MORNINGSIDE MANOR

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. The right to participate in establishing the with the resident and the resident's representative for 3 of 5 residents (Resident #8, Resident #48, and Resident #69) reviewed for Comprehensive Care Plans in that: The facility failed to ensure Resident #8, Resident#48, and Resident #69 or the resident's representative were invited to participate in the residents' care plan meeting. This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their care. Findings include: Record review of Resident # 8's face sheet dated 08/07/2025, revealed a [AGE] year-old female, admitted to facility on 05/19/2023. Her diagnoses included: Unspecified Injury of Head, Subsequent Encounter (a healthcare visit that occurs after the initial active treatment of a condition or injury; Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar - glucose); Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause). Record review of Resident #8's file revealed that resident participated in a care plan meeting with the facility team on 08/26/2025 at 1:56 PM. There was a care plan documented on 05/22/2025 with no care plan meeting documented as held with resident. The last previous care plan meetings held with resident were documented 09/12/2024. On 08/06/2025 at 11:16 AM, an interview with Resident #8 revealed she has attended a care plan meeting with the facility team but could not provide a specific date. Resident #8 does not wish for her nieces to attend her care plan meetings. Resident #8 is her own responsible party. Record review of Resident #48's face sheet dated 08/07/2025 revealed an [AGE] year-old male, admitted to facility on 07/16/2025. His diagnoses included: Wedge compression fracture of second lumbar vertebra, subsequent encounter with routine healing (a type of spinal fracture where the front part of the vertebra collapses, take a wedge shape); Type 2 diabetes mellitus with chronic kidney disease (a serious complication that develops over time when blood sugars and blood pressure are not well controlled); Acute Kidney Disease (a condition in which the kidneys suddenly can't filter waste from the blood). Record review of Resident #48's file revealed documentation noted in SW notes that family was contacted to attempt to have a care plan meeting on 07/22/2025. No documentation a care plan meeting held with resident or family on 07/22/2025. On 08/06/2025 at 12:10 PM, an interview with Resident #48 revealed he does not remember if he had a care plan meeting with the facility team. It was noted on the resident's face sheet that he was his own responsible party, and he had two brothers. Record review of Resident #69's face sheet dated 08/07/2025 revealed an [AGE] year-old male readmitted to the facility on [DATE]. Resident was admitted for skilled services on 07/25/2023 before discharging home. His diagnoses included: Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter (a global ischemia, resulting from a lack of perfusion of pressure during aneurysmal rupture: a brain aneurysm that bursts); Epilepsy, unspecified, not intractable, without status epilepticus (a group of disorders marked by problems in normal functioning of the brain); Chronic Atrial Fibrillation, Unspecified (an irregular and often very rapid heart rhythm). Record review of Resident #69's file revealed no documentation for initial care plan meeting with resident or resident representation. It was noted on Resident #69's face sheet that he was his own responsible party and has two sons and two daughters. On 08/06/2025 at 12:47 PM, an interview with Resident #69's family member revealed he believed that there has been a meeting in the past when Resident #69 was at facility last year. Family member stated the facility keeps the family well informed. On 08/07/2025 at 10:20 AM, an interview with the SW revealed that she had been employed at the facility as of 11/01/2024. The SW revealed that she tries to keep up with the documentation when care plan meetings are held. The SW does not use the Family/Resident Conference Form located in the facility's assessment task. SW stated she was not trained to use that form. The SW revealed she documented in the SW progress notes. The process the SW used to invite the residents and family members to the care plan meetings was by calling them or by emails. She personally invited the residents. The goals were to ensure that the residents or their representatives was invited to participate in the care plan meetings and documentation is completed during the meetings. Record review of the facility's Comprehensive Care Plans (revised November 2010) revealed in part, Our facility's Care Planning/Interdisciplinary Team in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had a right to secure and confidential personal and medical records for 6 (Residents #7, #9, #45, #61, #69, & #74) of 7 residents reviewed for privacy and confidentiality The facility failed to ensure the privacy and confidentiality of resident's clinical records that were not left on top of a treatment cart face up in the hallway unattended from 11:30 AM to 11:57 AM, for Resident #7, #9, #45, #61, #69, & #74 on 08/7/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy and confidentiality. Findings included: Record review of Resident #7's face sheet, dated 8/7/25, revealed a [AGE] year-old male with an initial admission of 09/14/23 and readmitted to the facility on [DATE]. His primary diagnosis was Altered mental Status, other diagnosis included Methicillin Resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere (MRSA is a type of bacteria that many antibiotics don't work on) and encounter for surgical aftercare following surgery on the genitourinary system (surgery on the urinary system). Record review of Resident #9's face sheet, dated 8/7/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe) and Chronic Peripheral Venous Insufficiency (a condition that occurs when veins in the legs or arms have difficulty returning blood to the heart). Record review of Resident #45's face sheet, dated 8/7/25, revealed an [AGE] year-old male admitted on [DATE] with a diagnoses of primary osteoarthritis right shoulder (this is a type of arthritis that occurs when flexible tissue at the ends of bones wear down) and non-pressure chronic ulcer of right heal and midfoot with other specified severity, pressure ulcer of right heal unstageable, and benign neoplasm of the parotid gland (cancer of the parathyroid gland located in the neck). Record review of Resident #61's face sheet, dated 8/7/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Vascular dementia (this is brain damage that is caused by multiple strokes that causes memory loss) and Type 2 Diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels). Record review of Resident #69's face sheet, dated 8/7/25, revealed an [AGE] year-old male with an initial admission of 7/25/23 and readmitted [DATE] with a primary diagnosis of traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter (head injury resulting in consciousness of 30 minutes or less). Record review of Resident #74's face sheet, dated 8/7/25, revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses of congestive heart failure and type 2 diabetes. Continuous observation on from 11:30 AM to 11:57 AM on 08/07/25 revealed 7 pages of residents' medical records spread on top of the treatment cart in the unit 5 hallway. The medical records were titled [facility name] dated 08/7/25. The documents had 6 columns, with handwritten notes in red ink as follows; first column had names of residents, second column had location of wound, third column had the stage of wound, the fourth was blank, the fifth had the treatments, and the sixth had the frequency. The documents were visible, face up, near resident's rooms and unattended on top of the treatment cart by the wall in unit 5 hallway with Residents # 7, #9, #45, #61, #69, & #74's medical records displayed. In an interview with the Treatment PA Assistant on 08/07/25 at 11:54 AM, it was revealed herself and a team of other NPs were in the facility doing wound treatments. She stated, oops we have been dinged for HIPPA, as she gathered the papers with the resident's medical records from the top of the treatment cart. When asked by Surveyor about the risk of leaving residents information out, Treatment PA did not state the risk of leaving residents information unattended and accessible to unauthorized persons. In an interview with the DON on 08/07/25 at 1:16 PM, she stated all medical persons are trained on HIPAA to protect resident information and privacy. She said every staff member is trained on HIPAA. She said she expected the contracted treatment team members to flip over the papers with residents' information, or best practice was to take document with them. She said she expected everyone to protect resident's records. She said the risk was access of resident's information to unauthorized persons. Interview with the ADM on 08/07/25 at 3:49 PM, she stated she expected all staff to handle clinical records with confidentiality. She said she expected staff to close, turn off, or lock computer screen when not in use. She said all staff were taught to protect resident information when they were hired. She said if documents were on paper, she expected staff to take it with them and to secure it. She said it was the staff's responsibility to make sure documents were secure. The ADM said that she had reached out to corporate office to request that the contracted treatment company not return to the facility. The ADM said risk of leaving residents information exposed was a breach of resident's privacy. Record review of the facility's policy titled Confidentiality of Information and Personal Privacy revised 12/15/ 2017 revealed: .the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #8) of 5 residents reviewed for quality of care. 1. The facility failed to accurately assess Resident #8's bowel and bladder status. 2. The facility failed to accurately access Resident #8's ability to voice her bowel and bladder needs. These failures could place resident with having inaccurate care plans and inappropriate identification of care needs. Findings included: Review of Resident #8's annual MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Unspecified Injury of Head, Subsequent Encounter (a healthcare visit that occurs after the initial active treatment of a condition or injury; Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar - glucose); Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause). She had adequate hearing, clear speech, was always understood and had adequate vision with glasses. Her BIMS score was 15, which indicated memory fully intact. She did not have any issues with inattention, disorganized thinking or altered levels of consciousness. Her mood assessment reflected no issues. She had no delusions, hallucinations or psychosis. She was noted to have verbal behaviors towards others and wandering during the assessment period, but no physical behaviors directed towards others. She required limited assistance for bed mobility, locomotion, dressing, eating, toilet use and personal hygiene. She had no range of motion impairments and used a walker and wheelchair for mobility. She needed partial/moderate assistance with tub/shower transfers. It was noted in the MDS she was frequently incontinent with bladder and occasionally incontinent of bowel. No toileting program had not been used. The DON signed as the RN assessment coordinator verifying assessment as complete on 06/08/2025. Review of Resident #8's Bowel and Bladder assessment dated [DATE] revealed Resident #8 was continent of both bowel and bladder. Does not require a toileting plan. Review of Bowel and Bladder assessment dated [DATE] revealed Resident #8 was incontinent of bladder and continent of bowel. Does not require a toileting plan. Review of Resident #8's Plan of Care Tasks History dated 07/15/2025 through 08/07/2025 revealed Resident #8 was continent of bowel and bladder with no episodes of incontinence. On 08/06/2025 at 1:10 PM, interview with DON revealed that Resident #8 is not incontinent of bowel and bladder. Informed DON that Resident#8's MDS noted that resident is frequently incontinent of bladder and had occasional episodes of bowel incontinence. DON stated she will inform the MDS Coordinator to correct the mistake. On 08/07/2025 at 2:47 PM, interview with MDS Coordinator revealed he had worked at the facility since 2014. He works at both buildings. Responsible for all the MDS for building. Completes MDS almost daily. Monday through Friday. The process is to interview residents on paper in person and document information in the MDS program. He evaluated the resident in their room. Completed the MDS within the 14-day window. Every 90 days and if there had been a change in condition and end up in the hospital or a fall. Completed an annual MDS as well. Evaluating vision and hearing the SW completes, looks at progress notes such as shortness of breath when their bed is lowered, assess their skin for any breakdown. When a resident discharged home and return a new MDS is completed. A discharge MDS is completed when they discharged home. If a resident is discharged more than 72 hours from the facility and must return to facility a new MDS will have to be completed. Resident #8 has been labeled as having issues with bowel and bladder incontinence according to the POC. If these questions are answered yes, it will automatically trigger the MDS that resident has a bowel and bladder incontinence problem. The DON revealed resident does not have incontinence. The daily task notes resident is continent. He will go speak with the nurses if he has a question concerning discrepancies with the answer's r/t incontinence. On 08/07/2025 at 4:30 PM, interview with the ADM revealed that the MDS Coordinator completed all the MDS Assessments. The ADM's expectation is that the MDS are correct according to the assessment completed and that he is communicating with nursing staff to ensure accuracy of the assessments. No policy for MDS Accuracy was provided. Facility follows the RAI manual. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1 dated October 2019 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 16 (#6 , #3, #38, #56, #57, #120) in that:<BR/>1. Resident #6 received honey consistency liquids instead of nectar thick liquids.<BR/>2. Resident #3 did not have her 1/4 bed [NAME] in her care plan. <BR/>2. Resident #38 did not have her indwelling catheter in her care plan. <BR/>3. Resident #57 did not have her 1/4 bed rails in her care plan.<BR/>4. Resident #120 did not have her 1/4 bed rails in her care plan.<BR/>5. Resident #56 did not have his dentures mentioned in his care plan. <BR/>The facility failed to ensure Resident #6's care plan was comprehensive and updated to reflect Resident #2's doctor's order of needing honey consistency liquids instead of nectar thick liquids. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. <BR/>The Findings were:<BR/>Record review of Resident #6's admission record dated 6/7/2024 revealed a male was admitted on [DATE] with diagnoses that included dementia (loss of thinking, remembering, and reasoning skills), personal history of traumatic brain injury, dysphagia (a condition with difficulty in swallowing food or liquid), cognitive communication deficit, and muscle wasting and atrophy. <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected Resident #6's BIMS score was 99, indicating resident was not able to complete the interview with short term and long-term memory problems and severely impaired cognitive skills for daily decision making. It further reflected Resident #6 was severely impaired-never/rarely made decisions. The MDS also indicated Resident #6 was on a mechanically altered diet, requiring change in texture of food or liquids. <BR/>Record review of Resident #6's care plan, accessed 05/23/24, reflected [Resident #2] has potential nutrition problem r/t mechanically altered diet, revised on 03/06/2024, with an intervention of Administer Nectar thick liquid as ordered., initiated 11/30/2021 with no revision date.<BR/>Record Review of Resident #6's Doctor's diet orders reflected honey consistency liquids since 08/30/22.<BR/>1. Record review of Resident #3's admission Record dated 6/7/2024 revealed she was admitted on [DATE], age [AGE] with diagnoses of polyneuropathy, heart failure, cognitive communication deficit, and dementia.<BR/>Record review of Resident #3's consolidated physician's order 5/16/2023-TRANSFER ASSISTIVE DEVICE: X2, 1/4 rails up as per Dr's order while in bed, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury.<BR/>Record review of Resident #3's Quarterly MDS dated [DATE] revealed she had a BIMs of 2/15 (severely cognitively impaired), she used a wheelchair to mobilize, she was maximum assistance with transfers. <BR/>Record review of Resident #3's care plan dated 5/6/2024 revealed no care plan to address the 1/4 side rails. <BR/>Record review of Resident #3's Transfer Assist Device Assessment form dated 5/16/2023 revealed a recommendation of bilateral 1/4 [NAME].<BR/>Interview on 6/6/2024 at 4:10 PM LVN Q stated she just changed her bed on Monday of this week. <BR/>2. Record review of Resident #38's admission Record dated 6/7/2024, age [AGE] revealed she was admitted on [DATE] with diagnoses of altered mental status, acute kidney failure, cognitive communications deficit, dementia and retentions of urine. <BR/>Record review of #38's consolidated physician orders for June 2024 revealed she had an order for indwelling catheter with diagnoses of urine retention. <BR/>Record review of Resident #38's Quarterly MDS dated [DATE] revealed her BIMS was 99, with short/long-term memory, she used a wheelchair to mobilize, she was dependent with toileting, and had an indwelling catheter. <BR/>Record review of Resident #38's care plan dated 3/28/2024 revealed she had an indwelling catheter for neurogenic bladder but had no interventions. <BR/>Observation on 6/5/2024 at 11:40 AM revealed Resident # 38 was in the dining room eating by herself. The indwelling catheter bag was under the wheelchair and had privacy bag. <BR/>Interview on 6/6/2024 at 6:18 PM with the DON revealed Resident #38 did not have interventions for her indwelling catheter. The DON stated the nursing department, nurse manager (DON, ADON) did the care plans for nursing section in resident care areas. The DON stated the resident interventions were to monitor for quinks, care, size, nursing staff would benefit from seeing care plan. The DON stated nurses look at the care plan for catheters. <BR/>3. Record review of Resident #57's admission Record dated 6/7/2024, age [AGE] revealed he had a diagnosis of diabetes II, need for assistance with personal care, and history of falls. <BR/>Record review of Resident #57's Quarterly MDS dated [DATE] revealed her BIMS score was 6/15 (severe cognitive impairment), used a manual wheelchair, and max assist with transfers. <BR/>Record review of Resident #57's care plan dated 6/3/2024 revealed no care plan for 1/4 bed rails. <BR/>Record review of Resident #57's Transfer Assist Device Assessment form dated 5/17/2023 revealed a recommendation of bilateral 1/4 [NAME].<BR/>Observation on 6/5/2024 at 11:30 AM revealed Resident #57 had &frac14; hand [NAME] in her bed. Resident # 57 was not in the room.<BR/>Observation on 6/5/2024 at 3:34 PM revealed two &frac14; handrails on Resident #57's bed. Observation of Resident #57 w as sitting in her wheelchair. <BR/>4. Record review of Resident #120's admission Record dated 6/7/2024 revealed she was admitted on [DATE], age [AGE] with a diagnoses of end stage renal disease, diabetes II, abnormal gait/mobility and heart failure. <BR/>Record review of Resident #120's consolidated physician orders for June 2024 revealed an order for 5/20/2024-TRANSFER ASSISTIVE DEVICE: X2, 1/4 rails up as per physician order while in bed, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury.<BR/>Record review of Resident #120's admission MDS dated [DATE] revealed she was BIMS 15/15 (cognitively intact), mobilized in wheelchair, impairment on one side of lower extremity, and roll left and right required partial/moderate assistance. <BR/>Record review of Resident #120's care plan dated 5/13/2024 revealed no care plan for 1/4 bed rails.<BR/>Record review of Resident #120's Transfer Assist Device assessment dated [DATE] recommendation left and right &frac14; side rails.<BR/>Observation on 6/4/20/24 at 11:29 AM revealed Resident #120 was in bed and had two 1/4 side rails on each side of her bed. <BR/>Interview on 6/7/2024 at 11:50 AM with the ADM stated the &frac14; bed rails risk would be staff does not know the rails were in place. No other response. <BR/>5. Record review of Resident #56's admission Record dated 6/9/2024 revealed he was admitted on [DATE], age [AGE] with diagnoses of alcoholic cirrhosis of liver (impaired liver function caused by formation of scar tissue) and major depressive disorder.<BR/>Record review of Resident #56's Quarterly MDS dated [DATE] revealed he had a BIMS of 8/15 (moderately cognitively impaired) and nothing noted in Section L- Oral/Dental Status. <BR/>Record review of Resident #56's care plan, undated, revealed no mention of dentures. <BR/>During an interview on 06/06/24 at 02:00 PM, Resident #56's RP revealed Resident #56 had been going to the dentist recently to get his dentures fixed. <BR/>During an interview on 06/06/24 at 01:47 PM, Resident #56's dentist revealed she was seeing Resident #56 to repair his dentures. <BR/>During an interview on 06/07/24 at 12:13 PM, the DON revealed dentures should be care planned so the CNAs know what to do for the resident's care when it comes to oral care. <BR/>During an interview on 05/24/24 at 11:19 AM, Speech Therapist C (ST C) revealed if a resident was determined to need honey thickened liquids and received nectar thickened liquids there could be a chance of aspiration where a solid or liquids could get into the airways. She further revealed this could lead to aspiration pneumonia which could cause a resident to be hospitalized . She revealed if a resident was more compromised there could be more severe health consequences, including death. ST C revealed there had been times where a resident may refuse a liquid if they knew they could not tolerate it, which could cause dehydration. She further revealed she had not heard of a resident at this facility complaining about this scenario, however, you may not be able to know this if a resident was nonverbal. <BR/>During an interview on 05/24/24 at 03:23 PM, the RD revealed the facility was giving resident honey thickened liquids. She further revealed CNAs were providing liquids to Resident #2 in between meals but would have to ask the DON how the CNAs knew what liquids to give Resident #2. <BR/>During an interview on 05/24/24 03:54 PM, MDS nurse P and MDS nurse Q stated CNAs followed tasks that were developed from care plans. MDS nurse P confirmed Resident #2's care plan reflected an intervention of Administer Nectar thickened liquid as ordered. She further confirmed this would turn into a task on their POC dashboard for the CNAs to follow. MDS nurse Q confirmed Resident #2's POC Shift Dashboard record, accessed on 05/24/24 at 11:01 AM, revealed there was a directive to give Resident #2 Nectar Thick Liquids. MDS nurse P and MDS nurse Q revealed if resident was receiving Nectar thickened liquids and needed honey thickened liquids, this could cause aspiration. <BR/>Left VM for doctor and NP on 05/24/24 at 3:20 PM. <BR/>During an interview on 5/30/24 at 02:33 PM, the administrator and the DON revealed nursing staff received liquids from the kitchen, which would be honey thickened liquids. If the kitchen did not give these liquids, the DON would get involved and ensure the correct liquid was given. <BR/>Record review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, revised March 2022, reflected, 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. <BR/>Record review of the facility policy dated 4/6/2009 revealed The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care of services to the resident. Record Review of POC Shift Dashboard and interview with CNA D, dated 05/24/24 at 11:01 AM, reflected Resident #2 received NUTRITION- Fluids: NECTAR THICK LIQUIDS QShift. CNA D revealed she was following this directive and giving Resident #2 Nectar thickened liquids. <BR/>There were no observations of Resident #2 receiving nectar thickened liquids. Meals and snacks included honey thickened liquids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for 1 (Resident #12) of 7 resident reviewed for enteral tube feeding, in that: The facility failed to assess, obtain physician order, care plan, and obtain consent for Resident #12 to self-administer her bolus feedings via the g-tube two times a day. This failure could place residents with G-tubes at risk of needs not met and a decline in resident's health. Findings included: Record review of Resident #12's face sheet dated 8/14/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), type 2 diabetes, breast cancer, neoplasm of uncertain behavior of pharynx (throat cancer), and difficulty swallowing. Review of Resident #12's quarterly MDS dated [DATE] reflected Resident #12 had a BIMS of 15, indicating cognitive intact. She makes self-understood, and she understands others. The document reflected Resident #12 had a feeding tube and received 26-50% of her nutrition and 500 cc/day or less fluid through the feeding tube. Record review of Resident #12's physician orders for August 2025 reflected: - MIC-KEY G-TUBE 20FR 3.5CM, 5CC BALLOON LAST CHANGE 9/25/24- active 09/25/24. - Enteral Feed Protocol: Hydration Flush every shift Flush enteral tube with 90____ mL of water before and after feeding for hydration. Total volume of water flush _180____ mL/24hr- Active 11/18/22. - Enteral Feed Protocol: Placement every shift Check tube for proper placement by auscultation and inspect stomach contents prior to: - Each Feeding - Flush - Medication administration May obtain x-ray for placement of feeding tube if indicated- Active 11/18/22. - Enteral Feed Protocol: Residual every shift Check for residual by aspirating stomach contents Q shift, if more than 100mL of stomach contents is aspirated, return the contents to the stomach, hold feeding and notify the physician for further instruction- Active 11/17/22. - Residents with PO diets may use house available supplement whenever Ensure or other name brand nutritional supplement is ordered- Active 11/17/22. -Residents with PO diet may have a Regular Diet according to texture modification for monthly activities and holidays- Active 11/17/22. - [Resident#12] may take medications PO or by PEG-tube depending on how she feels regarding her ability to swallow due to her history of throat cancer. every shift related to neoplasm of uncertain behavior of pharynx- Active 12/27/22. -Enteral Feed Protocol: Administration Set and Supplies every night shift Change administration set (spike, cap, and bag) daily on night shift. Date and label with each change. Change syringe/irrigation set daily on night shift- Active 11/18/22. - Enteral Feed Protocol: Cleanse Stoma Site everyday shift Cleanse stoma site with NS, pat dry and apply sterile split sponge if needed Q shift and PRN- Active 11/18/22. - Enteral Feed Order two times a day ([brand name] 1.2) Formula to be administered via bolus _2___ times per day for a total of 474___ cc's and __711_ calories in 24 hours- Active 11/19/25. - Special Diet: REGULAR diet Consistency: REGULAR texture, Liquid: THIN consistency. -The physician orders did not reflect self-administration of eternal feeding by Resident. Record review of Resident #12's care plan initiated 02/7/23 revealed a focus: I have bolus enteral feedings r/t Dysphagia and Chronic fatigue syndrome and have a Regular diet to eat by mouth as I tolerate, family signed wavier.Goal: will receive diet as ordered and will maintain weight over next 90 days Target Date: 05/30/2025Interventions: Provide bolus feeding and flushes as ordered. Observe for nausea/vomiting and report to MD. -The care plan did not reflect Resident #12 could self-administer her own g-tube bolus feeding two times a day via the g-tube. Record review of quarterly nutrition assessment completed on 05/28/25 by Dietitian did not reflect any weight loss concerns. It reflected that Resident #12 liked to do things herself, and her weight was improving with a goal weight of 148 lbs. Record Review of Resident #12's monthly weights reflected no concerns.-8/5/25-120.8lbs-7/10/25- 120.2lbs-5/18/25- 119.5lbs Record review of assessments on 08/5/25, did not reflect a completed self- administration assessment for g-tube bolus feeding two times a day via the g-tube. Record review of consent and waiver did not reflect self- administration consent or waiver for g-tube bolus feeding two times a day via the g-tube. In an observation and interview with Resident #12 on 08/05/25 at 1:30 PM, revealed Resident #12 in her room. She stated she had not eaten lunch, because she did not like the food. She said she was going to do her bolus feeding via her g-tube. She stated she had been trained many years before coming to the facility. She stated she was very comfortable doing her own feeding. No concerns during self-administration of bolus feeding and a new gauze dressing was applied to the MIC-KEY stoma and attachment cleaned and stored after administration of bolus. In an interview with the dietician on 08/05/25 at 2:33 PM, revealed Resident #12 was monitored for weight loss monthly. She said nursing was responsible for assessing and care planning for Resident #12's g-tube self-administration. She said it was important to assess the resident so that you can know that they can safely do the feeding. The Dietitian said she had no input on the care plan and assessment, but she did note on the quarterly nutrition assessment that Resident #12 liked to do things by herself. She said she did not see any risk to the resident self-administering the feeds because she was maintaining and even gaining weight. In an interview at 08/06/25 at 3:21 PM, LVN C said she was assigned to care for Resident #12, and she used to try and do the feeding for Resident #12 when she first moved to the facility but Resident #12 would yell and scream at her. She said Resident #12 does not like anyone to touch her feeding tube. LVN C stated she has monitored Resident #12 as she did her own feeding, and she had no concerns with the procedure. LVN C stated she did not do an assessment for Resident #12 to self-feed, and she did not do the care plans for the residents because it was not in her scope of practice. She said Resident #12 should not be in the skilled facility because she did everything for herself and refused help from the staff. She said Resident #12 is very independent and very mobile. She said that the nurses made sure that all the supplies are changed daily such as the syringe and they made sure that she has the formula. LVN C stated that Resident #12 was up the whole night and slept during the day and she did not want to be woken up. LVN C said that they monitor for infection as well by discarding any open or left over formula and making sure she has cleaning solution for the MIC-KEY attachment. LVN C said there was no risk to Resident #12 self-administering because she's been doing it long before she came here. In an interview on 08/07/25 at 12:06 PM, the ADON B said Resident #12 should be in independent living because she does everything herself. ADON B stated Resident #12 did not like anyone doing her feedings. She said they were monitoring Resident #12's weight and that the G-tube was only used for supplemental when resident had poor oral intake. ADON B said the expectation was that a resident that self-administer got an assessment before they were allowed to self-administer. She said she thought it had already been done prior to her working at the facility. ADON B stated she believed Resident #12 was care planned to self-administer feedings. In an interview with the DON on 08/07/25 at 1:16 PM, she said she went and observed Resident #12 do her feeding today and she had no concerns. She said Resident #12 was very independent and before she came to the facility, she already had the g-tube and was feeding herself. The DON said that she would reach out to the physician and obtain a physician order to self-administer formular via g-tube. She said Resident #12 had a care plan to self-administer but it may have resolved. She said she did not know who had resolved that care plan. The DON said that the ADON had completed a self-administration assessment on of 08/6/25. She said she was responsible for making sure that all care areas were care planned but the nurse could do assessments and get physician orders. She said that if there were any concerns then they would discuss the issues in the morning meetings. She said the expectation was that the nurses would supervise the residents during feeding however for residents that could do it themselves they had the right to do it themselves. She said there was no risk to Resident #12 because she had a high BIMS and could safely self-administer the feeding. The DON said that she was not aware that they needed a consent to self-administer bolus feedings. Record review of a medication self-administration evaluation completed on 08/06/25 for Resident #12 reflected no concerns for self-administration evaluation. Record review of facility Policy Self-Administrating of Drugs, revision date April 2009 reflected: As part of their overall evaluation, the staff and the Attending/On Call Physician will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. In addition to general evaluation of decision-making capacity, the staff and Attending/On Call Physician will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels, b. Comprehension of the purpose and proper dosage and administration time for his or her medications, c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them, and d. Ability to recognize risks and major adverse consequences of his or her medications. Record review of facility Policy Enteral Nutrition revised May 2009 reflected in part 1. The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 3. A Dietitian will conduct a full nutritional assessment within current initial assessment timeframes. Current Standards of Practice, facility formulary, and facility policies will be the basis for the assessment and recommendations. The Dietitian will confirm or modify initial orders based on the complete nutritional assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 1 of 7 residents (Resident #170) reviewed for pharmacy services. <BR/>LVN U dispensed Resident #170's medications (11 pills) and stored them in a small pill cup in the medication cart with the intention of administering the medications at a later time and continued to dispense and administer medications for other residents.<BR/>This failure could place residents at risk for harm by medication administration errors.<BR/>The findings included:<BR/>A record review of Resident #170's admission record dated 06/07/2024 revealed an admission date of 05/24/2024 with diagnoses which included hypertension (high blood pressure), diabetes type II (a condition where the body's cells cannot readily accept sugars from the blood), hyperlipidemia (a condition where the blood too much fat (lipids)).<BR/>A record review of Resident #170's admission MDS assessment dated [DATE] revealed Resident #170 was a [AGE] year-old male assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. <BR/>A record review of Resident #170's physicians' orders dated 06/07/2024, revealed Resident #170 was prescribed the following medications to be administered daily at 08:00 AM: <BR/>1. <BR/>Amlodipine 5mg (used to trat high blood pressure).<BR/>2. <BR/>Aspirin 81mg (used to prevent heart attacks).<BR/>3. <BR/>Fish oil capsule 1000mg (used for dietary supplement).<BR/>4. <BR/>Lisinopril 40mg (used to treat high blood pressure).<BR/>5. <BR/>Multivitamin (used for a dietary supplement).<BR/>6. <BR/>Sertraline 100mg (used to treat depression).<BR/>7. <BR/>Vitamin C (used as a dietary supplement).<BR/>8. <BR/>Donepezil 10mg (used to treat dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities)).<BR/>9. <BR/>Gabapentin 600mg (used to treat nerve pain).<BR/>10. <BR/>Hydralazine 50mg (used to treat high blood pressure).<BR/>11. <BR/>Sennosides-Docusate Sodium 8.6-50mg (used to treat constipation). <BR/>During an observation and interview on 06/07/2024 at 08:12 AM revealed LVN U attended her medication cart and was preparing medications for another Resident. Observations of LVN U opening drawers of the medication cart revealed the top drawer had a small clear plastic cup with pills. LVN U stated the cup contained Resident #170's morning medications. LVN U stated she had dispensed Resident #170's medications and attempted to administer Resident #170 his medications and was unable to do so due to Resident #170 was not available and was in the shower. LVN U stated she had stored the loose pills in their pill cup for a later attempt to administer. LVN U stated she then proceeded to dispense and administer medications to other residents. <BR/>During an observation and interview on 06/07/2024 at 08:20 AM revealed the DON approach the medication cart and inquire of LVN U here status on medication administration and the surveyor reported to the DON that LVN U had Resident #170's medications in a pill cup. The DON inquired of LVN U the nature of the pills in the cup and LVN U reported the pills were dispensed for Resident #170 however Resident #170 was in the shower. The DON stated LVN U should have disposed the medications and would need to re-dispense the medications when Resident #170 became available. <BR/>During an interview on 06/07/2024 at 0859 AM the DON stated medications should be dispensed and administered prior to dispensing and administering medications for the next Resident. <BR/>A record review of the facility's policy titled Storage of Medications dated April 2009, revealed, Policy Interpretation and Implementation: Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they were received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner <BR/>A record review of the American Association of Post-Acute Care Nursing's website: Resident Safety and Nurse Workarounds - AAPACN accessed 06/11/2024, titled, Resident Safety and Nurse Workarounds, revealed, Nurse workarounds defined .Nurse workarounds are actions that nurses take to deliver care and accomplish the work assigned to them, despite those actions' deviating from protocol and policy .workarounds occur in SNFs (Skilled Nursing Facility's) .For example, a nurse who pops medication from a multi-dose card and pre-pours pills or places them in medication cups to be administered later, for one or more residents, does not intend to cause harm. Nurses do this so they can dispense medications quickly, saving precious time and allowing them to move on to the next task they must complete. But the intended time-saver exposes patients to the risk of harm. While an error probably will not occur every time a workaround is used, when one does occur, the harm is likely to be significant

Based on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 5 medication carts in that: Two insulin pens were not labeled with an open date in Unit 5 nurse med cart.Two insulin pens were expired in Unit 5 nurse med cart. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.Findings included: Observation of Unit 5 med cart on 8/6/2025 at 9:06am revealed there were 2 insulin pens for Resident #4 and Resident #74 that did not have an open date on them. There were also 1 insulin pen for Resident #74 that was opened on 5/23/2025 and 1 insulin pen for Resident #22 that was opened on 6.24 In an interview with LVN A on 8/6/2025 at 9:07am, he stated that insulin pens should be labeled with an open date and once opened, the insulin pen should be discarded after 28 days. He admitted that he forgot to check his carts for expired insulin pens and label them accordingly. In an interview with the DON on 8/7/2025 at 10:50am, she stated that all nurses were supposed to audit med carts weekly. DON performed spot checks occasionally on med carts. She stated the following were to be done during med cart audit: checking for expired medications, discontinuing medications that are not in use, checking for any pens, vials that needed to be dated and labeled, making sure the cart is clean and organized. She stated that the risk of giving residents expired medication included decreased medication potency, adverse effects, and if the medications were insulin, the risks included hyperglycemia or hypoglycemia. In a review of facility's undated medication administration checklist, called Mock survey medication pass,, revealed for injectable medications, nurses were to date vials when opened (i.e., insulin for 28 days). Review of the facility's Labeling of medication containers, dated April 2009, revealed that one of the requirements for individual medication container labeling included .the date that the medication was dispensed. In an observation on 08/07/25 at 11:30 AM and at 11:57 AM, a Treatment cart was unlocked and unattended with the lock mechanism out (indicating it was unlocked) in Unit 5 hallway, against the wall facing outwards to the hallway. Residents and staff were walking by the unlocked Treatment Cart. The facility staff attending to Treatment cart were inside a resident's room and could not see the cart. It was out of view. In an interview with the Treatment PA on 08/07/25 at 11:57 AM, it was revealed herself and a team of other NPs were in the facility doing wound treatments and some were in training, and they had left the Treatment cart unlocked. She did not state the risk of leaving the Treatment cart unlocked, unattended and out of view. Interview on 08/07/25 at 12:06 PM with ADON B revealed, the facility had a contract Treatment NP and her assistant that did treatments for the facility. She said the expectation was the Treatment cart should be locked when staff was not directly working with the cart. She stated the expectation was that even the contracted staff would follow policy and procedures and lock and secure the medication cart when not in use. She said all nursing staff were responsible for securing medications when not in use. She said the potential risk was a resident may get into the cart and grab something. She said it was a safety concern. In an interview with the DON on 08/07/25 at 1:16 PM, she revealed that it was disheartening that it was not her facility staff that left the Treatment cart unlocked. She said the expectation for all staff was that they would follow policy and procedures, and lock and secure the Treatment cart when not in use. She said the risk was unauthorized access to the cart. Interview on 08/07/25 at 3:49 PM with the Administrator revealed, the Treatment Cart should be locked if it was out of sight and staff were not actively working in the cart. She said the expectation was that all staff would follow company policies and procedures and the expectation for contract personnel was to follow facility policies and to always keep the resident safe. Record review of the facility's policy Administering Medication revised in April 2009 reflected 9.During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. Record review the facility's policy Security of Medication cart, revision date April 2009, reflected 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The cart must be locked before the nurse enters the resident's room. 3. Medication carts must be securely locked at all times when out of the nurse's view. 4. When the medication cart is not being used, it must be locked and parked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #45) of 7 residents reviewed for infection control. The facility failed to follow EBP (Enhanced Barrier Precautions) procedures for Resident #45 when the wound treatment team failed to wear PPE while providing wound care to Resident #45 on 08/07/25. This failure affected residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #45's face sheet, dated 8/7/25, revealed an [AGE] year-old male admitted on [DATE] with a diagnoses of primary osteoarthritis right shoulder (this is a type of arthritis that occurs when flexible tissue at the ends of bones wear down) and non-pressure chronic ulcer of right heal and midfoot with other specified severity, pressure ulcer of right heal unstageable, and benign neoplasm of the parotid gland (cancer of the parathyroid gland located in the neck) Record review of Resident #45's quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating cognitively intact. Further review of MDS indicated Resident #45 had a diabetic foot ulcer and required application of dressings to feet. Record review of Resident #45's care plan, dated 07/01/25, revealed the Resident #45 was at risk for infection and was on enhanced barrier precautions r/t wound at risk for multidrug resistance organism. Wear gowns and gloves for high contact resident care activities with a goal of resident not showing any signs and symptoms of infection. Interventions included: Educate Resident / Representative on infection control practices, Educate Resident / Representative on techniques to prevent infection, such as handwashing, adequate rest, nutrition and avoidance of crowds and Evaluate wounds for signs / symptoms of infection. Record review of Resident #45's physician orders for August 2025 reflected:-Enhanced Barrier Precautions r/t wound care. at risk for multidrug-resistance organism. wear gowns and gloves for high-contact resident care activities. Every shift. Order active 07/01/25.Record Review of Resident #45's treatment note dated 08/05/25 by wound physician reflected: Wound #1 Location: Right heel 1.5cm x 0.9cm x 0.1cmPrimary Etiology: Diabetic ulcerArea cleansed with wound cleanser and [brand name] solution, patted dry. Applied collagen then calcium alginate with AG [refers to wound dressing that incorporates silver] to wound bed and covered with silicone dressing.20% slough 80% granulation. Moderate serosanguineous drainage [this is drainage that is mixed consisting of thin watery pale-yellow fluid and bloody red fluid]. Periwound callused edges. No odor. No pain Observation on 08/07/25 at 11:30 AM revealed Resident #45's door signage on the door read Gloves and gowns should be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Perform hand sanitation before entering the room and prior to leaving the room. Postings at the resident's room entrance indicating the resident was on enhanced barrier precautions. Resident #45's door was open with privacy curtain slightly halfway. Five staff were observed in the resident's room. Three stood at the foot of the bed and two were providing wound care. None of the five staff were wearing PPE for EBP and of the two providing wound care none wore gowns for EBP. The two staff wore blue gloves. In an interview on 08/07/25 at 11:54 AM, the PA stated they were a contracted wound treatment company, and she had some NP's training with her. She said there were no precaution necessary for Resident #45 for EBP. Pointing to the signage on Resident #45's door, she said Resident# 45 did not have drainage in his wound and did not require to be on EBP. She stated, No risk to resident, he does not have any fluids or infection. Interview on 08/07/25 at 12:06 PM with ADON B revealed she was one of the infection control preventionists. She stated all staff, including contract staff, were expected to follow infection control policy and procedure. She said all the nurse managers and DON were responsible for monitoring infection and implementing infection control training. She said all contract personnels were educated about facility policies and following infection control. ADON B said she was disappointed that the outside company did not follow the facility policies. She said she expected the treatment team that was providing wound care to wear gowns for EBP as per facility policy for EBP. She said the risk was spreading infection. In an interview with the DON on 08/07/25 at 1:16 PM, she stated all staff were expected to use standard infection control precautions including EBP wherever it was applicable. The DON stated she had in serviced on infection control, including EBP, and she was upset that the contract company did not follow the facility infection policy and procedures. The DON said she was responsible for monitoring that infection control precautions were being followed. She said the risk was spreading infection. Record review of the facility's Infection Prevention & Control Tracking Log and Antibiotic Stewardship on 08/06/25, did not reveal an infection pattern in last 90 days. Record Review of the facility's Enhanced Barrier Precautions policy, dated March 2024, reflected, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .1. a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. 2. Initiation of Enhanced Barrier Precautions: a. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. ii. Chronic wounds (pressure ulcers stage III & IV, diabetic foot ulcers, and venous ulcers) > 6 weeks old, even if resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: a. Residents placed on EBP will be identified using an orange star on their name tag outside the door of their room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #54) reviewed for call lights. <BR/>Resident #54 was placed in her room without access to her call light. On 06/05/2024 CNA P assisted Resident #54 in her wheelchair to her room and placed her out of reach of her call light. <BR/>This failure could place residents at risk for harm by not having the ability to call for assistance. <BR/>The findings included:<BR/>A record review of Resident #54's admission record dated 06/06/2024 revealed an admission date of 04/01/2023 with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (a condition where the eye's optic nerve, which provides information to the brain, is damaged and will cause gradual vision loss), atherosclerosis of the aorta (a condition characterized by the gradual buildup of plaque in the largest artery in your body). <BR/>A record review of Resident #54's annual MDS assessment dated [DATE], revealed Resident #54 was a [AGE] year-old female assessed with an ability to hear as, Moderate difficulty - speaker has to increase volume and speak distinctly, with impaired vision, Impaired - sees large print, but not regular print in newspapers/books, and had clear speech, was attentive, and did not have disorganized thinking. Further review of the assessment revealed Resident #54 had not refused any care provided. Resident #54 was assessed as always incontinent of bowel and bladder. Resident #54 was assessed as, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity, Or the assistance of 2 or more helpers is required for the resident to complete the activity for the following abilities: <BR/>Eating, oral hygiene, toileting hygiene, personal hygiene, shower / bathing dressing, and transferring.<BR/>Manual wheelchair - Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.<BR/>Manual wheelchair, Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.<BR/>A record review of Resident #54's care plan dated 06/06/2024 revealed, The resident has a potential for communication problem Hearing deficit .The resident will be able to make basic needs known on a daily basis through the review date .Be conscious of resident position when in groups, activities, dining room to promote proper communication with others . Ensure/provide a safe environment: Call light in reach <BR/>During an observation and interview on 06/05/2024 at 11:05 AM revealed Resident #54 loudly calling out for attention. Resident #54 was observed seated in her wheelchair in her room positioned mid room equidistant from her bed and the entry door. Resident #54's call light rested upon her bed and out of her reach by an approximate 3 feet. Resident #54 stated she was brought into her room by a CNA and left there without an ability to call for assistance. Resident #54 stated she did not have a call light within her reach. Resident #54 stated she was angry that staff do not take time with their care, (they) rush with care and run off. <BR/>During an observation and interview on 06/05/2024 at 11:16 AM revealed CNA P entered Resident #54's room responding to Resident #54's loud vocalizations calling out for assistance. Upon CNA P's entrance Resident #54 began with a complaint alleging you left me here .you said you would be right back .I had to yell to get you here . Resident #54 continued in an irritable manner and would often over speak CNA P, .you all are always in a rush and leave CNA P stated she had assisted Resident #54 in her wheelchair to her room and placed Resident #54 where she sat in her wheelchair as observed. CNA P stated Resident #54's call light was on Resident #54's bed and out of reach from Resident #54. CNA P stated she positioned Resident #54 away from her bedside due to Resident #54's preference. CNA P stated she had not attempted to place Resident #54's call light at her side. CNA P then attempted to reposition Resident #54's call light and succeeded to place Resident #54's call light at Resident #54's side, secured to her wheelchair. Resident #54 continued to verbalize irritably, don't tell your stories .you left me here .without lunch .with the button over there <BR/>During an interview on 06/07/2024 at 09:04 AM the DON stated call lights were to be placed within a residents reach. The DON added there maybe times when residents may not be able to be placed next to their call lights, e.g., during activities, when residents have their ability to self-ambulate within their room, and according to their preferences, residents in their room should have their call lights within reach. <BR/>During an interview on 06/09/2024 at 12:20 PM the DON stated the facility's policy for call lights was to adhere to the CMS regulations regarding call lights . <BR/>A record review of the CMS's State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities dated 02/03/2023, revealed, GUIDANCE .Reasonable accommodation(s) of resident needs and preferences includes, but is not limited to, individualizing the physical environment of the resident's bedroom and bathroom, as well as individualizing common living areas as much as feasible .PROCEDURES .Observe residents in their rooms and common areas and interview residents, if possible, to determine if their environment accommodates their needs and preferences .Determine if the resident has the call system within reach and is able to use it if desired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. <BR/>On 03/23/24, LVN A and LVN C failed to notify the Medical Doctor 3 out of 7 neuro checks were not being done for 12 hours. Resident #6 was hospitalized on [DATE] and returned 03/27/24 with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech .<BR/>An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 09:00 PM. While the IJ was removed on 06/09/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential harm because all staff not been trained on. <BR/>The findings were: <BR/>Record review of Resident #6's admission record, accessed 06/07/24, reflected the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and dementia (neurodegenerative disease that affects memory, thinking and interferes with daily life). It further reflected Resident #6 returned to the facility on [DATE] with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech .<BR/>Record review of Resident #6's significant change in status MDS, dated [DATE], reflected a BIMS score of 99, indicating resident was unable to complete the interview. Further review of this MDS reflected Resident #6's cognitive skills for daily decision making was severely impaired with short term and long term memory problems. <BR/>Record Review of nursing progress note, authored by LVN A on 03/22/24 at 01:20 PM, reflected Resident #6's RP reported Resident #6 could not hold her beverage. This progress note further revealed NP B ordered neuro checks Q 4 hrs x 3days, notify NP of any deficit. <BR/>Record review of Orders- Administration Note , authored by LVN C, reflected:<BR/>03/23/24 at 02:02 AM Neuro check was not done due to [Resident #6] being asleep<BR/>03/23/24 at 04:55 AM Neuro check was not done due to refusal<BR/>Record review of Orders- Administration Note , authored by LVN A, reflected:<BR/>03/23/24 at 09:06 AM Neuro check was not done due to family member refused since [Resident #6] was sleeping<BR/>Record review of Resident #6's Medication Administration Record for March, undated, revealed neuro checks that were done were: 03/22/24 at 04:00 PM and 08:00PM, 03/23/24 at 12:00 PM and 04:00 PM. <BR/>Record review of nursing notes from 03/23/24 revealed no documentation of NP or MD being notified of neuro checks not being done per order. <BR/>During an interview on 06/07/24 at 10:20 AM, Resident #6's RP 2 revealed on Friday [03/22/24] Resident #6 had weakness in her hands because she was not able to hold a cup of V8 in order to drink it. They revealed they reported this to LVN A. She further revealed the facility said she was fine so Resident #6's RP 2 let it go. Residents #6's RP 2 continued to reveal the next day on Saturday [03/23/24], Resident #6 speech got worse and Resident #6's balance was off. Resident #6's RP 2 revealed she asked resident to be sent out to the hospital because Resident #6 was not at baseline and got worse. She further revealed the facility called regular transport to send out resident. <BR/>Record Review of Resident #6's hospital record with admission date 03/23/24 revealed history of CVA and dysphagia s/p cerebral infarction. [Resident #6] present with slurring in speech that started yesterday at 1 PM, as well as clumsiness and weakness in her left upper extremity that was noted when she attempts to hold objects like a cup. Hospital records further reflected a new diagnosis and chief complaint of cerebrovascular accident (CVA). <BR/>During an interview on 06/07/24 at 12:41 PM, the DON revealed LVN A reported to her that the family declined having Resident #6's vital signs checked overnight and wanted to wait and see if Resident #6 would get better. <BR/>During an interview on 06/07/24 at 01:17 PM, LVN A revealed Resident #6 had stroke like symptoms on 03/22/24, but family declined having Resident #6 sent out to the hospital. LVN A further revealed the family wanted LVN A to contact Resident #6's NP to see what she recommended. LVN A revealed NP ordered neuro checks every 4 hours for 3 days. LVN A revealed Resident #6's family declined having neuro checks done when Resident #6 was asleep. LVN A further revealed she did not contact NP B that neuro checks were not done. LVN A also revealed she did not explain what could happen if Resident #6 had a stroke because Resident #6 had a history of having a stroke, so the family knew information about strokes. <BR/>Left voicemail for LVN C on 06/07/24 at 05:21 PM. <BR/>During an interview on 06/07/24 at 05:02 PM the DON revealed NP B was not contacted because there were no deficits in neuro checks, which was how the doctor order read. The DON revealed the NP B would not have been contacted if the family refused neuro checks. <BR/>During an interview on 06/07/2024 at 05:29 PM NP B stated LVN A reported on 03/22/2024 Resident #6 had a change of condition, with weakness in arms and NP B issued an order for Neurological assessments every 4 hours for 3 days. NP B stated she was not aware the orders for Resident #6 Neurological assessments were not performed for 12 hours and would have wanted to be notified when her orders were not followed. NP B stated neurological assessment deficits would indicate a potential for a stroke. NP B stated if the neurological assessment deficit were revealed it would have warranted an immediate hospitalization. <BR/>During an interview on 06/09/24 at 03:16 PM, the Medical Director stated he was given a report for Resident #6's missed neurological assessments from 03/23/2024 on 06/08/2024. The Medical Director confirmed he did not know about these missed neurological assessments before 06/08/24. He stated the ideal would be for the prescriber to be given a report when the orders given were not able to be completed. <BR/>Record Review of facility's policy, revised April 2009, Change in a Resident's Condition or Status, reflected 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: f. refusal of treatment or medications.<BR/>An Immediate Jeopardy (IJ) was identified on 06/07/2024 at 09:00 PM and presented to the Administrator, a plan of removal was requested. <BR/>The following Plan of Removal submitted by the facility was accepted on 06/08/2024 01:46 PM.<BR/>Immediate Jeopardy Plan of Removal Verification <BR/>6/8/2024 <BR/>All residents with orders for neuro checks are at risk of the orders not being followed or prescriber not being notified of the refusals. <BR/>During an interview on 06/08/24 at 02:30 PM, the Administrator revealed the census was 79 and there were 0 residents currently being assessed for neurological assessments. <BR/>Action to correct and remove IJ: <BR/>1.) Verify that current orders are being followed as prescribed by physician/NP. The DON and/or designee will complete this by noon 6/8/2024. <BR/>During an interview on 06/09/24 at 12:22 PM, the DON stated she and her staff reviewed all the current residents' physicians' orders for compliance and all evidenced compliant. <BR/>During an interview on 06/08/24 at 02:30 PM, the Administrator revealed there were no residents on neuro checks and 2 residents had received neurological assessments in the recent past, Resident #44 and Resident #48. <BR/>During an interview on 06/09/24 at 12:22 PM, the DON stated 2 residents (Resident #44 and Resident #48) had received neurological assessments per post fall protocols. The DON stated there were no residents ordered to receive neurological assessments since 03/23/2024 when Resident #6 was ordered neurological assessments due to her stroke-like symptoms. <BR/>A record review of the facility's census revealed 2 of 79 residents (Resident #44 and Resident #48) had completed worksheets for neurological assessments:<BR/>o <BR/>A record review of Resident #44's neurological assessment worksheet dated 05/21/2024, revealed Resident #44 was assessed every 15 minutes 5 times, assessed every 30 minutes 4 times, assessed every hour three times, and every 4 hours 4 times. <BR/>o <BR/>A record review of Resident #48's neurological assessment worksheet dated 05/21/2024, revealed Resident #44 was assessed every 15 minutes 7 times, assessed every hour eight times. <BR/>2.) All licensed nurses will be in-serviced regarding the need to notify physician/NP of any refusals that keep us from following orders prescribed. The DON and/or designee will complete in-service with team by 6/9/2024. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who are unavailable will attempt to be reached by phone call, text message, and email by DON/Designee. DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred. <BR/>During an interview on 06/08/24 at 03:02 PM, the DON provided documents titled in-service education attendance record, dated 06/07/24, and facility policy's Change in a Resident's Condition or Status, revised November 2010, and Refusal of Medications and Treatments, Documentation of, revised April 2009. The DON revealed licensed nurses could not work a shift until they have received in-services for following orders and reporting orders that could not be performed and have been sent an email to go to her office to be educated before working a shift. <BR/>A record review of the facility's nursing roster revealed 23 / 34 licensed nurses were employed. 19 licensed nurses were full time, and 15 licensed nurses were part time. <BR/>A record review of the facility's nursing roster and schedule revealed 13 nurses worked the 07:00 AM shift to 07:00 PM shift and 10 worked the 07:00 PM to 07:00 PM shift. <BR/>A record review of the facility's in-service titled Change of Condition; refusal of treatment . dated 06/07/2024, revealed 23 Nurses received the in-service. <BR/>Interviews:<BR/>07:00 AM to 07:00 PM shift:<BR/>7 Of 14 nurses, 50%, who worked the 07:00 AM to 07:00 PM shift were interviewed. A sample of the interviews follow:<BR/>During an interview on 06/09/24 at 10:53 AM, LVN J revealed he received training on reporting to MD or NP if the resident's doctor's orders were not being fulfilled. <BR/>During an interview on 06/09/24 at 10:59 AM, ADON D and LVN E revealed they were trained in contacting a resident's MD or NP if they were not able to fulfill doctor's orders. They further revealed they could make person centered changes to help fulfill their orders.<BR/>During an interview on 06/09/24 at 11:10 AM, RN F, RN G, and LVN H not able to carry out a doctor's order they will notify the doctor or NP. RN gave examples of some doctor's orders that need to be followed.<BR/>During an interview on 06/09/24 at 02:22 PM, the DON revealed she was in-serviced on change of condition policy and refusal of treatment/medication by the COO. <BR/>Interviews:<BR/>07:00 PM to 07:00 AM shift:<BR/>6 of 9 licensed nurses, 67%, who regularly worked the 07:00 PM to 07:00 AM shift were interviewed. A sample of the interviews follow:<BR/>During an interview on 06/09/24 at 10:59 AM, LVN I revealed she was trained in contacting a resident's MD or NP if they were not able to fulfill doctor's orders. They further revealed they could make person centered changes to help fulfill their orders.<BR/>During an interview on 06/09/24 at 12:22 PM, DON revealed LVN C (who regularly worked 6 PM- 6 AM) could not be contacted to be in-serviced. LVN C had been taken off the schedule until she was able to be in-serviced.<BR/>During an interview on 06/09/24 at 01:28 PM, LVN K revealed she was educated recently to follow doctor's orders and report to doctor or NP if a resident was not able to receive a treatment or medication. <BR/>During an interview on 06/09/24 at 01:43 PM, LVN L revealed she was in-serviced on how to complete a change in condition assessment and notify doctor if any doctor's orders were not fulfilled.<BR/>During an interview on 06/09/24 at 01:55 PM, LVN M revealed she was educated recently to follow doctor's orders and contact MD or NP if an order was not fulfilled.<BR/>During an interview on 06/09/24 at 02:01 PM, LVN N revealed she would contact the doctor if a resident refused treatment, refused medication, or had a change in condition.<BR/>During an interview on 06/09/24 at 02:09 PM, LVN O revealed he was trained to contact the doctor if medications or treatments were not fulfilled. <BR/>3.) Physicians/NP partners will be notified to provide team with more concise orders and to consider the nurse's feedback regarding specific resident's characteristics or preferences when deciding a plan of action. The communication with our physician partners will be completed by 6/10/2024. <BR/>During a joint interview on 06/09/2024 at 11:00 AM the Administrator and the DON stated the facility has partnered with all facility medical providers to have a consensus to develop and implement improved physicians' orders to better reflect residents needs and preferences i.e., may assess while awake, may reattempt x3, and please report to physicians after 2x refusals. <BR/>the Administrator and the DON stated the facility has sent emails to the medical director and all supporting and attending physicians and nurse practitioners. The Administrator stated the facility held an AD-HOC QAPI meeting to review the Plan of Removal. <BR/>During an interview on 06/09/2024 at 03:18 PM the Medical Director stated the facility informed him of the immediate jeopardy on 06/08/2024 and the facility held an AD-HOC QAPI meeting to review the immediate jeopardy and develop a plan of removal. The medical Director stated he was given a report for resident #6's missed neurological assessments from 03/23/2024 on 06/08/2023. The Medical Director stated the ideal would be for the prescriber to be given a report when the orders given were not able to be completed. <BR/>4.) The DON/Designee will review 24-hour report daily for change of condition UDA including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact DON/Designee if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily x14 days, weekly x4 weeks, monthly x3 months, and periodically thereafter. <BR/>During a joint interview on 06/09/2024 at 11:00 AM the administrator and the DON stated the facility would daily monitor the 24-hour reports for any changes of condition, to include neurological assessments, refusals of any assessments, treatments and or orders: and follow up documentation with reports to physicians. The Administrator and the DON stated the monitoring will be conducted for 14 days, then 4 weeks, and then for 3 months.<BR/>Record review of Daily Neurological Checks dated 6/8/2024, 6/9/2024 No new neurological checks, created by DON. The Daily Neurological Checks, included Resident name, Date, Notification to family, notification of MD, refusals of vital signs, notification of neurological assessments, Is this care planned and comments sections. <BR/>Record review of Weekly Neurological Checks blank sheet, includes resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections. <BR/>Record review of Monthly Neurological Checks Monthly blank sheet, includes resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections.<BR/>Record review of E-Interact Daily Change of Condition Assessment, dated 6/8/2024 and 6/9/2024. This included resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections.<BR/>Record review of Daily 24 hour report, dated 6/8/2024, 6/9/2024 revealed no neurological checks for residents. <BR/>Record review of Weekly 24 hour report, for weekly monitoring blank, included resident name, date, progress note refusals EMR refusals, order note refusals, Is this care planned and comments section. <BR/>5.) All residents have the potential to be affected by this alleged deficit practice. At risk resident will be identified by reviewing 24 hr. report, (for) changes of condition assessment and neurological checks.<BR/>A record review of the facility's unit 6's Nurses station 24-hr report revealed no residents were followed for a change of condition and no residents had refused any treatments.<BR/>Reviews: (Monitoring)<BR/>1.) Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with DON weekly to audit and verify this review has been completed. This will be ongoing for the next two months. <BR/>2.) Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis. <BR/>Record review of QAPI Performance for Improvement instructor, Administrator dated 6/8/202 from 9 AM -10 AM. Subject: Notify of Changes. The QUAPI in-service included the Administrator, DON, CDM, Admissions, Business Manager, Maintenance, Housekeeping, ADON, Activity Director, Social Worker, Human Resources and Medical Director. System of Concerns: In-service on Notification of Changes. Concerning IJ F580 Notify of Changes. <BR/>3.) A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body. <BR/>During an interview on 06/09/2024 at 03:14 PM the Administrator stated the facility's Chief Operating Officer would have oversight and monitoring the facility's Plan of Removal for the following six months. <BR/>The Administrator and the DON was informed the Immediate Jeopardy was removed on 06/09/24 at 04:07 PM. The facility remained out of compliance at a severity level of potential harm and a scope of pattern 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 observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Resident #54) reviewed for their right to voice grievances to the facility.<BR/>CNA P failed to report and document Resident #54's complaint she was left without a call light, left unattended, and received rushed care. <BR/>This failure could place residents at risk for harm by not having their grievances addressed.<BR/>The findings included:<BR/>A record review of Resident #54's admission record dated 06/06/2024 revealed an admission date of 04/01/2023 with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (a condition where the eye's optic nerve, which provides information to the brain, is damaged and will cause gradual vision loss), atherosclerosis of the aorta (a condition characterized by the gradual buildup of plaque in the largest artery in your body). <BR/>A record review of Resident #54's annual MDS assessment dated [DATE], revealed Resident #54 was a [AGE] year-old female assessed with an ability to hear as, Moderate difficulty - speaker has to increase volume and speak distinctly, with impaired vision, Impaired - sees large print, but not regular print in newspapers/books, and had clear speech, was attentive, and did not have disorganized thinking. Further review of the assessment revealed Resident #54 had not refused any care provided. Resident #54 was assessed as always incontinent of bowel and bladder. Resident #54 was assessed as, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity, Or the assistance of 2 or more helpers is required for the resident to complete the activity for the following abilities: <BR/>Eating, oral hygiene, toileting hygiene, personal hygiene, shower / bathing dressing, and transferring.<BR/>Manual wheelchair - Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.<BR/>Manual wheelchair, Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.<BR/>A record review of Resident #54's care plan dated 06/06/2024 revealed, The resident has a potential for communication problem Hearing deficit .The resident will be able to make basic needs known on a daily basis through the review date .Be conscious of resident position when in groups, activities, dining room to promote proper communication with others . Ensure/provide a safe environment: Call light in reach <BR/>A record review of the facility's grievance report logbook revealed grievances for the last 8 months . A review of the grievances revealed no evidence for a grievance for Resident #54. <BR/>During an observation and interview on 06/05/2024 at 11:05 AM revealed Resident #54 loudly calling out for attention. Resident #54 was observed seated in her wheelchair in her room positioned mid room equidistant from her bed and the entry door. Resident #54's call light rested upon her bed and out of her reach by an approximate 3 feet. Resident #54 stated she was brought into her room by a CNA and left there without an ability to call for assistance. Resident #54 stated she did not have a call light within her reach. Resident #54 stated she was angry that staff do not take time with their care, (they) rush with care and run off. <BR/>During an observation and interview on 06/05/2024 at 11:16 AM revealed CNA P entered Resident #54's room responding to Resident #54's loud vocalizations calling out for assistance. Upon CNA P's entrance Resident #54 began with a complaint alleging you left me here .you said you would be right back .I had to yell to get you here . Resident #54 continued in an irritable manner and would often over speak CNA P, .you all are always in a rush and leave CNA P stated she had assisted Resident #54 in her wheelchair to her room and placed Resident #54 where she sat in her wheelchair as observed. CNA P stated Resident #54's call light was on Resident #54's bed and out of reach from Resident #54. CNA P stated she positioned Resident #54 away from her bedside due to Resident #54's preference. CNA P stated she had not attempted to place Resident #54's call light at her side. CNA P then attempted to reposition Resident #54's call light and succeeded to place Resident #54's call light at Resident #54's side, secured to her wheelchair. Resident #54 continued to verbalize irritably, don't tell your stories .you left me here .without lunch .with the button over there CNA P stated she understood Resident #54 had made a complaint and was asked what do you do when a Resident makes a complaint? CNA P stated, I have explained to her (Resident #54) I cannot stay here; I have other work to do. CNA P stated Resident #54 had a desire for someone to stay with her and she could not due to her duties. <BR/>During an interview on 06/07/2024 at 09:04 AM the DON stated staff should assist residents with a grievance report. <BR/>During an interview on 06/08/2024 at 02:03 PM the Administrator stated she was unaware of Resident #54's grievance and would look into the event on 06/05/2024 with CNA P and Resident #54. The Administrator stated she would provide a grievance policy. <BR/>A record review of the facility's Grievances, Resident / Responsible Party policy dated 08/01/2017, revealed, Policy Interpretation and Implementation: A resident has the right to voice grievances without discrimination or reprisal. Grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; and a resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to behavior of other residents. The resident has the right to obtain a written decision regarding his or her grievance. Grievances are not limited to formal written grievances and may also include residents verbalized complaints to facility staff. It is the intent of this facility to make prompt efforts to resolve including facility acknowledgment of complaints grievances. Staff will work actively towards resolution of complaints and grievances

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 16 (#6 , #3, #38, #56, #57, #120) in that:<BR/>1. Resident #6 received honey consistency liquids instead of nectar thick liquids.<BR/>2. Resident #3 did not have her 1/4 bed [NAME] in her care plan. <BR/>2. Resident #38 did not have her indwelling catheter in her care plan. <BR/>3. Resident #57 did not have her 1/4 bed rails in her care plan.<BR/>4. Resident #120 did not have her 1/4 bed rails in her care plan.<BR/>5. Resident #56 did not have his dentures mentioned in his care plan. <BR/>The facility failed to ensure Resident #6's care plan was comprehensive and updated to reflect Resident #2's doctor's order of needing honey consistency liquids instead of nectar thick liquids. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. <BR/>The Findings were:<BR/>Record review of Resident #6's admission record dated 6/7/2024 revealed a male was admitted on [DATE] with diagnoses that included dementia (loss of thinking, remembering, and reasoning skills), personal history of traumatic brain injury, dysphagia (a condition with difficulty in swallowing food or liquid), cognitive communication deficit, and muscle wasting and atrophy. <BR/>Record review of Resident #6's annual MDS, dated [DATE], reflected Resident #6's BIMS score was 99, indicating resident was not able to complete the interview with short term and long-term memory problems and severely impaired cognitive skills for daily decision making. It further reflected Resident #6 was severely impaired-never/rarely made decisions. The MDS also indicated Resident #6 was on a mechanically altered diet, requiring change in texture of food or liquids. <BR/>Record review of Resident #6's care plan, accessed 05/23/24, reflected [Resident #2] has potential nutrition problem r/t mechanically altered diet, revised on 03/06/2024, with an intervention of Administer Nectar thick liquid as ordered., initiated 11/30/2021 with no revision date.<BR/>Record Review of Resident #6's Doctor's diet orders reflected honey consistency liquids since 08/30/22.<BR/>1. Record review of Resident #3's admission Record dated 6/7/2024 revealed she was admitted on [DATE], age [AGE] with diagnoses of polyneuropathy, heart failure, cognitive communication deficit, and dementia.<BR/>Record review of Resident #3's consolidated physician's order 5/16/2023-TRANSFER ASSISTIVE DEVICE: X2, 1/4 rails up as per Dr's order while in bed, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury.<BR/>Record review of Resident #3's Quarterly MDS dated [DATE] revealed she had a BIMs of 2/15 (severely cognitively impaired), she used a wheelchair to mobilize, she was maximum assistance with transfers. <BR/>Record review of Resident #3's care plan dated 5/6/2024 revealed no care plan to address the 1/4 side rails. <BR/>Record review of Resident #3's Transfer Assist Device Assessment form dated 5/16/2023 revealed a recommendation of bilateral 1/4 [NAME].<BR/>Interview on 6/6/2024 at 4:10 PM LVN Q stated she just changed her bed on Monday of this week. <BR/>2. Record review of Resident #38's admission Record dated 6/7/2024, age [AGE] revealed she was admitted on [DATE] with diagnoses of altered mental status, acute kidney failure, cognitive communications deficit, dementia and retentions of urine. <BR/>Record review of #38's consolidated physician orders for June 2024 revealed she had an order for indwelling catheter with diagnoses of urine retention. <BR/>Record review of Resident #38's Quarterly MDS dated [DATE] revealed her BIMS was 99, with short/long-term memory, she used a wheelchair to mobilize, she was dependent with toileting, and had an indwelling catheter. <BR/>Record review of Resident #38's care plan dated 3/28/2024 revealed she had an indwelling catheter for neurogenic bladder but had no interventions. <BR/>Observation on 6/5/2024 at 11:40 AM revealed Resident # 38 was in the dining room eating by herself. The indwelling catheter bag was under the wheelchair and had privacy bag. <BR/>Interview on 6/6/2024 at 6:18 PM with the DON revealed Resident #38 did not have interventions for her indwelling catheter. The DON stated the nursing department, nurse manager (DON, ADON) did the care plans for nursing section in resident care areas. The DON stated the resident interventions were to monitor for quinks, care, size, nursing staff would benefit from seeing care plan. The DON stated nurses look at the care plan for catheters. <BR/>3. Record review of Resident #57's admission Record dated 6/7/2024, age [AGE] revealed he had a diagnosis of diabetes II, need for assistance with personal care, and history of falls. <BR/>Record review of Resident #57's Quarterly MDS dated [DATE] revealed her BIMS score was 6/15 (severe cognitive impairment), used a manual wheelchair, and max assist with transfers. <BR/>Record review of Resident #57's care plan dated 6/3/2024 revealed no care plan for 1/4 bed rails. <BR/>Record review of Resident #57's Transfer Assist Device Assessment form dated 5/17/2023 revealed a recommendation of bilateral 1/4 [NAME].<BR/>Observation on 6/5/2024 at 11:30 AM revealed Resident #57 had &frac14; hand [NAME] in her bed. Resident # 57 was not in the room.<BR/>Observation on 6/5/2024 at 3:34 PM revealed two &frac14; handrails on Resident #57's bed. Observation of Resident #57 w as sitting in her wheelchair. <BR/>4. Record review of Resident #120's admission Record dated 6/7/2024 revealed she was admitted on [DATE], age [AGE] with a diagnoses of end stage renal disease, diabetes II, abnormal gait/mobility and heart failure. <BR/>Record review of Resident #120's consolidated physician orders for June 2024 revealed an order for 5/20/2024-TRANSFER ASSISTIVE DEVICE: X2, 1/4 rails up as per physician order while in bed, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury.<BR/>Record review of Resident #120's admission MDS dated [DATE] revealed she was BIMS 15/15 (cognitively intact), mobilized in wheelchair, impairment on one side of lower extremity, and roll left and right required partial/moderate assistance. <BR/>Record review of Resident #120's care plan dated 5/13/2024 revealed no care plan for 1/4 bed rails.<BR/>Record review of Resident #120's Transfer Assist Device assessment dated [DATE] recommendation left and right &frac14; side rails.<BR/>Observation on 6/4/20/24 at 11:29 AM revealed Resident #120 was in bed and had two 1/4 side rails on each side of her bed. <BR/>Interview on 6/7/2024 at 11:50 AM with the ADM stated the &frac14; bed rails risk would be staff does not know the rails were in place. No other response. <BR/>5. Record review of Resident #56's admission Record dated 6/9/2024 revealed he was admitted on [DATE], age [AGE] with diagnoses of alcoholic cirrhosis of liver (impaired liver function caused by formation of scar tissue) and major depressive disorder.<BR/>Record review of Resident #56's Quarterly MDS dated [DATE] revealed he had a BIMS of 8/15 (moderately cognitively impaired) and nothing noted in Section L- Oral/Dental Status. <BR/>Record review of Resident #56's care plan, undated, revealed no mention of dentures. <BR/>During an interview on 06/06/24 at 02:00 PM, Resident #56's RP revealed Resident #56 had been going to the dentist recently to get his dentures fixed. <BR/>During an interview on 06/06/24 at 01:47 PM, Resident #56's dentist revealed she was seeing Resident #56 to repair his dentures. <BR/>During an interview on 06/07/24 at 12:13 PM, the DON revealed dentures should be care planned so the CNAs know what to do for the resident's care when it comes to oral care. <BR/>During an interview on 05/24/24 at 11:19 AM, Speech Therapist C (ST C) revealed if a resident was determined to need honey thickened liquids and received nectar thickened liquids there could be a chance of aspiration where a solid or liquids could get into the airways. She further revealed this could lead to aspiration pneumonia which could cause a resident to be hospitalized . She revealed if a resident was more compromised there could be more severe health consequences, including death. ST C revealed there had been times where a resident may refuse a liquid if they knew they could not tolerate it, which could cause dehydration. She further revealed she had not heard of a resident at this facility complaining about this scenario, however, you may not be able to know this if a resident was nonverbal. <BR/>During an interview on 05/24/24 at 03:23 PM, the RD revealed the facility was giving resident honey thickened liquids. She further revealed CNAs were providing liquids to Resident #2 in between meals but would have to ask the DON how the CNAs knew what liquids to give Resident #2. <BR/>During an interview on 05/24/24 03:54 PM, MDS nurse P and MDS nurse Q stated CNAs followed tasks that were developed from care plans. MDS nurse P confirmed Resident #2's care plan reflected an intervention of Administer Nectar thickened liquid as ordered. She further confirmed this would turn into a task on their POC dashboard for the CNAs to follow. MDS nurse Q confirmed Resident #2's POC Shift Dashboard record, accessed on 05/24/24 at 11:01 AM, revealed there was a directive to give Resident #2 Nectar Thick Liquids. MDS nurse P and MDS nurse Q revealed if resident was receiving Nectar thickened liquids and needed honey thickened liquids, this could cause aspiration. <BR/>Left VM for doctor and NP on 05/24/24 at 3:20 PM. <BR/>During an interview on 5/30/24 at 02:33 PM, the administrator and the DON revealed nursing staff received liquids from the kitchen, which would be honey thickened liquids. If the kitchen did not give these liquids, the DON would get involved and ensure the correct liquid was given. <BR/>Record review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, revised March 2022, reflected, 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. <BR/>Record review of the facility policy dated 4/6/2009 revealed The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care of services to the resident. Record Review of POC Shift Dashboard and interview with CNA D, dated 05/24/24 at 11:01 AM, reflected Resident #2 received NUTRITION- Fluids: NECTAR THICK LIQUIDS QShift. CNA D revealed she was following this directive and giving Resident #2 Nectar thickened liquids. <BR/>There were no observations of Resident #2 receiving nectar thickened liquids. Meals and snacks included honey thickened liquids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. <BR/>The facility failed to ensure Resident # 6 was assessed as ordered for neuro-checks every 4 hours x 3 days. Resident # 6 was sent to hospital and returned to the facility on [DATE] with new diagnoses to include: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech.<BR/>An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on 6/29/2024 . While the IJ was removed on 6/30/2024, the facility remained out of compliance at a scope of pattern and a severity level lowered to no actual harm that is not Immediate Jeaperdy due to the facility's need to monitor and evaluate the effectiveness of the corrective actions.<BR/>This failure could result in assessments not being completed as ordered could result in residents' not receiving the necessary care resulting in a decline in health and or death. This could affect all resident with assistive devices and could result in no orders for resident care. <BR/>The findings included: <BR/>Record review of Resident #6's admission record, accessed 06/07/24, reflected the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and dementia (neurodegenerative disease that affects memory, thinking and interferes with daily life). It further reflected Resident #6 returned to the facility on [DATE] with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech.<BR/>Record Review of nursing progress note, authored by LVN A on 03/22/24 at 1:20 PM, reflected Resident #6's RP reported Resident #6 could not hold her beverage. This progress notes further revealed NP B ordered neuro checks Q 4 hrs x 3days, and to notify NP of any deficit. Record Review revealed Neuro-checks were not started until 4:00 pm. <BR/>Record review of Orders- Administration Note , authored by LVN C, reflected:<BR/>03/23/24 at 02:02 AM Neuro check was not done due to [Resident #6] being asleep. <BR/>03/23/24 at 04:55 AM Neuro check was not done due to[family member] refusal.<BR/>Record review of Orders- Administration Note , authored by LVN A, reflected:<BR/>03/23/24 at 09:06 AM Neuro check was not done due to family member refused since [Resident #6] was sleeping.<BR/>Record review of nursing notes from 03/23/24 revealed no documentation of NP<BR/>or MD being notified of neuro checks not being done per order.<BR/>During an interview on 6/25/2024 at 6:35 pm LVN A revealed she did not explain what could happen if Resident #6 had a stroke to the family, because Resident #6 had a history of having a stroke, so the family knew information about strokes.<BR/>LVN A said when the resident/family refused neuro checks she did not go back and attempt to reassess the resident until the next 4-hour interval.<BR/>During an interview on 6/25/2024 at 6:49 pm, LVN C stated Resident #6's family member did not allow her to do one of the neuro checks (12 midnight) 3/23/2024 the resident was sleeping. The Resident refused neuro checks at 4:00 am. LVN C further revealed she did not contact NP B when neuro checks were not done. LVN C also revealed she did not explain what could happen if Resident #6 had a stroke because Resident #6 had a history of having a stroke.LVN C said when the resident/family refused neuro checks she did not go back and attempt to reassess the resident until the next 4-hour interval. She further revealed she tried once, and the resident hit me. The resident said leave me alone. <BR/>During a telephone interview on 6/28/2024 at 12:30 pm NP B stated she remembers the nurses calling her in March 2024 regarding stroke like symptoms, she doesn't recall the specifics, but she feels they let her know how the resident was based on their long-time knowledge of the resident. The nurses once they found the resident to have a change sent her to the hospital. She stated based on the statements of the nurses was how she was sent to the hospital.<BR/>Resident #6 was admitted to hospital on [DATE] and diagnosed with: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech.<BR/>The plan of removal was submitted by the facility and was accepted on 06/29/24 at 10:07 AM. It was documented as follows:<BR/>Action to correct and remove IJ:<BR/>1.) Verify that all assessments were being followed as ordered by physician/NP. The DON and/or designee will complete this by noon 06/29/24.<BR/>2.) All licensed nurses will be in-serviced regarding the need to notify physician/NP<BR/>immediately of any refusals that keep us from following physician ordered assessments. The DON and/or designee will complete an in-service with the team by 06/30/24. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who were unavailable will attempt to be reached by phone call, text message, and email by the DON/Designee. The DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred.<BR/>3.) The DON/Designee will review 24-hour report daily for change of condition UDA (Unified Defined Assessment-a change of condition assessment) including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact the DON/Designee immediately if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily x14 days, weekly x4 weeks, monthly x3 months, and periodically thereafter.<BR/>4.) All residents have the potential to be affected by this alleged deficient practice. At risk residents will be identified by reviewing 24-hour report, changes of condition assessment and neurological checks.<BR/>Reviews:<BR/>1.) Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with the DON weekly to audit and verify this review has been completed. This will be ongoing for the next two months.<BR/>2.) Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis.<BR/>3.) A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body.<BR/>The facility's POR verification was as follows:<BR/>In an interview on 06/29/24 at 12:53 PM the DON stated all but 1 of the 24 nurses had been in-serviced to notify the physician immediately if a resident refused an assessment and the 1 nurse who had not been in-serviced would not be scheduled until they received the in-service.<BR/>Interviews on 06/29/24 from 12:05 PM to 4:05 PM with 8 nurses (3 RNs and 5 LVNs), five of whom worked the day shift (6 AM to 6 PM) and three of whom worked the night shift (6 PM to 6 AM), revealed they were in-serviced to immediately notify the resident's physician/NP if a resident refused to have an assessment completed, to document the resident refused the assessment in the nurse's progress notes and the physician was notified, and to notify the resident's responsible party.<BR/>In an interview on 06/29/24 at 4:01 PM, the DON stated she had printed out all the physician orders and verified the assessments had been completed. <BR/>In a further interview on 06/29/24 at 4:20 PM, the DON stated there was only one resident who had orders for neurological checks that were initiated on 06/28/24 and completed 06/29/24 and the resident did not refuse the neurological assessments.<BR/>In an interview on 06/29/24 at 4:52 PM the DON stated she would review the 24-hour reports, the orders in the EHR, and the change of condition reports daily for notation of change of condition in a resident. The DON stated the Weekend Supervisor and the ADON would continue the monitoring when she was not in the facility. The DON stated an ad hoc QAPI meeting was held on 06/28/24 with the Medical Director and department heads in reference to the IJ for not completing an ordered assessment. The DON stated the Chief Operating Officer would conduct weekly audits of the facility's monitoring of compliance with ordered assessments. <BR/>In an interview on 06/29/24 at 5:09 PM the Administrator stated she reviewed the 24-hour reports with the DON for ordered assessments. The DON in-serviced the nurses on ensuring ordered assessments were completed and to notify the physician immediately if an assessment was refused by the resident. The Administrator stated they would obtain daily the 24-hours reports from the EHR to monitor ordered assessments. The Administrator said an ad hoc QAPI meeting was held on 06/28/24 and not notifying the physician when a resident refused an assessment was reviewed and discussed. The Medical Director, the DON, the ADON and other department heads were present at the ad hoc QAPI meeting. The Administrator stated the Chief Operating Officer would conduct the weekly audits of compliance with monitoring physician order assessments.<BR/>Record review of an undated, untitled list of nurses revealed 24 nurses were employed at the facility.<BR/>Record review of the In-Service Education Attendance Record dated 06/28/24, for Completing assessments as ordered per physician/NP, revealed 23 nurses had been in-serviced.<BR/>Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for reviews of the 24-Hour report. The 24-Hour Report monitoring form had columns for the resident's name, date, progress notes refusals, EMH refusals, order note refusals, and if it was care planned.<BR/>Record review of the facility's POR verification binder revealed on the 24-Hour Report daily monitoring sheets revealed on the first row was handwritten 06/29/24 no refusals (i.e., no refusal of care/medications/assessments). On the second row was handwritten a resident's name, date of 06/30/24, notation the resident refused a medication, it was care planned the resident would refuse the medication, and the physician was informed.<BR/>Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for reviews of the E-Interact Change of Condition Assessment. The E-Interact Change of Condition Assessment monitoring form had columns for the resident's name, date, notification to family, notification to the physician, notification of refusal of treatment, notification of refusal of meds, and if it was care planned.<BR/>Record review of the Daily E-Interact Change of Condition Assessment form revealed residents who had a change of condition on 06/28/24 and 06/29/24 were listed, all the resident's physicians and RP's were notified and none of the residents refused care or assessments.<BR/>Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for Neurological Checks audits. The Neurological Checks monitoring form had columns for the resident's name, date, notification to family, notification to the physician, refusals of vital signs, notification of neurological assessments, and if it was care planned. <BR/>Record review of the Order Listing Report, dated 06/29/24, revealed there was only 1 resident with orders for neurological checks to be completed in a 24-hour period.<BR/>In an interview on 06/29/24 at 4:20 PM, the DON stated there was 1 resident who had orders for neurological checks and there was another resident who had a fall on 06/28/24 that neurological checks were being done on. Both residents were listed on the Daily Neurological Checks monitoring sheet. <BR/>Record review of the Daily Neurological Checks monitoring sheet revealed 2 residents were listed on 06/28/24 for neurological checks, their physician's and RP's were notified, and the residents did not refuse the assessment. On 06/29/24 there were no residents with orders for neurological checks.<BR/>Record review of an In-Service Education Attendance Record, dated 06/28/24, revealed an ad hoc QAPI meeting was held at 6 PM to discuss assessment documentation and all assessments were not being completed as ordered could result in residents not receiving the necessary care resulting in a decline in their health or even death. The meeting was conducted by the Administrator and in attendance were the Medical Director, the Activity Director, the ADON, the DON, the BOM, the dietitian, and the housekeeping director.<BR/>An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on 6/29/2024 . While the IJ was removed on 6/30/2024, the facility remained out of compliance at a scope of pattern and a severity level lowered to no actual harm that is not Immediate Jeaperdy due to the facility's need to monitor and evaluate the effectiveness of the corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 1 of 7 residents (Resident #170) reviewed for pharmacy services. <BR/>LVN U dispensed Resident #170's medications (11 pills) and stored them in a small pill cup in the medication cart with the intention of administering the medications at a later time and continued to dispense and administer medications for other residents.<BR/>This failure could place residents at risk for harm by medication administration errors.<BR/>The findings included:<BR/>A record review of Resident #170's admission record dated 06/07/2024 revealed an admission date of 05/24/2024 with diagnoses which included hypertension (high blood pressure), diabetes type II (a condition where the body's cells cannot readily accept sugars from the blood), hyperlipidemia (a condition where the blood too much fat (lipids)).<BR/>A record review of Resident #170's admission MDS assessment dated [DATE] revealed Resident #170 was a [AGE] year-old male assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. <BR/>A record review of Resident #170's physicians' orders dated 06/07/2024, revealed Resident #170 was prescribed the following medications to be administered daily at 08:00 AM: <BR/>1. <BR/>Amlodipine 5mg (used to trat high blood pressure).<BR/>2. <BR/>Aspirin 81mg (used to prevent heart attacks).<BR/>3. <BR/>Fish oil capsule 1000mg (used for dietary supplement).<BR/>4. <BR/>Lisinopril 40mg (used to treat high blood pressure).<BR/>5. <BR/>Multivitamin (used for a dietary supplement).<BR/>6. <BR/>Sertraline 100mg (used to treat depression).<BR/>7. <BR/>Vitamin C (used as a dietary supplement).<BR/>8. <BR/>Donepezil 10mg (used to treat dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities)).<BR/>9. <BR/>Gabapentin 600mg (used to treat nerve pain).<BR/>10. <BR/>Hydralazine 50mg (used to treat high blood pressure).<BR/>11. <BR/>Sennosides-Docusate Sodium 8.6-50mg (used to treat constipation). <BR/>During an observation and interview on 06/07/2024 at 08:12 AM revealed LVN U attended her medication cart and was preparing medications for another Resident. Observations of LVN U opening drawers of the medication cart revealed the top drawer had a small clear plastic cup with pills. LVN U stated the cup contained Resident #170's morning medications. LVN U stated she had dispensed Resident #170's medications and attempted to administer Resident #170 his medications and was unable to do so due to Resident #170 was not available and was in the shower. LVN U stated she had stored the loose pills in their pill cup for a later attempt to administer. LVN U stated she then proceeded to dispense and administer medications to other residents. <BR/>During an observation and interview on 06/07/2024 at 08:20 AM revealed the DON approach the medication cart and inquire of LVN U here status on medication administration and the surveyor reported to the DON that LVN U had Resident #170's medications in a pill cup. The DON inquired of LVN U the nature of the pills in the cup and LVN U reported the pills were dispensed for Resident #170 however Resident #170 was in the shower. The DON stated LVN U should have disposed the medications and would need to re-dispense the medications when Resident #170 became available. <BR/>During an interview on 06/07/2024 at 0859 AM the DON stated medications should be dispensed and administered prior to dispensing and administering medications for the next Resident. <BR/>A record review of the facility's policy titled Storage of Medications dated April 2009, revealed, Policy Interpretation and Implementation: Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they were received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner <BR/>A record review of the American Association of Post-Acute Care Nursing's website: Resident Safety and Nurse Workarounds - AAPACN accessed 06/11/2024, titled, Resident Safety and Nurse Workarounds, revealed, Nurse workarounds defined .Nurse workarounds are actions that nurses take to deliver care and accomplish the work assigned to them, despite those actions' deviating from protocol and policy .workarounds occur in SNFs (Skilled Nursing Facility's) .For example, a nurse who pops medication from a multi-dose card and pre-pours pills or places them in medication cups to be administered later, for one or more residents, does not intend to cause harm. Nurses do this so they can dispense medications quickly, saving precious time and allowing them to move on to the next task they must complete. But the intended time-saver exposes patients to the risk of harm. While an error probably will not occur every time a workaround is used, when one does occur, the harm is likely to be significant

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 1 of 8 residents (Resident #6) reviewed for food and nutrition services.<BR/>The facility failed to ensure Resident #6 had a physician's order for a pureed diet with nectar thickened liquids. The resident was prescribed a pureed diet with thin liquids and was provided a pureed diet with nectar thickened liquids. <BR/>This deficient practice could place residents who are provided a modified texture diet at risk poor intake, and weight loss and diminished quality of life.<BR/>The findings were:<BR/>Record review of Resident #6's admission record, accessed 06/07/24, revealed the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and mild protein-calorie malnutrition.<BR/>Record review of Resident #6's significant change in status MDS, dated [DATE], reflected a BIMS score of 99, indicating resident was unable to complete the interview. Further review of this MDS reflected Resident #6's cognitive skills for daily decision making was severely impaired with short term and long-term memory problems. Resident #6's MDS assessment further revealed resident was on a mechanically altered diet- require change in texture of food or liquids while a resident.<BR/>Record review of Resident #6's physician's orders for May 2024 revealed the following diet order: Special Diet: REGULAR diet Consistency: PUREED texture, Liquid: THIN consistency with an order date of 04/01/2024. <BR/>Record review of Resident #6's comprehensive person-centered care plan, undated, revealed the following focus area: [Resident #6] has swallowing problems r/t cerebral infarction, dysphagia with interventions to include Special diet: REGULAR diet, Consistency: PUREED texture, Liquid: THIN consistency, initiated 04/01/2024. <BR/>Record Review of Resident #6's weight loss history revealed no weight loss since 04/01/2024. <BR/>During an interview on 06/04/24 at 12:10 PM and record review of Resident #6's lunch meal ticket revealed it stated: DIET: Pureed, *Regular, Nectar, Resident #6's RP 1 revealed there was a nectar thickener packet on Resident #6's lunch meal tray and they had to add it to the V8 to make it nectar thickened. Resident #6's RP 1 further revealed she was unaware of the nursing staff thickened the liquids, because it has been their job to thicken the liquids for their mom. <BR/>During an interview on 06/04/24 at 12:19 PM, LVN U revealed Resident #6 should have nectar thickened liquids, according to her meal tray ticket. He further revealed the kitchen was supposed to thicken her fluids to be nectar thickened. <BR/>During an interview on 06/05/24 at 10:33 AM, Resident #6's RP 2 revealed the family comes to lunch with Resident #6 and had to thicken Resident #6's liquids to nectar consistency. This family member was able to describe the process of thickening Resident #6's liquids. It was later observed that Resident #6 received a nectar thickening packet on her 06/05/24 lunch meal tray ticket to thicken the liquids on her tray ticket. <BR/>During a combined interview on 06/06/24 at 10:52 AM, the RD revealed Resident #6's family requested for Resident #6 to have nectar thickened liquids. She further revealed she was allowed to downgrade diets from thin to nectar thickened liquids on Point Click Care and meal tray cards. The CDM revealed the kitchen did not thicken liquids to the nectar consistency, because by the time they would get to the resident, the liquids that were thickened in the kitchen would be too thickened and hard to drink. The CDM further revealed the trays that need to have liquids thickened to nectar consistency were sent with packets of thickening agents for the nursing staff to add to liquid when they put the residents' trays down. They both revealed residents needed to have the right consistency as a safety precaution to prevent adverse reactions such as coughing or choking. <BR/>Record review of the facility's policy Thickened liquids, revised 1/24, reflected the following:<BR/>Thickened liquids will be available for those who have difficulty swallowing thin liquids. Liquids will be thickened to the degree specified in the physician or designee's orders.<BR/>Physician/designee orders thickened liquids in medical record.<BR/>Food and Nutrition Department ensures resident nutrition profile is updated with thickened liquid order and provides thickened liquids per community approved diets.<BR/>Record review of the facility's policy, Physician delegated diet and nutrition orders, revised 01/24, reflected A resident's attending physician may delegate the task of writing diet orders to a qualified dietitian .

Based on observations, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that:<BR/>1. Ice machine had a pink film across the lip of the ice shoot.<BR/>2. Low temperature dishwasher temperature for wash cycle was 114 degrees Fahrenheit and 115 degrees Fahrenheit. should have been 120 degrees Fahrenheit. <BR/>3. The Dish machine log was not completed.<BR/>4. Dietary aid _G_ was at dish machine and had several jewelry on, such as rings and bracelets. <BR/>This failure could place residents at risk of cross contamination Ns food borne illness. <BR/>The Findings included were:<BR/>1. <BR/>Observation on 4/18/23 at 9:45 AM to 10:00 AM during the initial tour of kitchen with the CDM and the FSM revealed the following:<BR/>a. <BR/> the ice machine had a pink film across the lip of the ice machine.<BR/>b. <BR/>The dishwasher was a low temperature machine running the wash cycle was at 114 degrees Fahrenheit. <BR/>c. <BR/>the dish machine log was missing temperatures from 4/15/2023-4/16/2023 for the dinner temperature check, and 4/17/2023 missing temperature for breakfast, lunch and dinner check. <BR/>d. <BR/>Dietary aide G was washing dishes while using the dish machine and had several rings, bracelets on both hands and had long fingernails. Dietary aide G was not wearing gloves.<BR/>Interview on 4/18/23 at 9:46 AM during the initial tour of kitchen with the CDM stated cranberry juice must have spilled in the ice machine. The FSM stated the ice machine was completely cleaned inside once a month or as needed. The FSM stated the dish machine was a low temperature. The CDM and FSM had no comment at the time . about the ice machine.<BR/>2. Observation on 4/21/2023 at 1:04 PM dietary aide G was wearing several rings, bracelets and long fingernails while washing dishes in the dish machine area. Dietary aide G was not wearing gloves.<BR/>Observation on 4/21/2023 at 1:04 PM the low temperature dish machine wash cycle was at 115 degrees Fahrenheit. <BR/>Observation on 4/21/2023 at 1:08 PM the plate guard on the dish machine revealed The equipment is intended for the washing and sanitizing of dishes and glassware as well as pots., pans and utensils. Hot Water sanitizing revealed wash temperature was 160-degree Fahrenheit minimum and Chemical sanitizing was documented Wash temperature at 130 degrees Fahrenheit minimum. <BR/>Interview on 4/21/2023 at 1:05 PM dietary aide G had no comment. on her jewelry. <BR/>Interview on 4/21/2023 at 1: 18 PM, the FSM stated the staff should not be wearing rings, bracelets and long fingernails in the kitchen. The FSM stated she talked to the dish machine vendor and stated they will be getting hot water booster for dish machine. <BR/>Interview on 4/21/2023 at 1:37 PM, the CDM confirmed the dish machine log was not completely filled out and created a new log for staff to better read and record dish machine times. The CDM stated dietary staff should not be wearing jewelry or have long fingernails in the kitchen. The CDM stated the dish machine wash cycle needs to be hotter, so the vendor said they need a booster. <BR/>Record review of the facility's policy Ware Washing dated 4/14/2003 revealed Primary Responsibility Director, Food Service Supervisor, Purpose: To reduce bacterial and the possibility of transmission of undesirable food borne organisms. Th e local, state, and federal regulations pertaining to public health safety. Policy: Dishes and other reusable components of meal service shall be washed using he proper temperature, correct chemicals and then air-dried. Procedure: 1. The #4 position is responsible for monitoring the dish machine for the proper temperature, wash and rinse 120-140 degrees. 3. The supervisor on duty will be responsible to see that he chlorine is tested and logged on the proper form daily. 4. The supervisor on duty is responsible to report any malfunctions of the machine, plumbing or chemicals to appropriate service associates. Fingernail Care: unless wearing intact gloves in good repair, no fingernail polish or artificial nails are allowed when working with exposed food. Clothing/jewelry: Avoid wearing jewelry such as dangling earrings and rings. <BR/>Record review of the facility's policy Dishwasher dated 2/18/299 revealed 1. The dishwasher is responsible for maintaining the dish machine at the proper temperature, wash 120 degrees Fahrenheit. 3. The check (temperature form for dish washer) must be done and entered on the sheet three times a day, before breakfast, dinner and supper.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .<BR/>Based on interviews and record reviews the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized, for 1 of 8 Residents (Resident #19) reviewed for complete and accurate medical records, in that:<BR/>Resident #19 medical record was missing 7 of 16 weekly Skin Assessments since 1/01/2023. <BR/>This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors or delays in care and treatment. <BR/>The findings included:<BR/>Record review of Resident #19's admission Record revealed she was an [AGE] year-old female and was admitted to the facility on [DATE]. <BR/>Record review of Resident #19's quarterly MDS dated [DATE] revealed primary reason for admission was non traumatic brain dysfunction related to dementia. Cognitive Patterns section revealed Resident #19 was unable to complete BIMS assessment. Functional Status section for bathing revealed Resident #19 was at total dependence level and required one-person physical assistance. Skin Conditions section revealed Resident #19 had a formal, clinical assessment that indicated she was at risk of developing pressure injuries. Resident #19 required a pressure reducing device for chair and applications of ointments/medications (other than to feet). <BR/>Record review of Resident #19's Care Plan revealed a focus area of potential for alteration in skin integrity with the following associated interventions: monitor and document skin condition weekly, notify physician and family if any abnormalities noted, initiated 7/25/2022. <BR/>Record review of Resident #19's Order Summary revealed orders for Skin Assessment weekly, Tuesdays on the day shift initiated 7/13/2022. <BR/>Record review of Resident #19's Assessments tab of the electronic health record revealed the Skin and Wound - Total Body Skin Assessments were missing on the following dates: <BR/>*3/28/2023, <BR/>*3/7/2023, <BR/>*2/21/2023, <BR/>*2/07/2023, <BR/>*1/31/2023, <BR/>*1/24/2023, and<BR/>*1/10/2023. <BR/>In an interview on 4/21/2023 at 8:00 PM, the DON reviewed the Assessments Tab of the electronic health record for Resident #19 stated there were multiple missing weekly Skin Assessments The DON stated there were intermittent skin assessments not documented on the same dates listed above. The DON stated this failure could negatively affect the residents by not having accurate medical records. The DON stated the direct care nurses on duty the day the assessments were due were expected to complete the assessment. <BR/>Record review of Skin and Wound Management Policy and Procedure, revised 9/06/2010, entitled II-15-021 Pressure Ulcers, revealed under step 4.) Weekly skin assessments will be performed routinely on all residents. Additional skin assessments will be performed if ordered or indicated. 5.) Assessment tools are utilized to create a plan of care .care plan modifications will be made as necessary. Physician orders will be followed. 6.) .weekly skin assessments .will be documented and maintained in the residents' clinical record. <BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for 2 of 8 Residents (Residents #25 and #36) reviewed for medication administration errors, in that:<BR/>The Facility staff administered 28 medications of which 7 were administered to Residents #25 and # 36, 1 to 1.5 hours after they were scheduled, which resulted in a 27% medication error rate.<BR/>This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings included:<BR/>Resident #25<BR/>A record review of Resident #25's face sheet, dated 04/20/2023, revealed an admission date of 11/20/2020, with diagnoses which included acute kidney failure, major depressive disorder, type II diabetes [a disease which the body cannot use sugar due to poor insulin levels result in too much damaging sugar in the blood], glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve], and hypertension [high blood pressure]. <BR/>A record review of Resident #25's quarterly MDS, dated [DATE], revealed Resident #25 was a [AGE] year-old-female who had impaired sight, used glasses, could usually make herself understood, and utilized a hearing aide. Record review of Resident #25's BIMS score revealed a 15 out of 15, which indicated no mental cognitive impairment.<BR/>A record review of Resident #25's care plan, dated 04/20/2023, revealed, Resident #25 requires and antidepressant medication duloxetine, related to depression . give antidepressant medications ordered by physician. monitor document side effects and effectiveness . resident #25 has impaired visual function related to glaucoma . monitor document report to doctor the following signs and symptoms of acute eye problems: change inability to perform activities of daily life, declines in mobility, sudden visual loss . I have diabetes mellitus . diabetes medication as ordered by doctor, monitor document for side effects and effectiveness .<BR/>A record review of Resident #25's physician's orders revealed Resident #25 was to receive the following medications twice a day at 08:00 AM and again at 08:00 PM: allopurinol 1 tablet 100 MG [works by reducing the production of uric acid in the body. High levels of uric acid may cause gout attacks or kidney stones]; duloxetine 30mg 1 tablet [used to manage major depressive disorder]; glipizide 2.5mg 1 tablet [lowers blood sugar by causing the pancreas to produce insulin (a natural substance that is needed to break down sugar in the body) and helping the body use insulin efficiently]; hydralazine 25mg 1 tablet [a medication used to treat high blood pressure and heart failure]; metoprolol 50mg 1 tablet [used alone or in combination with other medications to treat high blood pressure]; dorzolamide-timolol 2-0.5% 2 drops in each eye [the combination of dorzolamide and timolol is used to treat eye conditions, including glaucoma and eye high pressure].<BR/>During an observation, interview, and record review, on 04/20/2023 at 09:19 AM revealed LVN D was the charge nurse for unit 3. A record review of the unit-3 medication administration records revealed 8 residents were highlighted in red. LVN D stated the residents highlighted in red were indicated to receive late medication administration. LVN D stated the professional standard for medication administration was for the medications to be administered within 1 hour prior and up to 1 hour past the prescribed medication administration time. LVN D stated residents who would be receiving late medications were, Residents #5, #7, #24, #25, #32, #36, #54, and #61. LVN D stated he had not given any supervisor a report of the upcoming late administration of medications. LVN D stated he had not given any physician a report of the up coming late medication administrations. LVN D stated he intended to continue with the medication administration for the residents on unit-3 and began to prepare medications for Resident #25 which were scheduled for administration at 08:00 AM. LVN D prepared allopurinol 1 tablet 100 MG; duloxetine 30mg 1; glipizide 2.5mg 1 tablet; hydralazine 25mg 1 tablet; metoprolol 50mg 1 tablet; dorzolamide-timolol 2-0.5% 2 drops in each eye. Observation revealed LVN D administered the medications to Resident #25 at 09:23 AM.<BR/>Resident #36<BR/>A record review of Resident #36's admission record, dated 04/20/2023, revealed an admission date of 11/17/2022, with diagnoses which included, hypertension [high blood pressure] and constipation. <BR/>A record review of Resident #36's quarterly MDS, dated [DATE], revealed Resident #36 was an [AGE] year-old-female who had adequate hearing and vision, and could usually make herself understood. Resident #36 had a BIMS score of 5 out of 15 indicated severe mental cognitive impairment. <BR/>A record review of Resident #36's care plan, dated 04/20/2023, revealed, [resident number 36] has a potential for dehydration or fluid deficit related to diuretic use . administer medications as ordered. monitor document for side effects and effectiveness . monitor document report as needed any signs and symptoms of dehydration . notify physician if persistent symptoms of diarrhea, nausea vomiting unresolved past 48 hours.<BR/>A record review of Resident #36's physician's orders revealed Resident #36 was to receive the following medications twice a day at 08:00 AM and again at 08:00 PM: docusate, 1 capsule, 100mg [used for relief of constipation] and losartan, 1 tablet, 50mg [used to control high blood pressure]. <BR/>During an observation and interview, on 04/20/2023 at 09:50 AM revealed Medication Aide E assisted LVN D administer medications to residents who resided on unit 3. MA E stated he was originally assigned to administer medications on unit-4 and was reassigned to assist MA F and LVN D on unit-3 to help resolve the late medication administration. Observation revealed MA E prepare medications for Resident #36. MA E prepared docusate 1 capsule 100mg and losartan I tablet 50mg. MA E stated the medications were scheduled for 08:00 AM administration. Observation revealed MA E administered the medications at 10:01 AM. <BR/>During an interview on 04/2023 at 09:30 AM the DON and the ADON stated they had not received any report from nursing staff to alert for the upcoming late medication for the residents residing on unit 3. The ADON stated the expectation was for any nurse or medication aide who had upcoming late medication administration should give leadership an alert as to allow interventions to help eliminate the late medication administration. The DON stated measures to mitigate the late medication administration were being implemented, MA E was assigned to assist with medication administration on unit-3 and the medical director was to receive a report of the late medication administrations. The DON and the ADON stated the expectation were for residents to receive medications at the prescribed time the medication was ordered.<BR/>A record review of the facility's policy Administering Medications, dated April 2009, revealed, policy interpretation and implementation: the director of nursing services will supervise and direct all nursing personnel who administer medications and or have related functions. medications must be administered in accordance with the orders, including any required time frame . the individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication . medications may not be prepared in advance and must be administered within one hour of their prescribed time .

Based on observations, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that:<BR/>1. Ice machine had a pink film across the lip of the ice shoot.<BR/>2. Low temperature dishwasher temperature for wash cycle was 114 degrees Fahrenheit and 115 degrees Fahrenheit. should have been 120 degrees Fahrenheit. <BR/>3. The Dish machine log was not completed.<BR/>4. Dietary aid _G_ was at dish machine and had several jewelry on, such as rings and bracelets. <BR/>This failure could place residents at risk of cross contamination Ns food borne illness. <BR/>The Findings included were:<BR/>1. <BR/>Observation on 4/18/23 at 9:45 AM to 10:00 AM during the initial tour of kitchen with the CDM and the FSM revealed the following:<BR/>a. <BR/> the ice machine had a pink film across the lip of the ice machine.<BR/>b. <BR/>The dishwasher was a low temperature machine running the wash cycle was at 114 degrees Fahrenheit. <BR/>c. <BR/>the dish machine log was missing temperatures from 4/15/2023-4/16/2023 for the dinner temperature check, and 4/17/2023 missing temperature for breakfast, lunch and dinner check. <BR/>d. <BR/>Dietary aide G was washing dishes while using the dish machine and had several rings, bracelets on both hands and had long fingernails. Dietary aide G was not wearing gloves.<BR/>Interview on 4/18/23 at 9:46 AM during the initial tour of kitchen with the CDM stated cranberry juice must have spilled in the ice machine. The FSM stated the ice machine was completely cleaned inside once a month or as needed. The FSM stated the dish machine was a low temperature. The CDM and FSM had no comment at the time . about the ice machine.<BR/>2. Observation on 4/21/2023 at 1:04 PM dietary aide G was wearing several rings, bracelets and long fingernails while washing dishes in the dish machine area. Dietary aide G was not wearing gloves.<BR/>Observation on 4/21/2023 at 1:04 PM the low temperature dish machine wash cycle was at 115 degrees Fahrenheit. <BR/>Observation on 4/21/2023 at 1:08 PM the plate guard on the dish machine revealed The equipment is intended for the washing and sanitizing of dishes and glassware as well as pots., pans and utensils. Hot Water sanitizing revealed wash temperature was 160-degree Fahrenheit minimum and Chemical sanitizing was documented Wash temperature at 130 degrees Fahrenheit minimum. <BR/>Interview on 4/21/2023 at 1:05 PM dietary aide G had no comment. on her jewelry. <BR/>Interview on 4/21/2023 at 1: 18 PM, the FSM stated the staff should not be wearing rings, bracelets and long fingernails in the kitchen. The FSM stated she talked to the dish machine vendor and stated they will be getting hot water booster for dish machine. <BR/>Interview on 4/21/2023 at 1:37 PM, the CDM confirmed the dish machine log was not completely filled out and created a new log for staff to better read and record dish machine times. The CDM stated dietary staff should not be wearing jewelry or have long fingernails in the kitchen. The CDM stated the dish machine wash cycle needs to be hotter, so the vendor said they need a booster. <BR/>Record review of the facility's policy Ware Washing dated 4/14/2003 revealed Primary Responsibility Director, Food Service Supervisor, Purpose: To reduce bacterial and the possibility of transmission of undesirable food borne organisms. Th e local, state, and federal regulations pertaining to public health safety. Policy: Dishes and other reusable components of meal service shall be washed using he proper temperature, correct chemicals and then air-dried. Procedure: 1. The #4 position is responsible for monitoring the dish machine for the proper temperature, wash and rinse 120-140 degrees. 3. The supervisor on duty will be responsible to see that he chlorine is tested and logged on the proper form daily. 4. The supervisor on duty is responsible to report any malfunctions of the machine, plumbing or chemicals to appropriate service associates. Fingernail Care: unless wearing intact gloves in good repair, no fingernail polish or artificial nails are allowed when working with exposed food. Clothing/jewelry: Avoid wearing jewelry such as dangling earrings and rings. <BR/>Record review of the facility's policy Dishwasher dated 2/18/299 revealed 1. The dishwasher is responsible for maintaining the dish machine at the proper temperature, wash 120 degrees Fahrenheit. 3. The check (temperature form for dish washer) must be done and entered on the sheet three times a day, before breakfast, dinner and supper.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .<BR/>Based on interviews and record reviews the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized, for 1 of 8 Residents (Resident #19) reviewed for complete and accurate medical records, in that:<BR/>Resident #19 medical record was missing 7 of 16 weekly Skin Assessments since 1/01/2023. <BR/>This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors or delays in care and treatment. <BR/>The findings included:<BR/>Record review of Resident #19's admission Record revealed she was an [AGE] year-old female and was admitted to the facility on [DATE]. <BR/>Record review of Resident #19's quarterly MDS dated [DATE] revealed primary reason for admission was non traumatic brain dysfunction related to dementia. Cognitive Patterns section revealed Resident #19 was unable to complete BIMS assessment. Functional Status section for bathing revealed Resident #19 was at total dependence level and required one-person physical assistance. Skin Conditions section revealed Resident #19 had a formal, clinical assessment that indicated she was at risk of developing pressure injuries. Resident #19 required a pressure reducing device for chair and applications of ointments/medications (other than to feet). <BR/>Record review of Resident #19's Care Plan revealed a focus area of potential for alteration in skin integrity with the following associated interventions: monitor and document skin condition weekly, notify physician and family if any abnormalities noted, initiated 7/25/2022. <BR/>Record review of Resident #19's Order Summary revealed orders for Skin Assessment weekly, Tuesdays on the day shift initiated 7/13/2022. <BR/>Record review of Resident #19's Assessments tab of the electronic health record revealed the Skin and Wound - Total Body Skin Assessments were missing on the following dates: <BR/>*3/28/2023, <BR/>*3/7/2023, <BR/>*2/21/2023, <BR/>*2/07/2023, <BR/>*1/31/2023, <BR/>*1/24/2023, and<BR/>*1/10/2023. <BR/>In an interview on 4/21/2023 at 8:00 PM, the DON reviewed the Assessments Tab of the electronic health record for Resident #19 stated there were multiple missing weekly Skin Assessments The DON stated there were intermittent skin assessments not documented on the same dates listed above. The DON stated this failure could negatively affect the residents by not having accurate medical records. The DON stated the direct care nurses on duty the day the assessments were due were expected to complete the assessment. <BR/>Record review of Skin and Wound Management Policy and Procedure, revised 9/06/2010, entitled II-15-021 Pressure Ulcers, revealed under step 4.) Weekly skin assessments will be performed routinely on all residents. Additional skin assessments will be performed if ordered or indicated. 5.) Assessment tools are utilized to create a plan of care .care plan modifications will be made as necessary. Physician orders will be followed. 6.) .weekly skin assessments .will be documented and maintained in the residents' clinical record. <BR/>.

Based on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for dumpster 1 of 2 reviewed for garbage disposal. The facility failed to ensure the doors on dumpster 1 were secured. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: Observation on 08/05/25 at 8:36 AM, reflected the facility's dumpster area, which was outside of the dietary department to the right side of the parking lot were two commercial size dumpsters. Dumpster 1 had the left and right-side doors open which were 1/2 full of garbage. Interview on 08/05/25 at 8:40 AM, reflected the KD stated the dumpsters were for the entire facility and not just the kitchen. He stated the lids and doors on the dumpsters were supposed to be closed to keep all trash contained. He stated that the risk of the dumpster doors being opened could attract rodents. Interview on 08/05/25 at 3:31 PM, the FSS stated the kitchen and housekeeping were responsible for making sure the dumpsters were closed. He stated that the dumpsters were for the entire facility. He stated that the risk of dumpster 1 being left opened could cause critters to get into the trash. Interview on 08/07/25 at 1:15 PM, the HS revealed the housekeeping department were mainly responsible, but the dumpsters are universal to the entire facility. He stated it is not okay for the dumpster doors to be open. He stated he expected his staff to have a constant diligence on both dumpsters to be sure they were always closed. He stated that the risk of dumpster 1 doors being left open could cause a few different factors such as having unwanted rodents like racoons or skunks, infection control, or a potential of cross-contamination. Interview on 08/07/25 at 4:00 PM, the ADM revealed the dumpsters were community dumpsters, but the dietary department and housekeeping staff mainly used it. She stated she expected her department heads to manage dumpster 1 as a team and keep it closed. She stated the risk of dumpster 1 being left open exposes them to having unsanitary practices or could cause critters to wonder into the trash. Record review of the facility's policy Disposal of Garbage and Refuse, revised on 01/25 stated: Policy: The facility shall properly dispose of kitchen garbage and refuse. Policy Explanation and Compliance Guidelines: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 3 of 9 residents (confidential residents in group) reviewed for frequency of meals.<BR/>The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart.<BR/>This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. <BR/>Findings included: <BR/>Record review of the resident snack list (undated), was provided by the DM. There were 4 residents that received three times a day, to include HS snacks. The snack list provided by the DM were residents that had dialysis. There was no resident list with HS snacks provided. <BR/>Record review of the resident roster dated 6/4/2024 reflected a census of 79 residents. <BR/>Record review of the posted Meal Service Times in the dining room revealed the following:<BR/>Breakfast - 7:20 -8:00 AM <BR/>Lunch - 11:35-12:00 AM <BR/>Evening meal - 4:20 -5:00 PM- There is no posting to advise any resident a snack or availability of type of snack after specified times. <BR/>During interview on 6/6/2024 at 1: 00 PM with residents in group of 9 residents, it was brought to the attention of the state surveyors that they have not been made aware of options of a snack which were available to residents. Residents said they were not offered any HS snacks by staff. <BR/>During interview on 6/6/2024 at 2:29 PM with Restorative Aide/CNA R stated she worked (7-3:30pm) stated there was a snack box in the nursing station refrigerator.<BR/>During interview on 6/6/2024 at 4:17 PM with LVN Q stated she worked 6AM-6PM. LVN Q stated resident came to staff if they wanted some snacks, such as cookies, chips, sandwiches. LVN Q stated the diabetic resident were able to have snacks for the nursing refrigerator that were low in sugar.<BR/>During interview on 6/06/2024 at 6:15 PM with CNA S stated she worked for 31 yrs., on the 6PM-6AM shift. CNA S stated she provided HS snacks to residents if they asked her. CNA S stated she did not go around and offer residents a snack.<BR/>During interview on 6/6/2024 at 6:29 PM CNA T stated she worked for 1 year at the in facility. CNA T stated there were resident snacks in the refrigerator behind the nurse's station . CNA T stated she had not offered HS snacks to every resident, only if residents asked her. <BR/>During interview on 6/6/2024 at 6:33 PM the CDM, director of culinary services, stated she only had a dialysis snack list. CDM stated no other snacks go out from the kitchen. <BR/>During interview on 6/6/2024 at 6:35 PM with the DM stated they place resident snacks in the nursing station refrigerator. <BR/>During interview on 6/7/2024 at 11:32 AM with the ADM stated snacks were offered at bedtime to residents, nursing department and anytime a resident request a snack. The ADM stated the bedtime snacks were offered after dinner. The ADM stated if resident were not offered snacks, resident will be hungry and diabetic residents could have an effect on their blood sugars. The ADM stated resident can ask for snacks and nursing department can provided snacks. The ADM stated the Activities department had snacks when they have functions throughout the day. No other response.<BR/>Record Review of the Facility Policies and Procedures for Resident Food Services dated 5/95 revealed, SNACKS- Procedures: Nursing offers bedtime snacks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 70 (Resident #53) residents reviewed for MDS transmittal in that:<BR/>Resident #53's 5-day MDS assessment dated [DATE] and discharge MDS assessment dated [DATE] was not submitted as of 4/21/2023.<BR/>This deficient practice could place residents at risk of not having their assessments transmitted timely.<BR/>Findings included:<BR/>Record review Resident #53's admission record dated 4/20/2023 revealed he was admitted on [DATE] and readmitted on [DATE] with a discharge date d 1/8/2023. Resident #53's diagnoses included shortness of breath, fluid overload, acute respiratory failure, acute pulmonary edema, pleural effusion, dysphasia, cognitive communication deficit, chronic kidney disease, altered mental status, diabetes II, dependence of renal dialysis, anemia, major depressive disorder, end stage renal disease, and anemia. <BR/>Record review of Resident #53's EMR (electronic medical record) indicated the 5- day MDS dated [DATE] and discharge MDS dated [DATE] was documented as completed under the MDS tab. Further review revealed both the MDS assessment were not submitted on the electronic transmittal log signed by MDS nurse. <BR/>Interview on 4/21/2023 at 3:34 PM the MDS nurse, revealed Resident #53 was discharged to hospital dated 1/8/2023 at 6 PM. The MDS nurse stated Resident #53's MDS's were not submitted. The MDS nurse stated they forgot to push button to submit the MDS to CMS. The MDS nurse stated he had 14 days to submit a discharge MDS. The MDS nurse stated he was responsible for resident MDS's and the stated they follow the CMS RAI MDS [NAME]. The 5-day MDS assessments should have been submitted on 12/28/2023 and the discharge MDS should have been submitted on 1/22/2023. <BR/>Interview on 4/21/2023 at 3:58 PM the Administrator stated she was not aware that an MDS was not submitted to CMS. The Administrator stated she was not here at the time. The Administrator did not say anything else and just wrote the concerns down on a piece of paper. <BR/>Record review of the facility's policy Resident Assessment Instrument dated November 2010 revealed A Comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility faield to ensure resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for for 3 of 21 (Room#243, Room#237 and room [ROOM NUMBER]) resident rooms during initial rounds in that:<BR/>1. <BR/>room [ROOM NUMBER]'s bathroom, the shower chair had black substance on the back side of the nylon mesh used to hold up body in place and at the bottom side of shower chair. <BR/>2. <BR/> room [ROOM NUMBER]'s bathroom shower curtain had black substance on it. <BR/>3. <BR/>room [ROOM NUMBER]'s bathroom shower curtain had brown substance on it.<BR/>This could affect residents and place residents at risk for infections. <BR/>The Findings included were:<BR/>1.Observation on 4/18/2023 at 11:28 AM in room [ROOM NUMBER] the shower curtain had black substance on it. (alongside of mesh seems that meet plastic pipes)<BR/>2.Observations on 4/18/2023 at 11:35 AM in room [ROOM NUMBER]'s bathroom, the shower chair had black substance on the back side of the nylon mesh used to hold up body in place and the bottom of shower chair. <BR/>Observation on 4/20/2023 at 9:40 AM in bathroom of room [ROOM NUMBER] revealed the shower chair had black substance. <BR/>3.Observation on 4/19/23 at 2:32 PM in room [ROOM NUMBER]'s bathroom shower curtain had brown substance on it. <BR/>Interview on 4/18/2023 at 11:39 AM, housekeeper H was in the hallway, this surveyor asked for her to come to rooms #243, #237, #246, she stated the shower chair had black a substance on the shower chair. The housekeeper H revealed she cleaned resident rooms daily, including showers. The housekeeper H stated the CNA's clean the resident shower chairs. <BR/>Interview on 4/18/2023 at 1:17 PM, CNA I, she was in the hallway and asked by surveyor to come to room [ROOM NUMBER], #237, #246, she stated the shower chair had black substance on the back side of the nylon mesh and the bottom of the shower chair. The CNA I revealed she cleaned the resident shower chairs after each resident use but did not clean the back side or bottom of the shower chair. CNA I stated she cleaned on top of shower chair where the resident sits for showers. CNA I stated the housekeeper cleans the resident shower chairs and curtains. CNA I stated she would report to housekeeping about shower rooms. <BR/>Observations on 4/20/2023 at 4:33 PM RN J stated resident room [ROOM NUMBER] shower chair had black substance, room [ROOM NUMBER] shower curtain had mildew and room [ROOM NUMBER] shower curtain had mildew. <BR/>Interview on 4/20/23 at 4:33 PM with RNJ stated the resident shower chair and curtains for rooms #243, #237 and #246 had mildew and black substance on them. RN J stated the shower rooms were not reported to the nurse but will let housekeeping supervisor and maintenance supervisor aware.<BR/>Observation and interview on at 4/20/23 at 4:44 PM the housekeeping supervisor and maintenance supervisor observed rooms #243, #237 and #246. The housekeeping supervisor stated the CNAs clean after and in between residents, this should be reported into maintenance software, we can pressure wash the shower chairs, staff could also call the front desk, she does work order, or they tell maintenance. The maintenance supervisor stated the shower chair was not safe, so it will be removed from room. <BR/>Interview on 4/21/2023 at 3:58 PM with the Administrator discussed concerns with resident room shower chair and shower curtains. The Administrator did not say anything and wrote down the surveyor concerns with resident shower rooms. Surveyor asked for policy, no policy provided before exit.