EDGEMERE ESTATES

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #72) of 8 residents reviewed for baseline care plans.<BR/>Resident #72 physician's progress note dated 01/16/2023 indicated that she was being admitted to the facility for pain control, but her baseline care plan did not address pain management. <BR/>This failure could put residents at risk of not receiving pain management.<BR/>Findings include:<BR/>Record review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident had an acute compression fracture at T12 [a broken vertebrae]. She had mostly severe pain, 9-10 on pain scale, constant with slight variation . and was to be admitted to the facility for pain management and physical therapy. <BR/>Record review of Resident #72's nurse progress note dated 01/24/2023 at 12:28 PM documented that the resident had abdominal pain and that the physician had ordered a KUB (X-ray study of urinary and gastrointestinal systems). <BR/>Record review of Resident #72's physician's note dated 01/25/2022 documented that the resident had abdominal pain with nausea which she rated as a 4 out of 10. <BR/>Record review of Resident #72's electronic diagnosis listing accessed on 02/08/2023 documented that she had diagnoses including wedge compression fracture of T11-T12 vertebra [broken vertebrae], subsequent encounter for fracture with routine healing; unspecified displaced fracture of surgical neck of right humerus [broken arm], subsequent encounter for fracture with routine healing; pain, unspecified; and chronic pain due to trauma. <BR/>Record review of Resident #72's Physician's Orders List dated 02/08/2023 documented an order dated 01/23/2023 that she was to receive 50 MG of tramadol (a pain medication) every 8 hours as needed for pain, an order for one gram of diclofenac sodium 1% gel (for pain) was to be applied to the affected area twice a day for pain, and an order dated 01/23/2023 for 5 MG of baclofen (a medicine used for muscle spasms and pain) every 8 hours as needed for pain. <BR/>Record review of Resident #72's care plan on 02/08/2023 at 5:16 PM, documented no care plan to address pain. <BR/>In interview and observation on 02/08/23 at 09:09 AM, Resident #72 was observed sitting in bed holding her lower abdomen and moaning. She was breathing heavily and so was having difficulty speaking. She said that she had lots of pain across her lower abdomen. She said that staff had brought her medicine for pain that morning but that she threw it up when she took the medicine. She said that she had pain even when she slept and that the therapy staff got mad when she could not participate because of her pain. She said that her right arm had been broken, that it had been fixed, but it was broken again, and it caused her pain. <BR/>In an interview on 02/08/2023 at 9:25 AM, NA F said that Resident #72 always complained of pain in her stomach and her right hand. The NA said that she always reported the resident's pain to the nurse. <BR/>In an interview on 02/08/23 at 09:43 AM, LVN G said that she was aware of Resident #72's pain which was chronic due to gall stones. She said the pain was in the resident's flank (between the lower ribs and the top of the hips) and radiated to her hips. The LVN said that the resident received pain medication although she sometimes refused it because of nausea. <BR/>Record review of Resident #72's revised care plan dated 02/09/2023 documented in part multiple changes to the resident's care plan on 02/09/2023 which included the addition of a pain-focused care plan. The care plan for pain documented that she was at risk for pain due to arthritis. Five interventions were listed including that pain medication was to be administered, and she was to be monitored for worsening of pain and the physician was to be notified of changes. All interventions were dated 02/09/2023. <BR/>In an interview on 02/08/2023 at 7:15 PM MDS Nurse C said that at admission the baseline care plan was created by reviewing diagnoses, orders and other information such as resident's COVID-19 status and record of falls. The MDS nurse said she had seven days from admission to complete the baseline care plan. She said that she did not know if Resident #72 had issues with pain control because she was not directly responsible for creating care plans for residents who were receiving skilled services such as resident #72. MDS Nurse C said that currently a nurse from the corporate level was trying to help with the care plans for skilled residents. When asked about changes to Resident #72's care plan dated 02/09/2023 she was not able to say who had made changes to include pain in the care plan. <BR/>Record Review of the facility policy Care Plans - Comprehensive (undated) documented that care plans would incorporate risk factors associated with identified problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for 1 (Resident #3) of 3 residents reviewed for discharges. <BR/>The facility failed to ensure Resident #3 had a safe discharge when he left AMA to his home. <BR/>This failure could place residents at risk of inappropriate transfers and diminished continuity of care. <BR/>Findings included: <BR/>Record review of Resident #3 ' s face sheet dated 02/05/25, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #3 ' s hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. <BR/>Record review of Resident #3 ' s admission MDS dated [DATE], revealed no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Resident #3 was coded for risk of pressure ulcers and unhealed pressure ulcers. Resident #3 was coded for stage 3 pressure ulcer. Resident #3 was to have pressure reducing devices for chair, for bed, turning/repositioning program, pressure/ulcer/injury care, applications of ointments/medications, and hydration interventions. Resident #3 was occasionally urinary incontinent and frequently bowel incontinent. <BR/>Record review of Resident #3 ' s Skin Issues Assessment generated by the Wound Care Nurse dated 01/30/25, revealed, left gluteus/ buttock pressure ulcer/ injury stage 3, 9 cm by 3.5 cm by 0.2 cm. <BR/>Record review of Resident #3 ' s Order Recap dated 01/30/25, revealed, left buttock stage 3 pressure wound. Cleanse with NS and pat dry with a 4 by 4-inch gauze. Apply collagen powder to the wound bed granulated tissue. Cover with foam border dressing. One time a day related to Pressure Ulcer of Other site, Unstageable. Order dated 01/30/25, revealed nursing Intervention: Turn and reposition every hour every shift. <BR/>Record review of Resident #3 ' s Grievance/Complaint Report dated 02/03/25, revealed, that the admission Coordinator started the grievance/complaint report and then was passed to the Social Worker to follow up with. It was noted that No wound care had been given on bed sores, the family was having to conduct incontinence care, and medications were not being given. Review of the Grievance/Complaint Report revealed, there was no follow-up mentioned on the facility follow up or the resolution of what the facility was going to do with wound care not being provided for Resident #3, incontinence care, and medications not being given. <BR/>During an interview on 02/05/25 at 1:50 PM, with LVN B, she stated she came in Monday morning (02/03/25) and was informed that Resident #3 wanted to be transferred to another facility. LVN B stated the family member had informed her that Resident #3 had a bad weekend. LVN B stated she was not informed by the family member nor Resident #3 on what the concerns were. LVN B stated on 02/04/25 that the family member went to the nurse ' s station and requested the AMA form and signed out Resident #3. LVN B stated she helped put Resident #3 in the car and off he went. LVN B stated she informed the NP who responded with what happened. <BR/>During an interview on 2/5/25 at 4:03 pm, the ADON stated that the Social Worker knew that Resident #3 was going home, but they (nursing department) themselves had not been informed. The ADON stated that during this time, they had been trying to get in contact with the facility where Resident #3 was supposed to be discharged . The ADON stated that APS should have been called due to the home not being a safe discharge option, considering the clinical care Resident #3 required. <BR/>During an interview on 02/05/25 at 4:36 PM, with the Social Worker, she stated that she would need to review the policy to determine whether the facility was required to call and confirm if the resident arrived at the facility or home safely. The Social Worker stated that it did not appear that the policy required such a call. The Social Worker stated that Resident #3 ' s family member had informed them that she was going to take him home. The Social Worker stated that if the resident required skilled services, particularly wound care, it would need to be assessed whether his home was a safe and appropriate environment for him. The SW stated that they would refer this matter to the nursing team. The Social Worker stated that it had been one day since Resident #3 ' s discharge, and they had not yet discussed the situation with the nurse. The SW stated that the reason for not discussing it with the nurse was that they had planned to ask whether the resident ' s wound required consideration for continued care. The SW stated that they were unsure if the wound care nurses were present at the time. The SW stated that a referral to Adult Protective Services (APS) would be made if necessary. The SW stated that they needed to consult with nursing staff to determine if a referral was required. The SW stated that, within the past 24 hours, there had been no discussion to determine whether the home was an appropriate setting for Resident #3 or if APS needed to be contacted. <BR/>During an interview on 2/7/25 at 11:09 am, the NP stated when the resident left AMA, he was initially informed only that he had left. It wasn ' t until later that he was told the reasons behind his departure. The NP stated he should have been notified that Monday (2/3/25) when the facility became aware of issues such as wound care not being completed, medications not being administered, and incontinence care concerns. The NP stated he should have been informed the day the patient left AMA. At that point, they could have spoken with Resident #3, assessed the situation, and potentially found a resolution. The NP stated that waiting to notify him until after the fact limited the options for intervention. The NP stated when a resident leaves AMA, it is ultimately their decision. The NP stated he strongly believed that any resident choosing to leave against medical advice should have the opportunity to speak with their provider before signing the discharge form. The NP stated that conversation could help assess risks and explore alternatives. <BR/>During an interview on 2/10/25 at 11:01 am, the Administrator stated that if a resident left Against Medical Advice (AMA), the decision to call APS would depend on the patient ' s situation. The Administrator stated that APS was contacted, but they did not know the exact date it was done but it had not been completed at the time of AMA. The Administrator stated that concerns about the SW ' s performance required a Performance Enhancement Plan (PEP). The Administrator stated that the concerns regarding the SW were consistent across various situations. <BR/>Record review of the facility ' s Discharging a Resident without a Physician ' s Approval Policy dated 10/22, revealed, A physician ' s order was obtained for discharges, unless a resident or representative was discharging himself or herself against medical advice. <BR/>If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will: discuss with the resident, (and or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that was not equipped to meet his/her needs and attempt to ascertain why the resident was choosing that location. <BR/>Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect was necessary. The referral should be made at the time of discharge. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 3 (Resident #7, Resident #10 and Resident #11 ) of 5 residents reviewed for wounds. <BR/>The facility failed to provide wound care for Resident #7's arterial wound (arterial ulcers, are painful injuries in your skin caused by poor circulation) of the right second toe. <BR/>The facility failed to provide wound care for Resident #10's pressure wound to the right second toe. <BR/>The facility failed to provide wound care for Resident #11's dehiscence wound right forefoot. <BR/>This failure could affect others by placing them at risk of potential medical complications related to wounds. <BR/>Findings included: <BR/>Resident #7<BR/>Record review of Resident #7's face sheet dated 02/06/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #7's hospital history and physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with history of right big toe osteomyelitis (infection of the bone) and having it amputated, heart failure, and myocardial infarction (a condition where blood flow to the heart muscle is blocked, leading to damage or death of heart tissue). <BR/>Record review of Resident #7's quarterly MDS dated [DATE], revealed, no BIMS score was taken to measure the cognition of the resident. Resident #7 was diagnosed with Diabetes Mellitus and Osteomyelitis. Resident #7 was coded for risk of pressure ulcers/injuries. Treatments coded were pressure reducing device for chair, reducing device for bed, and applications of ointments/medications. <BR/>Record review of Resident #7's Order Recap dated 01/08/25, revealed, arterial wound of the right second toe. Cleanse wound with NS or wound cleanser. Pat dry with 4 by 4-inch gauze. Apply betadine (a topical antiseptic that provides infection protection against a variety of germs for minor cuts, scrapes, and burns) to eschar (a dry, black or brown crust of dead tissue that forms on the surface of a burn, ulcer, or other wound) area. Cover with kerlix (a brand of gauze bandage roll used to protect wounds) and secure with cloth tape. One time a day related to other acute osteomyelitis, other site. <BR/>Record review of Resident #7's care plan dated 12/06/24, revealed, presented with arterial wound of the right second toe 1cm by 1 cm by 0.3 cm. Provide wound care per treatment order. <BR/>Record review of Resident #7's Administration Report dated 01/01/25-01/31/25, revealed, wound care was not provided on 01/11/25 and 01/25/25. Review of the Administration Report dated 12/01/24-12/31/24, revealed, wound care was not provided on 12/02/24, 12/03/24, 12/07/24, 12/22/24, 12/27/24, 12/28/24, 12/29/24. <BR/>Resident #10<BR/>Record review of Resident #10's face sheet dated 02/06/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #10's hospital history and physical (was in the facility system) dated 05/24/23, revealed, a [AGE] year-old female (age was updated to reflect 2025) diagnosed with Atherosclerosis (a chronic disease that affects the arteries, causing them to become narrowed and hardened) and hypertension (a condition where the blood pressure in the arteries is persistently elevated above normal levels). <BR/>Record review of Resident #10's quarterly MDS dated [DATE], revealed, a BIMS score of 2 and severely impaired cognition to be able to recall or make daily decisions. Resident #10 was coded for risk of pressure ulcer/injuries. Treatments were pressure reducing device for chair, reducing device for bed, applications of ointments/medications. <BR/>Record review of Resident #10's Order Recap dated 10/30/24, revealed, right second toe wound. Cleanse with NS. Apply collagen/silver sheet. Cover with 4 by 4-inch gauze. Secure with cloth tape one time a day related to abrasion to right lower leg. <BR/>Record review of Resident #10's care plan dated 12/10/24, revealed, an arterial wound of the right second toe 1.2cm by 1.2cm. Measure ulcer on at regular intervals and monitor ulcer for signs of infection. <BR/>Record review of Resident #10's Administration Report dated 12/01/24-12/31/24, revealed, wound care was not provided on 12/02/24, 12/03/24, 12/07/24, 12/08/24, 12/14/24, 12/22/24, 12/27/24, 12/28/24, 12/29/24. Review of the Administration Report dated 01/01/25-01/31/25, revealed, wound care not provided on 01/03/25, 01/11/25, 01/18/25, 01/19/25, 01/25/25. Review of the Administration Report dated 02/01/25-02/28/25, revealed, wound care not provided on 02/01/25. <BR/>Resident #11<BR/>Record review of Resident #11's face sheet dated 02/06/25, revealed, a [AGE] year-old female diagnosed with traumatic amputation of one left lesser toe and right lesser toe disruption of wound, pressure chronic ulcer of other part of left foot, Atherosclerosis of native arteries of right leg with ulceration of other part of foot, open wound to right foot, pressure ulcer of elbow stage 3, Diabetes. admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #11's quarterly MDS dated [DATE], revealed, there was no BIMS score conducted to measure the cognition for Resident #11. Resident #11 was coded for risk of pressure ulcer/injuries. Treatments were to use pressure reducing device for chair, reducing device for bed, and surgical wound care. <BR/>Record review of Resident #11's Order Recap dated 01/29/25, revealed, right forefoot dehiscence wound. Cleanse with NS. Pat dry with 4 by 4-inch gauze. Apply betadine to the area and cover with kerlix. Secure with cloth tape. <BR/>Record review of Resident #11's care plan dated 12/06/24, revealed, a post-surgical dehisced wound of the right second toe 1cm by 1cm by 1.5cm. Provide wound care per treatment order. <BR/>Record review of Resident #11's Administration Report dated 12/01/24-12/31/24, revealed, wound care was not provided on 12/02/24, 12/03/24. Review of the Administration Report dated 01/01/25-01/31/25, revealed, wound care was not provided on 01/08/25, 01/09/25, 01/10/25, 01/11/25, 01/12/25. Review of the Administration Report dated 02/01/25-02/28/25, revealed, wound care was not provided on 02/02/25. <BR/>Observation and interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated the facility had been having issues for several months with wound care not being provided on the weekends. The Treatment Nurse stated she, and the EX -DON were providing in-services and education on providing wound care. The Treatment Nurse stated she had created a binder with the residents who needed to have wound care done for each hallway nurse that was broken down to make it easy for them. The Treatment Nurse stated even with that they were still having issues with wound care. The Treatment Nurse stated she had reported it to the ADON and the Administrator who asked her for a list of residents and that they would follow up with those residents. The Treatment Nurse stated she had not seen anything being done by the Administrator and keeps reporting it in the morning meetings. The Treatment Nurse stated she had been letting them know every Monday and has to go back to re-check all the residents' wounds. The Treatment Nurse stated she had not seen any of the wounds from the residents getting worse. The Treatment Nurse stated on 02/01/25-02/02/25, wound care was not provided for Resident #7 and Resident #11 from 200 hall. The Treatment Nurse stated in the facility system it would let the nurse know when it was time to give the wound care as it comes up green and if it was not completed it would turn red. It was observed on the facility system that Resident #7 and Resident #11 were all red. <BR/>During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated that yesterday (02/05/25) the facility did an audit and found the same concerning trend to be found with the residents in 400 hall. The ADON stated the only hall to provide wound care for the weekend (02/01/25-02/02/25) was 300 hall. The ADON stated it has been a battle for the pasted couple of months (3) with not having wound care being provided for the residents at the facility. The ADON stated the Treatment Nurse created a binder and divided it between the halls so it would make it easier for the assigned nurses to complete wound care. <BR/>During an interview on 02/06/25 at 11:22 AM, with CNA C, she stated she did not observe wound care being conducted on the weekend (02/01/25-02/02/25). <BR/>During an interview on 02/07/25 at 9:47 AM, with LVN G, she stated there have been times she was not able to complete all the wound cares for the residents. LVN G stated she had passed it on in report to the other oncoming nurse but did not verify later on to see if it had been completed. <BR/>During an interview on 02/07/25 at 10:39 AM, with the Wound Care Doctor, he stated he was not informed of residents missing wound care. The Wound Care Doctor stated the Treatment Nurse has mentioned some issues but did not tell him the details of those issues. The Wound Care Doctor stated the nurses were to be providing wound care. The Wound Care Doctor stated these issues had not been brought to his attention especially major lapses with wound care. The Wound Care Doctor stated he should have been informed of any missed wound care or changes to significant changes. The Wound Care Doctor stated the risk of deterioration, infection, or necrosis(a type of cell death that occurs when cells are irreversibly damaged and lose their normal functions).<BR/>During an interview on 02/10/25 at 11:45 AM, with Interim-DON, he stated the Treatment Nurse was to be providing wound care during the weekdays and the nurses on the weekends since there was no Treatment Nurse working. The Interim-DON stated not doing wound care could have a negative effect on the resident where the wound could get worse or infected. The Interim-DON stated he was not notified that wound care was not being provided on the weekends and if known he would have taken action immediately. The Interim-DON stated it should have been expected that the nurses notify him that wound care was not being done. <BR/>Record review of the facility Skin policy dated 07/22, revealed, A Pressure Injury Prevention Care Plan will be completed by the Treatment Nurse or Charge nurse and interventions implemented for all Residents based upon the Braden Scale score in conjunction with clinical judgement and review of other risk factors. An updated Pressure Injury Prevention Care Plan will be completed upon a change in Braden Scale score or a change in condition.<BR/>The Director of Nursing or designee will audit and verify system compliance weekly including prevention-focused rounding and education as appropriate.<BR/>Rounding will be completed by the Charge Nurse, Treatment Nurse and Nurse Manager for observations of pressure sore prevention, including, but not limited to best practices such as off-loading, turning and repositioning. <BR/>The Quality of Assurance and Performance Improvement Review will include the findings from random audits of documentation completion: Physician Orders, Pressure Injury Care Plan, Non-Pressure Injury Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 5 residents reviewed for pressure ulcers/wounds. <BR/>The facility failed to provide wound care for Resident #3's pressure ulcer stage 3 to the left buttock on 02/01/25 and 02/02/25.<BR/>This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. <BR/>Findings include:<BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on [DATE] to the facility. Resident #3 discharged on 02/04/25<BR/>Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer.<BR/>Record review of Resident #3's admission MDS dated [DATE], revealed, no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Resident #3 was coded for risk of pressure ulcers and unhealed pressure ulcers. Resident #3 was coded for stage 3 pressure ulcer. Resident #3 was to have pressure reducing devices for chair, for bed, turning/repositioning program, pressure/ulcer/injury care, applications of ointments/medications, and hydration interventions. <BR/>Record review of Resident #3's Skin Issues Assessment generated by the Wound Care Nurse dated 01/30/25, revealed, left gluteus/ buttock pressure ulcer/ injury stage 3, 9 cm by 3.5 cm by 0.2 cm. <BR/>Record review of Resident #3's Order Recap dated 01/30/25, revealed, left buttock stage 3 pressure wound. Cleanse with NS and pat dry with a 4 by 4-inch gauze. Apply collagen powder to the wound bed granulated tissue. Cover with foam border dressing. One time a day related to Pressure Ulcer of Other site, Unstageable. <BR/>- <BR/>Order dated 01/30/25, revealed nursing Intervention: Turn and reposition every hour every shift. <BR/>Record review of Resident #3's Administration Report dated 02/01/25-02/28/25, revealed, wound care was not completed for 02/01/25 and 02/02/25 for Resident #3. <BR/>Record review of Resident #3's progress notes for 02/01/25-02/02/25, revealed, there was no nursing note indicating if wound care was provided or not. <BR/>During an interview on 02/05/25 at 1:18 PM, with Resident #3's Family member, she stated that wound care was not being done during the weekend as Resident #3 still had the same dressing on since his arrival to the facility. <BR/>During an interview on 02/05/25 at 1:50 PM, with LVN B, she stated the family member had informed her that Resident #3 had a bad weekend. LVN B stated the family member had mentioned that Resident #3 did not have wound care done on the weekend (02/01/25-02/02/25). LVN B stated she checked if Resident #3 had wound care done on the weekend and confirmed it had not been done. LVN B stated that there was not a Wound Care Nurse on the weekend, but all nurses were able to provide wound care. LVN B stated the weekend nurses were responsible for providing wound care. LVN B stated the risk of not providing wound care could be the wound getting worse or infection. <BR/>interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated she provided wound care during the weekdays and on the weekends, the nurses were to be providing the wound care. The Treatment Nurse stated the nurses on the weekend would be able to provide wound care for those residents needing wound care. The Treatment Nurse stated Resident #3 had not had his wound care done on 02/01/25 and on 02/02/25. The Treatment Nurse stated the negative outcome could be a delay in the wound in healing. <BR/>During an interview on 02/05/25 at 3:09 PM, with the Social Worker, she stated the staff was not assisting as they should be with Resident #3. The Social Worker stated the family member felt Resident #3 was not getting the correct wound care treatment. <BR/>During an interview on 02/05/25 at 3:29 PM, with LVN A, she stated wound care was being provided for Resident #3 on 02/01/25-02/02/25. LVN A stated she had forgotten to document that wound care was provided for Resident #3. LVN A stated she had looked at the MARs earlier that day for Resident #3's orders for wound care and remembered it. LVN A stated from what she remembered she went ahead and conducted the wound care later on in the day without looking at the wound care orders. LVN A stated she forgot to document it on the facility system. LVN A stated she was trained to look at the orders and would look at them earlier in the day and then would give treatment. LVN A stated the risk of not conducting wound care could be a risk of infection. <BR/>During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated wound care was supposed to be done as ordered. The ADON stated during the weekday the Treatment Nurse conducts the wound care and on the weekend the nurses are able and have to do the wound care. The ADON stated that nurses are trained to look at the orders while gathering the supplies for the wound treatment and cannot be looking at the orders earlier in the day and doing the wound treatment without looking to verify the orders. The ADON stated the risk would be a decline in the resident's condition. <BR/>During an interview on 02/06/25 at 8:42 PM, with LVN F, she stated she did not provide wound care when she worked the weekend because she was busy doing other things. LVN F stated there could be a negative outcome of not providing wound care which would depend on the situation of the resident. <BR/>Observation and interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated the facility had been having issues for several months with wound care not being provided on the weekends. The Treatment Nurse stated she, and the EX-DON were providing in-services and education on providing wound care. The Treatment Nurse stated she had created a binder with the residents who needed to have wound care done for each hallway nurse that was broken down to make it easy for them. The Treatment Nurse stated even with that they were still having issues with wound care. The Treatment Nurse stated she had reported it to the ADON and the Administrator who asked her for a list of residents and that they would follow up with those residents. The Treatment Nurse stated she had not seen anything being done by the Administrator and keeps reporting it in the morning meetings. The Treatment Nurse stated she had been letting them know every Monday and has to go back to re-check all the residents' wounds. The Treatment Nurse stated she had not seen any of the wounds from the residents getting worse. The Treatment Nurse stated on 02/01/25-02/02/25, wound care was not provided for Resident #3 and other residents from 200 hall. The Treatment Nurse stated in the facility system it would let the nurse know when it was time to give the wound care as it comes up green and if it was not completed it would turn red. <BR/>During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated that yesterday (02/05/25) the facility did an audit and found the same concerning trend to be found with the residents in 400 hall. The ADON stated the only hall to provide wound care for the weekend (02/01/25-02/02/25) was 300 hall. The ADON stated it has been a battle for the pasted couple of months (3) with not having wound care being provided for the residents at the facility. The ADON stated the Treatment Nurse created a binder and divided it between the halls so it would make it easier for the assigned nurses to complete wound care. <BR/>During an interview on 02/06/25 at 11:22 AM, with CNA C, she stated she did not observe wound care being conducted on the weekend (02/01/25-02/02/25). <BR/>During an interview on 02/07/25 at 9:47 AM, with LVN G, she stated there have been times she was not able to complete all the wound cares for the residents. LVN G stated she had passed it on in report to the other oncoming nurse but did not verify later on to see if it had been completed. <BR/>During an interview on 02/07/25 at 10:39 AM, with the Wound Care Doctor, he stated he was not informed of residents missing wound care. The Wound Care Doctor stated the Treatment Nurse has mentioned some issues but did not tell him the details of those issues. The Wound Care Doctor stated the nurses were to be providing wound care. The Wound Care Doctor stated these issues had not been brought to his attention especially major lapses with wound care. The Wound Care Doctor stated he should have been informed of any missed wound care or changes to significant changes. The Wound Care Doctor stated the risk of deterioration, infection, or necrosis(a type of cell death that occurs when cells are irreversibly damaged and lose their normal functions).<BR/>During an interview on 02/10/25 at 11:45 AM, with Interim-DON, he stated the Treatment Nurse was to be providing wound care during the weekdays and the nurses on the weekends since there was no Treatment Nurse working. The Interim-DON stated not doing wound care could have a negative effect on the resident where the wound could get worse or infected. The Interim-DON stated he was not notified that wound care was not being provided on the weekends and if known he would have taken action immediately. The Interim-DON stated it should have been expected that the nurses notify him that wound care was not being done. <BR/>Record review of the facility Skin policy dated 07/22, revealed, A Pressure Injury Prevention Care Plan will be completed by the Treatment Nurse or Charge nurse and interventions implemented for all Residents based upon the Braden Scale score in conjunction with clinical judgement and review of other risk factors. An updated Pressure Injury Prevention Care Plan will be completed upon a change in Braden Scale score or a change in condition.<BR/>The Director of Nursing or designee will audit and verify system compliance weekly including prevention-focused rounding and education as appropriate.<BR/>Rounding will be completed by the Charge Nurse, Treatment Nurse and Nurse Manager for observations of pressure sore prevention, including, but not limited to best practices such as off-loading, turning and repositioning. <BR/>The Quality of Assurance and Performance Improvement Review will include the findings from random audits of documentation completion: Physician Orders, Pressure Injury Care Plan, Non-Pressure Injury Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 residents (Resident #14 and Resident #57) of 7 reviewed for medication administration and 1 of 1 medication room.<BR/>-LVN H failed to administer insulin with meal per physician order for Resident #14. <BR/>-LVN I administered Resident #57 medication through feeding tube without checking for residuals first.<BR/>-Medication room had expired medications<BR/>This deficient practice could cause a decline in health of residents due to incorrect medication administration or administration of expired medications. <BR/>Findings included:<BR/>Resident #14<BR/>Review of Resident #14's Face Sheet dated 02/10/2023 documented a [AGE] year-old female with an admission date of 12/07/18. <BR/>Review of a History and Physical dated 06/29/2022 documented Resident #14 had a history of Type 2 Diabetes and at the time of the assessment was taking HumaLog 5 units with meals subcutaneously three times a day. The H&P stated, Monitor blood glucose levels .continue with all medications as prescribed.<BR/>Record review of Physician orders dated 08/31/2021 documented HUMALOG 100 UNIT/ML VIAL ADMINISTER 5 UNITS WITH MEALS SUBCUT TID. <BR/>Review of Comprehensive Care Plan dated 11/28/2022 documented Resident #14 had potential for hypoglycemia episodes secondary to Diabetes. Goal would be to minimize the risk for hypoglycemia through interventions such as administering insulin as ordered and monitor blood sugars.<BR/>Review of Annual MDS assessment dated [DATE] documented Resident #14 had a BIMS score of 6 meaning she was severely cognitively impaired. It also revealed she had a diagnosis of Diabetes and had taken Insulin at the time of the assessment. <BR/>Observation of medication pass on 02/08/2023 at 3:24 PM, revealed LVN H checked Resident # 14's blood sugar and it was 173. She then checked the physician order and drew 5 units of Humalog insulin. LVN H injected the insulin into the right lower abdomen subcutaneously. LVN H then gathered her supplies, disposed of them, and left the room. Resident #14 was not eating a meal at the time of insulin administration. <BR/>In an interview with LVN H on 02/08/2023 at 3:51 PM, she said dinner was served at 5:00 PM. She said she was supposed to provide a snack to the residents who are given insulin if no meal is provided. She said the snack should be provided within 30 minutes of administration. She said the risks of not providing snacks or meal after insulin administration could be that the blood sugar could drop. She said the nurses had been trained on insulin administration. <BR/>In an interview with LVN I on 02/10/2023 at 09:05 AM, she said it was procedure to provide insulin with meals or provide a snack after administration. She said risks for not doing so could be dropping of blood sugar in the resident.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said when a nurse would administer insulin that was ordered with meals, there had to be food or a meal available to be given with the medication. He said if there was no food, he would wait until there was a tray or a snack for the resident. He said the nurses were trained on providing meals with insulin administration.<BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the insulin should be given around dinner time that way the residents' blood sugar would not drop. She said usually the medication would be given 10 minutes before meal.<BR/>Resident #57<BR/>Review of Resident #57's Face Sheet dated 02/10/2023 demonstrated a [AGE] year-old male with an admission date of 12/16/2022. <BR/>Review of a History and Physical dated 12/17/2022 demonstrated he had a Gastrotomy tube and was receiving tube feedings. <BR/>Review of Physician orders dated 01/25/2023 demonstrated Resident #57 had Glucerna feedings @65 ml/hour through his feeding tube. <BR/>Review of Comprehensive Care Plan dated 01/09/2023 demonstrated Resident #57 had G-tube and required ostomy care. Goal was to minimize risk for complications related to G-tube daily through interventions such as flushing the tube.<BR/>Review of Quarterly MDS assessment dated [DATE] demonstrated Resident #57 had a BIMS score of 6, meaning he was severely cognitively impaired and had memory impairments. It also revealed he had a feeding tube and was receiving tube feedings. <BR/>Observation of medication pass on 02/09/23 at 08:41 AM, revealed LVN I was preparing to administer medications to Resident #57. She disconnected the tube feeding from the tube and connected the syringe. She then flushed the feeding tube with 30 cc of water, and then administered the medications. She was observed not checking the for residuals or placement of the feeding tube prior to medication administration. <BR/>In an interview with LVN I on 02/10/23 at 09:05 AM, she said the proper procedure for G-tube medication administration was to check the feeding tube for patency and check for residuals. She said she had checked the tube in the morning during rounds, but not before administering medications. She said the risks for not checking for residuals could be that the resident could aspirate from the feeding, and the feeding tube could be misplaced.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said before administering a medication through a G-tube, it was nursing practice to aspirate the G-tube and check for residuals. He said the tube had to be checked for patency. <BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the nurses were trained to check for residuals and patency of the feeding tube every time they would give a medication. She said it was important to do so in order to check if the residents were not processing the feeding. She could not state when the nurses had been trained last. <BR/>Review of Humalog Manufacturer information dated 11/2019 read in part .HUMALOG starts acting fast. Inject HUMALOG within 15 minutes before or right after you eat a meal .<BR/>Review of facility policy titled Administering Medications dated 3/24/22 read in part .Medications shall be administered in a safe, and timely manner, and as prescribed .Medications must be administered in accordance with the orders .The individual administering the medication must check the label three times to verify the right medication .right time before giving the medication .<BR/>Review of facility policy titled Administering Medications through an Enteral Tube undated read in part .Steps in procedure .confirm the placement of feeding tube .check gastric residual volume to assess for tolerance of enteral feeding . <BR/>Medication Room<BR/>Observations on 02/08/23 at 11:38 AM, revealed the medication room had expired medications. The first cabinet in the medication room had two bottles of Vitamin C with an expiration date of 9/2022. The second cabinet had one bottle of Pro-Stat with and expiration date of 9/2022, and two bottles of UTI-Stat with an expiration date of 10/2022. <BR/>Observation and interview with DON on 02/08/23 at 11:45 AM, revealed the DON stated the medication room was checked and stocked by Central Supply. She said the medications should have not been in the room because they were expired. She said risks for keeping them in the room could be that the nurses and aides could administer them to residents. She said the nurses were trained on ensuring there were no expired medications. <BR/>In an interview with Central Supply on 02/08/23 at 1:59 PM, he said he was responsible for stocking the medication room with supplies and making sure the medications were good. He said he was not responsible for going through the medications and checking if they were expired. He said the nursing staff were responsible for checking the medications before grabbing them and taking them for their medication cart. He said since the state was at the facility, the nurses probably took the expired medications and hid them in the medication room. <BR/>Record review of facility policy titled Storage of Medications undated read in part .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts .shall not be left unattended if open or otherwise potentially available to others .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #3, Resident #8, and Resident #13) of 3 residents reviewed for care plans. <BR/>The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #3, #8, and #13. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. <BR/>Findings include:<BR/>Resident #3:<BR/>Record review of Resident #3's admission Record, dated 01/29/2025, reflected a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident # 3's History and Physical dated 03/16/2023, revealed diagnoses to include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe).<BR/>Record review of Resident # 3's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #3 was receiving oxygen therapy. <BR/>Record review of Resident #3's Order Summary Report dated 01/30/2025, revealed an order with start time of 10/08/2024 for O2 at 2 liters, keep O2 saturations above 85%.<BR/>Review of Resident #3's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 94% to 97%.<BR/>Record review of Resident #3's comprehensive care plan dated 01/30/2025, revealed Resident #3's oxygen therapy was not care planned. <BR/>During an observation and interview on 01/29/2025 at 2:18 p.m., Resident #3 was lying in bed with nasal cannula on and oxygen set at 2 liters. Resident #3 said she did not have any concerns with the services at the facility.<BR/>Resident #8:<BR/>Record review of Resident #8's admission Record, dated 01/30/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident # 8's History and Physical dated 01/07/2025, revealed diagnoses to include COPD (lung disease that block airflow and make it difficult to breathe) on 2 L nasal cannula, and acute on chronic hypoxemic respiratory failure (a sudden worsening of pre-existing chronic condition where the body is not getting enough oxygen). <BR/>Record review of Resident # 8's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #8 was receiving oxygen therapy. <BR/>Record review of Resident #8's Order Summary Report dated 01/30/2025, revealed an order with start time 01/07/2025 Oxygen: Oxygen at 3 liters per nasal cannula continuous every day and night shift related to Hypoxemia. <BR/>Record review of Resident #8's comprehensive care plan dated 01/30/2025, revealed Resident #8's oxygen therapy was not care planned. <BR/>Review of Resident #8's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>During an observation on 01/30/2025 at 3:08 p.m., Resident #8 was observed asleep in bed. Resident #8 was observed wearing a nasal cannula with oxygen concentrator set at 3 liters. <BR/>Resident #13:<BR/>Record review of Resident #13's admission Record, dated 01/31/2025, reflected [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #13's History and Physical dated 06/08/2022, revealed diagnoses to include chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), and chronic respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body).<BR/>Record review of Resident #13's MDS dated [DATE], revealed a BIMS score of 05 indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #13 was receiving oxygen therapy. <BR/>Record review of Resident #13's Order Summary Report dated 01/31/2025, revealed an order with start time of 10/07/2024 for O2 via nasal cannula at 2 liters continuous to maintain saturation above 90%. <BR/>Review of Resident #13's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>Record review of Resident #13's comprehensive care plan dated 01/31/2025, revealed Resident #13's oxygen therapy was not care planned. <BR/>During an observation on 01/31/2025 at 8:42 a.m., Resident #13 was lying in bed asleep with nasal cannula on and oxygen set at 2 liters. No issues identified with oxygen concentrator or tubing. <BR/>During an interview on 01/29/2025 at 10:48 a.m., the ADON said all care plans should include oxygen therapy. The ADON said MDS Coordinator was responsible for care plans. The ADON said the facility had a recent change of ownership at the beginning of December 2024 and some information from previous care plans did not transition into the electronic health record at the time of the change. The ADON said many documents were printed but not readily available on the floor for staff. The ADON said the facility previously had two MDS Coordinators but now only have one. <BR/>During an interview on 01/30/2025 at 4:11 p.m., the MDS Coordinator said she was in charge of getting the care plans up to date. The MDS Coordinator said she had 21 days from admission to complete the comprehensive care plan. The MDS Coordinator said oxygen therapy should be care planned. The MDS Coordinator said for the last two months she was the only MDS Coordinator which had caused her to be backed up. The MDS Coordinator said some of the care plans had not been updated. The MDS Coordinator said the risk of care plans not being updated was possible risk of residents not receiving the necessary care or service.<BR/>Review of the facility-provided Patient Care Management System dated November 2017, revealed in part A Comprehensive, Person-centered Plan of Care, consistent with resident rights must be completed by the 21st day after admission. The care plan must be based on assessments completed within the previous 15 months in the Patient's/Resident's active record and use the results of the assessments to develop, review and revise the Patient's/Resident's comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue). <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00, indicating her cognition was severely impaired, and she was dependent on staff for transfers. <BR/>Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/ 2 person transfers with interventions that included safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate and goal was will remain free from injury. <BR/>In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes in place. The transfer was completed without incident, and no anxiety was observed.<BR/>In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included the resident swinging, tipping over, and possibly falling. CNA B stated she had received training on proper mechanical lift transfer procedures.<BR/>In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent movement and released only when ready to move the lift. The DON stated one CNA maneuvered the mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and quarterly random competency checks were conducted by the DON and lead CNA.<BR/>In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed by direct care staff who were trained at hire, annually, and as needed during competency checks. The Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated the risk of not following those steps included potential injury to the resident or staff. <BR/>Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked position on the wheelchair, shower or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 2 of 22 residents (Resident #16 and #178).<BR/>The facility failed to ensure resident call lights were within reach for 2 residents (Resident #16 and #178).<BR/>This failure placed residents at risk of having their needs unmet when they are unable to contact staff.<BR/>Findings included:<BR/>Resident #16 <BR/>Record review of Resident #16's face sheet dated 04/30/2025 revealed Resident #16 was originally admitted to facility on 02/10/2016 and readmitted on [DATE].<BR/>Record review of Resident #16's History and physical dated 05/08/24 revealed a [AGE] year-old female diagnosed with vascular dementia. <BR/>Record review of Resident #16's Quarterly MDS dated [DATE] revealed Resident #16's BIMS score was 02 indicating severe cognitive impairment. Resident needed Extensive assistance with bed mobility, transfers and toileting (resident involved in activity; staff provide weight bearing support). <BR/>Record review of Resident #16's care plan reviewed on 04/05/24 revealed she was at risk for falls, and interventions included to ensure call light is available to resident.<BR/>An observation on 04/28/25 at 10:15 a.m., revealed Resident #16's call light was pinned between two pillows that she was laying on top of. <BR/>Resident #178<BR/>Record review of Resident #178's face sheet dated 04/30/2025 revealed a [AGE] year-old male that was admitted to facility on 04/03/2025.<BR/>Record review of Resident #178's medical diagnosis list revealed, Resident #178 was diagnosed with cognitive communication deficit, and unspecified dementia. <BR/>Record review of Resident #178's Quarterly MDS dated [DATE] revealed no BIMS score. Resident was dependent( helper does all the effort) for toileting , bed mobility and transfers <BR/>Record review of Resident #178's care plan dated 04/05/2025 revealed he was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/ comprehension, unaware of safety needs. Interventions included to ensure call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. <BR/>An observation on 4/28/25 at 10:05 a.m., revealed Resident #178's call light was on the floor next to the head of the bed, while he was sleeping in bed. <BR/>In an interview on 04/30/2025 at 12:19 p.m., with the DON she said the call lights were for patients to be able to call for assistance. She stated call bells should be kept within residents' reach. She stated the CNA's, nurses and overall, all staff were responsible for ensuring residents call lights were within reach. She stated that if call lights were not kept within residents' reach, then residents could possibly not be able to call for help when needed. She stated that an Inservice for call lights was done recently. <BR/>In an interview with LVN A on 04/30/2025 at 12:50 p.m.,she said that the call lights were supposed to be within reach of all residents. She stated that all staff were responsible for ensuring call lights were within reach of residents. She stated that residents were rounded every 2 hours and as needed. She stated that if the call lights were not within reach of the resident, residents could sustain a fall, or they would not be able to call for help. She stated that the facility was always providing in-services regarding call lights, and she stated that the most recent was at the beginning of April 2025.<BR/>In an interview with CNA B on 4/30/25 at 1:00 p.m, she said that call lights were for residents to use to call for assistance and for staff to attend to them as soon as possible. She stated that call lights were to always be in reach of the resident. She stated that CNAs and nurses were responsible for ensuring call lights were always within reach for the residents. She stated that if call lights were not within reach, it could delay care and could result in a resident sustaining a fall. She stated that the facility was constantly conducting in-services on keeping call lights within reach and answering them in a timely manner, but she could not remember the most recent one. <BR/>Review of facility policy dated September 2022 and titled Call System, Resident read in part Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue). <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00, indicating her cognition was severely impaired, and she was dependent on staff for transfers. <BR/>Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/ 2 person transfers with interventions that included safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate and goal was will remain free from injury. <BR/>In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes in place. The transfer was completed without incident, and no anxiety was observed.<BR/>In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included the resident swinging, tipping over, and possibly falling. CNA B stated she had received training on proper mechanical lift transfer procedures.<BR/>In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent movement and released only when ready to move the lift. The DON stated one CNA maneuvered the mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and quarterly random competency checks were conducted by the DON and lead CNA.<BR/>In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed by direct care staff who were trained at hire, annually, and as needed during competency checks. The Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated the risk of not following those steps included potential injury to the resident or staff. <BR/>Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked position on the wheelchair, shower or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 residents (Resident #14 and Resident #57) of 7 reviewed for medication administration and 1 of 1 medication room.<BR/>-LVN H failed to administer insulin with meal per physician order for Resident #14. <BR/>-LVN I administered Resident #57 medication through feeding tube without checking for residuals first.<BR/>-Medication room had expired medications<BR/>This deficient practice could cause a decline in health of residents due to incorrect medication administration or administration of expired medications. <BR/>Findings included:<BR/>Resident #14<BR/>Review of Resident #14's Face Sheet dated 02/10/2023 documented a [AGE] year-old female with an admission date of 12/07/18. <BR/>Review of a History and Physical dated 06/29/2022 documented Resident #14 had a history of Type 2 Diabetes and at the time of the assessment was taking HumaLog 5 units with meals subcutaneously three times a day. The H&P stated, Monitor blood glucose levels .continue with all medications as prescribed.<BR/>Record review of Physician orders dated 08/31/2021 documented HUMALOG 100 UNIT/ML VIAL ADMINISTER 5 UNITS WITH MEALS SUBCUT TID. <BR/>Review of Comprehensive Care Plan dated 11/28/2022 documented Resident #14 had potential for hypoglycemia episodes secondary to Diabetes. Goal would be to minimize the risk for hypoglycemia through interventions such as administering insulin as ordered and monitor blood sugars.<BR/>Review of Annual MDS assessment dated [DATE] documented Resident #14 had a BIMS score of 6 meaning she was severely cognitively impaired. It also revealed she had a diagnosis of Diabetes and had taken Insulin at the time of the assessment. <BR/>Observation of medication pass on 02/08/2023 at 3:24 PM, revealed LVN H checked Resident # 14's blood sugar and it was 173. She then checked the physician order and drew 5 units of Humalog insulin. LVN H injected the insulin into the right lower abdomen subcutaneously. LVN H then gathered her supplies, disposed of them, and left the room. Resident #14 was not eating a meal at the time of insulin administration. <BR/>In an interview with LVN H on 02/08/2023 at 3:51 PM, she said dinner was served at 5:00 PM. She said she was supposed to provide a snack to the residents who are given insulin if no meal is provided. She said the snack should be provided within 30 minutes of administration. She said the risks of not providing snacks or meal after insulin administration could be that the blood sugar could drop. She said the nurses had been trained on insulin administration. <BR/>In an interview with LVN I on 02/10/2023 at 09:05 AM, she said it was procedure to provide insulin with meals or provide a snack after administration. She said risks for not doing so could be dropping of blood sugar in the resident.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said when a nurse would administer insulin that was ordered with meals, there had to be food or a meal available to be given with the medication. He said if there was no food, he would wait until there was a tray or a snack for the resident. He said the nurses were trained on providing meals with insulin administration.<BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the insulin should be given around dinner time that way the residents' blood sugar would not drop. She said usually the medication would be given 10 minutes before meal.<BR/>Resident #57<BR/>Review of Resident #57's Face Sheet dated 02/10/2023 demonstrated a [AGE] year-old male with an admission date of 12/16/2022. <BR/>Review of a History and Physical dated 12/17/2022 demonstrated he had a Gastrotomy tube and was receiving tube feedings. <BR/>Review of Physician orders dated 01/25/2023 demonstrated Resident #57 had Glucerna feedings @65 ml/hour through his feeding tube. <BR/>Review of Comprehensive Care Plan dated 01/09/2023 demonstrated Resident #57 had G-tube and required ostomy care. Goal was to minimize risk for complications related to G-tube daily through interventions such as flushing the tube.<BR/>Review of Quarterly MDS assessment dated [DATE] demonstrated Resident #57 had a BIMS score of 6, meaning he was severely cognitively impaired and had memory impairments. It also revealed he had a feeding tube and was receiving tube feedings. <BR/>Observation of medication pass on 02/09/23 at 08:41 AM, revealed LVN I was preparing to administer medications to Resident #57. She disconnected the tube feeding from the tube and connected the syringe. She then flushed the feeding tube with 30 cc of water, and then administered the medications. She was observed not checking the for residuals or placement of the feeding tube prior to medication administration. <BR/>In an interview with LVN I on 02/10/23 at 09:05 AM, she said the proper procedure for G-tube medication administration was to check the feeding tube for patency and check for residuals. She said she had checked the tube in the morning during rounds, but not before administering medications. She said the risks for not checking for residuals could be that the resident could aspirate from the feeding, and the feeding tube could be misplaced.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said before administering a medication through a G-tube, it was nursing practice to aspirate the G-tube and check for residuals. He said the tube had to be checked for patency. <BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the nurses were trained to check for residuals and patency of the feeding tube every time they would give a medication. She said it was important to do so in order to check if the residents were not processing the feeding. She could not state when the nurses had been trained last. <BR/>Review of Humalog Manufacturer information dated 11/2019 read in part .HUMALOG starts acting fast. Inject HUMALOG within 15 minutes before or right after you eat a meal .<BR/>Review of facility policy titled Administering Medications dated 3/24/22 read in part .Medications shall be administered in a safe, and timely manner, and as prescribed .Medications must be administered in accordance with the orders .The individual administering the medication must check the label three times to verify the right medication .right time before giving the medication .<BR/>Review of facility policy titled Administering Medications through an Enteral Tube undated read in part .Steps in procedure .confirm the placement of feeding tube .check gastric residual volume to assess for tolerance of enteral feeding . <BR/>Medication Room<BR/>Observations on 02/08/23 at 11:38 AM, revealed the medication room had expired medications. The first cabinet in the medication room had two bottles of Vitamin C with an expiration date of 9/2022. The second cabinet had one bottle of Pro-Stat with and expiration date of 9/2022, and two bottles of UTI-Stat with an expiration date of 10/2022. <BR/>Observation and interview with DON on 02/08/23 at 11:45 AM, revealed the DON stated the medication room was checked and stocked by Central Supply. She said the medications should have not been in the room because they were expired. She said risks for keeping them in the room could be that the nurses and aides could administer them to residents. She said the nurses were trained on ensuring there were no expired medications. <BR/>In an interview with Central Supply on 02/08/23 at 1:59 PM, he said he was responsible for stocking the medication room with supplies and making sure the medications were good. He said he was not responsible for going through the medications and checking if they were expired. He said the nursing staff were responsible for checking the medications before grabbing them and taking them for their medication cart. He said since the state was at the facility, the nurses probably took the expired medications and hid them in the medication room. <BR/>Record review of facility policy titled Storage of Medications undated read in part .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts .shall not be left unattended if open or otherwise potentially available to others .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.<BR/>1. <BR/>Food products in dry storage and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings include:<BR/>Observation on 02/07/2023 at 8:10 a.m., in the dry storage was a 106 oz dented can of mixed fruits on the rollout shelve. <BR/>- <BR/>Dry storage area, a 16 oz clear bag enriched macaroni was sitting on the mid shelve inside a zip lock bag undated and opened. <BR/>- <BR/>In the back of the house kitchen prep area, the middle refrigerator inside on the top shelve was a 5.6 qt 6-inch-deep clear plastic container with salsa mid-way with a clear plastic wrap with its ends floating outwards and not gripping the container securing a closed hold. <BR/>- <BR/>In the back of the house kitchen prep area, in refrigerator on top shelf was a 6-inch metal deep pan full of green lettuce leaf was not wrapped properly with plastic wrap. Plastic wrap is not gripping onto the pan and in the front part of the pan that is visible to us to view has a opening about half an inch. <BR/>- <BR/>In the back of the house kitchen prep area, on the top shelve in the refrigerator was a 4 in deep metal pan with cherry tomatoes in it. The plastic wrap was not gripping the pan properly and was not making a proper seal. <BR/>- <BR/>In the back of the house kitchen prep area, middle freezer was a clear wrapped plastic bag of chicken breast that were not labeled/ dated. <BR/>- <BR/>In the back of the house kitchen prep area, on top freezer was a bag of yellow squash dated [DATE]. <BR/>- <BR/>In the back of the house kitchen prep area, on the top shelve was a bag of red skinned potatoes 2.5 lbs. and halfway gone that were dated 217 [DATE] 05. <BR/>- <BR/>In between the kitchen and the back of the house was a holding shelf that had a 23oz bag of hamburger buns with no date. <BR/>- <BR/>In the front of the house kitchen area, a refrigerator on the top shelf was a one-gallon clear pouring container that contained lemonade that was expired as labeled (02/05/2023 to 02/06/2023).<BR/>- <BR/>In front of the house kitchen area, a refrigerator on the middle shelves had 54 5 oz plastic tumbler cups full of milk that were expired (02/05/2023 to 02/06/2023). <BR/>Interview on 02/07/2023 at 8:20 a.m., Dietary Manager stated the Macaroni was to be closed properly and was not common practice leaving it open. Dietary Manager stated the macaroni has to be closed properly so insects don't get in and the product get damaged. Dietary Manager stated dietary staff are in-serviced and receive monthly trainings. Dietary Manager stated the damaged cans are separated and are to go into her office. Dietary Manager stated damaged cans are damaged products and due to the damage can contain air. Dietary Manger stated staff are trained when doing the truck when products come in and check the food items when putting them away. Dietary Manager stated the dietary staff are to check and inspect the food items/packages before using them. Dietary Manager stated the yellow squash and the red skin potatoes have been fed to the residents. Dietary Manager stated the supplier had confirmed the date on the yellow squash the date it was packaged. Dietary Manager stated supplier did not tell them what the expiration date was. Dietary Manager stated she oversees the dietary staff are labeling and checking the foods when they are put away. Dietary Manager stated it is important to put the expiration dates. <BR/>Interview on 02/08/2023 at 11:02 a.m., Dietitian stated dietary staff go through basic training to work in the kitchen and the Dietary Manager oversees this. Dietitian stated she does audits once a month and orally instructs dietary staff on logging temps, safety, diets, portion sizes, labeling, and storage. Dietitian stated the yellow squash and red skin potatoes outdated was no risk to the residents because they were in the freezer and has temperature control. Dietitian stated cans dented needed to be placed aside because they can contain botulism. Dietitian stated of the dented can was fruit then there can be a risk of botulism and would be a risk to the residents if they ingest it. <BR/>Interview on 02/09/2023 at 1:51 p.m., Dietary Staff J stated there is no specific training to be able to do the truck. Dietary Staff J stated she sees the dates and places the older foods on the top and the newer food on the bottom of shelves. Dietary Staff J stated when the food comes out of the box we date it and place the name on the items. Dietary Staff J stated the dietary staff have not received any training on labeling. Dietary Staff J stated the dietary staff are to check the bag(s) to see if it is not spoiled. Dietary Staff J stated if we had it like that (yellow squash and red skin potatoes) outdated we should have thrown it away. Dietary Staff J stated dietary staff are trained through the food handlers' program which trains dietary staff on dates, labeling, and checking food items. Dietary Staff J stated they also receive training from the facility. Dietary Staff J stated the red potatoes were used and given to the residents. Dietary Staff J stated she would have voiced it out as a concern with the date on the squash. Dietary Staff J stated staff are trained to check out the foods before using them. Dietary Staff J stated the residents can get sick by serving them expired food.<BR/>Interview on 02/09/2023 at 2:08 p.m., Dietary Staff K stated she was trained by the facility which gave her a curriculum and by the Dietary Manager. Dietary Staff K stated the dietary staff were in-serviced to wash hands, labels, and do temperatures. Dietary Staff K stated the dietary staff are to put the dates on everything and place all the old foods in front to be used first. Dietary Staff K stated dietary staff when putting food away check the food items with the dates and to see if they are spoiled. Dietary Staff K stated she had learned in other areas that some food items can last a year. Dietary Staff K stated the facility does not have a policy that states that the facility can use food that is a couple months to a year old. Dietary Staff K stated there is a risk with not checking the dates because those being server the red skinned potatoes to the resident could get botulism. <BR/>Record review of facility policy dated 10/01/2018 of Food Delivers stated to ensure that all food prepared by the facility is of good quality, there facility will follow HACCP guidelines for receiving and inspecting foods delivered to the facility. Food Deliver Policy indicates on procedure line 2, The Nutrition and Foodservice Manager or designees will inspect all deliveries to ensure that the food is not spoiled or adulterated. C. all cans must be in good condition and not dented. <BR/>Record review of facility policy dated 10/01/2018 of Food Storage stated to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Food Storage Policy indicated on dry storage procedure line d., to ensure freshness, store opened and bulk items in tightly covered containers. All containers' must be labeled and dated. Food Storage Policy refrigerator procedure line d., date, label, and tightly seal all refrigerator foods using clean, nonabsorbent, covered containers' that are approved for food storage. <BR/>Record review of facility in-service dated 12/16/2021 of Dry Food Summary was given for labeling and dating.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in four of four halls reviewed for condition of handrails. <BR/>The facility failed to ensure that the handrails throughout the facility did not have the paint worn off them. <BR/>This failure could put residents at risk of feeling a decreased sense of well-being, and at increased risk for splinters because of the poorly maintained condition of the handrails. <BR/>Findings included: <BR/>Handrails: <BR/>Observation on 03/14/2024 at 2:30 PM of the handrails in the 100 and 200 halls revealed that the brown paint on all handrails was worn through and that the wood showed through the paint. <BR/>Observation of the handrails at hall 300 on 3/13/2024 at 3:42 PM revealed that the brown paint on all handrails along the hallway was scraped and worn and wood showed through the paint. <BR/>Observation of the handrails at hall 400 on 3/13/2024 at 3:46 PM revealed that the brown paint on all handrails along the hallway was scraped and worn and wood showed through the paint. <BR/>Supply Storage Rooms in 100 and 200 Halls: <BR/>Soiled Utility Room: <BR/>Observation on 03/14/24 at 9:39 AM - 10:01 AM with ADON and Central Supply Clerk revealed: <BR/>-Mop Basin had black substance around the sides and area around the drain. The plaster and paint were chipped, with multiple holes on walls and black marks where Mop Basin was located. The borders on the walls were full of dust. The floor in the soiled utility room had large areas covered with black marks, dried water stains, and dusty floor, piece of paper on the floor and small paper particles throughout the room. <BR/>-The wall directly below locked cabinets revealed wall had large areas of plaster had fallen off and chipped paint on the wall directly where boxes of gloves were stored. <BR/>Storage Room located in Hallway that connects the 100 and 200 Halls revealed: <BR/>Observation on 03/14/24 at 10:05 AM with ADON, Maintenance Director and Central Supply Clerk revealed Ceiling Light was missing the light cover. There was a large brown water stain above ceiling light that extended to the area where supply boxes were stored on the floor. <BR/>Interview on 03/14/24 at 11:38 AM, the Maintenance Supervisor confirmed floors in storage rooms were dusty, had black stains, boxes were stored on the floor, mop basin had back stains around the inside and outside of the basin, storage racks were full of dust and dried white stains, clean supplies were stored with contaminated containers and/or next to vacuum cleaners in clean storage room, confirm light cover was missing in one storage room. He stated the brown water stain on ceiling in the storage room was caused by a water leak from air conditioner. He stated, Nursing had not reported the water leak to maintenance. <BR/>Interview and record review with Administrator on 03/14/24 at 11:30 AM confirmed all the environmental findings observed in Storage Rooms where nursing supplies were kept. The administrator said he was not aware of any issues with the storage room walls, dried water stain on the ceiling, missing light cover and the dirty floors. <BR/>Review of facility ' s undated policy and procedures on Cleaning and Disinfection of Environmental Surfaces revealed: Policy Statement-Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standards. Policy Interpretation: The following categories are used to distinguish levels of sterilization/disinfection necessary for items used in resident care and those in the resident ' s environment. Non-critical items are those that come in contact with skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails and floors. Housekeeping surfaces (e.g. floors) will be cleaned on a regular basis, when surfaces are visibly soiled. Walls in resident areas will be cleaned when these surfaces are visibly contaminated or soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies that prohibit and prevent abuse for 1 (Resident #7) of 8 residents reviewed for abuse. <BR/>The facility failed to implement their abuse policy when they failed to immediately suspend CNA B after Resident #7's RP reported a physical restraint allegation. <BR/>This failure could place residents at risk of potential continued mistreatment and abuse. <BR/>Findings included: <BR/>Record review of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated April 2021 read in part Investigating Allegations: 6- any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. <BR/>Record review of Resident #7's face sheet dated 9/18/24 revealed a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses of anxiety and dementia. <BR/>Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, indicating she was severely cognitively impaired and was dependent for toileting. <BR/>Record review of Resident #7's care plan dated 06/01/24 revealed focus area for Resident #7 is refusing care, including brief changes; is having physically aggressive behavior with interventions that included Talk in calm voice when care is refused; Report care refusal to RP and MD; Monitor for any skin impairment; Do not argue with resident; Talk in calm voice when behavior is disruptive; Refer to Social Services for evaluation; Reinforce unacceptability of verbal abuse; Remove from public area when behavior is disruptive and unacceptable; Monitor and document target behaviors; Assist in selection of appropriate coping mechanisms; Requires 2 staff members in room at all times; Administer behavior medications as ordered by physician. <BR/>Record review of Resident #7's grievance dated 07/31/24, written by the SW, revealed RP reports CNA B physically restrained <BR/>Resident #7 while changing her. RP did not witness but was outside bathroom while 3 CNAs were inside changing Resident #7. RP stated it was the male CNA. The DON was contacted on 07/31/24. Summary/ Findings revealed CNA B stated she (Resident #7) hit one of her arms against the wall but didn't see any bruising at the moment and the 3 CNAs assisted with the toilet transfer. Statement from CNAs (CNA A, CNA B and CNA C) were gathered, abuse and neglect in-services signed by staff. situation was reported to SO . The grievance was marked as resolved as of 08/01/24 with interventions that included CNA B removed from Resident #7's care and RP was contacted with investigation results. <BR/>Record review of CNA B's timecard revealed he worked the following days and hours after the allegation was received on 07/31/24: 07/31/24 from 2:50 pm- 9:56 pm; 08/01/24 from 9:25 pm- 11:38 pm. <BR/>During an attempted interview on 09/18/24 at 1:14 pm, a call was placed to CNA C with no answer and was unable to leave a VM to return call. <BR/>During an interview on 09/18/24 at 1:42 pm, CNA A stated she was familiar with Resident #7 and she required 2 person assist with toileting and was advised to always provide care with 2 persons for witnesses to care provided. CNA A stated her, and CNA C were asked by Resident #7's RP to change her brief on 07/28/24 . CNA A stated when CNA C arrived to Resident #7 to assist with the toilet transfer, Resident #7's RP excused herself from the room. CNA A stated herself and CNA C were at Resident #7's sides and CNA B was in front of her to assist with the toilet transfer. CNA A stated when CNA C placed the gait belt on Resident #7 and asked her to stand up, Resident #7 started swinging her hands attempting to hit them. CNA A stated Resident #7 was left alone to calm down and when she calmed down, CNA C attempted to assist with transfer again and Resident #7 complied with no issues. CNA A stated CNA C then excused himself and herself CNA A stayed with Resident #7. CNA A stated she did not notice any bruising to Resident #7 and denied any physical restraints used. CNA A stated she was asked to write a statement a few days later due to the allegation that was made and was not suspended. <BR/>During an interview on 09/19/24 at 11:05 am, Resident #7 was greeted, and she did not acknowledge Surveyor. <BR/>During an interview on 09/19/24 at 2:55 pm, the DON stated she had been notified of the allegation by SW on 07/31/24 but could not remenber at what time the allegation had been initially report. The DON stated she initiated her investigation and had followed up with Resident #7's RP who denied witnessing the toilet transfer and only stated the bruises had been a result of the transfer. The DON stated she finished the investigation at the time the incident was submitted, on 08/06/2024 at 4:51pm. The DON stated Resident #7's RP did not think it was due to being aggressive only that it occurred because of the transfer. The DON stated she interviewed CNA A, CNA B, and CNA C who denied the physical restraint allegation and all 3 had witnessed the toilet transfer. The DON stated they all stated Resident #7 had become combative during the toilet transfer and denied noticing any bruising at the moment. The DON stated she had not suspended the alleged APs due to all 3 witnessing the incident. The DON stated she finished her investigation on 08/01/24. The DON stated per their abuse policy the CNAs should have been suspended until the investigation was completed. The DON stated the failure to suspend CNA A, CNA B, and CNA C could have placed residents at risk for possible continued abuse. The DON stated she had not received any complaints related to abuse against the 3 CNAs and stated SW had conducted safety surveys with random residents in that hallway with no findings. <BR/>During an interview on 09/19/24 at 3:26 pm, CNA B stated he was familiar with Resident #7 care and she required 2 person assist with toileting and also required 2 person care provided due to the combative behavior and the RP's accusatory behavior. CNA B stated he had been asked by one of the CNAs to assist with the toilet transfer on 07/28/24. CNA B stated when he arrived to Resident #7's room the RP excused herself and left the room. CNA B stated in the restroom the other CNAs (CNA A and CNA C) were at her side and he was facing her. CNA B stated when he placed the gait belt on Resident #7, she started swinging her arms around and had hit the wall and the sink. CNA B stated they backed away to allow her to calm down. CNA B stated she calmed down and asked her to assist to a standing position to get her on the toilet and she complied. CNA B stated he then left the restroom and the CNAs stayed with her. CNA B stated when he got out of the restroom the RP was outside and apologized on Resident #7's behalf and stated I know how she gets. CNA B stated a few days later he was questioned and was surprised due to RP not mentioning anything that day he assisted with the toilet transfer. CNA B denied the allegation and stated he was not suspended. <BR/>During an interview on 09/20/24 at 3:12 pm, the Administrator stated it was her first week working at the facility and had not known about the self-reports pending . The Administrator stated based on the abuse policy it would have been expected for the APs to be suspended until the investigation was completed regardless of the many witnesses present at the time of the allegation. the Administrator stated failure to suspend the APs after an allegation made placed residents at risk for possible continued abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #3, Resident #8, and Resident #13) of 3 residents reviewed for care plans. <BR/>The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #3, #8, and #13. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. <BR/>Findings include:<BR/>Resident #3:<BR/>Record review of Resident #3's admission Record, dated 01/29/2025, reflected a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident # 3's History and Physical dated 03/16/2023, revealed diagnoses to include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe).<BR/>Record review of Resident # 3's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #3 was receiving oxygen therapy. <BR/>Record review of Resident #3's Order Summary Report dated 01/30/2025, revealed an order with start time of 10/08/2024 for O2 at 2 liters, keep O2 saturations above 85%.<BR/>Review of Resident #3's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 94% to 97%.<BR/>Record review of Resident #3's comprehensive care plan dated 01/30/2025, revealed Resident #3's oxygen therapy was not care planned. <BR/>During an observation and interview on 01/29/2025 at 2:18 p.m., Resident #3 was lying in bed with nasal cannula on and oxygen set at 2 liters. Resident #3 said she did not have any concerns with the services at the facility.<BR/>Resident #8:<BR/>Record review of Resident #8's admission Record, dated 01/30/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident # 8's History and Physical dated 01/07/2025, revealed diagnoses to include COPD (lung disease that block airflow and make it difficult to breathe) on 2 L nasal cannula, and acute on chronic hypoxemic respiratory failure (a sudden worsening of pre-existing chronic condition where the body is not getting enough oxygen). <BR/>Record review of Resident # 8's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #8 was receiving oxygen therapy. <BR/>Record review of Resident #8's Order Summary Report dated 01/30/2025, revealed an order with start time 01/07/2025 Oxygen: Oxygen at 3 liters per nasal cannula continuous every day and night shift related to Hypoxemia. <BR/>Record review of Resident #8's comprehensive care plan dated 01/30/2025, revealed Resident #8's oxygen therapy was not care planned. <BR/>Review of Resident #8's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>During an observation on 01/30/2025 at 3:08 p.m., Resident #8 was observed asleep in bed. Resident #8 was observed wearing a nasal cannula with oxygen concentrator set at 3 liters. <BR/>Resident #13:<BR/>Record review of Resident #13's admission Record, dated 01/31/2025, reflected [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #13's History and Physical dated 06/08/2022, revealed diagnoses to include chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), and chronic respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body).<BR/>Record review of Resident #13's MDS dated [DATE], revealed a BIMS score of 05 indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #13 was receiving oxygen therapy. <BR/>Record review of Resident #13's Order Summary Report dated 01/31/2025, revealed an order with start time of 10/07/2024 for O2 via nasal cannula at 2 liters continuous to maintain saturation above 90%. <BR/>Review of Resident #13's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>Record review of Resident #13's comprehensive care plan dated 01/31/2025, revealed Resident #13's oxygen therapy was not care planned. <BR/>During an observation on 01/31/2025 at 8:42 a.m., Resident #13 was lying in bed asleep with nasal cannula on and oxygen set at 2 liters. No issues identified with oxygen concentrator or tubing. <BR/>During an interview on 01/29/2025 at 10:48 a.m., the ADON said all care plans should include oxygen therapy. The ADON said MDS Coordinator was responsible for care plans. The ADON said the facility had a recent change of ownership at the beginning of December 2024 and some information from previous care plans did not transition into the electronic health record at the time of the change. The ADON said many documents were printed but not readily available on the floor for staff. The ADON said the facility previously had two MDS Coordinators but now only have one. <BR/>During an interview on 01/30/2025 at 4:11 p.m., the MDS Coordinator said she was in charge of getting the care plans up to date. The MDS Coordinator said she had 21 days from admission to complete the comprehensive care plan. The MDS Coordinator said oxygen therapy should be care planned. The MDS Coordinator said for the last two months she was the only MDS Coordinator which had caused her to be backed up. The MDS Coordinator said some of the care plans had not been updated. The MDS Coordinator said the risk of care plans not being updated was possible risk of residents not receiving the necessary care or service.<BR/>Review of the facility-provided Patient Care Management System dated November 2017, revealed in part A Comprehensive, Person-centered Plan of Care, consistent with resident rights must be completed by the 21st day after admission. The care plan must be based on assessments completed within the previous 15 months in the Patient's/Resident's active record and use the results of the assessments to develop, review and revise the Patient's/Resident's comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue). <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00, indicating her cognition was severely impaired, and she was dependent on staff for transfers. <BR/>Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/ 2 person transfers with interventions that included safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate and goal was will remain free from injury. <BR/>In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes in place. The transfer was completed without incident, and no anxiety was observed.<BR/>In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included the resident swinging, tipping over, and possibly falling. CNA B stated she had received training on proper mechanical lift transfer procedures.<BR/>In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent movement and released only when ready to move the lift. The DON stated one CNA maneuvered the mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and quarterly random competency checks were conducted by the DON and lead CNA.<BR/>In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed by direct care staff who were trained at hire, annually, and as needed during competency checks. The Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated the risk of not following those steps included potential injury to the resident or staff. <BR/>Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked position on the wheelchair, shower or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 2 of 22 residents (Resident #16 and #178).<BR/>The facility failed to ensure resident call lights were within reach for 2 residents (Resident #16 and #178).<BR/>This failure placed residents at risk of having their needs unmet when they are unable to contact staff.<BR/>Findings included:<BR/>Resident #16 <BR/>Record review of Resident #16's face sheet dated 04/30/2025 revealed Resident #16 was originally admitted to facility on 02/10/2016 and readmitted on [DATE].<BR/>Record review of Resident #16's History and physical dated 05/08/24 revealed a [AGE] year-old female diagnosed with vascular dementia. <BR/>Record review of Resident #16's Quarterly MDS dated [DATE] revealed Resident #16's BIMS score was 02 indicating severe cognitive impairment. Resident needed Extensive assistance with bed mobility, transfers and toileting (resident involved in activity; staff provide weight bearing support). <BR/>Record review of Resident #16's care plan reviewed on 04/05/24 revealed she was at risk for falls, and interventions included to ensure call light is available to resident.<BR/>An observation on 04/28/25 at 10:15 a.m., revealed Resident #16's call light was pinned between two pillows that she was laying on top of. <BR/>Resident #178<BR/>Record review of Resident #178's face sheet dated 04/30/2025 revealed a [AGE] year-old male that was admitted to facility on 04/03/2025.<BR/>Record review of Resident #178's medical diagnosis list revealed, Resident #178 was diagnosed with cognitive communication deficit, and unspecified dementia. <BR/>Record review of Resident #178's Quarterly MDS dated [DATE] revealed no BIMS score. Resident was dependent( helper does all the effort) for toileting , bed mobility and transfers <BR/>Record review of Resident #178's care plan dated 04/05/2025 revealed he was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/ comprehension, unaware of safety needs. Interventions included to ensure call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. <BR/>An observation on 4/28/25 at 10:05 a.m., revealed Resident #178's call light was on the floor next to the head of the bed, while he was sleeping in bed. <BR/>In an interview on 04/30/2025 at 12:19 p.m., with the DON she said the call lights were for patients to be able to call for assistance. She stated call bells should be kept within residents' reach. She stated the CNA's, nurses and overall, all staff were responsible for ensuring residents call lights were within reach. She stated that if call lights were not kept within residents' reach, then residents could possibly not be able to call for help when needed. She stated that an Inservice for call lights was done recently. <BR/>In an interview with LVN A on 04/30/2025 at 12:50 p.m.,she said that the call lights were supposed to be within reach of all residents. She stated that all staff were responsible for ensuring call lights were within reach of residents. She stated that residents were rounded every 2 hours and as needed. She stated that if the call lights were not within reach of the resident, residents could sustain a fall, or they would not be able to call for help. She stated that the facility was always providing in-services regarding call lights, and she stated that the most recent was at the beginning of April 2025.<BR/>In an interview with CNA B on 4/30/25 at 1:00 p.m, she said that call lights were for residents to use to call for assistance and for staff to attend to them as soon as possible. She stated that call lights were to always be in reach of the resident. She stated that CNAs and nurses were responsible for ensuring call lights were always within reach for the residents. She stated that if call lights were not within reach, it could delay care and could result in a resident sustaining a fall. She stated that the facility was constantly conducting in-services on keeping call lights within reach and answering them in a timely manner, but she could not remember the most recent one. <BR/>Review of facility policy dated September 2022 and titled Call System, Resident read in part Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue). <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00, indicating her cognition was severely impaired, and she was dependent on staff for transfers. <BR/>Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/ 2 person transfers with interventions that included safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate and goal was will remain free from injury. <BR/>In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes in place. The transfer was completed without incident, and no anxiety was observed.<BR/>In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included the resident swinging, tipping over, and possibly falling. CNA B stated she had received training on proper mechanical lift transfer procedures.<BR/>In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent movement and released only when ready to move the lift. The DON stated one CNA maneuvered the mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and quarterly random competency checks were conducted by the DON and lead CNA.<BR/>In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed by direct care staff who were trained at hire, annually, and as needed during competency checks. The Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated the risk of not following those steps included potential injury to the resident or staff. <BR/>Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked position on the wheelchair, shower or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the residents' goals and preferences for one (Resident #30) of four residents reviewed for provision of respiratory care. <BR/> Resident #30 was not assisted in putting on her CPAP mask every night as per physician ' s orders. <BR/> This failure could result in residents having increased difficulty sleeping, decreased sleep quality, and increased instances of sleep apnea (a sleep disorder where breathing stops and starts). <BR/>Findings included: <BR/>Record review of Resident #30 ' s face sheet dated 03/14/2023 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #30 ' s History and Physical dated 02/21/2023 reveled she had diagnoses including COPD (Chronic Obstructive Pulmonary disease - a condition where airways are narrowed, and breathing is difficult); Chronic respiratory failure with hypoxia (a condition where airways are narrowed or damaged and there is reduced oxygen in the blood); Sleep disorder (changes in sleep that can negatively affect health.) Medications included a CPAP to be used nightly and 2 liters per minute of oxygen at night as needed. The History and Physical revealed that Resident #30 ' s family member said that facility staff was not placing her CPAP because the distilled water in the machine had not been used. The resident said she was not sleeping, although staff reported she was. <BR/>Record review of Resident #30 ' s quarterly MDS dated [DATE] revealed she had a BIMS of 9 (Moderate cognitive impairment). She had no symptoms of delirium or psychosis. She had no behavioral symptoms including rejection of care during the 7-day look back period. She had diagnoses including COPD or chronic lung disease, and Respiratory failure. The MDS indicated she was not receiving oxygen therapy. <BR/> Record review of Resident #30 ' s Care plan dated 01/26/2023 revealed she refused to use her C-Pap Machine. The goal was that her episodes of refusing to use the CPAP machine would diminish. Interventions included to report CPAP refusal to the physician, and explain why the CPAP was important. The Care Plan did not address the difficulty the resident had trying to put the CPAP machine on herself. <BR/>Record review of Resident #30 ' s physicians orders dated 11/15/2023 revealed she was to use a CPAP machine daily at bedtime. The physician's order dated 01/26/2024 revealed that her compliance with use of the CPAP machine was to be documented in progress notes and the physician was to be notified if she was noncompliant. <BR/>Record review of Resident #30 ' s progress note by LVN A dated 1/9/2024 revealed the resident was prompted throughout the night to keep her c-pap on with no success. The resident had intermittent labored breathing. <BR/> Record review of Resident #30 ' s MAR for February 2024 revealed she was non-complaint with use of the CPAP machine on 02/14/2024 and 02/23/2024. <BR/> Record review of Resident #30 ' s nursing progress notes February 2024 revealed no corresponding nursing notes regarding her refusal to use the CPAP machine as required by physician ' s order. <BR/>Record review of Resident #30 ' s MAR for March 2024 (03/01/2024 - 03/12/2024) revealed she had no instances of non-compliance with use of the CPAP machine. <BR/> Record review of Resident #30 ' s respiratory therapy report dated 03/14/2024 for 12/15/2023 - 03/13/2024 revealed she used the CPAP machine 33 out of 90 days and had not used the CPAP machine on 57 nights. During February 2024 she did not use the CPAP machine on 02/01, 02/02, 02/03, 02/04, 02/07, 02/09, 02/10, 02/14, 02/16, 02/17, 02/19, 02/22, 02/23, 02/24, 02/28 and 02/29/2024. Between 03/01/2024 and 03/13/2024 she did not use the CPAP machine the nights of 03/01, 03/02, 03/01, 03/08, 03/09, 03/11, 03/12 and 03/13/2024. <BR/>In an interview on 03/11/24 at 11:19 AM Resident #30 ' s family member said that staff were not putting the CPAP on the resident at night. The family member said a man came in to look at the machine and said they [nursing staff] do not put it on her. The resident said she had difficulty putting the CPAP mask by herself. <BR/>In a telephone interview on 03/14/24 at 09:28 AM Respiratory Therapist C revealed that he was familiar with Resident #30 and that he could provide records of her use of the CPAP machine. <BR/>In an interview on 03/14/24 at 11:34 AM Respiratory Therapist C revealed that review of Resident #30 Therapy Report documented that in March 2024 the resident did not have the CPAP mask on at all, and that between 12/15 and 3/13 she did not use the CPAP machine 57 times. The Respiratory Therapist state that not using the CPAP machine put Resident #30 at risk of poor sleep quality and increased instances of sleep apnea. <BR/>In an interview on 03/14/24 at 02:10 PM the DON revealed that nurse should be documenting if Resident #30 refused to use her CPAP machine. She stated that without the use of the CPAP machine the resident would be at increased risk of sleep apnea and might lose breathing at night. She said the nurses should be following physician ' s orders to document instances when Resident #30 refused to use the CPAP machine. <BR/>In an interview on 03/14/24 at 02:28 PM ADON D revealed she thought Resident #30 was generally compliant with all orders including use of the CPAP machine. She stated that noncompliance with use of the CPAP machine could result in Resident #30 ' s feeling winded, short of breath, and might exacerbate her COPD. <BR/>In an interview on 03/14/24 at 04:16 PM LVN A revealed that during the time she had worked with Resident 30, she had been told by other staff that the resident refused to use the CPAP machine. LVN A said she put the CPAP mask on Resident #30 herself because the resident was not able to put it on herself. The LVN said she had not had any difficulties with Resident #30 ' s use of the CPAP after educating the resident about the risks of not using the CPAP. The LVN said that if the resident did not want to put the machine on right away the LVN would go back and put it on her later in the evening. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #72) of 8 residents reviewed for baseline care plans.<BR/>Resident #72 physician's progress note dated 01/16/2023 indicated that she was being admitted to the facility for pain control, but her baseline care plan did not address pain management. <BR/>This failure could put residents at risk of not receiving pain management.<BR/>Findings include:<BR/>Record review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident had an acute compression fracture at T12 [a broken vertebrae]. She had mostly severe pain, 9-10 on pain scale, constant with slight variation . and was to be admitted to the facility for pain management and physical therapy. <BR/>Record review of Resident #72's nurse progress note dated 01/24/2023 at 12:28 PM documented that the resident had abdominal pain and that the physician had ordered a KUB (X-ray study of urinary and gastrointestinal systems). <BR/>Record review of Resident #72's physician's note dated 01/25/2022 documented that the resident had abdominal pain with nausea which she rated as a 4 out of 10. <BR/>Record review of Resident #72's electronic diagnosis listing accessed on 02/08/2023 documented that she had diagnoses including wedge compression fracture of T11-T12 vertebra [broken vertebrae], subsequent encounter for fracture with routine healing; unspecified displaced fracture of surgical neck of right humerus [broken arm], subsequent encounter for fracture with routine healing; pain, unspecified; and chronic pain due to trauma. <BR/>Record review of Resident #72's Physician's Orders List dated 02/08/2023 documented an order dated 01/23/2023 that she was to receive 50 MG of tramadol (a pain medication) every 8 hours as needed for pain, an order for one gram of diclofenac sodium 1% gel (for pain) was to be applied to the affected area twice a day for pain, and an order dated 01/23/2023 for 5 MG of baclofen (a medicine used for muscle spasms and pain) every 8 hours as needed for pain. <BR/>Record review of Resident #72's care plan on 02/08/2023 at 5:16 PM, documented no care plan to address pain. <BR/>In interview and observation on 02/08/23 at 09:09 AM, Resident #72 was observed sitting in bed holding her lower abdomen and moaning. She was breathing heavily and so was having difficulty speaking. She said that she had lots of pain across her lower abdomen. She said that staff had brought her medicine for pain that morning but that she threw it up when she took the medicine. She said that she had pain even when she slept and that the therapy staff got mad when she could not participate because of her pain. She said that her right arm had been broken, that it had been fixed, but it was broken again, and it caused her pain. <BR/>In an interview on 02/08/2023 at 9:25 AM, NA F said that Resident #72 always complained of pain in her stomach and her right hand. The NA said that she always reported the resident's pain to the nurse. <BR/>In an interview on 02/08/23 at 09:43 AM, LVN G said that she was aware of Resident #72's pain which was chronic due to gall stones. She said the pain was in the resident's flank (between the lower ribs and the top of the hips) and radiated to her hips. The LVN said that the resident received pain medication although she sometimes refused it because of nausea. <BR/>Record review of Resident #72's revised care plan dated 02/09/2023 documented in part multiple changes to the resident's care plan on 02/09/2023 which included the addition of a pain-focused care plan. The care plan for pain documented that she was at risk for pain due to arthritis. Five interventions were listed including that pain medication was to be administered, and she was to be monitored for worsening of pain and the physician was to be notified of changes. All interventions were dated 02/09/2023. <BR/>In an interview on 02/08/2023 at 7:15 PM MDS Nurse C said that at admission the baseline care plan was created by reviewing diagnoses, orders and other information such as resident's COVID-19 status and record of falls. The MDS nurse said she had seven days from admission to complete the baseline care plan. She said that she did not know if Resident #72 had issues with pain control because she was not directly responsible for creating care plans for residents who were receiving skilled services such as resident #72. MDS Nurse C said that currently a nurse from the corporate level was trying to help with the care plans for skilled residents. When asked about changes to Resident #72's care plan dated 02/09/2023 she was not able to say who had made changes to include pain in the care plan. <BR/>Record Review of the facility policy Care Plans - Comprehensive (undated) documented that care plans would incorporate risk factors associated with identified problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents has a right to a dignified existence for 1 resident (Resident #2) out of 14 reviewed for rights to a dignified existence in that: <BR/>Therapy Staff G told Resident #2 she should be working and not talking, and that tape would be put on her mouth if she continued to talk, leaving Resident #2 feeling embarrassed, and reluctant to talk to anyone while involved in therapy. <BR/>This failure could result in residents feeling embarrassed, reluctant to talk and reluctant to engage in therapy, affecting their progress in achieving their goals for rehabilitation. <BR/>Finding include: <BR/>Closed record review of Resident #2's face sheet dated 03/27/2024 revealed that she was [AGE] years old, was admitted to the facility on [DATE] and discharged home on [DATE]. <BR/>Closed record review of Resident #2's history and physical dated 02/22/2024 revealed she had a total left knee replacement on 02/15/2024 and had her gallbladder removed on 02/17/2024. Treatment plans included evaluation by physical and occupational therapy. <BR/>Closed record review of Resident #2's admission MDS dated [DATE] revealed she had a BIMS score of 13 (cognitively intact). She had no symptoms of delirium, depression or psychosis and had no behavioral symptoms. She required She required substantial assistance for lower body dressing and putting on/taking off foot wear. She required moderate assistance for toileting and bathing. She recently had knee replacement surgery. She had received 318 minutes of occupational therapy starting on 02/22/2024 and 311 minutes of physical therapy starting on 02/22/2024. <BR/>Closed record review of Resident #2's care plan dated 02/24/2024 revealed she was at risk for falls. Interventions included to be referred to physical therapy for evaluation. Care plan dated 02/24/2024 stated she required staff assistance with bathing. The physical therapist was to work with her on transfers and ambulation, and the occupational therapist was to work with her on ADL re-training. Care Plan dated 02/24/2024 stated she required assistance for some ADL's. Nursing and nursing assistants were to encourage the resident to participate with PT and OT as ordered.<BR/>Closed record review of Resident #2's physician's orders dated 02/22/2024 revealed she was to be evaluated by physical therapy and occupational therapy and treated as needed. <BR/>Closed record review of Resident #2's Resident Incident Report dated 03/14/2024 revealed that on 03/14/2024 Resident #2's family member reported to the social worker that during the first week of therapy a male therapist (discipline not identified) had placed a piece of tape over the resident's mouth while doing therapy. The family member reported that Resident #2 was talking with two male residents (Resident #12 and an unidentified resident.) Resident #2 was examined with no new injuries/bruises or skin issues identified. <BR/>Record review of social services interview summaries dated 03/14/2024 revealed that during an interview with Resident #2, the resident said that during her first week of therapy she was on the exercise bike talking with two male residents [Resident 12 and an unidentified resident] , when a therapist approached her and placed yellow paper tape over her mouth.<BR/>Record review of a written statement dated 03/14/2024 by Therapy Staff G revealed he that at some point between 02/25/2024 and 03/01/2024 he playfully told Resident #2 .we need more work and less talking . after which Therapy Staff G jokingly said .we use tape . The written statement said Resident #2 laughed and continued exercising. <BR/>Record review of Therapy Staff G's employee record revealed that the criminal history check and EMR/NAR checks had been conducted as required and that no concerns were identified. <BR/>Record review of grievances revealed no grievances had been raised regarding Therapy Staff G besides the one that was brought to the attention of the facility on 03/14/2024. The grievance documentation .<BR/>In an interview on 04/01/ 2024 at 8:28 AM, the family member of Resident #2 said she was not able to pinpoint when the incident occurred. She said Resident #2 reported that she was in the therapy room and greeted two male residents. She said hello to one and the other resident asked why she did not say hello to him. She started to explain when Therapy Staff G said, Here we don't talk, and put tape on her mouth. The resident reported to her family member that it made her very embarrassed. The resident told her family member she did not remember who removed the tape from her mouth because she was focused on remembering not to speak, and that she thought about the incident all day. The resident said the tape placed on her mouth was white. <BR/>In observation, record review and interview on 04/01/2024 at 9:09 AM with the Rehabilitation Director, the therapy room was inspected for tape of any kind. No tape was observed except for scotch tape. Record review revealed that Resident #2 received occupational therapy services from Therapy Staff G daily from 2/26 - 2/29/24, 3/1 - 3/4/24, 3/8/24 and 3/11 - 3/14 2024. The the Rehabilitation Director said she had not heard of any concerns regarding Therapy Staff G except the alleged incident with Resident #2. The Rehab Director said she had been advised of the allegation by the facility Administrator who investigated the allegation. She stated that since therapy services were provided through contract with the facility, information about the allegation had also been passed along her supervisor. The Rehabilitation Director stated that Therapy Staff G was suspended for one day during the investigation of the allegation, and that she spoke to Therapy Staff G and took his statement regarding the incident. The Rehabilitation Director counseled Therapy Staff G about professionalism. The Rehabilitation Director discussed the allegations with other employees, but no one said they had heard or seen this event. There was no camera in the therapy room. <BR/>In an interview on 04/01/2024 at 9:30 AM Therapy Staff H said she had never heard or said that a resident's mouth would be taped. She said that the last time there had been tape in the therapy room was over a year ago. She said it was kinesiology tape, and it was never white. <BR/>In an interview on 04/01/2024 at 9:33 AM Therapy Staff I said he had never heard or said that they would tape a resident's mouth for any reason. <BR/>In an interview on 04/01/2024 at 10:15 AM, Therapy Staff G revealed that he remembered working with Resident #2. He said that Resident #2 was initially very quiet, but that during the last few weeks before her discharge, she became more talkative. Therapy Staff G said he was joking with Resident #2 during the 2-3 weeks before her discharge. He revealed he told Resident #2 Menos platicar y mas tarbajar, si no se [NAME] tape asi [Less talking and more work, if not we put a tape like this] - and that he gestured to the resident putting tape over his mouth. Therapy Staff G said both he and Resident #2 laughed and that was it. Therapy Staff G stated he did not use tape in his work, and that there was no tape in the vicinity of the residents in the therapy room. Therapy Staff G's time log was reviewed with him, but he was unable to pinpoint the time frame during which the incident took place. He denied putting tape on Resident #2's mouth and denied showing her a piece of tape. He stated that if he put tape on her mouth would most likely be considered abuse. <BR/>In a follow-up interview on 04/01/2024 at 10:34 AM, Resident #2's family member said that if the type of tape used was scotch tape, the resident would have mentioned it. <BR/>In a telephone interview on 04/01/2024 at 10:48 AM, Resident #2 revealed she received therapy for her arms. She said she did not remember the therapists but that they treated her well. Resident #2 said the therapists did not joke around with her. She said Therapy Staff G put tape on her mouth that was like packing tape, not scotch tape. She said she did not see anyone else with tape on their mouths. She said there were other residents and workers in the room at the time of the incident but did not remember who they were. She stated that the incident embarrassed her, and she did not talk to anyone in therapy anymore except to say hello and good morning. Resident #2 was not able to recall remember when the incident occurred but thought it was in the middle of her stay at the facility.<BR/>In an interview on 04/01/2024 at 11:13 AM, Resident #12 revealed he was receiving therapy for his arms and legs. He said he sometimes chatted with the residents. He said he had not been told not to talk to other residents. Resident #12 said he had not heard a therapist tell another resident they should not be talking and had not seen therapists using tape. He said he had not seen therapists put tape on someone's mouth. <BR/>In an interview on 04/01/2024 at 11:52 AM, Resident #15 revealed she was getting physical therapy and that the workers treated her with dignity and respect. <BR/>In an interview on 04/01/2024 at 11:55 AM, Resident #16 said he had been in the facility since December and was getting all forms of therapy. He said the therapists treated him well. He had not seen them use tape in therapy and had not been told he could not talk. He said he had not seen therapists use tape on resident's mouths. <BR/>In an interview on 04/01/2024 at 12:00 PM Resident #17 said she received occupation and physical therapy. She said she had worked with Therapy Staff G and he was nice. She said that all the therapy staff joked around. She said no tape had been used with her or other residents, and that she had not been told not to talk. <BR/>In an interview on 04/01/2024 at 12:05 PM the family member of Resident #18 said she had been with the resident to therapy a few times. The family member said the therapy staff treated the resident with dignity and respect. She had not seen the therapists use tape with anyone and had not heard them tell anyone not to talk. She did the therapist who provided services to the resident was a woman. <BR/>Record review of the facility policy Resident Rights (undated) revealed employees shall treat all residents with kindness, respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 14 residents reviewed for neglect in that: <BR/>Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A who was responsible for Resident #1 did not know the process and procedures that were to be followed when a full-code resident was found unresponsive, resulting in the resident not being provided CPR. <BR/>An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. While the IJ was removed on [DATE] at 6:55 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm, because all staff had not been trained on Emergency Response Procedure and Calling a Code. <BR/>These failures could place residents at risk for serious injury, hospitalization and/or death.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated [DATE] revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged on [DATE] due to death in the facility. The face sheet did not indicate his code status. <BR/>Record review of Resident #1's history and physical dated [DATE] revealed he had diagnoses including coronary artery disease (damage or disease of the hearts major blood vessels), osteomyelitis (infection in the bone), Diabetes mellitus with hyperglycemia (Diabetes with high blood sugar), hypertension (high blood pressure, vascular dementia (dementia caused by blood clots in the brain) and hemiparesis affecting left side as late effect of cerebrovascular accident (Stroke affecting his left side). <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 8 (moderate cognitive impairment). He had symptoms of delirium including fluctuating periods of inattention and disorganized thinking. He had symptoms of psychosis including hallucinations (seeing something that is not actually there). He had no symptomatic behaviors. He was dependent on staff for toileting, bathing, dressing, personal hygiene, sitting up, and transferring between surfaces. <BR/>Record review of Resident #1's care plan dated [DATE] revealed he was a full code status, that the facility would honor his wishes regarding code status and attempt to resuscitate him should arrest occur. His physician would be contacted, emergency services would be notified, and family would be notified. <BR/>Record review of Resident #1's physician's orders dated [DATE] revealed no orders concerning his code status. <BR/>Record review of Resident #1's Advance Directives information in his electronic record accessed [DATE] revealed his CPR (Resuscitation) Status was Attempt CPR. <BR/>Record review of Resident #1's progress note dated [DATE] at 10:53 AM by RN A documented the following Resident found unresponsive by this nurse, initially attempted vitals but was unsuccessful, CPR initiated immediately, code cart brought to room, AED in place with commands initiated, 911 called, CPR continued till EMS arrived and took over. DON, Administrator, and MD notified. Family called and updated. All questions and concerns addressed.<BR/>Record review of the fire department's Hospital Care Report for Resident #1 dated [DATE] beginning at 7:55:12 AM revealed that paramedics were dispatched to the facility at 7:56 AM and arrived at the resident's bedside at 8:07 AM. The resident was pale and cold, pulseless and apneic (not breathing) and facility staff were performing compressions. Facility staff reported to the paramedics they noticed the resident was not breathing at around 7:20 AM and had called 911 around 7:55 AM. The paramedics took over compressions, established IV (needle in a vein) access, placed oxygen on the resident and administered epinephrine (adrenaline) and normal saline. The patient (Resident #1) was found in asystole (without a heartbeat) and remained in the same cardiac rhythm. The paramedics contacted physician (unidentified) who gave permission to discontinue ALS (Advance Life Support) interventions. CPR was discontinued on [DATE] at 8:17 AM. The paramedics advised the nurse at the facility of the doctor's orders, and the paramedics left. The resident was not transported from the facility.<BR/>Record review of the facility's self-report Intake Investigation Worksheet dated [DATE] revealed an allegation of neglect because RN A found Resident #1 unresponsive on [DATE] at 7:38 AM but did not initiate CPR until 16 minutes later at 7:55 AM. <BR/>In an interview on [DATE] at 8:31 AM, the ADON revealed she received a telephone call at 7:40 AM on [DATE] from the DON that RN A had texted the DON at 7:38 AM that Resident #1 had expired. The DON asked the ADON to go to the facility to initiate CPR and call 911. The ADON stated she arrived at the facility at 7:54 AM and found RN A at the nurse's station at the front of the building. Per the ADON she asked RN A who was with Resident #1 and RN A said No one. The ADON stated she then ran to Resident #1's room with RN A and when she arrived the crash cart was in the resident's room but there were no staff members there. The ADON said she called 911 at 7:55 AM while RN A initiated CPR assisted by LVN D, and CNAs C and E who had arrived at the room by then. Per the ADON, CNA C had gone into Resident #1's room to get him up for breakfast, found him unresponsive, and notified RN A. The ADON stated she asked RN A why CPR was not initiated, and RN A said that he was already cold and grey, and that she (RN A) did not know what to do, that this type of situation was handled differently in the hospital where she had worked before. [RN A date of hire [DATE]]. The ADON stated that RN A had not alerted other nurses in the facility about Resident #1's condition. She said that an investigation was done, with RN A being suspended and later terminated in response to the investigation. <BR/>In an interview on [DATE] at 12:39 PM, the DON revealed that when CNA C told RN A that Resident #1 was unresponsive and the RN found the resident unresponsive, the RN should have started the code. She said the Code Blue procedure involved the nurse getting help from other staff in announcing Code Blue on the intercom, taking the crash cart and AED to the resident's room, and calling 911 while responding nurses and other responding staff would place a back board under the resident, start chest compressions, place and use the ambu-bag (bag used to help a patient's breathing), place the AED pads on the patient's chest and follow instructions from the AED machine. The DON said that that these compressions, use of the ambu-bag and following instructions from the AED should continue until paramedics arrived to take over the situation. She said that RN A was suspended pending investigation of the incident, and later was terminated. <BR/>In an interview on [DATE] at 4:59 PM the DON revealed that the facility had not done any training about how to respond to this type of emergency [an unresponsive patient who is full-code], because nothing like this had happened before. She stated that nurses learned about CPR in outside classes when they got their CPR cards renewed. <BR/>Telephone attempts to reach RN A were made on [DATE] at 9:34 AM, and on [DATE] at 8:15 AM, 9:21 AM, and 11:24 AM with no response although requests for a return call were left in her digital mailbox. <BR/>Record review of RN A's personnel file revealed she was hired on [DATE]. She initialed a New Hire Orientation Acknowledgement that included location and information about the AED on [DATE].<BR/>In an interview on [DATE] at 8:31 AM, LVN D said she became aware of the incident involving Resident #1 before breakfast on [DATE] when RN A came to her asking what the procedure was when a resident was found with no vital signs. LVN D said RN A was not sure if Resident #1 had a DNR order or had a full code status. LVN D said she went to the nurse's station and found a green sheet of paper in his file [denotes full code status] and then looked in his electronic chart which also showed he had a full code status. LVN D said when she discovered Resident #1 had a full-code status she ran to get the crash cart and AED, took them to Resident #1's room. LVN D stated when she arrived at Resident #1's room the room was empty. LVN D said she and RN A arrived at the resident's room together and put the board under his back, opened the AED and placed patches on the resident, started CPR. LVN D said the AED did not shock him. At some point the ADON arrived and was using the ambu-bag. LVN D was not able to state when the ADON arrived. <BR/>In an interview on [DATE] at 8:56 CNA E revealed that the morning of [DATE] around 7:25 AM, she was walking down the 400 hall when CNA C came out of Resident #1's room and said he was not moving. CNA E said she looked at Resident #1 who looked grey and was cold to the touch. CNA E said she and CNA C stepped outside the room where RN A had her cart and told the RN that she needed to go into the room because Resident #1 was gone. CNA E said the RN went into Resident #1's room, touched the resident, and pulled the sheet over his head. CNA E said she told the RN Don't do that and the RN pulled the sheet back down. CNA E said the RN then left the room and once outside asked the CNA (CNA E) what the procedure was. CNA E said she did not respond to the RN's question but instead told CNA C what the CNAs did when told by a nurse that a resident had died (wash the body, change the linens, use a towel to close the mouth). <BR/>In a telephone interview on [DATE] at 10:52 AM, CNA C revealed she arrived for work on [DATE] around 6:00 AM and began her work. After readying several residents for breakfast, she asked RN A what she needed to for Resident #1. RN A told her to get him up for breakfast, but when CNA C entered Resident #1's room to begin getting him ready, she saw that the resident's face and hands were discolored, and his mouth was wide open. The CNA said she looked at the resident's chest and did not see him breathing. CNA C said she walked out of room and told RN A something was wrong with Resident #1, that he was not breathing and was not ok. CNA C said she went with RN A into Resident #1's room and saw the RN check the resident's pulse and breathing. The CNA followed the RN out of the resident's room where RN A was heard asking CNA E what the procedure was because it was different in different states. CNA C stated she was later going to the dining room to help with breakfast when she saw the ADON, RN A and LVN D go to Resident #1's room with the crash cart. She followed them to the resident's room where she observed the three nurses place the back board, start chest compressions, attach the AED to the resident, and begin use of the ambu-bag. <BR/>In an interview on [DATE] at 4:22 PM, LVN F revealed that on [DATE] before breakfast (was not able to give specific time) she heard unidentified staff members saying that Resident #1 had expired. LVN F said she was surprised because no one had called a Code Blue. LVN F said she went to Resident #1's room where LVN D, RN A and CNA C were beginning to place the back board under the resident and to start compressions. <BR/>Record review of the facility's policy Emergency Procedure - Cardiopulmonary Resuscitation dated 02/2018 revealed that if an individual is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/Basic life support) shall initiate CPR unless it is know that a DNR order that specifically prohibits CPR and/or external defibrillation exists for the individual. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR order or a physician's order to not administer CPR. <BR/>Record review of the facility's policy Abuse and Neglect - Clinical Protocol dated [DATE] revealed that the definition of neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The physician and staff will help identify risk factors for abuse within the facility such as those related to staffing such as poor preparation, training, and lack of knowledge or skills that might affect how the residents are being cared for. Staff and management will help identify situations that might constitute or could be construed as neglect such as inattention to advance directives. <BR/>This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:25 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 10:25 AM.<BR/>The Plan of Removal was accepted on [DATE] at 12:12 PM: <BR/>[DATE]<BR/>Employee was interview and statement taken. <BR/>This was completed by [DON name] RN, DON and [ADON name] LVN, ADON on [DATE].<BR/>Met with Administrator and decision was made to suspend employee same day on [DATE].<BR/>This was completed by [DON name] RN, DON and [Administrator name], Administrator on [DATE].<BR/>Investigation begin by interviewing staff members and taking written statements.<BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>[DATE]<BR/>Full code and DNR audit were completed to ensure, physician order, code status icon and correct colored paper (green or red) is in chart for all residents. <BR/>This was completed by [LVN B Name] LVN, Medical records on [DATE].<BR/>Continued to take statements from staff members. <BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>Audit CPR certification for nurses completed<BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>CPR certification class was scheduled for Thursday [DATE] at 1:30pm.<BR/>This was completed by [ADON name] LVN, ADON on [DATE].<BR/>In-service on where to find a residents' code status provided to staff.<BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>[DATE]<BR/>In-services on ''Emergency response procedure, calling a code'' provided to staff.<BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>Continue investigation by taking staff statements. <BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>[DATE]<BR/>In-services continued on ''Emergency response procedure, calling a code''<BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>Continue investigation by taking staff statements. <BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>[DATE]<BR/>Continue investigation by taking staff statements. <BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>[DATE]<BR/>In-serviced nurses about what to do when a patient is full code or DNR and found with no signs of life. <BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>Facilities Plan to ensure compliance quickly<BR/>[DATE]<BR/>Staff in-service on ''Abuse and neglect'' and ''Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support''. Staff members will not assume any job responsibilities until training has been received by DON/designee<BR/>This was completed by [DON name] RN/DON on [DATE].<BR/>This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards to knowledge about abuse and neglect and how to reach/do in a code blue situation.<BR/>DON/designee will report monthly to QAPI<BR/>[DATE] and ongoing <BR/>CPR certification class and emergency mock drill training provided on [DATE] at 1:30pm. <BR/>Will be completed by [Business owner's name] (Owner of [Business name and location]).<BR/>This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. <BR/>DON/designee will report monthly to QAPI<BR/>Ongoing <BR/>Emergency mock drills training quarterly.<BR/>Will be completed by [Business owner's name] (Owner of [Business name and location]).<BR/>This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. <BR/>DON/designee will report monthly to QAPI<BR/>Plan of Removal was verified a follows: <BR/> - Confirmed through interview and record review (DON, [DATE] 4:59 PM; HR Manager [DATE], 9:43 AM) that alleged perpetrator was interviewed, suspended and terminated. <BR/> - Through interview with 3 LVNs from 6 AM to 6 PM shift and two LVNs from 6 PM to 6 AM shift confirmed understanding of training regarding response to resident without signs of life (LVN F, [DATE] 4:22 PM; LVNs - [DATE] 9:04AM, [DATE] 2:22 PM, 5:08 PM, 5:16 PM.) <BR/> - Confirmed through interview (Medical Records Director, [DATE] at 3:11 PM) that an audit was performed on all resident records to ensure accuracy of resident code status; confirmed through record review of residents physical and electronic charts ([DATE] at 4:04 PM) the accuracy of resident code status for 12 sample residents (Census of 75).<BR/> - Confirmed through record review (audit listing with nurse's names and CPR expiration dates) and interview (DON [DATE], 5:05 PM) that nurses' CPR training status was audited, and that the facility has taken action to train one nurse whose CPR training was expired. <BR/> - Confirmed through observation (Group trainings observed [DATE], at 2:07 PM, 2:50 PM, 3:58 PM), interview (DON [DATE] at 5:05 PM) and documentation (Inservice sign-ins dated [DATE], [DATE], [DATE], [DATE]) that trainings regarding calling a code and regarding determining a resident's code status as identified in the plan of removal were provided. <BR/> - Confirmed through interview (Administrator [DATE] 3:30 PM) and record review (Service Agreement dated [DATE]) that the facility entered into a service agreement with a provider of BLS and First aid/CPR/AED courses.<BR/> - Confirmed through interview and record review that ANE training is provided to employees and through interviews with 13 staff (RN (DON [DATE] 5:05 PM; RN [DATE] 2:03 PM), LVN (LVN F, [DATE] 4:22 PM; LVNs [DATE], 5:08 PM, 5:16 PM, CNAs - [DATE] at 10:52, [DATE], 1:52 PM, 1:59 PM, 2:33 PM, 2:57 PM, 3:07 PM, 3:30 PM; 3:40 PM), Restorative Aide ([DATE], 2:11 PM), Activities Director ([DATE], 2:16 PM) understanding of the concept of neglect.<BR/> - Confirmed through interview that employees (DON [DATE] 5:05 PM) who have not completed Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support training will not assume job responsibilities until training has been done. <BR/>The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:55 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure personnel provided 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 (Resident #1) of 14 residents reviewed for physician's orders for provision of basic life support in that: <BR/>Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A went to the resident's room and checked him for signs of life but did not know how to respond when she did not find a pulse, and did not immediately start CPR or other life-sustaining measures, resulting in Resident #1's wishes to be resuscitated not being honored. <BR/>An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. While the IJ was removed on [DATE] at 6:55 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm, because all staff had not been trained on Emergency Response Procedure and Calling a Code. <BR/>These failures could place residents at risk for serious injury, hospitalization and/or death.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated [DATE] revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged on [DATE] due to death in the facility. The face sheet did not indicate his code status. <BR/>Record review of Resident #1's history and physical dated [DATE] revealed he had diagnoses including coronary artery disease (damage or disease of the hearts major blood vessels), osteomyelitis (infection in the bone), Diabetes mellitus with hyperglycemia (Diabetes with high blood sugar), hypertension (high blood pressure), vascular dementia (dementia caused by blood clots in the brain) and hemiparesis affecting left side as late effect of cerebrovascular accident (Stroke affecting his left side). <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 8 (moderate cognitive impairment). He had symptoms of delirium including fluctuating periods of inattention and disorganized thinking. He had symptoms of psychosis including hallucinations (seeing something that is not actually there). He had no symptomatic behaviors. He was dependent on staff for toileting, bathing, dressing, personal hygiene, sitting up, and transferring between surfaces. <BR/>Record review of Resident #1's care plan dated [DATE] revealed he was a full code status, that the facility would honor his wishes regarding code status and attempt to resuscitate him should arrest occur. His physician would be contacted, emergency services would be notified, and family would be notified. <BR/>Record review of Resident #1's physician's orders dated [DATE] revealed no orders concerning his code status. <BR/>Record review of Resident #1's Advance Directives information in his electronic record accessed [DATE] revealed his CPR (Resuscitation) Status was Attempt CPR. <BR/>Record review of Resident #1's progress note dated [DATE] at 10:53 AM by RN A documented the following Resident found unresponsive by this nurse, initially attempted vitals but was unsuccessful, CPR initiated immediately, code cart brought to room, AED in place with commands initiated, 911 called, CPR continued till EMS arrived and took over. DON, Administrator, and MD notified. Family called and updated. All questions and concerns addressed.<BR/>Record review of the fire department's Hospital Care Report for Resident #1 dated [DATE] beginning at 7:55:12 AM revealed that paramedics were dispatched to the facility at 7:56 AM and arrived at the resident's bedside at 8:07 AM. The resident was pale and cold, pulseless and apneic (not breathing) and facility staff were performing compressions. Facility staff reported to the paramedics they noticed the resident was not breathing at around 7:20 AM and had called 911 around 7:55 AM. The paramedics took over compressions, established IV (needle in a vein) access, placed oxygen on the resident and administered epinephrine (adrenaline) and normal saline. The patient (Resident #1) was found in asystole (without a heartbeat) and remained in the same cardiac rhythm. The paramedics contacted physician (unidentified) who gave permission to discontinue ALS (Advance Life Support) interventions. CPR was discontinued on [DATE] at 8:17 AM. The paramedics advised the nurse at the facility of the doctor's orders, and the paramedics left. The resident was not transported from the facility.<BR/>Record review of the facility's self-report Intake Investigation Worksheet dated [DATE] revealed an allegation of neglect because RN A found Resident #1 unresponsive on [DATE] at 7:38 AM but did not initiate CPR until 16 minutes later at 7:55 AM. <BR/>In an interview on [DATE] at 8:31 AM, the ADON revealed she received a telephone call at 7:40 AM on [DATE] from the DON that RN A had texted the DON at 7:38 AM that Resident #1 had expired. The DON asked the ADON to go to the facility to initiate CPR and call 911. The ADON stated she arrived at the facility at 7:54 AM and found RN A at the nurse's station at the front of the building. Per the ADON she asked RN A who was with Resident #1 and RN A said No one. The ADON stated she then ran to Resident #1's room with RN A and when she arrived the crash cart was in the resident's room but there were no staff members there. The ADON said she called 911 at 7:55 AM while RN A initiated CPR assisted by LVN D, and CNAs C and E who had arrived at the room by then. Per the ADON, CNA C had gone into Resident #1's room to get him up for breakfast, found him unresponsive, and notified RN A. The ADON stated she asked RN A why CPR was not initiated, and RN A said that he was already cold and grey, and that she (RN A) did not know what to do, that this type of situation was handled differently in the hospital where she had worked before. [RN A date of hire [DATE]]. The ADON stated that RN A had not alerted other nurses in the facility about Resident #1's condition. She said that an investigation was done, with RN A being suspended and later terminated in response to the investigation. <BR/>In an interview on [DATE] at 12:39 PM, the DON revealed that when CNA C told RN A that Resident #1 was unresponsive and the RN found the resident unresponsive, the RN should have started the code. She said the Code Blue procedure involved the nurse getting help from other staff in announcing Code Blue on the intercom, taking the crash cart and AED to the resident's room, and calling 911 while responding nurses and other responding staff would place a back board under the resident, start chest compressions, place and use the ambu-bag (bag used to help a patient's breathing), place the AED pads on the patient's chest and follow instructions from the AED machine. The DON said that that these compressions, use of the ambu-bag and following instructions from the AED should continue until paramedics arrived to take over the situation. She said that RN A was suspended pending investigation of the incident, and later was terminated. <BR/>In an interview on [DATE] at 4:59 PM the DON revealed that the facility had not done any training about how to respond to this type of emergency [an unresponsive patient who is full-code], because nothing like this had happened before. She stated that nurses learned about CPR in outside classes when they got their CPR cards renewed. <BR/>Telephone attempts to reach RN A were made on [DATE] at 9:34 AM, and on [DATE] at 8:15 AM, 9:21 AM, and 11:24 AM with no response although requests for a return call were left in her digital mailbox. <BR/>Record review of RN A's personnel file revealed she was hired on [DATE]. She initialed a New Hire Orientation Acknowledgement that included location and information about the AED on [DATE].<BR/>In an interview on [DATE] at 8:31 AM, LVN D said she became aware of the incident involving Resident #1 before breakfast on [DATE] when RN A came to her asking what the procedure was when a resident was found with no vital signs. LVN D said RN A was not sure if Resident #1 had a DNR order or had a full code status. LVN D said she went to the nurse's station and found a green sheet of paper in his file [denotes full code status] and then looked in his electronic chart which also showed he had a full code status. LVN D said when she discovered Resident #1 had a full-code status she ran to get the crash cart and AED, took them to Resident #1's room. LVN D stated when she arrived at Resident #1's room the room was empty. LVN D said she and RN A arrived at the resident's room together and put the board under his back, opened the AED and placed patches on the resident, started CPR. LVN D said the AED did not shock him. At some point the ADON arrived and was using the ambu-bag. LVN D was not able to state when the ADON arrived. <BR/>In an interview on [DATE] at 8:56 CNA E revealed that the morning of [DATE] around 7:25 AM, she was walking down the 400 hall when CNA C came out of Resident #1's room and said he was not moving. CNA E said she looked at Resident #1 who looked grey and was cold to the touch. CNA E said she and CNA C stepped outside the room where RN A had her cart and told the RN that she needed to go into the room because Resident #1 was gone. CNA E said the RN went into Resident #1's room, touched the resident, and pulled the sheet over his head. CNA E said she told the RN Don't do that and the RN pulled the sheet back down. CNA E said the RN then left the room and once outside asked the CNA (CNA E) what the procedure was. CNA E said she did not respond to the RN's question but instead told CNA C what the CNAs did when told by a nurse that a resident had died (wash the body, change the linens, use a towel to close the mouth). <BR/>In a telephone interview on [DATE] at 10:52 AM, CNA C revealed she arrived for work on [DATE] around 6:00 AM and began her work. After readying several residents for breakfast, she asked RN A what she needed to for Resident #1. RN A told her to get him up for breakfast, but when CNA C entered Resident #1's room to begin getting him ready, she saw that the resident's face and hands were discolored, and his mouth was wide open. The CNA said she looked at the resident's chest and did not see him breathing. CNA C said she walked out of room and told RN A something was wrong with Resident #1, that he was not breathing and was not ok. CNA C said she went with RN A into Resident #1's room and saw the RN check the resident's pulse and breathing. The CNA followed the RN out of the resident's room where RN A was heard asking CNA E what the procedure was because it was different in different states. CNA C stated she was later going to the dining room to help with breakfast when she saw the ADON, RN A and LVN D go to Resident #1's room with the crash cart. She followed them to the resident's room where she observed the three nurses place the back board, start chest compressions, attach the AED to the resident, and begin use of the ambu-bag. <BR/>In an interview on [DATE] at 4:22 PM, LVN F revealed that on [DATE] before breakfast (was not able to give specific time) she heard unidentified staff members saying that Resident #1 had expired. LVN F said she was surprised because no one had called a Code Blue. LVN F said she went to Resident #1's room where LVN D, RN A and CNA C were beginning to place the back board under the resident and to start compressions. <BR/>In an interview and record review on [DATE] at 3:45 PM with the Administrator and the DON, the Administrator revealed that nurses are given a one-day orientation to the facility policies, and three days of orientation on the floor with experienced nurses regarding protocol to make sure nurses are ready to work the floor. The DON then signs the paperwork regarding orientation. The Administrator stated that that the orientation with experienced nurses on the floor included the AED, the Crash Cart and how to determine code status. When asked when the crash cart and determining code status were not included on the orientation check list, the Administrator stated that the AED is on the orientation check list, and the Crash Cart was in the same area as the AED. <BR/>Record review of the facility's policy Emergency Procedure - Cardiopulmonary Resuscitation dated 02/2018 revealed that if an individual is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/Basic life support) shall initiate CPR unless it is know that a DNR order that specifically prohibits CPR and/or external defibrillation exists for the individual. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR order or a physician's order to not administer CPR. <BR/>Record review of the facility's policy Abuse and Neglect - Clinical Protocol dated [DATE] revealed that the definition of neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The physician and staff will help identify risk factors for abuse within the facility such as those related to staffing such as poor preparation, training, and lack of knowledge or skills that might affect how the residents are being cared for. Staff and management will help identify situations that might constitute or could be construed as neglect such as inattention to advance directives. <BR/>This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:25 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 10:25 AM.<BR/>The Plan of Removal was accepted on [DATE] at 12:12 PM: <BR/>[DATE]<BR/>Employee was interview and statement taken. <BR/>This was completed by [DON name] RN, DON and [ADON name] LVN, ADON on [DATE].<BR/>Met with Administrator and decision was made to suspend employee same day on [DATE].<BR/>This was completed by [DON name] RN, DON and [Administrator name], Administrator on [DATE].<BR/>Investigation begin by interviewing staff members and taking written statements.<BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>[DATE]<BR/>Full code and DNR audit were completed to ensure, physician order, code status icon and correct colored paper (green or red) is in chart for all residents. <BR/>This was completed by [LVN B Name] LVN, Medical records on [DATE].<BR/>Continued to take statements from staff members. <BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>Audit CPR certification for nurses completed<BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>CPR certification class was scheduled for Thursday [DATE] at 1:30pm.<BR/>This was completed by [ADON name] LVN, ADON on [DATE].<BR/>In-service on where to find a residents' code status provided to staff.<BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>[DATE]<BR/>In-services on ''Emergency response procedure, calling a code'' provided to staff.<BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>Continue investigation by taking staff statements. <BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>[DATE]<BR/>In-services continued on ''Emergency response procedure, calling a code''<BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>Continue investigation by taking staff statements. <BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>[DATE]<BR/>Continue investigation by taking staff statements. <BR/>This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE].<BR/>[DATE]<BR/>In-serviced nurses about what to do when a patient is full code or DNR and found with no signs of life. <BR/>This was completed by [DON name] RN, DON on [DATE].<BR/>Facilities Plan to ensure compliance quickly<BR/>[DATE]<BR/>Staff in-service on ''Abuse and neglect'' and ''Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support''. Staff members will not assume any job responsibilities until training has been received by DON/designee<BR/>This was completed by [DON name] RN/DON on [DATE].<BR/>This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards to knowledge about abuse and neglect and how to reach/do in a code blue situation.<BR/>DON/designee will report monthly to QAPI<BR/>[DATE] and ongoing <BR/>CPR certification class and emergency mock drill training provided on [DATE] at 1:30pm. <BR/>Will be completed by [Business owner's name] (Owner of [Business name and location]).<BR/>This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. <BR/>DON/designee will report monthly to QAPI<BR/>Ongoing <BR/>Emergency mock drills training quarterly.<BR/>Will be completed by [Business owner's name] (Owner of [Business name and location]).<BR/>This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. <BR/>DON/designee will report monthly to QAPI<BR/>Plan of Removal was verified a follows: <BR/> - Confirmed through interview and record review (DON, [DATE] 4:59 PM; HR Manager [DATE], 9:43 AM) that alleged perpetrator was interviewed, suspended and terminated. <BR/> - Through interview with 3 LVNs from 6 AM to 6 PM shift and two LVNs from 6 PM to 6 AM shift confirmed understanding of training regarding response to resident without signs of life (LVN F, [DATE] 4:22 PM; LVNs - [DATE] 9:04AM, [DATE] 2:22 PM, 5:08 PM, 5:16 PM.) <BR/> - Confirmed through interview (Medical Records Director, [DATE] at 3:11 PM) that an audit was performed on all resident records to ensure accuracy of resident code status; confirmed through record review of residents physical and electronic charts ([DATE] at 4:04 PM) the accuracy of resident code status for 12 sample residents (Census of 75).<BR/> - Confirmed through record review (audit listing with nurse's names and CPR expiration dates) and interview (DON [DATE], 5:05 PM) that nurses' CPR training status was audited, and that the facility has taken action to train one nurse whose CPR training was expired. <BR/> - Confirmed through observation (Group trainings observed [DATE], at 2:07 PM, 2:50 PM, 3:58 PM), interview (DON [DATE] at 5:05 PM) and documentation (Inservice sign-ins dated [DATE], [DATE], [DATE], [DATE]) that trainings regarding calling a code and regarding determining a resident's code status as identified in the plan of removal were provided. <BR/> - Confirmed through interview (Administrator [DATE] 3:30 PM) and record review (Service Agreement dated [DATE]) that the facility entered into a service agreement with a provider of BLS and First aid/CPR/AED courses.<BR/> - Confirmed through interview and record review that ANE training is provided to employees and through interviews with 13 staff (RN (DON [DATE] 5:05 PM; RN [DATE] 2:03 PM), LVN (LVN F, [DATE] 4:22 PM; LVNs [DATE], 5:08 PM, 5:16 PM, CNAs - [DATE] at 10:52, [DATE], 1:52 PM, 1:59 PM, 2:33 PM, 2:57 PM, 3:07 PM, 3:30 PM; 3:40 PM), Restorative Aide ([DATE], 2:11 PM), Activities Director ([DATE], 2:16 PM) understanding of the concept of neglect.<BR/> - Confirmed through interview that employees (DON [DATE] 5:05 PM) who have not completed Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support training will not assume job responsibilities until training has been done. <BR/>The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:55 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 6 (Resident #61) residents reviewed for right to receive written notification. <BR/>The facility failed to provide Resident #61 a written notice of a room change before the resident was moved. <BR/>This failure could place all residents at risk of being displaced without notice and/or reason and decrease of quality of life being in a new environment. <BR/>Findings included: <BR/>Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. <BR/>Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact.<BR/>Record review of Resident #61's care plan dated 01/16/24 revealed Resident #61 had history of false accusations and being critical of staff has expressed verbally aggressive behavior. <BR/>Record review of Resident #61's SW progress note dated 1/26/24 and signed by SW on 1/26/24revealed resident set for room change. Notified by central supply who was assisting in the room that [Resident 61] was wanting to speak to Administrator. SW and Administrator headed to room [ROOM NUMBER]. [Resident 61] verbalized she did not want to move to 404. The administrator then notified the resident that she was not able to remain in that room due to reports received. <BR/>Record review of Resident #61's SW progress note dated 2/8/24 and signed by SW on 3/11/24 revealed meeting in private dining room with local Ombudsman, Administrator, SW, Resident #61, and 2 of Resident #61 family members. Meeting regarding room change for resident on 1/26/24. Resident #61's family member began by vernalizing dissatisfaction with the room change and how the situation was handled by facility. Resident #61's family member how chaotic she remembers the situation being when she arrived. The administrator explained the situation that transpired and Resident #61's family member stated expressed how she felt his (the administrator) demeanor came across as callous through the way he spoke. SW also explained the situation, reiterating that in the moment both parties, [Resident #61] and roommate had to be assessed and action had to be taken to deescalate the situation. The family of roommate had reported that [Resident #61] was being verbally aggressive towards them upon admission. During the discussion with [Resident #61] she denied the verbal aggression. Due to previous verbal conflicts reported by previous roommates. The administrator notified the resident she would be moved to a different room. Resident #61's family member continued to express dissatisfaction with the situation and verbalized being upset with staff. Family to be notified of any and all changes with resident and all aspects of care.<BR/>Record review of Resident #61's Ombudsman case file revealed case was opened on 2/2/24. Intake summary read in part phone call from [Resident #61] that administrator forcefully took her out of her room and slap her hand. Left her at the hallway to be transfer to another hallway isolated from other residents. [Resident #61] stated that the family member of the roommate complaint about something that [Resident #61] said the night before and administrator kick her out of her room. Further review of the case file revealed :<BR/>*dated 2/24/24 read in part [Resident #61] stated that the Administrator informed her that the roommate family who was placed the night before had complaint about her and told her that she needed to leave the room without given her the five days' notice or no investigation of what was the situation of the complaint. The Social Worker told [Resident #61] that she was going to contact the Managing Local Ombudsman (MLO) for a meeting for further discussion, but until this date social worker has not contact the Ombudsman. MLO obtain consent to report the incident to CII, which MLO did that same day. <BR/>*dated 2/8/24 read in part MLO attended a care plan meeting with a complaint with a resident about an incident that happened on 1/25/24 with [Resident #61] and the roommate. We discussed the incident and according to administrator he already spoke with resident about moving her to another room which she agree but once she saw the room she didn't wat to transfer. The roommate's family stated to the staff that [Resident #61] told them in an aggressive and ugly way to get out of her room. Then the Administrator decided to move her right away due to the complaint, he wanted to avoid any conflict between [Resident #61] and the family. MLO mentioned about State regulations that they were not implemented, and resident rights were violated. [Resident #61] has never got aggressive, and she wanted a better explanation but there was no proper investigation. [Resident #61] and her family are not happy with the way administrator handles the situation, and her family knows [Resident #61] can be difficult. Family was not involved to remedy the situation before or after the incident. [Resident #61]'s family member did ask the administrator to keep them involved to assist in the situation with [Resident #61], so the previous incident won't happen again like [Resident #61] describe it. The Administrator agreed to keep the family on the loop whenever there is a situation with [Resident #61]. [Resident #61] did share in the meeting that she was scared of the Administrator because he has threatened her that he is the one who governs the facility. <BR/>During an interview on 3/11/24 at 10:00 am, Resident #61 was alert and oriented to person, place, time, and event. Resident #61 stated she was moved rooms little over a month ago due to a new roommate who had placed a complaint about her. Resident #61 stated she had questioned the Administrator on why she was moved and was told he had received enough complaints of her and had decided she would have to be the one moved out of the room. Resident #61 stated she did not receive a written notice regarding the room change. Resident #61 stated she felt intimidated and humiliated. <BR/>During an interview on 3/11/24 at 10:51 am, the Ombudsman stated he had received a call from Resident #61 who had stated that she had been forcefully removed from her room by the Administrator. <BR/>A call was placed to Resident #61's RP on 3/11/24 at 11:13 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. The call was not returned by the time of survey exit.<BR/>During an interview on 3/11/24 at 11:28 am, the SW stated Resident #61 had been moved rooms a few weeks back due to a complaint from roommate that she had been verbally aggressive with her. The SW stated herself and the Administrator had suggested the room change to Resident #61 who had verbalized understanding at the time. The SW stated the facility then decided to move her belongings to the new room, and when the staff went to move her belongings Resident #61 had become upset and requested to talk to the Administrator. The SW stated the facility had a meeting with the Ombudsman, Resident #61, the Administrator, the SW, and 2 of Resident #61's family members on 2/8/24. The SW stated because of the nature of the complaint and history of Resident#61 having issues with roommates, the Administrator had decided to move her rooms and possibly finding her a room to herself. <BR/>During an interview on 3/11/24 at 3:43 pm, the Administrator stated Resident #61 had a history of conflict with roommates in the past. The Administrator stated Resident #61's roommates' family had complained of her being verbally aggressive. The Administrator stated because of the history Resident #61 had with conflicts with other roommates, he decided to move her and had spoken to her about moving rooms. The Administrator stated Resident #61 was shown the room across and eventually moved hallways entirely where she could have a room by herself. The Administrator stated a 5-day written notice was not provided to Resident #61 because he wanted to prevent the situation from escalating with both residents.<BR/>Record review of Room Change/Roommate Assignment policy dated May 2017 read in part changes in room or roommate assessment shall be made when the facility deems it necessary or when the resident requests the change. Prior to changing a room or roommate assessment all parties involved in the change/assessment (e.g., residents and their representatives) will be given a _ hour/day notice advance notice of such change. Advance notice of roommate change will include why the change in being made and anu information that will assist the roommate in becoming acquainted with his or her new roommate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately notify and consult with the resident ' s physician when there was a significant change in a resident ' s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 21 (Resident #283) residents reviewed for change in condition. <BR/>The facility failed to immediately inform NP/MD of Resident #283 change in condition addressing her behaviors towards wearing her Prevalon boots as orderd by the physician for healing of pressure ulcers. <BR/>This failure placed Resident #283 at risk of serious decrease in health related to delayed treatment of healing her pressure ulcers. <BR/>Findings included: <BR/>Record Review of Resident #283 face sheet dated 03/14/2024 revealed she was an [AGE] year old and was initially admitted to the facility on [DATE]. <BR/>Record Review of Resident #283 quarterly MDS dated [DATE] revealed she has been accounted for unstageable pressure ulcers. <BR/>Record Review of Resident #283 ' s care plan dated 03/01/2024, Resident #283 presents with an unstageable pressure wound of the right heel 2x2cm interventions; evaluated skin, Skin during showers, provide pressure reducing surfaces on bed and chair, Repositioning Schedule, Perform wound care as ordered, maintain pain meds <BR/>Record Review of Resident #283 ' s Care Plan dated 03/01/24, Resident #283 presents with an unstageable pressure wound of the left heel 1.5x1.5cm. Interventions state; Provide pressure reducing surfaces on bed and chair, Repositioning Schedule, Perform wound care as ordered, maintain pain meds <BR/>Record Review of Resident #283 ' s care plan interventions dated 03/04/2024, revealed that interventions are in place to minimize risk for skin breakdown daily and ongoing over the next 90 days. One Interventions included provide treatment as ordered by physician. <BR/>Record Review of Resident #283 physician orders start date 03/01/2024 revealed, Patient to wear Prevalon boots to bilateral feel while in bed. <BR/>During an observation on 03/11/24 at 09:45 am, Resident #283 was lying asleep in bed and Prevalon boots were seen on top of laundry hamper and not on Resident #283 feet. <BR/>During an observation on 03/13/2024 at 02:42 pm, Resident #283 was asleep in bed and Prevalon boots were on Residents #283 wheelchair and not on her feet. <BR/>In an interview and observation on 03/13/2024 at 04:49 pm, with LVN B, stated that Resident #283 ulcers are unstageable and are DTI wound. State RN Surveyor N was present during observation of pressure ulcer wounds. LVN B indicated that Resident #283 has behaviors and does not want the Prevalon boots on, her behaviors are ongoing where she moves her feet back and forth removing the Prevalon boots, or she would put her feet to the side of the bed where she tries to remove them by kicking them off. The resident is then redirected. LVN B indicated that her behaviors are reported on the 24-hour report or on the progress notes, but her behaviors are not care planned. LVN B then placed Prevalon boots on Resident#283 feet. The Prevalon boots were on the wheelchair of the Resident. <BR/>During an observation on 03/14/204 at 09:30 a.m., Resident #283 was in bed asleep with no Prevalon boots on. <BR/>In an interview on 03/14/2024 at 11:30 am, with CNA G stated that if Resident #283 does take Prevalon boots off they are to notify the nurse or LVN who will then add it into the 24-hour report notes. <BR/>In an interview on 03/14/24 at 02:35 pm, ADON D stated that if Resident #283 was having ongoing behaviors of her removing the prevelon boots they should have reported it on the 24-hour reports, or on the progress notes. Which would have indicated a triggered alert for a behavioral plan to be implemented on the MDS but there was not anything reported. ADON D looked through progress notes and care plan, but the only thing documented was on 03/13/2024. ADON D stated that the risk of her Resident not wearing the Prevalon boots as ordered could result in the wounds getting worse and not healing. <BR/>In an interview on 03/14/2024, at 03:21pm with LVN B stated that prior to yesterday he did not report that she was having behaviors regarding removing her Prevalon boots, and that no one has reported to him that she takes them off. LVN B stated that it's here and there when she has behaviors and not really ongoing. LVN B stated it is the responsibility of any CNA or any staff to place the boots on and report it if she is having behaviors, but it is mainly the CNA ' s because they are the ones who place her in bed and back to the wheelchair. <BR/>Record review of the facility policy Change in a Residents condition Status dated April 2007 states the facility shall promptly notify the resident, his or her attending physicians, and representative (sponsor) of changes in the resident ' s medical mental condition and/or status. The Nurse supervisor/charge nurse will notify the residents attending physician or on call physician when there has been a change; F. Refusal of treatment of medications (two or more consecutive times), I. Instructions to notify the physicians of changes in the resident ' s condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 2 of 6 (Resident #383 and Resident #61 ) reviewed for resident rights. <BR/>The facility failed to initiate and complete a grievance for Resident #383's family who complained of Resident #61. <BR/>The facility failed to initiate and complete a grievance for Resident #61 who did not want to move rooms and room change notice was not provided. <BR/>These failures could place residents at risk for grievances not being addressed or resolved promptly. <BR/>Findings included: <BR/>Resident #383 <BR/>Record review of Resident #383's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #383's history and physical dated 2/7/24 revealed diagnoses of dementia with agitation. <BR/>Record review of Resident #383's progress notes from 1/25/24 through 2/9/24 revealed no documentation regarding her family concerns regarding Resident #61's verbal aggression that was reported to SW. <BR/>A call was placed to Resident #383's RP on 3/14/24 at 9:40 am, the phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. The call was not returned by the time of survey exit.<BR/>Reviewed grievances for January 2024, February 2024, and March 2024 no grievance was found for Resident #383s' complaint regarding Resident #61 verbal aggression. <BR/>Resident #61 <BR/>Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. <BR/>Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact.<BR/>Record review of Resident #61's care plan dated 1/16/24 revealed Resident #61 had history of false accusations and being critical of staff has expressed verbally aggressive behavior. <BR/>Record review of Resident #61's SW progress note dated 1/26/24 and signed by SW on 1/26/24revealed resident set for room change. Notified by central supply who was assisting in the room that [Resident 61] was wanting to speak to Administrator. SW and Administrator headed to room [ROOM NUMBER]. [Resident 61] verbalized she did not want to move to 404. The administrator then notified the resident that she was not able to remain in that room due to reports received. The administrator then wheeled the resident towards the door into the hallway where [Resident #61] continuously stated she was not moving to 404. Administrator and SW discussed, and administrator identified room [ROOM NUMBER] as available for resident to go into private room. [Resident #61] was notified she would go into private room and verbalized no concern. [Resident #61's family member] then appeared in hallway and SW and administrator spoke with niece to inform her of events that transpired. <BR/>Record review of Resident #61's SW progress note dated 2/8/24 and signed by SW on 3/11/24 revealed meeting in private dining room with local Ombudsman, Administrator, SW, Resident #61, and 2 of Resident #61 family members. Meeting regarding room change for resident on 1/26/24. Resident #61's family member began by vernalizing dissatisfaction with the room change and how the situation was handled by facility. Resident #61's family member how chaotic she remembers the situation being when she arrived. The administrator explained the situation that transpired and Resident #61's family member stated expressed how she felt his (the administrator) demeanor came across as callous through the way he spoke. SW also explained the situation, reiterating that in the moment both parties, [Resident #61] and roommate had to be assessed and action had to be taken to deescalate the situation. The family of roommate had reported that [Resident #61] was being verbally aggressive towards them upon admission. During the discussion with [Resident #61] she denied the verbal aggression. Due to previous verbal conflicts reported by previous roommates. The administrator notified the resident she would be moved to a different room. Resident #61's family member continued to express dissatisfaction with the situation and verbalized being upset with staff. [Resident #61] then spoke to the Administrator and notified him that she was scared of him and that he as forcefully moved her to room. Ombudsman also verbalized requiring a written notice and advance notice of room change. Administrator reported that change was done to avoid further escalation of confrontation. [Resident #61] remained in 100 hall. Family to be notified of any and all changes with resident and all aspects of care.<BR/>Record review of Resident #61's Ombudsman case file revealed case was opened on 2/2/24. Intake summary read in part phone call from [Resident #61] that administrator forcefully took her out of her room and slap her hand. Left her at the hallway to be transfer to another hallway isolated from other residents. [Resident #61] stated that the family member of the roommate complaint about something that [Resident #61] said the night before and administrator kick her out of her room. Journal entries dated 2/24/24 read in part [Resident #61] reported to the Ombudsman that the administrator physically assault her by forcefully taken her out from her room. [Resident #61] stated that this incident happened on January 25th, 2024. [Resident #61] stated that the Administrator informed her that the roommate family who was placed the night before had complaint about her and told her that she needed to leave the room without given her the five days' notice or no investigation of what was the situation of the complaint. She continues to state the Administrator grab her wheelchair and push her out of her room, she put her wheelchair brakes to stop him to further discuss the situation about the complaint because she was not aware of an issue. The Social Worker told [Resident #61] that she was going to contact the Managing Local Ombudsman (MLO) for a meeting for further discussion, but until this date social worker has not contact the Ombudsman. MLO obtain consent to report the incident to CII, which MLO did that same day. Journal entry dated 2/8/24 read in part MLO attended a care plan meeting with a complaint with a resident about an incident that happened on 1/25/24 with [Resident #61] and the roommate. [Resident #61] inform MLO that administrator forcefully took her out from her room to be transfer to another room. [Resident #61]'s family member was in the meeting and her niece was in the meeting with the Social worker as well. We discussed the incident and according to administrator he already spoke with resident about moving her to another room which she agree but once she saw the room she didn't wat to transfer. The roommate's family stated to the staff that [Resident #61] told them in an aggressive and ugly way to get out of her room. Then the Administrator decided to move her right away due to the complaint, he wanted to avoid any conflict between [Resident #61] and the family. MLO mentioned about State regulations that they were not implemented, and resident rights were violated. [Resident #61] has never got aggressive, and she wanted a better explanation but there was no proper investigation. [Resident #61] and her family are not happy with the way administrator handles the situation, and her family knows [Resident #61] can be difficult. Family was not involved to remedy the situation before or after the incident. [Resident #61]'s family member did ask the administrator to keep them involved to assist in the situation with [Resident #61], so the previous incident won't happen again like [Resident #61] describe it. The Administrator agreed to keep the family on the loop whenever there is a situation with [Resident #61]. [Resident #61] did share in the meeting that she was scared of the Administrator because he has threatened her that he is the one who governs the facility. <BR/>Reviewed grievances for January 2024, February 2024, and March 2024 no grievance was found for Resident #61s complaint of not wanting to move rooms and written notice not provided. <BR/>During an interview on 3/11/24 at 10:00 am, Resident #61 was alert and oriented to person, place, time, and event. Resident #61 stated she was moved rooms little over a month ago due to a new roommate who had placed a complaint about her. Resident #61 stated when she was moved, the Administrator had forcefully kicked her out of the room by pushing her wheelchair out and placed her in the hallway. Resident #61 stated she had questioned the Administrator on why she was moved and was told he had received enough complaints of her and had decided she would have to be the one moved out of the room. Resident #61 stated she did not receive a written notice regarding the room change. Resident #61 stated she felt intimidated and humiliated. <BR/>During an interview on 3/11/24 at 10:51 am, the Ombudsman stated he had received a call from Resident #61 who had stated that she had been forcefully removed from her room by the Administrator. <BR/>A call was placed to Resident #61's RP on 3/11/24 at 11:13 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. The call was not returned by the time of survey exit.<BR/>During an interview on 3/11/24 at 11:28 am, the SW stated Resident #61 had been moved rooms a few weeks back due to a complaint from roommate that she had been verbally aggressive with her. The SW stated herself and the Administrator had suggested the room change to Resident #61 who had verbalized understanding at the time. The SW stated the facility then decided to move her belongings to the new room, and when the staff went to move her belongings Resident #61 had become upset and requested to talk to the Administrator. The SW stated the facility had a meeting with the Ombudsman, Resident #61, the Administrator, the SW, and 2 of Resident #61's family members on 2/8/24. The SW stated they had discussed the room change in which Resident #61 had voiced the Administrator had forced her out of the room by pushing her with the wheelchair. The SW stated she did not complete a grievance for either Resident #383's family complaint regarding Resident #61 and did not complete grievance for Resident #61's refusal of being moved and/or families concerns regarding how the situation was handled. The SW stated because the issue was resolved then, she did not complete a grievance form. The SW stated per policy a grievance should had been completed to have proper documentation on actions taken and follow up with both parties. <BR/>During an interview on 3/14/24 at 11:08 am, the Administrator stated he did not know if grievance should had been completed for Resident #383's complaint regarding Resident #61. The Administrator reviewed policy and stated based on policy it was expected for the SW to complete a grievance for Resident #383. The Administrator stated there was no risk because it was resolved the same day and both parties were good with outcome.<BR/>Record review of Filing Grievances/ Complaints policy dated March 2023 read in part our facility will assist resident's individual representative (sponsors), other interested family members, or residents' advocates in filing grievances or complaints when such requests are made. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. Upon receipt of a written grievance and/or complaint, the Grievance Official will investigate the allegations and submit a written report of such findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 (Resident #61) residents reviewed for abuse. <BR/>The facility failed to implement their abuse policy on reporting to State Office Resident #61's allegation of the Administrator slapping hand when forced out of her room. <BR/>This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. <BR/>Findings include: <BR/>Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. <BR/>Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact.<BR/>Record review of Resident #61's care plan dated 1/16/24 revealed Resident #61 had history of false accusations and being critical of staff has expressed verbally aggressive behavior. <BR/>Record review of TULIP revealed no self-report for Resident #61's allegation of slap in hand by the Administrator. <BR/>Record review of Resident #61's SW progress note dated 1/26/24 and signed by SW on 1/26/24revealed resident set for room change. Notified by central supply who was assisting in the room that [Resident 61] was wanting to speak to Administrator. SW and Administrator headed to room [ROOM NUMBER]. [Resident 61] verbalized she did not want to move to 404. The administrator then notified the resident that she was not able to remain in that room due to reports received. The administrator then wheeled the resident towards the door into the hallway where [Resident #61] continuously stated she was not moving to 404. Administrator and SW discussed, and administrator identified room [ROOM NUMBER] as available for resident to go into private room. [Resident #61] was notified she would go into private room and verbalized no concern. [Family member] then appeared in hallway and SW and administrator spoke with [Family Member] to inform her of events that transpired. <BR/>Record review of Resident #61's SW progress note dated 2/8/24 and signed by SW indicated .[Resident #61] expressed that the Administrator had forced her wheelchair out of the room stating that at one point, she held her hand to the wall where removed the hand from the wall. In previous conversations with resident, she had stated the Administrator had forced her out of the hallway but did not mention it being a physical matter .<BR/>Record review of Resident #61's Ombudsman case file revealed case was opened on 2/2/24. Intake summary read in part phone call from [Resident #61] that administrator forcefully took her out of her room and slap her hand. Left her at the hallway to be transfer to another hallway isolated from other residents. Journal entries dated 2/24/24 read in part [Resident #61] reported to the Ombudsman that the administrator physically assault her by forcefully taken her out from her room. [Resident #61] stated that this incident happened on January 25th, 2024. [Resident #61] stated that the Administrator grab her wheelchair and push her out of her room, she put her wheelchair brakes to stop him to further discuss the situation about the complaint because she was not aware of an issue. The Administrator continue to push her with the wheelchair when [Resident #61] grab the door frame and the Administrator slap her hand so she can let go at the door frame. He (the administrator) continue to push her out of the room and finally left her at the hallway. Staff took her to the new assigned room in an isolated hallway. [Resident #61] feels humiliated, retaliation, threaten by the administrator that he will be discharging her, feels abused by the administrator and her resident right been violated. [Resident #61] has stated that Administrator has told her many times he is the one with the authority at the facility and makes the final decisions. The Social Worker told her that they were going to move her again to another room but she did not specify when. [Resident #61] stated she does not want to be moved out of the facility, but feels the administrator will forcefully move her out. The Social Worker told [Resident #61] that she was going to contact the Managing Local Ombudsman for a meeting for further discussion, but until this date social worker has not contact the Ombudsman. MLO obtain consent to report the incident to CII, which MLO did that same day. Journal entry dated 2/8/24 read in part MLO attended a care plan meeting with a complaint with a resident about an incident that happened on 1/25/24 with [Resident #61] and the roommate. [Resident #61] inform MLO that administrator forcefully took her out from her room to be transfer to another room. Also, [Resident #61] stating that he (the administrator) did slap her arm so she can let go at the door frame so he can push her wheelchair. <BR/>During an interview on 3/11/24 at 10:00 am, Resident #61 was alert and oriented to person, place, time, and event. Resident #61 stated she was moved rooms little over a month ago due to a new roommate who had placed a complaint about her. Resident #61 stated when she was moved, the Administrator had forcefully kicked her out of the room by pushing her wheelchair out and placed her in the hallway. Resident #61 stated as the Administrator was pushing her out of the room in the wheelchair, she had attempted to put the brakes on the wheelchair to prevent him wheeling her out and it was unsuccessful. Resident #61 stated she then placed her hand on the door frame prior to exiting the door in attempts of resisting being pushed out all the way, and the Administrator had slapped her hand to get her to remove her hand from the door frame. Resident #61 stated she called the Ombudsman and had notified him of the incident where she was forced out of her room and the Administrator slapping her hand. Resident #61 stated she had also told the SW of the situation, and nothing had been done. Resident #61 stated she felt scared, intimidated and humiliated. <BR/>During an interview on 3/11/24 at 10:51 am, the Ombudsman stated he had received a call from Resident #61 who had stated that she had been forcefully removed from her room by the Administrator. The Ombudsman stated Resident #61 gave details when she was forced out of the room by the Administrator and said he (the administrator) had slapped her hand when she placed her hand on the door frame to prevent being pushed out of the door all the way. <BR/>A call was placed to Resident #61's RP on 3/11/24 at 11:13 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. <BR/>During an interview on 3/11/24 at 11:17 am, the DON stated she was aware Resident #61 had been moved rooms a few weeks back but was not aware of details regarding the move. The DON stated she was not notified of Resident #61 allegation of being slapped in the hand by the Administrator. The DON stated she did not know who she would report the allegation of slap in the hand if the alleged perpetrator was the abuse coordinator but would have to report to State Office. <BR/>During an interview on 3/11/24 at 11:28 am, the SW she did not recall Resident #61 alleging a slap in the hand by the Administrator. The SW stated she did not have a progress note and/or documentation regarding the 2/8/24 meeting. The SW stated the Administrator was the abuse coordinator and did not know who she would report an allegation of abuse when the Abuse Coordinator/ Administrator was the alleged perpetrator. The SW stated she did not report the allegation of slap in the hand because she did not recall that topic mentioned during the meeting held on 2/8/24. <BR/>During an interview on 3/11/24 at 3:43 pm, the Administrator stated he did not report the allegation Resident #61 had made against him regarding the slap in the hand because there were witnesses in the room and the meeting was held with the Ombudsman to discuss what had transpired. The Administrator stated he was the abuse coordinator and if an allegation was made against him someone else would have to report and/or investigate the allegation. The Administrator stated the SW was aware of the allegation and had gathered witnessed statements from the witnesses in the room. The Administrator stated he did not provide a statement and was not suspended pending investigation due to him not having direct care with the resident. The Administrator stated based on abuse policy the allegation Resident #61 had made about him hitting her should had been reported to State Office. <BR/>During an interview on 3/11/24 at 5:13 pm, the Administrator stated today was the first time he heard allegation that he hit her (Resident #61) and he denied having done that. The Administrator said he would be suspended pending investigation and Corporate Director of Operations would conduct the investigation. <BR/>During an interview on 3/12/24 at 8:34 am, Maintenance staff stated he was asked by the Administrator to assist with Resident #61's move to a different room. The Maintenance staff stated that Central Supply and him, had gone to Resident #61's room to start gathering her belongings and she had become upset and requested to speak to the Administrator. The Maintenance staff stated the Administrator had gone to Resident #61's room and discussed the room change that had been agreed to. The Maintenance staff stated his back was facing the door and had not seen the Administrator assist Resident #61 out the room. The Maintenance staff stated because his back was facing the door he did not see the Administrator slap Resident #61. The Maintenance staff stated he did not hear anything concerning noise, Resident #61 was only very upset and arguing with the Administrator. The Maintenance staff stated Central Supply was in the room and may have seen any interaction between the Administrator and Resident #61. <BR/>During an interview on 3/12/24 at 8:53 am, Central Supply stated she had been asked to assist Maintenance staff with gathering Resident #61 belongings for room change. Central Supply stated when they both were in Resident #61 room she became upset and had requested to speak to the Administrator and had stepped out to get him. Central Supply stated when the Administrator came to Resident #61 came to the room, she stayed by the restroom area where it was few feet away from the bed and saw him talking to her. Central Supply stated she appeared very upset and does not know what was said because she did not speak Spanish. Central Supply stated he saw the Administrator wheel Resident #61 out of her room and did not see him put any hands on Resident #61. Central Supply stated she did not see the Administrator slap Resident #61's hand. <BR/>During an interview on 3/13/24 at 11:28 am, Executive Director of Clinical Services stated they had been notified of Resident #61's allegation of slap in the hand by the Administrator. The Executive Director of Clinical Services stated the Corporate Director of Operations was the lead investigator in the case. The Executive Director of Clinical Services stated whoever was present during the meeting with the Ombudsman when the allegation was brought should have reported it to the corporate office and State Office. The Executive Director of Clinical Services stated it was expected for the SW and even the Administrator to have reported the alleged incident immediately. The Executive Director of Clinical Services stated failure to report any allegation of abuse could result in failure of investigation to be completed and alleged perpetrator still working in the facility. <BR/>A call was placed to Resident #61's RP on 3/12/24 at 9:01 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. The call was not returned by the time of survey exit. <BR/>During an interview on 3/12/24 at 12:35 pm, Resident #61 stated the SW had gone to speak to her regarding the allegation against the Administrator this morning. Resident #61 stated she was asked if she had any other information she wanted to share and was told they'd be checking in on her weekly to see how she was doing. Resident #61 stated she felt better knowing the facility was taking her allegation serious and something was being done.<BR/>During an interview on 3/13/24 at 2:35 pm, Corporate Director of Operations stated she was notified of Resident #61's slap in hand allegation on Monday 3/11/24 and immediately suspended the Administrator. The Corporate Director of Operations said the abuse policy should have been followed regardless of witnesses in the room due to the allegation. The Corporate Director of Operations stated it was expected for the SW and the Administrator to have reported the allegation immediately to the corporate office and State Office. The Corporate Director of Operations stated she followed up with the Administrator who denied slapping Resident #61's hand. The Corporate Director of Operations stated the DON had called in the abuse allegation to State Office and had requested assistance from the SW to gather statements and interview other residents while the Executive Director of Clinical Services arrived to the facility to assist onsite. The Corporate Director of Operations stated she finished reviewing the interviews and statements gathered Monday (3/11/24) evening and because there was a witness who saw the interaction the allegation was inconclusive and cleared the Administrator to return to work on Tuesday 3/12/24. The Corporate Director of Operations stated she completed a one0to-one in-service with the Administrator and DON regarding reporting abuse allegations being reported to ensure investigation is thoroughly conducted. <BR/>Record review of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated April 2021 read in part all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations to the Administrator and Authorities: 2) the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 (Resident #61) residents reviewed for abuse. <BR/>The facility failed to ensure Resident #61's allegation of the Administrator slapping hand when forced out of her room was thoroughly investigated. <BR/>This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. <BR/>Findings include: <BR/>Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. <BR/>Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact.<BR/>Record review of Resident #61's care plan dated 1/16/24 revealed Resident #61 had history of false accusations and being critical of staff has expressed verbally aggressive behavior. <BR/>Record review of TULIP revealed no self-report for Resident #61's allegation of slap in hand by the Administrator. <BR/>Record review of Resident #61's SW progress note dated 1/26/24 and signed by SW on 1/26/24revealed resident set for room change. Notified by central supply who was assisting in the room that [Resident 61] was wanting to speak to Administrator. SW and Administrator headed to room [ROOM NUMBER]. [Resident 61] verbalized she did not want to move to 404. The administrator then notified the resident that she was not able to remain in that room due to reports received. The administrator then wheeled the resident towards the door into the hallway where [Resident #61] continuously stated she was not moving to 404. Administrator and SW discussed, and administrator identified room [ROOM NUMBER] as available for resident to go into private room. [Resident #61] was notified she would go into private room and verbalized no concern. [Family member] then appeared in hallway and SW and administrator spoke with [Family Member] to inform her of events that transpired. <BR/>Record review of Resident #61's SW progress note dated 2/8/24 and signed by SW indicated .[Resident #61] expressed that the Administrator had forced her wheelchair out of the room stating that at one point, she held her hand to the wall where removed the hand from the wall. In previous conversations with resident, she had stated the Administrator had forced her out of the hallway but did not mention it being a physical matter .<BR/>Record review of Resident #61's Ombudsman case file revealed case was opened on 2/2/24. Intake summary read in part phone call from [Resident #61] that administrator forcefully took her out of her room and slap her hand. Left her at the hallway to be transfer to another hallway isolated from other residents. Journal entries dated 2/24/24 read in part [Resident #61] reported to the Ombudsman that the administrator physically assault her by forcefully taken her out from her room. [Resident #61] stated that this incident happened on January 25th, 2024. [Resident #61] stated that the Administrator grab her wheelchair and push her out of her room, she put her wheelchair brakes to stop him to further discuss the situation about the complaint because she was not aware of an issue. The Administrator continue to push her with the wheelchair when [Resident #61] grab the door frame and the Administrator slap her hand so she can let go at the door frame. He (the administrator) continue to push her out of the room and finally left her at the hallway. Staff took her to the new assigned room in an isolated hallway. [Resident #61] feels humiliated, retaliation, threaten by the administrator that he will be discharging her, feels abused by the administrator and her resident right been violated. [Resident #61] has stated that Administrator has told her many times he is the one with the authority at the facility and makes the final decisions. The Social Worker told her that they were going to move her again to another room but she did not specify when. [Resident #61] stated she does not want to be moved out of the facility, but feels the administrator will forcefully move her out. The Social Worker told [Resident #61] that she was going to contact the Managing Local Ombudsman for a meeting for further discussion, but until this date social worker has not contact the Ombudsman. MLO obtain consent to report the incident to CII, which MLO did that same day. Journal entry dated 2/8/24 read in part MLO attended a care plan meeting with a complaint with a resident about an incident that happened on 1/25/24 with [Resident #61] and the roommate. [Resident #61] inform MLO that administrator forcefully took her out from her room to be transfer to another room. Also, [Resident #61] stating that he (the administrator) did slap her arm so she can let go at the door frame so he can push her wheelchair. <BR/>During an interview on 3/11/24 at 10:00 am, Resident #61 was alert and oriented to person, place, time, and event. Resident #61 stated she was moved rooms little over a month ago due to a new roommate who had placed a complaint about her. Resident #61 stated when she was moved, the Administrator had forcefully kicked her out of the room by pushing her wheelchair out and placed her in the hallway. Resident #61 stated as the Administrator was pushing her out of the room in the wheelchair, she had attempted to put the brakes on the wheelchair to prevent him wheeling her out and it was unsuccessful. Resident #61 stated she then placed her hand on the door frame prior to exiting the door in attempts of resisting being pushed out all the way, and the Administrator had slapped her hand to get her to remove her hand from the door frame. Resident #61 stated she called the Ombudsman and had notified him of the incident where she was forced out of her room and the Administrator slapping her hand. Resident #61 stated she had also told the SW of the situation, and nothing had been done. Resident #61 stated she felt scared, intimidated and humiliated. <BR/>During an interview on 3/11/24 at 10:51 am, the Ombudsman stated he had received a call from Resident #61 who had stated that she had been forcefully removed from her room by the Administrator. The Ombudsman stated Resident #61 gave details when she was forced out of the room by the Administrator and said he (the administrator) had slapped her hand when she placed her hand on the door frame to prevent being pushed out of the door all the way. <BR/>A call was placed to Resident #61's RP on 3/11/24 at 11:13 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. <BR/>During an interview on 3/11/24 at 11:17 am, the DON stated she was aware Resident #61 had been moved rooms a few weeks back but was not aware of details regarding the move. The DON stated she was not notified of Resident #61 allegation of being slapped in the hand by the Administrator. The DON stated she did not know who she would report the allegation of slap in the hand if the alleged perpetrator was the abuse coordinator but would have to report to State Office. <BR/>During an interview on 3/11/24 at 11:28 am, the SW she did not recall Resident #61 alleging a slap in the hand by the Administrator. The SW stated she did not have a progress note and/or documentation regarding the 2/8/24 meeting. The SW stated the Administrator was the abuse coordinator and did not know who she would report an allegation of abuse when the Abuse Coordinator/ Administrator was the alleged perpetrator. The SW stated she did not report the allegation of slap in the hand because she did not recall that topic mentioned during the meeting held on 2/8/24. <BR/>During an interview on 3/11/24 at 3:43 pm, the Administrator stated he did not report the allegation Resident #61 had made against him regarding the slap in the hand because there were witnesses in the room and the meeting was held with the Ombudsman to discuss what had transpired. The Administrator stated he was the abuse coordinator and if an allegation was made against him someone else would have to report and/or investigate the allegation. The Administrator stated the SW was aware of the allegation and had gathered witnessed statements from the witnesses in the room. The Administrator stated he did not provide a statement and was not suspended pending investigation due to him not having direct care with the resident. The Administrator stated based on abuse policy the allegation Resident #61 had made about him hitting her should had been reported to State Office. <BR/>During an interview on 3/11/24 at 5:13 pm, the Administrator stated today was the first time he heard allegation that he hit her (Resident #61) and he denied having done that. The Administrator said he would be suspended pending investigation and Corporate Director of Operations would conduct the investigation. <BR/>During an interview on 3/12/24 at 8:34 am, Maintenance staff stated he was asked by the Administrator to assist with Resident #61's move to a different room. The Maintenance staff stated that Central Supply and him, had gone to Resident #61's room to start gathering her belongings and she had become upset and requested to speak to the Administrator. The Maintenance staff stated the Administrator had gone to Resident #61's room and discussed the room change that had been agreed to. The Maintenance staff stated his back was facing the door and had not seen the Administrator assist Resident #61 out the room. The Maintenance staff stated because his back was facing the door he did not see the Administrator slap Resident #61. The Maintenance staff stated he did not hear anything concerning noise, Resident #61 was only very upset and arguing with the Administrator. The Maintenance staff stated Central Supply was in the room and may have seen any interaction between the Administrator and Resident #61. <BR/>During an interview on 3/12/24 at 8:53 am, Central Supply stated she had been asked to assist Maintenance staff with gathering Resident #61 belongings for room change. Central Supply stated when they both were in Resident #61 room she became upset and had requested to speak to the Administrator and had stepped out to get him. Central Supply stated when the Administrator came to Resident #61 came to the room, she stayed by the restroom area where it was few feet away from the bed and saw him talking to her. Central Supply stated she appeared very upset and does not know what was said because she did not speak Spanish. Central Supply stated he saw the Administrator wheel Resident #61 out of her room and did not see him put any hands on Resident #61. Central Supply stated she did not see the Administrator slap Resident #61's hand. <BR/>During an interview on 3/13/24 at 11:28 am, Executive Director of Clinical Services stated they had been notified of Resident #61's allegation of slap in the hand by the Administrator. The Executive Director of Clinical Services stated the Corporate Director of Operations was the lead investigator in the case. The Executive Director of Clinical Services stated whoever was present during the meeting with the Ombudsman when the allegation was brought should have reported it to the corporate office and State Office. The Executive Director of Clinical Services stated it was expected for the SW and even the Administrator to have reported the alleged incident immediately. The Executive Director of Clinical Services stated failure to report any allegation of abuse could result in failure of investigation to be completed and alleged perpetrator still working in the facility. <BR/>A call was placed to Resident #61's RP on 3/12/24 at 9:01 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. The call was not returned by the time of survey exit. <BR/>During an interview on 3/12/24 at 12:35 pm, Resident #61 stated the SW had gone to speak to her regarding the allegation against the Administrator this morning. Resident #61 stated she was asked if she had any other information she wanted to share and was told they'd be checking in on her weekly to see how she was doing. Resident #61 stated she felt better knowing the facility was taking her allegation serious and something was being done.<BR/>During an interview on 3/13/24 at 2:35 pm, Corporate Director of Operations stated she was notified of Resident #61's slap in hand allegation on Monday 3/11/24 and immediately suspended the Administrator. The Corporate Director of Operations said the abuse policy should have been followed regardless of witnesses in the room due to the allegation. The Corporate Director of Operations stated it was expected for the SW and the Administrator to have reported the allegation immediately to the corporate office and State Office. The Corporate Director of Operations stated she followed up with the Administrator who denied slapping Resident #61's hand. The Corporate Director of Operations stated the DON had called in the abuse allegation to State Office and had requested assistance from the SW to gather statements and interview other residents while the Executive Director of Clinical Services arrived to the facility to assist onsite. The Corporate Director of Operations stated she finished reviewing the interviews and statements gathered Monday (3/11/24) evening and because there was a witness who saw the interaction the allegation was inconclusive and cleared the Administrator to return to work on Tuesday 3/12/24. The Corporate Director of Operations stated she completed a one0to-one in-service with the Administrator and DON regarding reporting abuse allegations being reported to ensure investigation is thoroughly conducted. <BR/>Record review of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated April 2021 read in part all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations to the Administrator and Authorities: 2) the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that assessments accurately reflected residents ' status for 1 (Resident # 30) of 21 residents reviewed for accuracy of assessment. <BR/> The facility failed to ensure that Resident #30 ' s MDS reflected her refusal to use her C-PAP machine (machine that uses air pressure to help breathing). <BR/>This failure put residents at risk of poor sleep, increased incidence of sleep apnea (sleep disorder where breathing stops and starts). <BR/>Findings included: <BR/>Record review of Resident #30 ' s face sheet dated 03/14/2023 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #30 ' s History and Physical dated 02/21/2023 reveled she had diagnoses including COPD (Chronic Obstructive Pulmonary disease - a condition where airways are narrowed, and breathing is difficult); Chronic respiratory failure with hypoxia (a condition where airways are narrowed or damaged and there is reduced oxygen in the blood); Sleep disorder (changes in sleep that can negatively affect health.) Medications included a CPAP to be used nightly and 2 liters per minute of oxygen at night as needed. The History and Physical revealed that Resident #30 ' s family member said that facility staff was not placing her CPAP because the distilled water in the machine had not been used. The resident said she was not sleeping, although staff reported she was. <BR/>Record review of Resident #30 ' s quarterly MDS dated [DATE] revealed she had a BIMS of 9 (Moderate cognitive impairment). She had no symptoms of delirium or psychosis. She had no behavioral symptoms including rejection of care during the 7-day look back period. She had diagnoses including COPD or chronic lung disease, and Respiratory failure. The MDS indicated she was not receiving oxygen therapy. <BR/>Record review of Resident #30 ' s Care plan dated 01/26/2023 revealed she refused to use her C-Pap Machine. <BR/>Record review of Resident #30 ' s physicians orders dated 11/15/2023 revealed she was to use a CPAP machine daily at bedtime. The physician's order dated 01/26/2024 revealed that her compliance with use of the CPAP machine was to be documented in progress notes and the physician was to be notified if she was noncompliant. <BR/>Record review of Resident #30 ' s progress note by LVN A dated 1/9/2024 revealed the resident was prompted throughout the night to keep her c-pap on with no success. The resident had intermittent labored breathing. <BR/>Record review of Resident #30 ' s MAR for February 2024 revealed she was non-complaint with use of the CPAP machine on 02/14/2024 and 02/23/2024. <BR/>Record review of Resident #30 ' s nursing progress notes February 2024 revealed no corresponding nursing notes regarding her refusal to use the CPAP machine as required by physician ' s order. <BR/>Record review of Resident #30 ' s MAR for March 2024 (03/01/2024 - 03/12/2024) revealed she had no instances of non-compliance with use of the CPAP machine. <BR/>Record review of Resident #30 ' s respiratory therapy report dated 03/14/2024 for 12/15/2023 - 03/13/2024 revealed she used the CPAP machine 33 out of 90 days and had not used the CPAP machine on 57 nights. During February 2024 she did not use the CPAP machine on 02/01, 02/02, 02/03, 02/04, 02/07, 02/09, 02/10, 02/14, 02/16, 02/17, 02/19, 02/22, 02/23, 02/24, 02/28 and 02/29/2024. Between 03/01/2024 and 03/13/2024 she did not use the CPAP machine the nights of 03/01, 03/02, 03/01, 03/08, 03/09, 03/11, 03/12 and 03/13/2024. <BR/>In an interview on 03/11/24 at 11:19 AM Resident #30 ' s family member said that staff were not putting the CPAP on the resident at night. The family member said a man came in to look at the machine and said they [nursing staff] do not put it on her. The resident said she had difficulty putting the CPAP mask by herself. <BR/>In a telephone interview on 03/14/24 at 09:28 AM Respiratory Therapist C revealed that he was familiar with Resident #30 and that he could provide records of her use of the CPAP machine. <BR/>In an interview on 03/14/24 at 11:34 AM Respiratory Therapist C revealed that review of Resident #30 Therapy Report documented that in March 2024 the resident did not have the CPAP mask on at all, and that between 12/15 and 3/13 she did not use the CPAP machine 57 times. The Respiratory Therapist stated that not using the CPAP machine put Resident #30 at risk of poor sleep quality and increased instances of sleep apnea. <BR/>In an interview on 03/14/24 at 02:10 PM the DON revealed that nurse should be documenting if Resident #30 refused to use her CPAP machine. She stated that without the use of the CPAP machine the resident would be at increased risk of sleep apnea and might lose breathing at night. She said the nurses should be following physician ' s orders to document instances when Resident #30 refused to use the CPAP machine. <BR/>In an interview on 03/14/24 at 02:28 PM ADON D revealed she thought Resident #30 was generally compliant with all orders including use of the CPAP machine. She stated that noncompliance with use of the CPAP machine could result in Resident #30 ' s feeling winded, short of breath, and might exacerbate her COPD. <BR/> In an interview on 03/14/24 at 04:16 PM LVN A revealed that during the time she had worked with Resident 30, she had been told by other staff that the resident refused to use the CPAP machine. LVN A said she put the CPAP mask on Resident #30 because the resident was not able to put it on herself. The LVN said she had not had any difficulties with Resident #30 ' s use of the CPAP after educating the resident about the risks of not using the CPAP. The LVN said that if the resident did not want to put the machine on right away the LVN would go back and put it on her later in the evening. <BR/>Record review of the facility policy Resident Assessment Instrument (MDS 2.0) revised 04/2007 revealed in part that the purpose of the resident assessment was to describe resident ' s capability to perform daily life functions and to identify significant impairments in functional capacity. The information derived from the assessment enabled the staff to plan care to allow the resident to reach his/her highest practicable level of function to include behavioral symptoms. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 5 residents reviewed for pressure ulcers/wounds. <BR/>The facility failed to provide wound care for Resident #3's pressure ulcer stage 3 to the left buttock on 02/01/25 and 02/02/25.<BR/>This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. <BR/>Findings include:<BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on [DATE] to the facility. Resident #3 discharged on 02/04/25<BR/>Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer.<BR/>Record review of Resident #3's admission MDS dated [DATE], revealed, no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Resident #3 was coded for risk of pressure ulcers and unhealed pressure ulcers. Resident #3 was coded for stage 3 pressure ulcer. Resident #3 was to have pressure reducing devices for chair, for bed, turning/repositioning program, pressure/ulcer/injury care, applications of ointments/medications, and hydration interventions. <BR/>Record review of Resident #3's Skin Issues Assessment generated by the Wound Care Nurse dated 01/30/25, revealed, left gluteus/ buttock pressure ulcer/ injury stage 3, 9 cm by 3.5 cm by 0.2 cm. <BR/>Record review of Resident #3's Order Recap dated 01/30/25, revealed, left buttock stage 3 pressure wound. Cleanse with NS and pat dry with a 4 by 4-inch gauze. Apply collagen powder to the wound bed granulated tissue. Cover with foam border dressing. One time a day related to Pressure Ulcer of Other site, Unstageable. <BR/>- <BR/>Order dated 01/30/25, revealed nursing Intervention: Turn and reposition every hour every shift. <BR/>Record review of Resident #3's Administration Report dated 02/01/25-02/28/25, revealed, wound care was not completed for 02/01/25 and 02/02/25 for Resident #3. <BR/>Record review of Resident #3's progress notes for 02/01/25-02/02/25, revealed, there was no nursing note indicating if wound care was provided or not. <BR/>During an interview on 02/05/25 at 1:18 PM, with Resident #3's Family member, she stated that wound care was not being done during the weekend as Resident #3 still had the same dressing on since his arrival to the facility. <BR/>During an interview on 02/05/25 at 1:50 PM, with LVN B, she stated the family member had informed her that Resident #3 had a bad weekend. LVN B stated the family member had mentioned that Resident #3 did not have wound care done on the weekend (02/01/25-02/02/25). LVN B stated she checked if Resident #3 had wound care done on the weekend and confirmed it had not been done. LVN B stated that there was not a Wound Care Nurse on the weekend, but all nurses were able to provide wound care. LVN B stated the weekend nurses were responsible for providing wound care. LVN B stated the risk of not providing wound care could be the wound getting worse or infection. <BR/>interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated she provided wound care during the weekdays and on the weekends, the nurses were to be providing the wound care. The Treatment Nurse stated the nurses on the weekend would be able to provide wound care for those residents needing wound care. The Treatment Nurse stated Resident #3 had not had his wound care done on 02/01/25 and on 02/02/25. The Treatment Nurse stated the negative outcome could be a delay in the wound in healing. <BR/>During an interview on 02/05/25 at 3:09 PM, with the Social Worker, she stated the staff was not assisting as they should be with Resident #3. The Social Worker stated the family member felt Resident #3 was not getting the correct wound care treatment. <BR/>During an interview on 02/05/25 at 3:29 PM, with LVN A, she stated wound care was being provided for Resident #3 on 02/01/25-02/02/25. LVN A stated she had forgotten to document that wound care was provided for Resident #3. LVN A stated she had looked at the MARs earlier that day for Resident #3's orders for wound care and remembered it. LVN A stated from what she remembered she went ahead and conducted the wound care later on in the day without looking at the wound care orders. LVN A stated she forgot to document it on the facility system. LVN A stated she was trained to look at the orders and would look at them earlier in the day and then would give treatment. LVN A stated the risk of not conducting wound care could be a risk of infection. <BR/>During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated wound care was supposed to be done as ordered. The ADON stated during the weekday the Treatment Nurse conducts the wound care and on the weekend the nurses are able and have to do the wound care. The ADON stated that nurses are trained to look at the orders while gathering the supplies for the wound treatment and cannot be looking at the orders earlier in the day and doing the wound treatment without looking to verify the orders. The ADON stated the risk would be a decline in the resident's condition. <BR/>During an interview on 02/06/25 at 8:42 PM, with LVN F, she stated she did not provide wound care when she worked the weekend because she was busy doing other things. LVN F stated there could be a negative outcome of not providing wound care which would depend on the situation of the resident. <BR/>Observation and interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated the facility had been having issues for several months with wound care not being provided on the weekends. The Treatment Nurse stated she, and the EX-DON were providing in-services and education on providing wound care. The Treatment Nurse stated she had created a binder with the residents who needed to have wound care done for each hallway nurse that was broken down to make it easy for them. The Treatment Nurse stated even with that they were still having issues with wound care. The Treatment Nurse stated she had reported it to the ADON and the Administrator who asked her for a list of residents and that they would follow up with those residents. The Treatment Nurse stated she had not seen anything being done by the Administrator and keeps reporting it in the morning meetings. The Treatment Nurse stated she had been letting them know every Monday and has to go back to re-check all the residents' wounds. The Treatment Nurse stated she had not seen any of the wounds from the residents getting worse. The Treatment Nurse stated on 02/01/25-02/02/25, wound care was not provided for Resident #3 and other residents from 200 hall. The Treatment Nurse stated in the facility system it would let the nurse know when it was time to give the wound care as it comes up green and if it was not completed it would turn red. <BR/>During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated that yesterday (02/05/25) the facility did an audit and found the same concerning trend to be found with the residents in 400 hall. The ADON stated the only hall to provide wound care for the weekend (02/01/25-02/02/25) was 300 hall. The ADON stated it has been a battle for the pasted couple of months (3) with not having wound care being provided for the residents at the facility. The ADON stated the Treatment Nurse created a binder and divided it between the halls so it would make it easier for the assigned nurses to complete wound care. <BR/>During an interview on 02/06/25 at 11:22 AM, with CNA C, she stated she did not observe wound care being conducted on the weekend (02/01/25-02/02/25). <BR/>During an interview on 02/07/25 at 9:47 AM, with LVN G, she stated there have been times she was not able to complete all the wound cares for the residents. LVN G stated she had passed it on in report to the other oncoming nurse but did not verify later on to see if it had been completed. <BR/>During an interview on 02/07/25 at 10:39 AM, with the Wound Care Doctor, he stated he was not informed of residents missing wound care. The Wound Care Doctor stated the Treatment Nurse has mentioned some issues but did not tell him the details of those issues. The Wound Care Doctor stated the nurses were to be providing wound care. The Wound Care Doctor stated these issues had not been brought to his attention especially major lapses with wound care. The Wound Care Doctor stated he should have been informed of any missed wound care or changes to significant changes. The Wound Care Doctor stated the risk of deterioration, infection, or necrosis(a type of cell death that occurs when cells are irreversibly damaged and lose their normal functions).<BR/>During an interview on 02/10/25 at 11:45 AM, with Interim-DON, he stated the Treatment Nurse was to be providing wound care during the weekdays and the nurses on the weekends since there was no Treatment Nurse working. The Interim-DON stated not doing wound care could have a negative effect on the resident where the wound could get worse or infected. The Interim-DON stated he was not notified that wound care was not being provided on the weekends and if known he would have taken action immediately. The Interim-DON stated it should have been expected that the nurses notify him that wound care was not being done. <BR/>Record review of the facility Skin policy dated 07/22, revealed, A Pressure Injury Prevention Care Plan will be completed by the Treatment Nurse or Charge nurse and interventions implemented for all Residents based upon the Braden Scale score in conjunction with clinical judgement and review of other risk factors. An updated Pressure Injury Prevention Care Plan will be completed upon a change in Braden Scale score or a change in condition.<BR/>The Director of Nursing or designee will audit and verify system compliance weekly including prevention-focused rounding and education as appropriate.<BR/>Rounding will be completed by the Charge Nurse, Treatment Nurse and Nurse Manager for observations of pressure sore prevention, including, but not limited to best practices such as off-loading, turning and repositioning. <BR/>The Quality of Assurance and Performance Improvement Review will include the findings from random audits of documentation completion: Physician Orders, Pressure Injury Care Plan, Non-Pressure Injury Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue). <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00, indicating her cognition was severely impaired, and she was dependent on staff for transfers. <BR/>Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/ 2 person transfers with interventions that included safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate and goal was will remain free from injury. <BR/>In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes in place. The transfer was completed without incident, and no anxiety was observed.<BR/>In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included the resident swinging, tipping over, and possibly falling. CNA B stated she had received training on proper mechanical lift transfer procedures.<BR/>In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent movement and released only when ready to move the lift. The DON stated one CNA maneuvered the mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and quarterly random competency checks were conducted by the DON and lead CNA.<BR/>In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed by direct care staff who were trained at hire, annually, and as needed during competency checks. The Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated the risk of not following those steps included potential injury to the resident or staff. <BR/>Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked position on the wheelchair, shower or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident with urinary incontinence, based on the resident ' s comprehensive assessment, the facility must ensure that the resident receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 (Resident #32) residents reviewed for urinary catheter. <BR/>The facility failed to ensure Resident #32 ' s subpubic catheter was properly secured. <BR/>This failure placed residents at risk of possible pain and trauma due to the catheter not being properly secured on the leg. <BR/>Findings included: <BR/>Record review of Resident #32 ' s history and physical dated 11/23/2023 revealed diagnoses of UTI (urinary tract infection), dementia, suprapubic catheter. <BR/>Record review of Resident #32 ' s quarterly MDS assessment dated [DATE] revealed he had a BIMS of 3 (cognitively severely impaired) and had a dwelling catheter. <BR/>Record review of Resident #32 ' s care plan dated 12/05/2023 revealed Resident #32 has a subpubic catheter: Indwelling related to obstructive uropathy with interventions of Secure tubing to thigh to prevent pulling. <BR/>Record review of Resident #32 ' s physician order dated 8/25/23 revealed Leg strap placement check every shift. <BR/>During an observation and interview on 3/13/24 at 9:41 am, CNA F stated the resident ' s catheter was not properly secured. The patch was dated 2/14/24. CNA F stated the nurse knew about it since the nurse is the one that replaces the patch. The lock on the patch was not latching to keep the catheter secure and stated it had been like that for a while but did not specify how long. CNA F stated that the risk included pulling on the catheter when staff is provided care. <BR/>Interview on 03/13/24 9:52 AM, LVN E said the catheter was below the bladder. The catheter was not properly secured. The latch was not latching or locking correctly. LVN E stated that the nurses and CNAs were responsible for checking that catheters are positioned correctly. LVN C said the risk of pulling a catheter could cause trauma. LVN E said that on the 6th and 20th of every month, catheters for residents need to be changed. LVN E stated that the patch was dated 2/21/24. LVN E said the patch was changed as needed. LVN E said she does not receive reports if a CNA or an LVN finds the catheter was not secured properly. LVN E said that staff receive training online regarding catheters twice a year. <BR/>In an interview and observation on 03/13/24 02:00 PM LVN E, stated that catheters need to be checked every time that the resident was changed. LVN E said that Resident #32 changed every 2 hours because he needs to be repositioned. LVN E said that Resident #32 E can communicate if he's in pain and he will notify the staff. <BR/>In an interview on 03/14/24 01:30 PM with DON, she stated that for urinary catheters to be properly secured, they need to be secured with the immobilizer device, which goes on their leg or thigh, that way it is secure and not bothering the patient. The DON said the staff responsible for checking for the catheter was the nurse in charge of the resident, but it was expected that the CNA's also check and make sure it's stabilized. The DON said that if a CNA observes that if a catheter was not stabilized or properly secure, the CNA would need to communicate it to the nurse after putting the catheter to the side and has made sure that it's not bothering the resident and that the catheter bag is not touching the floor. The DON stated that staff checks that the catheters are secured as needed and throughout the shift. She said that the person responsible for overseeing the Nurses and CNAs are checking the catheters is the ADON and then the DON supervises her. DON said that the risk of a catheter not being properly secured is that the catheter can hurt the resident. The resident can start bleeding and it can worsen the situation. DON stated that if a Nurse or CNA finds a catheter not properly secure, the expectation is for the nurse to remove the patch and put a new one that can properly secure the catheter. DON stated that the last in-service regarding catheters was provided on February 22, 2024. She stated that she does not know how often it needs to be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the residents' goals and preferences for one (Resident #30) of four residents reviewed for provision of respiratory care. <BR/> Resident #30 was not assisted in putting on her CPAP mask every night as per physician ' s orders. <BR/> This failure could result in residents having increased difficulty sleeping, decreased sleep quality, and increased instances of sleep apnea (a sleep disorder where breathing stops and starts). <BR/>Findings included: <BR/>Record review of Resident #30 ' s face sheet dated 03/14/2023 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #30 ' s History and Physical dated 02/21/2023 reveled she had diagnoses including COPD (Chronic Obstructive Pulmonary disease - a condition where airways are narrowed, and breathing is difficult); Chronic respiratory failure with hypoxia (a condition where airways are narrowed or damaged and there is reduced oxygen in the blood); Sleep disorder (changes in sleep that can negatively affect health.) Medications included a CPAP to be used nightly and 2 liters per minute of oxygen at night as needed. The History and Physical revealed that Resident #30 ' s family member said that facility staff was not placing her CPAP because the distilled water in the machine had not been used. The resident said she was not sleeping, although staff reported she was. <BR/>Record review of Resident #30 ' s quarterly MDS dated [DATE] revealed she had a BIMS of 9 (Moderate cognitive impairment). She had no symptoms of delirium or psychosis. She had no behavioral symptoms including rejection of care during the 7-day look back period. She had diagnoses including COPD or chronic lung disease, and Respiratory failure. The MDS indicated she was not receiving oxygen therapy. <BR/> Record review of Resident #30 ' s Care plan dated 01/26/2023 revealed she refused to use her C-Pap Machine. The goal was that her episodes of refusing to use the CPAP machine would diminish. Interventions included to report CPAP refusal to the physician, and explain why the CPAP was important. The Care Plan did not address the difficulty the resident had trying to put the CPAP machine on herself. <BR/>Record review of Resident #30 ' s physicians orders dated 11/15/2023 revealed she was to use a CPAP machine daily at bedtime. The physician's order dated 01/26/2024 revealed that her compliance with use of the CPAP machine was to be documented in progress notes and the physician was to be notified if she was noncompliant. <BR/>Record review of Resident #30 ' s progress note by LVN A dated 1/9/2024 revealed the resident was prompted throughout the night to keep her c-pap on with no success. The resident had intermittent labored breathing. <BR/> Record review of Resident #30 ' s MAR for February 2024 revealed she was non-complaint with use of the CPAP machine on 02/14/2024 and 02/23/2024. <BR/> Record review of Resident #30 ' s nursing progress notes February 2024 revealed no corresponding nursing notes regarding her refusal to use the CPAP machine as required by physician ' s order. <BR/>Record review of Resident #30 ' s MAR for March 2024 (03/01/2024 - 03/12/2024) revealed she had no instances of non-compliance with use of the CPAP machine. <BR/> Record review of Resident #30 ' s respiratory therapy report dated 03/14/2024 for 12/15/2023 - 03/13/2024 revealed she used the CPAP machine 33 out of 90 days and had not used the CPAP machine on 57 nights. During February 2024 she did not use the CPAP machine on 02/01, 02/02, 02/03, 02/04, 02/07, 02/09, 02/10, 02/14, 02/16, 02/17, 02/19, 02/22, 02/23, 02/24, 02/28 and 02/29/2024. Between 03/01/2024 and 03/13/2024 she did not use the CPAP machine the nights of 03/01, 03/02, 03/01, 03/08, 03/09, 03/11, 03/12 and 03/13/2024. <BR/>In an interview on 03/11/24 at 11:19 AM Resident #30 ' s family member said that staff were not putting the CPAP on the resident at night. The family member said a man came in to look at the machine and said they [nursing staff] do not put it on her. The resident said she had difficulty putting the CPAP mask by herself. <BR/>In a telephone interview on 03/14/24 at 09:28 AM Respiratory Therapist C revealed that he was familiar with Resident #30 and that he could provide records of her use of the CPAP machine. <BR/>In an interview on 03/14/24 at 11:34 AM Respiratory Therapist C revealed that review of Resident #30 Therapy Report documented that in March 2024 the resident did not have the CPAP mask on at all, and that between 12/15 and 3/13 she did not use the CPAP machine 57 times. The Respiratory Therapist state that not using the CPAP machine put Resident #30 at risk of poor sleep quality and increased instances of sleep apnea. <BR/>In an interview on 03/14/24 at 02:10 PM the DON revealed that nurse should be documenting if Resident #30 refused to use her CPAP machine. She stated that without the use of the CPAP machine the resident would be at increased risk of sleep apnea and might lose breathing at night. She said the nurses should be following physician ' s orders to document instances when Resident #30 refused to use the CPAP machine. <BR/>In an interview on 03/14/24 at 02:28 PM ADON D revealed she thought Resident #30 was generally compliant with all orders including use of the CPAP machine. She stated that noncompliance with use of the CPAP machine could result in Resident #30 ' s feeling winded, short of breath, and might exacerbate her COPD. <BR/>In an interview on 03/14/24 at 04:16 PM LVN A revealed that during the time she had worked with Resident 30, she had been told by other staff that the resident refused to use the CPAP machine. LVN A said she put the CPAP mask on Resident #30 herself because the resident was not able to put it on herself. The LVN said she had not had any difficulties with Resident #30 ' s use of the CPAP after educating the resident about the risks of not using the CPAP. The LVN said that if the resident did not want to put the machine on right away the LVN would go back and put it on her later in the evening. <BR/>

Based on observations, interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 of 4 days reviewed and the census was wrongly documented. <BR/>The facility failed to post the required staffing information for 3/11/24. <BR/>The facility failed to accurately document the census for 60 days of 73 days reviewed in January 2024, February 2024, and March 1st through the 13th. <BR/>This failure could place residents, their families, and facilities, and visitors at risk of not having access to correct information regarding staffing data and facility census. <BR/>Findings included: <BR/>During an observation on 3/11/24 at 9:17 am, the public access area nursing station had a daily sheet posting information which included facility name, census, total hours for RNs,. LVNs, CNAs, MAs, and shift times that was dated 3/10/24. <BR/>During an observation on 3/11/24 at 12:01 pm, the public access area nursing station had a daily sheet posting information which included facility name, census, total hours for RNs,. LVNs, CNAs, MAs, and shift times that was dated 3/10/24.<BR/>Record review of January 2024 census revealed, 1/1/24 the census was 85. The direct care staffing log dated 1/1/24 revealed census of 83. <BR/>Record review of January 2024 census revealed, 1/2/24 the census was 84. The direct care staffing log dated 1/2/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/3/24 the census was 85. The direct care staffing log dated 1/3/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/4/24 the census was 86. The direct care staffing log dated 1/4/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/5/24 the census was 85. The direct care staffing log dated 1/5/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/6/24 the census was 85. The direct care staffing log dated 1/6/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/7/24 the census was 84. The direct care staffing log dated 1/7/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/8/24 the census was 84. The direct care staffing log dated 1/8/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/9/24 the census was 85. The direct care staffing log dated 1/9/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/10/24 the census was 84. The direct care staffing log dated 1/10/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/11/24 the census was 85. The direct care staffing log dated 1/11/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/13/24 the census was 81. The direct care staffing log dated 1/13/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/14/24 the census was 81. The direct care staffing log dated 1/14/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/15/24 the census was 82. The direct care staffing log dated 1/15/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/16/24 the census was 82. The direct care staffing log dated 1/16/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/17/24 the census was 83. The direct care staffing log dated 1/17/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/19/24 the census was 80. The direct care staffing log dated 1/19/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/20/24 the census was 80. The direct care staffing log dated 1/20/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/20/24 the census was 80. The direct care staffing log dated 1/20/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/21/24 the census was 79. The direct care staffing log dated 1/21/24 revealed the census was blank.<BR/>Record review of January 2024 census revealed, 1/22/24 the census was 80. The direct care staffing log dated 1/22/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/23/24 the census was 79. The direct care staffing log dated 1/23/24 revealed the census was blank. <BR/>Record review of January 2024 census revealed, 1/24/24 the census was 81. The direct care staffing log dated 1/24/24 revealed census of 80.<BR/>Record review of January 2024 census revealed, 1/25/24 the census was 79. The direct care staffing log dated 1/25/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/26/24 the census was 80. The direct care staffing log dated 1/26/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/28/24 the census was 80. The direct care staffing log dated 1/28/24 revealed census of 79.<BR/>Record review of January 2024 census revealed, 1/29/24 the census was 80. The direct care staffing log dated 1/29/24 revealed census of 79.<BR/>Record review of January 2024 census revealed, 1/30/24 the census was 82. The direct care staffing log dated 1/30/24 revealed census of 80.<BR/>Record review of January 2024 census revealed, 1/31/24 the census was 80. The direct care staffing log dated 1/31/24 revealed census of 81.<BR/>Record review of February 2024 census revealed, 2/1/24 the census was 79. The direct care staffing log dated 2/1/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/2/24 the census was 79. The direct care staffing log dated 2/2/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/4/24 the census was 78. The direct care staffing log dated 2/4/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/5/24 the census was 78. The direct care staffing log dated 2/5/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/6/24 the census was 78. The direct care staffing log dated 2/6/24 revealed census of 81.<BR/>Record review of February 2024 census revealed, 2/7/24 the census was 79. The direct care staffing log dated 2/7/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/8/24 the census was 79. The direct care staffing log dated 2/8/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/9/24 the census was 78. The direct care staffing log dated 2/9/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/10/24 the census was 78. The direct care staffing log dated 2/10/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/11/24 the census was 76. The direct care staffing log dated 2/11/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/12/24 the census was 76. The direct care staffing log dated 2/12/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/13/24 the census was 73. The direct care staffing log dated 2/13/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/14/24 the census was 74. The direct care staffing log dated 2/14/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/15/24 the census was 74. The direct care staffing log dated 2/15/24 revealed census of 73.<BR/>Record review of February 2024 census revealed, 2/16/24 the census was 74. The direct care staffing log dated 2/16/24 revealed census of 73.<BR/>Record review of February 2024 census revealed, 2/19/24 the census was 75. The direct care staffing log dated 2/19/24 revealed census of 74.<BR/>Record review of February 2024 census revealed, 2/20/24 the census was 75. The direct care staffing log dated 2/20/24 revealed census of 74.<BR/>Record review of February 2024 census revealed, 2/21/24 the census was 77. The direct care staffing log dated 2/21/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/22/24 the census was 77. The direct care staffing log dated 2/22/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/24/24 the census was 78. The direct care staffing log dated 2/24/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/25/24 the census was 79. The direct care staffing log dated 2/25/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/26/24 the census was 80. The direct care staffing log dated 2/26/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/27/24 the census was 81. The direct care staffing log dated 2/27/24 revealed census of 78.<BR/>Record review of February 2024 census revealed, 2/28/24 the census was 81. The direct care staffing log dated 2/28/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/2/24 the census was 81. The direct care staffing log dated 3/2/24 revealed census of 80.<BR/>Record review of March 2024 census revealed, 3/3/24 the census was 81. The direct care staffing log dated 3/3/24 revealed census of 80.<BR/>Record review of March 2024 census revealed, 3/5/24 the census was 79. The direct care staffing log dated 3/5/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/6/24 the census was 77. The direct care staffing log dated 3/6/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/7/24 the census was 77. The direct care staffing log dated 3/7/24 revealed census of 78.<BR/>Record review of March 2024 census revealed, 3/9/24 the census was 75. The direct care staffing log dated 3/9/24 revealed census of 77.<BR/>Record review of March 2024 census revealed, 3/10/24 the census was 75. The direct care staffing log dated 3/10/24 revealed census of 77.<BR/>Record review of March 2024 census revealed, 3/11/24 the census was 75. The direct care staffing log dated 3/11/24 revealed the census was blank.<BR/>Record review of March 2024 census revealed, 3/12/24 the census was 77. The direct care staffing log dated 3/12/24 revealed census of 75.<BR/>During an interview on 3/14/24 at 11:39 am, the ADON stated the Lead CNA was responsible for completing the daily staffing posting. The ADON stated the Lead CNA had a binder with the copies in place where she prefilled the dates for a weeks' worth and would complete the daily staffing census the day before and would leave it for the nurses to post the following morning. The ADON stated the nurses and/or the Lead CNA would have to verify the daily census at the beginning of the shift. The ADON stated she did not know what kind of risk there was for the census not being accurate and stated she knew it was a State Office requirement. <BR/>During an interview on 3/14/24 at 12:03 pm, the Lead CNA stated she was responsible for completing the daily staffing sheet. The Lead CNA stated she would complete the daily staffing sheet at the end of the shift for the following day and would leave it in the nurse's station for the nurses to post in the morning. The Lead CNA did not have an answer for the census being wrong and did not know of any risk for the daily census being wrong . <BR/>Record review of Posting Direct Care Daily Staffing Number policy dated July 2016 read in part our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Shift information shall be recorded on the nursing staff directly responsible for resident care form for each shift. The information recorded on the form shall include: the resident census at the beginning of the shift for which the information is posted. Within 2 hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the nursing staff directly responsible for resident care form/ the shift supervisor shall date the form, record the census, and post the staffing information in the location designated by

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 residents (Resident #14 and Resident #57) of 7 reviewed for medication administration and 1 of 1 medication room.<BR/>-LVN H failed to administer insulin with meal per physician order for Resident #14. <BR/>-LVN I administered Resident #57 medication through feeding tube without checking for residuals first.<BR/>-Medication room had expired medications<BR/>This deficient practice could cause a decline in health of residents due to incorrect medication administration or administration of expired medications. <BR/>Findings included:<BR/>Resident #14<BR/>Review of Resident #14's Face Sheet dated 02/10/2023 documented a [AGE] year-old female with an admission date of 12/07/18. <BR/>Review of a History and Physical dated 06/29/2022 documented Resident #14 had a history of Type 2 Diabetes and at the time of the assessment was taking HumaLog 5 units with meals subcutaneously three times a day. The H&P stated, Monitor blood glucose levels .continue with all medications as prescribed.<BR/>Record review of Physician orders dated 08/31/2021 documented HUMALOG 100 UNIT/ML VIAL ADMINISTER 5 UNITS WITH MEALS SUBCUT TID. <BR/>Review of Comprehensive Care Plan dated 11/28/2022 documented Resident #14 had potential for hypoglycemia episodes secondary to Diabetes. Goal would be to minimize the risk for hypoglycemia through interventions such as administering insulin as ordered and monitor blood sugars.<BR/>Review of Annual MDS assessment dated [DATE] documented Resident #14 had a BIMS score of 6 meaning she was severely cognitively impaired. It also revealed she had a diagnosis of Diabetes and had taken Insulin at the time of the assessment. <BR/>Observation of medication pass on 02/08/2023 at 3:24 PM, revealed LVN H checked Resident # 14's blood sugar and it was 173. She then checked the physician order and drew 5 units of Humalog insulin. LVN H injected the insulin into the right lower abdomen subcutaneously. LVN H then gathered her supplies, disposed of them, and left the room. Resident #14 was not eating a meal at the time of insulin administration. <BR/>In an interview with LVN H on 02/08/2023 at 3:51 PM, she said dinner was served at 5:00 PM. She said she was supposed to provide a snack to the residents who are given insulin if no meal is provided. She said the snack should be provided within 30 minutes of administration. She said the risks of not providing snacks or meal after insulin administration could be that the blood sugar could drop. She said the nurses had been trained on insulin administration. <BR/>In an interview with LVN I on 02/10/2023 at 09:05 AM, she said it was procedure to provide insulin with meals or provide a snack after administration. She said risks for not doing so could be dropping of blood sugar in the resident.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said when a nurse would administer insulin that was ordered with meals, there had to be food or a meal available to be given with the medication. He said if there was no food, he would wait until there was a tray or a snack for the resident. He said the nurses were trained on providing meals with insulin administration.<BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the insulin should be given around dinner time that way the residents' blood sugar would not drop. She said usually the medication would be given 10 minutes before meal.<BR/>Resident #57<BR/>Review of Resident #57's Face Sheet dated 02/10/2023 demonstrated a [AGE] year-old male with an admission date of 12/16/2022. <BR/>Review of a History and Physical dated 12/17/2022 demonstrated he had a Gastrotomy tube and was receiving tube feedings. <BR/>Review of Physician orders dated 01/25/2023 demonstrated Resident #57 had Glucerna feedings @65 ml/hour through his feeding tube. <BR/>Review of Comprehensive Care Plan dated 01/09/2023 demonstrated Resident #57 had G-tube and required ostomy care. Goal was to minimize risk for complications related to G-tube daily through interventions such as flushing the tube.<BR/>Review of Quarterly MDS assessment dated [DATE] demonstrated Resident #57 had a BIMS score of 6, meaning he was severely cognitively impaired and had memory impairments. It also revealed he had a feeding tube and was receiving tube feedings. <BR/>Observation of medication pass on 02/09/23 at 08:41 AM, revealed LVN I was preparing to administer medications to Resident #57. She disconnected the tube feeding from the tube and connected the syringe. She then flushed the feeding tube with 30 cc of water, and then administered the medications. She was observed not checking the for residuals or placement of the feeding tube prior to medication administration. <BR/>In an interview with LVN I on 02/10/23 at 09:05 AM, she said the proper procedure for G-tube medication administration was to check the feeding tube for patency and check for residuals. She said she had checked the tube in the morning during rounds, but not before administering medications. She said the risks for not checking for residuals could be that the resident could aspirate from the feeding, and the feeding tube could be misplaced.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said before administering a medication through a G-tube, it was nursing practice to aspirate the G-tube and check for residuals. He said the tube had to be checked for patency. <BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the nurses were trained to check for residuals and patency of the feeding tube every time they would give a medication. She said it was important to do so in order to check if the residents were not processing the feeding. She could not state when the nurses had been trained last. <BR/>Review of Humalog Manufacturer information dated 11/2019 read in part .HUMALOG starts acting fast. Inject HUMALOG within 15 minutes before or right after you eat a meal .<BR/>Review of facility policy titled Administering Medications dated 3/24/22 read in part .Medications shall be administered in a safe, and timely manner, and as prescribed .Medications must be administered in accordance with the orders .The individual administering the medication must check the label three times to verify the right medication .right time before giving the medication .<BR/>Review of facility policy titled Administering Medications through an Enteral Tube undated read in part .Steps in procedure .confirm the placement of feeding tube .check gastric residual volume to assess for tolerance of enteral feeding . <BR/>Medication Room<BR/>Observations on 02/08/23 at 11:38 AM, revealed the medication room had expired medications. The first cabinet in the medication room had two bottles of Vitamin C with an expiration date of 9/2022. The second cabinet had one bottle of Pro-Stat with and expiration date of 9/2022, and two bottles of UTI-Stat with an expiration date of 10/2022. <BR/>Observation and interview with DON on 02/08/23 at 11:45 AM, revealed the DON stated the medication room was checked and stocked by Central Supply. She said the medications should have not been in the room because they were expired. She said risks for keeping them in the room could be that the nurses and aides could administer them to residents. She said the nurses were trained on ensuring there were no expired medications. <BR/>In an interview with Central Supply on 02/08/23 at 1:59 PM, he said he was responsible for stocking the medication room with supplies and making sure the medications were good. He said he was not responsible for going through the medications and checking if they were expired. He said the nursing staff were responsible for checking the medications before grabbing them and taking them for their medication cart. He said since the state was at the facility, the nurses probably took the expired medications and hid them in the medication room. <BR/>Record review of facility policy titled Storage of Medications undated read in part .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts .shall not be left unattended if open or otherwise potentially available to others .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #65, Resident #24, and Resident #51) of 5 residents reviewed for unnecessary medications. <BR/>Resident #65 was prescribed Seroquel/quetiapine (an antipsychotic) to treat depression. <BR/>Resident #51 was prescribed Olanzapine (an antipsychotic) to treat major depression. <BR/>Resident #24 was prescribed Seroquel/quetiapine (an antipsychotic) to treat restlessness and agitation. <BR/>This failure put residents at unnecessary risk of side effects from psychotropic medications. <BR/>Findings included: <BR/>Resident #65 <BR/>Record review of Resident #65 ' s face sheet dated 03/14/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #65 ' s History and Physical dated 05/24/2023 revealed she had a past medical history of Alzheimer ' s dementia with psychosis. She was assessed as having Major depressive disorder, recurrent episode. Treatment plan included to continue Seroquel [brand name for quetiapine] for Major depressive disorder. <BR/>Record review of Resident #65 ' s quarterly MDS dated [DATE] revealed she had a BIMS score of 6 (severe cognitive impairment). She had symptoms of delirium (disturbance in mental abilities resulting in confused thinking) including intermittent confused thinking. She did not have symptoms of depression or psychosis. Her diagnoses included Alzheimer ' s disease, non-Alzheimer ' s dementia, anxiety disorder, depression, and psychotic disorder other than schizophrenia. She had been taking antipsychotic, antianxiety, and antidepressant medications. Antipsychotics were received on an ongoing basis. It was noted that a GDR had been attempted on 09/08/2023. <BR/>Record review of Resident #65 ' s 5-Day MDS dated [DATE] revealed she had a BIMS of 8 (moderate cognitive impairment). She had symptoms of delirium (disturbance in mental abilities resulting in confused thinking) including intermittent confused thinking. She did not have symptoms of depression or psychosis. Her diagnoses included Alzheimer ' s disease, non-Alzheimer ' s dementia, anxiety disorder, depression, and Psychotic disorders other than schizophrenia. She had been taking antipsychotic, antianxiety, and antidepressant medications. No issues were found during drug review. <BR/>Record review of Resident #65 ' s care plans revealed a care plan dated 12/13/2023 for Seroquel (quetiapine). The care plan stated she was at risk for side effects, with a goal that she would have no injury related to antipsychotic medication usage/side effects daily and ongoing over the next 90 days. <BR/>Record review of Resident #65 ' s physician ' s orders dated 12/15/2023 revealed that she was to receive one 25 MG tablet of quetiapine fumarate (Seroquel) each day to treat major depressive disorder, recurrent, unspecified. <BR/>Record review of Resident #65 ' s physicians ' note dated 02/21/2024 revealed the assessment identified diagnoses included Alzheimer ' s disease and Other recurrent depressive disorders. 25 MG of Quetiapine was to be continued for dementia. Buspirone and Escitalopram Oxalate were to be continued for recurrent depressive disorder. <BR/>Record review of Resident #65 ' s physician ' s progress note dated 01/10/2024 revealed that she was to continue to receive one quetiapine fumarate 25 MG tablet at bedtime for dementia associated with other underlying disease, with agitation, unspecified dementia severity. <BR/>Record review of Resident #65 ' s physician ' s progress note dated 02/21/2024 revealed that she was to continue to receive one quetiapine fumarate 25 MG tablet at bedtime for dementia associated with other underlying disease, with agitation, unspecified dementia severity. <BR/>Record review of Resident #65 ' s MAR for February 2024 revealed she was administered one 25 MG tablet of quetiapine fumarate (Seroquel) daily. <BR/>Record review of Resident #65 ' s MAR for March 2024 (accessed 3/12/2023) revealed she was administered one 25 MG tablet of quetiapine fumarate (Seroquel) daily from 03/01/2024 through 03/11/2024. <BR/>In an interview on 03/14/2024 at 3:11 PM the DON revealed that Major depressive disorder was an appropriate indication for administration of quetiapine. <BR/>In an interview on 03/14/2024 at 3:14 PM in an interview MDS Nurse H revealed that she was not familiar with the risks associated with quetiapine. She said that she communicated with the physicians to find out about the match between medications and diagnoses, and that if there were changes in medications, she communicated these to the DON. She stated that she was not responsible for determining if a particular medication was indicated for a particular diagnosis. <BR/>Multiple attempts were made to communicate with Resident #65 ' s physician, but a return phone call was not received prior to exiting the facility. <BR/>Resident #51 <BR/>Record Review of Resident #51 Administration Record start date 08/25/2023, revealed the assessment identified diagnosis included Major Depression, recurrent, mild. Olanzapine 2.5 MG is used for an antipsychotic medication. <BR/>Record Review of Resident #51 ' s Quarterly MDS dated [DATE] has a BIMS score of 6 (Severe cognitive impairment) he did not have any symptoms of delirium. His diagnosis included Alzheimer's disease, Anxiety Disorder, Depression, Psychotic Disorder, and Schizophrenia. It was noted that a GDR had been attempted on 08/02/2023. He had been taking an antipsychotic, antianxiety. No issues were found during the drug review. <BR/>Record review of Resident #65 ' s care plans revealed a care plan dated 11/18/2022 for Olanzapine. The care plan stated he was at risk for side effects, with a goal that she would have no injury related to antipsychotic medication usage/side effects daily and ongoing over the next 90 days. <BR/>In an interview on 03/14/2024 at 03:14 pm, the DON stated she was not responsible for determining if a particular medication was indicated for a particular diagnosis, that it would be the MDS Nurse H. The DON was asked if she knew what Seroquel or Olanzapine were treated for, and she stated she did not know. She would have to search it and was not familiar with any antipsychotic modifications. The DON provided a phone number to MDS Nurse H, as she was out for the day. <BR/>An interview was attempted with MDS Nurse H via telephone on 03/14/2024 at 04:15pm, voicemail was left as she did not answer. <BR/>Resident #24 <BR/>Record Review of Resident #24 face sheet dated 03/14/2024, revealed she was [AGE] years old, who was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #24 ' s History and Physical dated 05/12/2023 revealed she had a past medical history of Alzheimer ' s, dementia, and Vascular Dementia. She was assessed as having behavior present, fluctuates (comes and goes, changes in severity). <BR/>Record review of Resident #24 ' s quarterly MDS dated [DATE] revealed she had a BIMS of 4 (Severe cognitive Impairment) She had symptoms of delirium (behaviors present, fluctuates). She did not have symptoms of depression or psychosis. Her diagnoses included Alzheimer ' s disease, non-Alzheimer ' s dementia, anxiety disorder, depression. She had been taking an antipsychotic, and antidepressant medications. Antipsychotics were received on a routine basis. It was noted that a GDR was not attempted. <BR/>Record review of Resident #24 ' s care plans revealed a care plan dated 11/16/2023 for Seroquel (quetiapine). The care plan stated she was at risk for side effects, with a goal that she would have no injury related to antipsychotic medication usage/side effects daily and ongoing over the next 90 days. <BR/>Record review of Resident #24 ' s physicians ' note dated 11/16/2023 revealed the assessment identified diagnoses included Restlessness and Agitation. 25 MG of Quetiapine was to be given one tablet by mouth twice daily. <BR/>In an interview on 03/14/2024 at 03:14 pm, the DON stated she was not responsible for determining if a particular medication was indicated for a particular diagnosis, that it would be the MDS Nurse H. The DON was asked if she knew if Seroquel or Olanzipine were treated for, she stated she did not know. She would have to search it and was not familiar with any antipsychotic modifications. The DON provided a phone number to MDS Nurse H, as she was out for the day. <BR/>In an interview on 03/14/2024 at 04:45pm, the DON stated a GDR was not done for Resident #24 because the antipsychotic was started by hospice on 11/16/2023. <BR/>Multiple attempts were made to communicate with Resident #65 ' s physician, but a return phone call was not received prior to exiting the facility. <BR/>An interview was attempted with MDS Nurse H via telephone on 03/14/2024 at 04:15pm, voicemail was left as she did not answer. <BR/>Record review of the facility policy revealed when a resident participates in the hospice program, a coordination plan of care between the facility, hospice agency, and residents/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. <BR/>Record review of the facility policy Antipsychotic Medication Use revised 4/2007 revealed that antipsychotic medication would be used only when necessary to treat a specific condition. Conditions/diagnoses for which antipsychotics could be prescribed included: depression with psychotic features, and treatment refractory major depression; or for dementing illness with associated behavioral symptoms. <BR/>Record review of the website drugs.com on 03/19/2024 revealed that Seroquel (quetiapine) was used to treat schizophrenia or in patients with bipolar disorder. Quetiapine may increase the risk of death in older adults with mental health problems related to dementia. Olanzapine is an antipsychotic medication used to treat psychotic conditions such as schizophrenia and bipolar disorder. Drugs.com had a warning that olanzapine is not approved for use in older adults with dementia-related conditions and may increase the risk of death in older adults with dementia-related psychosis and is not approved for this use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.<BR/>1. <BR/>Food products in dry storage and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings include:<BR/>Observation on 02/07/2023 at 8:10 a.m., in the dry storage was a 106 oz dented can of mixed fruits on the rollout shelve. <BR/>- <BR/>Dry storage area, a 16 oz clear bag enriched macaroni was sitting on the mid shelve inside a zip lock bag undated and opened. <BR/>- <BR/>In the back of the house kitchen prep area, the middle refrigerator inside on the top shelve was a 5.6 qt 6-inch-deep clear plastic container with salsa mid-way with a clear plastic wrap with its ends floating outwards and not gripping the container securing a closed hold. <BR/>- <BR/>In the back of the house kitchen prep area, in refrigerator on top shelf was a 6-inch metal deep pan full of green lettuce leaf was not wrapped properly with plastic wrap. Plastic wrap is not gripping onto the pan and in the front part of the pan that is visible to us to view has a opening about half an inch. <BR/>- <BR/>In the back of the house kitchen prep area, on the top shelve in the refrigerator was a 4 in deep metal pan with cherry tomatoes in it. The plastic wrap was not gripping the pan properly and was not making a proper seal. <BR/>- <BR/>In the back of the house kitchen prep area, middle freezer was a clear wrapped plastic bag of chicken breast that were not labeled/ dated. <BR/>- <BR/>In the back of the house kitchen prep area, on top freezer was a bag of yellow squash dated [DATE]. <BR/>- <BR/>In the back of the house kitchen prep area, on the top shelve was a bag of red skinned potatoes 2.5 lbs. and halfway gone that were dated 217 [DATE] 05. <BR/>- <BR/>In between the kitchen and the back of the house was a holding shelf that had a 23oz bag of hamburger buns with no date. <BR/>- <BR/>In the front of the house kitchen area, a refrigerator on the top shelf was a one-gallon clear pouring container that contained lemonade that was expired as labeled (02/05/2023 to 02/06/2023).<BR/>- <BR/>In front of the house kitchen area, a refrigerator on the middle shelves had 54 5 oz plastic tumbler cups full of milk that were expired (02/05/2023 to 02/06/2023). <BR/>Interview on 02/07/2023 at 8:20 a.m., Dietary Manager stated the Macaroni was to be closed properly and was not common practice leaving it open. Dietary Manager stated the macaroni has to be closed properly so insects don't get in and the product get damaged. Dietary Manager stated dietary staff are in-serviced and receive monthly trainings. Dietary Manager stated the damaged cans are separated and are to go into her office. Dietary Manager stated damaged cans are damaged products and due to the damage can contain air. Dietary Manger stated staff are trained when doing the truck when products come in and check the food items when putting them away. Dietary Manager stated the dietary staff are to check and inspect the food items/packages before using them. Dietary Manager stated the yellow squash and the red skin potatoes have been fed to the residents. Dietary Manager stated the supplier had confirmed the date on the yellow squash the date it was packaged. Dietary Manager stated supplier did not tell them what the expiration date was. Dietary Manager stated she oversees the dietary staff are labeling and checking the foods when they are put away. Dietary Manager stated it is important to put the expiration dates. <BR/>Interview on 02/08/2023 at 11:02 a.m., Dietitian stated dietary staff go through basic training to work in the kitchen and the Dietary Manager oversees this. Dietitian stated she does audits once a month and orally instructs dietary staff on logging temps, safety, diets, portion sizes, labeling, and storage. Dietitian stated the yellow squash and red skin potatoes outdated was no risk to the residents because they were in the freezer and has temperature control. Dietitian stated cans dented needed to be placed aside because they can contain botulism. Dietitian stated of the dented can was fruit then there can be a risk of botulism and would be a risk to the residents if they ingest it. <BR/>Interview on 02/09/2023 at 1:51 p.m., Dietary Staff J stated there is no specific training to be able to do the truck. Dietary Staff J stated she sees the dates and places the older foods on the top and the newer food on the bottom of shelves. Dietary Staff J stated when the food comes out of the box we date it and place the name on the items. Dietary Staff J stated the dietary staff have not received any training on labeling. Dietary Staff J stated the dietary staff are to check the bag(s) to see if it is not spoiled. Dietary Staff J stated if we had it like that (yellow squash and red skin potatoes) outdated we should have thrown it away. Dietary Staff J stated dietary staff are trained through the food handlers' program which trains dietary staff on dates, labeling, and checking food items. Dietary Staff J stated they also receive training from the facility. Dietary Staff J stated the red potatoes were used and given to the residents. Dietary Staff J stated she would have voiced it out as a concern with the date on the squash. Dietary Staff J stated staff are trained to check out the foods before using them. Dietary Staff J stated the residents can get sick by serving them expired food.<BR/>Interview on 02/09/2023 at 2:08 p.m., Dietary Staff K stated she was trained by the facility which gave her a curriculum and by the Dietary Manager. Dietary Staff K stated the dietary staff were in-serviced to wash hands, labels, and do temperatures. Dietary Staff K stated the dietary staff are to put the dates on everything and place all the old foods in front to be used first. Dietary Staff K stated dietary staff when putting food away check the food items with the dates and to see if they are spoiled. Dietary Staff K stated she had learned in other areas that some food items can last a year. Dietary Staff K stated the facility does not have a policy that states that the facility can use food that is a couple months to a year old. Dietary Staff K stated there is a risk with not checking the dates because those being server the red skinned potatoes to the resident could get botulism. <BR/>Record review of facility policy dated 10/01/2018 of Food Delivers stated to ensure that all food prepared by the facility is of good quality, there facility will follow HACCP guidelines for receiving and inspecting foods delivered to the facility. Food Deliver Policy indicates on procedure line 2, The Nutrition and Foodservice Manager or designees will inspect all deliveries to ensure that the food is not spoiled or adulterated. C. all cans must be in good condition and not dented. <BR/>Record review of facility policy dated 10/01/2018 of Food Storage stated to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Food Storage Policy indicated on dry storage procedure line d., to ensure freshness, store opened and bulk items in tightly covered containers. All containers' must be labeled and dated. Food Storage Policy refrigerator procedure line d., date, label, and tightly seal all refrigerator foods using clean, nonabsorbent, covered containers' that are approved for food storage. <BR/>Record review of facility in-service dated 12/16/2021 of Dry Food Summary was given for labeling and dating.

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 13 of 14 meetings reviewed for QAPI. <BR/>The facility did not ensure the MD, or a representative and Infection Preventionist attended QAPI meetings. <BR/>This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. <BR/>Findings included: <BR/>Interview on 03/14/24 at 10:23 AM, the DON revealed the facility held monthly QAPI meetings. The DON stated all department heads, and the Medical Director attended the QAPI meetings. The DON stated the Medical Director had only attended one QAPI meeting in 2023 and none in 2024. <BR/>Record review on 03/14/24 10:28 AM with the DON of QAPI Signature Sheets for 2023 revealed the following: <BR/>02/16/23 Medical Director and/or designee did not attend QAPI meeting. <BR/>03/15/23 Medical Director and/or designee did not attend QAPI meeting; Infection Preventionist did not attend QAPI meeting. <BR/>04/12/23 Medical Director and/or designee did not attend QAPI meeting; Infection Preventionist did not attend QAPI meeting. <BR/>05/11/23 Medical Director and/or designee did not attend QAPI meeting; Infection Preventionist did not attend QAPI meeting. <BR/>06/21/23 Medical Director and/or designee did not attend QAPI meeting. <BR/>07/13/23 Medical Director and/or designee did not attend QAPI meeting. <BR/>08/09/23 Medical Director and/or designee did not attend QAPI meeting. <BR/>09/06/23 Medical Director and/or designee did not attend QAPI meeting. <BR/>10/04/23 Medical Director and/or designee did not attend QAPI meeting. <BR/>11/05/23 Medical Director attended QAPI meeting. <BR/>12/13/23 Medical Director and/or designee did not attend QAPI meeting. <BR/>01/12/24 Medical Director and/or designee did not attend QAPI meeting; Infection Preventionist did not attend QAPI meeting. <BR/>02/07/24 Medical Director and/or designee did not attend QAPI meeting; Infection Preventionist did not attend QAPI meeting. <BR/>03/06/24 Medical Director and/or designee did not attend QAPI meeting; Infection Preventionist did not attend QAPI meeting. <BR/>In an interview on 03/14/24 at 10:33 AM, the DON reported that she had just hired a new IP, so she had been filling in as the IP. <BR/>In an interview on 03/14/24 at 11:26 AM, the Administrator reported that they conducted monthly QAPI meetings. He stated that all department heads attended the QAPI meeting. He stated the Medical Director only attended Quarterly QAPI meetings. The Administrator confirmed that the Medical Director had only attended one QAPI in 2023 and none in 2024. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one (Resident #37) of 21 residents reviewed for safe operating condition of patient care equipment and for 1 of 1 kitchen reviewed for safe operating equipment. <BR/>-The facility failed to ensure that the mechanical lift (Hoyer) sling used to transfer Resident #37 was in good working order, resulting in a sling strap tearing, and Resident #37 falling to the floor. <BR/>-The facility failed to keep the ice machine in safe operating condition. <BR/>This failure could result in residents fearing transfers using a mechanical lift, and serious injury, including fractures. This failure could place residents at risk of foodborne illnesses. <BR/>Findings included: <BR/>Record review of Resident #37 ' s face sheet dated 03/14/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #37 ' s quarterly MDS dated [DATE] revealed he had a BIMS score of 12 (moderate cognitive impairment). He was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and personal hygiene. He was dependent on staff for bed to chair/ chair to bed transfers and tub/shower transfers. He was always incontinent of bowel and bladder. His diagnoses included end-stage renal disease (kidney failure), heart failure, and morbid obesity. <BR/>Record review of Resident #37 ' s care plan dated 03/07/2024 revealed he was at risk for falls, and the maintenance department was to check all Hoyer lift nets and straps to make sure they were not torn or old and could be used safely. His care plan dated 06/20/2023 revealed he would receive assistance with ADLs. <BR/>Record review of Resident #37 ' s Resident Incident Report dated 03/14/2024 revealed that on 03/06/2024 he was being transferred from a shower chair in a Hoyer sling when the Hoyer strap broke. He was observed to be on the floor on his left side and said he had pain in his left leg. His physician was notified and x-ways of his left hip and leg were ordered. <BR/>Record review of Resident #37 ' s Nursing Progress Note dated 03/06/2024 revealed that at 2:45 PM a CNA (unidentified) called LVN I into his room, where the resident was observed laying on the floor on his left side. Per the CNAs (2) they were transferring the resident onto the bed after his shower when the Hoyer strap broke. The resident voiced pain to the left leg down to the ankle. The resident was able to move his left arm and denied any new pain except throbbing to his left leg. <BR/>In an interview and observation on 03/11/24 at 10:58 AM Resident #37 revealed that on the past Wednesday [03/06/2024] staff members were transferring him in a Hoyer lift when the sling broke and he fell to the ground landing on his left side. Resident #37 was observed to have a bruise on his left wrist. Resident #37 said an x-ray machine was brought om and the did [his] whole left side and found nothing. He said that he hit his left foot on the lift and that his side under his left breast hurt. <BR/>In interviews with three CNAs (CNA J on 03/14/24 at 11:53 AM; CNA K on 03/14/24 11:28 AM, and the Lead CNA on 03/14/24 at12:09 PM) all confirmed that they had received prior training to check Hoyer slings to make sure they were in good condition. <BR/>In an interview on 03/14/24 at 01:28 PM Laundry Worker M revealed she had been instructed and does inspect Hoyer nets for wear. She said that if there was a problem with the condition of the sling, she would tell the Maintenance/Housekeeping Manager. <BR/>In an interview on 03/14/2024 at 2:55 PM the DON said that in response to Resident #37 ' s fall, staff had been in-serviced to make sure to hook the Hoyer sling to the mechanical lift using two loops instead of one in order to reduce the risk of a sling strap breaking and a resident falling to the ground. <BR/>Ice Machine: <BR/>Observation on 03/11/24 at 8:36 AM, with the [NAME] revealed the ice machine had white calcium build-up inside on right side of ice machine and rusted areas where hinged plastic door closed. It was observed that there was white calcium build up and rust around the bottom of the ice machine. The [NAME] reported that the ice machine was cleaned once a month. <BR/>Observation and interview on 03/13/24 at 1:22 PM, with Dietary Manager demonstrated to the state surveyor that the ice machine had been leaking water from the ice maker that drips directly into the ice bin. She stated, This has been going on for approximately 6 months. That is what is causing the white calcium build-up and rust inside on the right side of the ice machine where the water is leaking, and calcium build up down the sides and bottom of the ice machine, and on the tile floor around the ice machine. The Administrator and the Maintenance Director are aware that the ice machine has been leaking water for 6 months and are pending an approval on a quote to replace the ice machine. It was observed that the vent on the ice machine had a copious amount of light gray lint. <BR/>Interview on 03/13/24 at with Maintenance Director confirmed that ice machine had been leaking water for several months and that he cleaned the ice machine as needed to keep the water from leaking into the ice bin. He stated, We have several quotes for a new ice machine and are pending corporate approval. <BR/>Record review of the facility policy Safe Lifting and Movement of Residents revised 4/2007 revealed that the facility would use mechanical lifting devices to protect the safety and well-being of residents. Mechanical lift equipment shall undergo routine checks and maintenance by nursing and maintenance staff to ensure that equipment remains in good working order. <BR/>

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in four of four halls reviewed for condition of handrails. <BR/>The facility failed to ensure that the handrails throughout the facility did not have the paint worn off them. <BR/>This failure could put residents at risk of feeling a decreased sense of well-being, and at increased risk for splinters because of the poorly maintained condition of the handrails. <BR/>Findings included: <BR/>Handrails: <BR/>Observation on 03/14/2024 at 2:30 PM of the handrails in the 100 and 200 halls revealed that the brown paint on all handrails was worn through and that the wood showed through the paint. <BR/>Observation of the handrails at hall 300 on 3/13/2024 at 3:42 PM revealed that the brown paint on all handrails along the hallway was scraped and worn and wood showed through the paint. <BR/>Observation of the handrails at hall 400 on 3/13/2024 at 3:46 PM revealed that the brown paint on all handrails along the hallway was scraped and worn and wood showed through the paint. <BR/>Supply Storage Rooms in 100 and 200 Halls: <BR/>Soiled Utility Room: <BR/>Observation on 03/14/24 at 9:39 AM - 10:01 AM with ADON and Central Supply Clerk revealed: <BR/>-Mop Basin had black substance around the sides and area around the drain. The plaster and paint were chipped, with multiple holes on walls and black marks where Mop Basin was located. The borders on the walls were full of dust. The floor in the soiled utility room had large areas covered with black marks, dried water stains, and dusty floor, piece of paper on the floor and small paper particles throughout the room. <BR/>-The wall directly below locked cabinets revealed wall had large areas of plaster had fallen off and chipped paint on the wall directly where boxes of gloves were stored. <BR/>Storage Room located in Hallway that connects the 100 and 200 Halls revealed: <BR/>Observation on 03/14/24 at 10:05 AM with ADON, Maintenance Director and Central Supply Clerk revealed Ceiling Light was missing the light cover. There was a large brown water stain above ceiling light that extended to the area where supply boxes were stored on the floor. <BR/>Interview on 03/14/24 at 11:38 AM, the Maintenance Supervisor confirmed floors in storage rooms were dusty, had black stains, boxes were stored on the floor, mop basin had back stains around the inside and outside of the basin, storage racks were full of dust and dried white stains, clean supplies were stored with contaminated containers and/or next to vacuum cleaners in clean storage room, confirm light cover was missing in one storage room. He stated the brown water stain on ceiling in the storage room was caused by a water leak from air conditioner. He stated, Nursing had not reported the water leak to maintenance. <BR/>Interview and record review with Administrator on 03/14/24 at 11:30 AM confirmed all the environmental findings observed in Storage Rooms where nursing supplies were kept. The administrator said he was not aware of any issues with the storage room walls, dried water stain on the ceiling, missing light cover and the dirty floors. <BR/>Review of facility ' s undated policy and procedures on Cleaning and Disinfection of Environmental Surfaces revealed: Policy Statement-Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standards. Policy Interpretation: The following categories are used to distinguish levels of sterilization/disinfection necessary for items used in resident care and those in the resident ' s environment. Non-critical items are those that come in contact with skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails and floors. Housekeeping surfaces (e.g. floors) will be cleaned on a regular basis, when surfaces are visibly soiled. Walls in resident areas will be cleaned when these surfaces are visibly contaminated or soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 6 (Resident #61) of 6 reviewed for allegations of abuse. <BR/>The facility failed to ensure the Administrator followed internal abuse policy, report allegations of abuse to State Office, and conduct thorough abuse allegation investigation. <BR/>These failures could place all residents at risk of continued abuse by not immediately following the facility policy of abuse, neglect, exploitation, or misappropriation - reporting and investigating. <BR/>Findings included: <BR/>Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. <BR/>Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact.<BR/>Record review of Resident #61's care plan dated 1/16/24 revealed Resident #61 had history of false accusations and being critical of staff has expressed verbally aggressive behavior. <BR/>Record review of TULIP revealed no self-report for Resident #61's allegation of slap in hand by the Administrator. <BR/>Record review of Resident #61's SW progress note dated 1/26/24 and signed by SW on 1/26/24revealed resident set for room change. Notified by central supply who was assisting in the room that [Resident 61] was wanting to speak to Administrator. SW and Administrator headed to room [ROOM NUMBER]. [Resident 61] verbalized she did not want to move to 404. The administrator then notified the resident that she was not able to remain in that room due to reports received. The administrator then wheeled the resident towards the door into the hallway where [Resident #61] continuously stated she was not moving to 404. Administrator and SW discussed, and administrator identified room [ROOM NUMBER] as available for resident to go into private room. [Resident #61] was notified she would go into private room and verbalized no concern. [Family member] then appeared in hallway and SW and administrator spoke with [Family Member] to inform her of events that transpired. <BR/>Record review of Resident #61's SW progress note dated 2/8/24 and signed by SW indicated .[Resident #61] expressed that the Administrator had forced her wheelchair out of the room stating that at one point, she held her hand to the wall where removed the hand from the wall. In previous conversations with resident, she had stated the Administrator had forced her out of the hallway but did not mention it being a physical matter .<BR/>Record review of Resident #61's Ombudsman case file revealed case was opened on 2/2/24. Intake summary read in part phone call from [Resident #61] that administrator forcefully took her out of her room and slap her hand. Left her at the hallway to be transfer to another hallway isolated from other residents. Journal entries dated 2/24/24 read in part [Resident #61] reported to the Ombudsman that the administrator physically assault her by forcefully taken her out from her room. [Resident #61] stated that this incident happened on January 25th, 2024. [Resident #61] stated that the Administrator grab her wheelchair and push her out of her room, she put her wheelchair brakes to stop him to further discuss the situation about the complaint because she was not aware of an issue. The Administrator continue to push her with the wheelchair when [Resident #61] grab the door frame and the Administrator slap her hand so she can let go at the door frame. He (the administrator) continue to push her out of the room and finally left her at the hallway. Staff took her to the new assigned room in an isolated hallway. [Resident #61] feels humiliated, retaliation, threaten by the administrator that he will be discharging her, feels abused by the administrator and her resident right been violated. [Resident #61] has stated that Administrator has told her many times he is the one with the authority at the facility and makes the final decisions. The Social Worker told her that they were going to move her again to another room but she did not specify when. [Resident #61] stated she does not want to be moved out of the facility, but feels the administrator will forcefully move her out. The Social Worker told [Resident #61] that she was going to contact the Managing Local Ombudsman for a meeting for further discussion, but until this date social worker has not contact the Ombudsman. MLO obtain consent to report the incident to CII, which MLO did that same day. Journal entry dated 2/8/24 read in part MLO attended a care plan meeting with a complaint with a resident about an incident that happened on 1/25/24 with [Resident #61] and the roommate. [Resident #61] inform MLO that administrator forcefully took her out from her room to be transfer to another room. Also, [Resident #61] stating that he (the administrator) did slap her arm so she can let go at the door frame so he can push her wheelchair. <BR/>During an interview on 3/11/24 at 10:00 am, Resident #61 was alert and oriented to person, place, time, and event. Resident #61 stated she was moved rooms little over a month ago due to a new roommate who had placed a complaint about her. Resident #61 stated when she was moved, the Administrator had forcefully kicked her out of the room by pushing her wheelchair out and placed her in the hallway. Resident #61 stated as the Administrator was pushing her out of the room in the wheelchair, she had attempted to put the brakes on the wheelchair to prevent him wheeling her out and it was unsuccessful. Resident #61 stated she then placed her hand on the door frame prior to exiting the door in attempts of resisting being pushed out all the way, and the Administrator had slapped her hand to get her to remove her hand from the door frame. Resident #61 stated she called the Ombudsman and had notified him of the incident where she was forced out of her room and the Administrator slapping her hand. Resident #61 stated she had also told the SW of the situation, and nothing had been done. Resident #61 stated she felt scared, intimidated and humiliated. <BR/>During an interview on 3/11/24 at 10:51 am, the Ombudsman stated he had received a call from Resident #61 who had stated that she had been forcefully removed from her room by the Administrator. The Ombudsman stated Resident #61 gave details when she was forced out of the room by the Administrator and said he (the administrator) had slapped her hand when she placed her hand on the door frame to prevent being pushed out of the door all the way. <BR/>A call was placed to Resident #61's RP on 3/11/24 at 11:13 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. <BR/>During an interview on 3/11/24 at 11:17 am, the DON stated she was aware Resident #61 had been moved rooms a few weeks back but was not aware of details regarding the move. The DON stated she was not notified of Resident #61 allegation of being slapped in the hand by the Administrator. The DON stated she did not know who she would report the allegation of slap in the hand if the alleged perpetrator was the abuse coordinator but would have to report to State Office. <BR/>During an interview on 3/11/24 at 11:28 am, the SW she did not recall Resident #61 alleging a slap in the hand by the Administrator. The SW stated she did not have a progress note and/or documentation regarding the 2/8/24 meeting. The SW stated the Administrator was the abuse coordinator and did not know who she would report an allegation of abuse when the Abuse Coordinator/ Administrator was the alleged perpetrator. The SW stated she did not report the allegation of slap in the hand because she did not recall that topic mentioned during the meeting held on 2/8/24. <BR/>During an interview on 3/11/24 at 3:43 pm, the Administrator stated he did not report the allegation Resident #61 had made against him regarding the slap in the hand because there were witnesses in the room and the meeting was held with the Ombudsman to discuss what had transpired. The Administrator stated he was the abuse coordinator and if an allegation was made against him someone else would have to report and/or investigate the allegation. The Administrator stated the SW was aware of the allegation and had gathered witnessed statements from the witnesses in the room. The Administrator stated he did not provide a statement and was not suspended pending investigation due to him not having direct care with the resident. The Administrator stated based on abuse policy the allegation Resident #61 had made about him hitting her should had been reported to State Office. <BR/>During an interview on 3/11/24 at 5:13 pm, the Administrator stated today was the first time he heard allegation that he hit her (Resident #61) and he denied having done that. The Administrator said he would be suspended pending investigation and Corporate Director of Operations would conduct the investigation. <BR/>During an interview on 3/12/24 at 8:34 am, Maintenance staff stated he was asked by the Administrator to assist with Resident #61's move to a different room. The Maintenance staff stated that Central Supply and him, had gone to Resident #61's room to start gathering her belongings and she had become upset and requested to speak to the Administrator. The Maintenance staff stated the Administrator had gone to Resident #61's room and discussed the room change that had been agreed to. The Maintenance staff stated his back was facing the door and had not seen the Administrator assist Resident #61 out the room. The Maintenance staff stated because his back was facing the door he did not see the Administrator slap Resident #61. The Maintenance staff stated he did not hear anything concerning noise, Resident #61 was only very upset and arguing with the Administrator. The Maintenance staff stated Central Supply was in the room and may have seen any interaction between the Administrator and Resident #61. <BR/>During an interview on 3/12/24 at 8:53 am, Central Supply stated she had been asked to assist Maintenance staff with gathering Resident #61 belongings for room change. Central Supply stated when they both were in Resident #61 room she became upset and had requested to speak to the Administrator and had stepped out to get him. Central Supply stated when the Administrator came to Resident #61 came to the room, she stayed by the restroom area where it was few feet away from the bed and saw him talking to her. Central Supply stated she appeared very upset and does not know what was said because she did not speak Spanish. Central Supply stated he saw the Administrator wheel Resident #61 out of her room and did not see him put any hands on Resident #61. Central Supply stated she did not see the Administrator slap Resident #61's hand. <BR/>During an interview on 3/13/24 at 11:28 am, Executive Director of Clinical Services stated they had been notified of Resident #61's allegation of slap in the hand by the Administrator. The Executive Director of Clinical Services stated the Corporate Director of Operations was the lead investigator in the case. The Executive Director of Clinical Services stated whoever was present during the meeting with the Ombudsman when the allegation was brought should have reported it to the corporate office and State Office. The Executive Director of Clinical Services stated it was expected for the SW and even the Administrator to have reported the alleged incident immediately. The Executive Director of Clinical Services stated failure to report any allegation of abuse could result in failure of investigation to be completed and alleged perpetrator still working in the facility. <BR/>A call was placed to Resident #61's RP on 3/12/24 at 9:01 am, phone call was not answered and VM box was full. The surveyor was not able to leave VM to return the call. The call was not returned by the time of survey exit. <BR/>During an interview on 3/12/24 at 12:35 pm, Resident #61 stated the SW had gone to speak to her regarding the allegation against the Administrator this morning. Resident #61 stated she was asked if she had any other information she wanted to share and was told they'd be checking in on her weekly to see how she was doing. Resident #61 stated she felt better knowing the facility was taking her allegation serious and something was being done.<BR/>During an interview on 3/13/24 at 2:35 pm, Corporate Director of Operations stated she was notified of Resident #61's slap in hand allegation on Monday 3/11/24 and immediately suspended the Administrator. The Corporate Director of Operations said the abuse policy should have been followed regardless of witnesses in the room due to the allegation. The Corporate Director of Operations stated it was expected for the SW and the Administrator to have reported the allegation immediately to the corporate office and State Office. The Corporate Director of Operations stated she followed up with the Administrator who denied slapping Resident #61's hand. The Corporate Director of Operations stated the DON had called in the abuse allegation to State Office and had requested assistance from the SW to gather statements and interview other residents while the Executive Director of Clinical Services arrived to the facility to assist onsite. The Corporate Director of Operations stated she finished reviewing the interviews and statements gathered Monday (3/11/24) evening and because there was a witness who saw the interaction the allegation was inconclusive and cleared the Administrator to return to work on Tuesday 3/12/24. The Corporate Director of Operations stated she completed a one0to-one in-service with the Administrator and DON regarding reporting abuse allegations being reported to ensure investigation is thoroughly conducted. <BR/>Record review of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated April 2021 read in part all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations to the Administrator and Authorities: 2) the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 three of three hallways and 1 resident (Resident #283) of 14 residents observed for infection control practices during enteral feeding. <BR/>-The facility failed to store contaminated resident equipment in the designated storage area. <BR/>-The facility failed to store reusable water containers off the floor in the Therapy Room. <BR/>-The facility failed to store supply boxes off the floor in storage rooms. <BR/>-The facility failed to prevent cross contamination was not storing clean and dirty equipment on separate racks. <BR/>Findings included: <BR/>Linen Rack; Linen Hampers: <BR/>Observation on 03/11/24 at 9:29 AM, revealed clean linen cart cover had a hole on the right side approximately the size of a nickel. <BR/>Observation on 03/11/24 at 9:30 AM, with LVN B revealed 1 yellow linen hamper was in the hallway and the cover was slightly open. LVN B stated linen hampers should be closed and stored in shower rooms when not in use. <BR/>Interview on 03/14/24 at the Maintenance Director stated the linen cart covers should be free of holes to prevent contamination of clean linen. <BR/>Equipment: <BR/>Observation on 03/11/24 at 9:35 AM, revealed three oxygen concentrators, one feeding pole with attached feeding pump, one plastic 3 drawer cart that contained PPE, and one nebulizer machine were stored in a connecting hallway between 100 and 200 hallways. <BR/>Interview on 03/11/24 at 9:44 AM, with the Activities Staff reported that he worked in the activities department and was covering for the Central Supply Clerk because she was on leave. He reported that he was not sure why the equipment was stored in the hallway that connects 100 and 200 hallways. <BR/>Interview on 03/11/24 at 9:45 AM, the DON revealed that the equipment that was stored in the hallway that connects the 100 and 200 hallways had been removed from the resident rooms because residents were discharged , and 1 oxygen concentrator was not working. She stated the equipment had been there for a couple of days and did not know where the equipment should be stored. <BR/>Therapy Room: <BR/>Observation on 03/11/24 at 9:39 AM, revealed seven 6 emptied 5-gallon reusable water bottles and one full 5-gallon reusable water bottle were stored on the floor directly across the water dispensing machine in the therapy room. <BR/>Interview on 03/11/24 at 9:40 AM, COTA (certified occupational assistant) revealed that the 5-gallon reusable water bottles were always stored on the floor close to the water dispensing machine in the therapy room. <BR/>Supply Storage Rooms in 100 and 200 Halls: <BR/> 200 Hall <BR/>Soiled Utility Room: <BR/>Observation on 03/14/24 at 9:39 AM - 10:01 AM with the ADON and Central Supply Clerk revealed: <BR/>-Mop Basin had black substance around the sides and area around the drain. <BR/>-Six commercial paper roll towels were stored on a rack and a large container that had dark brown substance in the bottom, black cover was full of dust and brown and white particles, stored next to two vacuum cleaners that were covered with dust and dried stains. The plastic pallet was full of dust, covered with dried black stains, and paper particles. <BR/>-Metal side rails were stored on the floor. <BR/>-The large black plastic rack was full of dust and covered with white dried stains, 22 torn, dusty floor mats were stored on the rack. There was a Faucet Connector hanging from the side of the storage rack. There was a mop bucket stored next to the rack where floor mats were stored. Multiple empty boxes were stored on the floor next to a gray trash hamper. <BR/>100 Hall: <BR/>Observation on 03/14/24 at 10:05 AM with the ADON and Central Supply Clerk revealed room [ROOM NUMBER] was being used as a storage room: The ADON reported that Hall 100 was temporarily closed and was designated as the COVID unit whenever they had a COVID outbreak. The door to the room was open. There was a sign posted on the door to Keep Door Closed at All Times. Many cardboard boxes were stored on the floor. The ADON stated some of the boxes opened and contained COVID testing kits. There was a mattress stored on the floor. There were two large cardboard Storage File Boxes that contained papers stored on the floor next to the entrance to the bathroom. <BR/>Storage Room located in Hallway that connects the 100 and 200 Halls revealed: <BR/>Observation on 03/14/24 at 10:05 AM with the ADON, Maintenance Director, and Central Supply Clerk revealed 3 oxygen concentrators, 1 enteral feeding pump attached to IV pole, 1 drawer storage cart that contained PPE, and 1 nebulizer machine that had been removed from resident rooms and had not been disinfected were stored in the storage room with the clean supplies in the same storage room. The ADON stated she did not know who had stored the contaminated equipment in the clean storage room. It was observed that boxes of briefs and enteral formulas were stored on the floor next to the contaminated equipment. The ceiling light was missing cover. There was a large brown water stain above ceiling light that extended to the area where supply boxes were stored on the floor. <BR/>Central Supply Room located in 200 Hall: <BR/>Observation on 03/14/24 at 10:05 AM with the ADON and Central Supply Clerk revealed: Boxes of supplies were stored on the floor. <BR/>Review of facility ' s undated policy and procedures on Cleaning and Disinfection of Environmental Surfaces revealed: Policy Statement-Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standards. Policy Interpretation: The following categories are used to distinguish levels of sterilization/disinfection necessary for items used in resident care and those in the resident ' s environment. Non-critical items are those that come in contact with skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails and floors. Housekeeping surfaces (e.g. floors) will be cleaned on a regular basis, when surfaces are visibly soiled. Walls in resident areas will be cleaned when these surfaces are visibly contaminated or soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #3, Resident #8, and Resident #13) of 3 residents reviewed for care plans. <BR/>The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #3, #8, and #13. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. <BR/>Findings include:<BR/>Resident #3:<BR/>Record review of Resident #3's admission Record, dated 01/29/2025, reflected a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident # 3's History and Physical dated 03/16/2023, revealed diagnoses to include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe).<BR/>Record review of Resident # 3's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #3 was receiving oxygen therapy. <BR/>Record review of Resident #3's Order Summary Report dated 01/30/2025, revealed an order with start time of 10/08/2024 for O2 at 2 liters, keep O2 saturations above 85%.<BR/>Review of Resident #3's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 94% to 97%.<BR/>Record review of Resident #3's comprehensive care plan dated 01/30/2025, revealed Resident #3's oxygen therapy was not care planned. <BR/>During an observation and interview on 01/29/2025 at 2:18 p.m., Resident #3 was lying in bed with nasal cannula on and oxygen set at 2 liters. Resident #3 said she did not have any concerns with the services at the facility.<BR/>Resident #8:<BR/>Record review of Resident #8's admission Record, dated 01/30/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident # 8's History and Physical dated 01/07/2025, revealed diagnoses to include COPD (lung disease that block airflow and make it difficult to breathe) on 2 L nasal cannula, and acute on chronic hypoxemic respiratory failure (a sudden worsening of pre-existing chronic condition where the body is not getting enough oxygen). <BR/>Record review of Resident # 8's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #8 was receiving oxygen therapy. <BR/>Record review of Resident #8's Order Summary Report dated 01/30/2025, revealed an order with start time 01/07/2025 Oxygen: Oxygen at 3 liters per nasal cannula continuous every day and night shift related to Hypoxemia. <BR/>Record review of Resident #8's comprehensive care plan dated 01/30/2025, revealed Resident #8's oxygen therapy was not care planned. <BR/>Review of Resident #8's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>During an observation on 01/30/2025 at 3:08 p.m., Resident #8 was observed asleep in bed. Resident #8 was observed wearing a nasal cannula with oxygen concentrator set at 3 liters. <BR/>Resident #13:<BR/>Record review of Resident #13's admission Record, dated 01/31/2025, reflected [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #13's History and Physical dated 06/08/2022, revealed diagnoses to include chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), and chronic respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body).<BR/>Record review of Resident #13's MDS dated [DATE], revealed a BIMS score of 05 indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #13 was receiving oxygen therapy. <BR/>Record review of Resident #13's Order Summary Report dated 01/31/2025, revealed an order with start time of 10/07/2024 for O2 via nasal cannula at 2 liters continuous to maintain saturation above 90%. <BR/>Review of Resident #13's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>Record review of Resident #13's comprehensive care plan dated 01/31/2025, revealed Resident #13's oxygen therapy was not care planned. <BR/>During an observation on 01/31/2025 at 8:42 a.m., Resident #13 was lying in bed asleep with nasal cannula on and oxygen set at 2 liters. No issues identified with oxygen concentrator or tubing. <BR/>During an interview on 01/29/2025 at 10:48 a.m., the ADON said all care plans should include oxygen therapy. The ADON said MDS Coordinator was responsible for care plans. The ADON said the facility had a recent change of ownership at the beginning of December 2024 and some information from previous care plans did not transition into the electronic health record at the time of the change. The ADON said many documents were printed but not readily available on the floor for staff. The ADON said the facility previously had two MDS Coordinators but now only have one. <BR/>During an interview on 01/30/2025 at 4:11 p.m., the MDS Coordinator said she was in charge of getting the care plans up to date. The MDS Coordinator said she had 21 days from admission to complete the comprehensive care plan. The MDS Coordinator said oxygen therapy should be care planned. The MDS Coordinator said for the last two months she was the only MDS Coordinator which had caused her to be backed up. The MDS Coordinator said some of the care plans had not been updated. The MDS Coordinator said the risk of care plans not being updated was possible risk of residents not receiving the necessary care or service.<BR/>Review of the facility-provided Patient Care Management System dated November 2017, revealed in part A Comprehensive, Person-centered Plan of Care, consistent with resident rights must be completed by the 21st day after admission. The care plan must be based on assessments completed within the previous 15 months in the Patient's/Resident's active record and use the results of the assessments to develop, review and revise the Patient's/Resident's comprehensive care plan.

Based on observations, interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 of 4 days reviewed and the census was wrongly documented. <BR/>The facility failed to post the required staffing information for 3/11/24. <BR/>The facility failed to accurately document the census for 60 days of 73 days reviewed in January 2024, February 2024, and March 1st through the 13th. <BR/>This failure could place residents, their families, and facilities, and visitors at risk of not having access to correct information regarding staffing data and facility census. <BR/>Findings included: <BR/>During an observation on 3/11/24 at 9:17 am, the public access area nursing station had a daily sheet posting information which included facility name, census, total hours for RNs,. LVNs, CNAs, MAs, and shift times that was dated 3/10/24. <BR/>During an observation on 3/11/24 at 12:01 pm, the public access area nursing station had a daily sheet posting information which included facility name, census, total hours for RNs,. LVNs, CNAs, MAs, and shift times that was dated 3/10/24.<BR/>Record review of January 2024 census revealed, 1/1/24 the census was 85. The direct care staffing log dated 1/1/24 revealed census of 83. <BR/>Record review of January 2024 census revealed, 1/2/24 the census was 84. The direct care staffing log dated 1/2/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/3/24 the census was 85. The direct care staffing log dated 1/3/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/4/24 the census was 86. The direct care staffing log dated 1/4/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/5/24 the census was 85. The direct care staffing log dated 1/5/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/6/24 the census was 85. The direct care staffing log dated 1/6/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/7/24 the census was 84. The direct care staffing log dated 1/7/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/8/24 the census was 84. The direct care staffing log dated 1/8/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/9/24 the census was 85. The direct care staffing log dated 1/9/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/10/24 the census was 84. The direct care staffing log dated 1/10/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/11/24 the census was 85. The direct care staffing log dated 1/11/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/13/24 the census was 81. The direct care staffing log dated 1/13/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/14/24 the census was 81. The direct care staffing log dated 1/14/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/15/24 the census was 82. The direct care staffing log dated 1/15/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/16/24 the census was 82. The direct care staffing log dated 1/16/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/17/24 the census was 83. The direct care staffing log dated 1/17/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/19/24 the census was 80. The direct care staffing log dated 1/19/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/20/24 the census was 80. The direct care staffing log dated 1/20/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/20/24 the census was 80. The direct care staffing log dated 1/20/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/21/24 the census was 79. The direct care staffing log dated 1/21/24 revealed the census was blank.<BR/>Record review of January 2024 census revealed, 1/22/24 the census was 80. The direct care staffing log dated 1/22/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/23/24 the census was 79. The direct care staffing log dated 1/23/24 revealed the census was blank. <BR/>Record review of January 2024 census revealed, 1/24/24 the census was 81. The direct care staffing log dated 1/24/24 revealed census of 80.<BR/>Record review of January 2024 census revealed, 1/25/24 the census was 79. The direct care staffing log dated 1/25/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/26/24 the census was 80. The direct care staffing log dated 1/26/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/28/24 the census was 80. The direct care staffing log dated 1/28/24 revealed census of 79.<BR/>Record review of January 2024 census revealed, 1/29/24 the census was 80. The direct care staffing log dated 1/29/24 revealed census of 79.<BR/>Record review of January 2024 census revealed, 1/30/24 the census was 82. The direct care staffing log dated 1/30/24 revealed census of 80.<BR/>Record review of January 2024 census revealed, 1/31/24 the census was 80. The direct care staffing log dated 1/31/24 revealed census of 81.<BR/>Record review of February 2024 census revealed, 2/1/24 the census was 79. The direct care staffing log dated 2/1/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/2/24 the census was 79. The direct care staffing log dated 2/2/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/4/24 the census was 78. The direct care staffing log dated 2/4/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/5/24 the census was 78. The direct care staffing log dated 2/5/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/6/24 the census was 78. The direct care staffing log dated 2/6/24 revealed census of 81.<BR/>Record review of February 2024 census revealed, 2/7/24 the census was 79. The direct care staffing log dated 2/7/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/8/24 the census was 79. The direct care staffing log dated 2/8/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/9/24 the census was 78. The direct care staffing log dated 2/9/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/10/24 the census was 78. The direct care staffing log dated 2/10/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/11/24 the census was 76. The direct care staffing log dated 2/11/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/12/24 the census was 76. The direct care staffing log dated 2/12/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/13/24 the census was 73. The direct care staffing log dated 2/13/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/14/24 the census was 74. The direct care staffing log dated 2/14/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/15/24 the census was 74. The direct care staffing log dated 2/15/24 revealed census of 73.<BR/>Record review of February 2024 census revealed, 2/16/24 the census was 74. The direct care staffing log dated 2/16/24 revealed census of 73.<BR/>Record review of February 2024 census revealed, 2/19/24 the census was 75. The direct care staffing log dated 2/19/24 revealed census of 74.<BR/>Record review of February 2024 census revealed, 2/20/24 the census was 75. The direct care staffing log dated 2/20/24 revealed census of 74.<BR/>Record review of February 2024 census revealed, 2/21/24 the census was 77. The direct care staffing log dated 2/21/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/22/24 the census was 77. The direct care staffing log dated 2/22/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/24/24 the census was 78. The direct care staffing log dated 2/24/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/25/24 the census was 79. The direct care staffing log dated 2/25/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/26/24 the census was 80. The direct care staffing log dated 2/26/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/27/24 the census was 81. The direct care staffing log dated 2/27/24 revealed census of 78.<BR/>Record review of February 2024 census revealed, 2/28/24 the census was 81. The direct care staffing log dated 2/28/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/2/24 the census was 81. The direct care staffing log dated 3/2/24 revealed census of 80.<BR/>Record review of March 2024 census revealed, 3/3/24 the census was 81. The direct care staffing log dated 3/3/24 revealed census of 80.<BR/>Record review of March 2024 census revealed, 3/5/24 the census was 79. The direct care staffing log dated 3/5/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/6/24 the census was 77. The direct care staffing log dated 3/6/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/7/24 the census was 77. The direct care staffing log dated 3/7/24 revealed census of 78.<BR/>Record review of March 2024 census revealed, 3/9/24 the census was 75. The direct care staffing log dated 3/9/24 revealed census of 77.<BR/>Record review of March 2024 census revealed, 3/10/24 the census was 75. The direct care staffing log dated 3/10/24 revealed census of 77.<BR/>Record review of March 2024 census revealed, 3/11/24 the census was 75. The direct care staffing log dated 3/11/24 revealed the census was blank.<BR/>Record review of March 2024 census revealed, 3/12/24 the census was 77. The direct care staffing log dated 3/12/24 revealed census of 75.<BR/>During an interview on 3/14/24 at 11:39 am, the ADON stated the Lead CNA was responsible for completing the daily staffing posting. The ADON stated the Lead CNA had a binder with the copies in place where she prefilled the dates for a weeks' worth and would complete the daily staffing census the day before and would leave it for the nurses to post the following morning. The ADON stated the nurses and/or the Lead CNA would have to verify the daily census at the beginning of the shift. The ADON stated she did not know what kind of risk there was for the census not being accurate and stated she knew it was a State Office requirement. <BR/>During an interview on 3/14/24 at 12:03 pm, the Lead CNA stated she was responsible for completing the daily staffing sheet. The Lead CNA stated she would complete the daily staffing sheet at the end of the shift for the following day and would leave it in the nurse's station for the nurses to post in the morning. The Lead CNA did not have an answer for the census being wrong and did not know of any risk for the daily census being wrong . <BR/>Record review of Posting Direct Care Daily Staffing Number policy dated July 2016 read in part our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Shift information shall be recorded on the nursing staff directly responsible for resident care form for each shift. The information recorded on the form shall include: the resident census at the beginning of the shift for which the information is posted. Within 2 hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the nursing staff directly responsible for resident care form/ the shift supervisor shall date the form, record the census, and post the staffing information in the location designated by

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident with urinary incontinence, based on the resident ' s comprehensive assessment, the facility must ensure that the resident receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 (Resident #32) residents reviewed for urinary catheter. <BR/>The facility failed to ensure Resident #32 ' s subpubic catheter was properly secured. <BR/>This failure placed residents at risk of possible pain and trauma due to the catheter not being properly secured on the leg. <BR/>Findings included: <BR/>Record review of Resident #32 ' s history and physical dated 11/23/2023 revealed diagnoses of UTI (urinary tract infection), dementia, suprapubic catheter. <BR/>Record review of Resident #32 ' s quarterly MDS assessment dated [DATE] revealed he had a BIMS of 3 (cognitively severely impaired) and had a dwelling catheter. <BR/>Record review of Resident #32 ' s care plan dated 12/05/2023 revealed Resident #32 has a subpubic catheter: Indwelling related to obstructive uropathy with interventions of Secure tubing to thigh to prevent pulling. <BR/>Record review of Resident #32 ' s physician order dated 8/25/23 revealed Leg strap placement check every shift. <BR/>During an observation and interview on 3/13/24 at 9:41 am, CNA F stated the resident ' s catheter was not properly secured. The patch was dated 2/14/24. CNA F stated the nurse knew about it since the nurse is the one that replaces the patch. The lock on the patch was not latching to keep the catheter secure and stated it had been like that for a while but did not specify how long. CNA F stated that the risk included pulling on the catheter when staff is provided care. <BR/>Interview on 03/13/24 9:52 AM, LVN E said the catheter was below the bladder. The catheter was not properly secured. The latch was not latching or locking correctly. LVN E stated that the nurses and CNAs were responsible for checking that catheters are positioned correctly. LVN C said the risk of pulling a catheter could cause trauma. LVN E said that on the 6th and 20th of every month, catheters for residents need to be changed. LVN E stated that the patch was dated 2/21/24. LVN E said the patch was changed as needed. LVN E said she does not receive reports if a CNA or an LVN finds the catheter was not secured properly. LVN E said that staff receive training online regarding catheters twice a year. <BR/>In an interview and observation on 03/13/24 02:00 PM LVN E, stated that catheters need to be checked every time that the resident was changed. LVN E said that Resident #32 changed every 2 hours because he needs to be repositioned. LVN E said that Resident #32 E can communicate if he's in pain and he will notify the staff. <BR/>In an interview on 03/14/24 01:30 PM with DON, she stated that for urinary catheters to be properly secured, they need to be secured with the immobilizer device, which goes on their leg or thigh, that way it is secure and not bothering the patient. The DON said the staff responsible for checking for the catheter was the nurse in charge of the resident, but it was expected that the CNA's also check and make sure it's stabilized. The DON said that if a CNA observes that if a catheter was not stabilized or properly secure, the CNA would need to communicate it to the nurse after putting the catheter to the side and has made sure that it's not bothering the resident and that the catheter bag is not touching the floor. The DON stated that staff checks that the catheters are secured as needed and throughout the shift. She said that the person responsible for overseeing the Nurses and CNAs are checking the catheters is the ADON and then the DON supervises her. DON said that the risk of a catheter not being properly secured is that the catheter can hurt the resident. The resident can start bleeding and it can worsen the situation. DON stated that if a Nurse or CNA finds a catheter not properly secure, the expectation is for the nurse to remove the patch and put a new one that can properly secure the catheter. DON stated that the last in-service regarding catheters was provided on February 22, 2024. She stated that she does not know how often it needs to be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the residents' goals and preferences for one (Resident #30) of four residents reviewed for provision of respiratory care. <BR/> Resident #30 was not assisted in putting on her CPAP mask every night as per physician ' s orders. <BR/> This failure could result in residents having increased difficulty sleeping, decreased sleep quality, and increased instances of sleep apnea (a sleep disorder where breathing stops and starts). <BR/>Findings included: <BR/>Record review of Resident #30 ' s face sheet dated 03/14/2023 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #30 ' s History and Physical dated 02/21/2023 reveled she had diagnoses including COPD (Chronic Obstructive Pulmonary disease - a condition where airways are narrowed, and breathing is difficult); Chronic respiratory failure with hypoxia (a condition where airways are narrowed or damaged and there is reduced oxygen in the blood); Sleep disorder (changes in sleep that can negatively affect health.) Medications included a CPAP to be used nightly and 2 liters per minute of oxygen at night as needed. The History and Physical revealed that Resident #30 ' s family member said that facility staff was not placing her CPAP because the distilled water in the machine had not been used. The resident said she was not sleeping, although staff reported she was. <BR/>Record review of Resident #30 ' s quarterly MDS dated [DATE] revealed she had a BIMS of 9 (Moderate cognitive impairment). She had no symptoms of delirium or psychosis. She had no behavioral symptoms including rejection of care during the 7-day look back period. She had diagnoses including COPD or chronic lung disease, and Respiratory failure. The MDS indicated she was not receiving oxygen therapy. <BR/> Record review of Resident #30 ' s Care plan dated 01/26/2023 revealed she refused to use her C-Pap Machine. The goal was that her episodes of refusing to use the CPAP machine would diminish. Interventions included to report CPAP refusal to the physician, and explain why the CPAP was important. The Care Plan did not address the difficulty the resident had trying to put the CPAP machine on herself. <BR/>Record review of Resident #30 ' s physicians orders dated 11/15/2023 revealed she was to use a CPAP machine daily at bedtime. The physician's order dated 01/26/2024 revealed that her compliance with use of the CPAP machine was to be documented in progress notes and the physician was to be notified if she was noncompliant. <BR/>Record review of Resident #30 ' s progress note by LVN A dated 1/9/2024 revealed the resident was prompted throughout the night to keep her c-pap on with no success. The resident had intermittent labored breathing. <BR/> Record review of Resident #30 ' s MAR for February 2024 revealed she was non-complaint with use of the CPAP machine on 02/14/2024 and 02/23/2024. <BR/> Record review of Resident #30 ' s nursing progress notes February 2024 revealed no corresponding nursing notes regarding her refusal to use the CPAP machine as required by physician ' s order. <BR/>Record review of Resident #30 ' s MAR for March 2024 (03/01/2024 - 03/12/2024) revealed she had no instances of non-compliance with use of the CPAP machine. <BR/> Record review of Resident #30 ' s respiratory therapy report dated 03/14/2024 for 12/15/2023 - 03/13/2024 revealed she used the CPAP machine 33 out of 90 days and had not used the CPAP machine on 57 nights. During February 2024 she did not use the CPAP machine on 02/01, 02/02, 02/03, 02/04, 02/07, 02/09, 02/10, 02/14, 02/16, 02/17, 02/19, 02/22, 02/23, 02/24, 02/28 and 02/29/2024. Between 03/01/2024 and 03/13/2024 she did not use the CPAP machine the nights of 03/01, 03/02, 03/01, 03/08, 03/09, 03/11, 03/12 and 03/13/2024. <BR/>In an interview on 03/11/24 at 11:19 AM Resident #30 ' s family member said that staff were not putting the CPAP on the resident at night. The family member said a man came in to look at the machine and said they [nursing staff] do not put it on her. The resident said she had difficulty putting the CPAP mask by herself. <BR/>In a telephone interview on 03/14/24 at 09:28 AM Respiratory Therapist C revealed that he was familiar with Resident #30 and that he could provide records of her use of the CPAP machine. <BR/>In an interview on 03/14/24 at 11:34 AM Respiratory Therapist C revealed that review of Resident #30 Therapy Report documented that in March 2024 the resident did not have the CPAP mask on at all, and that between 12/15 and 3/13 she did not use the CPAP machine 57 times. The Respiratory Therapist state that not using the CPAP machine put Resident #30 at risk of poor sleep quality and increased instances of sleep apnea. <BR/>In an interview on 03/14/24 at 02:10 PM the DON revealed that nurse should be documenting if Resident #30 refused to use her CPAP machine. She stated that without the use of the CPAP machine the resident would be at increased risk of sleep apnea and might lose breathing at night. She said the nurses should be following physician ' s orders to document instances when Resident #30 refused to use the CPAP machine. <BR/>In an interview on 03/14/24 at 02:28 PM ADON D revealed she thought Resident #30 was generally compliant with all orders including use of the CPAP machine. She stated that noncompliance with use of the CPAP machine could result in Resident #30 ' s feeling winded, short of breath, and might exacerbate her COPD. <BR/>In an interview on 03/14/24 at 04:16 PM LVN A revealed that during the time she had worked with Resident 30, she had been told by other staff that the resident refused to use the CPAP machine. LVN A said she put the CPAP mask on Resident #30 herself because the resident was not able to put it on herself. The LVN said she had not had any difficulties with Resident #30 ' s use of the CPAP after educating the resident about the risks of not using the CPAP. The LVN said that if the resident did not want to put the machine on right away the LVN would go back and put it on her later in the evening. <BR/>

Based on observations, interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 of 4 days reviewed and the census was wrongly documented. <BR/>The facility failed to post the required staffing information for 3/11/24. <BR/>The facility failed to accurately document the census for 60 days of 73 days reviewed in January 2024, February 2024, and March 1st through the 13th. <BR/>This failure could place residents, their families, and facilities, and visitors at risk of not having access to correct information regarding staffing data and facility census. <BR/>Findings included: <BR/>During an observation on 3/11/24 at 9:17 am, the public access area nursing station had a daily sheet posting information which included facility name, census, total hours for RNs,. LVNs, CNAs, MAs, and shift times that was dated 3/10/24. <BR/>During an observation on 3/11/24 at 12:01 pm, the public access area nursing station had a daily sheet posting information which included facility name, census, total hours for RNs,. LVNs, CNAs, MAs, and shift times that was dated 3/10/24.<BR/>Record review of January 2024 census revealed, 1/1/24 the census was 85. The direct care staffing log dated 1/1/24 revealed census of 83. <BR/>Record review of January 2024 census revealed, 1/2/24 the census was 84. The direct care staffing log dated 1/2/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/3/24 the census was 85. The direct care staffing log dated 1/3/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/4/24 the census was 86. The direct care staffing log dated 1/4/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/5/24 the census was 85. The direct care staffing log dated 1/5/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/6/24 the census was 85. The direct care staffing log dated 1/6/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/7/24 the census was 84. The direct care staffing log dated 1/7/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/8/24 the census was 84. The direct care staffing log dated 1/8/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/9/24 the census was 85. The direct care staffing log dated 1/9/24 revealed census of 86.<BR/>Record review of January 2024 census revealed, 1/10/24 the census was 84. The direct care staffing log dated 1/10/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/11/24 the census was 85. The direct care staffing log dated 1/11/24 revealed census of 83.<BR/>Record review of January 2024 census revealed, 1/13/24 the census was 81. The direct care staffing log dated 1/13/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/14/24 the census was 81. The direct care staffing log dated 1/14/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/15/24 the census was 82. The direct care staffing log dated 1/15/24 revealed census of 84.<BR/>Record review of January 2024 census revealed, 1/16/24 the census was 82. The direct care staffing log dated 1/16/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/17/24 the census was 83. The direct care staffing log dated 1/17/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/19/24 the census was 80. The direct care staffing log dated 1/19/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/20/24 the census was 80. The direct care staffing log dated 1/20/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/20/24 the census was 80. The direct care staffing log dated 1/20/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/21/24 the census was 79. The direct care staffing log dated 1/21/24 revealed the census was blank.<BR/>Record review of January 2024 census revealed, 1/22/24 the census was 80. The direct care staffing log dated 1/22/24 revealed census of 82.<BR/>Record review of January 2024 census revealed, 1/23/24 the census was 79. The direct care staffing log dated 1/23/24 revealed the census was blank. <BR/>Record review of January 2024 census revealed, 1/24/24 the census was 81. The direct care staffing log dated 1/24/24 revealed census of 80.<BR/>Record review of January 2024 census revealed, 1/25/24 the census was 79. The direct care staffing log dated 1/25/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/26/24 the census was 80. The direct care staffing log dated 1/26/24 revealed census of 81.<BR/>Record review of January 2024 census revealed, 1/28/24 the census was 80. The direct care staffing log dated 1/28/24 revealed census of 79.<BR/>Record review of January 2024 census revealed, 1/29/24 the census was 80. The direct care staffing log dated 1/29/24 revealed census of 79.<BR/>Record review of January 2024 census revealed, 1/30/24 the census was 82. The direct care staffing log dated 1/30/24 revealed census of 80.<BR/>Record review of January 2024 census revealed, 1/31/24 the census was 80. The direct care staffing log dated 1/31/24 revealed census of 81.<BR/>Record review of February 2024 census revealed, 2/1/24 the census was 79. The direct care staffing log dated 2/1/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/2/24 the census was 79. The direct care staffing log dated 2/2/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/4/24 the census was 78. The direct care staffing log dated 2/4/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/5/24 the census was 78. The direct care staffing log dated 2/5/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/6/24 the census was 78. The direct care staffing log dated 2/6/24 revealed census of 81.<BR/>Record review of February 2024 census revealed, 2/7/24 the census was 79. The direct care staffing log dated 2/7/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/8/24 the census was 79. The direct care staffing log dated 2/8/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/9/24 the census was 78. The direct care staffing log dated 2/9/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/10/24 the census was 78. The direct care staffing log dated 2/10/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/11/24 the census was 76. The direct care staffing log dated 2/11/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/12/24 the census was 76. The direct care staffing log dated 2/12/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/13/24 the census was 73. The direct care staffing log dated 2/13/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/14/24 the census was 74. The direct care staffing log dated 2/14/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/15/24 the census was 74. The direct care staffing log dated 2/15/24 revealed census of 73.<BR/>Record review of February 2024 census revealed, 2/16/24 the census was 74. The direct care staffing log dated 2/16/24 revealed census of 73.<BR/>Record review of February 2024 census revealed, 2/19/24 the census was 75. The direct care staffing log dated 2/19/24 revealed census of 74.<BR/>Record review of February 2024 census revealed, 2/20/24 the census was 75. The direct care staffing log dated 2/20/24 revealed census of 74.<BR/>Record review of February 2024 census revealed, 2/21/24 the census was 77. The direct care staffing log dated 2/21/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/22/24 the census was 77. The direct care staffing log dated 2/22/24 revealed census of 75.<BR/>Record review of February 2024 census revealed, 2/24/24 the census was 78. The direct care staffing log dated 2/24/24 revealed census of 79.<BR/>Record review of February 2024 census revealed, 2/25/24 the census was 79. The direct care staffing log dated 2/25/24 revealed census of 80.<BR/>Record review of February 2024 census revealed, 2/26/24 the census was 80. The direct care staffing log dated 2/26/24 revealed census of 77.<BR/>Record review of February 2024 census revealed, 2/27/24 the census was 81. The direct care staffing log dated 2/27/24 revealed census of 78.<BR/>Record review of February 2024 census revealed, 2/28/24 the census was 81. The direct care staffing log dated 2/28/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/2/24 the census was 81. The direct care staffing log dated 3/2/24 revealed census of 80.<BR/>Record review of March 2024 census revealed, 3/3/24 the census was 81. The direct care staffing log dated 3/3/24 revealed census of 80.<BR/>Record review of March 2024 census revealed, 3/5/24 the census was 79. The direct care staffing log dated 3/5/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/6/24 the census was 77. The direct care staffing log dated 3/6/24 revealed census of 81.<BR/>Record review of March 2024 census revealed, 3/7/24 the census was 77. The direct care staffing log dated 3/7/24 revealed census of 78.<BR/>Record review of March 2024 census revealed, 3/9/24 the census was 75. The direct care staffing log dated 3/9/24 revealed census of 77.<BR/>Record review of March 2024 census revealed, 3/10/24 the census was 75. The direct care staffing log dated 3/10/24 revealed census of 77.<BR/>Record review of March 2024 census revealed, 3/11/24 the census was 75. The direct care staffing log dated 3/11/24 revealed the census was blank.<BR/>Record review of March 2024 census revealed, 3/12/24 the census was 77. The direct care staffing log dated 3/12/24 revealed census of 75.<BR/>During an interview on 3/14/24 at 11:39 am, the ADON stated the Lead CNA was responsible for completing the daily staffing posting. The ADON stated the Lead CNA had a binder with the copies in place where she prefilled the dates for a weeks' worth and would complete the daily staffing census the day before and would leave it for the nurses to post the following morning. The ADON stated the nurses and/or the Lead CNA would have to verify the daily census at the beginning of the shift. The ADON stated she did not know what kind of risk there was for the census not being accurate and stated she knew it was a State Office requirement. <BR/>During an interview on 3/14/24 at 12:03 pm, the Lead CNA stated she was responsible for completing the daily staffing sheet. The Lead CNA stated she would complete the daily staffing sheet at the end of the shift for the following day and would leave it in the nurse's station for the nurses to post in the morning. The Lead CNA did not have an answer for the census being wrong and did not know of any risk for the daily census being wrong . <BR/>Record review of Posting Direct Care Daily Staffing Number policy dated July 2016 read in part our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Shift information shall be recorded on the nursing staff directly responsible for resident care form for each shift. The information recorded on the form shall include: the resident census at the beginning of the shift for which the information is posted. Within 2 hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the nursing staff directly responsible for resident care form/ the shift supervisor shall date the form, record the census, and post the staffing information in the location designated by

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #72) of 8 residents reviewed for baseline care plans.<BR/>Resident #72 physician's progress note dated 01/16/2023 indicated that she was being admitted to the facility for pain control, but her baseline care plan did not address pain management. <BR/>This failure could put residents at risk of not receiving pain management.<BR/>Findings include:<BR/>Record review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident had an acute compression fracture at T12 [a broken vertebrae]. She had mostly severe pain, 9-10 on pain scale, constant with slight variation . and was to be admitted to the facility for pain management and physical therapy. <BR/>Record review of Resident #72's nurse progress note dated 01/24/2023 at 12:28 PM documented that the resident had abdominal pain and that the physician had ordered a KUB (X-ray study of urinary and gastrointestinal systems). <BR/>Record review of Resident #72's physician's note dated 01/25/2022 documented that the resident had abdominal pain with nausea which she rated as a 4 out of 10. <BR/>Record review of Resident #72's electronic diagnosis listing accessed on 02/08/2023 documented that she had diagnoses including wedge compression fracture of T11-T12 vertebra [broken vertebrae], subsequent encounter for fracture with routine healing; unspecified displaced fracture of surgical neck of right humerus [broken arm], subsequent encounter for fracture with routine healing; pain, unspecified; and chronic pain due to trauma. <BR/>Record review of Resident #72's Physician's Orders List dated 02/08/2023 documented an order dated 01/23/2023 that she was to receive 50 MG of tramadol (a pain medication) every 8 hours as needed for pain, an order for one gram of diclofenac sodium 1% gel (for pain) was to be applied to the affected area twice a day for pain, and an order dated 01/23/2023 for 5 MG of baclofen (a medicine used for muscle spasms and pain) every 8 hours as needed for pain. <BR/>Record review of Resident #72's care plan on 02/08/2023 at 5:16 PM, documented no care plan to address pain. <BR/>In interview and observation on 02/08/23 at 09:09 AM, Resident #72 was observed sitting in bed holding her lower abdomen and moaning. She was breathing heavily and so was having difficulty speaking. She said that she had lots of pain across her lower abdomen. She said that staff had brought her medicine for pain that morning but that she threw it up when she took the medicine. She said that she had pain even when she slept and that the therapy staff got mad when she could not participate because of her pain. She said that her right arm had been broken, that it had been fixed, but it was broken again, and it caused her pain. <BR/>In an interview on 02/08/2023 at 9:25 AM, NA F said that Resident #72 always complained of pain in her stomach and her right hand. The NA said that she always reported the resident's pain to the nurse. <BR/>In an interview on 02/08/23 at 09:43 AM, LVN G said that she was aware of Resident #72's pain which was chronic due to gall stones. She said the pain was in the resident's flank (between the lower ribs and the top of the hips) and radiated to her hips. The LVN said that the resident received pain medication although she sometimes refused it because of nausea. <BR/>Record review of Resident #72's revised care plan dated 02/09/2023 documented in part multiple changes to the resident's care plan on 02/09/2023 which included the addition of a pain-focused care plan. The care plan for pain documented that she was at risk for pain due to arthritis. Five interventions were listed including that pain medication was to be administered, and she was to be monitored for worsening of pain and the physician was to be notified of changes. All interventions were dated 02/09/2023. <BR/>In an interview on 02/08/2023 at 7:15 PM MDS Nurse C said that at admission the baseline care plan was created by reviewing diagnoses, orders and other information such as resident's COVID-19 status and record of falls. The MDS nurse said she had seven days from admission to complete the baseline care plan. She said that she did not know if Resident #72 had issues with pain control because she was not directly responsible for creating care plans for residents who were receiving skilled services such as resident #72. MDS Nurse C said that currently a nurse from the corporate level was trying to help with the care plans for skilled residents. When asked about changes to Resident #72's care plan dated 02/09/2023 she was not able to say who had made changes to include pain in the care plan. <BR/>Record Review of the facility policy Care Plans - Comprehensive (undated) documented that care plans would incorporate risk factors associated with identified problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #3, Resident #8, and Resident #13) of 3 residents reviewed for care plans. <BR/>The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #3, #8, and #13. <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. <BR/>Findings include:<BR/>Resident #3:<BR/>Record review of Resident #3's admission Record, dated 01/29/2025, reflected a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident # 3's History and Physical dated 03/16/2023, revealed diagnoses to include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe).<BR/>Record review of Resident # 3's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #3 was receiving oxygen therapy. <BR/>Record review of Resident #3's Order Summary Report dated 01/30/2025, revealed an order with start time of 10/08/2024 for O2 at 2 liters, keep O2 saturations above 85%.<BR/>Review of Resident #3's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 94% to 97%.<BR/>Record review of Resident #3's comprehensive care plan dated 01/30/2025, revealed Resident #3's oxygen therapy was not care planned. <BR/>During an observation and interview on 01/29/2025 at 2:18 p.m., Resident #3 was lying in bed with nasal cannula on and oxygen set at 2 liters. Resident #3 said she did not have any concerns with the services at the facility.<BR/>Resident #8:<BR/>Record review of Resident #8's admission Record, dated 01/30/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident # 8's History and Physical dated 01/07/2025, revealed diagnoses to include COPD (lung disease that block airflow and make it difficult to breathe) on 2 L nasal cannula, and acute on chronic hypoxemic respiratory failure (a sudden worsening of pre-existing chronic condition where the body is not getting enough oxygen). <BR/>Record review of Resident # 8's MDS dated [DATE], revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #8 was receiving oxygen therapy. <BR/>Record review of Resident #8's Order Summary Report dated 01/30/2025, revealed an order with start time 01/07/2025 Oxygen: Oxygen at 3 liters per nasal cannula continuous every day and night shift related to Hypoxemia. <BR/>Record review of Resident #8's comprehensive care plan dated 01/30/2025, revealed Resident #8's oxygen therapy was not care planned. <BR/>Review of Resident #8's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>During an observation on 01/30/2025 at 3:08 p.m., Resident #8 was observed asleep in bed. Resident #8 was observed wearing a nasal cannula with oxygen concentrator set at 3 liters. <BR/>Resident #13:<BR/>Record review of Resident #13's admission Record, dated 01/31/2025, reflected [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #13's History and Physical dated 06/08/2022, revealed diagnoses to include chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), and chronic respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body).<BR/>Record review of Resident #13's MDS dated [DATE], revealed a BIMS score of 05 indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #13 was receiving oxygen therapy. <BR/>Record review of Resident #13's Order Summary Report dated 01/31/2025, revealed an order with start time of 10/07/2024 for O2 via nasal cannula at 2 liters continuous to maintain saturation above 90%. <BR/>Review of Resident #13's O2 Saturation summary from 01/15/2025 to 01/31/2025 revealed O2 saturations ranged between 93% to 96%.<BR/>Record review of Resident #13's comprehensive care plan dated 01/31/2025, revealed Resident #13's oxygen therapy was not care planned. <BR/>During an observation on 01/31/2025 at 8:42 a.m., Resident #13 was lying in bed asleep with nasal cannula on and oxygen set at 2 liters. No issues identified with oxygen concentrator or tubing. <BR/>During an interview on 01/29/2025 at 10:48 a.m., the ADON said all care plans should include oxygen therapy. The ADON said MDS Coordinator was responsible for care plans. The ADON said the facility had a recent change of ownership at the beginning of December 2024 and some information from previous care plans did not transition into the electronic health record at the time of the change. The ADON said many documents were printed but not readily available on the floor for staff. The ADON said the facility previously had two MDS Coordinators but now only have one. <BR/>During an interview on 01/30/2025 at 4:11 p.m., the MDS Coordinator said she was in charge of getting the care plans up to date. The MDS Coordinator said she had 21 days from admission to complete the comprehensive care plan. The MDS Coordinator said oxygen therapy should be care planned. The MDS Coordinator said for the last two months she was the only MDS Coordinator which had caused her to be backed up. The MDS Coordinator said some of the care plans had not been updated. The MDS Coordinator said the risk of care plans not being updated was possible risk of residents not receiving the necessary care or service.<BR/>Review of the facility-provided Patient Care Management System dated November 2017, revealed in part A Comprehensive, Person-centered Plan of Care, consistent with resident rights must be completed by the 21st day after admission. The care plan must be based on assessments completed within the previous 15 months in the Patient's/Resident's active record and use the results of the assessments to develop, review and revise the Patient's/Resident's comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue). <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00, indicating her cognition was severely impaired, and she was dependent on staff for transfers. <BR/>Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/ 2 person transfers with interventions that included safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate and goal was will remain free from injury. <BR/>In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes in place. The transfer was completed without incident, and no anxiety was observed.<BR/>In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included the resident swinging, tipping over, and possibly falling. CNA B stated she had received training on proper mechanical lift transfer procedures.<BR/>In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent movement and released only when ready to move the lift. The DON stated one CNA maneuvered the mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and quarterly random competency checks were conducted by the DON and lead CNA.<BR/>In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed by direct care staff who were trained at hire, annually, and as needed during competency checks. The Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated the risk of not following those steps included potential injury to the resident or staff. <BR/>Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked position on the wheelchair, shower or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 residents (Resident #14 and Resident #57) of 7 reviewed for medication administration and 1 of 1 medication room.<BR/>-LVN H failed to administer insulin with meal per physician order for Resident #14. <BR/>-LVN I administered Resident #57 medication through feeding tube without checking for residuals first.<BR/>-Medication room had expired medications<BR/>This deficient practice could cause a decline in health of residents due to incorrect medication administration or administration of expired medications. <BR/>Findings included:<BR/>Resident #14<BR/>Review of Resident #14's Face Sheet dated 02/10/2023 documented a [AGE] year-old female with an admission date of 12/07/18. <BR/>Review of a History and Physical dated 06/29/2022 documented Resident #14 had a history of Type 2 Diabetes and at the time of the assessment was taking HumaLog 5 units with meals subcutaneously three times a day. The H&P stated, Monitor blood glucose levels .continue with all medications as prescribed.<BR/>Record review of Physician orders dated 08/31/2021 documented HUMALOG 100 UNIT/ML VIAL ADMINISTER 5 UNITS WITH MEALS SUBCUT TID. <BR/>Review of Comprehensive Care Plan dated 11/28/2022 documented Resident #14 had potential for hypoglycemia episodes secondary to Diabetes. Goal would be to minimize the risk for hypoglycemia through interventions such as administering insulin as ordered and monitor blood sugars.<BR/>Review of Annual MDS assessment dated [DATE] documented Resident #14 had a BIMS score of 6 meaning she was severely cognitively impaired. It also revealed she had a diagnosis of Diabetes and had taken Insulin at the time of the assessment. <BR/>Observation of medication pass on 02/08/2023 at 3:24 PM, revealed LVN H checked Resident # 14's blood sugar and it was 173. She then checked the physician order and drew 5 units of Humalog insulin. LVN H injected the insulin into the right lower abdomen subcutaneously. LVN H then gathered her supplies, disposed of them, and left the room. Resident #14 was not eating a meal at the time of insulin administration. <BR/>In an interview with LVN H on 02/08/2023 at 3:51 PM, she said dinner was served at 5:00 PM. She said she was supposed to provide a snack to the residents who are given insulin if no meal is provided. She said the snack should be provided within 30 minutes of administration. She said the risks of not providing snacks or meal after insulin administration could be that the blood sugar could drop. She said the nurses had been trained on insulin administration. <BR/>In an interview with LVN I on 02/10/2023 at 09:05 AM, she said it was procedure to provide insulin with meals or provide a snack after administration. She said risks for not doing so could be dropping of blood sugar in the resident.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said when a nurse would administer insulin that was ordered with meals, there had to be food or a meal available to be given with the medication. He said if there was no food, he would wait until there was a tray or a snack for the resident. He said the nurses were trained on providing meals with insulin administration.<BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the insulin should be given around dinner time that way the residents' blood sugar would not drop. She said usually the medication would be given 10 minutes before meal.<BR/>Resident #57<BR/>Review of Resident #57's Face Sheet dated 02/10/2023 demonstrated a [AGE] year-old male with an admission date of 12/16/2022. <BR/>Review of a History and Physical dated 12/17/2022 demonstrated he had a Gastrotomy tube and was receiving tube feedings. <BR/>Review of Physician orders dated 01/25/2023 demonstrated Resident #57 had Glucerna feedings @65 ml/hour through his feeding tube. <BR/>Review of Comprehensive Care Plan dated 01/09/2023 demonstrated Resident #57 had G-tube and required ostomy care. Goal was to minimize risk for complications related to G-tube daily through interventions such as flushing the tube.<BR/>Review of Quarterly MDS assessment dated [DATE] demonstrated Resident #57 had a BIMS score of 6, meaning he was severely cognitively impaired and had memory impairments. It also revealed he had a feeding tube and was receiving tube feedings. <BR/>Observation of medication pass on 02/09/23 at 08:41 AM, revealed LVN I was preparing to administer medications to Resident #57. She disconnected the tube feeding from the tube and connected the syringe. She then flushed the feeding tube with 30 cc of water, and then administered the medications. She was observed not checking the for residuals or placement of the feeding tube prior to medication administration. <BR/>In an interview with LVN I on 02/10/23 at 09:05 AM, she said the proper procedure for G-tube medication administration was to check the feeding tube for patency and check for residuals. She said she had checked the tube in the morning during rounds, but not before administering medications. She said the risks for not checking for residuals could be that the resident could aspirate from the feeding, and the feeding tube could be misplaced.<BR/>In an interview with LVN B on 02/10/23 at 9:56 AM, he said before administering a medication through a G-tube, it was nursing practice to aspirate the G-tube and check for residuals. He said the tube had to be checked for patency. <BR/>In an interview with DON on 02/10/23 at 03:28 PM, she said the nurses were trained to check for residuals and patency of the feeding tube every time they would give a medication. She said it was important to do so in order to check if the residents were not processing the feeding. She could not state when the nurses had been trained last. <BR/>Review of Humalog Manufacturer information dated 11/2019 read in part .HUMALOG starts acting fast. Inject HUMALOG within 15 minutes before or right after you eat a meal .<BR/>Review of facility policy titled Administering Medications dated 3/24/22 read in part .Medications shall be administered in a safe, and timely manner, and as prescribed .Medications must be administered in accordance with the orders .The individual administering the medication must check the label three times to verify the right medication .right time before giving the medication .<BR/>Review of facility policy titled Administering Medications through an Enteral Tube undated read in part .Steps in procedure .confirm the placement of feeding tube .check gastric residual volume to assess for tolerance of enteral feeding . <BR/>Medication Room<BR/>Observations on 02/08/23 at 11:38 AM, revealed the medication room had expired medications. The first cabinet in the medication room had two bottles of Vitamin C with an expiration date of 9/2022. The second cabinet had one bottle of Pro-Stat with and expiration date of 9/2022, and two bottles of UTI-Stat with an expiration date of 10/2022. <BR/>Observation and interview with DON on 02/08/23 at 11:45 AM, revealed the DON stated the medication room was checked and stocked by Central Supply. She said the medications should have not been in the room because they were expired. She said risks for keeping them in the room could be that the nurses and aides could administer them to residents. She said the nurses were trained on ensuring there were no expired medications. <BR/>In an interview with Central Supply on 02/08/23 at 1:59 PM, he said he was responsible for stocking the medication room with supplies and making sure the medications were good. He said he was not responsible for going through the medications and checking if they were expired. He said the nursing staff were responsible for checking the medications before grabbing them and taking them for their medication cart. He said since the state was at the facility, the nurses probably took the expired medications and hid them in the medication room. <BR/>Record review of facility policy titled Storage of Medications undated read in part .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts .shall not be left unattended if open or otherwise potentially available to others .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide a therapeutic diet as prescribed by the attending physician for 1 of 7 residents(Resident #22 ) reviewed for therapeutic diets.<BR/>The facility failed to ensure Resident #22 received mechanical soft and nectar thick diet and not receiving regular and thin liquids.<BR/>This failure could affect residents who receive mechanical soft and nectar diets of aspiration and choking. <BR/>Findings include: <BR/>Record review dated 02/09/2023 at 1:05 p.m., of facility Face Sheet for a [AGE] year-old female Resident #22 who was admitted [DATE] and readmitted on [DATE]. Resident #22 is diagnosed with dysphagia (difficult or discomfort in swallowing). <BR/>Observation on 02/07/2023 at 1:20 p.m , (Resident #22 family member called surveyor into Resident #22's room) Resident #22 was in her room laying in her bed elevated; turning red as she was trying to cough. Resident #22's eyes were closed. Residents' family member got up and began to pat her hard with her left hand on Resident's back. Patting was done with a great deal of force that the sound was loud. Five to seven pats were given until Resident #22 stated in Spanish se me [NAME] (It went down). Family member stopped patting Resident #22's back. Resident #22 laid back on inclined bed. <BR/>Observation on 02/07/2023 at 1:18 p.m., Resident #22's ticket showed texture of regular and fluid of thin liquids. Entree was 3 oz parmesan chicken, 2 Fl oz marinara sauce, starch &frac12; cup Italian vegetable blend, dessert 1 (2x2) blonde chocolate chip brownie, bread wheat dinner roll, dairy 8 Fl oz 2% milk, and condiment 1 margarine. Ticket was signed off by nurse who inspected tray and ticket. <BR/>Observation on 02/07/2023 at 1:28 p.m., Resident's (22) food plate consisted of chicken looking stringy/chopped texture. Spaghetti noodles were creamy wet looking and not cut up. Bread roll was whole and unknown if it was soft or hard. Veggie carrots were sliced from quarter size to dime size looking pickled, unknown if soft or hard. Other veggies possible peas looked mushy and pasty. A square size cake possibly chocolate was also given. <BR/>Observation on 02/10/2023 at 1:13 p.m., of facility Meal Suite Program (Program the facility uses to upload and print out resident diet tickets) in the kitchen is a way for Dietary Manager to input diet orders and print out diet tickets. The Meal Suite revealed that Resident #22 had been receiving regular texture and thin liquids.<BR/>Interview on 02/10/2023 at 1:13 p.m., Dietary Manager stated the Meal Suite program is where she uploads the diet orders and can make modifications as needed. Dietary Manager stated once uploaded she than prints them out as diet tickets. Dietary Manager stated the diet orders in Meal Suite had not been updated for Resident #22 since the day of the incident on 02/072023 (puree and nectar), so before that she had been receiving regular texture with thin liquids. Dietary Manager stated the risk of not updating the diet tickets was residents could choke. <BR/>Interview on 02/07/2023 at 1:34 p.m., with CNA A stated she was passing trays out and heard Resident #22's family member screaming. CNA A stated she gave her some lemonade. Resident #22 family member was hitting Resident #22 on her back. CNA A stated she lowered the bed and put her on her right side. CNA A stated Resident #22 was breathing a little better. CNA A stated the male nurse said that you should have not been feeding her that food and Resident #22 was on puree diet. CNA A stated she saw that she was completely red in her eyes and she was coughing and could hear very little air coming in and out. CNA A stated she was struggling to breath and Resident #22 family member was hitting her pretty hard on her back. CNA A stated Resident #22 family member had stated Resident #22 had spit out the food on a white towel. CNA A stated she looked at the Resident #22 food and it did not look chopped. CNA A stated based on her training it was not chopped food.<BR/>Interview on 02/07/2023 at 1:43 p.m., Resident #22's family member stated that LVN B told her not to be feeding Resident #22 and did not know why so was not able to feed her the food that was given. Resident #22's family member commented LVN B was going to order (recommend) Resident #22 receive puree food as Resident #22 needed her food downgraded. Resident #22's family member stated typically Resident #22 had been getting that kind of food like she had received in that size and texture. <BR/>Interview on 02/07/2023 at 2:07 p.m., LVN B stated Resident #22 got a little purple and asked Resident #22 to cough and resident was following commands. LVN B stated he believed the food being given to Resident #22 was rice a solid food. LVN B stated Resident #22 was mechanical soft as he checked the ticket and opened the food tray to make sure it matched. LVN B stated he would not say he remember 100 percent if it was mechanical soft. LVN B stated when he checks the trays, he looks at the meal tickets and makes sure that it reflects what was being served on the tray. LVN B stated he downgraded the change of diet for Resident #22. LVN B stated the nurses give the actual diet slips which have the changes of diet(s) on them (Recommendation/orders) to the Dietitian. LVN B stated Resident #22 was coughing pretty hard, had discoloration, was having a difficult time breathing. LVN B stated they are able to recommend downgrades in orders without a physician's approval but cannot upgrade due to needing the physician's approval. <BR/>Interview on 02/09/2023 at 1:51 p.m., Dietitian stated that she will get orders from the doctors and confirms the orders with the nurses. Dietitian stated the Dietary Manager will get the slip and relay it to her. Dietitian stated if she is not told there has been any changes in a resident's diet from the Dietary Manager than she will automatically default to the previous original order which in this case was regular texture with thin liquids. Dietitian stated she will conduct (mini) assessments on all new admissions and review the orders (Dietitian was shown all the orders for Resident #22, which included 01/18/2023 mechanical soft, moist and nectar). Dietitian stated she checked the order and didn't see it. Dietitian stated could be she overlooked it but she's super careful. Dietitian stated the risk to the residents could have been choking. <BR/>Interview on 02/09/2023 at 2:38 p.m., Dietary Manager stated she receives the diet slip orders from the nurses who receive orders from the Physician. Dietary Manager stated the Dietitian may also have recommendations on diet slip orders. Dietary Manager stated these orders must be approved by the physician. Dietary Manager stated the Dietitian will do assessments on residents quarterly and she will not relay any changes from a diet slip to the dietitian. Dietary Manager stated she will conduct assessments for new admissions only and on January 16th through the 25th she was out on vacation. Dietary Manager stated the Dietitian takes over with mini assessments when she's not there. Dietary Manager stated the Dietitian was the one who should have been checking on the new admissions that week (01/18/2023 when Resident #22 was admitted ). Dietary Manager stated she reviews and signs off on each diet slip. Dietary Manager stated when she came back on the 25th she reviewed and signed off on the slips. (Dietary Manager was shown Diet Slips from 01/24/23 (Moist & Minced / Nectar signed off) / 02/02/23 (Mechanical Soft / Thin Liquids signed off) Dietary Manager stated she does not know what happened with her updating the orders in the Meal Suite as Resident #22 was still getting regular texture and thin liquids. <BR/>Interview on 02/10/2023 at 10:30 a.m., CNA E stated when Resident #22 went to the dining room about a week or so ago she would have regular textured foods and thin liquids. CNA E stated since she has been working at the facility to now Resident #22 has always been regular texture and thin liquids which she was given. <BR/>Interview on 02/10/2023 at 11:19 a.m., LVN D stated Resident #22's family member was feeding her. LVN D stated Resident #22 is assistance with feeding. LVN D stated Resident #22 is mechanical soft at the time of the incident. <BR/>Interview on 02/10/2023 at 2:17 p.m., Speech Therapist stated Resident #22 was seen when readmitted for dysphagia from coming back from the hospital. Speech Therapist stated a swallow evaluation was done at the hospital where they did a modified swallow evaluation. Speech Therapist stated there were no problems with thin liquids. Speech Therapist stated on 01/19/2023 her assessment of Resident #22, there was no aspiration found with the thin liquids. Speech Therapist stated Resident #22 was mechanical soft. Speech Therapist stated for mechanical soft in terms of speech therapy was finely chopped food. Speech Therapist stated (shown a picture of Resident #22 food) the chicken would need to more chopped and Resident #22's food would need to be finer and more chopped. Speech Therapist stated the bread in the picture needs to be softer if Resident #22 was going to eat it. Speech Therapist stated there is a risk due to the resident's condition because Resident #22 would run the risk of aspiration because she could not chew. Record review on 02/09/20323 at 9:57 a.m., of facility Progress Notes for Resident #22 on 01/21/2023 at 1:57 p.m., Dietitian stated diet is regular, thin liquids.<BR/>Record review of facility Monthly Physicians Order Summary indicated on 01/18/2023; Resident #22 is to be texture Mechanical Soft and liquid Nectar. <BR/>Record review of facility Resident #22's Diet Order & Communication Slips for 01/18/2023 Mechanical Soft moist with nectar, 01/19/2023 thin liquids, 01/24/2023 nectar and moist and minced, 02/02/2023 thin liquids and mechanical soft. <BR/>Record review on 02/10/2023 at 2:16 p.m., of facility policy dated 2001 of Therapeutic diets stating the therapeutic diet shall be prescribed by the attending physician. Policy interpretation and implementation line 1., mechanically altered diets as well as diets modified for medical or nutritional needs will be considered Therapeutic Diets. Line 2., A therapeutic diet must be prescribed by the residents attending physician. The physicians diet order should match the terminology used by food services. Line 5 the food service manager will establish and use a trade identification system to ensure that each resident receives his or her diet as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the facility's Binding Arbitration Agreement was explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; that the resident or his or her representative acknowledges that he or she understands the agreement; that the agreement explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it; or that the agreement explicitly stated that neither the resident nor his or her representative were required to sign an agreement for binding arbitration as a condition of admission to the facility for two (Residents #186 and #35) of three residents reviewed for facility compliance with requirements for binding arbitration agreements. <BR/>The facility failed to adequately explain the intent of the binding arbitration agreement to Resident #186's representative.<BR/>The facility failed to include language in the Arbitration Agreement indicating that by signing the agreement the signer was saying he/she understood the agreement for Residents #186 and #35.<BR/>The facility's Arbitration Agreement failed to include information about the resident's or the resident representative's right to rescind the binding arbitration agreement within 30 calendar days of signing for Residents #186 and #35.<BR/>The facility's Arbitration Agreement failed to explicitly state that signing the arbitration agreement was not required as a condition for admission to the facility for Residents #186 and #35.<BR/>The facility failed to have Arbitration Agreements available in Spanish for Spanish speaking patients and/or patient representatives who spoke Spanish. <BR/>These failures put residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services to be performed by the nursing facility. <BR/>Findings include:<BR/>During the entrance conference on 02/07/2023 at 8:05 AM with the DON, a blank copy of the facility's admission packet and of the facility's binding arbitration agreement were requested and these were received by the survey team on 02/07/2023 by 5:00 PM.<BR/>Resident #186<BR/>Record review of Resident #186's Face Sheet dated 01/27/2023 documented in part that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident # 186's History and Physical dated 01/27/2023 documented that she had diagnoses including an undisplaced fracture of the first cervical vertebrae (broken neck), hypertension (high blood pressure), depression and diabetes. <BR/>Record review of Resident #186's Arbitration Agreement dated 01/27/2023 documented in part that the agreement was signed on 01/27/2023 by her family member and the facility Admissions Coordinator. The Arbitration Agreement did not include a statement indicating that by signing the agreement the signer was saying he/she understood the agreement. The Arbitration Agreement did not state that the resident or the resident's representative had the right to rescind the binding arbitration agreement within 30 calendar days of signing the agreement. The Arbitration Agreement did not include a statement explicitly stating that signing the binding arbitration agreement was not required as a condition of admission to the facility.<BR/>In an interview on 02/08/2023 at 1:28 PM, with Resident #186 and her family member, the resident was not able to answer questions about the care she was receiving in the facility. Her family member said that the resident was not able to answer questions. <BR/>In an interview on 02/10/23 at 01:05 PM, Resident #186's family member said that he had signed the resident's admission documents, including the arbitration agreement. He said that he did not know what the arbitration agreement said, and that the facility did not explain what the Arbitration Agreement meant.<BR/>Resident #35<BR/>Record review of Resident #35's Face Sheet dated 02/10/2023 documented in part that he was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #35's annual History and Physical dated 12/28/2022 documented that he had diagnoses including vascular dementia (memory problem caused by a stroke), and Hemiplegia following cerebral infarction affecting left nondominant side (paralysis of the left side due to a stroke). <BR/>Record review of Resident 35's Arbitration Agreement documented in part that it was signed by his responsible party on 02/18/2018. The Arbitration Agreement did not include a statement indicating that by signing the agreement the signer was saying he/she understood the agreement. The Arbitration Agreement did not state that the resident or the resident's representative had the right to rescind the binding arbitration agreement within 30 calendar days of signing the agreement. The Arbitration Agreement did not include a statement explicitly stating that signing the binding arbitration agreement was not required as a condition of admission to the facility.<BR/>In a group interview on 02/08/2023 at 1:30 PM, Resident #35 and other group members denied knowledge of the content or meaning of the facility's Arbitration Agreement. Of the eight residents present for the group interview, seven of them preferred to speak Spanish rather than English. <BR/>On 02/10/2023 at 01:20 PM, a telephone message was left on Resident #35's responsible party's voice mail requesting a call back. A telephone call back from the responsible party was not received prior to exit. <BR/>In an interview on 02/10/2023 at 02:02 PM, the admission Coordinator said she had been in her position for about a month. She said that she was still getting familiar with the contents of the admission packet and did not receive any training specific to the Arbitration Agreement. She said that she met with patients and/or family members to sign admission packet documents which included the Arbitration Agreement. She said that during her meetings with patients and/or family members to sign the contents of the admission packet she read the Arbitration Agreement along with the resident and/or family member. She said that she had never had to into depth to explain the Arbitration Agreement during her meetings with patients and/or family members to sign the contents of the admission packet. She said that the Arbitration Agreement was not available in Spanish. <BR/>In interviews on 02/10/2023 at 5:08 PM and 5:20 PM the Administrator said that the Arbitration Agreement contained in the admission packet provided to the survey team on 02/07/2023 was the Arbitration Agreement currently used by the facility, and that to his knowledge it was the document that had been in use since he became the facility administrator almost five years ago. The Administrator said that he was not aware of the requirement that the resident or his/her representative acknowledge that he/she understood the agreement; or that the agreement was required to explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it. The Administrator provided the surveyor another version of an arbitration agreement dated 09/2019 that he said he had received from his corporate office on that day (02/10/2023). He said that he was not aware of changes to the Arbitration Agreement until that that day (02/10/2023). He said that the facility did not have a Spanish-language version of the Arbitration Agreement, but that facility staff were working to create one.<BR/>A request for the facility policy regarding binding arbitration agreements was submitted to the DON on 02/10/2023 at 5:01 PM. A policy regarding binding arbitration agreements was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the facility's Binding Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties; or that the agreement provided for the selection of a venue that is convenient to both parties for two (Residents #186 and #35) of three residents reviewed for facility compliance with requirements for binding arbitration agreements. <BR/>The facility failed to ensure that it's Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties for Residents #186 and #35.<BR/>The facility failed to ensure that it's Arbitration Agreement provided for the selection of a venue that was convenient to both parties for Residents #186 and #35 . <BR/>These failures put residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services to be performed by the nursing facility. <BR/>Findings include:<BR/>During the entrance conference on 02/07/2023 at 8:05 AM with the DON, a blank copy of the facility's admission packet and of the facility's binding arbitration agreement were requested and these were received by the survey team on 02/07/2023 by 5:00 PM.<BR/>Resident #186<BR/>Record review of Resident #186's Face Sheet dated 01/27/2023 documented in part that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident # 186's History and Physical dated 01/27/2023 documented that she had diagnoses including an undisplaced fracture of the first cervical vertebrae (broken neck), hypertension (high blood pressure) , depression and diabetes. <BR/>Record review of Resident #186's Arbitration Agreement dated 01/27/2023 documented in part that the agreement was signed on 01/27/2023 by her family member and the facility Admissions Coordinator. The Arbitration Agreement did not provide for the selection of a neutral arbitrator agreed upon by both parties and the agreement did not provide for the selection of a venue that was convenient for both parties. <BR/>In an interview on 02/08/2023 at 1:28 PM with Resident #186 and her family member, the resident was not able to answer questions about the care she was receiving in the facility. Her family member said that the resident was not able to answer questions. <BR/>In an interview on 02/10/23 at 01:05 PM Resident #186's family member said that he had signed the resident's admission documents, including the arbitration agreement. He said that he did not know what the arbitration agreement said, and that the facility did not explain what the Arbitration Agreement meant.<BR/>Resident #35<BR/>Record review of Resident #35's Face Sheet dated 02/10/2023 documented in part that he was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #35's annual History and Physical dated 12/28/2022 documented that he had diagnoses including vascular dementia (memory problem caused by a stroke), and Hemiplegia following cerebral infarction affecting left nondominant side (paralysis of the left side due to a stroke). <BR/>Record review of Resident 35's Arbitration Agreement documented in part that it was signed by his responsible party on 02/18/2018. The Arbitration Agreement did not provide for the selection of a neutral arbitrator agreed upon by both parties and the agreement did not provide for the selection of a venue that was convenient to both parties. <BR/>In a group interview on 02/08/2023 at 1:30 PM Resident #35 and other group members denied knowledge of the content or meaning of the facility's Arbitration Agreement. <BR/>On 02/10/2023 at 01:20 PM a telephone message was left on Resident #35's responsible party's voice mail requesting a call back. A telephone call back from the responsible party was not received prior to exit. <BR/>In an interview on 02/10/2023 at 02:02 PM the admission Coordinator said she had been in her position for about a month. She said that she was still getting familiar with the contents of the admission packet and did not receive any training specific to the Arbitration Agreement. She said that she met with patients and/or family members to sign admission packet documents which included the Arbitration Agreement. She said that during her meetings with patients and/or family members to sign the contents of the admission packet she read the Arbitration Agreement along with the resident and/or family member. She said that she had never had to into depth to explain the Arbitration Agreement during her meetings with patients and/or family members to sign the contents of the admission packet. <BR/>In interviews on 02/10/2023 at 5:08 PM and 5:20 PM the Administrator said that the Arbitration Agreement contained in the admission packet provided to the survey team on 02/07/2023 was the Arbitration Agreement currently used by the facility, and that to his knowledge it was the document that had been in use since he became the facility administrator almost five years ago. The Administrator provided the surveyor another version of an arbitration agreement dated 09/2019 that he said he had received from his corporate office on that day (02/10/2023). He said that he was not aware of changes to the Arbitration Agreement until that that day (02/10/2023). <BR/>A request for the facility policy regarding binding arbitration agreements was submitted to the DON on 02/10/2023 at 5:01 PM. A policy regarding binding arbitration agreements was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents the right to formulate an advance directive for 2 (Resident #39 and Resident #69) of twenty-four residents reviewed for formulation of advance directives. <BR/>Residents #39 and #69's medical records did not accurately reflect their Texas Out of Hospital Do Not Resuscitate (TXOOHDNR) orders.<BR/>This failure could put residents at risk of not having their TXOOHDNR honored, resulting in receiving medical treatment they did not desire. <BR/>Findings include:<BR/>Resident #39 <BR/>Record review of Resident #39's face sheet dated [DATE] documented she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #39's History and Physical dated [DATE] documented she was assessed for diagnoses including high blood pressure, hyperlipidemia (abnormally high concentration of fats in the blood) diabetes with complications, chronic kidney disease stage five, and functional quadriplegia (complete inability to move). <BR/>Review of Resident #39's electronic medical record (reviewed [DATE]) indicated on the header for all screens that she had a Do Not Resuscitate Order (DNR). <BR/>Record review of Resident #39's physician orders documented a doctor's order dated [DATE] that she was a DNR. <BR/>Record review of Resident #39's TXOOHDNR documented it was signed by her physician on [DATE]. <BR/>Record review of Resident #39's care plan dated [DATE] documented she was Full Code, and resuscitation was to be attempted. <BR/>Resident #69 <BR/>Record review of Resident #69's face sheet dated [DATE] documented she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #69's History and Physical dated [DATE] documented she had diagnoses including high blood pressure (Hypertension), Diabetes, mild chronic kidney disease, and dementia. It documented that she had an active Out Of hospital DNR order in place. <BR/>Record review of Resident #69's electronic medical record (reviewed [DATE]) indicated on the header for all screens that she had a Do Not Resuscitate Order (DNR). <BR/>Record review of Resident #69's Physicians Orders List dated [DATE] documented an active physician's order dated [DATE] documenting that she was full code (CPR was to be attempted in case the heart stopped). No other order indicating that she had a DNR was located among her active physician's orders. <BR/>Record review of Resident # 69's TXOOHDNR documented that it was signed by her medical power of attorney/ legal guardian on [DATE]. It was signed by two witnesses on [DATE]. The TXOOHDNR order was signed by the physician on 11/18. The year it was signed by the physician was not indicated. <BR/>Record review of Resident #69's Care Plan dated [DATE] documented she had a full code status. Interventions included that resuscitation should be attempted if arrest occurred. <BR/>In an interview on [DATE] at 3:44 PM, the DON said she thought Resident #69 probably came in full code and when the DNR was initiated the physicians order was not changed and care plan was not updated. She said the Social Worker was responsible for advance directives including the DNRs. The risk to the resident was CPR would be provided although she had a DNR order. She said the signed TXOOHDNR form was the correct document to determine if the resident was to receive CPR or not and the doctor's order dated [DATE] was not correct. <BR/>In an interview on [DATE] at 3:50 PM, MDS Nurse C said records regarding DNRs for Residents #39 and #69 were set up before her time. She said the social worker was responsible for educating residents and care givers about advance directives including DNRs. She stated full code status was the default status in the absence of a DNR order. She said the risk to these residents of having incorrect information on their records regarding their code status was staff might start resuscitation although it is not what the resident or resident representative wanted. <BR/>In an interview on [DATE] at 5:34 PM, the Social Worker said she had been in the facility since [DATE] and had not had an opportunity to review the DNR status of older charts. She was not aware of the conflicting information about DNR status in the records for Residents #39 and #69. She said that she spoke to residents and families at the time of admission about advance directives and that if a DNR was enacted, she notified the team of the resident's DNR status and placed a copy on the DNR in the resident's file. She said that there was a risk to Residents #39 and #69 of not having their wishes honored as a result of the conflicting information on facility documents. She stated that the TXOOHDNR was the document that should be honored but did not know what the nurses would do if either Residents #39 or #69 had a cardiac arrest. <BR/>Record review of the facility policy Advance Directives dated [DATE] documented in part that Advance Directive would be respected in accordance with state law and facility policy. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The policy defined advance directives as including Do Not Resuscitate which indicated that in case of respiratory or cardiac failure the facility had been directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #72) of 24 residents reviewed for accuracy of resident's medical records. <BR/>A physician's order that the resident be observed on all rounds on every shift was entered into Resident #72's record incorrectly and documented that she was to be observed on all rounds every even- numbered day for Resident #72.<BR/>This failure could put residents at risk of having undetected changes in their conditions resulting in delayed response to resident's medical care needs. <BR/>Findings include:<BR/>Record Review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident was diagnosed with an acute compression fracture at T12 [a broken vertebrae]. <BR/>Record review of Resident #72's electronic diagnosis listing accessed on 02/08/2023 documented that she had diagnoses including wedge compression fracture of T11-T12 vertebra [broken vertebrae], subsequent encounter for fracture with routine healing; Essential (primary) hypertension [high blood pressure]; Unspecified displaced fracture of surgical neck of right humerus [broken arm], subsequent encounter for fracture with routine healing; Pain, unspecified; Chronic pain due to trauma; and Type 2 diabetes mellitus. <BR/>Record review of Resident #72's Physician's Orders List dated 02/08/2023 documented an order dated 01/26/2023 that she should be observed during all rounds made on every shift. <BR/>Record review of Resident #72's Nurses MAR for the month of January 2023 documented no observations were made on any of three shifts on 01/27, 01/29, or 01/31/2023. <BR/>Record review of Resident #72's Nurses MAR for the month of February 2023 documented no observations were made on any of three shifts on 02/01, 02/03, 02/05, or 02/07/2023. <BR/>In an interview on 02/09/23 at 02:03 PM, the ADON said she entered the physician's order to observe Resident #72 daily on all rounds incorrectly. She stated she entered the order to trigger observation of the resident every even-numbered day, (EDAYS) rather than daily. She said that she had the responsibility for auditing orders for newly admitted residents and was back-up for the nurses who also entered orders. She said that, as a result of her error, Resident #72 might have a change of condition that was delayed in detection. <BR/>The facility policy and procedure regarding documentation of physician's orders was requested on 02/10/2023 at 5:01 PM in a list of requests delivered to the DON but was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue). <BR/>Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00, indicating her cognition was severely impaired, and she was dependent on staff for transfers. <BR/>Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/ 2 person transfers with interventions that included safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate and goal was will remain free from injury. <BR/>In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes in place. The transfer was completed without incident, and no anxiety was observed.<BR/>In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included the resident swinging, tipping over, and possibly falling. CNA B stated she had received training on proper mechanical lift transfer procedures.<BR/>In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent movement and released only when ready to move the lift. The DON stated one CNA maneuvered the mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and quarterly random competency checks were conducted by the DON and lead CNA.<BR/>In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed by direct care staff who were trained at hire, annually, and as needed during competency checks. The Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated the risk of not following those steps included potential injury to the resident or staff. <BR/>Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked position on the wheelchair, shower or bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of * resident reviewed for provision of food in a form designed to meet individual needs. <BR/>The facility failed to ensure Resident #22 lunch meal was mechanical soft and nectar diet as ordered by the physician. <BR/>This failure could place residents who received mechanical soft and nectar diets at-risk of choking and aspiration.<BR/>Findings include: <BR/>Record review of facility Face Sheet indicated Resident #22 was a [AGE] year-old female who was admitted [DATE] and readmitted on [DATE]. Resident #22 was diagnosed with dysphagia (difficult or discomfort in swallowing). <BR/>Observation on 02/07/2023 at 1:20 p.m , (Resident #22 family member called surveyor into Resident #22's room) Resident #22 was in her room laying in her bed elevated; turning red as she was trying to cough. Resident #22's eyes were closed. Residents' family member got up and began to pat her hard with her left hand on Resident's back. Patting was done with a great deal of force that the sound was loud. Five to seven pats were given until Resident #22 stated in Spanish se me bajo (It went down). Family member stopped patting Resident #22's back. Resident #22 laid back on inclined bed. <BR/>Observation on 02/07/2023 at 1:18 p.m., Resident #22's ticket showed texture of regular and fluid of thin liquids. Entree was 3 oz parmesan chicken, 2 Fl oz marinara sauce, starch &frac12; cup Italian vegetable blend, dessert 1 (2x2) blonde chocolate chip brownie, bread wheat dinner roll, dairy 8 Fl oz 2% milk, and condiment 1 margarine. Ticket was signed off by nurse who inspected tray and ticket. <BR/>Observation on 02/07/2023 at 1:28 p.m., Resident #22's food plate consisted of chicken looking stringy/chopped texture. Spaghetti noodles were creamy wet looking and not cut up. Bread roll was whole and unknown if it was soft or hard. Veggie carrots were sliced from quarter size to dime size looking pickled, unknown if soft or hard. Other veggies possible peas looked mushy and pasty. A square size cake possibly chocolate was also given. <BR/>Observation on 02/10/2023 at 1:13 p.m., of facility Meal Suite Program (Program the facility uses to upload and print out resident diet tickets) in the kitchen is a way for Dietary Manager to input diet orders and print out diet tickets. The Meal Suite revealed that Resident #22 had been receiving regular texture and thin liquids.<BR/>Interview on 02/10/2023 at 1:13 p.m., Dietary Manager stated the Meal Suite program is where she uploads the diet orders and can make modifications as needed. Dietary Manager stated once uploaded she than prints them out as diet tickets. Dietary Manager stated the diet orders in Meal Suite had not been updated for Resident #22 since the day of the incident on 02/072023 (puree and nectar), so before that she had been receiving regular texture with thin liquids. Dietary Manager stated the risk of not updating the diet tickets was residents could choke. <BR/>Interview on 02/07/2023 at 1:34 p.m., with CNA A stated she was passing trays out and heard Resident #22's family member screaming. CNA A stated she gave her some lemonade. Resident #22 family member was hitting Resident #22 on her back. CNA A stated she lowered the bed and put her on her right side. CNA A stated Resident #22 was breathing a little better. CNA A stated the male nurse said that you should have not been feeding her that food and Resident #22 was on puree diet. CNA A stated she saw that she was completely red in her eyes and she was coughing and could hear very little air coming in and out. CNA A stated she was struggling to breath and Resident #22 family member was hitting her pretty hard on her back. CNA A stated Resident #22 family member had stated Resident #22 had spit out the food on a white towel. CNA A stated she looked at the Resident #22 food and it did not look chopped. CNA A stated based on her training it was not chopped food.<BR/>Interview on 02/07/2023 at 1:43 p.m., Resident #22's family member stated that LVN B told her not to be feeding Resident #22 and did not know why so was not able to feed her the food that was given. Resident #22's family member commented LVN B was going to order (recommend) Resident #22 receive puree food as Resident #22 needed her food downgraded. Resident #22's family member stated typically Resident #22 had been getting that kind of food like she had received in that size and texture. <BR/>Interview on 02/07/2023 at 2:07 p.m., LVN B stated Resident #22 got a little purple and asked Resident #22 to cough and resident was following commands. LVN B stated he believed the food being given to Resident #22 was rice a solid food. LVN B stated Resident #22 was mechanical soft as he checked the ticket and opened the food tray to make sure it matched. LVN B stated he would not say he remember 100 percent if it was mechanical soft. LVN B stated when he checks the trays, he looks at the meal tickets and makes sure that it reflects what was being served on the tray. LVN B stated he downgraded the change of diet for Resident #22. LVN B stated the nurses give the actual diet slips which have the changes of diet(s) on them (Recommendation/orders) to the Dietitian. LVN B stated Resident #22 was coughing pretty hard, had discoloration, was having a difficult time breathing. LVN B stated they are able to recommend downgrades in orders without a physician's approval but cannot upgrade due to needing the physician's approval. <BR/>Interview on 02/09/2023 at 1:51 p.m., Dietitian stated that she will get orders from the doctors and confirms the orders with the nurses. Dietitian stated the Dietary Manager will get the slip and relay it to her. Dietitian stated if she is not told there has been any changes in a resident's diet from the Dietary Manager than she will automatically default to the previous original order which in this case was regular texture with thin liquids. Dietitian stated she will conduct (mini) assessments on all new admissions and review the orders (Dietitian was shown all the orders for Resident #22, which included 01/18/2023 mechanical soft, moist and nectar). Dietitian stated she checked the order and didn't see it. Dietitian stated could be she overlooked it but she's super careful. Dietitian stated the risk to the residents could have been choking. <BR/>Interview on 02/09/2023 at 2:38 p.m., Dietary Manager stated she receives the diet slip orders from the nurses who receive orders from the Physician. Dietary Manager stated the Dietitian may also have recommendations on diet slip orders. Dietary Manager stated these orders must be approved by the physician. Dietary Manager stated the Dietitian will do assessments on residents quarterly and she will not relay any changes from a diet slip to the dietitian. Dietary Manager stated she will conduct assessments for new admissions only and on January 16th through the 25th she was out on vacation. Dietary Manager stated the Dietitian takes over with mini assessments when she's not there. Dietary Manager stated the Dietitian was the one who should have been checking on the new admissions that week (01/18/2023 when Resident #22 was admitted ). Dietary Manager stated she reviews and signs off on each diet slip. Dietary Manager stated when she came back on the 25th she reviewed and signed off on the slips. (Dietary Manager was shown Diet Slips from 01/24/23 (Moist & Minced / Nectar signed off) / 02/02/23 (Mechanical Soft / Thin Liquids signed off) Dietary Manager stated she does not know what happened with her updating the orders in the Meal Suite as Resident #22 was still getting regular texture and thin liquids. <BR/>Interview on 02/10/2023 at 10:30 a.m., CNA E stated when Resident #22 went to the dining room about a week or so ago she would have regular textured foods and thin liquids. CNA E stated since she has been working at the facility to now Resident #22 has always been regular texture and thin liquids which she was given. <BR/>Interview on 02/10/2023 at 11:19 a.m., LVN D stated Resident #22's family member was feeding her. LVN D stated Resident #22 is assistance with feeding. LVN D stated Resident #22 is mechanical soft at the time of the incident. <BR/>Interview on 02/10/2023 at 2:17 p.m., Speech Therapist stated Resident #22 was seen when readmitted for dysphagia from coming back from the hospital. Speech Therapist stated a swallow evaluation was done at the hospital where they did a modified swallow evaluation. Speech Therapist stated there were no problems with thin liquids. Speech Therapist stated on 01/19/2023 her assessment of Resident #22, there was no aspiration found with the thin liquids. Speech Therapist stated Resident #22 was mechanical soft. Speech Therapist stated for mechanical soft in terms of speech therapy was finely chopped food. Speech Therapist stated (shown a picture of Resident #22 food) the chicken would need to more chopped and Resident #22's food would need to be finer and more chopped. Speech Therapist stated the bread in the picture needs to be softer if Resident #22 was going to eat it. Speech Therapist stated there is a risk due to the resident's condition because Resident #22 would run the risk of aspiration because she could not chew. Record review on 02/09/20323 at 9:57 a.m., of facility Progress Notes for Resident #22 on 01/21/2023 at 1:57 p.m., Dietitian stated diet is regular, thin liquids.<BR/>Record review on 02/09/2023 at 1:50 p.m., of facility Monthly Physicians Order Summary indicated on 01/18/2023; Resident #22 is to be texture Mechanical Soft and liquid Nectar. <BR/>Record review of Resident #22's Diet Order & Communication Slips for 01/18/2023 Mechanical Soft moist with nectar, 01/19/2023 thin liquids, 01/24/2023 nectar and moist and minced, 02/02/2023 thin liquids and mechanical soft.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.<BR/>1. <BR/>Food products in dry storage and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings include:<BR/>Observation on 02/07/2023 at 8:10 a.m., in the dry storage was a 106 oz dented can of mixed fruits on the rollout shelve. <BR/>- <BR/>Dry storage area, a 16 oz clear bag enriched macaroni was sitting on the mid shelve inside a zip lock bag undated and opened. <BR/>- <BR/>In the back of the house kitchen prep area, the middle refrigerator inside on the top shelve was a 5.6 qt 6-inch-deep clear plastic container with salsa mid-way with a clear plastic wrap with its ends floating outwards and not gripping the container securing a closed hold. <BR/>- <BR/>In the back of the house kitchen prep area, in refrigerator on top shelf was a 6-inch metal deep pan full of green lettuce leaf was not wrapped properly with plastic wrap. Plastic wrap is not gripping onto the pan and in the front part of the pan that is visible to us to view has a opening about half an inch. <BR/>- <BR/>In the back of the house kitchen prep area, on the top shelve in the refrigerator was a 4 in deep metal pan with cherry tomatoes in it. The plastic wrap was not gripping the pan properly and was not making a proper seal. <BR/>- <BR/>In the back of the house kitchen prep area, middle freezer was a clear wrapped plastic bag of chicken breast that were not labeled/ dated. <BR/>- <BR/>In the back of the house kitchen prep area, on top freezer was a bag of yellow squash dated [DATE]. <BR/>- <BR/>In the back of the house kitchen prep area, on the top shelve was a bag of red skinned potatoes 2.5 lbs. and halfway gone that were dated 217 [DATE] 05. <BR/>- <BR/>In between the kitchen and the back of the house was a holding shelf that had a 23oz bag of hamburger buns with no date. <BR/>- <BR/>In the front of the house kitchen area, a refrigerator on the top shelf was a one-gallon clear pouring container that contained lemonade that was expired as labeled (02/05/2023 to 02/06/2023).<BR/>- <BR/>In front of the house kitchen area, a refrigerator on the middle shelves had 54 5 oz plastic tumbler cups full of milk that were expired (02/05/2023 to 02/06/2023). <BR/>Interview on 02/07/2023 at 8:20 a.m., Dietary Manager stated the Macaroni was to be closed properly and was not common practice leaving it open. Dietary Manager stated the macaroni has to be closed properly so insects don't get in and the product get damaged. Dietary Manager stated dietary staff are in-serviced and receive monthly trainings. Dietary Manager stated the damaged cans are separated and are to go into her office. Dietary Manager stated damaged cans are damaged products and due to the damage can contain air. Dietary Manger stated staff are trained when doing the truck when products come in and check the food items when putting them away. Dietary Manager stated the dietary staff are to check and inspect the food items/packages before using them. Dietary Manager stated the yellow squash and the red skin potatoes have been fed to the residents. Dietary Manager stated the supplier had confirmed the date on the yellow squash the date it was packaged. Dietary Manager stated supplier did not tell them what the expiration date was. Dietary Manager stated she oversees the dietary staff are labeling and checking the foods when they are put away. Dietary Manager stated it is important to put the expiration dates. <BR/>Interview on 02/08/2023 at 11:02 a.m., Dietitian stated dietary staff go through basic training to work in the kitchen and the Dietary Manager oversees this. Dietitian stated she does audits once a month and orally instructs dietary staff on logging temps, safety, diets, portion sizes, labeling, and storage. Dietitian stated the yellow squash and red skin potatoes outdated was no risk to the residents because they were in the freezer and has temperature control. Dietitian stated cans dented needed to be placed aside because they can contain botulism. Dietitian stated of the dented can was fruit then there can be a risk of botulism and would be a risk to the residents if they ingest it. <BR/>Interview on 02/09/2023 at 1:51 p.m., Dietary Staff J stated there is no specific training to be able to do the truck. Dietary Staff J stated she sees the dates and places the older foods on the top and the newer food on the bottom of shelves. Dietary Staff J stated when the food comes out of the box we date it and place the name on the items. Dietary Staff J stated the dietary staff have not received any training on labeling. Dietary Staff J stated the dietary staff are to check the bag(s) to see if it is not spoiled. Dietary Staff J stated if we had it like that (yellow squash and red skin potatoes) outdated we should have thrown it away. Dietary Staff J stated dietary staff are trained through the food handlers' program which trains dietary staff on dates, labeling, and checking food items. Dietary Staff J stated they also receive training from the facility. Dietary Staff J stated the red potatoes were used and given to the residents. Dietary Staff J stated she would have voiced it out as a concern with the date on the squash. Dietary Staff J stated staff are trained to check out the foods before using them. Dietary Staff J stated the residents can get sick by serving them expired food.<BR/>Interview on 02/09/2023 at 2:08 p.m., Dietary Staff K stated she was trained by the facility which gave her a curriculum and by the Dietary Manager. Dietary Staff K stated the dietary staff were in-serviced to wash hands, labels, and do temperatures. Dietary Staff K stated the dietary staff are to put the dates on everything and place all the old foods in front to be used first. Dietary Staff K stated dietary staff when putting food away check the food items with the dates and to see if they are spoiled. Dietary Staff K stated she had learned in other areas that some food items can last a year. Dietary Staff K stated the facility does not have a policy that states that the facility can use food that is a couple months to a year old. Dietary Staff K stated there is a risk with not checking the dates because those being server the red skinned potatoes to the resident could get botulism. <BR/>Record review of facility policy dated 10/01/2018 of Food Delivers stated to ensure that all food prepared by the facility is of good quality, there facility will follow HACCP guidelines for receiving and inspecting foods delivered to the facility. Food Deliver Policy indicates on procedure line 2, The Nutrition and Foodservice Manager or designees will inspect all deliveries to ensure that the food is not spoiled or adulterated. C. all cans must be in good condition and not dented. <BR/>Record review of facility policy dated 10/01/2018 of Food Storage stated to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Food Storage Policy indicated on dry storage procedure line d., to ensure freshness, store opened and bulk items in tightly covered containers. All containers' must be labeled and dated. Food Storage Policy refrigerator procedure line d., date, label, and tightly seal all refrigerator foods using clean, nonabsorbent, covered containers' that are approved for food storage. <BR/>Record review of facility in-service dated 12/16/2021 of Dry Food Summary was given for labeling and dating.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (100 Hall) of 4 medication carts reviewed for medication storage in that:<BR/>-100 Hall Medication Cart was left unlocked with OTC medications inside. <BR/>This deficient practice could place residents at risk of decline in health if medication was to be taken from opened medication cart. <BR/>Findings included:<BR/>Observations in the 100 Hall on 02/07/23 at 08:25 AM revealed that Medication Cart keys were found on top of the medication cart, where it was found to be open and unattended. The medication cart was located in the 100 hall where there were no residents at the time. <BR/>Observation and interview with DON on 02/08/23 at 11:45 AM, revealed there were OTC medications in the 100 hall medication cart that had been left opened the day before. The DON stated since there were no residents in the 100 Hall at the time, the nurses had left the medication cart in the hallway. She said the nurses knew to close and lock the medication cart when it was not in use. She said risks for leaving it open and unattended could be that residents could walk up to the medication cart and take medications. She said the residents could have side effects or a reaction to medications they were already taking. <BR/>Record review of facility policy titled Storage of Medications undated read in part .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts .shall not be left unattended if open or otherwise potentially available to others .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #72) of 24 residents reviewed for accuracy of resident's medical records. <BR/>A physician's order that the resident be observed on all rounds on every shift was entered into Resident #72's record incorrectly and documented that she was to be observed on all rounds every even- numbered day for Resident #72.<BR/>This failure could put residents at risk of having undetected changes in their conditions resulting in delayed response to resident's medical care needs. <BR/>Findings include:<BR/>Record Review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident was diagnosed with an acute compression fracture at T12 [a broken vertebrae]. <BR/>Record review of Resident #72's electronic diagnosis listing accessed on 02/08/2023 documented that she had diagnoses including wedge compression fracture of T11-T12 vertebra [broken vertebrae], subsequent encounter for fracture with routine healing; Essential (primary) hypertension [high blood pressure]; Unspecified displaced fracture of surgical neck of right humerus [broken arm], subsequent encounter for fracture with routine healing; Pain, unspecified; Chronic pain due to trauma; and Type 2 diabetes mellitus. <BR/>Record review of Resident #72's Physician's Orders List dated 02/08/2023 documented an order dated 01/26/2023 that she should be observed during all rounds made on every shift. <BR/>Record review of Resident #72's Nurses MAR for the month of January 2023 documented no observations were made on any of three shifts on 01/27, 01/29, or 01/31/2023. <BR/>Record review of Resident #72's Nurses MAR for the month of February 2023 documented no observations were made on any of three shifts on 02/01, 02/03, 02/05, or 02/07/2023. <BR/>In an interview on 02/09/23 at 02:03 PM, the ADON said she entered the physician's order to observe Resident #72 daily on all rounds incorrectly. She stated she entered the order to trigger observation of the resident every even-numbered day, (EDAYS) rather than daily. She said that she had the responsibility for auditing orders for newly admitted residents and was back-up for the nurses who also entered orders. She said that, as a result of her error, Resident #72 might have a change of condition that was delayed in detection. <BR/>The facility policy and procedure regarding documentation of physician's orders was requested on 02/10/2023 at 5:01 PM in a list of requests delivered to the DON but was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #72) of 24 residents reviewed for accuracy of resident's medical records. <BR/>A physician's order that the resident be observed on all rounds on every shift was entered into Resident #72's record incorrectly and documented that she was to be observed on all rounds every even- numbered day for Resident #72.<BR/>This failure could put residents at risk of having undetected changes in their conditions resulting in delayed response to resident's medical care needs. <BR/>Findings include:<BR/>Record Review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident was diagnosed with an acute compression fracture at T12 [a broken vertebrae]. <BR/>Record review of Resident #72's electronic diagnosis listing accessed on 02/08/2023 documented that she had diagnoses including wedge compression fracture of T11-T12 vertebra [broken vertebrae], subsequent encounter for fracture with routine healing; Essential (primary) hypertension [high blood pressure]; Unspecified displaced fracture of surgical neck of right humerus [broken arm], subsequent encounter for fracture with routine healing; Pain, unspecified; Chronic pain due to trauma; and Type 2 diabetes mellitus. <BR/>Record review of Resident #72's Physician's Orders List dated 02/08/2023 documented an order dated 01/26/2023 that she should be observed during all rounds made on every shift. <BR/>Record review of Resident #72's Nurses MAR for the month of January 2023 documented no observations were made on any of three shifts on 01/27, 01/29, or 01/31/2023. <BR/>Record review of Resident #72's Nurses MAR for the month of February 2023 documented no observations were made on any of three shifts on 02/01, 02/03, 02/05, or 02/07/2023. <BR/>In an interview on 02/09/23 at 02:03 PM, the ADON said she entered the physician's order to observe Resident #72 daily on all rounds incorrectly. She stated she entered the order to trigger observation of the resident every even-numbered day, (EDAYS) rather than daily. She said that she had the responsibility for auditing orders for newly admitted residents and was back-up for the nurses who also entered orders. She said that, as a result of her error, Resident #72 might have a change of condition that was delayed in detection. <BR/>The facility policy and procedure regarding documentation of physician's orders was requested on 02/10/2023 at 5:01 PM in a list of requests delivered to the DON but was not received prior to exit.

Based on observation, interview and record review the facility failed to ensure that residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and were posted in a place readily accessible to residents, and family members and legal representatives of residents for residents interviewed in a confidential group meeting. <BR/>The facility failed to have the survey manual readily accessible for the residents to view the survey. <BR/>This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey history. <BR/>Findings included: <BR/>During a confidential group meeting on 3/12/24 at 9:30 am, residents stated they did not know where or how to access the survey results in the facility. <BR/>During an observation on 03/13/24 at 9:00 am, survey results were in the lobby area. Survey results signs were posted in hallways near the nurse's station where it said it was in nurses' station and lobby area. A Code was needed to get out of the nurse's station to get to the lobby area.<BR/>During an observation and interview on 03/13/24 at 9:01 am, LVN B stated that the survey binder was in the lobby area, and it would not be readily accessible to residents because they would have to ask a staff member to open the door for them. LVN B stated he has not received any requests from residents and/or visitors to review the survey binder. <BR/>During an observation and interview on 03/13/24 at 9:11 am, LVN E looked for the survey results in the nurses' station and stated she could not find it. LVN E said the only survey results binder was in the lobby area. <BR/>During an observation and interview on 03/13/24 at 9:13 am, the DON stated the survey binder was in the lobby area. The DON did not answer if survey results were readily accessible to residents instead, she kept answering i guess we can move it (survey binder).<BR/>During an interview on 3/14/24 at 11:08 am, the Administrator stated the survey results binder was recently moved, and was not aware that it was not readily accessible. The Administrator stated he had not recently received complaints regarding the survey results not being readily accessible. <BR/>Record review of Displaying of Required Notices and Signage (not dated) read in part the facility will display required state and federal notices and signage that affect or concern employees, residents and/or visitors. The policy did not address the survey results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #72) of 24 residents reviewed for accuracy of resident's medical records. <BR/>A physician's order that the resident be observed on all rounds on every shift was entered into Resident #72's record incorrectly and documented that she was to be observed on all rounds every even- numbered day for Resident #72.<BR/>This failure could put residents at risk of having undetected changes in their conditions resulting in delayed response to resident's medical care needs. <BR/>Findings include:<BR/>Record Review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. <BR/>Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident was diagnosed with an acute compression fracture at T12 [a broken vertebrae]. <BR/>Record review of Resident #72's electronic diagnosis listing accessed on 02/08/2023 documented that she had diagnoses including wedge compression fracture of T11-T12 vertebra [broken vertebrae], subsequent encounter for fracture with routine healing; Essential (primary) hypertension [high blood pressure]; Unspecified displaced fracture of surgical neck of right humerus [broken arm], subsequent encounter for fracture with routine healing; Pain, unspecified; Chronic pain due to trauma; and Type 2 diabetes mellitus. <BR/>Record review of Resident #72's Physician's Orders List dated 02/08/2023 documented an order dated 01/26/2023 that she should be observed during all rounds made on every shift. <BR/>Record review of Resident #72's Nurses MAR for the month of January 2023 documented no observations were made on any of three shifts on 01/27, 01/29, or 01/31/2023. <BR/>Record review of Resident #72's Nurses MAR for the month of February 2023 documented no observations were made on any of three shifts on 02/01, 02/03, 02/05, or 02/07/2023. <BR/>In an interview on 02/09/23 at 02:03 PM, the ADON said she entered the physician's order to observe Resident #72 daily on all rounds incorrectly. She stated she entered the order to trigger observation of the resident every even-numbered day, (EDAYS) rather than daily. She said that she had the responsibility for auditing orders for newly admitted residents and was back-up for the nurses who also entered orders. She said that, as a result of her error, Resident #72 might have a change of condition that was delayed in detection. <BR/>The facility policy and procedure regarding documentation of physician's orders was requested on 02/10/2023 at 5:01 PM in a list of requests delivered to the DON but was not received prior to exit.

Based on observation, interview, and record review, the facility failed to post in a form and manner accessible to residents, resident representatives contact information including telephone numbers for Long Term Care Ombudsman program for residents interviewed in a confidential group meeting. <BR/>The facility failed to ensure the Ombudsman program information was posted in an area accessible for residents who required the use of wheelchair. <BR/>This failure placed residents at risk of not being informed about the Ombudsman Program. <BR/>Findings included:<BR/>During a confidential group meeting on 3/12/24 at 9:30 am, residents who were wheelchair bound stated they did not know where to find the local Ombudsman information.<BR/>During an observation and interview on 3/14/24 at 11:08 am, the Administrator stated the Ombudsman number was posted in the 100 hallway. The Administrator stated the Ombudsman number posting may have been too high for residents in wheelchairs to see. The Administrator stated he would move it down and stated the posting had been there for years and had not received complaints in the past. <BR/>Record review of Displaying of Required Notices and Signage (not dated) read in part the facility will display required state and federal notices and signage that affect or concern employees, residents and/or visitors. The policy did not address ready accessible to wheelchair bound resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that irregularities identified by reviews of resident's drug regimens by a licensed pharmacist were reported to the attending physician, the facility's medical director, and director of nursing, and that these reports were acted upon for 1 (Resident #40) of 14 residents whose drug regimens were reviewed. <BR/>The consulting pharmacist failed to act upon the dispensing pharmacist recommendations to administer prescribed medications according to manufacture specifications. <BR/>This failure placed residents at risk of not receiving medications according to manufacturer specifications placing them at increased risk of adverse drug effects and decline in their health status. <BR/>The findings included: <BR/>Resident #40<BR/>Observation on 03/13/24 3:20 PM during Medication Pass Observation with Medication Aide P stated she was going to administer Spironolactone 25 mg give one tablet by mouth bid. Pharmacy Label documented: Take with food or milk. Medication was administered at 4:11 PM. <BR/>-Review of Medication Blister Packet Pharmacy Label documented: Spironolactone 25 mg give one tablet by mouth bid. Take with food. <BR/>Review of Face Sheet dated 03/14/24 at 4:34 PM for Resident #40 revealed admit date : [DATE]; re-admitted [DATE]. <BR/>Review of History & Physical dated 05/24/23 for Resident #40 revealed [AGE] year-old female with diagnoses of hypertension, dementia. <BR/>Review of Annual MDS dated [DATE] for Resident #40 revealed Active Diagnoses: heart failure, hypertension. <BR/>Record Review 03/14/24 of Physician Orders dated March 2024 for Resident #40 revealed Spironolactone 25 mg give one tablet by mouth bid. <BR/>Record Review 03/14/24 of Medication Administration Record dated March 2024 for Resident #40 revealed Spironolactone 25 mg give one tablet by mouth bid. <BR/>Review of Consultant Pharmacist's Medication Regime Review: Listing of Residents Reviewed with No Recommendations dated 12/01/23 and 12/28/23 included Resident #40. <BR/>Review of Consultant Pharmacist's Medication Regime Review for Resident #40 dated 01/01/2024 and 01/29/24 did not document any recommendations to take Spironolactone with food. <BR/>Review of Consultant Pharmacist's Medication Regime Review: Listing of Residents Reviewed with No Recommendations dated 02/1/24 and 02/26/24 included Resident #40. <BR/>Review of Pharmaceutical Services Contract dated 02/01/24 revealed: During each month, the Pharmacy shall review computer generated Order Sheet, Medication Administration Records for accuracy.

Based on the observations, interviews, and record review the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1, & #2) of 2 dumpsters reviewed for food safety requirements. <BR/>-The facility failed to keep one of two plastic lids covered on Front Load Dumpster, making trash placed in dumpster visible. <BR/>- The facility failed to keep the side metal door cover close on Side Load Dumpster, making trash placed in dumpster visible. <BR/>This failure could place residents at risk of unsanitary conditions and risk for exposure to germs and diseases carried by insects and rodents. <BR/>Findings included: <BR/>Observation on 03/14/24 at 5:39 PM revealed Front Load Dumpster #1, half uncovered; there were cardboard boxes and plastic bags full of waste in dumpster; Side load dumpster was partially opened. <BR/>Interview on 03/14/24 at 5:40 with the Maintenance Director revealed front door dumpster was used by the nursing department and side load dumpster was used by dietary staff. He stated that dumpsters should always be kept covered to prevent insects and rodents from getting into the dumpsters. <BR/>Review of facility's policy on Garbage Receptacles revised on June 1, 2019, provided by Maintenance Director on 03/14/24 revealed: Policy: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Outdoor receptacles: Outdoor storage surface for refuse shall be constructed of nonabsorbent material such as concrete or asphalt and shall be smooth, durable, and sloped to drain. It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insects and rodents with doors/lids kept closed and no waste outside of the receptacle. All shall be maintained in good repair. Refuse shall be removed from the premises at a frequency that will minimize the development of objectionable odors and attract insects and rodents.