident #3 on Friday prior ([DATE]) and she did not have any injuries. LVN C stated it was late, so he reported to the oncoming nurse that they were getting x-rays and he left for the day. LVN C stated the DON had mentioned Resident #3 had hit her leg on the bus. He stated he did not witness the injury. He stated Resident #3 goes to Adult Day Care, M-W-F . He stated he did not know what sort of transportation she used to get the ADC. LVN C stated he had completed a whole head-to-toe assessment of Resident #3 on [DATE] and did not find any other injuries other than the left leg. He stated he was not working when the x-ray results came in. <BR/>During an interview on [DATE] at 1:34 pm, LVN D stated on [DATE] at 6:00 am she noticed an old looking bruise with some redness to Resident #3's left lower leg. She stated she told LVN C about it and documented it in the medical record. LVN D stated Resident #3 made a face when they moved her but did not complain of pain. She stated the bruise was approximately 2 x 4 inches to the left shin. LVN D stated she asked Resident #3 what happened, and she did not say anything. She stated she did not think too much about the bruise because it was on the shin, and it looked like a typical bruise. She stated none of the CNA staff had reported any incidents or injuries. She stated no one else had documented the bruise and that was why she reported it. She stated she went off duty and when she came back to work two days later learned that Resident #3 had a fracture. <BR/>During an interview on [DATE] at 3:45 pm, the DON stated they were not sure how Resident #3 got the fracture to her left leg. The DON stated Resident #3 went to Adult Day Care on Monday, Wednesday, and Friday by local disability public bus services. She stated a family member (who was now deceased ) had really pushed for the resident to go and ride the bus. She stated that family member had set up the services which pre-dated her time at the facility as the DON. The DON stated Resident #3 traveled on the public bus without staff in attendance. She stated it was adult-to-adult hand off at each location. The DON stated on Monday [DATE], Resident #3 told the Director of Rehabilitation that she hit her leg on the bus and the Director of Rehabilitation told her (DON). The DON stated during morning meeting they read the nurses notes that documented a bruise. She stated the resident's physician was on his way to the facility so wrote it on her list to have it addressed by the physician. She stated when the physician came to the building Resident #3 was at Adult Day Care. The DON stated she told the ADON (LVN C) to do an assessment of the resident when she returned from Adult Day Care and let her know what he found. The DON stated the ADON (LVN C) informed her that he had assessed the resident and had communicated with the physician who had ordered an x-ray. She stated on [DATE] at 5:50 am the x-ray results hit her phone and she immediately notified the physician of a left tibial fracture. The DON stated the physician had Resident #3 admitted to the hospital for an orthopedic consult. The DON stated she came back to the facility after treatment at the hospital with a brace to her leg and orders for follow up in 4-6 weeks. The DON stated they were treating Resident #3 for a left tibial fracture of unknown origin but according to Resident #3 she hit her leg on the bus. The DON stated Resident #3's BIMS score was 0 which indicated the resident was severely cognitively impaired. She stated she did not believe the assessment was accurate because the resident could have a conversation if she wanted to. The DON stated just because the resident did not answer questions did not mean she did not understand. The DON stated she (DON) understood questions presented to her (DON) about how she could be certain Resident #3 understood conversation given Resident #3 had documented intellectual disabilities along with chromosomal abnormalities, but she (DON) had no response to the question. The DON stated when there was an injury of unknown origin the facility looks for possible reasons for it, talks to staff, looks for possible sources and does an investigation. She stated an investigation was done. The DON stated the facility did talk about reporting the incident to HHSC but did not report it. She stated they did not report it because Resident #3 was able to give a reliable statement to the Director of Rehabilitation on what happened to her. The DON stated they still did not know how it occurred, just that it occurred on the bus. The DON stated it seemed logical to her that because Resident #3's custom wheelchair was big and not easily moveable that maybe her leg got pinched between the wheelchair and the bus although she had no evidence to prove it, it just seemed logical. <BR/>During an interview on [DATE] at 4:45 pm, the Director of Rehabilitation stated one of her assistants was working with Resident #3 and called her over because she was grimacing on Friday [DATE]. She stated she looked at both legs and they were swollen from the thigh down which was common for this resident. She stated she noted the left leg was more swollen than the right, so she told her assistant to stop working with her on that day and let her rest. She stated there was no bruising of any kind to the left leg. The Director of Rehabilitation stated on Monday, [DATE] during morning meeting they reviewed that a bruise was noted to her left leg. She stated when Resident #3 came to rehab, she noted the resident bruising and redness to the left shin and a slight indentation. She stated no therapy was performed on her lower extremities and she talked to the DON. She stated she found out they were going to do an x-ray that day of her left leg. The Director of Rehabilitation stated she asked Resident #3 what happened. She stated Resident #3 responded the bus but that was all she told her. The Director of Rehabilitation stated sometimes Resident #3 would talk and sometimes she would not. She stated she would not say anything other than the bus. The Director of Rehabilitation stated they took Resident #3 back to her room and laid her down in bed. She stated she then reported it to Resident #3's charge nurse, whom she could not remember her name, just that it was a female. She stated the nurse responded appropriately and stated she would look at her leg. She stated she did not report it to the DON but knew the DON knew about it because she it was discussed during morning meeting. <BR/>During an interview on [DATE] at 5:20 p.m., Resident #3's family member stated on [DATE], when Resident #3 got back from Adult Day Care it was reported to the family member that the resident had a bruise on her leg (unknown which leg) and that the facility was going to take x-rays. The family member stated the next day he learned she had a fractured leg. He stated he did not understand how it happened. He stated the facility reported they did not know how it happened, just that she was going to the hospital. The family member stated he called the Administrator and asked her how it happened, and she did not know but she was going to investigate and call the bus company. He stated nobody knows what happened. The family member stated he did not get a report of any falls. He stated he thought she might have had a fall in [DATE] but could not remember. He stated Resident #3 could not move on her own and could not just fall out of bed. He stated he felt frustrated about what was happening at the nursing home and their lack of answers. <BR/>During an interview on [DATE] at 5:53 p.m., the Administrator stated LVN D reported Resident #3 had a bruise, and she (Administrator) mentioned it in morning meeting. Then the Director of Rehabilitation mentioned in the morning meeting that Resident #3 had pain during rehab and she told the nurse. She stated the bruise was noted on [DATE] and a nurse got an order from x-rays, and they proceeded from there. The Administrator stated they did not report the injury to HHSC (State Reporting Agency) because Resident #3 told them it happened on the bus. The Administrator stated Resident #3 had not told them how the injury occurred, just that it happened on the bus. The Administrator stated the time frame for reporting abuse or serious injury was 2 hours. The Administrator stated the facility abuse policy indicated they should report suspected abuse and neglect but, in this case, she did not suspect abuse, so she did not report. <BR/>Record review of a facility policy, titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (undated) revealed: g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met i. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident ii. The injury is suspicious because of the extent of the injury or the locations of the injury .F. Reporting and Response: The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials (including to the State Survey Agency .)in accordance with State law through established procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, had evidence that all alleged violations were thoroughly investigated, prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. for 4 of 10 residents (Resident #1, #2, #3, #4) reviewed for the allegations of abuse, neglect, exploitation and or mistreatment.<BR/>1. On 12/3/2024 the facility failed to investigate an allegation of abuse and or mistreatment when Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry.<BR/>2. On 12/23/2024 the facility failed to investigate an allegation of neglect and or mistreatment when Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. Resident #2 alleged the nurse handed her the gauze dressing and told her to do it herself. <BR/>3. On 3/12/2025 the facility failed to investigate an allegation of abuse with rough incontinent care, when Resident #3 alleged diaper grabbed and pulled up to give her wedgy.<BR/>4. On 3/13/2025 the facility failed to investigate an allegation of verbal abuse when Resident #4 alleged staff insulted him by stating he smelled like an animal. <BR/>These failures could have harmed residents by not having their allegations of ANE investigated.<BR/>The findings included :<BR/>1. A record review of Resident #1's admission record dated 6/19/2025, revealed an admission date of 3/23/2025 with diagnoses which included cerebral vascular accident (a stroke) and seizures (a surge of electrical activity in the brain).<BR/>A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old-female admitted for long term care and assessed with a BIMS score of 9 out of a possible 15 which indicated severe cognitive impairment. <BR/>A record review of Resident #1's care plan dated 6/19/2025 revealed, I have impaired cognitive function AEB SEVERE IMPAIRMENT ON MY BIMS r/t sic [related to] neurological symptoms . Engage the resident in simple activities that avoid overly demanding tasks. I have a communication impairment due to no speech pattern but able to communicate with gestures & mouthing words. Utilize nonverbal cues and gestures to communicate with resident <BR/>A record review of Resident #1's grievance report dated 12/03/2024 revealed the previous administrator documented a grievance report on behalf of Resident #1 when Resident #1's representative made an allegation of abuse. The previous administrator documented, [Resident #1's representative] reported that her [Resident #1] called her yesterday afternoon. She stated that [Resident #1] had complained that a female nurse had treated her poorly. [Resident #1's representative] stated that her [Resident #1] began to cry and this is rare for her to do. <BR/>2. A record review of Resident #2's admission record, dated 6/19/2025, revealed an admission date of 8/9/2024 and a discharge date of 1/31/2025 with diagnoses which included encounter for attention to gastrostomy (aka a feeding tube, a device that's inserted into the stomach through the abdomen. It's used to supply nutrition and medications, aka percutaneous endoscopic gastrostomy (PEG), G tube.) <BR/>A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old-female admitted for rehabilitation care. Resident #2 was assessed with a BIMS score of 14 out of a possible 15, which indicated intact cognition. <BR/>A record review of Resident #2's care plan dated 1/31/2025 revealed, require assistance ADL's due to generalized weakness, . Bed Mobility: I require extensive assistance in self-performance with 2-person physical assistance staff support. Dressing: I require extensive assistance in self-performance with 1-person physical assistance staff support. Eating G-tube: I am NPO. I require total assistance in self-performance with 1-person physical assistance staff support. I require total nutrition and hydration through my gastrostomy tube <BR/>A record review of Resident #2's grievance report dated 12/23/2024 revealed the DON documented Resident #2 alleged a night nurse came in her room handed her a gauze and told her to change her PEG dressing herself. RN did not clean site or assist her, only left room.<BR/>During an interview on 6/20/2025 at 10:50 AM the DON stated she did not recall the grievance report dated 12/3/2024 for Resident #1 nor the grievance report for Resident #2 dated 12/23/2024 but did state all grievance reports were reviewed by the IDT which included the previous administrator who would have been the ANE prevention coordinator at the time. The DON stated she had investigated but not reported the results of the investigation to the state agency. <BR/>3. A record review of Resident #3's admission record dated 6/19/2025 revealed an admission date of 3/25/2025 and a discharge date of 4/24/2025 with diagnoses which included end stage renal disease (kidneys no longer work as they should to meet the body's needs and dialysis is required), severe obesity, and acquired absence of left leg above the knee. <BR/>A record review of Resident #3's discharge MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old female admitted for rehabilitation and assessed with a BIMS score of 15 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #3's care plan dated 4/24/2025 revealed, I have had Amputation of AKA to left leg . Monitor/document emotional status of resident. Observe residents' acceptance of body image changes, ability to cope with physical changes. Be supportive. Encourage resident to vent fears, concerns, and any other relevant feelings. Monitor/document pain management. Document frequency, duration, intensity of pain, phantom pain. Report to physician if medications are not effective. I require limited to extensive assistance ADL's . toileting: I require supervision, limited to extensive assistance in self-performance with 1-person physical assistance staff support <BR/>A record review of Resident #3's grievance report dated 3/12/2025 revealed the SW documented Resident #3 alleged a lady provided rough incontinent care causing soreness to her amputated leg, Afro-American lady 10:00 PM came in to ask change was needed and was rough. Diaper grabbed and pulled up to give her a wedgie. Diaper had to be loosened to breathe. [Resident #3] felt she was inconvenienced 2x's. She was wiped roughly by the aide. A turned her rough. Amputated leg is sore. <BR/>During an interview on 6/19/2025 at 3:50 PM the ADON stated she recalled discussing the allegation from Resident #3 with the DON and the administrator and Resident #3 could not recall the incident the next day and there were no staff that worked that day who fit the description. The ADON stated she had not reported the results of the investigation to the state agency and the reporting could have been made by the Administrator.<BR/>4. A record review of Resident #4's admission record dated 6/19/2025 revealed an admission date of 8/12/2024 with diagnoses which included adjustment disorder with depressed mood (a mood disorder that causes a persistent feeling of sadness and loss of interest. it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and Parkinson's disease (a movement disorder of the nervous system that worsens over time).<BR/>A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 8 out of a possible 15 which indicated severe cognitive impairment. <BR/>A record review of Resident #4's care plan dated 6/19/2025 revealed, sic[Resident #4] requires staff assistance with ADL Self Care Performance due to dementia . BATHING: [NAME] requires X 1 staff participation with bathing . has hx of depression . Monitor/document report to Nurse/MD s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness <BR/>A record review of Resident #4's grievance report dated 3/13/2025 revealed the SW documented Resident #4's alleged verbal abuse, sic[Resident #4] said very early in the morning a CNA Afro-American doesn't remember name came into room with another CNA and told him that he smelled like an animal. <BR/>During an interview on 6/19/2025 at 3:50 PM the ADON stated she recalled discussing the allegation from Resident #4 with the DON and the administrator and the Resident could not recall the incident the next day and there were no staff that worked that day fit the description. <BR/>During an interview on 6/18/2025 at 4:40 PM the Administrator reviewed the grievance reports for residents as follows:<BR/>1. On 12/3/2024 Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry.<BR/>2. On 12/23/2024 Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. Resident #2 alleged the nurse handed her the gauze dressing and told her to do it herself. <BR/>3. On 3/12/2025 Resident #3 alleged diaper grabbed and pulled up to give her wedgy.<BR/>4. On 3/13/2025 Resident #4 alleged staff insulted him by stating he smelled like an animal. <BR/>A record review of the Texas Unified Licensure Information Portal (a database for incidents and allegations of ANE) website https://txhhs.my.salesforce.com/?ec=302&startURL=%2Fvisualforce%2Fsession%3Furl%3Dhttps%253A%252F%252Ftxhhs.lightning.force.com%252Flightning%252F<BR/>accessed 6/19/2025, revealed no evidence of a report for the alleged instances of ANE from the period of 12/3/2024 to 6/19/2025<BR/>The administrator stated all the grievances reviewed would have warranted a report of alleged ANE to the state agency. The administrator stated he was not the administrator in December 2024 but was the administrator during March 2025. The administrator stated he had not recognized the grievances as reportable allegations of ANE at the time. The Administrator stated the risks to residents could be their allegations of ANE would not be reported. <BR/>A record review of the facility's Reporting Allegations or Suspicions of Abuse undated policy revealed, Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC . <BR/>- are reported immediately,<BR/>- but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury,<BR/>- or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 15 residents (Resident #4) reviewed for accuracy of medical records, in that:<BR/>The facility failed to document Resident #1's pronouncement of death, discharge from the facility and disposition of the body. <BR/>This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>-Coordinate care with hospice care. <BR/>Record review of Resident #1's progress notes revealed the following:<BR/>- [DATE]- .patient noted to be pale, no respirations noted, not able to obtain vital signs. Hospice informed and DON informed. Pending call back from hospice. Documented by Agency LVN B<BR/>There were no notes after this documentation on [DATE]. <BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated when a resident expired on hospice care she was trained to document in the resident medical record a note when hospice pronounced death and where the resident was going after the death. LVN A stated when the resident's body left the facility, she would also document in the progress notes in detail. LVN A stated she was, old school, and had worked in a lot of nurses' homes. LVN A stated she knew she had to document every little thing and not to leave anything out. LVN A stated it was important to document so other people would know what was done. LVN A stated, If it wasn't documented, it wasn't done. <BR/>During an interview on [DATE] at 3:25 p.m., Agency LVN B stated she was an agency LVN with a local nurse staffing agency. Agency LVN B stated she first worked in the facility one time on the [DATE]. Agency LVN B stated on [DATE] close to the end of the shift, Resident #1 was passing (actively dying). Agency LVN B stated she provided comfort care, and the death was expected. Agency LVN B stated she noted in the medical record that the resident was had expired by noting she was pale and without respirations. Agency LVN B stated she notified hospice as required and left for the day before hospice had arrived to pronounce the resident's death. <BR/>During an interview on [DATE] at 4:51 p.m. LVN C stated Resident #1 expired during shift change on [DATE]. LVN C stated the other nurse (identified as Agency LVN B) notified hospice. LVN C stated hospice showed up 30 minutes later to declare the death and notified the mortuary. LVN C stated she did not make a note of the pronouncement of death. LVN C stated, I guess I was supposed to. LVN C stated she did not document because she figured the previous nurse had already documented something. LVN C stated she did not document the disposition of the body or when the body left the facility because she did not know she was supposed to. LVN C stated she typically made a note when a resident was discharged and why they were leaving but not when the body was discharged from the facility. LVN C stated it was important to document so others knew the time of death and when the body left although she thought that was a hospice responsibility. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated she expected nursing staff to document pronouncement of death, disposition of the body, who it was released to and, time the body left the facility in the progress notes. The DON stated documentation was important to show the resident was provided care and they were taken care of at the facility. <BR/>Record review of the facility's document titled, Charting and Documentation, dated [DATE], revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #8) of 18 reviewed for environment, in that: <BR/>Resident #8's bathroom contained potentially hazardous materials. <BR/>This deficient practice could result in residents, staff, and/or the public coming into contact with potentially hazardous materials. <BR/>The findings were: <BR/>Record review of Resident #8's face sheet, dated 11/06/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia Moderate with Psychotic Symptoms, Legal Blindness as Defined in USA, and Anxiety Disorder. <BR/>Record review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. <BR/>Record review of Resident #8's care plan, undated, revealed [Resident #8] has delusions, hallucinations, auditory or visual related to dementia or other psychiatric disorder. [Resident #8] has potential for injury due to unqualified visual loss, right eye, glaucoma, cataracts, and has a diagnosis for legally blind.<BR/>Observation on 11/03/2024 at 9:30 a.m. revealed cleaning supplies were stored behind a shower curtain in Resident #8's bathroom. Further observation revealed the supplies were each labeled with hazard warnings including: <BR/>*Two containers of disinfecting spray, 19 ounces each, with warning label, hazardous to humans, may cause eye irritation, avoid contact with eyes and skin.<BR/>*One container of isopropyl alcohol with warning label, warning flammable.<BR/>*One container of bleach, 16 ounce, with warning label, danger keep out of reach of children, corrosive, causes irreversible eye damage and skin burns.<BR/>*Two containers multipurpose cleaner, 56 ounces each, with warning label, may irritate eyes.<BR/>*One container germicidal alcohol wipes, 160 wipes, with warning label, keep out of reach of children, hazardous to humans.<BR/>*Two containers of bleach gel, 30 ounces each, with warning label, warning eye and skin irritant, not recommended for use by persons with heart conditions or chronic respiratory problems.<BR/>During an interview with RN D on 11/04/2024 at 11:25 a.m., RN D confirmed the above listed cleaning supplies were present in Resident #8's bathroom and should not have been. RN D confirmed that Resident #8 was legally blind, had a diagnosis of dementia, and that it was unsafe for her to have cleaning supplies within reach. <BR/>During an interview with the DON on 11/05/2024 at 2:50 p.m., the DON stated cleaning supplies should not be present in resident rooms so that residents do not come into contact with potentially hazardous materials. The DON stated that Resident #8's family member cleans her room and likely brought the supplies. The DON stated she would remove the items from Resident #8's room and remind the resident and her family not to bring potentially hazardous materials into the facility. <BR/>Record review of the facility policy, Homelike Environment, dated February 2021, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>The facility failed to ensure all foods in the refrigerator were labeled and dated with use by dates.<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.<BR/>The findings were:<BR/>During an observation and interview with the Food Service Director on 09/19/2023 at 10:51 a.m., revealed an unlabeled storage bag with ground meat and meat links dated 9/19/23 and an unlabeled storage bag of a yellow substance dated 9/19/23. The FSD called out to [NAME] H and reeducated that all items must be labeled. [NAME] H revealed the items to be pan sausage, sausage links and scrambled eggs from that morning which had been saved for the following days puree. The FSD instructed the [NAME] to discard the items. Further tour of the kitchen revealed a storage bag with a substance labeled as Pizza Mix dated 9/15/23. [NAME] H was asked if the date of 09/15/23 was a use by date or the date the Pizza Mix was prepared, and [NAME] H stated he did not know as he did not work that day. The FSD instructed [NAME] H to throw the Pizza Mix away. Further observation revealed three premade turkey and cheese sandwiches were noted in the refrigerator, dated 9/12/23, which the FSD stated was the prepared date. The FSD stated a few sandwiches were prepared ahead for residents who chose not to eat what was on the menu, however, she stated the sandwiches were past the use by date. The FSD stated kitchen staff were trained that foods must be labeled and dated to protect the residents from food borne illnesses. She added that she planned to provide additional training for all staff.<BR/>Record review of the facility's policy titled, Food Receiving and Storage, revised October 2017, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready -to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a 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.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (8) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation result in serious bodily injury for 1 of 4 Residents (Resident #3) whose records were reviewed for abuse and neglect., in that;<BR/>The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #3 suffered a fracture to her left tibia (lower leg).<BR/>This deficient practice could affect any resident and could contribute to further abuse and neglect. <BR/>The findings were:<BR/>Record review of Resident #3's face sheet dated [DATE] revealed an admission date of [DATE] and a readmission date of [DATE] with diagnoses which included: moderate intellectual disabilities, autistic disorder, and unspecified fracture of upper end of tibia, initial encounter for closed fracture (break in one of the bones of the lower leg) ([DATE]). <BR/>Record review of Resident #3's Care Plan last reviewed/revised on [DATE] revealed the resident had a communication problem related to neurological symptoms, cognitive function, intellectual disability, autistic disorder with impaired thought processes, developmental delay, difficulty making decisions, impaired decision making and long-term memory loss and was able to voice some needs. Interventions included: Resident #3 needed staff to anticipate, meet her needs, and assist with all decision making. The care plan indicated Resident #3 said the word yes mainly. <BR/>Record review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 0 which indicated a severe cognitive impairment. The assessment revealed the resident had unclear speech, could sometimes make herself understood, and could sometimes understand others. The MDS assessment revealed Resident #3 required maximum assistance to total dependence with ADL care, was not able to ambulate and had total dependence on staff for transfers. <BR/>Record review of Resident #3's x-ray results (obtained by facility in facility) dated [DATE] revealed: an acute to early subacute transverse fracture of the left proximal tibial shift with diffuse osteopenia. (New to approximately 1 month old fracture to upper part of one of the bones in the lower left leg with demineralization of the bones which can result is bones that are brittle and break easily). <BR/>Record review of Resident #3's hospital records dated [DATE] revealed Resident #3 was a wheelchair and bedbound resident who resided in a LTC facility and presented to the hospital via EMS with a left proximal tibia fracture. The report revealed per outside x-ray done on [DATE] which revealed acute to early subacute transverse fracture of the proximal tibial shaft. Patient intellectually impaired due to birth defects (and) cannot give history. Resident admitted and treated for left tibia fracture .<BR/>Record review of TULIP on [DATE] revealed the facility had not self-reported Resident #3's fracture to the left tibia. <BR/>During an observation/interview of Resident #3 on [DATE] at 1:58 p.m. at a local hospital revealed the resident was awake and alert in a hospital bed watching cartoons on the television. Resident #3 had obvious facial, hand and foot abnormalities typical of someone with a chromosomal defect. She was pleasant with a childlike demeanor. Resident #3 answered yes/no questions with unknown accuracy. Resident #3 was able to give inconsistent word responses at times to simple questions. She was not able to state how she obtained the injury to her left leg. She was not able to answer the question of where she was or why she was there. She was not able to give detailed interview questions due to her cognitive status and additional details were unable to be elicited. <BR/>During an interview on [DATE] at 2:08 p.m., an RN at a local hospital stated Resident #3 had a chromosomal abnormality and was intellectually disabled. She stated the resident had arrived at the facility with a left leg brace and x-rays confirmed she had a fracture to the left tibia. The RN stated the facility had stated Resident #3 had broken her left leg by bumping it while getting in the facility van on an unknown date. She stated Resident #3 was not able to say what had happened to her due to her intellectual disability. She stated Resident #3 had not stated anything that could be understood other than crying for her momma. She stated Resident #3 had spinal stenosis and functional paraplegia and it was possible she was unable to feel when she was initially injured although she could feel pain when her leg was moved. <BR/>During an interview on [DATE] at 7:39 p.m., LVN C stated he worked as a charge nurse, treatment nurse and ADON. He stated on Monday ([DATE]) around 5:00 p.m., he was told by the DON that Resident #3 had a bruise to her left leg. He stated the DON asked him to assess Resident #3 because he does skin assessments and because he was the wound care nurse. He stated when he assessed Resident #3, he noticed she had edema (swelling) to her leg at baseline (typical for the resident). He stated there was slight redness that was warm to touch and painful and he noticed a big bruise to her left leg. LVN C stated the bruise was the whole shin area approximately 12 inches long and wrapped around the back of the left calf into the soft tissue. He stated the darkest part of the bruise was on the front. LVN C stated Resident #3 only complained of pain when he touched the front of the shin and not the calf. He stated when he moved the left leg the resident moaned and complained of pain by making facial grimaces and then verbally stated it hurt. LVN C stated he notified Resident #3's physician about the bruises and the redness and warmth, and he sent the physician a picture. LVN C stated the physician responded by ordering an x-ray. LVN C stated he had performed a skin assessment on Resident #3 on Friday prior ([DATE]) and she did not have any injuries. LVN C stated it was late, so he reported to the oncoming nurse that they were getting x-rays and he left for the day. LVN C stated the DON had mentioned Resident #3 had hit her leg on the bus. He stated he did not witness the injury. He stated Resident #3 goes to Adult Day Care, M-W-F . He stated he did not know what sort of transportation she used to get the ADC. LVN C stated he had completed a whole head-to-toe assessment of Resident #3 on [DATE] and did not find any other injuries other than the left leg. He stated he was not working when the x-ray results came in. <BR/>During an interview on [DATE] at 1:34 pm, LVN D stated on [DATE] at 6:00 am she noticed an old looking bruise with some redness to Resident #3's left lower leg. She stated she told LVN C about it and documented it in the medical record. LVN D stated Resident #3 made a face when they moved her but did not complain of pain. She stated the bruise was approximately 2 x 4 inches to the left shin. LVN D stated she asked Resident #3 what happened, and she did not say anything. She stated she did not think too much about the bruise because it was on the shin, and it looked like a typical bruise. She stated none of the CNA staff had reported any incidents or injuries. She stated no one else had documented the bruise and that was why she reported it. She stated she went off duty and when she came back to work two days later learned that Resident #3 had a fracture. <BR/>During an interview on [DATE] at 3:45 pm, the DON stated they were not sure how Resident #3 got the fracture to her left leg. The DON stated Resident #3 went to Adult Day Care on Monday, Wednesday, and Friday by local disability public bus services. She stated a family member (who was now deceased ) had really pushed for the resident to go and ride the bus. She stated that family member had set up the services which pre-dated her time at the facility as the DON. The DON stated Resident #3 traveled on the public bus without staff in attendance. She stated it was adult-to-adult hand off at each location. The DON stated on Monday [DATE], Resident #3 told the Director of Rehabilitation that she hit her leg on the bus and the Director of Rehabilitation told her (DON). The DON stated during morning meeting they read the nurses notes that documented a bruise. She stated the resident's physician was on his way to the facility so wrote it on her list to have it addressed by the physician. She stated when the physician came to the building Resident #3 was at Adult Day Care. The DON stated she told the ADON (LVN C) to do an assessment of the resident when she returned from Adult Day Care and let her know what he found. The DON stated the ADON (LVN C) informed her that he had assessed the resident and had communicated with the physician who had ordered an x-ray. She stated on [DATE] at 5:50 am the x-ray results hit her phone and she immediately notified the physician of a left tibial fracture. The DON stated the physician had Resident #3 admitted to the hospital for an orthopedic consult. The DON stated she came back to the facility after treatment at the hospital with a brace to her leg and orders for follow up in 4-6 weeks. The DON stated they were treating Resident #3 for a left tibial fracture of unknown origin but according to Resident #3 she hit her leg on the bus. The DON stated Resident #3's BIMS score was 0 which indicated the resident was severely cognitively impaired. She stated she did not believe the assessment was accurate because the resident could have a conversation if she wanted to. The DON stated just because the resident did not answer questions did not mean she did not understand. The DON stated she (DON) understood questions presented to her (DON) about how she could be certain Resident #3 understood conversation given Resident #3 had documented intellectual disabilities along with chromosomal abnormalities, but she (DON) had no response to the question. The DON stated when there was an injury of unknown origin the facility looks for possible reasons for it, talks to staff, looks for possible sources and does an investigation. She stated an investigation was done. The DON stated the facility did talk about reporting the incident to HHSC but did not report it. She stated they did not report it because Resident #3 was able to give a reliable statement to the Director of Rehabilitation on what happened to her. The DON stated they still did not know how it occurred, just that it occurred on the bus. The DON stated it seemed logical to her that because Resident #3's custom wheelchair was big and not easily moveable that maybe her leg got pinched between the wheelchair and the bus although she had no evidence to prove it, it just seemed logical. <BR/>During an interview on [DATE] at 4:45 pm, the Director of Rehabilitation stated one of her assistants was working with Resident #3 and called her over because she was grimacing on Friday [DATE]. She stated she looked at both legs and they were swollen from the thigh down which was common for this resident. She stated she noted the left leg was more swollen than the right, so she told her assistant to stop working with her on that day and let her rest. She stated there was no bruising of any kind to the left leg. The Director of Rehabilitation stated on Monday, [DATE] during morning meeting they reviewed that a bruise was noted to her left leg. She stated when Resident #3 came to rehab, she noted the resident bruising and redness to the left shin and a slight indentation. She stated no therapy was performed on her lower extremities and she talked to the DON. She stated she found out they were going to do an x-ray that day of her left leg. The Director of Rehabilitation stated she asked Resident #3 what happened. She stated Resident #3 responded the bus but that was all she told her. The Director of Rehabilitation stated sometimes Resident #3 would talk and sometimes she would not. She stated she would not say anything other than the bus. The Director of Rehabilitation stated they took Resident #3 back to her room and laid her down in bed. She stated she then reported it to Resident #3's charge nurse, whom she could not remember her name, just that it was a female. She stated the nurse responded appropriately and stated she would look at her leg. She stated she did not report it to the DON but knew the DON knew about it because she it was discussed during morning meeting. <BR/>During an interview on [DATE] at 5:20 p.m., Resident #3's family member stated on [DATE], when Resident #3 got back from Adult Day Care it was reported to the family member that the resident had a bruise on her leg (unknown which leg) and that the facility was going to take x-rays. The family member stated the next day he learned she had a fractured leg. He stated he did not understand how it happened. He stated the facility reported they did not know how it happened, just that she was going to the hospital. The family member stated he called the Administrator and asked her how it happened, and she did not know but she was going to investigate and call the bus company. He stated nobody knows what happened. The family member stated he did not get a report of any falls. He stated he thought she might have had a fall in [DATE] but could not remember. He stated Resident #3 could not move on her own and could not just fall out of bed. He stated he felt frustrated about what was happening at the nursing home and their lack of answers. <BR/>During an interview on [DATE] at 5:53 p.m., the Administrator stated LVN D reported Resident #3 had a bruise, and she (Administrator) mentioned it in morning meeting. Then the Director of Rehabilitation mentioned in the morning meeting that Resident #3 had pain during rehab and she told the nurse. She stated the bruise was noted on [DATE] and a nurse got an order from x-rays, and they proceeded from there. The Administrator stated they did not report the injury to HHSC (State Reporting Agency) because Resident #3 told them it happened on the bus. The Administrator stated Resident #3 had not told them how the injury occurred, just that it happened on the bus. The Administrator stated the time frame for reporting abuse or serious injury was 2 hours. The Administrator stated the facility abuse policy indicated they should report suspected abuse and neglect but, in this case, she did not suspect abuse, so she did not report. <BR/>Record review of a facility policy, titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (undated) revealed: g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met i. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident ii. The injury is suspicious because of the extent of the injury or the locations of the injury .F. Reporting and Response: The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials (including to the State Survey Agency .)in accordance with State law through established procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in th comprehenvsive assessment, for 1 of 3 Residents (Resident #1 reviewed for care plans, in that: <BR/>The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address hospice information, details of hospice care provided and coordination of services.<BR/>This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>- Coordinate care with hospice care. The plan of care did not specify what care was coordinated or how it was provided to the resident. <BR/>- Hospice Care program as ordered. The plan of care did not specify how the plan was applied to the resident or what services were provided. <BR/>- Monitor for complaints of pain or discomfort and provide interventions as orders. The plan of care did not specify the interventions or how they should be applied to Resident #1. <BR/>The plan of care did not list the name, phone number, or contact information of the hospice agency used for Resident #1.<BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated Resident #1 received hospice care and expired last week (date unknown). LVN A stated a hospice aide would come and bathe Resident #1 and a hospice RN came to visit Resident #1. LVN A stated she did not know how often they came to see the resident. LVN A stated Resident #1 had medications ordered for pain by hospice. <BR/>Attempted interview with Resident #1's hospice company on [DATE] at 2:42 p.m. was unsuccessful. <BR/>During an interview on [DATE] at 5:23 p.m., the Corporate MDS Nurse stated the facility had not had a MDS Coordinator for approximately 3 weeks. The Corporate MDS Nurse stated Resident #1's care plan for hospice services was missing critical information for hospice care. The Corporate MDS Nurse stated the care plan should have what specific hospice program was used, how often the facility should call hospice and what services were provided. The Corporate MDS Nurse stated the hospice care plan should have hospice specific information. The Corporate MDS Nurse stated Resident #1's care plan was initiated on [DATE] and was based on the MDS assessment. The Corporate MDS Nurse stated care plans should be updated for change of condition. The Corporate MDS Nurse stated the MDS Coordinator, DON or charge nurses could update the care plan. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated the care plans for hospice should include the hospice and diagnoses, how the facility was providing care to the resident. The DON stated the hospice care plan should also include why the resident was on hospice, expectations from hospice, when the facility was supposed to call hospice, contact information for hospice. The DON stated every hospice was different. The DON stated some hospices sent aides, some did not. The DON stated the hospice care plan should include coordination of care information. The DON stated the MDS person was responsible for updating care plan and the facility currently did not have a MDS Coordinator. The DON stated a corporate person who knew the facility came several times a week to do care plans. The DON stated it was important to have an accurate care plan so the facility knew what type of care they needed to provide to the resident. <BR/>During an interview on [DATE] at 6:15 p.m., the Administrator stated the MDS Coordinator was responsible for resident care plans. The Administrator stated she had oversight of MDS.<BR/>Record review of a facility policy, titled Care Plans, Comprehensive Person-Centered, dated [DATE] revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being j. Reflect the resident's expressed wishes regarding care and treatment goals l. Identify the professional services that are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs 2 of 8 resident rooms (Resident #42 and Resident #44) reviewed for call lights.<BR/>The facility failed to ensure Resident #42 and Resident 44's call lights were within reach and placed for easy access.<BR/>The deficient practice could place residents at risk of not receiving care or attention needed. <BR/>Findings included:<BR/>Record review of Resident #42's face sheet, dated 09/21/2023, revealed the resident was originally admitted to the facility on [DATE] with diagnoses which included: benign neoplasm of prostate, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified macular degeneration, legal blindness, hypertension, senile degeneration of brain, chronic atrial fibrillation, and hearing loss.<BR/>Record review of Resident #42's admission MDS assessment, dated 07/14/2023, revealed the resident's BIMS score was 00, which indicated severe cognitive impairment. The resident required extensive assistance (staff provide weight bearing support) with two persons physical assistance for bed mobility, dressing and extensive assistance (staff provide weight bearing support) with one person's physical assistance for toileting.<BR/>Record review of Resident #42's care plan, target date of 10/26/2023, revealed Resident #42 had ADL (activities of daily living) self-care performance deficit r/t deconditioning, and interventions reflected to encourage resident to use call bell to call for assistance.<BR/>Record review of Resident #44's face sheet, dated 09/20/2023, revealed the resident was originally admitted to the facility on [DATE] (original admission date 01/31/2023) with diagnoses which included: chronic obstructive pulmonary disease, peripheral vascular disease, history of falling, partial traumatic amputation of right foot, hypertension, metabolic encephalopathy, type 2 diabetes mellitus without complications, acute embolism and thrombosis of unspecified deep veins of right lower extremity and anemia. <BR/>Record review of Resident #44's Quarterly MDS assessment, dated 06/14/2023, revealed the resident's BIMS score was 7, which indicated moderate cognitive impairment. The resident required extensive assistance (staff provide weight bearing support) with one person's physical assistance for bed mobility, transfers, and toileting.<BR/>Record review of Resident #44's care plan, target date of 10/26/2023, revealed Resident #44 required assistance with ADL (activities of daily living) due to generalized weakness, impaired physical mobility, lack of coordination, and interventions reflected call light will be in reach and call lights will be answered promptly. <BR/>Observation on 09/19/2023 at 11:07 a.m. revealed Resident #42 was sleeping in bed with soft touch padded call light hanging over the foot of Resident #42's foot board opposite side of mattress. Resident #42 sleeping with head at the head of the bed on right side facing the wall with arms under the covers.<BR/>Interview on 09/19/2023 at 11:12 a.m. with LVN F revealed Resident 42's call light should have been where Resident #42 was able to reach it. <BR/>Observation and interview on 09/19/2023 revealed Resident #44 in bed with head of bed elevated and call light wrapped around the quarter rail at the head of bed hanging down the side of the bed. Resident #44 attempted to locate call light when asked if able to reach call light but was not able to locate. Resident #44 stated he did use his call light when he needed help but was not able to find it. <BR/>Interview and observation on 09/19/2023 at 11:24 a.m. LVN F stated Resident #44 needed reminders to use the call light, however at the time it was out of reach and Resident #44 would not have been able to use the call light. LVN F then placed the call light across Resident #44's chest and Resident #44 pressed the button demonstrating the ability to press the button. LVN F further stated it was the responsibility of all staff when providing care to residents to ensure call lights were within reach. <BR/>Interview on 09/21/2023 at 2:40 p.m. with the DON revealed call lights should be where residents could reach them. The DON further stated it was especially important for residents who could not ambulate on their own so the resident could call for assistance. <BR/>Record review of the facility's Nursing Policies and Procedures-Fundamentals Call Lights/Bell policy, revealed under Policy, To provide the resident a means of communication for needs with staff. Procedure: #5 Leave resident comfortable. Place the call device within the resident's reach before leaving the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 8 residents (Residents #10 and #25) whose assessments were reviewed, in that:<BR/>The facility failed to ensure Resident #10 and #25's Quarterly MDS Assessments were coded correctly for bed rails. <BR/>This failure could place residents at-risk for inadequate care due to inaccurate assessments. <BR/>The findings were:<BR/>1. Record review of Resident #10's face sheet, dated 09/22/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, diabetes, bipolar disorder, and mild cognitive impairment.<BR/>Record review of Resident #10's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. Further review of the assessment indicated Resident #10 had a bed rail; coded as (1) used less than daily.<BR/>Record review of Resident #10's care plan with last review completed on 08/17/2023 did not reveal a focus area for bed rails. Further review revealed a focus for ADL assistance because of generalized weakness with intervention of 1-person physical assistance staff support.<BR/>Record review of Resident #10's electronic medical record active orders as of 09/22/2023 revealed no current order for bed rails. Further review revealed an order, may have &frac14; siderails x 2 for turning and repositioning with a discontinued date of 11/11/2020.<BR/>2. Record review of Resident #25's face sheet dated 09/22/2023 revealed an initial admission date of 03/21/2019 with a recent admission of 04/20/2021 and diagnoses which included major depressive disorder, generalized anxiety disorder, low back pain, and muscle weakness.<BR/>Record review of Resident #25's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 04, which indicated severe cognitive impairment. Further review of the assessment indicated Resident #25 had a bed rail; coded as (1) used less than daily.<BR/>Record review of Resident #25's Care Plan with last review completed on 07/29/2023 revealed a focus [Resident] may have &frac14; side rails x 2 for assistance with turning/repositioning and safety. Interventions included Assess on an ongoing basis for need for side rail use for bed mobility and safety. Further review revealed a second focus area I have &frac14; siderails (x2) up for: enabler for positioning while in bed, safety precautions: due to poor/decreased body control. <BR/>Record review of Resident #25's assessments in the electronic medical record revealed a side rail evaluation and consent dated 07/20/2021 that indicated the resident had side rails for the left and right sides to serve as enabler bars.<BR/>Review of Resident #25's Order Summary Report, Active Orders as of 09/20/2023, revealed an order, 1/4 SIDERAIL AS ENABLER X 2, dated 11/01/2021 with no end date. <BR/>During an observation and interview with LVN G on 09/20/2023 at 11:14 a.m., LVN G confirmed Resident #25's bed did not have rails. LVN G added that she could not recall the resident's bed ever having rails.<BR/>In an interview with the MDS Coordinator on 09/22/2023 at 8:25 p.m., the MDS Coordinator revealed when the CNAs chart ADL care they sometimes choose side rails for mobility and that triggers to the MDS. The MDS Coordinator added that the responsibility would be up to her to take it off of there. <BR/>In an interview with the DON on 09/22/2023 at 8:45 p.m., the DON revealed the MDS Coordinator should complete an assessment of each resident and would be responsible for the accuracy of MDS assessments. The DON further revealed the facility did not have a policy regarding MDS assessments because they use the RAI Manual. <BR/>Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, revealed, P0100: Physical Restraints: After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. Code 1, used less than daily: if the item met the definition and was used less than daily. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in th comprehenvsive assessment, for 1 of 3 Residents (Resident #1 reviewed for care plans, in that: <BR/>The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address hospice information, details of hospice care provided and coordination of services.<BR/>This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>- Coordinate care with hospice care. The plan of care did not specify what care was coordinated or how it was provided to the resident. <BR/>- Hospice Care program as ordered. The plan of care did not specify how the plan was applied to the resident or what services were provided. <BR/>- Monitor for complaints of pain or discomfort and provide interventions as orders. The plan of care did not specify the interventions or how they should be applied to Resident #1. <BR/>The plan of care did not list the name, phone number, or contact information of the hospice agency used for Resident #1.<BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated Resident #1 received hospice care and expired last week (date unknown). LVN A stated a hospice aide would come and bathe Resident #1 and a hospice RN came to visit Resident #1. LVN A stated she did not know how often they came to see the resident. LVN A stated Resident #1 had medications ordered for pain by hospice. <BR/>Attempted interview with Resident #1's hospice company on [DATE] at 2:42 p.m. was unsuccessful. <BR/>During an interview on [DATE] at 5:23 p.m., the Corporate MDS Nurse stated the facility had not had a MDS Coordinator for approximately 3 weeks. The Corporate MDS Nurse stated Resident #1's care plan for hospice services was missing critical information for hospice care. The Corporate MDS Nurse stated the care plan should have what specific hospice program was used, how often the facility should call hospice and what services were provided. The Corporate MDS Nurse stated the hospice care plan should have hospice specific information. The Corporate MDS Nurse stated Resident #1's care plan was initiated on [DATE] and was based on the MDS assessment. The Corporate MDS Nurse stated care plans should be updated for change of condition. The Corporate MDS Nurse stated the MDS Coordinator, DON or charge nurses could update the care plan. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated the care plans for hospice should include the hospice and diagnoses, how the facility was providing care to the resident. The DON stated the hospice care plan should also include why the resident was on hospice, expectations from hospice, when the facility was supposed to call hospice, contact information for hospice. The DON stated every hospice was different. The DON stated some hospices sent aides, some did not. The DON stated the hospice care plan should include coordination of care information. The DON stated the MDS person was responsible for updating care plan and the facility currently did not have a MDS Coordinator. The DON stated a corporate person who knew the facility came several times a week to do care plans. The DON stated it was important to have an accurate care plan so the facility knew what type of care they needed to provide to the resident. <BR/>During an interview on [DATE] at 6:15 p.m., the Administrator stated the MDS Coordinator was responsible for resident care plans. The Administrator stated she had oversight of MDS.<BR/>Record review of a facility policy, titled Care Plans, Comprehensive Person-Centered, dated [DATE] revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being j. Reflect the resident's expressed wishes regarding care and treatment goals l. Identify the professional services that are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinence/perineal care, in that: <BR/>CNA A and CNA B used multiple passes with the same wipe while providing incontinence/perineal care to Resident #1. <BR/>This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 8/24/23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous condition in men in which the prostate gland is enlarged causing blockage of urine flow out of the bladder), chronic kidney disease stage 3 (damage to kidneys affecting how blood is filtered), and type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy).<BR/>Record review of Resident #1's most recent admission MDS assessment, dated 6/27/23 revealed the resident was severely cognitively impaired for daily decision-making skills and was frequently incontinent of bowel and bladder.<BR/>Record review of Resident #1's comprehensive care plan, review date 7/7/23 revealed the resident had bowel and bladder incontinence related to prostate enlargement and loss of control with interventions that included to check the resident as required for incontinence and to wash, rinse and dry perineum.<BR/>Observation on 8/24/23 at 10:07 a.m., during incontinence/perineal care, CNA A made multiple passes with one wipe to clean Resident #1's buttock area. CNA B made multiple passes with one wipe to clean Resident #1's inner thighs.<BR/>During an interview on 8/24/23 at 11:19 a.m., CNA A revealed she realized she had been using one wipe and had made several passes to clean Resident #1's buttock area. CNA A stated, I realized it was improper but, in the moment, I was just thinking I need to clean the resident, but again I just got caught up in the moment. CNA A revealed, making multiple passes with one wipe was considered cross contamination and Resident #1 could cause the resident to get sick. CNA A revealed she had not received any incontinence/perineal care training since the former ADON had done the training a year ago.<BR/>During an interview on 8/24/23 at 12:08 p.m., CNA B revealed she was working at the facility through an agency and revealed any training received was completed while in CNA school. CNA B revealed she was not aware she had used one wipe multiple times to clean Resident #1's thighs.<BR/>During an interview on 8/24/23 at 4:23 p.m., the DON revealed, during incontinence/peri care, staff should be wiping from front to back with one wipe per pass, otherwise there would be the introduction of the potential for infection. <BR/>Record review of the nursing competency training titled, Perineal Care, dated 6/14/23 revealed CNA A had satisfied the requirements for performing incontinence/perineal care.<BR/>Record review of the facility policy and procedure, titled Perineal Care, revision date February 2018 revealed in part, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Continue to wash the perineum moving from inside outward to the thighs, rinse perineum thoroughly in same direction, using fresh water and a clean washcloth .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 4 of 17 residents (Resident #40, Resident #44, Resident # 47, and Resident #49) reviewed for respiratory care. <BR/>1. The facility failed to replace the oxygen concentrator humidification reservoirs in a timely manner. <BR/>2. Facility failed to ensure Resident #44 and Resident #49 nebulizer supplies were bagged and dated to prevent cross contamination. <BR/>These deficient practices could affect residents who receive oxygen therapy and nebulizer treatments which could contribute to respiratory infections.<BR/>The findings included: <BR/>1. Record review of admission record dated 9/22/2023, revealed Resident #47 was a [AGE] year-old man originally admitted to the facility on [DATE]. <BR/>Record review of the comprehensive MDS assessment dated [DATE], revealed Resident #47's primary medical condition category for admission was related to acute and chronic respiratory failure. Other active diagnoses included pneumonia and respiratory failure. Resident #47 was coded as requiring oxygen therapy in the previous 14 days while not a resident, and also while a resident, and required an invasive mechanical ventilator in the previous 14 days while not a resident. <BR/>Record review of the care plan, reviewed 7/14/2023, revealed Resident #47 had a focus area of tracheostomy [in incision in the windpipe to relieve obstruction to breathing] status, with the associated intervention: oxygen via tracheostomy per medical doctor orders or as needed, titrate to keep saturation above 92%. Additional focus area included altered cardiovascular status with the associated intervention: give oxygen as ordered by the physician. <BR/>Record review of order summary report dated 9/22/2023, revealed Resident #47 had active physician's orders for T-piece (tracheostomy) as tolerated Flo2 titrate to keep saturation above 92%. <BR/>In an observation on 9/19/2023 at 12:26 PM, revealed Resident #47 was sitting upright, with a tracheostomy, independently feeding himself. The oxygen concentrator was on, running at 4 liters per minute with humidification. The humidification reservoir had a handwritten date that indicated it was placed on 9/11/2023 (p1). <BR/>In an observation on 9/20/2023 at 12:39 PM, revealed Resident #47 was sitting upright in bed watching television. The oxygen concentrator was on, running at 4 liters per minute with humidification. The humidification reservoir had the same handwritten date that indicated it was placed on 9/11/2023. <BR/>Record review of admission record, dated 9/19/2023, revealed Resident #40 was a [AGE] year-old female originally admitted to the facility on [DATE]. <BR/>Record review of the quarterly MDS assessment, dated 8/08/2023, revealed Resident #40's primary medical condition category for admission was chronic respiratory failure. Active diagnoses included chronic respiratory failure, with hypoxia (low oxygenation) or hypercapnia (higher than normal level of carbon dioxide, a metabolic waste product, in the blood that is normally excreted upon exhalation), and tracheostomy status. Resident #40 was coded as requiring oxygenation in the previous 14 days, while a resident. <BR/>Record review of the care plan, reviewed 8/11/2023, revealed Resident #40 had a focus area of tracheostomy status, with the associated intervention: administer humidified O2 as prescribed. Additional focus area included at-risk for acute respiratory failure with the associated intervention: oxygen as ordered. Resident #40 had a focus area of oxygen via T-piece through tracheostomy with the associated intervention: administer O2 as ordered. <BR/>Record review of order summary report dated 9/21/2023, revealed Resident #40 had active physician's orders for T-piece (tracheostomy) as tolerated Flo2 titrate to keep saturation above 90%. <BR/>In an observation on 9/19/2023 at 12:36 PM, Resident #40 presented supine in bed with head of bed elevated 30-45 degrees, with tracheostomy. Oxygen concentrator was on, running at 1.5 liters per minute with humidification. Humidification reservoir had handwritten date that indicated it was placed on 9/11/2023 (p2). <BR/>In an interview on 9/22/2023 at 3:21 PM, RT D stated she was responsible for oxygen concentrators including if the resident required humidification. RT D stated humidification reservoirs were good for 7 days. RT D stated most residents that required humidification, needed the reservoir to be changed much sooner than 7 days, because they run out sooner than that. RT D stated the date would be written in marker on the date it was placed. RT D stated she had placed a new humidification reservoir earlier today, 9/22/2023, for Resident #47 but did not make note of the date on the old, nearly empty humidification reservoir. When shown photograph (p1 and p2) of the dated humidification reservoirs for Resident #47 and #40, RT D stated that the date on the humidification reservoirs indicated they were placed 9/11/2023 and should have been changed no later than 9/18/2023. <BR/>In an interview on 9/22/2023 at 8:42 PM, the DON stated she believe the humidifier reservoirs were good for 10-12 days, but she would have to check. The DON stated the frequency of replacing the humidifier reservoir would depend upon the condition of the resident. The DON stated she believed that the risk to residents would be low if the humidifier reservoir was not changed as frequently as required since it was a closed system. The DON stated she would provide a policy if there was one.2. Record review of Resident #44's face sheet, dated 09/20/2023, revealed Resident #44 was admitted on [DATE] with an original admission date of 01/31/2023 with diagnoses which included: chronic obstructive pulmonary disease, peripheral vascular disease, acute kidney injury and personal history of COVID-19.<BR/>2. Record review of Resident #44's Quarterly MDS, dated [DATE], revealed Resident #44's BIMS score was 07, which indicated severe cognitive impairment.<BR/>Record review of Resident #44's care plan with a last care plan review completed date of 07/29/2023 and a targeted date 10/26/2023, revealed Resident #44 had a Focus: I am at risk for SOB, chest pain, edema, elevated B/P Dx: acute kidney injury and an Interventions: Administer medications as prescribed. <BR/>Record review of Resident #44's physician order summary report, dated, 09/21/2023, revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1mg/ml via mask every 6 hours related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation.<BR/>Observation and interview on 09/19/2023 at 11:07 a.m. of Resident #44 revealed nebulizer mask with tubing dated 09/02/2023 sitting on top of nebulizer machine open to air and not bagged. Resident #44 stated it was used when needed. <BR/>Interview on 09/19/2023 at 11:24 a.m. LVN F revealed Resident #44's nebulizer mask should have been bagged after each use. LVN F further revealed the date on the nebulizer tubing was 09/02/2023 and typically the mask and tubing should be changed once a week which was done by the night shift. <BR/>Record review of Resident #49's face sheet, dated 09/21/2023, revealed Resident #49 was admitted on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia.<BR/>Record review of Resident #49's 5-day MDS, dated [DATE], revealed Resident #49's BIMS score was 15, which indicated intact cognition.<BR/>Record review of Resident #49's care plan with a last care plan review completed date of 08/11/2023 and a targeted date 11/09/2023, revealed Resident #49 had a Focus: The resident has shortness of breath r/t COPD, sleep apnea, and chronic respiratory failure with hypoxia and an Interventions: Albuterol sulfate inhalation nebulization (2.5MG/3ML) 0.083% (Albuterol Sulfate) as physician ordered. <BR/>Record review of Resident #49's physician order summary report, dated, 09/21/2023, revealed an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083 (Albuterol Sulfate) 3 ml inhale orally via nebulizer every 8 hours as need for COPD. <BR/>Observation and interview on 09/19/2023 at 12:40 p.m. revealed Resident #49's handheld nebulizer at bedside on the dresser upright in the holder on the back of the machine not bagged. Resident #49 stated the facility staff had not changed the handheld nebulizer or tubing out since admission and it was never bagged. <BR/>Interview on 09/19/2023 at 12:58 p.m. LVN A revealed the respiratory therapist did the breathing treatments and was not aware of the protocol regarding the handheld nebulizer.<BR/>Interview on 09/19/2023 at 1:02 p.m. the RT revealed it would be beneficial to Resident #49's for the handheld nebulizer to be bagged when not in use, and the RT further stated he was not sure when it was changed but it should be changed once a week. The RT stated putting the handheld nebulizer in a bag prevented cross contamination. <BR/>Interview on 09/21/2023 at 2:45 p.m. with the DON stated the nebulizer mask should have been changed weekly and should have been bagged to keep it clean. The DON further stated by bagging the mask or mouthpiece it kept them from getting dirty.<BR/>Record review of the facility's policy titled Nursing Policies & Procedures Oxygen and Nebulizer Disposable Equipment Replacement, revealed Purpose: To maintain a clean environment for oxygen and aerosol nebulizer administration for those resident' receiving oxygen or aerosol nebulizer therapy. Procedure: 1. Apply a new oxygen cannula, humidifier bottle, oxygen tubing and or handheld nebulizer mask in the resident room when ordered. It is recommended that all disposable equipment be dated when opened from the manufacturer's packaging. 2. All disposable supplies/equipment will be changed per facility policy to maintain clean .equipment. <BR/>Record review of the facility's policy titled Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, revealed under Steps in the Procedure #29 When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. #30 Change equipment and tubing according to facility protocol or when visibly soiled .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three residents (Residents #31, #36, and #54) out of 5 residents reviewed for medication administration in that:<BR/>1. <BR/>Resident #31 had metoprolol (a medication for high blood pressure) administered outside the parameters as ordered by the physician.<BR/>2. <BR/>Resident #36 had ibrutinib (a medication for cancer) administered without a pharmacy label.<BR/>3. <BR/>Resident #54 had midodrine (a medication low blood pressure) administered outside of the parameters as ordered by the physician and Resident #54 missed administration of hydralazine (a medication for elevated blood pressure). <BR/>This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and possible adverse reactions. <BR/>The findings include:<BR/>1. <BR/>Record review of the admission record, dated 9/19/2023, revealed Resident #31 was a [AGE] year-old male originally admitted to the facility on [DATE]. <BR/>Record review of the quarterly MDS assessment, dated 6/30/2023, revealed Resident #31's primary medical condition for admission was acute respiratory failure with hypoxia [lack of oxygen to the brain]. Other active diagnoses included hypertension [high blood pressure].<BR/>Record review of the care plan, reviewed 8/03/2023, revealed Resident #31 had a focus area of: treat diagnosis of hypertension; with the following associated interventions: medication to treat hypertension per medical doctor's orders.<BR/>Record review of the order summary report, dated 9/21/2023, revealed Resident #31 had active physician's orders for metoprolol, hold if systolic blood pressure was less than 100 and heart rate was less than 65.<BR/>In an observation on 9/21/2023 at 8:11 AM, revealed LVN A obtained vital signs on Resident #31 that included a blood pressure of 110/66 and a heart rate of 64. LVN A entered the statistics into the electronic health record and prepared Resident #31's medications for administration. LVN A administered medications to Resident #31 that included metoprolol. <BR/>Record review of Resident #31's medication administration record for September 2023 revealed, the 8:00 AM metoprolol dose was administered on 9/21/2023 when Resident #31's heart rate was documented at 64.<BR/>2. <BR/>Record review of the admission record, dated 9/21/2023, revealed Resident #36 was an [AGE] year-old male originally admitted to the facility on [DATE]. <BR/>Record for review of the comprehensive MDS assessment, dated 8/18/2023, revealed Resident #36's the primary medical condition category for admission was progressive neurological conditions. Other active diagnoses included cancer. <BR/>Record review of the care plan, reviewed 8/31/2023, revealed Resident #36 had a focus area of I take ibrutinib for my leukemia; with the following associated interventions: administer medications . as ordered. Additional focus area included, resident has lymphocytic leukemia [type of cancer that affects white blood cells]; with the following associated interventions: give medications as ordered .Ibrutinib Oral tablet 420 milligrams per day.<BR/>Record review of the order summary report, dated 9/21/2023, revealed Resident #36 had active physician's orders: ibrutinib oral tablet 420 milligrams, 1 tablet by mouth one time a day related to chronic lymphocytic leukemia of B-cell type not having achieved remission, with a start date of 8/12/2023. <BR/>In an observation on 9/21/2023 at 7:48 AM, LVN A prepared and administered medications that included ibrutinib to Resident #36. The medication was dispensed from a blister pack type card with the word Ibrutinib printed on it, that did not include a standard pharmacy label with Resident #36's name, dosage, frequency, or expiration date. LVN A stated, Resident #36's family member brought the medication from a Veterans Affairs pharmacy to the facility on a regular basis because it was a cancer treatment and was expensive. <BR/>Record review of the medication administration record for September 2023, revealed Resident #36 received the 8:00 AM dose of ibrutinib 1 tablet 420 milligrams on 9/21/2023.<BR/>3. <BR/>Record review admission record dated 9/21/2023, revealed Resident #54 was a [AGE] year-old male originally admitted to the facility on [DATE]. <BR/>Record review of the discharge MDS assessment, dated 8/26/2023, revealed Resident #54's active diagnoses included unspecified paraplegia [type of paralysis that affects the lower half of the body].<BR/>Record review of the order summary report dated 9/21/2023, revealed Resident #54 had active physician's orders for: hydralazine 10 milligrams one tablet enterally every eight hours as needed for hypertension [high point pressure] for systolic blood pressure greater than 160 with a start date of 8/18/2023; midodrine 10 milligrams one tablet enterally three times a day for hypotension [low blood pressure] hold for systolic blood pressure greater than 120 with the start date of 8/18/2023. <BR/>Record review of the medication administration record for August 2023 revealed Resident #54 was administered: <BR/>Midodrine 10 mg on 8/19/2023 at 8:00 AM when his blood pressure was 129/68 by RN I; <BR/>Midodrine 10 mg on 8/19/2023 at 12:00 PM when his blood pressure was 129/68 by RN I; <BR/>Midodrine 10 mg on 8/29/2023 at 4:00 PM when his blood pressure was 125/67 by Nurse K. <BR/>Record review of the medication administration record for September 2023, revealed Resident #54 did not receive hydralazine on 9/08/2023 at 8:00 AM, when his blood pressure was 170/89 by LVN J. <BR/>In an interview on 9/21/2023 at 3:15 PM, the DON stated the parameters should be followed as ordered by the physician. The DON stated harm could occur if medication was given out of the parameters set by the physician. The DON stated the medication ibrutinib for Resident #36 was a medication the resident's family member provided from the Veterans Affair pharmacy as a condition of admission due to its high cost. The DON stated the medication was removed from its original, bulky box and the individual cards were placed in the medication cart for administration. The DON stated she was sure the original bulky box was labeled correctly with the required elements. The DON stated she would provide appropriate policies. <BR/>Record review of Administering Medications policy, revised December 2012, revealed in step 3. Medications must be administered in accordance with orders .;7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method; 9. The expiration/beyond use date on the medication label must be checked prior to administering. The policy did not address assessing parameters, or holding medications if parameters were not met. <BR/>Record review of the Medications Brought to The Facility by The Resident/Family policy, revised April 2007, revealed in Step 3c. the contents of each container are labeled in accordance with established policies; d. the contents of each container have been verified by a licensed pharmacist. <BR/>Record review of Labeling of Medication Containers policy, revised April 2007, revealed in Step 3. labels for individual drug containers shall include all necessary information, such as: a. the residents name; b. the prescribing physician's name; d. the name, strength, and quantity of the drug; f. the date that the medication was dispensed; h. the expiration date when applicable; and i. directions for use. <BR/>Review of Lippincott procedures, Oral drug administration, revised 5/19/2022, accessed 9/28/2023, from: https://procedures.lww.com/lnp/view.do?pId=5455001, revealed, under the subheading Special Considerations, Assess parameters, such as blood pressure and pulse, as necessary before administering a medication with dose-holding parameters. Additionally, compare the drug label to the order in the patient's medical record; further, Check the expiration date on the medication. Under the heading, Special Considerations, Don't administer a medication from a poorly labeled or unlabeled container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 7.69%, based on 2 errors out of 26 opportunities, which involved 1 of 6 residents (Resident #1) reviewed for medication administration and medication errors.<BR/>RN A administered Resident #1's medications: a 10 gram of carafate tablet (an anti-ulcer medication) and 30 milliliters of 10 gm/15mL enulose solution (a laxative used to treat constipation), scheduled at 04:00 p.m., at 05:29 p.m., one hour and twenty-nine minutes late.<BR/>These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 01/17/2025, reflected Resident #1 was admitted initially on 11/14/2024 and re-admitted on [DATE]. Resident #1 was noted to be [AGE] years old.<BR/>Record review of Resident #1's Medical Diagnoses Report, undated, accessed 01/17/2025, reflected Resident #1 was diagnosed with biliary cirrhosis (a chronic and progressive liver disease caused by inflammation, obstruction, and damage within the liver), fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances), and gastro-esophageal reflex disease with esophagitis (a chronic digestive disorder where stomach acid or bile causes inflammation of the esophagus) without bleeding. <BR/>Record review of the Quarterly MDS assessment, dated 12/02/2024 and signed as completed on 12/09/2024 by the DON, reflected Resident #1 had a BIMS score of 15, indicating she was cognitively intact. Resident #1 was coded as occasionally incontinent for urinary and bowel continence. <BR/>Record review of Resident #1's Care Plan, undated, accessed 01/17/2025, reflected Resident #1 had the following focuses:<BR/> 1. a focus area of .history of GERD with the following interventions: <BR/> - Give my medications as ordered. Monitor/document my side effects and effectiveness. and<BR/> - Monitor/document/report to my MD PRN s/sx of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V, indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, Dysphagia, substernal chest pain, increased gag response.;<BR/> and a goal to remain free from discomfort, complications or s/sx related to dx of GERD through review date. Target date of goal noted as 03/04/2025. <BR/> 2. a focus area of .history of constipation with an intervention to Monitor/document/report to my MD PRN s/sx of complications related to constipation: and a goal to have a normal bowel movement at least every 3 day through the review date. Target date of goal noted as 03/04/2025.<BR/>Record review of Resident #1's Order Summary Report, dated as Active Orders As Of: 01/17/2025, reflected Resident #1 had the following active physician orders: <BR/> - Carafate Tablet 1 GM (Sucralfate) Give 1 tablet by mouth two times a day for GERD BEFORE MEALS, noted as active order status, order date: 01/17/2025 and start date: 01/18/2025. No end date noted.<BR/> - Carafate Tablet 1 GM (Sucralfate) Give 1 tablet by mouth two times a day for GERD BEFORE MEALS, noted as active order status, order date: 11/08/2024 and start date: 11/08/2024. No end date noted. <BR/> - Enulose Solution 10 GM/15ML (Lactulose Encephalopathy) Give 30 ml by mouth three times a day for constipation, noted as active order status, order date: 11/08/2024 and start date: 11/08/2024. No end date noted. <BR/>Record review of Resident #1's 1/1/2025 - 1/31/2025 Medication Administration Record, printed on 01/17/2024, reflected the schedule for Resident #1's carafate tablet 1 gm was scheduled for administration at 0700 (07:00 a.m.) and 1600 (04:00 p.m.) and her 30 milliliters of enulose solution 10 gm/15 mL was scheduled for 0800 (08:00 a.m.), 1200 (12:00 p.m.), and 1600 (04:00 p.m.). Resident #1's order for carafate tablet, started on 11/08/2024 was scheduled to be discontinued on 01/17/2025 at 05:51 p.m. and the order scheduled to start on 01/18/2024 was to start at 07:00 a.m. on 01/18/2025. <BR/>During an observation on 01/17/2025 at 05:29 p.m., RN A was observed to administer the following medications to Resident #1: 1 tablet carafate tablet 1 gm and 30 milliliters of enulose solution 10 gm/15 mL. The carafate and enulose orders were observed to be highlighted in red on RN A's electronic medical record screen and noted to be scheduled for administration at 1600 (04:00 p.m.). The dinner meal tray was observed to be delivered to Resident #1 after the medication administration. <BR/>During an interview on 01/17/2025 at 08:12 p.m., RN A confirmed the administration of the carafate tablet and enulose solution to Resident #1 at 05:29 p.m. were late. RN A stated the medication administration for Resident #1 was late due to this shift was his first time working on this side of the hall and he was not very familiar with the residents and their medications. RN A stated he was new to the facility and was still working on picking up his pace with the medication administration procedures. He stated he was trained during orientation on the facility procedures for medication administration and how to use and read the electronic medical record program. <BR/>During an interview on 01/17/2025 at 08:15 p.m., the DON revealed she and the facility provide staff training on medication administration several times per year, often focusing on different topics that fall under the umbrella of medication administration. The DON confirmed RN A was a new staff member and his late medication administration was most likely due to his lack of familiarity with the residents and their medications he was administering. The DON stated she did not believe the carafate having been administered around an hour and 30 minutes late would have impacted Resident #1, if Resident #1 received it prior to her meal. The DON stated the late administration of the carafate may have only minimized its effectiveness in coating Resident #1's stomach prior to her meal. The DON stated the 30-minute late administration of the enulose would not have impacted Resident #1. <BR/>Record review of facility policy, Administering Medications, date illegible, reflected under Policy Statement, Medications are administered in a safe and timely manner, and as prescribed., and under Policy Interpretation and Implementation, <BR/>5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:<BR/> a. enhancing optimal therapeutic effect of the medication;<BR/> b. preventing potential medication or food interactions; and <BR/> c. honoring resident choices and preferences, consistent with his or her care plan. and <BR/>7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed ensure residents are free of any significant medication errors for three residents (Residents #31, #36, and #54) out of 5 residents reviewed for medication administration in that:<BR/>1. <BR/>Resident #31 had metoprolol (a medication for high blood pressure) administered outside the parameters as ordered by the physician.<BR/>2. <BR/>Resident #36 had ibrutinib (a medication for cancer) administered without an appropriate label.<BR/>3. <BR/>Resident #54 had midodrine (a medication low blood pressure) administered outside of the parameters as ordered by the physician. Resident #54 missed administration of hydralazine (a medication for elevated blood pressure). <BR/>This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and possible adverse reactions. <BR/>The findings include:<BR/>1. <BR/>Record review of the admission record, dated 9/19/2023, revealed Resident #31 was a [AGE] year-old male originally admitted on [DATE]. <BR/>Record review of the quarterly MDS assessment, dated 6/30/2023, revealed Resident #31's primary medical condition for admission was acute respiratory failure with hypoxia [lack of oxygen to the brain]. Other active diagnoses included hypertension [high blood pressure].<BR/>Record review of the care plan, reviewed 8/03/2023, revealed Resident #31 had a focus area of: treat diagnosis of hypertension; with the following associated interventions: medication to treat hypertension per medical doctor orders.<BR/>Record review of the order summary report, dated 9/21/2023, revealed Resident #31 had active physician orders for metoprolol, hold if systolic blood pressure less than 100 and heart rate less than 65.<BR/>Record review of Resident #31's medication administration record for September 2023 revealed, the 8:00 AM metoprolol dose was administered on 9/21/2023 when Resident #31's heart rate was documented at 64.<BR/>In an observation on 9/21/2023 at 8:11 AM, LVN A obtained vital signs on Resident #31 that included a blood pressure of 110 / 66 and a heart rate of 64. LVN A entered these statistics into the electronic health record and prepared Resident #31's medications for administration. LVN A administered medications to Resident #31 that included metoprolol. <BR/>2. <BR/>Record review of the admission record, dated 9/21/2023, revealed Resident #36 was an [AGE] year-old male originally admitted on [DATE]. <BR/>Record for review of the comprehensive MDS assessment, dated 8/18/2023, revealed Resident #36's the primary medical condition category for admission was progressive neurological conditions. Other active diagnoses included cancer. <BR/>Record review of the care plan, reviewed 8/31/2023, revealed Resident #36 had a focus area of I take ibrutinib for my leukemia; with the following associated interventions: administer medications . as ordered. Additional focus area included, resident has lymphocytic leukemia; with the following associated interventions: give medications as ordered .Ibrutinib Oral tablet 420 milligrams per day.<BR/>Record review of the order summary report, dated 9/21/2023, revealed Resident #36 had active physician orders: ibrutinib oral tablet 420 milligrams, 1 tablet by mouth one time a day related to chronic lymphocytic leukemia of B-cell type not having achieved remission, with a start date of 8/12/2023. <BR/>Record review of the medication administration record for September 2023, revealed Resident #36 received the 8:00 AM dose of ibrutinib 1 tablet 420 milligrams on 9/21/2023.<BR/>In an observation on 9/21/2023 at 7:48 AM, LVN A prepared and administered medications that included ibrutinib to Resident #36. The medication was dispensed from a blister pack type card that did not include a standard pharmacy label with Resident #36 name, dosage, frequency, or expiration date. LVN A stated, Resident #36's wife brings this medication from a Veterans Affairs pharmacy to the facility on a regular basis because it is a cancer treatment and is expensive. <BR/>3. <BR/>Record review admission record dated 9/21/2023, revealed Resident #54 was a [AGE] year-old male originally admitted on [DATE]. <BR/>Record review of the discharge MDS assessment, dated 8/26/2023, revealed Resident #54's active diagnoses included unspecified paraplegia [type of paralysis that affects the lower half of the body].<BR/>Record review of the order summary report dated 9/21/2023, revealed Resident #54 and active physician orders for: hydralazine 10 milligrams one tablet enterally every eight hours as needed for hypertension [high point pressure] for systolic blood pressure greater than 160 with a start date of 8/18/2023; midodrine 10 milligrams one tablet enterally three times a day for hypotension [low blood pressure] hold for systolic blood pressure greater than 120 with the start date of 8/18/2023. <BR/>Record review of the medication administration record for August 2023 revealed Resident #54 was administered: <BR/>Midodrine 10 mg on 8/19/2023 at 8:00 AM when his blood pressure was 129/68 by RN I; <BR/>Midodrine 10 mg on 8/19/2023 at 12:00 PM when his blood pressure was 129/68 by RN I; <BR/> Midodrine 10 mg on 8/29/2023 at 4:00 PM when his blood pressure was 125/67 by Nurse K. <BR/>Record review of the medication administration record for September 2023, revealed Resident #54 did not receive hydralazine on 9/08/2023 at 8:00 AM, when his blood pressure was 170/89 by LVN J. <BR/>In an interview on 9/21/2023 at 3:15 PM, the DON stated the parameters should be followed as ordered by the physician. The DON stated harm could occur if medication is given out of the parameters set by the physician. The DON stated the medication ibrutinib for Resident #36 was a medication the residents wife provided from the Veterans Affair pharmacy as a condition of admission due to its high cost. The DON stated the medication was removed from its original, bulky box and the individual cards were placed in the medication cart for administration. The DON stated she was sure the original bulky box was labeled correctly with the required elements. The DON stated she would provide appropriate policies. <BR/>Record review of Administering Medications policy, revised December 2012, revealed in step 3. Medications must be administered in accordance with orders .;7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method; 9. The expiration/beyond use date on the medication label must be checked prior to administering. The policy did not address assessing parameters, or holding medications if parameters were not met. <BR/>Record review of the Medications Brought to The Facility by The Resident/ Family policy, revised April 2007, revealed in Step 3c. the contents of each container are labeled in accordance with established policies; d. the contents of each container have been verified by a licensed pharmacist. <BR/>Record review of Labeling of Medication Containers policy, revised April 2007, revealed in Step 3. labels for individual drug containers shall include all necessary information, such as: a. the residents name; b. the prescribing physician's name; d. the name, strength, and quantity of the drug; f. the date that the medication was dispensed; h. the expiration date when applicable; and i. directions for use. <BR/>Review of Lippincott procedures, Oral drug administration, revised 5/19/2022, accessed 9/28/2023, from: https://procedures.lww.com/lnp/view.do?pId=5455001, revealed, under the subheading Special Considerations, Assess parameters, such as blood pressure and pulse, as necessary before administering a medication with dose-holding parameters. Additionally, compare the drug label to the order in the patient's medical record; further, Check the expiration date on the medication. Under the heading, Special Considerations, Don't administer a medication from a poorly labeled or unlabeled container.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>The facility failed to ensure all foods in the refrigerator were labeled and dated with use by dates.<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.<BR/>The findings were:<BR/>During an observation and interview with the Food Service Director on 09/19/2023 at 10:51 a.m., revealed an unlabeled storage bag with ground meat and meat links dated 9/19/23 and an unlabeled storage bag of a yellow substance dated 9/19/23. The FSD called out to [NAME] H and reeducated that all items must be labeled. [NAME] H revealed the items to be pan sausage, sausage links and scrambled eggs from that morning which had been saved for the following days puree. The FSD instructed the [NAME] to discard the items. Further tour of the kitchen revealed a storage bag with a substance labeled as Pizza Mix dated 9/15/23. [NAME] H was asked if the date of 09/15/23 was a use by date or the date the Pizza Mix was prepared, and [NAME] H stated he did not know as he did not work that day. The FSD instructed [NAME] H to throw the Pizza Mix away. Further observation revealed three premade turkey and cheese sandwiches were noted in the refrigerator, dated 9/12/23, which the FSD stated was the prepared date. The FSD stated a few sandwiches were prepared ahead for residents who chose not to eat what was on the menu, however, she stated the sandwiches were past the use by date. The FSD stated kitchen staff were trained that foods must be labeled and dated to protect the residents from food borne illnesses. She added that she planned to provide additional training for all staff.<BR/>Record review of the facility's policy titled, Food Receiving and Storage, revised October 2017, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready -to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a 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.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (8) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, and smoking safety for 3 (Residents #25, #33 and #35) of 3 residents reviewed did not have their smoking assessment.<BR/>1. The facility failed to ensure a smoking assessment was completed for Resident #25 quarterly.<BR/>2. The facility failed to ensure a smoking assessment was completed for Resident #33 upon admission. <BR/>3. The facility failed to ensure a smoking assessment was completed for Resident #35 quarterly.<BR/>This failure could affect smoking residents and could result in harm if policies were not followed.<BR/>The findings included:<BR/>1. Record review of Resident #25's face sheet dated 09/22/2023 revealed an initial admission date of 03/21/2019 with a recent admission of 04/20/2021 and diagnoses which included major depressive disorder, generalized anxiety disorder, low back pain, and muscle weakness.<BR/>Record review of Resident #25's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 04, which indicated severe cognitive impairment. <BR/>Record review of Resident #25's care plan with last review completed on 07/29/2023 did not reveal a focus to address Resident #25 was a smoker. <BR/>Record review of Resident #25's most recent smoking assessment dated [DATE] revealed the resident was safe to smoke with supervision. Resident #25 did not have an updated quarterly smoking assessment.<BR/>2. Record review of Resident #33's face sheet dated 09/22/2023 revealed an initial admission date of 10/06/2022 with a recent admission of 07/02/2023 and diagnoses which included heart failure, chronic kidney disease, and major depressive disorder.<BR/>Record review of Resident #33's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated the resident had no cognitive impairment. <BR/>Record review of Resident #33's care plan with last review completed on 07/20/2023 did not reveal a care plan to address Resident #33 was a smoker. Further review revealed a focus for non-compliance and listed Resident #33's non-compliance with physician orders, medications, diet, and smoking. There were no goals or interventions for smoking in the care plan.<BR/>Record review of Resident #33's assessments revealed Resident #33 did not have a smoking assessment completed upon admission. Further review revealed a smoking assessment from the resident's prior admission that indicated resident must be supervised, wear a smoking apron, and not maintain own smoking materials per facility policy.<BR/>3. Record review of Resident #35's face sheet dated 09/22/2023 revealed an initial admission date of 06/04/2022 with a recent admission of 09/03/2022 and diagnoses which included major depressive disorder, anxiety disorder, alcohol dependence, and cocaine dependence.<BR/>Record review of Resident #35's Annual MDS, dated [DATE], revealed the resident's BIMS score was 13, which indicated the resident had no cognitive impairment. <BR/>Record review of Resident #35's care plan with last review completed on 09/21/2023 did not reveal a focus to address Resident #35 was a smoker. <BR/>Record review of Resident #35's most recent smoking assessment dated [DATE] revealed the resident was safe to smoke with supervision. Resident #35 did not have an updated quarterly smoking assessment.<BR/>Record review of the SMOKER LIST, dated 7/7/23, revealed Resident #25, Resident #33, Resident #35 as identified smokers at the facility. <BR/>In an interview with the DON on 09/22/2023 at 8:56 p.m., the DON stated smoking evaluations were completed on all residents who are identified as smokers upon admission. The DON added that smoking assessments were updated, quarterly and annually, according to the MDS schedule. The DON reported the AD was responsible for completing smoking assessments.<BR/>In an interview with the Administrator on 09/22/2023 at 9:05 p.m., the Administrator confirmed smoking assessments were updated quarterly per policy. The Administrator stated the PRN SW completed the assessments however when she was not available any nursing staff could complete the assessments to ensure they were completed timely.<BR/>Record review of the facility's policy titled, Smoking Policy - Residents, revised July 2017, revealed, This facility shall establish and maintain safe resident smoking practices, 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: (d) Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 15 residents (Resident #4) reviewed for accuracy of medical records, in that:<BR/>The facility failed to document Resident #1's pronouncement of death, discharge from the facility and disposition of the body. <BR/>This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>-Coordinate care with hospice care. <BR/>Record review of Resident #1's progress notes revealed the following:<BR/>- [DATE]- .patient noted to be pale, no respirations noted, not able to obtain vital signs. Hospice informed and DON informed. Pending call back from hospice. Documented by Agency LVN B<BR/>There were no notes after this documentation on [DATE]. <BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated when a resident expired on hospice care she was trained to document in the resident medical record a note when hospice pronounced death and where the resident was going after the death. LVN A stated when the resident's body left the facility, she would also document in the progress notes in detail. LVN A stated she was, old school, and had worked in a lot of nurses' homes. LVN A stated she knew she had to document every little thing and not to leave anything out. LVN A stated it was important to document so other people would know what was done. LVN A stated, If it wasn't documented, it wasn't done. <BR/>During an interview on [DATE] at 3:25 p.m., Agency LVN B stated she was an agency LVN with a local nurse staffing agency. Agency LVN B stated she first worked in the facility one time on the [DATE]. Agency LVN B stated on [DATE] close to the end of the shift, Resident #1 was passing (actively dying). Agency LVN B stated she provided comfort care, and the death was expected. Agency LVN B stated she noted in the medical record that the resident was had expired by noting she was pale and without respirations. Agency LVN B stated she notified hospice as required and left for the day before hospice had arrived to pronounce the resident's death. <BR/>During an interview on [DATE] at 4:51 p.m. LVN C stated Resident #1 expired during shift change on [DATE]. LVN C stated the other nurse (identified as Agency LVN B) notified hospice. LVN C stated hospice showed up 30 minutes later to declare the death and notified the mortuary. LVN C stated she did not make a note of the pronouncement of death. LVN C stated, I guess I was supposed to. LVN C stated she did not document because she figured the previous nurse had already documented something. LVN C stated she did not document the disposition of the body or when the body left the facility because she did not know she was supposed to. LVN C stated she typically made a note when a resident was discharged and why they were leaving but not when the body was discharged from the facility. LVN C stated it was important to document so others knew the time of death and when the body left although she thought that was a hospice responsibility. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated she expected nursing staff to document pronouncement of death, disposition of the body, who it was released to and, time the body left the facility in the progress notes. The DON stated documentation was important to show the resident was provided care and they were taken care of at the facility. <BR/>Record review of the facility's document titled, Charting and Documentation, dated [DATE], revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinence/perineal care, in that: <BR/>CNA A and CNA B used multiple passes with the same wipe while providing incontinence/perineal care to Resident #1. <BR/>This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 8/24/23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous condition in men in which the prostate gland is enlarged causing blockage of urine flow out of the bladder), chronic kidney disease stage 3 (damage to kidneys affecting how blood is filtered), and type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy).<BR/>Record review of Resident #1's most recent admission MDS assessment, dated 6/27/23 revealed the resident was severely cognitively impaired for daily decision-making skills and was frequently incontinent of bowel and bladder.<BR/>Record review of Resident #1's comprehensive care plan, review date 7/7/23 revealed the resident had bowel and bladder incontinence related to prostate enlargement and loss of control with interventions that included to check the resident as required for incontinence and to wash, rinse and dry perineum.<BR/>Observation on 8/24/23 at 10:07 a.m., during incontinence/perineal care, CNA A made multiple passes with one wipe to clean Resident #1's buttock area. CNA B made multiple passes with one wipe to clean Resident #1's inner thighs.<BR/>During an interview on 8/24/23 at 11:19 a.m., CNA A revealed she realized she had been using one wipe and had made several passes to clean Resident #1's buttock area. CNA A stated, I realized it was improper but, in the moment, I was just thinking I need to clean the resident, but again I just got caught up in the moment. CNA A revealed, making multiple passes with one wipe was considered cross contamination and Resident #1 could cause the resident to get sick. CNA A revealed she had not received any incontinence/perineal care training since the former ADON had done the training a year ago.<BR/>During an interview on 8/24/23 at 12:08 p.m., CNA B revealed she was working at the facility through an agency and revealed any training received was completed while in CNA school. CNA B revealed she was not aware she had used one wipe multiple times to clean Resident #1's thighs.<BR/>During an interview on 8/24/23 at 4:23 p.m., the DON revealed, during incontinence/peri care, staff should be wiping from front to back with one wipe per pass, otherwise there would be the introduction of the potential for infection. <BR/>Record review of the nursing competency training titled, Perineal Care, dated 6/14/23 revealed CNA A had satisfied the requirements for performing incontinence/perineal care.<BR/>Record review of the facility policy and procedure, titled Perineal Care, revision date February 2018 revealed in part, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Continue to wash the perineum moving from inside outward to the thighs, rinse perineum thoroughly in same direction, using fresh water and a clean washcloth .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control in that: <BR/>CNA Trainee C did not perform hand hygiene after cleansing Resident #6's genitalia and before touching Resident #6's skin. CNA Trainee C did not perform hand hygiene between glove changes.<BR/>This deficient practice could affect all residents and place them at risk for infection.<BR/>The findings were:<BR/>Record review of Resident #6's face sheet, dated 6/1/23, revealed Resident #6 was admitted to the facility on [DATE] diagnoses of mild protein-calorie malnutrition, encephalopathy [a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke], unspecified, hemiplegia [paralysis of one side of the body] and hemiparesis [muscle weakness of one side of the body] following cerebral infarction [a disruption in the brain's blood flow] affecting left dominant side, dysphagia [difficulty swallowing following cerebral infarction, and pneumonia [a lung infection] due to Escherichia coli [a bacteria that normally lives in the intestines of healthy people and animals].<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 12, signifying moderate cognitive impairment.<BR/>Observation on 5/31/23 at 2:09 p.m. revealed CNA Trainee C entered Resident #6's room, performed hand hygiene, and put on gloves. CNA Trainee C undid Resident #6's adult brief and cleansed Resident #6's right groin area with a wipe, then used another wipe to cleanse the left groin area, then used another wipe to cleanse the base of Resident #6's penis, then used another wipe to cleanse the head of Resident #6's penis, then used another wipe to cleanse Resident #6's urinary catheter. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C put her soiled gloved hands on Resident #6's arm and thigh to assist Resident #6 to turn to his right side. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C then cleansed Resident #6's left buttocks with a wipe, then used another wipe to cleanse Resident #6's right buttocks, then used another wipe to cleanse between Resident #6's buttocks. CNA Trainee C removed her soiled gloves, did not perform hand hygiene and put on a new pair of gloves. CNA Trainee C picked up a clean adult brief and disposable drape sheet, which she positioned under Resident #6. Then CNA Trainee C touched Resident #6's arm and thigh to assist Resident #6 to turn onto his left side and better position the adult brief and disposable drape sheet. <BR/>During an interview on 5/31/23 at 2:15 p.m., CNA Trainee C stated she was still in CNA School and last received hand hygiene education at her school. When asked when should she perform hand hygiene, CNA Trainee C stated hand hygiene should be performed whenever she entered and exited a resident room whenever she touched something, whenever she changed a resident's adult brief, when she fed a resident. CNA Trainee C confirmed hand hygiene should be done between glove changes. CNA C stated she should have changed gloves after touching Resident #6's groin area. <BR/>During an interview on 6/1/23 at 9:52 a.m., when asked if the facility had a quality assurance process ensuring hand hygiene was done appropriately during incontinent care, the DON stated through the day, what should happen is that we should be observing random observations when we see the staff coming and doing care. We should be observing for proper technique. When asked what sort of negative effects could occur to the residents if a staff member wasn't performing hand hygiene appropriately during incontinent care, the DON stated potential for infection.<BR/>Record review of CNA Trainee C's Nursing Competency for Perineal Care, dated 12/29/22, revealed the following: places resident on side and cleans perineum and rectal area: front to back . removes gloves, discards properly, and washes hands. CNA Trainee C was deemed competent in perineal care.<BR/>Record review of a facility policy titled, Hand Hygiene, dated August 2015, revealed the following verbiage: use alcohol-based hand rub . or, alternative, soap . and water for the following situations: b. before and after direct contact with residents . h. before moving from a contaminated body site to a clean body site during resident care; .m. after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in th comprehenvsive assessment, for 1 of 3 Residents (Resident #1 reviewed for care plans, in that: <BR/>The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address hospice information, details of hospice care provided and coordination of services.<BR/>This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>- Coordinate care with hospice care. The plan of care did not specify what care was coordinated or how it was provided to the resident. <BR/>- Hospice Care program as ordered. The plan of care did not specify how the plan was applied to the resident or what services were provided. <BR/>- Monitor for complaints of pain or discomfort and provide interventions as orders. The plan of care did not specify the interventions or how they should be applied to Resident #1. <BR/>The plan of care did not list the name, phone number, or contact information of the hospice agency used for Resident #1.<BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated Resident #1 received hospice care and expired last week (date unknown). LVN A stated a hospice aide would come and bathe Resident #1 and a hospice RN came to visit Resident #1. LVN A stated she did not know how often they came to see the resident. LVN A stated Resident #1 had medications ordered for pain by hospice. <BR/>Attempted interview with Resident #1's hospice company on [DATE] at 2:42 p.m. was unsuccessful. <BR/>During an interview on [DATE] at 5:23 p.m., the Corporate MDS Nurse stated the facility had not had a MDS Coordinator for approximately 3 weeks. The Corporate MDS Nurse stated Resident #1's care plan for hospice services was missing critical information for hospice care. The Corporate MDS Nurse stated the care plan should have what specific hospice program was used, how often the facility should call hospice and what services were provided. The Corporate MDS Nurse stated the hospice care plan should have hospice specific information. The Corporate MDS Nurse stated Resident #1's care plan was initiated on [DATE] and was based on the MDS assessment. The Corporate MDS Nurse stated care plans should be updated for change of condition. The Corporate MDS Nurse stated the MDS Coordinator, DON or charge nurses could update the care plan. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated the care plans for hospice should include the hospice and diagnoses, how the facility was providing care to the resident. The DON stated the hospice care plan should also include why the resident was on hospice, expectations from hospice, when the facility was supposed to call hospice, contact information for hospice. The DON stated every hospice was different. The DON stated some hospices sent aides, some did not. The DON stated the hospice care plan should include coordination of care information. The DON stated the MDS person was responsible for updating care plan and the facility currently did not have a MDS Coordinator. The DON stated a corporate person who knew the facility came several times a week to do care plans. The DON stated it was important to have an accurate care plan so the facility knew what type of care they needed to provide to the resident. <BR/>During an interview on [DATE] at 6:15 p.m., the Administrator stated the MDS Coordinator was responsible for resident care plans. The Administrator stated she had oversight of MDS.<BR/>Record review of a facility policy, titled Care Plans, Comprehensive Person-Centered, dated [DATE] revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being j. Reflect the resident's expressed wishes regarding care and treatment goals l. Identify the professional services that are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 15 residents (Resident #4) reviewed for accuracy of medical records, in that:<BR/>The facility failed to document Resident #1's pronouncement of death, discharge from the facility and disposition of the body. <BR/>This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>-Coordinate care with hospice care. <BR/>Record review of Resident #1's progress notes revealed the following:<BR/>- [DATE]- .patient noted to be pale, no respirations noted, not able to obtain vital signs. Hospice informed and DON informed. Pending call back from hospice. Documented by Agency LVN B<BR/>There were no notes after this documentation on [DATE]. <BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated when a resident expired on hospice care she was trained to document in the resident medical record a note when hospice pronounced death and where the resident was going after the death. LVN A stated when the resident's body left the facility, she would also document in the progress notes in detail. LVN A stated she was, old school, and had worked in a lot of nurses' homes. LVN A stated she knew she had to document every little thing and not to leave anything out. LVN A stated it was important to document so other people would know what was done. LVN A stated, If it wasn't documented, it wasn't done. <BR/>During an interview on [DATE] at 3:25 p.m., Agency LVN B stated she was an agency LVN with a local nurse staffing agency. Agency LVN B stated she first worked in the facility one time on the [DATE]. Agency LVN B stated on [DATE] close to the end of the shift, Resident #1 was passing (actively dying). Agency LVN B stated she provided comfort care, and the death was expected. Agency LVN B stated she noted in the medical record that the resident was had expired by noting she was pale and without respirations. Agency LVN B stated she notified hospice as required and left for the day before hospice had arrived to pronounce the resident's death. <BR/>During an interview on [DATE] at 4:51 p.m. LVN C stated Resident #1 expired during shift change on [DATE]. LVN C stated the other nurse (identified as Agency LVN B) notified hospice. LVN C stated hospice showed up 30 minutes later to declare the death and notified the mortuary. LVN C stated she did not make a note of the pronouncement of death. LVN C stated, I guess I was supposed to. LVN C stated she did not document because she figured the previous nurse had already documented something. LVN C stated she did not document the disposition of the body or when the body left the facility because she did not know she was supposed to. LVN C stated she typically made a note when a resident was discharged and why they were leaving but not when the body was discharged from the facility. LVN C stated it was important to document so others knew the time of death and when the body left although she thought that was a hospice responsibility. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated she expected nursing staff to document pronouncement of death, disposition of the body, who it was released to and, time the body left the facility in the progress notes. The DON stated documentation was important to show the resident was provided care and they were taken care of at the facility. <BR/>Record review of the facility's document titled, Charting and Documentation, dated [DATE], revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 7.69%, based on 2 errors out of 26 opportunities, which involved 1 of 6 residents (Resident #1) reviewed for medication administration and medication errors.<BR/>RN A administered Resident #1's medications: a 10 gram of carafate tablet (an anti-ulcer medication) and 30 milliliters of 10 gm/15mL enulose solution (a laxative used to treat constipation), scheduled at 04:00 p.m., at 05:29 p.m., one hour and twenty-nine minutes late.<BR/>These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 01/17/2025, reflected Resident #1 was admitted initially on 11/14/2024 and re-admitted on [DATE]. Resident #1 was noted to be [AGE] years old.<BR/>Record review of Resident #1's Medical Diagnoses Report, undated, accessed 01/17/2025, reflected Resident #1 was diagnosed with biliary cirrhosis (a chronic and progressive liver disease caused by inflammation, obstruction, and damage within the liver), fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances), and gastro-esophageal reflex disease with esophagitis (a chronic digestive disorder where stomach acid or bile causes inflammation of the esophagus) without bleeding. <BR/>Record review of the Quarterly MDS assessment, dated 12/02/2024 and signed as completed on 12/09/2024 by the DON, reflected Resident #1 had a BIMS score of 15, indicating she was cognitively intact. Resident #1 was coded as occasionally incontinent for urinary and bowel continence. <BR/>Record review of Resident #1's Care Plan, undated, accessed 01/17/2025, reflected Resident #1 had the following focuses:<BR/> 1. a focus area of .history of GERD with the following interventions: <BR/> - Give my medications as ordered. Monitor/document my side effects and effectiveness. and<BR/> - Monitor/document/report to my MD PRN s/sx of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V, indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, Dysphagia, substernal chest pain, increased gag response.;<BR/> and a goal to remain free from discomfort, complications or s/sx related to dx of GERD through review date. Target date of goal noted as 03/04/2025. <BR/> 2. a focus area of .history of constipation with an intervention to Monitor/document/report to my MD PRN s/sx of complications related to constipation: and a goal to have a normal bowel movement at least every 3 day through the review date. Target date of goal noted as 03/04/2025.<BR/>Record review of Resident #1's Order Summary Report, dated as Active Orders As Of: 01/17/2025, reflected Resident #1 had the following active physician orders: <BR/> - Carafate Tablet 1 GM (Sucralfate) Give 1 tablet by mouth two times a day for GERD BEFORE MEALS, noted as active order status, order date: 01/17/2025 and start date: 01/18/2025. No end date noted.<BR/> - Carafate Tablet 1 GM (Sucralfate) Give 1 tablet by mouth two times a day for GERD BEFORE MEALS, noted as active order status, order date: 11/08/2024 and start date: 11/08/2024. No end date noted. <BR/> - Enulose Solution 10 GM/15ML (Lactulose Encephalopathy) Give 30 ml by mouth three times a day for constipation, noted as active order status, order date: 11/08/2024 and start date: 11/08/2024. No end date noted. <BR/>Record review of Resident #1's 1/1/2025 - 1/31/2025 Medication Administration Record, printed on 01/17/2024, reflected the schedule for Resident #1's carafate tablet 1 gm was scheduled for administration at 0700 (07:00 a.m.) and 1600 (04:00 p.m.) and her 30 milliliters of enulose solution 10 gm/15 mL was scheduled for 0800 (08:00 a.m.), 1200 (12:00 p.m.), and 1600 (04:00 p.m.). Resident #1's order for carafate tablet, started on 11/08/2024 was scheduled to be discontinued on 01/17/2025 at 05:51 p.m. and the order scheduled to start on 01/18/2024 was to start at 07:00 a.m. on 01/18/2025. <BR/>During an observation on 01/17/2025 at 05:29 p.m., RN A was observed to administer the following medications to Resident #1: 1 tablet carafate tablet 1 gm and 30 milliliters of enulose solution 10 gm/15 mL. The carafate and enulose orders were observed to be highlighted in red on RN A's electronic medical record screen and noted to be scheduled for administration at 1600 (04:00 p.m.). The dinner meal tray was observed to be delivered to Resident #1 after the medication administration. <BR/>During an interview on 01/17/2025 at 08:12 p.m., RN A confirmed the administration of the carafate tablet and enulose solution to Resident #1 at 05:29 p.m. were late. RN A stated the medication administration for Resident #1 was late due to this shift was his first time working on this side of the hall and he was not very familiar with the residents and their medications. RN A stated he was new to the facility and was still working on picking up his pace with the medication administration procedures. He stated he was trained during orientation on the facility procedures for medication administration and how to use and read the electronic medical record program. <BR/>During an interview on 01/17/2025 at 08:15 p.m., the DON revealed she and the facility provide staff training on medication administration several times per year, often focusing on different topics that fall under the umbrella of medication administration. The DON confirmed RN A was a new staff member and his late medication administration was most likely due to his lack of familiarity with the residents and their medications he was administering. The DON stated she did not believe the carafate having been administered around an hour and 30 minutes late would have impacted Resident #1, if Resident #1 received it prior to her meal. The DON stated the late administration of the carafate may have only minimized its effectiveness in coating Resident #1's stomach prior to her meal. The DON stated the 30-minute late administration of the enulose would not have impacted Resident #1. <BR/>Record review of facility policy, Administering Medications, date illegible, reflected under Policy Statement, Medications are administered in a safe and timely manner, and as prescribed., and under Policy Interpretation and Implementation, <BR/>5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:<BR/> a. enhancing optimal therapeutic effect of the medication;<BR/> b. preventing potential medication or food interactions; and <BR/> c. honoring resident choices and preferences, consistent with his or her care plan. and <BR/>7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in th comprehenvsive assessment, for 1 of 3 Residents (Resident #1 reviewed for care plans, in that: <BR/>The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address hospice information, details of hospice care provided and coordination of services.<BR/>This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>- Coordinate care with hospice care. The plan of care did not specify what care was coordinated or how it was provided to the resident. <BR/>- Hospice Care program as ordered. The plan of care did not specify how the plan was applied to the resident or what services were provided. <BR/>- Monitor for complaints of pain or discomfort and provide interventions as orders. The plan of care did not specify the interventions or how they should be applied to Resident #1. <BR/>The plan of care did not list the name, phone number, or contact information of the hospice agency used for Resident #1.<BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated Resident #1 received hospice care and expired last week (date unknown). LVN A stated a hospice aide would come and bathe Resident #1 and a hospice RN came to visit Resident #1. LVN A stated she did not know how often they came to see the resident. LVN A stated Resident #1 had medications ordered for pain by hospice. <BR/>Attempted interview with Resident #1's hospice company on [DATE] at 2:42 p.m. was unsuccessful. <BR/>During an interview on [DATE] at 5:23 p.m., the Corporate MDS Nurse stated the facility had not had a MDS Coordinator for approximately 3 weeks. The Corporate MDS Nurse stated Resident #1's care plan for hospice services was missing critical information for hospice care. The Corporate MDS Nurse stated the care plan should have what specific hospice program was used, how often the facility should call hospice and what services were provided. The Corporate MDS Nurse stated the hospice care plan should have hospice specific information. The Corporate MDS Nurse stated Resident #1's care plan was initiated on [DATE] and was based on the MDS assessment. The Corporate MDS Nurse stated care plans should be updated for change of condition. The Corporate MDS Nurse stated the MDS Coordinator, DON or charge nurses could update the care plan. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated the care plans for hospice should include the hospice and diagnoses, how the facility was providing care to the resident. The DON stated the hospice care plan should also include why the resident was on hospice, expectations from hospice, when the facility was supposed to call hospice, contact information for hospice. The DON stated every hospice was different. The DON stated some hospices sent aides, some did not. The DON stated the hospice care plan should include coordination of care information. The DON stated the MDS person was responsible for updating care plan and the facility currently did not have a MDS Coordinator. The DON stated a corporate person who knew the facility came several times a week to do care plans. The DON stated it was important to have an accurate care plan so the facility knew what type of care they needed to provide to the resident. <BR/>During an interview on [DATE] at 6:15 p.m., the Administrator stated the MDS Coordinator was responsible for resident care plans. The Administrator stated she had oversight of MDS.<BR/>Record review of a facility policy, titled Care Plans, Comprehensive Person-Centered, dated [DATE] revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being j. Reflect the resident's expressed wishes regarding care and treatment goals l. Identify the professional services that are responsible for each element of care.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 4 medication carts reviewed for security and control, in that:<BR/>1. LVN E left the 100-hall medication cart unattended, unsupervised, and unlocked.<BR/>2. RT K left the 200-hall respiratory therapy medication cart unattended, unsupervised, and unlocked. <BR/>These failures could place residents at risk of misappropriation of property, not receiving the therapeutic effects of medications, and or adverse effects of medications. <BR/>The findings included: <BR/>During an observation and interview on 6/17/2025 at 12:34 PM revealed the medication cart for the 100-hall was unattended, unsupervised, and unlocked while parked on the hall, as evidenced by the protruding unlocked mechanism. The cart was observed for 10 minutes while residents and CNAs ambulated in the hall. Continued observation revealed the ADON approached the medication cart and locked the cart. The ADON stated the cart was assigned to a nurse, but she was unaware of the nurse's name. The ADON stated she was also unaware of the nurse's whereabouts. The ADON stated the medication cart had medications, to include narcotics, stored within. The ADON stated the expectation was for medication carts to be locked when not attended. <BR/>During an observation and interview on 6/17/2025 at 1:09 PM revealed the 200-hall respiratory therapy medication cart was unattended, unsupervised, and unlocked while parked on the 200-hall, as evidenced by the protruding unlocked mechanism. Continued observation revealed CNAs and residents ambulated by the cart. After 5 minutes of observations CNA I stated the cart belonged to RT K and pointed him out by the nurse's station. RT K was informed of his unattended and unsupervised medication cart to which he stated, I was in a resident's room providing care . I could not see my cart while I was in the room. <BR/>During an interview on 6/17/2025 at 1:20 PM the ADON stated she learned the 100-hall medication cart was assigned to LVN E. <BR/>During an interview on 6/17/2025 at 1:50 PM LVN E stated she left the medication cart unlocked due to human error.<BR/>During an interview on 6/20/2025 at 12:28 PM the DON stated the expectation was for all medication carts to be locked when not attended by nursing staff and the risk to residents could be not receiving the therapeutic effects of their medications. <BR/>A record review of the facility's Security of Medication Cart policy dated April 2007 revealed, Policy heading: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: . <BR/>3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room.<BR/>4. Medication carts must be securely locked at all times when out of the nurse's view.<BR/>5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control in that: <BR/>CNA Trainee C did not perform hand hygiene after cleansing Resident #6's genitalia and before touching Resident #6's skin. CNA Trainee C did not perform hand hygiene between glove changes.<BR/>This deficient practice could affect all residents and place them at risk for infection.<BR/>The findings were:<BR/>Record review of Resident #6's face sheet, dated 6/1/23, revealed Resident #6 was admitted to the facility on [DATE] diagnoses of mild protein-calorie malnutrition, encephalopathy [a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke], unspecified, hemiplegia [paralysis of one side of the body] and hemiparesis [muscle weakness of one side of the body] following cerebral infarction [a disruption in the brain's blood flow] affecting left dominant side, dysphagia [difficulty swallowing following cerebral infarction, and pneumonia [a lung infection] due to Escherichia coli [a bacteria that normally lives in the intestines of healthy people and animals].<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 12, signifying moderate cognitive impairment.<BR/>Observation on 5/31/23 at 2:09 p.m. revealed CNA Trainee C entered Resident #6's room, performed hand hygiene, and put on gloves. CNA Trainee C undid Resident #6's adult brief and cleansed Resident #6's right groin area with a wipe, then used another wipe to cleanse the left groin area, then used another wipe to cleanse the base of Resident #6's penis, then used another wipe to cleanse the head of Resident #6's penis, then used another wipe to cleanse Resident #6's urinary catheter. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C put her soiled gloved hands on Resident #6's arm and thigh to assist Resident #6 to turn to his right side. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C then cleansed Resident #6's left buttocks with a wipe, then used another wipe to cleanse Resident #6's right buttocks, then used another wipe to cleanse between Resident #6's buttocks. CNA Trainee C removed her soiled gloves, did not perform hand hygiene and put on a new pair of gloves. CNA Trainee C picked up a clean adult brief and disposable drape sheet, which she positioned under Resident #6. Then CNA Trainee C touched Resident #6's arm and thigh to assist Resident #6 to turn onto his left side and better position the adult brief and disposable drape sheet. <BR/>During an interview on 5/31/23 at 2:15 p.m., CNA Trainee C stated she was still in CNA School and last received hand hygiene education at her school. When asked when should she perform hand hygiene, CNA Trainee C stated hand hygiene should be performed whenever she entered and exited a resident room whenever she touched something, whenever she changed a resident's adult brief, when she fed a resident. CNA Trainee C confirmed hand hygiene should be done between glove changes. CNA C stated she should have changed gloves after touching Resident #6's groin area. <BR/>During an interview on 6/1/23 at 9:52 a.m., when asked if the facility had a quality assurance process ensuring hand hygiene was done appropriately during incontinent care, the DON stated through the day, what should happen is that we should be observing random observations when we see the staff coming and doing care. We should be observing for proper technique. When asked what sort of negative effects could occur to the residents if a staff member wasn't performing hand hygiene appropriately during incontinent care, the DON stated potential for infection.<BR/>Record review of CNA Trainee C's Nursing Competency for Perineal Care, dated 12/29/22, revealed the following: places resident on side and cleans perineum and rectal area: front to back . removes gloves, discards properly, and washes hands. CNA Trainee C was deemed competent in perineal care.<BR/>Record review of a facility policy titled, Hand Hygiene, dated August 2015, revealed the following verbiage: use alcohol-based hand rub . or, alternative, soap . and water for the following situations: b. before and after direct contact with residents . h. before moving from a contaminated body site to a clean body site during resident care; .m. after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control in that: <BR/>CNA Trainee C did not perform hand hygiene after cleansing Resident #6's genitalia and before touching Resident #6's skin. CNA Trainee C did not perform hand hygiene between glove changes.<BR/>This deficient practice could affect all residents and place them at risk for infection.<BR/>The findings were:<BR/>Record review of Resident #6's face sheet, dated 6/1/23, revealed Resident #6 was admitted to the facility on [DATE] diagnoses of mild protein-calorie malnutrition, encephalopathy [a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke], unspecified, hemiplegia [paralysis of one side of the body] and hemiparesis [muscle weakness of one side of the body] following cerebral infarction [a disruption in the brain's blood flow] affecting left dominant side, dysphagia [difficulty swallowing following cerebral infarction, and pneumonia [a lung infection] due to Escherichia coli [a bacteria that normally lives in the intestines of healthy people and animals].<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 12, signifying moderate cognitive impairment.<BR/>Observation on 5/31/23 at 2:09 p.m. revealed CNA Trainee C entered Resident #6's room, performed hand hygiene, and put on gloves. CNA Trainee C undid Resident #6's adult brief and cleansed Resident #6's right groin area with a wipe, then used another wipe to cleanse the left groin area, then used another wipe to cleanse the base of Resident #6's penis, then used another wipe to cleanse the head of Resident #6's penis, then used another wipe to cleanse Resident #6's urinary catheter. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C put her soiled gloved hands on Resident #6's arm and thigh to assist Resident #6 to turn to his right side. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C then cleansed Resident #6's left buttocks with a wipe, then used another wipe to cleanse Resident #6's right buttocks, then used another wipe to cleanse between Resident #6's buttocks. CNA Trainee C removed her soiled gloves, did not perform hand hygiene and put on a new pair of gloves. CNA Trainee C picked up a clean adult brief and disposable drape sheet, which she positioned under Resident #6. Then CNA Trainee C touched Resident #6's arm and thigh to assist Resident #6 to turn onto his left side and better position the adult brief and disposable drape sheet. <BR/>During an interview on 5/31/23 at 2:15 p.m., CNA Trainee C stated she was still in CNA School and last received hand hygiene education at her school. When asked when should she perform hand hygiene, CNA Trainee C stated hand hygiene should be performed whenever she entered and exited a resident room whenever she touched something, whenever she changed a resident's adult brief, when she fed a resident. CNA Trainee C confirmed hand hygiene should be done between glove changes. CNA C stated she should have changed gloves after touching Resident #6's groin area. <BR/>During an interview on 6/1/23 at 9:52 a.m., when asked if the facility had a quality assurance process ensuring hand hygiene was done appropriately during incontinent care, the DON stated through the day, what should happen is that we should be observing random observations when we see the staff coming and doing care. We should be observing for proper technique. When asked what sort of negative effects could occur to the residents if a staff member wasn't performing hand hygiene appropriately during incontinent care, the DON stated potential for infection.<BR/>Record review of CNA Trainee C's Nursing Competency for Perineal Care, dated 12/29/22, revealed the following: places resident on side and cleans perineum and rectal area: front to back . removes gloves, discards properly, and washes hands. CNA Trainee C was deemed competent in perineal care.<BR/>Record review of a facility policy titled, Hand Hygiene, dated August 2015, revealed the following verbiage: use alcohol-based hand rub . or, alternative, soap . and water for the following situations: b. before and after direct contact with residents . h. before moving from a contaminated body site to a clean body site during resident care; .m. after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in th comprehenvsive assessment, for 1 of 3 Residents (Resident #1 reviewed for care plans, in that: <BR/>The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address hospice information, details of hospice care provided and coordination of services.<BR/>This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMs score of 12, which indicated a moderate cognitive impairment and was on hospice care. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to diagnoses of severe protein calorie malnutrition with interventions which included: <BR/>- Coordinate care with hospice care. The plan of care did not specify what care was coordinated or how it was provided to the resident. <BR/>- Hospice Care program as ordered. The plan of care did not specify how the plan was applied to the resident or what services were provided. <BR/>- Monitor for complaints of pain or discomfort and provide interventions as orders. The plan of care did not specify the interventions or how they should be applied to Resident #1. <BR/>The plan of care did not list the name, phone number, or contact information of the hospice agency used for Resident #1.<BR/>During an interview on [DATE] at 1:11 p.m., LVN A stated Resident #1 received hospice care and expired last week (date unknown). LVN A stated a hospice aide would come and bathe Resident #1 and a hospice RN came to visit Resident #1. LVN A stated she did not know how often they came to see the resident. LVN A stated Resident #1 had medications ordered for pain by hospice. <BR/>Attempted interview with Resident #1's hospice company on [DATE] at 2:42 p.m. was unsuccessful. <BR/>During an interview on [DATE] at 5:23 p.m., the Corporate MDS Nurse stated the facility had not had a MDS Coordinator for approximately 3 weeks. The Corporate MDS Nurse stated Resident #1's care plan for hospice services was missing critical information for hospice care. The Corporate MDS Nurse stated the care plan should have what specific hospice program was used, how often the facility should call hospice and what services were provided. The Corporate MDS Nurse stated the hospice care plan should have hospice specific information. The Corporate MDS Nurse stated Resident #1's care plan was initiated on [DATE] and was based on the MDS assessment. The Corporate MDS Nurse stated care plans should be updated for change of condition. The Corporate MDS Nurse stated the MDS Coordinator, DON or charge nurses could update the care plan. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated the care plans for hospice should include the hospice and diagnoses, how the facility was providing care to the resident. The DON stated the hospice care plan should also include why the resident was on hospice, expectations from hospice, when the facility was supposed to call hospice, contact information for hospice. The DON stated every hospice was different. The DON stated some hospices sent aides, some did not. The DON stated the hospice care plan should include coordination of care information. The DON stated the MDS person was responsible for updating care plan and the facility currently did not have a MDS Coordinator. The DON stated a corporate person who knew the facility came several times a week to do care plans. The DON stated it was important to have an accurate care plan so the facility knew what type of care they needed to provide to the resident. <BR/>During an interview on [DATE] at 6:15 p.m., the Administrator stated the MDS Coordinator was responsible for resident care plans. The Administrator stated she had oversight of MDS.<BR/>Record review of a facility policy, titled Care Plans, Comprehensive Person-Centered, dated [DATE] revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being j. Reflect the resident's expressed wishes regarding care and treatment goals l. Identify the professional services that are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 (Resident #1 and #3) reviewed for hospice services, in that:<BR/>1. The facility failed to obtain Resident #1's hospice Plan of Care, Hospice Consent and Election Form and Physician Certification of Terminal Illness from the hospice company. <BR/>2. The facility failed to obtain Resident #3's hospice Plan of Care, Hospice Consent and Election Form and Physician Certification of Terminal Illness from the hospice company. <BR/>These failures could place residents at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings were:<BR/>1. Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: anemia, severe protein-calorie malnutrition (unintentional weight loss), metabolic encephalopathy (abnormalities that affect brain function), and altered mental status. The face sheet indicated Resident #1 was discharged from the facility on [DATE] because she had expired. <BR/>Record review of Resident #1's [DATE] order summary revealed a physician order dated [DATE] to admitted to hospice services with a primary diagnoses of severe protein-calorie malnutrition<BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed the resident received hospice care in the facility. <BR/>Record review of Resident #1's Care Plan, undated, revealed Resident #1 had a plan of care for hospice care related to a diagnosis of severe protein calorie malnutrition with interventions which included: <BR/>- Coordinate care with hospice care. <BR/>During on observation on [DATE] at 1:18 p.m. revealed resident hospice books were located on a bookshelf at the nurses station. Resident #1's hospice book was empty of all personalized information and did not contain a hospice Plan of Care, Hospice Consent and Election Form and Physician Certification of Terminal Illness. <BR/>2. Record review of Resident #3's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses which included: vitamin B12 deficiency anemia, unspecified dementia, and adult failure to thrive. <BR/>Record review of Resident #3's [DATE] order summary revealed a physician order dated [DATE] to admit to hospice under routine level of care for Alzheimer's disease.<BR/>Record review of Resident #3's admission MDS, dated [DATE],3 revealed the resident received hospice care in the facility. <BR/>Record review of Resident #3's Care Plan, undated, revealed the resident was on hospice care for routine level of care with diagnoses of Alzheimer's disease with interventions which included coordinate care with hospice. <BR/>During on observation on [DATE] at 1:18 p.m. revealed resident hospice books were located on a bookshelf at the nurses station. Resident #3's hospice book was empty of all personalized information and did not contain a hospice Plan of Care, Hospice Consent and Election Form and Physician Certification of Terminal Illness. <BR/>During an interview on [DATE] at 1:11 p.m. LVN A stated resident hospice records were kept in the hospice books at the nurses station. LVN A stated Resident #1 and Resident #3's books did not have any information about the resident's in the books. LVN A stated she though the patient, name and demographics, family and diseases and things about the patient were kept in the book. LVN A stated things the facility did not have in their system. LVN A stated she did not know specifically what went into the books. <BR/>Attempted phone interview on [DATE] at 2:42 p.m. with Resident #1's hospice company was unsuccessful.<BR/>Attempted phone interview on [DATE] at 2:42 p.m. with Resident #3's hospice company was unsuccessful.<BR/>During an interview on [DATE] at 5:08 p.m. with the DON and Administrator, the DON stated that both Resident #1's and Resident #3's hospice books were empty. The Administrator stated she called both hospice companies about the missing hospice documents. The Administrator stated both hospice companies stated the required hospice documents were electronic and only provided to the facility upon request. <BR/>During an interview on [DATE] at 5:10 p.m., the Administrator stated she reviewed Residents #1's and #3's electronic medical record and the hospice documents had not been uploaded into the medical record. <BR/>During an interview on [DATE] at 6:03 p.m., the DON stated the facility should have hospice coordination of care information. The DON stated it was important because it indicated what type of care was provided to the resident. <BR/>During an interview on [DATE] at 6:15 p.m., the Administrator stated the DON and Administrator together were responsible for hospice oversight. <BR/>Record review of a facility policy, titled Hospice Program dated [DATE] revealed: 12. Our facility has designated (left blank) to coordinate care provided to the resident by our facility staff and hospice staff. He or she is responsible for the following d. Obtaining the following information from hospice: 1. the most recent hospice plan of care specific to each resident 2. Hospice election form 3. Physician eradication and recertification of terminal illness specific to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 8 residents (Resident #8) reviewed for notifying the LTC Ombudsman of the residents' discharge. <BR/>Resident #8 was discharged on 12/2/2024 without a notice to the LTC state ombudsman.<BR/>This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman. <BR/> The findings included:<BR/>A record review of Resident #8's admission record dated 6/19/2025 revealed an admission date of 9/5/2024 with diagnoses which included Guillain-Barre disease (a condition in which the body's immune system attacks the nerves. It can cause weakness, numbness, or paralysis), respiratory failure, and a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea, to facilitate respirations).<BR/>A record review of Resident #8's discharge MDS assessment revealed Resident #8 was a [AGE] year-old male admitted for LTC and discharged , for elevated care at a hospital, without an expectation for a return to the facility.<BR/>A record review of Resident #8's medical record revealed no evidence of a discharge notice to the state ombudsman. <BR/>During an interview on 6/17/2025 at 3:19 PM the state Ombudsman stated she had no evidence the facility had notified her of Resident #8's discharge. The Ombudsman stated she visited the facility often and had had few notices from the facility. <BR/>During an interview on 6/19/2025 at 3:45 PM the SW stated she has been the facility's SW since March 2025 and has been directed by the Administrator to not coordinate with the ombudsman. The SW stated she had no evidence for a report to the state Ombudsman for Resident #8's discharge. The SW stated a record review of Resident #8's medical record revealed Resident #8's representative was dissatisfied with his health status and wished to discharge Resident #8 as soon as possible to the hospital. The SW stated the IDT cooperated for a safe discharge. The resident chose a hospital out of town. <BR/>During an interview on 6/19/2025 at 4:04 the DON stated she was not aware of any reports for discharges of residents to the state ombudsman. <BR/>During an interview on 6/19/2025 at 4:20 PM the Administrator stated he was not the administrator in December 2024 when Resident #8 was discharged and was unaware of the rule to notify the state ombudsman of any resident discharges. The Administrator stated a review of Resident #8's records could not evidence a notice to the state ombudsman for Resident #8's discharge.<BR/>A record review of the facility's Transfer or Discharge, Resident-Initiated Policy Statement dated October 2022, revealed, Residents may initiate a transfer or discharge from the facility. Policy Interpretation and Implementation: . 3. Resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility . Required Notices: 1. For resident-initiated transfers or discharges, sending a copy of the resident's notice of intent to leave the facility to the ombudsman is not required.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 4 medication carts reviewed for security and control, in that:<BR/>1. LVN E left the 100-hall medication cart unattended, unsupervised, and unlocked.<BR/>2. RT K left the 200-hall respiratory therapy medication cart unattended, unsupervised, and unlocked. <BR/>These failures could place residents at risk of misappropriation of property, not receiving the therapeutic effects of medications, and or adverse effects of medications. <BR/>The findings included: <BR/>During an observation and interview on 6/17/2025 at 12:34 PM revealed the medication cart for the 100-hall was unattended, unsupervised, and unlocked while parked on the hall, as evidenced by the protruding unlocked mechanism. The cart was observed for 10 minutes while residents and CNAs ambulated in the hall. Continued observation revealed the ADON approached the medication cart and locked the cart. The ADON stated the cart was assigned to a nurse, but she was unaware of the nurse's name. The ADON stated she was also unaware of the nurse's whereabouts. The ADON stated the medication cart had medications, to include narcotics, stored within. The ADON stated the expectation was for medication carts to be locked when not attended. <BR/>During an observation and interview on 6/17/2025 at 1:09 PM revealed the 200-hall respiratory therapy medication cart was unattended, unsupervised, and unlocked while parked on the 200-hall, as evidenced by the protruding unlocked mechanism. Continued observation revealed CNAs and residents ambulated by the cart. After 5 minutes of observations CNA I stated the cart belonged to RT K and pointed him out by the nurse's station. RT K was informed of his unattended and unsupervised medication cart to which he stated, I was in a resident's room providing care . I could not see my cart while I was in the room. <BR/>During an interview on 6/17/2025 at 1:20 PM the ADON stated she learned the 100-hall medication cart was assigned to LVN E. <BR/>During an interview on 6/17/2025 at 1:50 PM LVN E stated she left the medication cart unlocked due to human error.<BR/>During an interview on 6/20/2025 at 12:28 PM the DON stated the expectation was for all medication carts to be locked when not attended by nursing staff and the risk to residents could be not receiving the therapeutic effects of their medications. <BR/>A record review of the facility's Security of Medication Cart policy dated April 2007 revealed, Policy heading: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: . <BR/>3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room.<BR/>4. Medication carts must be securely locked at all times when out of the nurse's view.<BR/>5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 4 medication carts reviewed for security and control, in that:<BR/>1. LVN E left the 100-hall medication cart unattended, unsupervised, and unlocked.<BR/>2. RT K left the 200-hall respiratory therapy medication cart unattended, unsupervised, and unlocked. <BR/>These failures could place residents at risk of misappropriation of property, not receiving the therapeutic effects of medications, and or adverse effects of medications. <BR/>The findings included: <BR/>During an observation and interview on 6/17/2025 at 12:34 PM revealed the medication cart for the 100-hall was unattended, unsupervised, and unlocked while parked on the hall, as evidenced by the protruding unlocked mechanism. The cart was observed for 10 minutes while residents and CNAs ambulated in the hall. Continued observation revealed the ADON approached the medication cart and locked the cart. The ADON stated the cart was assigned to a nurse, but she was unaware of the nurse's name. The ADON stated she was also unaware of the nurse's whereabouts. The ADON stated the medication cart had medications, to include narcotics, stored within. The ADON stated the expectation was for medication carts to be locked when not attended. <BR/>During an observation and interview on 6/17/2025 at 1:09 PM revealed the 200-hall respiratory therapy medication cart was unattended, unsupervised, and unlocked while parked on the 200-hall, as evidenced by the protruding unlocked mechanism. Continued observation revealed CNAs and residents ambulated by the cart. After 5 minutes of observations CNA I stated the cart belonged to RT K and pointed him out by the nurse's station. RT K was informed of his unattended and unsupervised medication cart to which he stated, I was in a resident's room providing care . I could not see my cart while I was in the room. <BR/>During an interview on 6/17/2025 at 1:20 PM the ADON stated she learned the 100-hall medication cart was assigned to LVN E. <BR/>During an interview on 6/17/2025 at 1:50 PM LVN E stated she left the medication cart unlocked due to human error.<BR/>During an interview on 6/20/2025 at 12:28 PM the DON stated the expectation was for all medication carts to be locked when not attended by nursing staff and the risk to residents could be not receiving the therapeutic effects of their medications. <BR/>A record review of the facility's Security of Medication Cart policy dated April 2007 revealed, Policy heading: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: . <BR/>3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room.<BR/>4. Medication carts must be securely locked at all times when out of the nurse's view.<BR/>5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control in that: <BR/>CNA Trainee C did not perform hand hygiene after cleansing Resident #6's genitalia and before touching Resident #6's skin. CNA Trainee C did not perform hand hygiene between glove changes.<BR/>This deficient practice could affect all residents and place them at risk for infection.<BR/>The findings were:<BR/>Record review of Resident #6's face sheet, dated 6/1/23, revealed Resident #6 was admitted to the facility on [DATE] diagnoses of mild protein-calorie malnutrition, encephalopathy [a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke], unspecified, hemiplegia [paralysis of one side of the body] and hemiparesis [muscle weakness of one side of the body] following cerebral infarction [a disruption in the brain's blood flow] affecting left dominant side, dysphagia [difficulty swallowing following cerebral infarction, and pneumonia [a lung infection] due to Escherichia coli [a bacteria that normally lives in the intestines of healthy people and animals].<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 12, signifying moderate cognitive impairment.<BR/>Observation on 5/31/23 at 2:09 p.m. revealed CNA Trainee C entered Resident #6's room, performed hand hygiene, and put on gloves. CNA Trainee C undid Resident #6's adult brief and cleansed Resident #6's right groin area with a wipe, then used another wipe to cleanse the left groin area, then used another wipe to cleanse the base of Resident #6's penis, then used another wipe to cleanse the head of Resident #6's penis, then used another wipe to cleanse Resident #6's urinary catheter. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C put her soiled gloved hands on Resident #6's arm and thigh to assist Resident #6 to turn to his right side. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C then cleansed Resident #6's left buttocks with a wipe, then used another wipe to cleanse Resident #6's right buttocks, then used another wipe to cleanse between Resident #6's buttocks. CNA Trainee C removed her soiled gloves, did not perform hand hygiene and put on a new pair of gloves. CNA Trainee C picked up a clean adult brief and disposable drape sheet, which she positioned under Resident #6. Then CNA Trainee C touched Resident #6's arm and thigh to assist Resident #6 to turn onto his left side and better position the adult brief and disposable drape sheet. <BR/>During an interview on 5/31/23 at 2:15 p.m., CNA Trainee C stated she was still in CNA School and last received hand hygiene education at her school. When asked when should she perform hand hygiene, CNA Trainee C stated hand hygiene should be performed whenever she entered and exited a resident room whenever she touched something, whenever she changed a resident's adult brief, when she fed a resident. CNA Trainee C confirmed hand hygiene should be done between glove changes. CNA C stated she should have changed gloves after touching Resident #6's groin area. <BR/>During an interview on 6/1/23 at 9:52 a.m., when asked if the facility had a quality assurance process ensuring hand hygiene was done appropriately during incontinent care, the DON stated through the day, what should happen is that we should be observing random observations when we see the staff coming and doing care. We should be observing for proper technique. When asked what sort of negative effects could occur to the residents if a staff member wasn't performing hand hygiene appropriately during incontinent care, the DON stated potential for infection.<BR/>Record review of CNA Trainee C's Nursing Competency for Perineal Care, dated 12/29/22, revealed the following: places resident on side and cleans perineum and rectal area: front to back . removes gloves, discards properly, and washes hands. CNA Trainee C was deemed competent in perineal care.<BR/>Record review of a facility policy titled, Hand Hygiene, dated August 2015, revealed the following verbiage: use alcohol-based hand rub . or, alternative, soap . and water for the following situations: b. before and after direct contact with residents . h. before moving from a contaminated body site to a clean body site during resident care; .m. after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control in that: <BR/>CNA Trainee C did not perform hand hygiene after cleansing Resident #6's genitalia and before touching Resident #6's skin. CNA Trainee C did not perform hand hygiene between glove changes.<BR/>This deficient practice could affect all residents and place them at risk for infection.<BR/>The findings were:<BR/>Record review of Resident #6's face sheet, dated 6/1/23, revealed Resident #6 was admitted to the facility on [DATE] diagnoses of mild protein-calorie malnutrition, encephalopathy [a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke], unspecified, hemiplegia [paralysis of one side of the body] and hemiparesis [muscle weakness of one side of the body] following cerebral infarction [a disruption in the brain's blood flow] affecting left dominant side, dysphagia [difficulty swallowing following cerebral infarction, and pneumonia [a lung infection] due to Escherichia coli [a bacteria that normally lives in the intestines of healthy people and animals].<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 12, signifying moderate cognitive impairment.<BR/>Observation on 5/31/23 at 2:09 p.m. revealed CNA Trainee C entered Resident #6's room, performed hand hygiene, and put on gloves. CNA Trainee C undid Resident #6's adult brief and cleansed Resident #6's right groin area with a wipe, then used another wipe to cleanse the left groin area, then used another wipe to cleanse the base of Resident #6's penis, then used another wipe to cleanse the head of Resident #6's penis, then used another wipe to cleanse Resident #6's urinary catheter. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C put her soiled gloved hands on Resident #6's arm and thigh to assist Resident #6 to turn to his right side. CNA Trainee C did not change her soiled gloves and did not perform hand hygiene. CNA Trainee C then cleansed Resident #6's left buttocks with a wipe, then used another wipe to cleanse Resident #6's right buttocks, then used another wipe to cleanse between Resident #6's buttocks. CNA Trainee C removed her soiled gloves, did not perform hand hygiene and put on a new pair of gloves. CNA Trainee C picked up a clean adult brief and disposable drape sheet, which she positioned under Resident #6. Then CNA Trainee C touched Resident #6's arm and thigh to assist Resident #6 to turn onto his left side and better position the adult brief and disposable drape sheet. <BR/>During an interview on 5/31/23 at 2:15 p.m., CNA Trainee C stated she was still in CNA School and last received hand hygiene education at her school. When asked when should she perform hand hygiene, CNA Trainee C stated hand hygiene should be performed whenever she entered and exited a resident room whenever she touched something, whenever she changed a resident's adult brief, when she fed a resident. CNA Trainee C confirmed hand hygiene should be done between glove changes. CNA C stated she should have changed gloves after touching Resident #6's groin area. <BR/>During an interview on 6/1/23 at 9:52 a.m., when asked if the facility had a quality assurance process ensuring hand hygiene was done appropriately during incontinent care, the DON stated through the day, what should happen is that we should be observing random observations when we see the staff coming and doing care. We should be observing for proper technique. When asked what sort of negative effects could occur to the residents if a staff member wasn't performing hand hygiene appropriately during incontinent care, the DON stated potential for infection.<BR/>Record review of CNA Trainee C's Nursing Competency for Perineal Care, dated 12/29/22, revealed the following: places resident on side and cleans perineum and rectal area: front to back . removes gloves, discards properly, and washes hands. CNA Trainee C was deemed competent in perineal care.<BR/>Record review of a facility policy titled, Hand Hygiene, dated August 2015, revealed the following verbiage: use alcohol-based hand rub . or, alternative, soap . and water for the following situations: b. before and after direct contact with residents . h. before moving from a contaminated body site to a clean body site during resident care; .m. after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Resident #25) for care plan revisions, in that:<BR/>The facility failed to ensure bed rails were removed from Resident #25's care plan.<BR/>This failure could place residents at risk of receiving inappropriate care.<BR/>The findings include:<BR/>Record review of Resident #25's face sheet dated 09/22/2023 revealed an initial admission date of 03/21/2019 with a recent admission of 04/20/2021 and diagnoses which included major depressive disorder, generalized anxiety disorder, low back pain, and muscle weakness.<BR/>Record review of Resident #25's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 04, which indicated severe cognitive impairment. Further review of the assessment indicated Resident #25 had a bed rail; coded as (1) used less than daily.<BR/>Record review of Resident #25's Care Plan with last review completed on 07/29/2023 revealed a focus [Resident] may have &frac14; side rails x 2 for assistance with turning/repositioning and safety. Interventions included Assess on an ongoing basis for need for side rail use for bed mobility and safety. Further review revealed a second focus area I have &frac14; siderails (x2) up for: enabler for positioning while in bed, safety precautions: due to poor/decreased body control. <BR/>Review of Resident #25's Order Summary Report, Active Orders as of 09/20/2023, revealed an order, 1/4 SIDERAIL AS ENABLER X 2, dated 11/01/2021 with no end date. <BR/>During an observation and interview with LVN G on 09/20/2023 at 11:14 a.m., LVN G confirmed Resident #25's bed did not have rails. LVN G added that she could not recall resident's bed ever having rails.<BR/>In an interview with the MDS Coordinator on 09/22/2023 at 8:25 p.m., the MDS Coordinator stated, absolutely that would need to be revised. The MDS Coordinator added revisions were an IDT approach and with several people potentially involved in removing bed rails, if the communication doesn't occur, I can understand how that could be overlooked and the side rails not removed from the care plan. <BR/>In an interview with the DON on 09/22/2023 at 8:45 p.m., the DON revealed the revisions are completed during IDT meetings by nursing staff as well as during morning meeting when any significant changes are reported. The DON added that revisions were to be made as changes occurred and were the responsibility of each discipline as the change related to their area. <BR/>Record review of the facility's policy titled, Care Plans - Comprehensive, revised September 2010, revealed, 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 residents (Residents #3 and #43) reviewed for privacy, in that:<BR/>1. MA A and CNA B did not completely close Resident #3's privacy curtain while providing incontinent care.<BR/>2. CNA C and LVN D not completely close Resident #43's privacy curtain while providing catheter care<BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings include:<BR/>1. Record review of Resident #3's face sheet, dated 08/05/2022, revealed an admission date of 04/25/2022, with diagnoses which included: Amyotrophic lateral sclerosis (progressive nervous system disease causing loss of muscle control), Chronic Cholecystitis (inflammation of the gallbladder), and Chronic kidney disease (gradual loss of kidney function).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed the resident had a BIMS score of 9, which indicated moderate cognitive impairment Resident #3 required total care and, was always incontinent of bowel and bladder. <BR/>Observation on 08/04/2022 at 1:33 p.m. revealed MA A and CNA B provided incontinent care for Resident #3, and left the end of the resident's bed exposed which could be seen if someone had come in the room and by his roommate who was in the room. Further observation revealed Resident #3's genital area was exposed during care. <BR/>During an interview with MA A and CNA B on 08/04/2022 at 1:50 p.m., they confirmed the privacy curtain was not closed while they provided care for Resident #3. MA A stated the privacy curtain should have been completely closed. CNA B stated she did not know the privacy curtain had to be completely closed. <BR/>2. Record review of Resident #43's face sheet, dated 08/05/2022, revealed an admission date of 07/11/2022, with diagnoses which included: Dementia(loss of cognitive functioning), Parkinson's (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Functional quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso), Sepsis (body's response to infection causes injury to its own tissues and organs), Tracheostomy(incision in the windpipe made to relieve an obstruction to breathing)<BR/>Record review of Resident #43's admission MDS, dated [DATE], revealed the resident had a BIMS score of 0, which indicated severe cognitive impairment Resident #43 required total care, was always incontinent of bowel and, had an indwelling catheter. <BR/>Observation on 08/04/2022 at 2:10 p.m. revealed CNA C and LVN D provided catheter care for Resident #43, and left the end of the resident's bed exposed which could be seen if someone had come in the room and by her roommate who was in the room. Further review revealed Resident #43's genital area was exposed during care. <BR/>During an interview with CNA C and LVN D on 08/04/2022 at 2:35 p.m., they confirmed the privacy curtain was not closed while they provided care for Resident #43. CNA C stated the privacy curtain should have been completely closed. CNA C stated they had received training about residents rights, including the right to privacy. <BR/>During an interview with the DON on 08/04/2022 at 2:45 p.m., the DON stated the privacy curtain needed to be closed all the way during care. She stated they had provided training to the staff about privacy during care as a resident right. The DON added it was important for the dignity of the residents.<BR/>Record review of the facility's policy titled, Confidentiality of information and personal privacy, dated October 2017, revealed, The facility will strive to protect the resident's privacy regarding his or her [ ] medical treatment, [ .] personal care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 residents (Residents #3 and #43) reviewed for privacy, in that:<BR/>1. MA A and CNA B did not completely close Resident #3's privacy curtain while providing incontinent care.<BR/>2. CNA C and LVN D not completely close Resident #43's privacy curtain while providing catheter care<BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings include:<BR/>1. Record review of Resident #3's face sheet, dated 08/05/2022, revealed an admission date of 04/25/2022, with diagnoses which included: Amyotrophic lateral sclerosis (progressive nervous system disease causing loss of muscle control), Chronic Cholecystitis (inflammation of the gallbladder), and Chronic kidney disease (gradual loss of kidney function).<BR/>Record review of Resident #3's admission MDS, dated [DATE], revealed the resident had a BIMS score of 9, which indicated moderate cognitive impairment Resident #3 required total care and, was always incontinent of bowel and bladder. <BR/>Observation on 08/04/2022 at 1:33 p.m. revealed MA A and CNA B provided incontinent care for Resident #3, and left the end of the resident's bed exposed which could be seen if someone had come in the room and by his roommate who was in the room. Further observation revealed Resident #3's genital area was exposed during care. <BR/>During an interview with MA A and CNA B on 08/04/2022 at 1:50 p.m., they confirmed the privacy curtain was not closed while they provided care for Resident #3. MA A stated the privacy curtain should have been completely closed. CNA B stated she did not know the privacy curtain had to be completely closed. <BR/>2. Record review of Resident #43's face sheet, dated 08/05/2022, revealed an admission date of 07/11/2022, with diagnoses which included: Dementia(loss of cognitive functioning), Parkinson's (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Functional quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso), Sepsis (body's response to infection causes injury to its own tissues and organs), Tracheostomy(incision in the windpipe made to relieve an obstruction to breathing)<BR/>Record review of Resident #43's admission MDS, dated [DATE], revealed the resident had a BIMS score of 0, which indicated severe cognitive impairment Resident #43 required total care, was always incontinent of bowel and, had an indwelling catheter. <BR/>Observation on 08/04/2022 at 2:10 p.m. revealed CNA C and LVN D provided catheter care for Resident #43, and left the end of the resident's bed exposed which could be seen if someone had come in the room and by her roommate who was in the room. Further review revealed Resident #43's genital area was exposed during care. <BR/>During an interview with CNA C and LVN D on 08/04/2022 at 2:35 p.m., they confirmed the privacy curtain was not closed while they provided care for Resident #43. CNA C stated the privacy curtain should have been completely closed. CNA C stated they had received training about residents rights, including the right to privacy. <BR/>During an interview with the DON on 08/04/2022 at 2:45 p.m., the DON stated the privacy curtain needed to be closed all the way during care. She stated they had provided training to the staff about privacy during care as a resident right. The DON added it was important for the dignity of the residents.<BR/>Record review of the facility's policy titled, Confidentiality of information and personal privacy, dated October 2017, revealed, The facility will strive to protect the resident's privacy regarding his or her [ ] medical treatment, [ .] personal care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #48) of 18 residents reviewed, in that: <BR/>Resident #48 displayed signs and symptoms of depression and was not offered mental health services. <BR/>This deficient practice could place residents with mental health concerns at risk of diminished psychosocial well-being. <BR/>The findings were: <BR/>Record review of Resident #48's face sheet, dated 11/06/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Malignant Neoplasm of Overlapping Sites of Right Bronchus and Lung, Type 2 Diabetes Mellitus, and Unspecified Dementia. <BR/>Record review of Resident #48's quarterly MDS, dated [DATE], revealed a BIMS score of 9 which suggested moderate cognitive impairment. Further review revealed the resident responded affirmatively when asked if felt down, depressed, or hopeless.<BR/>Record review of Resident #48's care plan, undated, revealed, adjustment: lifestyle change resulting from admission .episodes of insomnia .risk for excessive weakness, tiredness, weight loss, and pain [related to] diagnosis of lung cancer. I am receiving chemotherapy as ordered by my oncologist.<BR/>Record review of Resident #48's clinical record revealed a progress note dated 04/09/2024, [Resident #48] reports episodes of depression, tiredness and poor concentration . <BR/>Further review revealed a progress note dated 05/07/2024, [Resident #48] reports episodes of depression, poor sleep, tiredness and poor concentration . feeling isolated because he would prefer to be home. <BR/>Further review revealed a progress note dated 07/09/2024, [Resident #48] reports episodes of depression, poor sleep, tiredness and poor concentration . He reports mild depression due to diagnosis of cancer. [Resident #48] spoke of feeling lonesome . <BR/>Further review revealed a progress note dated 10/08/2024, [Resident #48] reports infrequent episodes of depression and feelings of isolation. [Resident #48 stated] 'I have no place to go. I feel like a prisoner here.<BR/>During an interview with Resident #48 on 11/03/2024 at 9:42 a.m., Resident #48 stated he did not know why he resided at the facility, stated I am lonely, and I feel isolated and stated he felt like a prisoner. <BR/>Record review of Resident #48's clinical record as of 11/06/2024 revealed no referral to mental health services. <BR/>During an interview with the DON on 11/05/2024 at 2:35 p.m., the DON stated she did not know why Resident #48 had not been referred to mental health services and stated she was surprised it had not been done. The DON confirmed that Resident #48 had expressed feelings of depression and isolation and should have been referred to mental health services for psychosocial care and support. <BR/>During an interview with the [NAME] on 11/05/2024 at 3:39 p.m., the DON stated a referral to mental health services had been initiated for Resident #48. <BR/>Record review of the facility policy, Behavioral Health Services, revised February 2019, revealed, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being .

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse for 1 of 2 dumpsters (dumpster #1) in that: <BR/>Dumpster #1 had multiple filled garbage bags and empty boxes beside it with items visible on the ground and outside the dumpster. <BR/>This deficient practice could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents and expose them germs and diseases carried by vermin and rodents. <BR/>The findings included:<BR/>Observation on 08/23/2023 at 9:07 a.m. revealed Dumpster #1 had approximately 5 open and empty cardboard boxes along with approximately 6 clear industrial trash bags filled with various items, including but not limited to used adult briefs, disposable bed pads, used latex gloves and other unidentifiable paper type items on the ground beside the dumpster and the trash bags. <BR/>Observation on 08/24/2023 at 11:52 a.m. revealed Dumpster #1 had approximately 5 open and empty cardboard boxes along with approximately 6 clear industrial trash bags filled with various items, including but not limited to used adult briefs, disposable bed pads, used latex gloves and other unidentifiable paper type items on the ground beside the dumpster and the trash bags. <BR/>Observation on 08/24/2023 at 12:43 p.m. revealed Dumpster #1 had 3 clear industrial trash bags filled with various items including but not limited to adult briefs, disposable bed pads, used latex gloves and several other used latex gloves on the ground beside the dumpster and outside of the trash bags. <BR/>During an interview and observation of Dumpster #1 with the DM on 08/24/2023 , the DM stated, I am new to the facility the kitchen staff told me they saw you looking at the garbage dumpsters and about the trash they saw outside the dumpster. They said they thought nursing put that trash outside the dumpster, they were unaware that making sure all trash is put inside the dumpster is the responsibility of the kitchen staff. The DM explained she was a DM at a previous facility and was aware All trash should be inside the dumpster with the door closed so that it keeps pests away. The DM further stated, the trash being outside the dumpster did not affect the residents in anyway because they don ' t go down to the dumpster area. <BR/>During an interview with the Administrator on 08/24/2023 at 4:00 p.m., the Administrator stated, All of the trash and garbage should be placed in the dumpster, it should not have been outside of the dumpster. I do not believe it affected the residents. The Administrator stated, I do not have a policy for trash or garbage, but I will look for one. <BR/>Review of the 2017 U.S. Public Health Service, Food Code revealed the following: <BR/>Section 5-501.110 Storing Refuse, Recyclables, and Returnables <BR/>Refuse, recyclables and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. <BR/> No policy for trash or garbage was provided prior to exit.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse for 1 of 2 dumpsters (dumpster #1) in that: <BR/>Dumpster #1 had multiple filled garbage bags and empty boxes beside it with items visible on the ground and outside the dumpster. <BR/>This deficient practice could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents and expose them germs and diseases carried by vermin and rodents. <BR/>The findings included:<BR/>Observation on 08/23/2023 at 9:07 a.m. revealed Dumpster #1 had approximately 5 open and empty cardboard boxes along with approximately 6 clear industrial trash bags filled with various items, including but not limited to used adult briefs, disposable bed pads, used latex gloves and other unidentifiable paper type items on the ground beside the dumpster and the trash bags. <BR/>Observation on 08/24/2023 at 11:52 a.m. revealed Dumpster #1 had approximately 5 open and empty cardboard boxes along with approximately 6 clear industrial trash bags filled with various items, including but not limited to used adult briefs, disposable bed pads, used latex gloves and other unidentifiable paper type items on the ground beside the dumpster and the trash bags. <BR/>Observation on 08/24/2023 at 12:43 p.m. revealed Dumpster #1 had 3 clear industrial trash bags filled with various items including but not limited to adult briefs, disposable bed pads, used latex gloves and several other used latex gloves on the ground beside the dumpster and outside of the trash bags. <BR/>During an interview and observation of Dumpster #1 with the DM on 08/24/2023 , the DM stated, I am new to the facility the kitchen staff told me they saw you looking at the garbage dumpsters and about the trash they saw outside the dumpster. They said they thought nursing put that trash outside the dumpster, they were unaware that making sure all trash is put inside the dumpster is the responsibility of the kitchen staff. The DM explained she was a DM at a previous facility and was aware All trash should be inside the dumpster with the door closed so that it keeps pests away. The DM further stated, the trash being outside the dumpster did not affect the residents in anyway because they don ' t go down to the dumpster area. <BR/>During an interview with the Administrator on 08/24/2023 at 4:00 p.m., the Administrator stated, All of the trash and garbage should be placed in the dumpster, it should not have been outside of the dumpster. I do not believe it affected the residents. The Administrator stated, I do not have a policy for trash or garbage, but I will look for one. <BR/>Review of the 2017 U.S. Public Health Service, Food Code revealed the following: <BR/>Section 5-501.110 Storing Refuse, Recyclables, and Returnables <BR/>Refuse, recyclables and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. <BR/> No policy for trash or garbage was provided prior to exit.