Copperas Cove LTC Partners, Inc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #41 and Resident #58) of 14 residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #41's room was in a position that was accessible to Resident #41. <BR/>The facility failed to ensure the call light system in Resident #58's room was in a position that was accessible to Resident #58.<BR/>This failure could place Resident #41 and Resident #58 at risk of being unable to obtain assistance when needed and help in the event of an emergency. <BR/>Findings included: <BR/>Review of Resident #41's Face Sheet, dated 09/19/2024, reflected that Resident #41 was an [AGE] year-old male admitted [DATE]. Resident #41 was diagnosed with Alzheimer's disease (disorder that causes the brain to shrink and brain cells to eventually die) and heart failure (heart does not pump as well as it should). <BR/>Review of Resident #41's Comprehensive MDS (Minimum Data Set: tool used to measure health status) Assessment, dated 09/01/24, reflected that Resident #41 had moderate cognitive impairment with a BIMS (Brief Interview for Mental Status: tool used to screen cognitive function) score of 08. This assessment reflected that Resident #41 had a previous fall and required assistance with self-care needs. <BR/>Review of Resident #41's Care Plan, dated 08/28/24, reflected that Resident #41 required assistance with daily care. One intervention was to encourage Resident #41 to assist in his daily care as able. Another focus was that the resident has high potential for falls due to waking without assistive devices. Interventions listed in the care plan were to observe gait and report changes to therapy and encourage resident to have rest periods during the day.<BR/>An observation on 09/17/24 at 09:10 AM revealed that Resident #41 was lying in bed with his eyes closed. Resident #41's call light was looped over the fixture on the wall where the call light was plugged in. <BR/>Review of Resident #58's Face Sheet, dated 09/19/24, reflected that Resident #58 was an [AGE] year-old male admitted [DATE]. Resident #58 was diagnosed with dementia (decline in cognitive abilities) and major depressive disorder (feeling extremely sad, empty, or hopeless). <BR/>Review of Resident #58's Quarterly MDS Assessment, dated 08/02/24, reflected that Resident #58 had severely impaired cognition with a BIMS score of 07. Resident #58 had experienced falls and required assistance with all areas of self-care.<BR/>Review of Resident #58's Care Plan, dated 05/11/24, reflected that the resident lost balance while walking without assistive device. One intervention was to re-educate Resident #58 to ask for assistance as needed. <BR/>An observation on 09/17/24 at 09:12 revealed that Resident #58 was lying in bed. Resident #58's call light was looped over the fixture on the wall where the call light was plugged in. <BR/>During an interview on 09/17/24 at 10:15 AM, CNA G stated that the residents' call lights should have been within reach. CNA G stated that if a resident fell, had an emergency, or needed anything, the call light should be in his or her hand. CNA G stated that the residents depend on staff, and she tried to spend time with them and get to know their needs. <BR/>During an interview on 09/17/24 at 10:25 AM, CNA H stated that the residents should have had their call lights within reach. CNA H stated that the residents forgot what the call light was and had to be reminded every day what it was and how to use it. She stated that she checked more often on the ones who did not remember to use their call light. CNA H stated that if residents have their call light in reach, she can get to them quickly to get a drink, take them to the restroom, or help them with whatever they need. <BR/>During an interview on 09/17/24 at 12:45 PM, the ADON stated that all residents, even those who forget to use their call light, should have access to call any time they need assistance. The ADON stated that residents may try to get up, and risk falling, if they do not have their call light.<BR/>During an interview with the DON on 09/17/24 at 01:00 PM, she stated that it was important that the residents were able to express their needs. The DON stated that some of the residents were not able to get up on their own and that the call light was a safety net. The DON stated that some residents need assistance with transfers and must be able to make their needs known timely. She stated that staff round and check on the residents frequently, but a resident may need something soon after a staff member left his or her room. She stated that the call light should always be within reach. <BR/>The facility's policy Answering the Call Light, revised March 2021, reflected that when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #1) of 7 (seven) residents reviewed for weight loss.The facility failed to follow its procedures and provide effective interventions to prevent weight loss in Resident #1, who had a 10.39% weight loss between 10/09/25 and 11/03/25. Resident #1 was not weighed when she was admitted to the facility on [DATE]. Resident #1 was not weighed weekly x 4 weeks after her admission to the facility. Nutritional supplements were recommended by the RD on 10/15/25. They were ordered 11/14/25. Resident #1 died on [DATE].This failure could place residents at risk of dehydration, malnutrition, functional decline and death.Findings included:Record review of Resident #1's face sheet, dated 11/20/25, revealed an eighty-four-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), fracture of the right femur (a break in the thigh bone, which is the longest and strongest bone in the human body), recurrent depressive disorders (the person has a history of at least two depressive episodes (depressed mood or loss of pleasure or interest in activities) for long periods of time).Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly assessment dated [DATE] revealed a BIMS score of zero indicating severe cognitive issues. Record review of Resident #1's care plan revealed a focus dated 10/20/25 of Resident #1 refused to eat/resisted feeding with interventions dated 10/20/25 of 1. Administer medications as ordered. Monitor/document for side effects and effectiveness.2. Resident #1 needed encouragement/support to be independent with eating. Allow Resident #1 to feed self if desired, regardless of skill.3. Empower Resident #1 by allowing choices in mealtime, menu selection, dining location.4. Invite Resident #1 to food-related activities and offer food, beverages of choice to encourage intake. Record review of Resident #1's facility weights reflected two weight records 10/09/25 scale mechanical lift value 129.0 pounds and 11/03/25 scale mechanical lift value 115.6 pounds representing a weight loss of 10.39 percent in 25 days. Record review of Resident #1's progress notes dated 10/15/25 reflected Resident #1 refused meals. RD recommended providing supplemental support house supplement 2.0 120 ml QID in between meals; update related to food preferences to provide meals and snacks of choice. Record review of Resident #1's order dated 11/14/25 reflected diet supplement of house supplement order type medication aide supplement four times a day for house supplement 2.0 (a nutrient-dense supplement for managing weight loss, malnutrition) four times a day. Resident #1's November 2025 MAR for House Supplement four times a day for house supplement 2.0 four times a day reflected no refusals of supplement by Resident #1.Interview on 11/20/25 at 10:47 am with the DON reflected Resident #1 died on [DATE], and she was not on hospice care. The DON said Resident #1 died from failure to thrive. She said the RA did the facility weights and if the RA was not there, CNA B did resident weights. The DON said it was the responsibility of the ADON to make sure that the weights were taken. The DON said Resident #1 should have been weighed on 10/03/25 when she was admitted to the facility. The DON did not see documentation that Resident #1 refused to be weighed during Resident #1's time at the facility. She said the facility did not follow its policy for weighing residents. The DON said the possible negative effects of not weighing residents according to facility policy was that staff could not tell if residents had a significant amount of weight loss. She said when the RD entered the facility on 10/15/24, it would have been important to have given the RD the correct weight information for a resident who was not eating. The DON said the facility should have been on top of the weights. The DON said the RD recommended a supplement, but the supplement was not ordered until 11/14/25. She was not sure why it took so long for the order to be placed. She said Resident #1's supplement was not received timely and Resident #1's weight loss was not appropriately addressed. The DON said she knew the responsibility for weights and monitoring the ordering of supplements, fell on her. The DON said they did not know Resident #1 had that amount of weight loss, and had she known, she would have tried to get more supplements and spoken with the family to see if they would have been interested in hospice. The DON said she would have done a lot of things differently. She said the lack of addressing the weight loss could have led to Resident #1's failure to thrive and ultimately her death. Interview on 11/20/25 at 10:47 am with the RD reflected she saw Resident #1 on 10/15/25 and Resident #1 was not flagging for a significant weight loss. The RD said she saw Resident #1 on 11/11/25 for a significant weight loss. The RD said that Resident #1's weight loss would have given her a better picture of what was happening with Resident #1's nutrition. The RD said Resident #1 should have been weighed when she entered the facility. For some reason there was a gap in Resident #1's weights, and she did not know why. The RD said if the intervention she made 10/15/25 for supplements had been implemented, it might have made a difference, but she could not say for sure. The RD said she notified the DON that her recommendation made on 10/15/25 for Resident #1 to have a supplement was not ordered, the DON corrected it right away. The first weight The RD received for Resident #1 was 11/11/25. The RD stated had she known about Resident #1's weight loss, she might have added an intervention. Interview on 11/20/25 at 12:51 pm with the NP reflected Resident #1 came from another skilled nursing facility and the family wanted to hold off on hospice. The NP said she was aware that Resident #1 refused to eat. The NP said she did prescribe Resident #1 an appetite stimulate, but Resident #1 refused the medication. The NP said she ordered labs for Resident #1, and they all came back fine but Resident #1 refused food. The NP said she did not feel nutritional stimulants would have helped Resident #1, but she would have liked to have had more weights. The NP stated she had phone calls from the DON that consistently discussed Resident #1's refusal to eat. Interview on 11/21/25 at 10:57 am with the ADON reflected she had been the ADON at the facility for 1 (one) month. The ADON said CNA B, who was also responsible for transportation, was responsible for doing weights and the RA was also responsible for weights. She stated she would have to look at the weight policy before she was able to state the facility's policy for when residents should be weighed. She said maybe she was responsible for making sure residents were weighed according to facility policy, but she was unsure because she was still learning her role. She stated it was important to weigh residents and track their weight to see if they had lost weight because weight could affect everything. She stated weight can affect resident wound care, and their overall nutrition. If a resident lost weight, the facility should notify the family and the dietician to incorporate a change to the residents' diet, find out what the resident liked to eat, and encourage them to eat. In her experience, she had not been the person who was having to get resident weights. She would guess residents would be weighed on either a weekly or a monthly basis. She just knew the basics without referring to the policy. She did not do what she was supposed to do when the RD recommended supplements for Resident #1. She now knows the process of getting a RD recommended supplement ordered for a resident. If they did not check weights, residents could get malnourished and lose weight and a significant amount of weight loss could be determinantal. Even if a resident was refusing meals, weight should still be tracked so they can implement supplements accordingly. She said the possible negative effect of not implementing supplements for a resident who was not eating would be possible loss of weight. She did not know why Resident #1 died. Interview on 11/21/25 at 11:32 am with LVN F reflected it was important to weight residents to see if they were gaining or losing weight because the resident might have failure to thrive and may need a supplement. Residents should be weighed upon admission, then once a week, for 2 weeks, then 1 time a month if things were going well. The possible negative effect of not weighing a resident, who was not eating, was that you would not know the amount of weight lost, and it could be a significant change. If there was significant weight loss, the facility could bring in the RD and notify the NP or the MD, and they could add an order for supplements. If an order for a supplement was not entered for approximately a month, the resident could continue to lose weight. Interview on 11/21/25 at 12:01 pm with RA reflected she did the monthly weights for the residents. Some residents had weekly weights, but she did weights for the residents who had monthly weights. She did not know who did the resident weekly weights. She began working as the RA on 11/01/25. She did not enter the weights in the EMR. She was given a list of residents to weight, and she wrote their weight on a paper list and gave it to the DON. She did not know who entered the weights into the EMR. If a resident refused to be weighed, she told the nurse. Interview on 11/21/25 at 12:40 pm with CNA B reflected she did the weekly weights. No one asked her to do weights on Resident #1. She knew residents were weighed upon admission and every Monday for the next four weeks if they were under 100 pounds. It was important to take resident weights to see if they were losing or gaining weight. Residents might need to have an adjustment to their diet. You cannot tell if they need a food change if you do not take their weights. She said it was the responsibility of her and the DON to make sure weights were done. The facility had a change in management, and she was not sure if things had changed.Interview on 11/21/25 at 2:59 pm with the RCD reflected the facility policy on weights for residents was for residents to be weighed on admission and then once a week for the next 4 (four) weeks. She said the facility did not follow the policy, The policy was in place to make sure residents were not losing weight and to make sure residents' weight were stable. If they have this information the facility can intervene before residents lose too much weight. She said absolutely the interventions for the supplements recommended by the RD should have been put in place sooner. She said it was a system failure and the facility did not follow its policy with getting weights on admission and putting appropriate interventions in place when a weight trigger was noticed. The ADON was responsible for the dietary recommendations and did not follow through and notify the NP when the supplements were recommended by the RD. When the DON found out that the dietary recommendations were not put in place, the DON had the orders placed for the supplements. The ADON was responsible for doing the weights and she was aware she was responsible because she herself trained the ADON on the facility weight policy at the end of September. The DON thought the ADON was doing the weights. The failure was did not following the weight policy and a failure to delegate. Interview on 11/21/25 at 3:44 pm with the RDO reflected the weight policy was in place to monitor for weight loss, and weight gain and to provide the necessary interventions prior to weight becoming an issue. it was the responsibility of the ADON to make sure Resident #1's supplement was ordered on 10/15/25. She did not know why it did not get ordered on 10/15/25. Because the supplement was not ordered, Resident #1 did not receive timely supplement for nutritional support.Interview on 11/21/25 at 4:58 pm with the Administrator reflected the issues with not following facility weight and nutrition policy, not weighing Resident #1, and Resident #1 not receiving the recommended RD supplements when they were first recommended, was a system and communication failure. There was a communication breakdown between the RD and the facility nursing staff. The DON was responsible for the weights, and Resident #1's supplements should have been started earlier. It was the responsibility of the ADON to look at the RD recommendations and communicate the recommendation to the physician. It would have been Resident #1's right to refuse the supplement, but it was the facility's responsibility to offer the supplements. Record review of the facility's undated Weight Assessment and Intervention policy revealed Policy Statement - The nursing staff and the Dietitian will cooperate to prevent, monitor, & intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation - The nursing staff will measure resident weights on admission and weekly x 4 weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Significant weight loss will continue to be weighed weekly. All residents will be weighed monthly by the 10th. Weights will be recorded in Weight Record chart in the individual's medical record. The dietician will also review the Weight Record by the 30th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietitian whether or not the definition of Significant Weight Change is met. Significant Weight Changes are defined as: more or less than 5 percent within 30 days, more or less than 7.5 percent in 3 months; and more or less than I0 percent within 6 months. If a weight loss meets the definition of Significant, the Dietitian should discuss with the Interdisciplinary Team if a Significant Change MDS is necessary. Care Plan interventions will consider Severity of change, medical diagnosis (e.g., condition, prognosis, and stability); activities of daily living status, medications, psychological status, family input, resident preferences, and input from direct care givers. All team members will provide relevant information from their discipline to provide an interdisciplinary approach. Interventions for undesirable weight loss should focus first on food (example extra food, snacks, calorie-dense food), liquid nutritional supplements, per facility formulary may be considered if resident caloric intake remains inadequate to stabilize or increase weight. Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician my order tests. Appetite stimulants, or medications as appropriate. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. The Dietitian will discuss the weight issue with the resident and/or family. If a resident declines to participate in a weight loss goal, the Dietitian will document the resident's wishes, and those wishes will be respected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the environment was free of accident and hazards for 1 of 1 resident reviewed for transfers. (Resident #1) <BR/>The facility failed to ensure Resident #1 was transferred using a gait belt on two separate occasions. <BR/>This failure could place residents at risk of injuries and falls. <BR/>Findings included: <BR/>Record review of a face sheet dated 6/8/2022 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with the diagnoses of muscle weakness, need for assistance with personal care, knee contractures and arthritis. <BR/>Record review of a MDS dated [DATE] indicated Resident #1 was usually understood by others and was usually understood. Resident #1's BIMS was a 6 indicating severe cognition problems. The MDS indicated Resident #1 required total assistance of two staff for transfers. The MDS indicated Resident #1 required extensive assistance of one staff with bed mobility, locomotion, and eating. The MDS in the area of balance indicated Resident #1 was not steady in moving from seated to standing position and surface to surface transfers. <BR/>Record review of a comprehensive care plan dated 12/18/2021 indicated Resident #1 was at risk to fall due to a past stroke with left sided weakness and use of medications. The goal was to remain free from falls. Interventions included restorative therapy to continue to enhance quality of life and staff will assist with transfers. The care plan also indicated Resident #1 had limited physical mobility requiring the assistance of one for all transfers. The interventions indicated were staff to assist Resident #1 with all transfers, staff will encourage to be out of bed and to refer to physical therapy as needed. <BR/>During an observation and interview on 6/7/2022 at 8:25 a.m., CNA E transferred Resident #1 by having Resident #1 place her arms around CNA E's neck then CNA E encircled her arms around Resident #1's back and then pivoted her to the wheelchair. CNA E said she was the float aide assisting on Hall 100 today. CNA E said she should have used a gait belt. CNA E said she had been trained on transferring with a gait belt. CNA E said Resident #1 could suffer a fall if not transferred with a gait belt. <BR/>During an observation and interview on 6/8/22 at 11:59a.m., CNA G applied shoes on Resident #1 and then assisted her with a sitting up on the side of the bed. CNA G placed the wheelchair next to bed and locked the chair. CNA G wrapped her arms around the Resident #1's waist, lifted her off the bed, and pivoted her into the wheelchair. CNA G stated she had a gait belt available, but she never used one on Resident #1 because she was so light, and Resident #1 was able to push up with her feet to assist with the transfer. CNA G said she was unsure when her last in-service was on transferring a resident. CNA G stated she was taught in CNA training to use a gait belt with every transfer. CNA G stated not using a gait belt could result in Resident #1 falling. <BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON stated she was responsible for ensuring residents were transferred appropriately using a gait belt. The DON said the employees have annual checkoffs in July 2022. The DON indicated CNA G had just been certified as a nurse aide and therefore had not had an annual check off with the facility. The DON said she was unaware of new hire check offs, but the new employee receives 3 days of orientation. The DON said she had not conducted a recent in-service on transfers but had made gait belts available for all nursing staff. <BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator stated she expected the nursing staff to use a gait belt with transfers. The Administrator stated not using a gait belt with transfers could cause an injury to the resident or the employee. The Administrator stated the DON was responsible for transfer compliance. The Administrator was unsure of a form for checkoffs upon hire to ensure competency. <BR/>Record review of the facility's Procedural Guideline #39-Assisting a Resident to Transfer to Chair or Wheelchair, dated 1/2022 indicated the purpose was to transfer a resident to chair or wheelchair without trauma or avoidable pain. The policy included guidelines and precautions with moving and lifting of residents of knowing the abilities and limitations of the resident to participate in the move, request special instruction from the nurse as needed prior to the move . 4.A. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting fingers under it . E. Grasp the transfer belt with an under-hand grip and move the resident forward so the feet are flat on the floor. F. Lean forward and instruct the resident to place hand on your shoulders. Do not let the resident put their arms around your neck. G. Place your hands on either side of the transfer belt, and on prearranged signal, gradually assist the resident up into a standing position, supporting the knees and feet with your legs and feet as appropriate.

**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 be free from abuse, neglect, misappropriation of resident property and exploitation for three of five residents (Resident #1, Resident #2, and Resident #3 ) reviewed for drug diversion. 1. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #1.2. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #2.3. The facility failed to ensure LVN A did not take 30 (thirty) Torsemide 100 mg tablets prescribed for Resident #3. These failures could place residents at risk of misappropriation, medication errors and compromised health conditions. Findings include: Record review of the facility's self-report intake, dated 5/5/2025, revealed the following: Narrative of The IncidentSame nurse entered orders for three different residents for the same medication, Torsemide. The medications were then discontinued after the pharmacy delivered the medications. Medications were signed in by same nurse and facility unable to locate three of the four medication cards that were delivered. The Medical Director and NP deny giving nurse orders for Torsemide on any of the identified residents.1. Record review of Resident #1's face sheet, dated 7/9/2025, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Her diagnoses included: Hypothyroidism (thyroid produces too much thyroid hormone), Hypertension (high blood pressure), Age-related decline (natural changed in thinking speed, memory and cognitive abilities that occur when people age, Cerebral Infarction. Record review of Resident #1's Quarterly MDS assessment, dated 6/26/2025, revealed she had a BIMS score of 3, which indicated severely impaired cognition. Record review of Resident #1's Care Plan, initiated 4/10/2025, revealed focus areas which included: I have a Vitamin/Mineral deficiency. Intervention listed as Administer medication as ordered by M.D Record review of Resident #1's Order Summary, dated 3/8/2025 at 12:40 AM, revealed an unauthorized order entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for fluid overload. A verbal order was entered in PCC by LVN-A on 3/8/2025 at 9:24 PM to discontinue the Torsemide 100mg. Record review of the Delivery Manifest Report Details, Manifest ID: M412308X0000638512, dated 3/8/2025, revealed LVN-A received sixty (60) Torsemide 100mg tablets order for Resident #1. 2. Record review of Resident #2's face sheet, dated 7/9/2025, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE]. Her diagnoses included: Senile Degeneration of the Brain (cognitive decline), Major Depressive Disorder (persistent sadness and loss of interest in activities) and Hyperlipidemia (high cholesterol). Record review of Resident #2's Quarterly MDS assessment, dated 5/16/2025, revealed she had a BIMS score of 7, which indicated severely impaired cognition. Record review of Resident #2's Care Plan, initiated 5/4/2025, revealed focus areas which included: I have a Vitamin/Mineral deficiency. Intervention listed as Administer medication as ordered by M.D. Record review of Resident #2's Order Summary, dated 4/23/2025 at 9:16 PM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 4/23/2025 at 9:16 PM to discontinue the Torsemide 100mg. Record review of Delivery Manifest Report Details, Manifest ID: M412308X0000640574, dated 4/26/2025, revealed LVN-A received ten (10) Torsemide 100mg tablets order for Resident #2. Record review of Resident #2's Physician's Order, dated 4/29/2025 at 3:22 AM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 4/29/2025 at 3:22 AM to discontinue the Torsemide 100mg. Record review of Resident #2's Physician's Order, dated 4/29/2025 at 5:03 PM, revealed an unauthorized phone order was entered in PCC by LVN-A to discontinue the Torsemide 100mg. Record review of Delivery Manifest Report Details, Manifest ID: M412308X0000640770, dated 5/1/2025, revealed LVN-A received thirty (30) Torsemide 100mg tablets order for Resident #2. 3. Record review of Resident #3's face sheet, dated 7/9/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Type 2 Diabetes (body does not produce enough insulin), Hypertension (high blood pressure and Hyperlipidemia (high cholesterol). Record review of Resident #3's Quarterly MDS assessment, dated 5/16/2025, revealed she had a BIMS score of 7, which indicated severely impaired cognition. Record review of Resident #3's Order Summary, dated 5/2/2025 at 9:55 PM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 5/3/2025 at 10:46 PM to discontinue the Torsemide 100mg. Record review of the Delivery Manifest Report Details, Manifest ID: M412308X0000640825, dated 5/3/2025 revealed LVN-A received thirty (30) Torsemide 100mg tablets order for Resident #3. During an interview on 7/9/2025 at 4:45 PM, the CMA employed with the facility for one-year, stated she was in-serviced on misappropriation within the last month. She said she would report misappropriation and/or drug diversions to the DON and ADM. She said she had not seen any medications that were not been locked in the medication cart or room.During an interview on 7/9/2025 at 5:10 PM, CNA employed at the facility for 18 months, stated she received monthly training on misappropriation and stated she would report to the charge nurse, DON, and ADM. She said she had not seen any medications that had not been locked in the medication cart or room. During an interview on 7/9/2025 at 5:25 PM, LVN-C employed at the facility for three-years, stated she received monthly in-services on misappropriation. She said if she had identified something was missing, she would have tried to locate it and then report to the DON if it could not be located. She said when medications were received from the pharmacy, the nurse was responsible to receive them, sort and verify all medications were accounted for and they were passed off to the CMAs to put them into the medication cart. She said nurses were only allowed to enter standing orders and should have obtained an approval from the nurse practitioner or medical director for all other medication orders. She said, It was illegal to enter medication orders if we did not have approval from the medical director. During an interview on 7/9/2025 at 5:40 PM, LVN-D employed at the facility for ten-years, stated when medications were delivered by the pharmacy, the nurse checked the medications against the inventory and then it was handed-off to the medication aide and placed on the medication cart. She said narcotics were placed in the locked narcotics box by the nurse. She said nurses were only allowed to enter standing orders into PCC. She identified potential harm as, We could kill someone. During an interview with the DON on 7/9/2025 at 6:00 PM, the DON employed at the facility for three-months, stated she had placed at the nurses' station a misappropriation in-service and staff were reviewing. She reviewed the process for receiving medications when the pharmacy delivered them. She said only nurses were approved to sign for the medications and the nurse was to ensure the medication count was correct. She said two signatures were required when narcotics were received. She said she ran a report from the pharmacy system and could see that LVN-A signed for the missing Torsemide, which required only one signature. She said all mediation orders were reviewed daily by the DON and ADON. Three of the four medication cards for Torsemide remained missing at the time of the interview. She said she spoke with LVN-A who admitted she entered the orders and discontinue orders into PCC to check the functionality of the system. She said LVN-A denied receiving the Torsemide from the pharmacy and she did not know the whereabouts of the medication. During an interview with the ADM on 7/9/2025 at 6:30 PM, the ADM employed at the facility for eighteen-months, stated when the pharmacy dropped of medications, the nurses were responsible to verify each medication that was delivered and sign for the medication. She said nurses were not allowed to enter medication orders without an order from the nurse practitioner or medical director. She identified harm as the resident could have been double-dosed, had an allergic reaction, potentially overdosed, and had drug to drug interactions. She said the DON and ADON were responsible to review the medication orders during the week and the RN Supervisor was responsible on the weekends. She said the process had been tightened up (improved) since the Torsemide drug diversion. An interview was attempted on 7/9/2025 with LVN-A and was unsuccessful. Interviews were attempted on 7/10/2025 and 7/14/2025 with the Medical Director and were unsuccessful. Record review of the facility's in-service titled, Discontinued Medications, 2001 MED-PASS Revised April 2007, reflected the following: Policy statement - Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. Policy Interpretation and Implementation:1. A practitioner's order to discontinue a resident's medication must be documented in the resident's clinical record and on the medication administration record (MAR).2. The nurse receiving the order to discontinue a medication is responsible for recording the information (e.g., writing discontinued date, dating, and initialing MAR) and notifying the dispensing pharmacy of the discontinuation.3. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure that one (1) resident (Resident #1) of eight residents reviewed for transfer or discharge had the required documentation in the resident's medical record made by the physician and failed to provide information to the receiving health care provider for a safe and effective transition of care.<BR/>The facility discharged Resident #1 on 9/18/2025 without physician documentation in the EMR and without providing any clinical information for continuity of care to the receiving provider. <BR/>This failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm.<BR/>The findings included:<BR/>Review of Resident #1's Face Sheet dated 2/7/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included acute kidney failure, anemia (low iron count in the blood), anxiety disorder, sleep disorder, chronic pain syndrome, hypertension (high blood pressure), and traumatic brain injury.<BR/>Review of Resident # 1's order dated 9/18/2025 reflected Discharge immediately to law enforcement after assault and resisting arrest. Resident is a danger to herself and others.<BR/>Review of the MD letter dated 2/11/2025 reflected: By allowing [Resident #1] to remain in the facility I felt it would pose an immediate threat to the safety and wellbeing of the other residents residing in the facility.<BR/>Review of Resident #1's progress notes dated 9/18/2025 at 12:20 pm reflected MD called regarding residents' behavior and new order given to immediately discharge resident [due to] her being a danger to herself and others. Further review reflected Resident #1 had become verbally and physically aggressive towards staff by ramming her walker into the staff. The police were called and had come to the facility and arrested Resident #1. Additional review of progress notes reflected no progress note from the MD regarding clinical or medical reasons for immediate discharge of Resident #1.<BR/>During an interview on 2/12/2025 at 10:50 am the former MD stated Resident #1 had an escalation of behaviors on 9/18/2025 where she verbally and physically assaulted staff. He had given an order for her immediate discharge because the police had come to the facility and arrested Resident #1. The MD stated he had not provided any progress note in the EMR explaining how resident was a danger to herself or others until 2/12/2025. The MD provided a written letter regarding Resident #1's discharge at the time of this interview on 2/12/2025.<BR/>During an interview on 2/12/2025 at 12;30 pm, the ADM stated the police did not tell the facility where Resident #1 was being taken, so no medical records or clinical information was provided for Resident #1 at the time of her arrest and discharge. She stated to her knowledge, no one from the behavioral health hospital contacted the facility for information and no nursing staff from the facility had contacted the behavioral health hospital where Resident #1 was admitted providing medical or clinical records for continuity of care. The ADM also stated she was not aware the former MD had not put a progress note in the EMR when Resident #1 was discharged .<BR/>During an interview on 2/12/2025 at 12:35 pm, the DON stated that Resident #1 left with the police, she did not attempt to find out what behavior health facility Resident #1 had been taken to for treatment. The DON stated she did not provide any clinical information or medical records to the behavior health hospital where Resident #1 was taken after she was arrested. The DON stated the facility never heard from the behavior health hospital and once [Resident #1] was discharged I didn't think about it. It wasn't something we thought we needed to do. The DON stated a safe discharge was important to keep residents safe and ensure they would get the care they need.<BR/>During an interview on 2/12/2025 at 1:01 pm, the MR staff stated she had not been contacted by anyone from the behavioral health hospital for medical records for Resident #1 and MR staff stated she had not provided any medical records for continuity of care when Resident #1 was arrested. MR staff stated the place where Resident #1 would not have known anything about her care without the facility providing medical records.<BR/>During an interview on 2/12/2025 at 4:49 pm, the ADM stated her expectation was that all residents receive a safe discharge. The ADM stated her concerns with an unsafe discharge included a resident having adequate living space and adequate care. The ADM further stated for emergency discharges there should have been a progress note from the former MD to address the safety concerns with having Resident #1 on the facility.<BR/>Review of the facility policy Transfer or Discharge, Emergency revised August 2018 reflected: <BR/>Residents will not be transferred unless: c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, d. The health of individuals in the facility would otherwise be endangered. <BR/>Further review of the policy reflected: <BR/>4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident.

Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation.<BR/>1. <BR/>The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. <BR/>2. <BR/>The facility failed to ensure food stored in 1 of 1 reach in freezer and 2 of 2 reach in refrigerators were labeled and dated with use by date. <BR/>These failures could place residents at risk for food contamination and foodborne illness.<BR/>Findings Included: <BR/>Observations on 02/12/25 at 09:32 AM in the facility's only kitchen revealed:<BR/>1 of 1, 3-door reach in refrigerator contained:<BR/>- <BR/>1 large metal tray of cheesecake was not covered or sealed from air-borne contaminants or labeled with use by date. <BR/>- <BR/>1 large metal tray of gelatin, 1 medium plastic container of diced tomatoes, 1 medium plastic container of grape jelly, 1 medium plastic container of caramel, 1 medium plastic container of pumpkin filling, 1 medium plastic container of ketchup, 2 medium plastic containers marked BKF, 2 large zip-sealed bags of tortillas, and 1 large zip-sealed bag containing individually wrapped sandwiches were not labeled or dated with use by date. <BR/>2 of 2 reach in freezers contained 1 medium zip-sealed bag of enchiladas, 3 large bags of okra, 3 large bags of French fries, 1 large bag of French toast sticks, and 1 small zip-sealed bag of ice cream that were not labeled or dated with use by date. <BR/>In an interview on 02/12/25 at 09:40 AM with the DM, she stated it was her expectation that all items stored in the refrigerator and freezers were covered and sealed off from contaminants. She stated the cheesecake tray should've been covered and not exposed. She stated it was her expectation that all food items were labeled to identify what the item was and dated with the open date or the prepared date. She stated she did not believe items needed to have the use by date. She stated the dietary staff were trained on when to throw items out. She stated a potential negative outcome to not having food items covered or dated was that's how you get sick from items not being covered or knowing when it's made. <BR/>In an interview on 02/12/25 at 03:21 PM with [NAME] A, she stated that items stored in the refrigerator and freezers should be completely covered and have the date the item was opened or prepared as well as the use by date. She stated items were rotated every 3 days and said, I am not sure why they don't have the use by date, but I am sure we will get penalized for it . <BR/>In an interview on 02/12/25 at 4:44 PM with the ADM, she stated it was her expectation that items stored in the freezers and refrigerator were covered, labeled, and dated with the date the item was prepared or placed in the refrigerator/ freezer. She stated she did not believe items needed to be labeled with the use by date and said she didn't think the facility policy stated that either. She stated that food items that were left uncovered could cause food borne illness. She stated food borne illnesses have the potential to affect all residents when food items were not dated. <BR/>Review of the facility Food Receiving and Storage policy last revised November 2022 reflected:<BR/>Food shall be received and stored in a manner that complies with safe food handling practices.<BR/>All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). <BR/>Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. <BR/>Review of the 2022 U.S. Food and Drug Administration Food Code revealed:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. <BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if <BR/>(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and <BR/>(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.<BR/>3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. <BR/>(A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: <BR/>(2) Is in a container or PACKAGE that does not bear a date or day; or <BR/>3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. <BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #41 and Resident #58) of 14 residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #41's room was in a position that was accessible to Resident #41. <BR/>The facility failed to ensure the call light system in Resident #58's room was in a position that was accessible to Resident #58.<BR/>This failure could place Resident #41 and Resident #58 at risk of being unable to obtain assistance when needed and help in the event of an emergency. <BR/>Findings included: <BR/>Review of Resident #41's Face Sheet, dated 09/19/2024, reflected that Resident #41 was an [AGE] year-old male admitted [DATE]. Resident #41 was diagnosed with Alzheimer's disease (disorder that causes the brain to shrink and brain cells to eventually die) and heart failure (heart does not pump as well as it should). <BR/>Review of Resident #41's Comprehensive MDS (Minimum Data Set: tool used to measure health status) Assessment, dated 09/01/24, reflected that Resident #41 had moderate cognitive impairment with a BIMS (Brief Interview for Mental Status: tool used to screen cognitive function) score of 08. This assessment reflected that Resident #41 had a previous fall and required assistance with self-care needs. <BR/>Review of Resident #41's Care Plan, dated 08/28/24, reflected that Resident #41 required assistance with daily care. One intervention was to encourage Resident #41 to assist in his daily care as able. Another focus was that the resident has high potential for falls due to waking without assistive devices. Interventions listed in the care plan were to observe gait and report changes to therapy and encourage resident to have rest periods during the day.<BR/>An observation on 09/17/24 at 09:10 AM revealed that Resident #41 was lying in bed with his eyes closed. Resident #41's call light was looped over the fixture on the wall where the call light was plugged in. <BR/>Review of Resident #58's Face Sheet, dated 09/19/24, reflected that Resident #58 was an [AGE] year-old male admitted [DATE]. Resident #58 was diagnosed with dementia (decline in cognitive abilities) and major depressive disorder (feeling extremely sad, empty, or hopeless). <BR/>Review of Resident #58's Quarterly MDS Assessment, dated 08/02/24, reflected that Resident #58 had severely impaired cognition with a BIMS score of 07. Resident #58 had experienced falls and required assistance with all areas of self-care.<BR/>Review of Resident #58's Care Plan, dated 05/11/24, reflected that the resident lost balance while walking without assistive device. One intervention was to re-educate Resident #58 to ask for assistance as needed. <BR/>An observation on 09/17/24 at 09:12 revealed that Resident #58 was lying in bed. Resident #58's call light was looped over the fixture on the wall where the call light was plugged in. <BR/>During an interview on 09/17/24 at 10:15 AM, CNA G stated that the residents' call lights should have been within reach. CNA G stated that if a resident fell, had an emergency, or needed anything, the call light should be in his or her hand. CNA G stated that the residents depend on staff, and she tried to spend time with them and get to know their needs. <BR/>During an interview on 09/17/24 at 10:25 AM, CNA H stated that the residents should have had their call lights within reach. CNA H stated that the residents forgot what the call light was and had to be reminded every day what it was and how to use it. She stated that she checked more often on the ones who did not remember to use their call light. CNA H stated that if residents have their call light in reach, she can get to them quickly to get a drink, take them to the restroom, or help them with whatever they need. <BR/>During an interview on 09/17/24 at 12:45 PM, the ADON stated that all residents, even those who forget to use their call light, should have access to call any time they need assistance. The ADON stated that residents may try to get up, and risk falling, if they do not have their call light.<BR/>During an interview with the DON on 09/17/24 at 01:00 PM, she stated that it was important that the residents were able to express their needs. The DON stated that some of the residents were not able to get up on their own and that the call light was a safety net. The DON stated that some residents need assistance with transfers and must be able to make their needs known timely. She stated that staff round and check on the residents frequently, but a resident may need something soon after a staff member left his or her room. She stated that the call light should always be within reach. <BR/>The facility's policy Answering the Call Light, revised March 2021, reflected that when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the right to personal privacy during medical treatment and personal care for two (Resident #1 and Resident #10) of thirteen residents reviewed for privacy.<BR/>1. <BR/>The facility failed to ensure LVN E would close Resident #1's door while administering the resident's bolus feeding (method of tube feeding that delivers large amount of formula over a short period of time).<BR/>2. <BR/>The facility failed to ensure CNA B and CNA D would close Resident #10's door while transferring the resident.<BR/>These failures could place the residents at risk of not having their right to personal privacy maintained.<BR/>Findings included: <BR/>1. <BR/>Review of Resident #1's Face Sheet, dated 09/18/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #1's pertinent diagnoses included cerebral palsy (neurological condition that affects muscle movement) and dysphagia (difficulty in swallowing).<BR/>Review of Resident #1's Quarterly MDS Assessment, dated 07/05/2024, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident was on a feeding tube (tube placed into the stomach to help get nutrition) while a resident of the facility.<BR/>Review of Resident #1's Care Plan, dated 08/19/2024, reflected the resident required tube feeding.<BR/>Review of Resident #1's Physician Order, dated 07/07/2023, reflected three times a day Nutren 2.0 1 can and Leave Upright 30-45 minutes at 0500, 1100, and 1700.<BR/>Observation and interview with LVN E on 09/18/2024 at 10:41 AM revealed LVN E was about to do a bolus feeding for Resident #1 through the resident's g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). LVN E took Resident #1 from the activity area, ushered her to her room, and positioned her beside her bed. LVN E took the things needed from the nurse's cart and placed them on the resident's side table. LVN E proceeded to provide bolus feeding. LVN E did not close the door or pull the privacy curtain while providing the bolus feeding. LVN E stated she forgot to close the door before she provided the bolus feeding. She said the door should be closed every time a bolus feeding was given to provide privacy and give dignity to the resident. She said she would make sure she would close the door every time she would do a bolus feeding.<BR/>2. <BR/>Review of Resident #10's Face Sheet, dated 09/18/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #10's pertinent diagnoses included unsteadiness on feet and abnormalities of gait and mobility.<BR/>Review of Resident #10's Quarterly MDS Assessment, dated 07/05/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was dependent on staff for chair/bed-to-chair transfer.<BR/>Review of Resident #10's Care Plan, dated 09/17/2024, reflected the resident required two people for safe transfer due to paralysis on right side via Hoyer lift used for transfers.<BR/>Review of Resident #10's Physician Order, dated 03/09/2022, reflected may use Hoyer lift for safe transfer.<BR/>Observation on 09/17/2024 at 10:40 AM revealed CNA B and CNA D were about to transfer Resident #10 from the bed to wheelchair through Hoyer lift. CNA B and CNA D put the Hoyer sling under Resident #10. CNA D went out of the room to get the wheelchair from the hall. CNA B went out of the room and took the Hoyer lift from the hall. CNA B did not close the door after getting the Hoyer lift from the hall. CNA B and CNA D proceeded to transfer Resident #10 to his wheelchair. The door was open during the transfer. CNA B went out of the room with the Hoyer lift while CNA D stayed with the resident.<BR/>In an interview with CNA D on 09/17/2024 at 11:37 AM, CNA D stated they should have closed the door before transferring Resident #10 to his wheelchair. She said the door should be closed to provide privacy to the resident. She said closing the door or pulling the privacy curtain should be done not only during transfers but every time care was provided.<BR/>In an interview with CNA B on 09/17/2024 at 1:03 PM, CNA B stated he did not close the door after getting the Hoyer lift from the hall. CNA B said the door should have been closed when they transferred Resident #10. He said transferring the resident with the door open would be a dignity issue. CNA B said the resident could be embarrassed or their self-esteem could be affected when other people could see that he was dependent on others to go to his wheelchair.<BR/>In an interview with LVN F on 09/17/2024 at 1:49 PM, LVN F stated the door should be closed every time a staff was providing care to the residents. LVN F said some residents could not communicate and even though they were feeling embarrassed, they could not verbalize it. LVN F said she would remind the CNAs to close the door every time they transfer a resident or every time they were providing care.<BR/>In an interview with the DON on 09/18/2024 at 12:36 PM, the DON stated the door should be closed when the bolus formula was given to Resident #1 and the door should be closed when Resident #10 was transferred to his wheelchair. She said the door should be closed to provide privacy to the residents and to avoid embarrassment. The DON said all the staff, including her, were responsible in providing dignity to the residents. The DON said the expectation was for the staff to make sure that they were providing care, the residents' door should be closed, or the privacy curtain should be pulled. She concluded that she would continually remind the staff the importance of providing privacy and dignity through an in-service.<BR/>In an interview with the Administrator on 09/18/2024 at 12:49 PM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent embarrassment. She said the expectation was for the staff to close the door, not only during transfer and bolus feeding, but during all care provided. Said she would collaborate with the DON and the ADON to do an in-service about privacy and dignity.<BR/>In an interview with the ADON on 07/19/2024 at 8:49 AM, the ADON stated all care should be done in the privacy of the residents' room. He said care should be done where with the door was closed to provide dignity. He said it did not matter if the residents care or not, the door should still be closed while providing care. He said it was important that the residents would be safe and would not be embarrassed. He said he would coordinate with the DON to do an in-service about dignity.<BR/>Record review of facility's policy, Dignity 2001 MED-PASS, Inc. revised February 2021 revealed Policy Statement: each resident shall be cared for a manner that promotes and enhances his or her sense of well-being Feelings of self-worth and self-esteem . Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 6/6/2022 at 10:01 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock at the head of the bed.<BR/>During an observation on 6/6/2022 at 10:03 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock on the right side of the bed.<BR/>During an observation on 6/6/2022 at 10:13 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock at the head of the bed.<BR/>During an observation and interview on 6/6/2022 at 10:18 a.m., Resident #6's over the bed light did not have a string to turn the light off. The overbed light fixture had a thin blanket thumb tacked to the wall so that the room was dim enough to sleep. Resident # 6 indicated the light did not have a string therefore she could not sleep without covering the light with a blanket. Resident #6 indicated she had made the maintenance staff, but it has yet to be fixed. The room did not have an alternate light source overhead. <BR/>During an observation on 6/6/2022 at 12:15 p.m., resident room [ROOM NUMBER]B the over the bed light only flickered it did not produce any usable light. There was not a lighting source in the ceiling for this room. The only light source available was the over the bed light for bed A. <BR/>During an observation on 6/6/2022 at 12:20 p.m., resident room [ROOM NUMBER]'s over the bed light did not function. The room does not have an alternate light source overhead. The lighting in the room was supplied by the light over A bed . <BR/>During an observation on 6/7/2022 at 10:27 a.m., resident room [ROOM NUMBER] had scratches on the wall down to the sheet rock on the left side of the bed. <BR/>During an observation on 6/7/2022 at 4:12 p.m., resident room [ROOM NUMBER] had scratches to the wall down to the sheet rock on the right side of the bed.<BR/>During an observation and interview on 6/8/2022 at 10:54 a.m., the maintenance supervisor indicated he was responsible for ensuring the resident room walls were maintained in resident room #'s 104, 106, 108, 110 and 111, and over bed lights were functionable for resident room #'s 102; 107, and 108. The maintenance supervisor indicated he was advised of rooms needing repair by the staff by receiving work orders and by the new computer system (TELLS) which emails him a work order immediately. The maintenance supervisor indicated a resident could fall due to poor lighting and a resident could be embarrassed by their home appearing unmaintained. <BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON said she expected the resident rooms to be repaired, and the over the bed lights to function properly. The DON indicated a resident could suffer a fall from poor lighting. <BR/>Record Review of Work Orders, Maintenance dated April 2010 indicated Maintenance work orders shall be completed to establish a priority of maintenance service.<BR/>Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 7 of 41 (#s 102, 104, 106, 107, 108, 110 and 111) rooms and 3 of 15 residents reviewed for environment. (Resident #6, Resident #40 and Resident #42)<BR/>-The facility did not replace the missing arm pads for both arms of wheelchair for Resident #42. <BR/>-The facility failed to repair deep scrapped areas on the walls of resident room #'s 104, 106, 108, 110 and 111. <BR/>-The facility failed to repair the over bed lights for resident room #'s 102; 107, and 108.<BR/>These failures could place the residents at risk for unsafe environment.<BR/>Findings included:<BR/>Resident #42<BR/>Record Review of Resident #42 admission records indicate he is a [AGE] year-old male that was admitted on [DATE]. Resident #42 has a history of depression, chronic pain, post-traumatic stress disorder. <BR/>Record Review of Residents #42 MDS dated [DATE] indicates he had a BIMS score of 14 which indicated an intact cognition. Section G of MDS under ADL Self-Performance indicated Resident #42 required limited assistance with transfers and one-person physical assist. Section G0600 indicates that Resident #42 uses a wheelchair for mobility and section G0300 indicates that Resident #42 is scored a 2 for not steady and only able to stabilize with staff assistance during surface-to-surface transfers.<BR/>Record Review of Resident #42 care plan dated 4-8-22 indicated the resident was at risk for falls due to transferring himself to and from wheelchair without asking for help. The goal was to remain free from falls and the Interventions was staff will ensure the wheelchair was in good condition.<BR/>During observation and interview on 6-6-22 at 10:00 am, Resident #42 was propelling himself down the hallway and stated that he was going outside to smoke, arm pads were missing from both sides of his wheelchair. Resident #42 stated that he had one missing arm pad when he was admitted to the facility and the other recently fell off. Resident #42 stated that he has been really careful not to bump his arms on the bolts.<BR/>During observation on 6-8-22 at 11:00 a.m., Resident #42 was sitting up in wheelchair in his room, no padding on either arm rest of wheelchair. <BR/>During interview with Resident #42 on 6-8-22 at 12:08 p.m., Resident #42 stated he never reported the missing arm pads on his wheelchair to anyone. Resident #42 stated he just made sure he was careful every time he tried to transfer himself so that he did not hit his arms.<BR/>Resident #40<BR/>Record Review of Resident #40 admission record indicates he was a [AGE] year-old male with a history of hemiplegia, encephalopathy (brain disease), altered mental status, and hypotension. Resident #40 was admitted on [DATE].<BR/>Record Review of MDS dated [DATE] indicated Resident #40 has a BIMS score of 7 for severely impaired cognition. Section G of the MDS under ADL Self-Performance for bed mobility, Resident #40 required extensive assistance with bed mobility and one person assist with bed mobility. Under transfers, Resident #40 was required total dependence with all transfers and one person assist.<BR/>During observation on 6-6-22 at 10:10 am, Resident #40 was lying in bed covered up with blankets, bed was pushed up against the wall and the foot of the bed was up against the window; the bottom of the window frame was broken in half and the wood in the center was sticking straight up towards the blinds. Resident #42 is not interviewable.<BR/>During observation on 6-7-22 at 9:12 am, Resident #40 was lying in bed and the window frame remained broken. Resident #42 is not interviewable.<BR/>During observation on 6-8-22 at 11:15 am, Resident #40 was lying in bed covered with blankets and window frame remained broken with wood sticking up.<BR/>During interview with the maintenance director at 11:15 am, the maintenance director stated he had not worked in several months due to a car wreck and multiple surgeries. The Maintenance director stated employees are responsible for putting in a work order either online or in the order book and he checked the books and his computer daily on the days he worked. The Maintenance director stated he was not aware of the broken window frame and stated there was not an order to fix it. Record Review of the work orders indicated that no request had been made to fix the broken window frame. The Maintenance director stated he had started on 100 hall last week doing repairs such as painting and was currently on the 200 hall. He stated he would continue until he was finished will all the halls. The Maintenance director stated he walked into each room weekly to do water temperature checks and he had not noticed the broken window frame. He stated the broken frame could result in the resident getting hurt. He stated he was responsible for fixing all wheelchairs that are provided by the facility. He stated the only equipment that he does not fix are the ones under warranty by the VA because it would void the warranty on them. He stated the nursing or therapy department would notify him using the communication form online or do a work order in the maintenance book that a wheelchair needs to be fixed and he would take care of it. The Maintenance director stated he was not aware Resident #42 needed his wheelchair arm pads replaced. <BR/>During an interview with MA L on 6-8-22 at 9:31 a.m., MA L stated she had worked at the facility since 2012. MA L stated a wheelchair with no arm pads or a broken window frame should be reported to the maintenance man immediately using a form in his book at the nurse's station. MA L stated most of the time she would notify the charge nurse and the charge nurse will complete the maintenance form, or she will just tell the maintenance man when she saw him, and he would fix it. MA L stated she was not aware of the broken window frame or the wheelchair with no arm pads.<BR/>During an interview with LVN K on 6-8-22 at 8:11 a.m., LVN K stated she had worked at the facility for 3 years. LVN K stated every resident admitted to the facility was evaluated by the therapy department and therapy department was responsible for making sure the residents wheelchairs fit them properly and were in good working order. LVN K stated therapy discussed any issues they have with residents in the Focus meeting every morning. LVN K stated they should immediately tell maintenance about the broken wheelchair because it could hurt the resident and that was what residents used to position themselves. LVN K stated staff should call maintenance immediately for the broken wood sticking up in the window because the resident could get hurt on the wood. LVN K stated the charge nurses make rounds at least every hour and go into every room. LVN K stated they use communication notes in the computer to communicate issues with maintenance and the maintenance director checked his book every day he worked. LVN K stated everyone was responsible for reporting the wheelchair with no arm pads and the broken wood in the window because someone could get hurt. LVN K stated she was not aware of the broken window frame or the wheelchair with no arm pads. <BR/>During interview on 6-8-22 at 9:19 am., DON stated the broken wood in the window frame should have been reported by whoever saw it. The DON stated that nursing and Maintenance should have been notified. She stated Resident #40 could have moved his arms and hit it or got cut. DON reported nursing staff was required to make rounds every hour and walk into each room and check on residents. DON stated that management made room rounds every Monday, Wednesday, and Friday to check rooms and make sure that everything was tidy and neat. DON reported housekeeping cleaned all the resident's rooms daily and should have noticed the broken window and reported it. DON stated the broken window should not have been missed for more than 1 shift. DON stated Resident #42's wheelchair with no arm pads should have been reported immediately. DON stated the admitting nurse should have noticed the wheelchair and the resident should have been given a loner wheelchair until his could be fixed. DON stated every resident that was admitted to the facility was evaluated by the therapy department and they made sure the residents wheelchairs are the proper size and in working order. DON stated the broken wheelchair could put resident #42 at risk for injury.<BR/>During interview with the Administrator on 6-8-22 at 9:49 a.m., the Administrator stated the broken window should be reported by whomever finds it. The Administrator stated a work order should have been completed and the broken window should have been reported to her. The Administrator stated she expected nursing staff to complete 2-hour rounds on all residents and includes checking the rooms to make sure they have working light bulbs and rooms are neat/tidy. The Administrator stated residents could have been injured from the broken wood on the window frame or they could have been cut. The Administrator stated she was responsible for Maintenance if there was no one available or when Maintenance was out on leave. The Administrator stated the missing padding on the wheelchair pads should have been reported and fixed. The Administrator stated that if it was a VA resident the facility cannot fix the wheelchair because it could void the warranty, but the resident should have been given a loner wheelchair until his wheelchair can be fixed. The Administrator stated it was the responsibility of the admitting nurse to report the wheelchair. The Administrator stated every resident was looked at by therapy and therapy was responsible for making sure the residents wheelchairs are working properly. <BR/>During interview with the Rehab Director at 10:59 a.m., the Rehab director stated she had been with the facility for 3.5 years. The Rehab director stated she does not evaluate every resident, but therapy does screen every resident. The Rehab director stated that resident #42 would have been screened if he was independent and therapy must wait for authorization for all Veterans Affairs (VA) residents. The Rehab Director stated they are responsible for checking wheelchairs when therapy's screen residents. The Rehab Director stated the residents get their wheelchairs mixed up a lot and Resident #42 might not have been in his own wheelchair at the time of screening. The Rehab Director stated if Resident #42 was screened and the arm rest was missing, she would have notified maintenance at that time. The Rehab Director stated the missing arm pads could result in resident having sores on his arm and make it difficult for him to transfer. The Rehab Director stated there are extra wheelchairs available at facility that residents can borrow until they can get he's fixed. <BR/>Record Review of the Maintenance log on 6-8-22 indicated no orders were logged for Resident #40 or Resident #42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a person-centered plan of care and provide services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents reviewed for plans of care (#47). <BR/>The facility failed to care plan Resident #47 was not to have straws with her drinks.<BR/>These failures could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and/or a decline in physical well-being. <BR/>Findings included: <BR/>Record review of a face sheet dated 6/7/2022 indicated Resident #47 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnosis of acute respiratory failure with not enough oxygen difficulty swallowing, and dementia. <BR/>Record review of a physician's order dated 5/21/2019 indicated Resident #47 had an order for no straws with drinks. <BR/>Record review of an MDS dated [DATE] indicated Resident #47 was usually understood and usually could understand others. The MDS indicated Resident #47 required limited assistance of one staff for eating. <BR/>Record review of the undated comprehensive care plan in its entirety failed to mention Resident #47's diagnosis of difficulty swallowing and the need for no straws. <BR/>During an observation and interview on 6/6/2022 at 2:32 p.m., Resident #47 had a water pitcher with a straw in it on her over bed table. On the overbed light in Resident #47's room a sign was posted on green copy paper indicating NO STRAWS. Resident #47 was not able to be interviewed due to cognitive impairment. <BR/>During an observation on 6/7/2022 at 10:26 a.m., Resident #47's water pitcher at bedside had a straw in the pitcher. The signage on the overbed light for Resident #47's bed indicated NO STRAWS.<BR/>During an interview on 6/7/2022 at 11:25 a.m., the speech therapist said Resident #47 was on speech therapy at the present time. The speech therapist said Resident #47 was working on cognition and swallowing to ensure the toleration of her mechanical soft diet and thin liquids. The speech therapist said she was unaware of the physician's order for no straws. The speech therapist indicated she believed the signage was old. <BR/>During an observation and interview on 6/7/2022 at 12:07 p.m., LVN A said she was responsible for the care of Resident #47. LVN A said Resident #47 had a history of aspiration of fluids. LVN A said Resident #47 was not to have a straw due to being at risk for aspiration. LVN A removed the straw during the interview.<BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON said the care plan directed the care of a resident. The DON said when the care changes for a resident the care plan should be updated. The DON said the MDS nurse was responsible for updating the care plan and the Regional MDS nurse had oversight of the facility MDS nurse . <BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator said she expected the care plan to be updated to accurately reflect the resident's needs. The Administrator said the DON was responsible for ensuring the accuracy of the care plan as she signs off on them. <BR/>Record review of the facility's undated policy, Policy and Procedure Comprehensive Care Planning indicated the purpose was to ensure every resident had a comprehensive, complete, accurate, and all-inclusive specific care plan written timely to meet all requirements of the Resident Assessment Instrument and regulatory process to include all input from the intradisciplinary team members. 7. Every resident will have all active medical diagnosis along with medications and treatments related to the specific needs of each resident care planned and revised routinely. <BR/>Record review of the facility's policy, Physician orders dated June 2004 indicated physician orders must be given and managed in accordance with applicable laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for one (Resident #66) of three resident reviewed for pressure ulcers. <BR/>The facility failed to ensure LVN F cleaned the pressure ulcer on Resident #66's right heel from inside to outside.<BR/>This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers. <BR/>Findings included: <BR/>Review of Resident #66's Face Sheet, dated 09/18/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. One of Resident #66's diagnosis was type 2 diabetes mellitus (body has higher sugar level) without complications.<BR/>Review of Resident #66's Quarterly MDS Assessment, dated 08/13/2024, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident had one or more unhealed pressure ulcers.<BR/>Review of Resident #66's Comprehensive Care Plan, dated 07/27/2024, reflected the resident had an unstageable pressure injury right heel R/T immobility, nutrition, and disease process with one of the interventions to administer treatments as ordered.<BR/>Review of Resident #66's Physician's Order, dated 08/15/2024, reflected Cleanse unstageable to right heel with NS, pat dry, apply betadine, and cover with foam border dressing one time a day AND as needed, or if it becomes soiled or comes off.<BR/>Observation and interview on 09/17/2024 at 1:07 PM revealed LVN F prepared the things needed for Resident #66's wound care. LVN F washed her hands and put on a pair of gloves. She put pillows under Resident #66's right leg to access his right heel. LVN F peeled off the old dressing from the resident's right heel and discarded it. She took off her gloves and put on a new pair of gloves. She did not sanitize her hands before putting on the new pair of gloves. LVN F took some gauze, sprayed wound cleanser on the gauze, and started to clean the wound on the resident's right heel. LVN F started from inside the wound and then proceeded to clean around the wound using the same gauze. After cleaning around the wound, LVN F used the same gauze and cleaned again the inside of the wound. She did not get another gauze to clean the inside of the wound again. LVN F took the betadine, applied it to the wound, and covered the wound with a 4 by 4 border foam dressing. LVN F stated the proper way to clean the wound was from inside to outside. She said after cleaning the skin around the wound, the gauze should have been discarded. She said she should have gotten a clean gauze to clean the inner part of the wound again and not use the gauze that she used to clean the skin around the wound. LVN F said the gauze that touched the outside of the wound must not touch the inner portion of the wound because the skin surrounding the wound was not clean. She said she would remember to be careful to not touch the wound with the gauze that already touched the skin outside of the wound because the existing wound could get infected.<BR/>In an interview with the DON on 09/18/2024 at 12:36 PM, the DON stated the proper way of cleaning the wound was from the inside to outward. The DON said this method would promote healing, prevent cross contamination, and prevent infection. The DON said the expectation was for the staff to have a conscious effort in doing the right method of wound care. The DON further added she would re-educate the staff regarding wound care and closely monitor if they were following the policy and procedure for wound care.<BR/>In an interview with the Administrator on 09/18/2024 at 12:49 PM, the Administrator stated the staff should do whatever was the right procedure in doing wound care to promote healing. The Administrator said the expectation was for the staff to make sure proper technique was used in doing wound care to prevent wound infection. The Administrator said he would collaborate with the clinicians to remind the staff to use the proper technique for wound care.<BR/>In an interview with the ADON on 07/19/2024 at 8:49 AM, the ADON stated the proper technique in cleaning the wound was cleaning the center first and then the outside of the wound. The ADON also said the gauze should be discarded after each wipe. The ADON said improper wound care could cause cross contamination and infection. The ADON said the expectation was for the staff to know how to clean a wound to prevent unfavorable outcomes. The ADON said he would do an in-service about wound care and monitor their adherence to the right procedure of wound care.<BR/>Review of facility's policy Dressing, Sterile2001 MED-PASS, Inc. revised September 2013 revealed Procedure: . 14. Cleanse the wound from least contaminated area to the most contaminated area (usually, from the center outward).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the environment was free of accident and hazards for 1 of 1 resident reviewed for transfers. (Resident #1) <BR/>The facility failed to ensure Resident #1 was transferred using a gait belt on two separate occasions. <BR/>This failure could place residents at risk of injuries and falls. <BR/>Findings included: <BR/>Record review of a face sheet dated 6/8/2022 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with the diagnoses of muscle weakness, need for assistance with personal care, knee contractures and arthritis. <BR/>Record review of a MDS dated [DATE] indicated Resident #1 was usually understood by others and was usually understood. Resident #1's BIMS was a 6 indicating severe cognition problems. The MDS indicated Resident #1 required total assistance of two staff for transfers. The MDS indicated Resident #1 required extensive assistance of one staff with bed mobility, locomotion, and eating. The MDS in the area of balance indicated Resident #1 was not steady in moving from seated to standing position and surface to surface transfers. <BR/>Record review of a comprehensive care plan dated 12/18/2021 indicated Resident #1 was at risk to fall due to a past stroke with left sided weakness and use of medications. The goal was to remain free from falls. Interventions included restorative therapy to continue to enhance quality of life and staff will assist with transfers. The care plan also indicated Resident #1 had limited physical mobility requiring the assistance of one for all transfers. The interventions indicated were staff to assist Resident #1 with all transfers, staff will encourage to be out of bed and to refer to physical therapy as needed. <BR/>During an observation and interview on 6/7/2022 at 8:25 a.m., CNA E transferred Resident #1 by having Resident #1 place her arms around CNA E's neck then CNA E encircled her arms around Resident #1's back and then pivoted her to the wheelchair. CNA E said she was the float aide assisting on Hall 100 today. CNA E said she should have used a gait belt. CNA E said she had been trained on transferring with a gait belt. CNA E said Resident #1 could suffer a fall if not transferred with a gait belt. <BR/>During an observation and interview on 6/8/22 at 11:59a.m., CNA G applied shoes on Resident #1 and then assisted her with a sitting up on the side of the bed. CNA G placed the wheelchair next to bed and locked the chair. CNA G wrapped her arms around the Resident #1's waist, lifted her off the bed, and pivoted her into the wheelchair. CNA G stated she had a gait belt available, but she never used one on Resident #1 because she was so light, and Resident #1 was able to push up with her feet to assist with the transfer. CNA G said she was unsure when her last in-service was on transferring a resident. CNA G stated she was taught in CNA training to use a gait belt with every transfer. CNA G stated not using a gait belt could result in Resident #1 falling. <BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON stated she was responsible for ensuring residents were transferred appropriately using a gait belt. The DON said the employees have annual checkoffs in July 2022. The DON indicated CNA G had just been certified as a nurse aide and therefore had not had an annual check off with the facility. The DON said she was unaware of new hire check offs, but the new employee receives 3 days of orientation. The DON said she had not conducted a recent in-service on transfers but had made gait belts available for all nursing staff. <BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator stated she expected the nursing staff to use a gait belt with transfers. The Administrator stated not using a gait belt with transfers could cause an injury to the resident or the employee. The Administrator stated the DON was responsible for transfer compliance. The Administrator was unsure of a form for checkoffs upon hire to ensure competency. <BR/>Record review of the facility's Procedural Guideline #39-Assisting a Resident to Transfer to Chair or Wheelchair, dated 1/2022 indicated the purpose was to transfer a resident to chair or wheelchair without trauma or avoidable pain. The policy included guidelines and precautions with moving and lifting of residents of knowing the abilities and limitations of the resident to participate in the move, request special instruction from the nurse as needed prior to the move . 4.A. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting fingers under it . E. Grasp the transfer belt with an under-hand grip and move the resident forward so the feet are flat on the floor. F. Lean forward and instruct the resident to place hand on your shoulders. Do not let the resident put their arms around your neck. G. Place your hands on either side of the transfer belt, and on prearranged signal, gradually assist the resident up into a standing position, supporting the knees and feet with your legs and feet as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Resident #10, Resident #11, Resident #52, Resident #61, Resident #68, and Resident #222) of twelve residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure that Resident #10, #11, #52, and #68's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) were properly stored.<BR/>2. <BR/>The facility failed to ensure that Resident #61's CPAP (continuous positive airway pressure: machine use to deliver pressurized air through a mask to keep airways open) was stored properly. <BR/>3. <BR/>The facility failed to ensure that Resident #222's nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) was stored properly. The facility failed to provide humidified (moistened) oxygen to Resident #222. <BR/>These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Review of Resident #10's Face Sheet, dated 09/18/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #10's pertinent diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and history of COVID.<BR/>Review of Resident #10's Quarterly MDS Assessment, dated 07/05/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility.<BR/>Review of Resident #10's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. <BR/>Review of Resident #10's Physician Order, dated 01/28/2023, reflected May apply O2 per nasal cannula at 2-4L when in room for shortness of breath every shift for Shortness of Breath.<BR/>Observation and interview with Resident #10 on 09/17/2024 at 9:09 AM revealed Resident #10 was in his bed, awake. It was observed that he had a nasal cannula connected to an oxygen concentrator at 3 liters per minute. According to Resident #10, he was on oxygen all day and all night. The nasal cannula was on the floor. He said staff went inside the room to check on him but did not notice the nasal cannula was on the floor.<BR/>Review of Resident #11's Face Sheet, dated 09/18/2024, revealed Resident #11 was a [AGE] year-old female who was admitted to the facility 12/21/2022. Relevant diagnoses included hypertension and anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissue).<BR/>Review of Resident #11's Quarterly MDS Assessment, dated 07/28/24, revealed Resident #9 had a moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was on oxygen therapy during admission and while a resident of the facility. <BR/>Review of Resident #11's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy.<BR/>Review of Resident #11's Physician Order, dated 06/28/2024, revealed O2 @2LPM per nasal cannula at HS, at bedtime.<BR/>Observation and interview with Resident #11 on 09/04/2024 at 8:46 AM revealed Resident #11 was in her wheelchair, awake. It was observed that she had a nasal cannula connected to an oxygen concentrator. The nasal cannula was coiled on top of the oxygen concentrator. The nasal cannula was not bagged. According to Resident #11, she would seldom use the oxygen and she never saw a bag for the nasal cannula.<BR/>Review of Resident #52's Face Sheet, dated 09/18/2024, revealed Resident #52 was a [AGE] year-old female who was admitted to the facility 07/25/2024. Relevant diagnoses included asthma (lung disorder caused by narrowing of the airways) and anemia.<BR/>Review of Resident #52's Quarterly MDS Assessment, dated 07/28/24, revealed Resident #52 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. <BR/>Review of Resident #52's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy.<BR/>Review of Resident #52's Physician Order, dated 07/25/2024, revealed O2 @ 2L/min via NC every 1 hours as needed for SOB or SAT &gt; 92%.<BR/>Observation and interview with Resident #52 on 09/04/2024 at 9:19 AM revealed that Resident #52 was in her bed, awake. It was observed that she had an oxygen concentrator at the side of her bed with a nasal cannula connected to it. The nasal cannula was hanging on top of the oxygen concentrator. The nasal cannula was not bagged. According to Resident #52, she usually wore oxygen at night but would leave it inside the room every time she would go out of the room. <BR/>Review of resident #68's Face Sheet, dated 09/19/24, reflected that Resident #68 was a [AGE] year-old female admitted [DATE]. Resident #68 had a diagnoses of left tibia (long bone in lower leg) fracture and subsequent encounter for closed fracture (surgery to repair fracture). Resident #68 also had a diagnosis of COPD. <BR/>Review of Resident #68's Comprehensive MDS Assessment, dated 08/27/24, reflected that Resident #68 had intact cognition with a BIMS score of 15. Resident #68 had a diagnosis of COPD and was administered oxygen therapy. <BR/>Review of Resident #68's Care Plan, dated 09/03/2024, reflected that Resident #68 had COPD. An intervention was to identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes.<BR/>An observation and interview on 09/17/24 at 08:52 AM revealed that Resident #68 was sitting up in bed. Resident #68's nasal cannula was looped over the bedrail and not secured in a bag. The humidifier bottle was connected to the oxygen concentrator. The humidifier bottle had about 15 ml of water in it. There was no date on the oxygen tubing or humidifier bottle. Resident #68 stated they have been saying they will add water to the humidifier bottle. Resident #68 stated that she has told different staff members that it's drying me out. <BR/>2. <BR/>Review of Resident #61's Face Sheet, dated 09/19/2024, reflected that Resident #61 was a [AGE] year-old female. Resident #61 admitted on [DATE] with COPD (lung disease that blocks airflow and makes it difficult to breathe) and frontotemporal neurocognitive disorder (damage to the frontal and temporal lobes of the brain).<BR/>Review of Resident #61's Physician Orders, dated 02/02/24, reflected CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) per settings on machine at bedtime. <BR/>Review of Resident #61's Quarterly MDS Assessment, dated 09/03/2024, reflected<BR/>a BIMS Assessment was not appropriate because the resident was rarely/never understood and that Resident #61 was severely impaired - never/rarely made decision regarding tasks of daily life. Resident #61's Quarterly MDS Assessment reflected that Resident #61 had not used a CPAP within the last 14 days.<BR/>Review of Resident #61's Comprehensive Care Plan, dated 07/15/2024, reflected that Resident #61 was using a CPAP and one interventions for this focus included Staff will continue to apply CPAP as ordered. Staff will continue to monitor her for decline in respiratory status and report to doctor. <BR/>An observation on 09/17/24 at 09:25 AM revealed that Resident #61's CPAP machine was on the table next to her bed. The attached tubing and face mask was lying on the floor beside the resident's bed.<BR/>3. <BR/>Review of Resident #222's Face Sheet, dated 09/19/24, reflected that Resident #222 was a [AGE] year-old male. Resident #222 admitted on [DATE] with COPD and pneumonia (infection in the lungs).<BR/>Review of Resident #222's Comprehensive MDS Assessment, dated 09/09/24, reflected that Resident #222 had severe cognitive impairment with a BIMS score of 6. Resident #222 had a diagnosis of COPD and was administered oxygen therapy.<BR/>An observation on 09/17/24 at 8:45 am revealed that Resident #222 was lying in bed with his eyes closed. Resident #222's nebulizer mask was on the bedside table and not stored in a bag. Resident #222's nasal cannula tubing was connected to the oxygen concentrator (medical device that provides extra oxygen) and not to the humidifier bottle (adds moisture to air to help prevent nasal and throat irritation). The empty humidifier bottle was secured to the front of the oxygen concentrator. There was no date on the nebulizer tubing, the nasal cannula tubing, or the empty humidifier bottle. <BR/>During an interview with LVN G on 09/17/24 at 09:35 AM, she stated that the nasal cannula should have been bagged. LVN G stated that the nebulizer mask and CPAP should have also been bagged when the resident was not using them. She stated that because these items were not covered, they could have gotten bacteria on them and potentially caused the residents to get sick. <BR/>Observation and interview with LVN F on 09/17/2024 at 10:21 AM, LVN F stated the nasal cannula should not be exposed nor touching anything because it could cause cross contamination and infection. LVN F said the nasal cannula should be bagged when not in use. LVN F said she would go to Resident #10, #11, and #52's room, would disconnect the nasal cannula, and would throw it in the trash can. She said she was going to change all of it and put it in a bag if the residents were not using it.<BR/>In an interview with the DON on 09/18/2024 at 12:36 PM, the DON stated the nasal cannula should be bagged when not in use to keep it clean. She said if the nasal cannulas were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, or compromised oxygen administration. The DON said the staff, including her, were responsible in monitoring if the nasal cannula, the breathing mask, and the CPAP were bagged when not in use. She said there should be water in the humidifier to prevent irritation in the nose and throat. She said the expectation was for the staff to be mindful in making sure that the nasal cannula, the breathing mask, and the CPAP mask of the residents would be bagged when not in use. The DON said she would conduct an in-service and check-off about the respiratory care. She said she would personally monitor if the staff were bagging the nasal cannula the breathing mask, and the CPAP. <BR/>In an interview with the Administrator on 09/18/2024 at 12:49 PM, the Administrator stated everything that the residents were using should be kept clean to prevent infection. She said, for this incident, the nasal cannula the nasal cannula the breathing mask, and the CPAP should be bagged every time the resident was not using it. The Administrator said she would coordinate with the DON on how to go forward about the issue of respiratory care.<BR/>In an interview with the ADON on 07/19/2024 at 8:49 AM, the ADON stated the nasal cannula, the nasal cannula, the breathing mask, and the CPAP mask should be bagged when not in use. He said the purpose for bagging the nasal cannula was to prevent it from being exposed and touching surfaces that were dirty. He said cross contamination and possible respiratory infections could occur. He said the humidifier should have water in it to prevent dryness of the nasal passage. He said the expectation was for the staff to bag the nasal cannula when not in use. He said she would coordinate with the DON pertaining to respiratory care.<BR/>Record review of facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection MED-PASS, Inc. revised November 2011 revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy . Steps . 4. Check water levels of refillable humidifier units daily . d. refill with distilled water . 7. Change the oxygen cannulae and tubing every seven days . 8. Keep the oxygen cannula and tubing . in a plastic bag when not in use . Nebulizer . 7. Store the circuit in plastic bag, marked with date.

Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation.<BR/>1. <BR/>The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. <BR/>2. <BR/>The facility failed to ensure food stored in 1 of 1 reach in freezer and 2 of 2 reach in refrigerators were labeled and dated with use by date. <BR/>These failures could place residents at risk for food contamination and foodborne illness.<BR/>Findings Included: <BR/>Observations on 02/12/25 at 09:32 AM in the facility's only kitchen revealed:<BR/>1 of 1, 3-door reach in refrigerator contained:<BR/>- <BR/>1 large metal tray of cheesecake was not covered or sealed from air-borne contaminants or labeled with use by date. <BR/>- <BR/>1 large metal tray of gelatin, 1 medium plastic container of diced tomatoes, 1 medium plastic container of grape jelly, 1 medium plastic container of caramel, 1 medium plastic container of pumpkin filling, 1 medium plastic container of ketchup, 2 medium plastic containers marked BKF, 2 large zip-sealed bags of tortillas, and 1 large zip-sealed bag containing individually wrapped sandwiches were not labeled or dated with use by date. <BR/>2 of 2 reach in freezers contained 1 medium zip-sealed bag of enchiladas, 3 large bags of okra, 3 large bags of French fries, 1 large bag of French toast sticks, and 1 small zip-sealed bag of ice cream that were not labeled or dated with use by date. <BR/>In an interview on 02/12/25 at 09:40 AM with the DM, she stated it was her expectation that all items stored in the refrigerator and freezers were covered and sealed off from contaminants. She stated the cheesecake tray should've been covered and not exposed. She stated it was her expectation that all food items were labeled to identify what the item was and dated with the open date or the prepared date. She stated she did not believe items needed to have the use by date. She stated the dietary staff were trained on when to throw items out. She stated a potential negative outcome to not having food items covered or dated was that's how you get sick from items not being covered or knowing when it's made. <BR/>In an interview on 02/12/25 at 03:21 PM with [NAME] A, she stated that items stored in the refrigerator and freezers should be completely covered and have the date the item was opened or prepared as well as the use by date. She stated items were rotated every 3 days and said, I am not sure why they don't have the use by date, but I am sure we will get penalized for it . <BR/>In an interview on 02/12/25 at 4:44 PM with the ADM, she stated it was her expectation that items stored in the freezers and refrigerator were covered, labeled, and dated with the date the item was prepared or placed in the refrigerator/ freezer. She stated she did not believe items needed to be labeled with the use by date and said she didn't think the facility policy stated that either. She stated that food items that were left uncovered could cause food borne illness. She stated food borne illnesses have the potential to affect all residents when food items were not dated. <BR/>Review of the facility Food Receiving and Storage policy last revised November 2022 reflected:<BR/>Food shall be received and stored in a manner that complies with safe food handling practices.<BR/>All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). <BR/>Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. <BR/>Review of the 2022 U.S. Food and Drug Administration Food Code revealed:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. <BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if <BR/>(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and <BR/>(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.<BR/>3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. <BR/>(A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: <BR/>(2) Is in a container or PACKAGE that does not bear a date or day; or <BR/>3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. <BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #26) reviewed for incontinent care infection control practices. <BR/>MA H failed to use several wipes when cleansing Resident #26 perineal area and buttocks. <BR/>MA H failed to remove the soiled gloves prior to touching the clean brief, bed linen, Resident #26's purse, bed remote and, cloth teddy bear, and overbed table. <BR/>MA H failed to wash her hands or use hand sanitizer before or after providing care to Resident #26. <BR/>This failure could place any resident at the facility requiring incontinent care at risk for infections including but not limited to urinary tract infections. <BR/>Findings included:<BR/>Record review of a face sheet dated 6/7/2022 indicated Resident #26 was an [AGE] year-old-female who admitted on [DATE] and readmitted [DATE] with the diagnoses of need of assistance with personal care, lack of coordination, and unspecified dementia.<BR/>Record review of the comprehensive care plan dated 5/12/2015 with a revision on 11/6/2-17 and a target date of 7/24/2022 indicated Resident #26 was incontinent of bowel and bladder. The goal was to remain free from skin breakdown due to incontinence. The interventions included to check Resident #26 every 2 hours and as needed for incontinence with need to wash, rinse, and dry the perineum. <BR/> Record review of an MDS dated [DATE] indicated Resident #26 understands and was understood. The MDS indicated Resident #26 required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use, and personal hygiene. Resident #26 required total assistance with bathing. <BR/>During an observation and interview on 6/7/2022 at 8:53 a.m., MA H wiped Resident #26's perineal area 5 times using the same wet wipe. Then MA H rolled Resident #26 over and cleansed her bottom wiping 5 times with one other wet wipe. MA H used two wet wipes in the entire incontinent process. MA H while holding the last wet wipe in her right gloved hand applied the clean brief, reapplied the bed linen, moved Resident #26's black purse to the top of her bed, moved the cloth teddy bear to the top of the bed, used the bed remote to readjust the height of the bed, touched her own mask and moved the over bed table back over the Resident #26. MA H removed the trash from the trash can, opened the resident's door, walked down the hallway to the soiled utility before removing her gloves and cleansing of her hands. MA H indicated she was unaware she only used two wipes with incontinent care. MA H said not performing incontinent care correctly, washing of hands and removing of gloves could cause spreading of germs, and cross contamination. MA H said, I was so nervous. <BR/>Record review of a Certified Nursing Assistant Competency Evaluation dated 5/25/2021 indicated MA H was provided with annual competency in the areas of hand washing, perineal care, gait belt transfers, Hoyer lift, transfer, tub/shower baths. The Skills Competency Evaluation indicated 7. Using wipe cleanses the genital area, moving front to back, while using a new wipe for each stroke. 9. Using clean, wipe, cleanse the outer perineal area. Do not use dirty hand to gather wipes. 13. Change gloves and apply clean brief/waterproof pad avoiding contamination. 16. Remove gloves and wash hands prior to leaving resident's room. 17. After disposing of linen, and placing used equipment in designated storage area, wash hands. The Skills Competency Evaluation for MA H indicated she performed satisfactorily.<BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON indicated she expected the nursing staff providing incontinent care to use the one and done method. She indicated one wet wipe and discard. The DON indicated she expected the staff to washing their hands or use hand sanitizer. The DON said she expected the nursing staff to change their gloves when touching clean from dirty. The DON indicated the nursing staff have been checked off on incontinent care recently and this was an annual check off as well. The DON indicated she had not provided a recent in-service regarding incontinent care. The DON indicated she expected correct incontinent care to prevent infections, skin, and infection control issues. <BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator indicated she expected the nursing staff when providing incontinent care to provide the incontinent care according to the policy and procedure. The Administrator indicated following the policy and procedure would prevent infection, infection control issues and ensure safety. The Administrator indicated residents could have a negative outcome such as an infection. The Administrator indicated nursing was responsible for skills check offs annually and periodic checks to ensure compliance. <BR/>According to the CDC Epidemiology and Prevention of UTI a component of prevention a Urinary Tract Infection was to provide good perineal hygiene and UTIs are common and a significant cause of harm in long term care facilities. Accessed at https://www.cdc.gov/nhsn/pdfs/training/2018/ltcf/epidemmiology-prevention-uti-508.pdf accessed on 6/09/2022.<BR/>Record review of the facility's Infection Control policy, dated April 2012 indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. The objectives were to prevent, detect, investigate, and control infections in the facility. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contract and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident # 1) of 6 (Resident's 2.3.4.5.amd 6) residents reviewed for following hospital discharge orders.<BR/>The facility failed to follow hospital discharge orders for follow up with Urology secondary to a urethral stent (a thin tube placed between the kidney and bladder to help urine flow) placement on 4/26/2024.<BR/>On 10/12/24 at 5:10 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/16/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. <BR/>This failure resulted in Resident # 1 with worsening medical condition and Hospitalization. <BR/>Finding included: <BR/>Review of Resident # 1's face sheet reflected a [AGE] year old male originally admitted on [DATE] with a readmission on [DATE] with diagnoses that included type 2 diabetes mellitus without complications (is a chronic condition that happens when you have persistently high blood sugar levels effecting your body not to use insulin properly), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional, which can cause a backup of urine into the kidneys), and discharged to the hospital on [DATE].<BR/>Review of Resident # 1 Quarterly MDS dated [DATE] reflected a BIMS score of 10 (10-12 suggests moderate cognitive impairment). <BR/>Review of Resident #1's Care plan dated 9/18/2024 ad 10/11/2024 reflected in part: <BR/>Focus: Resident # 1 has a hx of UTI's (infection that affects the urinary tract, the system for drainage of urine), urinary retention (the inability to completely empty the bladder), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional, which can cause back up of urine into the kidneys.)<BR/>Goal: Resident will not have an UTI through the review date. Target Date 12/6/2024.<BR/>Interventions/Task Check at least every 2 hours for incontinence, wash, rinse, and dry soiled areas. Encourage adequate fluid intake, monitor/document/report to MD PRN for s/sx of UTI: Frequency, urgency, malaise (a vague feeling of bodily discomfort), foul smelling urine, dysuria (pain with urination), fever, nausea, vomiting, flank( lower back) pain, supra-pubic (area around the genitals), hematuria (blood in the urine), cloudy urine, altered mental status, loss of appetite, and behavioral changes.<BR/>Review of Resident # 1's medical record of Hospital A's history and physical and discharge orders dated 8/16/2024 reflected an order for follow up with urology in 1 week. The discharge diagnosis was a ureteral stone (stone in the urethra (a thin tube leading from the bladder) with hydronephrosis (a swelling of one or both kidneys due to urine build up). <BR/>Review of Resident # 1's medical records reflected no order for urology follow up from readmission [DATE]) through discharge (10/10/2024 ). Resident was assessed on 10/9/2024 for weakness, found to have a low-grade temperature all other vitals, resident was offered to go to emergency room and refused, MD was notified. On 10/10/2024 resident was found unresponsive with low blood pressure, emergency phone line was contacted, resident was transferred to the hospital. MD was notified. ADON notified Daughter of transfer. <BR/>Review of outside medical records of Resident # 1's for Hospital B's admitting history and physical dated 10/10/2024 by Physician C reflected Abdominal CT scan showed the presence of severe left-sided hydronephrosis (an accumulation of urine around the kidney) in spite of the presence of a stent. It was felt the patient likely septic shock is from the left Pyelonephritis (kidney infection). Admitting diagnosis to Hospital B on 10/10/2024 include Septic shock (a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to a dangerously low blood pressure and other abnormalities), occlusion of ureteral stent, acute renal failure, left pyelonephritis, and respiratory failure (the result of inadequate oxygen flow). Resident was incubated (a tube placed in the airway to assist with oxygen flow) and placed in ICU upon admission . <BR/>In an interview with the ADON on 10/12/2024 at 1:30 PM he stated that the readmission process was similar to the admission process. After report was received by the nurse and the resident has returned to the building and an assessment has been completed, the orders were reviewed. All new orders were to be verified with the resident's physician, medication orders were then sent to the pharmacy, and any follow up appointments sent to transportation for scheduling. He was not sure how the appointment for Resident # 1 was missed and he admitted he reviewed the orders again and was not able to locate the orders. It was his expectation that all orders to be confirmed with resident doctor and followed . He stated that after the orders are uploaded to the electronic medical record it is review by the DON or himself. He stated that not setting up the follow up appointment could result in worsening medical condition and failure of interventions that may have occurred during the appointment or hospital stay. <BR/>Interview with RN Weekend supervisor on 10/12/2024 at 1:00 PM she stated that she also works are the charge nurse during the week at times. She stated when a resident returns from the hospital the nurse assigned to the hall , completes a head to toe assessment, reviews the discharge information and calls the doctor with any changes, sends any medication to pharmacy, any follow up appointments are sent to the transportation coordinator and the discharge paperwork is placed in the medical records basket. She stated missing an order could be harmful to the resident.<BR/>Interview with DON on 10/14/2024 at 9:30 am she stated that when a resident is returned to the facility from a medical appointment or hospital stay the nurse assigned to their hall will do an physical assessment, review the discharge or review of medical appointment and call to verify with the doctor any new orders, fax new medications to pharmacy and notify transportation of any new appointments. She or the ADON will review the discharge or review of medical appointment once uploaded to the medical record which can be sometimes 2-3 later depending on when the resident returned to the building. She stated that potential harm is possible when doctors' appointment is missed either not scheduled or not attended. <BR/>In an interview with CNA E who was responsible for transportation on 10/14/2024 at 1:30 PM she stated that she was not notified of an appointment for Resident # 1 for urology consult in August and she reviewed her book to verify. <BR/>Attempted a phone interview with the agency nurse that readmitted Resident # 1 on 8/16/2024, no answer, and no voicemail set up . <BR/>Interview with the ADM on 10/12/2024 at 3 PM revealed her expectations were that when a resident returned from the facility after seeing a medical provider, either a doctor visit, emergency room visit, or hospital stay that the order was to be reviewed and carried out . Nursing is responsible for carrying out physician orders, the nurse assigned to the hall does the assessment and order review when the resident returns to the facility. <BR/>Review on 12/12/2024 at 1:00 PM of the policy titled admission Assessment and Follow up: Role of the Nurse revised September 2012 revealed 7. Conduct an admission assessment (history and physical) including a. A summary of the individual's recent medical history, including hospitalization, acute illness, and overall status prior to admission. B. Relevant medical, social, and family history C. a list of active medical diagnoses and patient problems (such as recurrent fall or impaired mobility) especially those most related to reasons for admission to the facility and those that are affecting function.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 10/12/2024 at 5:10 PM. The Administrator was notified. The Administrator was provided with the IJ template on 10/14/2024 at 6:00 PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 10/16/24 at 8:07 am:<BR/>Plan of Removal for Immediate Jeopardy F 684. Action Taken The following is a plan of removal, which was immediately implemented at the facility, to remedy the immediate jeopardy which was imposed on 10/14/2024 at 5:10 PM. On 10/12/2024 an abbreviated survey was initiated at the facility. On 10/14/2024 the surveyor provided an immediate Jeopardy (IJ) Template notification the regulatory services have determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to follow physician orders regarding a follow up appointment that needed to be completed for the resident.<BR/>The follow actions will be completed by 5:00 PM on 10/15/2024 with continued follow-up scheduled staff. <BR/>1. <BR/>An Inservice regarding Physician orders policy and procedure of admission/readmission was initiated with licensed clinical staff on 10/14/2024 by the DON and ADON. Scheduled staff will be completed before allowing patient assignment/care.<BR/>2. <BR/>The past 90 days of active admissions/readmission will have a full chart order review by the Regional Corporate nurse, the DON, and the ADON to ensure compliance with applicable physician orders in place. 41 residents' readmission/admission orders were reviewed for accuracy. Of the 41 residents 12 residents required physician contact/order review to ensure accuracy. This will be completed by 10/15/2024.<BR/>3. <BR/>Regional nurse-corporate completed an in-service with the DON and ADON regarding review of physician orders and implementation of orders per policy and procedure. This was completed 10/14/2024.<BR/>4. <BR/>A review of the policy titled admission assessment and follow up- Role of the Nurse was reviewed on 10/14/2024 at 5:45 PM by the regional director of operation and the Regional Nurse Consultant with the following changes in response to this identified immediate jeopardy: * Title change to include readmissions as part of the policy with definition that admission in the policy represents readmission as well as defined. * The policy has been reviewed and updated to define who is responsible for the initial step of the admission/readmission process and implementation of a follow up process for compliance review. <BR/>Monitoring for complaint ,(IJ) the DON and/designee will review all admission/readmissions and follow up accordingly regarding orders daily during the weekdays. The weekend RN supervisor will be responsible for Saturday and Sunday admission/readmission audit reviews. The IDT will review and assess the admissions/readmissions weekly to determine what further actions/ interventions or changes were needed if necessary. Members of the meeting were to include the ADM, the DON, the ADON, the MDS Coordinator, the Social Worker, the Therapy representative, the RNC, and RDO.<BR/>Record review of in-service dated 10/15/2024 and 10/16/2024 revealed all licensed staff that were on duty between 10/12/2024 and 10/16/2024 signed the in-service for Physician orders and Admission/readmission policy . All staff not in serviced will complete the training prior to the start of their shift. <BR/>Record review of audit of charts reviewed by the RNC and the DON revealed 12 residents which needed order verification . All residents' physicians were notified, and order clarification obtained. <BR/>In an interview on 10/16/2024 at 10:15 am the DON and the ADON stated they were in-serviced by the RNC on physician orders and the changes to the admission policy on 10/15/2024.<BR/>Interview on 10/16/2024 from 10:30 to 1:30 PM with 6/ 11 of Clinical staff from the AM staff, revealed they were in-serviced by the DON or the ADON on Physician orders and admission policy prior to the start of their shift. All staff interviewed were able to verbalize understanding and changes to policies . An attempt was made to contact a PM shift staff member with no answer and no returned phone call. <BR/>On 10/12/24 at 6:00 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/16/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 7 of 14 residents reviewed for ADLs. (Resident #'s 1, 23, 26, 29, 31, 32, and 47)<BR/>The facility did not provide assistance with facial hair removal for Resident #'s 23, 26, 29, 31, and 32.<BR/>The facility did not ensure Resident #'s 1, 23, 26, 29, 31, 32, and 47 was routinely assisted with a shower.<BR/>These failures could place residents who were dependent of staff to perform personal hygiene at risk for embarrassment, decreased self-esteem, or decreased quality of life. <BR/>Findings included: <BR/>1 .Record review of a face sheet dated 6/8/2022 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with the diagnoses of muscle weakness, need for assistance with personal care, knee contractures and arthritis. <BR/>Record review of a comprehensive care plan dated 5/14/2021 with a revision on 6/7/2021 indicated Resident #1 had an ADL self-care performance deficit with a goal of will gain more independence with daily care by staff will assist with showering as requested .<BR/>Record review of an Annual MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood. Resident #1's BIMS was a 6 indicating severe cognition problems. The MDS indicated Resident #1 required total assistance of two staff for transfers. The MDS indicated Resident #1 required extensive assistance of one staff with bed mobility, locomotion, and eating. The MDS indicated Resident #1 required total assistance of one staff to bathe. <BR/>Record review of the undated shower roster indicated Resident #1 was scheduled for a shower on Monday-Wednesday-Friday on the 6:00 p.m. to 6:00 a.m. shift.<BR/>Record review of Resident #1's bath sheets dated from 5/9/2022 through 6/8/2022 indicated Resident #1 had 6 showers of the 13 scheduled opportunities.<BR/>2.Record review of a face sheet dated 6/7/2022 indicated Resident #23 was an [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (memory loss disease), need for assistance with personal care, lack of coordination, muscle weakness and cognitive communication deficit. <BR/>The most recent Annual MDS dated [DATE] indicated Resident #23 rarely understood and sometimes understands. The MDS indicated Resident #23 required extensive assistance of 2 staff for bed mobility, transfers, and dressing. She requires extensive assistance of one staff for locomotion, and personal hygiene. Resident #23 required total assistance of two staff for bathing. <BR/>The comprehensive care plan with a revision date of 1/17/2017 indicated Resident #23 had an ADL self-care deficit and at times requires staff assistance and needs to be reminded to complete her ADLs with a goal she will maintain her current level of function. The intervention included the resident required extensive staff assistance with bathing/showering.<BR/>Record review of the undated shower roster indicated Resident #23 was to be provided a shower on Tuesday-Thursday-Saturday on the 6:00 a.m. to 6:00 p.m. shift.<BR/>Record review of the shower sheets dated 5/12/22 through 6/7/22 indicated Resident #23 was provided 6 showers of the 11 scheduled from 5/14/2022 until 6/7/2022.<BR/>During an observation on 6/6/2022 at 2:42 p.m., Resident #23 had hair to her chin. Resident #23 was non-verbal and could not communicate her feelings regarding hair to her chin.<BR/>During an observation on 6/7/2022 at 10:29 p.m., Resident #23 continued to have hair to her chin. <BR/>3 .Record review of a face sheet dated 6/7/2022 indicated Resident #26 was an [AGE] year-old-female who admitted on [DATE] and readmitted [DATE] with the diagnoses of need of assistance with personal care, lack of coordination, and unspecified dementia.<BR/>Record review of the comprehensive care plan dated 5/12/2015 with a revision on 1/25/2018 and a target date of 7/24/2022 indicated Resident #26 had an ADL self-care deficit related to her intellectual disability with a goal of maintaining a current level of function. The intervention included Resident #26 required one staff to assist with participation to dress, personal hygiene, and bathing.<BR/> Record review of an Annual MDS dated [DATE] indicated Resident #26 understands and was understood. The MDS indicated Resident #26 required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use, and personal hygiene. Resident #26 required total assistance with bathing. <BR/>Record review of the undated shower roster indicated Resident #26 was scheduled Monday-Wednesday-Friday on the 6:00 p.m. to 6:00 a.m. shift to receive her scheduled showers.<BR/>Record review of the shower sheets dated 5/9/22 through 6/8/22 indicated Resident #26 was scheduled for 13 showers opportunities and received 8 showers. <BR/>During an observation on 6/6/2022 at 9:57 a.m., Resident #26 had long hairs on her chin. <BR/>During an observation on 6/6/2022 at 12:20 p.m., Resident #26 continued to have hairs to her chin.<BR/>4.Record review of a face sheet dated 6/7/2022 indicated Resident #29 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of unsteadiness on feet, weakness, lack of coordination, and dementia.<BR/>Record review of a comprehensive care plan dated 12/29/2021 indicated Resident #29 required extensive assistance with all aspects of daily care with a goal to maintain good body hygiene. The care plan interventions included staff will assist with Resident #29's showers.<BR/>Record review of the most recent significant change MDS dated [DATE] indicated Resident #29 was understood and understands. The MDS indicated Resident #29 required extensive assistance of one staff for bathing.<BR/>Record review of the undated shower roster indicated Resident #29 was not named on the shower roster for any scheduled showers.<BR/>Record review of the shower sheets indicated Resident #29 received showers on the following days:<BR/>-5/9/22<BR/>-5/18/22<BR/>-5/23/22<BR/>-5/27/22<BR/>-6/1/22 <BR/>During an observation and interview on 6/6/2022 at 10:15 a.m., Resident #29 had chin hairs and she indicated she had not had a shower since the last Wednesday on 6/1/2022. <BR/>5.Record review of a face sheet dated 6/7/2022 indicated Resident # 31 was [AGE] year-old female with an original admission date of 7/5/2018 and a current admission date of 3/12/2020 with diagnoses of Bipolar Disorder dated 7/05/2018, Major depressive disorder dated 7052018, and generalized anxiety disorder dated 7/05/2018. <BR/>Record review of a comprehensive care plan 10/25/2019 indicated Resident #31 had an ADL self-care deficit with a goal to improve her current level of function. The care plan failed to address the bathing needs of Resident #31.<BR/>Record review of the most recent significant change MDS dated [DATE] indicated Resident #31 was usually understood and understands others. The MDS indicated Resident #31 had a BIMS of 8 indicating moderate cognitive impairment. The MDS indicated Resident #31 required total assistance of 1 staff for bathing. <BR/>Record review of the undated shower rosters indicated Resident #31 was scheduled for a shower on Tuesday-Thursday-Saturday on the 6:00 p.m.- 6:00 a.m.<BR/>Record review of the shower sheets dated 5/19/22 through 6/7/22 indicated Resident #31 received 4 showers out of 9 scheduled opportunities. <BR/>During an observation and interview on 6/6/2022 at 9:40 a.m., Resident #31 said she had one shower since last week. Resident #31 indicated her shower days were Tuesday-Thursday and Saturday. Resident #31 had hairs to her chin, and she voiced she needed them to be shaved off . <BR/>During an observation and interview on 6/7/2022 at 10:32 a.m., Resident #31 said she had not had a shower and nor had her hairs been shaved. Resident #31 said not getting her showers and shaved were normal routine. <BR/>During an observation on 6/7/2022 at 2:00 p.m., Resident #31 continued to have hair to her chin.<BR/>During an interview on 6/7/2022 at 4:12 p.m., CNA F indicated he was responsible for the showers on 100 Hall. CNA F indicated he showered Resident #31 this morning. CNA F indicated he failed to notice the hairs to Resident #31's chin. CNA F said he would take care of them at this time. CNA F said shaving was one of his tasks . <BR/>6.Record review of a face sheet dated 6/8/2022 indicated Resident #32 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of early onset Alzheimer's disease (a memory destroying disease), and difficulty swallowing. <BR/>Record review of a Care plan dated 10/17/2019 indicated Resident #32 indicated she required hands on assistance with most daily care and would have her needs met by the staff providing her showers.<BR/>Record review of a Significant Change MDS dated [DATE] indicated Resident #32 sometimes understood others and was sometimes understood. The MDS indicated Resident #32's daily decision-making abilities were severely impaired. The MDS indicated Resident #32 required extensive assistance with bed mobility, total assistance with dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #32 had no activity in the areas of transfers, walking in room or corridor, locomotion on or off the unit and bathing. <BR/>Record review of the undated resident shower roster indicated Resident #32 would have a shower on Monday-Wednesday-Friday on the 6:00 a.m.- 6:00 p.m. shift.<BR/>Record review of the shower sheets dated 5/9/2022 through 6/8/2022 indicated Resident #32 had 4 showers provided out of 14 scheduled showers.<BR/>During an observation on 6/6/2022 at 10:08 a.m., Resident #32 had long hairs to her chin. <BR/>7.Record review of a face sheet dated 6/7/2022 indicated Resident #47 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnosis of acute respiratory failure with lack of sufficient oxygen difficulty swallowing, and dementia. <BR/>Record review of an Annual MDS dated [DATE] indicated Resident #47 was usually understood and usually could understand others. The MDS indicated Resident #47 required total assistance of one staff member for bathing.<BR/>Record review of the undated comprehensive care plan for Resident #47 failed to address her ADL needs.<BR/>Record review of the resident undated shower roster indicated Resident #47 was scheduled Monday-Wednesday-Friday 6:00 a.m. -6:00 p.m. shift.<BR/>Record review of the resident shower sheets dated 5/9/22 through 6/8/22 indicated Resident #47 was provided 6 showers of the 14 scheduled showers. <BR/>During an interview with the resident council on 6/7/22 at 2:59 p.m., Resident #29 indicated she had not had a shower since the last Wednesday.<BR/>During an interview on 6/7/2022 at 4:16 p.m., LVN A stated the CNAs were responsible for the showers. LVN A said the binder at the nurse's desk had the resident shower roster. LVN A said the CNAs should review the shower roster daily and complete the shower sheets. LVN A the shower sheets were then turned in to the nurse. LVN A said she was responsible for reviewing the shower sheets, signing the shower sheets, and turning them in to the ADON by placing in the 24-hour binder .<BR/>During an observation and interview on 6/8/2022 at 8:32 a.m., CNA G stated she was responsible for ADLs on 100 Hall. CNA G said the shower book contained the shower lists and the shower sheets. CNA G said she completed a shower sheet after the shower and turned it into the nurse. CNA G said shower and shaving were the tasks provided on shower days. CNA G said a female resident would not want to have hairs to their chin, this would be embarrassing. CNA G said she was unable at times to provide showers due to staffing challenges. CNA G said she did not notice Resident #26 and Resident #32's hairs to their chins. CNA G indicated she would shave Resident #26 and 32's hairs to the chins.<BR/>During an interview on 6/8/2022 at 8:52 p.m., LVN K said she was responsible for the residents on Hall 100. LVN K said ensuring a resident received their ADLs were her responsibility. LVN K said the shower roster indicated the days a resident would receive a shower. LVN K said the CNAs would complete a shower sheet and she was required to sign the sheet indicating there were no issues. LVN K indicated shaving was a task completed by the CNAs and should be done with ADLs. LVN K indicated a female resident would feel embarrassed with hairs to their chins. <BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON said the charge nurses were responsible for ensuring the showers and shaving were completed by the CNAs. The DON said there was no auditing tool to ensure residents received their scheduled showers . The DON indicated she would implement a tool to mark showers provided. The DON indicated the lack of showers could affect a resident's skin condition and could cause infections. The DON said facial hair on a woman could affect their self-esteem.<BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator stated she expect a resident's ADLs to be completed in their entirety. She said not having their showers and shaving could impact their health and dignity. The Administrator indicated the ADON was responsible for monitoring the ADLs.<BR/>Record review of the facility's Procedural Guideline #28 indicated shaving the Resident dated 1/2022 indicated the purpose was to shave the resident and maintain appearance and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of 20 residents (Residents #24 and 27) reviewed for activities. <BR/>Residents #24 and 27, who spent most of their time in their rooms, did not have a program of activities based on their needs and preferences.<BR/>This failure placed residents at risk of depression and diminished quality of life. <BR/>Findings included:<BR/>Review of the undated face sheet for a resident number 24 reflected an [AGE] year old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, reduced mobility, need for assistance with personal care, dementia, lack of coordination, unsteadiness on feet, difficulty in walking, cognitive communication deficit, abnormalities of gait and mobility, malaise, limitation of activities, due to disability, muscle wasting atrophy, chronic pain, chronic, obstructive, pulmonary disease, and hypertension. <BR/>Review of a significant change MDS for Resident #24 dated 05/30/23 reflected she could not participate in the BIMS assessment for cognitive status. Review of Preferences for Customary Routine and Activities section reflected a staff assessment identifying Listening to Music as Resident #24's preference. <BR/>Review of the care plan for Resident #24 dated 07/07/22 reflected the following: Resident requires extensive assistance of staff for all transfers, she does not wheel self once up. All mobility per staff. There was no care planning present for activity preferences. <BR/>Review of a quarterly activity assessment for Resident #24 dated 05/16/23 and completed by the AD reflected she participated in bingo and arts & crafts with assistance. It also reflected that knowing her likes and dislikes at this point was difficult due to lack of communication from her, but she needed one to one assistance to participate in activities. <BR/>Review on 07/19/23 of activity progress notes recorded by the AD for Resident #24 from 03/31/23 to 06/12/23 reflected weekly notes listing the activities in which she participated, which included bingo, church, music therapy, arts & crafts, and parties. There were no notes recorded beyond 06/12/23.<BR/>Observation on 07/17/23 at 08:42 AM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room. <BR/>Observation on 07/17/23 at 09:35 AM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/17/23 at 10:13 AM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/17/23 at 12:07 PM in a gerichair at lunch in the dining room with staff helping her eat.<BR/>Observation on 07/17/23 at 01:35 PM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/17/23 at 03:12 PM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/18/23 at 08:09 AM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/18/23 at 11:33 AM PM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/18/23 at 02:47 PM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/19/23 at 08:15 AM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/19/23 at 10:00 AM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Observation on 07/19/23 at 01:44 PM revealed Resident #24 laying in her bed with her eyes closed and no music or other diversion in the room.<BR/>Review of Resident #27's face sheet dated 7/19/2023 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of Alzheimer's disease (type of dementia), hypermetropia (far-sightedness), unspecified pain, dysphagia (difficulty swallowing), spondylosis (age-related condition affecting joints), dorsalgia (back pain), adult failure to thrive, severe protein-calorie malnutrition, respiratory failure, kidney failure, and anxiety.<BR/>Review of Resident #27's MDS assessment dated [DATE] reflected a BIMS score of 8, which indicated moderately impaired cognition. <BR/>Review of Resident #27's care plan last revised on 7/05/2023 reflected he was on hospice, resided on the secured unit, and staff were to provide activities to him. There were no interventions related to activity preference, participation or involvement. <BR/>Review of Resident #27's quarterly activity participation review dated 7/02/2023 reflected Resident #27 did not participate in any activities and could not recognize his likes or dislikes. The assessment reflected Resident #27's activity goals were not met and Interventions/approaches have not been effective in attaining goals. New interventions/approaches have been added to the care plan. The assessment reflected we tried to many ways to encourage [Resident #27] to participate in activities but he prefer to stay in bed. There were no details as to which interventions, if any, were attempted for group or one-on-one activities. \<BR/>Review of Resident #27's progress notes reflected the following:<BR/>On 4/21/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 4/28/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 5/05/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 5/12/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 5/19/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 5/26/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 6/02/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 6/09/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 6/16/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 6/30/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 7/07/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>On 7/14/2023 the AD documented that Resident #27 did not socialize or participate in activities that week.<BR/>During an observation and interview on 7/17/2023 at 9:05 a.m., Resident #27 was observed lying in his bed. Resident #27 stated he had no concerns with his care.<BR/>An observation on 7/17/2023 at 10:41 a.m. revealed residents of the secured unit were congregating in the dining room and participating in a painting activity. Resident #27 was not present. <BR/>During an observation and interview on 7/18/2023 at 8:15 a.m., Resident #27 was observed lying in bed and he stated he had a headache. <BR/>An observation of the secured unit on 7/18/2023 at 11:59 a.m. revealed the AA was playing cards with some residents in the dining room. Resident #27 was not present. <BR/>During an observation and interview on 7/19/2023 at 3:15 p.m., Resident #27 stated he would enjoy playing cards and liked all kinds of music. <BR/>During an interview on 07/19/23 at 02:44 PM, the AD stated they had been keeping Resident #24 in activities before the past month, but she had been declining. The AD stated before the decline, Resident #24 came out for bingo and even though she would not play, they had her sit in there. The AD stated they did music therapy every day. When asked if Resident #24 was in music therapy this week, the AD stated she was not, because the CNAs woke her up early and got her back in bed early. The AD stated Resident #24 had not been in anything because she had been laying down. The AD clarified that meant Resident #24 had not received any activities since the last progress notes was entered on 06/12/23. When asked if the AD ever went into Resident #24's room to provide in-room activities, the AD stated Resident #24 was always sleeping when she went to her room. The AD stated since Resident #24 went on Hospice, a lot of things had changed with the resident, and the AD was trying to focus on the bigger group for activities, because that is what the activities program was for. The AD stated she was frustrated, because the CNAs just kept Resident #24 in her room and only got her up for meals. When asked again if she had provided any in-room activities for Resident #24, the AD stated she had spoken the other day to Resident #24's Hospice nurse about doing some music therapy, because some music therapy players with headphones had been donated. When asked precisely when she had spoken with the Hospice nurse, the AD stated it was two weeks prior but she idd not know exactly what day. When asked if she had implemented the music therapy with the donated machines, she said she had not. When asked why the Resident #24 had not received any music therapy since the conversation, the AD stated she had been very busy. The AD stated it was important that Resident #24 received activities, and a possible negative impact could be that Resident #24 could decline more due to being lonely.<BR/>During an interview on 7/19/2023 at 3:15 p.m., the AD stated she did not do one-on-one activities with Resident #27, and she did not know what kind of activities he enjoyed. The AD stated they tried to get Resident #27 to participate in activities but did not provide any examples or details describing interventions attempted. The AD stated the AA did activities with residents in the secured unit and documented activity participating in a book. The AD stated she checked the AA's activity log for that week and did not see any activities that Resident #27 had participated in. <BR/>During an interview on 07/19/23 at 03:42 PM, the DON stated she had seen the staff bring Resident #24 out to the common area for bingo and parties. The DON stated she could not say for sure whether she had seen Resident #24 in these activities in the past month or not. She stated she had not seen Resident #27 receiving any activities in his room, but she did not think he liked to do very much, even prior to going on Hospice. The DON stated her expectations as far as providing activities to residents who had experienced a decline and were staying in their rooms most of the time or residents who were refusing group activities was that the group activities would not be offered as often, but she would expect that new and creative options of recreational therapy be devised and offered. She stated a potential impact of not offering any recreational therapy to any person no matter their stage of life could be depression. <BR/>During an interview on 07/19/23 at 03:54 PM, the ADM stated residents who have declined and were spending most of their time in their rooms such as Resident #24 and 27 should still have received activities according to their preferences. The ADM stated he had instructed the AD just the week prior to increase the one-on-one activities, especially for the residents who spend most of their time in their rooms. The ADM stated he had also instructed her to make sure she was documenting visits. He stated the instruction was not in response to any failure on the AD's part but a part of ongoing staff development. When asked if the AD had enough time in her schedule to meet the requirement of providing in-room activities, the ADM stated she did have enough time with her activity assistant. When asked if the AD had access to resources that would assist her in developing activity plans for residents with changing needs, he stated they had tabs on the online training system for additional training modules that addressed many subjects and probably included activities. The ADM stated he was not sure if she had ever noticed the extra tab and he had not specifically pointed it out to her. When asked how he monitored for compliance with requirements for activities, he stated he did rounds and spoke to residents. He stated he did not have a particular process for monitoring compliance, but he frequently spoke to residents and family members to make sure they did not have any unmet needs. The ADM stated a potential negative impact of not receiving activities was the resident could suffer from depression and decreased quality of life.<BR/>Review of facility policy dated June 2018 and titled Activity Programs reflected the following: Activity programs are designed to meet the needs of and support the physical, mental and psychosocial well-being of each resident. 1. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive, or emotional health or activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 5. Our activity programs consist of individual, small group, and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote: a. self-esteem; b. comfort; c. pleasure; d. education; e. creativity; f. success; and g. independence.<BR/>Review of facility policy dated June 2018 and titled Individual Activities and Room Visit Program reflected the following: Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them. 1. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so. 2. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, the activities program provides individualized activities, consistent with the overall goals of an effective activities program. 3. Individualized activities offered are reflective of the resident's activity interests, as identified in the activity assessment, progress, notes, and the resident's comprehensive care plan. 4. It is recommended that residents with in-room activity programs receive, at a minimum, three in room visits per week. A typical in room visit is 10 to 15 minutes in length but may be longer is appropriate for the resident. 5. Activities for residents with behavioral or emotional problems and cannot participate in group. Activities include: a. uncomplicated activities that can be adapted to the level of the individuals, attention, span, and function; b. Activities, requiring short periods of concentration, to reduce frustration; and c. Activities tailored to address, specific underlying causes of the individuals behavior or attention limitation (e.g., familiar occupation-related activities, exercise and movement activities, engaging the resident in conversation, and using one to one activities such as looking at familiar pictures and photo albums). 6. Residents who choose not to attend group activities are encouraged to participate an independent activities. It is the responsibility of the facility and the activity staff to make regular contact with the residents who choose to pursue independent activities, maintain appropriate records, and offer supplies, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received food that accommodates resident allergies, intolerances, and preferences for one of eight residents (Resident #169) reviewed for food preferences. <BR/>Resident #169 was not given any meat or meat alternative in her meals for her first fourteen meals at the facility.<BR/>This failure placed residents at risk of weight loss, slow wound healing, and a lack of enjoyment.<BR/>Findings included:<BR/>Review of the undated face sheet for resident number 169, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia and hypertension.<BR/>Review of MDS assessments for Resident #169 reflected that none had yet been completed. <BR/>Review of the baseline care plan for Resident #169 dated 07/14/23 reflected the following: Resident is here for LTC. Able to make basic needs known. Mechanical soft diet and only eats fish for meat on Fridays.<BR/>Review of nursing progress notes for Resident #169 reflected the following on 07/14/23 12:39 PM Note Text: resident arrived for admission using walker and family present. A&O with some short term memory impairment noted. Res is pleasant and cooperative. denies pain or discomfort at this time. resident able to put herself in bed and position for comfort. instructed on room, call light, TV etc. Able to voice needs, denies needs at this time. lunch tray served. res diet reg/reg/no meat on Fridays except fish.<BR/>Review of admission Mini Nutritional Assessment for Resident #169 dated 07/18/23 reflected the following conditions:<BR/>-Weight 106 lbs; Height 66 inches (BMI 17)<BR/>-Food intake decline over the past three months: severe decline in intake<BR/>-Weight loss during the last three months: weight loss greater than 3 kg (6.6.lbs)<BR/>-Body mass intake weight in kg/height in m2: BMI less than 19<BR/>Review of an article from the Annals of Geriatric Medicine and Research titled What is the optimal Body Mass Index Range for Older Adults? and dated 03/22/22 reflected that an optimal body mass index for an older female (average age [AGE]) was 27-28.<BR/>Observation and interview on 07/17/23 at 12:50 PM revealed the lunch tray for Resident #169 had lima beans, tomatoes and okra, and corn bread but no meat. When asked if she ate meat, Resident #169 stated she liked meat and needed protein. She stated she only ate fish on Fridays for religious reasons, but she never said she did not want meat the other days of the week and did not understand why she had not received any meat. She stated she had not been receiving meat on her tray and thought the facility did not offer meat. <BR/>During an interview on 07/17/23 at 12:55 PM, CNA A stated she did not know why Resident #169 had no meat on her tray. She looked at Resident #169's meal ticket and pointed out that it said, No meat. CNA A stated she had not spoken to Resident #169 about whether she wanted meat on her tray or not.<BR/>Review of the lunch meal ticket for Resident #169 on 07/17/23 reflected Grnd Pork Roast w/ Gravy was crossed out with pen, and NO MEAT printed at the bottom.<BR/>Observation on 07/18/23 at 08:07 AM revealed Resident #169 had no meat on her breakfast tray. She had oatmeal, eggs, and toast on her tray and ate everything on her plate until it was empty.<BR/>Review of the breakfast meal ticket for Resident #169 on 07/18/23 reflected Grnd Sausage Link was crossed out in pen, and NO MEAT was printed on the bottom.<BR/>Observation on 07/18/23 at 12:15 PM revealed Resident #169 had no meat on her lunch tray. On her tray were mashed potatoes, green peas, a roll, and a piece of yellow cake with chocolate frosting. <BR/>Review of the lunch meal ticket for Resident #169 reflected Grnd Swiss Steak was crossed out, and NO MEAT was printed at the bottom.<BR/>During an interview on 07/19/23 at 10:55 AM, the DM stated she had not gone to speak with Resident #169 yet and had not met her. The DM stated Resident #169 had not received meat on her tray since she admitted , because that was what she and the family had requested. The DM stated she had been by Resident #169's room but the resident was always asleep when she went by. The DM stated she had interpreted the family's request and all the paperwork to mean Resident #169 did not want meat at all but only fish on Fridays. When asked how she would meet a resident's need for protein if the resident did not eat meat, the DM stated they did not really have a game plan in their system for a vegetarian. The DM stated they would need to call the dietitian. When asked if she had done that, she said she had not. <BR/>During an interview on 07/19/23 at 03:29 PM, the DON stated she monitored for compliance with diet orders by doing chart checks and participating in the care plan process. The DON stated Resident #169 came right around lunch on 07/14/23, and they wrote a ticket for Resident #169 and handed it to the DM. The DON stated they continued to try to ensure all the aspects of a new resident's care are accurate by initiating the care planning process and getting the family in for a care plan meeting as early as possible in the resident's stay. The DON stated she spoke to the family during Resident #169's admission and knew that the resident did not eat any meat other than fish on Fridays but ate regular meat the rest of the week. The DON stated she thought she also spoke to the DM about it and thought they were on the same page. The DON stated she also tried to assist with serving meals and tried to visit new residents in their rooms. The DON stated she had been in Resident #169's room several times and had not noticed or been alerted to the fact that she was not receiving meat with her meals. The DON stated she was also not aware the facility did not have a vegetarian diet plan. The [NAME] stated potential negative impacts to the resident not receiving meat or a meat alternative could be skin breakdown and weight loss. <BR/>During an interview on 07/19/23 at 03:54 PM the ADM stated it was the DM's job to make sure she had the preferences correct for all new admissions. The ADM stated he monitored for compliance with diet preferences by ensuring that all residents are interviewed for receiving the correct foods at mealtime and making sure their food tasted good. He stated that was part of customer service 101. When asked who was responsible for providing that service, he stated he did not have a designee to go back and ask how things were going. The ADM stated a potential negative outcome could have been weight loss. <BR/>Review of facility policy dated September 2008 and titled Resident Food Preferences reflected the following: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. 1. Upon the resident's admission or within 24 hours after his/her admission, the dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. <BR/>Review of facility policy dated October 2017 and titled Food and Nutrition Services reflected the following Policy statement- Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation.<BR/>1. <BR/>The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. <BR/>2. <BR/>The facility failed to ensure food stored in 1 of 1 reach in freezer and 2 of 2 reach in refrigerators were labeled and dated with use by date. <BR/>These failures could place residents at risk for food contamination and foodborne illness.<BR/>Findings Included: <BR/>Observations on 02/12/25 at 09:32 AM in the facility's only kitchen revealed:<BR/>1 of 1, 3-door reach in refrigerator contained:<BR/>- <BR/>1 large metal tray of cheesecake was not covered or sealed from air-borne contaminants or labeled with use by date. <BR/>- <BR/>1 large metal tray of gelatin, 1 medium plastic container of diced tomatoes, 1 medium plastic container of grape jelly, 1 medium plastic container of caramel, 1 medium plastic container of pumpkin filling, 1 medium plastic container of ketchup, 2 medium plastic containers marked BKF, 2 large zip-sealed bags of tortillas, and 1 large zip-sealed bag containing individually wrapped sandwiches were not labeled or dated with use by date. <BR/>2 of 2 reach in freezers contained 1 medium zip-sealed bag of enchiladas, 3 large bags of okra, 3 large bags of French fries, 1 large bag of French toast sticks, and 1 small zip-sealed bag of ice cream that were not labeled or dated with use by date. <BR/>In an interview on 02/12/25 at 09:40 AM with the DM, she stated it was her expectation that all items stored in the refrigerator and freezers were covered and sealed off from contaminants. She stated the cheesecake tray should've been covered and not exposed. She stated it was her expectation that all food items were labeled to identify what the item was and dated with the open date or the prepared date. She stated she did not believe items needed to have the use by date. She stated the dietary staff were trained on when to throw items out. She stated a potential negative outcome to not having food items covered or dated was that's how you get sick from items not being covered or knowing when it's made. <BR/>In an interview on 02/12/25 at 03:21 PM with [NAME] A, she stated that items stored in the refrigerator and freezers should be completely covered and have the date the item was opened or prepared as well as the use by date. She stated items were rotated every 3 days and said, I am not sure why they don't have the use by date, but I am sure we will get penalized for it . <BR/>In an interview on 02/12/25 at 4:44 PM with the ADM, she stated it was her expectation that items stored in the freezers and refrigerator were covered, labeled, and dated with the date the item was prepared or placed in the refrigerator/ freezer. She stated she did not believe items needed to be labeled with the use by date and said she didn't think the facility policy stated that either. She stated that food items that were left uncovered could cause food borne illness. She stated food borne illnesses have the potential to affect all residents when food items were not dated. <BR/>Review of the facility Food Receiving and Storage policy last revised November 2022 reflected:<BR/>Food shall be received and stored in a manner that complies with safe food handling practices.<BR/>All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). <BR/>Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. <BR/>Review of the 2022 U.S. Food and Drug Administration Food Code revealed:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. <BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if <BR/>(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and <BR/>(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.<BR/>3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. <BR/>(A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: <BR/>(2) Is in a container or PACKAGE that does not bear a date or day; or <BR/>3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. <BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.<BR/>

**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 be free from abuse for one (Resident #1) of four residents reviewed for abuse.<BR/>1. <BR/>CNA-A and CNA-B were seen on video surveillance verbally abusing Resident #1.<BR/>This failure could cause mental or emotional anguish in the residents who reside in the facility . <BR/>Findings included:<BR/>Record review of face sheet dated 2/8/23 revealed Resident #1 was a [AGE] year-old male with a diagnosis of dementia without behaviors and schizophrenia. <BR/>Record review of Care Plan dated 6/12/22 for Resident #1 revealed he has potential to demonstrate verbally abusive behaviors and behaviors are to be monitored.<BR/>Record review of MDS dated [DATE] for Resident #1 revealed he had a BIMS of 5 indicating the resident is cognitively impaired.<BR/>Record review of abuse, neglect, and exploitation policy undated revealed if abuse, neglect, or exploitation is suspected staff should notify abuse coordinator immediately. Alleged perpitrator should be suspended during investigation and abuse coordinator should report suspected abuse to state agency.<BR/>Record Review of electronic surveillance at facility dated 1/10/23 revealed a video of CNA-A and CNA-B speaking to Resident #1 in the hallway. When Resident #1 asked to go outside to smoke CNA-A told him Do I look like a smoke shop to you?. CNA-B was sitting in a chair in the hallway and told Resident #1 to go back to his room. When he turned to walk away CNA-B said you are Lucifer and I wish you would die already. Resident #1 repeated back what CNA-B said to her and CNA-B kicked her foot toward Resident #1. Resident #1 pushed his walker toward CNA-B and she got up from the chair and walked down the hallway while speaking loudly to Resident #1. Resident #1 pushed his walker down the hallway toward CNA-B and CNA-B pushed the walker back at Resident #1 forcefully. <BR/>In an interview on 2/8/23 at 1:25PM Resident #1 , said he felt safe at facility and staff treated him well. He said he had a difficult time remembering things sometimes. He said he had no concerns with the facility or care he is receiving.<BR/>In an interview on 2/8/23 at 1:28PM with CNA-C, she stated if she suspected abuse, she would stop the abuse if able and report it to the Abuse Coordinator . She said she felt the facility did a good job with training staff to prevent abuse and an adequate job training staff to work with dementia patients. She said Resident #1 did become moody at times but most of the time he was calm. <BR/>In an interview on 2/8/23 at 3:18PM with the Administrator, and the ADON, said they were made aware of the incident on 1/10/23 after the altercation was diffused. They said an assessment of Resident #1 was completed and no acute findings were present. They said there was no witnesses to the incident. They stated following the incident CNA-A and CNA-B were both moved away from Resident #1, sent home, suspended, and were terminated the next day (1/11/23). They said all employees were in-serviced on abuse and reporting abuse on 1/10/23. They said all employees went through abuse training upon hire and at least annually. They said all employees received training for dementia and behaviors regularly. They stated they were aware upon watching the video CNA-A and CNA-B both needed to be referred to the state nursing aide registry and had tried to do this after reporting the abuse allegation to the state agency. ADON said the nursing aide registry told her the state agency would have to report CNAs and that the facility could not file report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 4 (Resident # 31) residents reviewed for PASRR.<BR/>The facility failed to refer Resident #31 for PASRR Level ll assessment when a diagnosis of Mental Illness was identified after admission.<BR/>This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. <BR/>Findings included:<BR/>Record review of a face sheet dated 6/7/2022 indicated Resident # 31 was [AGE] year-old female with an original admission date of 7/5/2018 and a current admission date of 3/12/2020 with diagnoses of Bipolar Disorder dated 7/05/2018, Major depressive disorder dated 7/05/2018, and generalized anxiety disorder dated 7/05/2018. <BR/>Record review of a significant change MDS dated [DATE] indicated Resident #31 was usually understood and understands others. Resident #31's BIMS (score was an 8 indicating she had moderately impaired cognition. The MDS section, Preadmission Screening and Resident Review indicated Resident #31 did not have a serious mental illness and the section named Level II Preadmission Screening and Resident Review Conditions the box for serious mental illness was not marked indicating a presence of a mental illness. The MDS in the section of Resident Mood Interview indicated Resident #31 had the feelings of feeling down, depressed, or hopeless over 12-14 of the assessment days. The MDS section of Psychiatric/mood disorder indicated anxiety disorder, depression, and Bipolar disorder. The MDS section Medications received indicated Resident #31 received antipsychotic, antianxiety and antidepressants 7 of the 7 days reviewed and indicating received on a daily basis.<BR/>Record review of the consolidated physician orders dated 6/7/2022 indicated Resident # 31 was referred to [local] psychiatric Services on 9/27/2019, Bupropion HCL 150 mg one tablet by mouth one time daily for Bipolar disorder current episode depressed, Seroquel 125 mg by mouth at bedtime for Bipolar disorder current episode depressed, and Zoloft 50 mg by mouth every morning for Bipolar disorder current episode depressed. <BR/>Record review of a comprehensive care plan dated 4/10/21 with a revision date of 5/11/2021 indicated Resident #31 was prescribed Seroquel (an antipsychotic medication) for the treatment of Bipolar disorder . The interventions included to administer the medication as ordered, and the staff would monitor for adverse reactions.<BR/>Record review of Resident #31's PASRR Level 1 Screening completed on 7/05/2018 indicated section C0100 there was no evidence of an indicator this was an individual with a Mental Illness.<BR/>During an interview on 6/08/2022 at 11:06 a.m., the MDS nurse indicated she did not realize the MDS was not accurate until the surveyor asked to review the PASSR Level 1 Screen . The MDS nurse indicated she was responsible to ensure the PASSR was completed accurately and failing to do so could result in a resident not receiving needed services. The MDS nurse indicated Resident #31 did have diagnoses of a serious mental illness of Bipolar Disorder and Major Depression. The MDS nurse indicated Resident #31 was not receiving psychological services from the local authority or the facility contracted psychological services group. <BR/>During an interview on 6/08/2022 at 12:07 p.m., the DON indicated the MDS nurse and the Regional MDS nurse was responsible for ensuring the accuracy of the PASRRs. The DON indicated Resident #31 did have qualifying diagnoses for PASRR services. The DON indicated she was unaware of Resident #31 was not receiving psychiatric services for the facility's contracted psychiatric group, but she indicated she would research the matter . <BR/>During an interview on 6/08/2022 at 12:36 p.m., the Administrator indicated the MDS nurse had made her aware of the inaccurate PASRR screen for Resident #31. The Administrator indicated the MDS nurse was responsible for ensuring the PASRR was completed accurately to reflect the resident's status. The Administrator indicated Resident #31 and other residents may not receive the needed services when the PASRR was completed inaccurately. <BR/>Record review of the facility's policy and procedure for PL1/PASRR/NFSS 1012/PCSP with a revision date of 1/16/2019 indicated the facility will ensure compliance with all Phase l and Phase ll guidelines of the PASRR process for long term care. The policy indicated the MDS coordinator, marketing/admissions team/social worker/administrator/director of nurses were responsible to ensure the policy was enforced. Under section of procedures 1. F. If at any time a resident has a significant change, admits to hospice, discharges to another facility, or you receive information that might indicate the resident may have a mental illness diagnosis or condition not contained in the medical record, submit a PL I form for the resident to be evaluated by the Local Authority.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a person-centered plan of care and provide services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents reviewed for plans of care (#47). <BR/>The facility failed to care plan Resident #47 was not to have straws with her drinks.<BR/>These failures could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and/or a decline in physical well-being. <BR/>Findings included: <BR/>Record review of a face sheet dated 6/7/2022 indicated Resident #47 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnosis of acute respiratory failure with not enough oxygen difficulty swallowing, and dementia. <BR/>Record review of a physician's order dated 5/21/2019 indicated Resident #47 had an order for no straws with drinks. <BR/>Record review of an MDS dated [DATE] indicated Resident #47 was usually understood and usually could understand others. The MDS indicated Resident #47 required limited assistance of one staff for eating. <BR/>Record review of the undated comprehensive care plan in its entirety failed to mention Resident #47's diagnosis of difficulty swallowing and the need for no straws. <BR/>During an observation and interview on 6/6/2022 at 2:32 p.m., Resident #47 had a water pitcher with a straw in it on her over bed table. On the overbed light in Resident #47's room a sign was posted on green copy paper indicating NO STRAWS. Resident #47 was not able to be interviewed due to cognitive impairment. <BR/>During an observation on 6/7/2022 at 10:26 a.m., Resident #47's water pitcher at bedside had a straw in the pitcher. The signage on the overbed light for Resident #47's bed indicated NO STRAWS.<BR/>During an interview on 6/7/2022 at 11:25 a.m., the speech therapist said Resident #47 was on speech therapy at the present time. The speech therapist said Resident #47 was working on cognition and swallowing to ensure the toleration of her mechanical soft diet and thin liquids. The speech therapist said she was unaware of the physician's order for no straws. The speech therapist indicated she believed the signage was old. <BR/>During an observation and interview on 6/7/2022 at 12:07 p.m., LVN A said she was responsible for the care of Resident #47. LVN A said Resident #47 had a history of aspiration of fluids. LVN A said Resident #47 was not to have a straw due to being at risk for aspiration. LVN A removed the straw during the interview.<BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON said the care plan directed the care of a resident. The DON said when the care changes for a resident the care plan should be updated. The DON said the MDS nurse was responsible for updating the care plan and the Regional MDS nurse had oversight of the facility MDS nurse . <BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator said she expected the care plan to be updated to accurately reflect the resident's needs. The Administrator said the DON was responsible for ensuring the accuracy of the care plan as she signs off on them. <BR/>Record review of the facility's undated policy, Policy and Procedure Comprehensive Care Planning indicated the purpose was to ensure every resident had a comprehensive, complete, accurate, and all-inclusive specific care plan written timely to meet all requirements of the Resident Assessment Instrument and regulatory process to include all input from the intradisciplinary team members. 7. Every resident will have all active medical diagnosis along with medications and treatments related to the specific needs of each resident care planned and revised routinely. <BR/>Record review of the facility's policy, Physician orders dated June 2004 indicated physician orders must be given and managed in accordance with applicable laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that its residents were free of significant medication errors in of 1 of 14 residents (Resident #40) reviewed for significant medication errors. <BR/>The facility failed to hold Resident #40 Metoprolol tartrate (high blood pressure medicine) on 5-1-22, 5-5-22, 5-10-22, 5-14-22 and 5-16-22 based on the MD blood pressure parameters.<BR/>The facility failed to hold Resident #40 Norvasc (blood pressure medicine) on 5-1-22 and 5-10-22 based on the MD blood pressure parameters. <BR/>These failures could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician.<BR/>Findings included:<BR/>Record Review of Resident #40 admission record indicated the resident was [AGE] year-old male with a history of hemiplegia (paralysis on one side of the body), encephalopathy (brain disease), altered mental status, hypertension and hypotension. Resident #40 was admitted on [DATE].<BR/>Record Review of MDS dated [DATE] indicates that Resident #40 has a BIMS score of 7 for severely impaired cognition. Section I of the MDS indicates a diagnosis of hypertension.<BR/>Record Review of Resident #40's order summary report dated 6-7-22 indicated the following:<BR/>- Metoprolol tartrate tab 25 mg. Give 0.5 tab by mouth one time a day related to hypertension. Hold if bp is under 110/60 or pulse under 60. Start date 4-06-22<BR/>-Norvasc 2.5mg Give 1 tab by mouth in the morning for hypertension. Hold if blood pressure was under 110 systolic or 60 diastolic or pulse under 60. Start date 4-20-22.<BR/>Record Review of care plan dated 9-30-19 and revision on 10-10-19 indicated Resident #40 had hypertension. The goal indicated the resident will remain free from signs and symptoms of hypertension. An intervention indicated that blood pressure readings will be avoided after physical activity or emotion distress. <BR/>Record Review of Resident #40's MAR dated 5-1-22 to 5-31-22 indicated:<BR/>-On 5-1-22 blood pressure reading was 89/64 and pulse 66. MA administered Metoprolol and Norvasc outside of MD parameters.<BR/>-On 5-5-22 blood pressure reading was 95/49 and pulse 63. MA administered Metoprolol outside of MD parameters.<BR/>-On 5-10-22 blood pressure reading was 98/56 and pulse 68. MA administered Metoprolol and Norvasc outside of MD parameters. <BR/>-On 5-14-22 blood pressure reading was 84/54 and pulse 70. MA administered Metoprolol outside of MD parameters. <BR/>-On 5-16-22 blood pressure reading was 102/50 and pulse 55. Metoprolol was given outside of MD parameters. <BR/>An attempted Interview with MA on 6-8-22 at 8:56 a.m. and 11:12 a.m., was unsuccessful.<BR/>Interview with MA L on 6-8-22 at 09:31a.m., , MA L stated she has worked at the facility since 2012. MA L stated if blood pressure reading was below the parameters set by the MD, she would not give the blood pressure medications. MA L stated she would hold the medication and notify the charge nurse. MA L stated if blood pressure medication was given it could cause cardiac arrest. MA L stated residents having low blood pressure and holding their medication should have been reported to the charge nurse and doctor. MA L stated Resident #40 should have had his blood pressure monitored every 2 hours. MA L stated they had an in-service a week ago on medications but could not remember if it was focused on med errors.<BR/>Interview with LVN K on 6-8-22 at 8:11 a.m., LVN K reported she has worked at the facility for 3 years. LVN K stated they have in-services weekly, and they had an in-service last week on medication errors. LVN K stated the MA should not have given the blood pressure medication outside of the MD parameters and low blood pressure readings should have reported to her. LVN K stated the charge nurse was responsible for checks the TARS and the MA was also responsible for notifying the charge nurse. LVN K stated the DON was responsible for checking the electronic charts daily and letting the charge know if something was wrong. LVN K stated taking the blood pressure medication when having a low blood pressure could be fatal. LVN K stated t it could result in hypotension and they must rush the resident to the hospital. LVN K stated she was responsible for calling the MD if residents have low blood pressure and holding the medication. LVN K stated Resident #40 should have had his blood pressure checked later in the day. LVN K stated that holding the medication should have been be documented in the progress notes.<BR/>Interview with the DON on 6-8-22 at 9:19 a.m., the DON stated Resident #40's blood pressure medicine should have been held. The DON stated not holding the blood pressure medication could result in the resident having hypotension or crashing. The DON stated the MA should have notified the charge nurse when the blood pressure reading was low and what kind of cuff she was using. The DON stated the charge nurse would then take it with a manual cuff if an automatic was used and notified the MD of low reading. DON stated that resident vital signs are on the electronic chart and the DON is notified when vital signs are, out of whack, or any changes in condition. The DON stated she was responsible for monitoring the electronic charts. The DON stated she monitored the electronic charts PRN and management discussed any changes in conditions in their morning meeting. The DON stated the charge nurse was responsible for monitoring the vital signs and medications given by the medication aide and she was responsible for following up on the charge nurse. DON reported she was not sure when the last in-service was provided on medication errors.<BR/>Interview with the Administrator on 6-8-22 at 9:37 a.m., Administrator stated she expected staff to follow the instructions/parameters that were indicated by the MD. The Administrator stated nursing staff should have notified the MD. Administrator stated the DON and ADON are responsible for checking the MARs and resident vital signs to make sure it was done correctly. <BR/>Interview with Resident #40's MD on 6-8-22 at 8:40 a.m., the MD stated the facility could have used nursing judgement and called him to discuss the low blood pressure reading and he might have let them give the blood pressure medication depending on who the resident was, their body frame and past blood pressure readings, or the facility could have used the parameters he put in place for holding the medication. The MD stated that the facility was responsible for notifying him of any changes in conditions. <BR/>Record Review of the facility's policy, Administrating Medications dated April 2019 indicated the DON supervises and directs all personnel who administer medications and or have related functions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that laboratory services were obtained to meet the needs of residents for 1 of 14 residents reviewed for laboratory services (Resident #14). <BR/>The facility did not obtain a physician's ordered complete blood count (CBC) level for Resident #14. <BR/>This failure could place residents at risk of not receiving lab services as ordered. <BR/>Findings included: <BR/>A record review on 6/7/22 of the undated face sheet indicated Resident #14 admitted [DATE] and was [AGE] years old. <BR/>A record review on 6/7/22 of the physician's orders dated June 2022 indicated Resident #14 had diagnoses that included: Hallucinations, (seeing things that are not there), major depression, dementia with Lewy bodies, (significant mental decline), dysphagia following cerebrovascular disease, (trouble swallowing after a stroke), and osteoarthritis, (degenerative joint disease). <BR/>The physician's orders indicated:<BR/>11/30/21, CBC every 3 months. <BR/>A record review on 6/7/22, the MDS dated [DATE] indicated Resident #14 had short- and long-term memory problems, unclear speech, was sometimes understood by others and sometimes understood others. The MDS indicated she required the extensive assistance of 2 or more staff for bed mobility and transfer. <BR/>A record review on 6/7/22, of the Care Plan dated 6/6/22 indicated Resident #14 had impaired cognitive function with dementia and required placement on the secure unit due to wandering. The Care Plan Indicated Resident #14 required limited to extensive staff participation for bed mobility and transfer. <BR/>During an interview 6/7/22 at 2:19 PM, the DON said Resident #14 was due a CBC in February of 2022, but she did not have it. The DON said the CBC lab had not been done since November 2021. The DON the risk not getting the ordered CBC for a resident was you would not know lab values which could show if a resident had an infection, a problem, or possible side effects of a medication. The DON said the lab they use only allows a year's (12 months) worth of time to be ordered at once. She said Resident #14's order for a CBC had an original date of 11/30/20, therefore it would have fallen off 11/30/21. She said it was not the computer system that caused the lab order to fall off, it was the lab they used. <BR/>During an interview 6/7/22 at 2:23 PM, the ADON said the labs falling off after a year, and not getting them reordered was a communication problem. She said she and the DON thought MDS nurse was doing it. She said she had been at this facility since March 2022 and the DON had been at this facility since the end of February 2022. The ADON said it would be important to get an ordered CBC on a resident because that would let you know her hemoglobin and show if there were signs of an infection. <BR/>During an interview on 6/7/22 at 2:46 PM, the MDS nurse said she was not responsible for ensuring labs were obtained and orders renewed for labs that fell off after a year. She said she did not know until today labs fell off the physician's orders after a year. She said she had never been responsible for renewing labs after a year's time. She said the old DON and ADON were in the facility in November of 2021 and the DON that was in the facility in November 2021 asked her to assist putting in orders for Resident #14 and several other residents. She said she put in the physician's orders for Resident #14 for the CBC that was to be drawn every 3 months. She said with the new DON and ADON usually the ADON or the floor nurse will put in orders. She said if she was given orders from a MD, she would put them in. She said she misunderstood an email that was sent out by the DON in May of 2022. She said the DON indicated the ADON was responsible for pharmacy recommended labs and she understood the email to mean the ADON was responsible for all lab responsibilities including renewals of MD orders. <BR/>During an interview on 6/7/22 at 2:58 PM, the DON said she had been at this facility since February of 2022. She said at some point the MDS nurse was responsible for lab orders that needed to be renewed but she did not know when. She said the ADON was responsible for pharmacy recommendations regarding lab orders. She said she did not know who was responsible for renewing lab orders in November of 2021 because she was not the DON of the facility at that time. She said there was a miscommunication all the way around with who was responsible for labs that needed to be renewed after one year. She said she sent out an email in May of 2022 indicating the ADON was responsible for all pharmacy recommended labs. She said the MDS nurse misunderstood the email and believed the ADON was responsible for all labs that needed to be reviewed or renewed. The DON said the risk of not getting labs ordered by the MD could be UTI's, not knowing what blood levels were, and all kinds of things the labs would reveal that the MD would need to know. <BR/>During an interview on 6/7/22 at 3:11 PM, the ADON said she never thought she was responsible for renewing orders for labs that were over a year old, (labs that had fallen off). She said she was only responsible for lab recommendations from the pharmacy. She said she never checked the labs that were over a year old, or nearly a year old because she thought the MDS nurse did that. She said no one checking the labs that need to be renewed was bad for everyone. She said she was unsure what labs for residents could be missing or not done. She said they were currently doing an audit to see what labs were not done. She said they needed a system for tracking labs. She said she got to this facility in March of 2022. She said she could run a report from PCC (Point Click Care) to show what labs were due for each MD. She said at this time there was no tracking of lab monitoring in place. <BR/>During a telephone interview on 6/08/22 at 8:04 AM, a representative for the lab company said they never received a standing order for a CBC for Resident #14 every 3 months on 11/30/20 or 11/30/21. She said if they had received a standing order the order would have continued and would not have fallen off. She said the order for a CBC was given to them as a one-time order. She said orders do not fall off and orders are followed as long as the MD wants them followed. She said she did not have any documentation she could send me. <BR/>During an interview on 6/8/22 at 8:19 AM, the DON said she would speak with the representative at the lab company to make sure they had the process for calling in standing orders correct. She said they started a lab review yesterday for all residents. <BR/>During an interview on 6/8/22 at 8:43 AM, the administrator said she expected labs ordered by the MD to be done whether they were one time labs or standing orders for labs. She said the risk of residents not getting their labs would be they could need a medication change with an increased or decreased dosage, may need alternate medication, or abnormal labs could result in hospitalization. <BR/>During an interview on 6/8/22 at 9:04 AM the ADON said a standing order could be put into the pharmacy for one year but the orders had to be renewed after a year because the lab would not accept orders past one year. She said they could put in a standing order 4 times for every 3 months order, since the lab would only accept orders for one year. She said the orders would have to be renewed annually. <BR/>A record review on 6/8/22 of a lab revealed Resident #14 had a CBC on 11/10/21.<BR/>A record review on 6/8/22 of a policy and procedure for Physician's Orders dated June 2004 provided by the DON 6/7/22 indicated: <BR/>Physician orders must be given and managed in accordance with applicable laws and regulations .All physician orders must be carried out in accordance with state and federal laws.<BR/>A record review on 6/8/22 of a policy and procedure Lab and Diagnostic Test Results-Clinical Protocol, dated November 2018, provided by the DON 6/7/22 indicated: <BR/>1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.<BR/>2.The staff will process test requisitions and arrange for tests.<BR/>3.The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility .

Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation.<BR/>1. <BR/>The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. <BR/>2. <BR/>The facility failed to ensure food stored in 1 of 1 reach in freezer and 2 of 2 reach in refrigerators were labeled and dated with use by date. <BR/>These failures could place residents at risk for food contamination and foodborne illness.<BR/>Findings Included: <BR/>Observations on 02/12/25 at 09:32 AM in the facility's only kitchen revealed:<BR/>1 of 1, 3-door reach in refrigerator contained:<BR/>- <BR/>1 large metal tray of cheesecake was not covered or sealed from air-borne contaminants or labeled with use by date. <BR/>- <BR/>1 large metal tray of gelatin, 1 medium plastic container of diced tomatoes, 1 medium plastic container of grape jelly, 1 medium plastic container of caramel, 1 medium plastic container of pumpkin filling, 1 medium plastic container of ketchup, 2 medium plastic containers marked BKF, 2 large zip-sealed bags of tortillas, and 1 large zip-sealed bag containing individually wrapped sandwiches were not labeled or dated with use by date. <BR/>2 of 2 reach in freezers contained 1 medium zip-sealed bag of enchiladas, 3 large bags of okra, 3 large bags of French fries, 1 large bag of French toast sticks, and 1 small zip-sealed bag of ice cream that were not labeled or dated with use by date. <BR/>In an interview on 02/12/25 at 09:40 AM with the DM, she stated it was her expectation that all items stored in the refrigerator and freezers were covered and sealed off from contaminants. She stated the cheesecake tray should've been covered and not exposed. She stated it was her expectation that all food items were labeled to identify what the item was and dated with the open date or the prepared date. She stated she did not believe items needed to have the use by date. She stated the dietary staff were trained on when to throw items out. She stated a potential negative outcome to not having food items covered or dated was that's how you get sick from items not being covered or knowing when it's made. <BR/>In an interview on 02/12/25 at 03:21 PM with [NAME] A, she stated that items stored in the refrigerator and freezers should be completely covered and have the date the item was opened or prepared as well as the use by date. She stated items were rotated every 3 days and said, I am not sure why they don't have the use by date, but I am sure we will get penalized for it . <BR/>In an interview on 02/12/25 at 4:44 PM with the ADM, she stated it was her expectation that items stored in the freezers and refrigerator were covered, labeled, and dated with the date the item was prepared or placed in the refrigerator/ freezer. She stated she did not believe items needed to be labeled with the use by date and said she didn't think the facility policy stated that either. She stated that food items that were left uncovered could cause food borne illness. She stated food borne illnesses have the potential to affect all residents when food items were not dated. <BR/>Review of the facility Food Receiving and Storage policy last revised November 2022 reflected:<BR/>Food shall be received and stored in a manner that complies with safe food handling practices.<BR/>All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). <BR/>Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. <BR/>Review of the 2022 U.S. Food and Drug Administration Food Code revealed:<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. <BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.<BR/>(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if <BR/>(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and <BR/>(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.<BR/>3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. <BR/>(A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: <BR/>(2) Is in a container or PACKAGE that does not bear a date or day; or <BR/>3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. <BR/>FOOD shall be protected from cross contamination by:<BR/>(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #26) reviewed for incontinent care infection control practices. <BR/>MA H failed to use several wipes when cleansing Resident #26 perineal area and buttocks. <BR/>MA H failed to remove the soiled gloves prior to touching the clean brief, bed linen, Resident #26's purse, bed remote and, cloth teddy bear, and overbed table. <BR/>MA H failed to wash her hands or use hand sanitizer before or after providing care to Resident #26. <BR/>This failure could place any resident at the facility requiring incontinent care at risk for infections including but not limited to urinary tract infections. <BR/>Findings included:<BR/>Record review of a face sheet dated 6/7/2022 indicated Resident #26 was an [AGE] year-old-female who admitted on [DATE] and readmitted [DATE] with the diagnoses of need of assistance with personal care, lack of coordination, and unspecified dementia.<BR/>Record review of the comprehensive care plan dated 5/12/2015 with a revision on 11/6/2-17 and a target date of 7/24/2022 indicated Resident #26 was incontinent of bowel and bladder. The goal was to remain free from skin breakdown due to incontinence. The interventions included to check Resident #26 every 2 hours and as needed for incontinence with need to wash, rinse, and dry the perineum. <BR/> Record review of an MDS dated [DATE] indicated Resident #26 understands and was understood. The MDS indicated Resident #26 required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use, and personal hygiene. Resident #26 required total assistance with bathing. <BR/>During an observation and interview on 6/7/2022 at 8:53 a.m., MA H wiped Resident #26's perineal area 5 times using the same wet wipe. Then MA H rolled Resident #26 over and cleansed her bottom wiping 5 times with one other wet wipe. MA H used two wet wipes in the entire incontinent process. MA H while holding the last wet wipe in her right gloved hand applied the clean brief, reapplied the bed linen, moved Resident #26's black purse to the top of her bed, moved the cloth teddy bear to the top of the bed, used the bed remote to readjust the height of the bed, touched her own mask and moved the over bed table back over the Resident #26. MA H removed the trash from the trash can, opened the resident's door, walked down the hallway to the soiled utility before removing her gloves and cleansing of her hands. MA H indicated she was unaware she only used two wipes with incontinent care. MA H said not performing incontinent care correctly, washing of hands and removing of gloves could cause spreading of germs, and cross contamination. MA H said, I was so nervous. <BR/>Record review of a Certified Nursing Assistant Competency Evaluation dated 5/25/2021 indicated MA H was provided with annual competency in the areas of hand washing, perineal care, gait belt transfers, Hoyer lift, transfer, tub/shower baths. The Skills Competency Evaluation indicated 7. Using wipe cleanses the genital area, moving front to back, while using a new wipe for each stroke. 9. Using clean, wipe, cleanse the outer perineal area. Do not use dirty hand to gather wipes. 13. Change gloves and apply clean brief/waterproof pad avoiding contamination. 16. Remove gloves and wash hands prior to leaving resident's room. 17. After disposing of linen, and placing used equipment in designated storage area, wash hands. The Skills Competency Evaluation for MA H indicated she performed satisfactorily.<BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON indicated she expected the nursing staff providing incontinent care to use the one and done method. She indicated one wet wipe and discard. The DON indicated she expected the staff to washing their hands or use hand sanitizer. The DON said she expected the nursing staff to change their gloves when touching clean from dirty. The DON indicated the nursing staff have been checked off on incontinent care recently and this was an annual check off as well. The DON indicated she had not provided a recent in-service regarding incontinent care. The DON indicated she expected correct incontinent care to prevent infections, skin, and infection control issues. <BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator indicated she expected the nursing staff when providing incontinent care to provide the incontinent care according to the policy and procedure. The Administrator indicated following the policy and procedure would prevent infection, infection control issues and ensure safety. The Administrator indicated residents could have a negative outcome such as an infection. The Administrator indicated nursing was responsible for skills check offs annually and periodic checks to ensure compliance. <BR/>According to the CDC Epidemiology and Prevention of UTI a component of prevention a Urinary Tract Infection was to provide good perineal hygiene and UTIs are common and a significant cause of harm in long term care facilities. Accessed at https://www.cdc.gov/nhsn/pdfs/training/2018/ltcf/epidemmiology-prevention-uti-508.pdf accessed on 6/09/2022.<BR/>Record review of the facility's Infection Control policy, dated April 2012 indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. The objectives were to prevent, detect, investigate, and control infections in the facility. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contract and job responsibilities.

Based on observation, interview, and record review the facility failed to maintain all equipment in safe operating condition for 1 of 1 freezer in the kitchen.<BR/>The facility did not ensure the kitchen's reach in freezer was free from ice build-up.<BR/>This failure could place residents at risk of safety hazards and food spoilage and could result in of injury and illness.<BR/>Findings included:<BR/>During observations of the kitchen on 06/06/2022 at 09:30 a.m. the following were noted:<BR/>* ice build-up inside the reach in door facing freezer. Ice observed inside and around the freezer fan. <BR/>During an observation of the kitchen on 06/07/2022 at 10:35 a.m. the following were noted: <BR/>* ice build-up inside the reach in door facing freezer. Ice observed inside the reach in freezer.<BR/>During an observation of the kitchen on 06/08/2022 at 12:20 p.m. the following were noted: <BR/>* ice build-up inside the reach in door facing freezer. Ice observed inside and around the freezer fan. <BR/>Record review of a Quality Assurance Monitor I Kitchen/Food Service Observation sanitization audit dated 1/25/22 completed by Dietician M indicated the freezer had ice build-up. <BR/>Record review of a Quality Assurance Monitor I Kitchen/Food Service Observation sanitization audit dated 2/16/22 completed by Dietician N indicated freezer door not sealing properly and freezer gasket lining was broken, not sealing properly with significant frost. <BR/>During an interview on 6/8/22 at 9:59 a.m., Dietician M said she was aware of the ice build-up inside the reach in freezer. She said this issue was documented in her sanitation report that was sent to the Administrator, Dietary Manager, DON, and the Regional Nurse via email but she also notified the Dietary Manager of any findings during her walk through. Dietician M said ice build-up in the reach in freezer could cause food spoilage. <BR/>During an attempted telephone interview on 06/08/22 at 10:24 a.m., with Dietician N was unsuccessful due to no answer and no return call. <BR/>Record review of the maintenance log did not indicate any concerns from dietary listed on there. <BR/>During an interview on 6/8/22 at 10:59 a.m., Dietary Aide B said the evening dietary aides were responsible for cleaning the juice nozzle daily and the morning aides were responsible for putting the nozzle back on the juice machine. Dietary Aide B said she could not remember the last time the juice nozzle was cleaned. Dietary Aide B said not cleaning the nozzle could cause bacteria growth and foodborne illness.<BR/>During an interview on 6/8/22 at 11:10 a.m., the Dietary Manager said she was aware of the ice build-up inside the reach in freezer. The Dietary Manager said she had reported the ice build-up to maintenance since March 2022 by writing it down on the environmental worksheet and verbal on several occasions, but the issue had not been resolved. The Dietary manager said the freezer and fan should not have any ice build-up in it. The Dietary manager said ice build-up could cause the freezer to freeze up and food not be at the correct temperature <BR/>During an interview on 6/8/22 at 11:27 a.m., the Maintenance director said he was not aware of the ice-build up in the reach in freezer. He said he has been in and out due to medical issues since February 2022. The Maintenance director said he came back full time around May 2022. The Maintenance director said any issues were usually brought to his attention when they were put on the maintenance log. The Maintenance director said a new system was put in place about a few weeks ago where staff will report any issues directly through his email. <BR/>During an interview on 6/8/22 at 1:15 p.m., the Administrator said the dietary manager was responsible for reporting any issues happening in the kitchen at morning stand up meetings. The administrator said she had not been made aware of the current ice build-up in the freezer until surveyor intervention. The Administrator stated in the absence of the maintenance director that she should have followed up on the concerns listed from the dietician sanitation reports regarding the equipment malfunction that was sent to her via email. The Administrator said she was ensuring equipment in the facility were maintained and working by utilizing a computer software system that has check offs and logs book indicating the equipment was maintained. She said she was monitoring this by visual and verbal inspection. The Administrator said this was important to maintain properly functioning of equipment to meet resident's needs. The Administrator said this equipment failure could potentially cause food born illness due to improper temperature. <BR/>Record review of the facility's Refrigerators and Freezers policy revised on 4/2006 indicated .supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 6/6/2022 at 10:01 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock at the head of the bed.<BR/>During an observation on 6/6/2022 at 10:03 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock on the right side of the bed.<BR/>During an observation on 6/6/2022 at 10:13 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock at the head of the bed.<BR/>During an observation and interview on 6/6/2022 at 10:18 a.m., Resident #6's over the bed light did not have a string to turn the light off. The overbed light fixture had a thin blanket thumb tacked to the wall so that the room was dim enough to sleep. Resident # 6 indicated the light did not have a string therefore she could not sleep without covering the light with a blanket. Resident #6 indicated she had made the maintenance staff, but it has yet to be fixed. The room did not have an alternate light source overhead. <BR/>During an observation on 6/6/2022 at 12:15 p.m., resident room [ROOM NUMBER]B the over the bed light only flickered it did not produce any usable light. There was not a lighting source in the ceiling for this room. The only light source available was the over the bed light for bed A. <BR/>During an observation on 6/6/2022 at 12:20 p.m., resident room [ROOM NUMBER]'s over the bed light did not function. The room does not have an alternate light source overhead. The lighting in the room was supplied by the light over A bed . <BR/>During an observation on 6/7/2022 at 10:27 a.m., resident room [ROOM NUMBER] had scratches on the wall down to the sheet rock on the left side of the bed. <BR/>During an observation on 6/7/2022 at 4:12 p.m., resident room [ROOM NUMBER] had scratches to the wall down to the sheet rock on the right side of the bed.<BR/>During an observation and interview on 6/8/2022 at 10:54 a.m., the maintenance supervisor indicated he was responsible for ensuring the resident room walls were maintained in resident room #'s 104, 106, 108, 110 and 111, and over bed lights were functionable for resident room #'s 102; 107, and 108. The maintenance supervisor indicated he was advised of rooms needing repair by the staff by receiving work orders and by the new computer system (TELLS) which emails him a work order immediately. The maintenance supervisor indicated a resident could fall due to poor lighting and a resident could be embarrassed by their home appearing unmaintained. <BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON said she expected the resident rooms to be repaired, and the over the bed lights to function properly. The DON indicated a resident could suffer a fall from poor lighting. <BR/>Record Review of Work Orders, Maintenance dated April 2010 indicated Maintenance work orders shall be completed to establish a priority of maintenance service.<BR/>Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 7 of 41 (#s 102, 104, 106, 107, 108, 110 and 111) rooms and 3 of 15 residents reviewed for environment. (Resident #6, Resident #40 and Resident #42)<BR/>-The facility did not replace the missing arm pads for both arms of wheelchair for Resident #42. <BR/>-The facility failed to repair deep scrapped areas on the walls of resident room #'s 104, 106, 108, 110 and 111. <BR/>-The facility failed to repair the over bed lights for resident room #'s 102; 107, and 108.<BR/>These failures could place the residents at risk for unsafe environment.<BR/>Findings included:<BR/>Resident #42<BR/>Record Review of Resident #42 admission records indicate he is a [AGE] year-old male that was admitted on [DATE]. Resident #42 has a history of depression, chronic pain, post-traumatic stress disorder. <BR/>Record Review of Residents #42 MDS dated [DATE] indicates he had a BIMS score of 14 which indicated an intact cognition. Section G of MDS under ADL Self-Performance indicated Resident #42 required limited assistance with transfers and one-person physical assist. Section G0600 indicates that Resident #42 uses a wheelchair for mobility and section G0300 indicates that Resident #42 is scored a 2 for not steady and only able to stabilize with staff assistance during surface-to-surface transfers.<BR/>Record Review of Resident #42 care plan dated 4-8-22 indicated the resident was at risk for falls due to transferring himself to and from wheelchair without asking for help. The goal was to remain free from falls and the Interventions was staff will ensure the wheelchair was in good condition.<BR/>During observation and interview on 6-6-22 at 10:00 am, Resident #42 was propelling himself down the hallway and stated that he was going outside to smoke, arm pads were missing from both sides of his wheelchair. Resident #42 stated that he had one missing arm pad when he was admitted to the facility and the other recently fell off. Resident #42 stated that he has been really careful not to bump his arms on the bolts.<BR/>During observation on 6-8-22 at 11:00 a.m., Resident #42 was sitting up in wheelchair in his room, no padding on either arm rest of wheelchair. <BR/>During interview with Resident #42 on 6-8-22 at 12:08 p.m., Resident #42 stated he never reported the missing arm pads on his wheelchair to anyone. Resident #42 stated he just made sure he was careful every time he tried to transfer himself so that he did not hit his arms.<BR/>Resident #40<BR/>Record Review of Resident #40 admission record indicates he was a [AGE] year-old male with a history of hemiplegia, encephalopathy (brain disease), altered mental status, and hypotension. Resident #40 was admitted on [DATE].<BR/>Record Review of MDS dated [DATE] indicated Resident #40 has a BIMS score of 7 for severely impaired cognition. Section G of the MDS under ADL Self-Performance for bed mobility, Resident #40 required extensive assistance with bed mobility and one person assist with bed mobility. Under transfers, Resident #40 was required total dependence with all transfers and one person assist.<BR/>During observation on 6-6-22 at 10:10 am, Resident #40 was lying in bed covered up with blankets, bed was pushed up against the wall and the foot of the bed was up against the window; the bottom of the window frame was broken in half and the wood in the center was sticking straight up towards the blinds. Resident #42 is not interviewable.<BR/>During observation on 6-7-22 at 9:12 am, Resident #40 was lying in bed and the window frame remained broken. Resident #42 is not interviewable.<BR/>During observation on 6-8-22 at 11:15 am, Resident #40 was lying in bed covered with blankets and window frame remained broken with wood sticking up.<BR/>During interview with the maintenance director at 11:15 am, the maintenance director stated he had not worked in several months due to a car wreck and multiple surgeries. The Maintenance director stated employees are responsible for putting in a work order either online or in the order book and he checked the books and his computer daily on the days he worked. The Maintenance director stated he was not aware of the broken window frame and stated there was not an order to fix it. Record Review of the work orders indicated that no request had been made to fix the broken window frame. The Maintenance director stated he had started on 100 hall last week doing repairs such as painting and was currently on the 200 hall. He stated he would continue until he was finished will all the halls. The Maintenance director stated he walked into each room weekly to do water temperature checks and he had not noticed the broken window frame. He stated the broken frame could result in the resident getting hurt. He stated he was responsible for fixing all wheelchairs that are provided by the facility. He stated the only equipment that he does not fix are the ones under warranty by the VA because it would void the warranty on them. He stated the nursing or therapy department would notify him using the communication form online or do a work order in the maintenance book that a wheelchair needs to be fixed and he would take care of it. The Maintenance director stated he was not aware Resident #42 needed his wheelchair arm pads replaced. <BR/>During an interview with MA L on 6-8-22 at 9:31 a.m., MA L stated she had worked at the facility since 2012. MA L stated a wheelchair with no arm pads or a broken window frame should be reported to the maintenance man immediately using a form in his book at the nurse's station. MA L stated most of the time she would notify the charge nurse and the charge nurse will complete the maintenance form, or she will just tell the maintenance man when she saw him, and he would fix it. MA L stated she was not aware of the broken window frame or the wheelchair with no arm pads.<BR/>During an interview with LVN K on 6-8-22 at 8:11 a.m., LVN K stated she had worked at the facility for 3 years. LVN K stated every resident admitted to the facility was evaluated by the therapy department and therapy department was responsible for making sure the residents wheelchairs fit them properly and were in good working order. LVN K stated therapy discussed any issues they have with residents in the Focus meeting every morning. LVN K stated they should immediately tell maintenance about the broken wheelchair because it could hurt the resident and that was what residents used to position themselves. LVN K stated staff should call maintenance immediately for the broken wood sticking up in the window because the resident could get hurt on the wood. LVN K stated the charge nurses make rounds at least every hour and go into every room. LVN K stated they use communication notes in the computer to communicate issues with maintenance and the maintenance director checked his book every day he worked. LVN K stated everyone was responsible for reporting the wheelchair with no arm pads and the broken wood in the window because someone could get hurt. LVN K stated she was not aware of the broken window frame or the wheelchair with no arm pads. <BR/>During interview on 6-8-22 at 9:19 am., DON stated the broken wood in the window frame should have been reported by whoever saw it. The DON stated that nursing and Maintenance should have been notified. She stated Resident #40 could have moved his arms and hit it or got cut. DON reported nursing staff was required to make rounds every hour and walk into each room and check on residents. DON stated that management made room rounds every Monday, Wednesday, and Friday to check rooms and make sure that everything was tidy and neat. DON reported housekeeping cleaned all the resident's rooms daily and should have noticed the broken window and reported it. DON stated the broken window should not have been missed for more than 1 shift. DON stated Resident #42's wheelchair with no arm pads should have been reported immediately. DON stated the admitting nurse should have noticed the wheelchair and the resident should have been given a loner wheelchair until his could be fixed. DON stated every resident that was admitted to the facility was evaluated by the therapy department and they made sure the residents wheelchairs are the proper size and in working order. DON stated the broken wheelchair could put resident #42 at risk for injury.<BR/>During interview with the Administrator on 6-8-22 at 9:49 a.m., the Administrator stated the broken window should be reported by whomever finds it. The Administrator stated a work order should have been completed and the broken window should have been reported to her. The Administrator stated she expected nursing staff to complete 2-hour rounds on all residents and includes checking the rooms to make sure they have working light bulbs and rooms are neat/tidy. The Administrator stated residents could have been injured from the broken wood on the window frame or they could have been cut. The Administrator stated she was responsible for Maintenance if there was no one available or when Maintenance was out on leave. The Administrator stated the missing padding on the wheelchair pads should have been reported and fixed. The Administrator stated that if it was a VA resident the facility cannot fix the wheelchair because it could void the warranty, but the resident should have been given a loner wheelchair until his wheelchair can be fixed. The Administrator stated it was the responsibility of the admitting nurse to report the wheelchair. The Administrator stated every resident was looked at by therapy and therapy was responsible for making sure the residents wheelchairs are working properly. <BR/>During interview with the Rehab Director at 10:59 a.m., the Rehab director stated she had been with the facility for 3.5 years. The Rehab director stated she does not evaluate every resident, but therapy does screen every resident. The Rehab director stated that resident #42 would have been screened if he was independent and therapy must wait for authorization for all Veterans Affairs (VA) residents. The Rehab Director stated they are responsible for checking wheelchairs when therapy's screen residents. The Rehab Director stated the residents get their wheelchairs mixed up a lot and Resident #42 might not have been in his own wheelchair at the time of screening. The Rehab Director stated if Resident #42 was screened and the arm rest was missing, she would have notified maintenance at that time. The Rehab Director stated the missing arm pads could result in resident having sores on his arm and make it difficult for him to transfer. The Rehab Director stated there are extra wheelchairs available at facility that residents can borrow until they can get he's fixed. <BR/>Record Review of the Maintenance log on 6-8-22 indicated no orders were logged for Resident #40 or Resident #42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 14 (Resident #'s 32)) residents reviewed for care plans. <BR/>The facility failed to update Resident # 32's care plan to indicate she no longer needed to wear a helmet for safety due to falls. <BR/>These failures could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and/or a decline in physical well-being. <BR/>Findings included:<BR/>1.Record review of a face sheet dated 6/8/2022 indicated Resident #32 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of early onset Alzheimer's disease (a memory destroying disease), and difficulty swallowing. <BR/>Record review of a Care plan dated 10/17/2019 indicated Resident #32 had a high potential for falls and no safety awareness. The goal was Resident #32 would remain free of falls over the next 90 days. The interventions included staff will continue to use a wheelchair when Resident #32 was unsteady, and staff will re-apply a helmet for preventative measures for head injuries. <BR/>Record review of a MDS dated [DATE] indicated Resident #32 sometimes understood others and was sometimes understood. The MDS indicated Resident #32's daily decision-making abilities were severely impaired. The MDS indicated Resident #32 required extensive assistance with bed mobility, total assistance with dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #32 had no activity in the areas of transfers, walking in room or corridor, locomotion on or off the unit and bathing. The MDS section Balance indicated Resident #32 was not steady with moving from a seated to standing position and surface to surface transfers. The MDS section for falls indicated no falls since admission, reentry, or previous assessment. <BR/>During an observation on 6/6/2022 at 2:33 p.m., Resident #32 was lying in bed there was no helmet the resident and no one was in the room.<BR/>During an observation and interview on 6/7/2022 at 8:28 a.m., Resident #32 was in her room alone sitting in her Geri chair with no helmet on. CNA E indicated she was unaware of Resident #32 needing to wear a helmet. <BR/>During an interview on 6/7/2022 at 12:07 p.m., LVN A said she was unaware of Resident #32 needing to wear a helmet. LVN A stated she was unaware the care plan indicated Resident #32 was to wear a helmet to prevent serious head injuries from falls. LVN A indicated the care plan directs the care a resident would need. LVN A said she was responsible for ensuring the care plan was followed by the nursing staff .<BR/>During an interview on 6/7/2022 at 4:28 p.m., LVN A said the Resident #32's helmet was discontinued 2021 in September or October . LVN A was unsure why the care plan was not updated .<BR/>During an interview on 6/8/2022 at 8:52 a.m., LVN K said she was responsible for the care of Resident #32. She said when Resident #32 was in the unit she required the use of a helmet for falls but now she does not require the use of a helmet. LVN K indicated the care plan directed the resident care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 7 of 14 residents reviewed for ADLs. (Resident #'s 1, 23, 26, 29, 31, 32, and 47)<BR/>The facility did not provide assistance with facial hair removal for Resident #'s 23, 26, 29, 31, and 32.<BR/>The facility did not ensure Resident #'s 1, 23, 26, 29, 31, 32, and 47 was routinely assisted with a shower.<BR/>These failures could place residents who were dependent of staff to perform personal hygiene at risk for embarrassment, decreased self-esteem, or decreased quality of life. <BR/>Findings included: <BR/>1 .Record review of a face sheet dated 6/8/2022 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with the diagnoses of muscle weakness, need for assistance with personal care, knee contractures and arthritis. <BR/>Record review of a comprehensive care plan dated 5/14/2021 with a revision on 6/7/2021 indicated Resident #1 had an ADL self-care performance deficit with a goal of will gain more independence with daily care by staff will assist with showering as requested .<BR/>Record review of an Annual MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood. Resident #1's BIMS was a 6 indicating severe cognition problems. The MDS indicated Resident #1 required total assistance of two staff for transfers. The MDS indicated Resident #1 required extensive assistance of one staff with bed mobility, locomotion, and eating. The MDS indicated Resident #1 required total assistance of one staff to bathe. <BR/>Record review of the undated shower roster indicated Resident #1 was scheduled for a shower on Monday-Wednesday-Friday on the 6:00 p.m. to 6:00 a.m. shift.<BR/>Record review of Resident #1's bath sheets dated from 5/9/2022 through 6/8/2022 indicated Resident #1 had 6 showers of the 13 scheduled opportunities.<BR/>2.Record review of a face sheet dated 6/7/2022 indicated Resident #23 was an [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (memory loss disease), need for assistance with personal care, lack of coordination, muscle weakness and cognitive communication deficit. <BR/>The most recent Annual MDS dated [DATE] indicated Resident #23 rarely understood and sometimes understands. The MDS indicated Resident #23 required extensive assistance of 2 staff for bed mobility, transfers, and dressing. She requires extensive assistance of one staff for locomotion, and personal hygiene. Resident #23 required total assistance of two staff for bathing. <BR/>The comprehensive care plan with a revision date of 1/17/2017 indicated Resident #23 had an ADL self-care deficit and at times requires staff assistance and needs to be reminded to complete her ADLs with a goal she will maintain her current level of function. The intervention included the resident required extensive staff assistance with bathing/showering.<BR/>Record review of the undated shower roster indicated Resident #23 was to be provided a shower on Tuesday-Thursday-Saturday on the 6:00 a.m. to 6:00 p.m. shift.<BR/>Record review of the shower sheets dated 5/12/22 through 6/7/22 indicated Resident #23 was provided 6 showers of the 11 scheduled from 5/14/2022 until 6/7/2022.<BR/>During an observation on 6/6/2022 at 2:42 p.m., Resident #23 had hair to her chin. Resident #23 was non-verbal and could not communicate her feelings regarding hair to her chin.<BR/>During an observation on 6/7/2022 at 10:29 p.m., Resident #23 continued to have hair to her chin. <BR/>3 .Record review of a face sheet dated 6/7/2022 indicated Resident #26 was an [AGE] year-old-female who admitted on [DATE] and readmitted [DATE] with the diagnoses of need of assistance with personal care, lack of coordination, and unspecified dementia.<BR/>Record review of the comprehensive care plan dated 5/12/2015 with a revision on 1/25/2018 and a target date of 7/24/2022 indicated Resident #26 had an ADL self-care deficit related to her intellectual disability with a goal of maintaining a current level of function. The intervention included Resident #26 required one staff to assist with participation to dress, personal hygiene, and bathing.<BR/> Record review of an Annual MDS dated [DATE] indicated Resident #26 understands and was understood. The MDS indicated Resident #26 required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use, and personal hygiene. Resident #26 required total assistance with bathing. <BR/>Record review of the undated shower roster indicated Resident #26 was scheduled Monday-Wednesday-Friday on the 6:00 p.m. to 6:00 a.m. shift to receive her scheduled showers.<BR/>Record review of the shower sheets dated 5/9/22 through 6/8/22 indicated Resident #26 was scheduled for 13 showers opportunities and received 8 showers. <BR/>During an observation on 6/6/2022 at 9:57 a.m., Resident #26 had long hairs on her chin. <BR/>During an observation on 6/6/2022 at 12:20 p.m., Resident #26 continued to have hairs to her chin.<BR/>4.Record review of a face sheet dated 6/7/2022 indicated Resident #29 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of unsteadiness on feet, weakness, lack of coordination, and dementia.<BR/>Record review of a comprehensive care plan dated 12/29/2021 indicated Resident #29 required extensive assistance with all aspects of daily care with a goal to maintain good body hygiene. The care plan interventions included staff will assist with Resident #29's showers.<BR/>Record review of the most recent significant change MDS dated [DATE] indicated Resident #29 was understood and understands. The MDS indicated Resident #29 required extensive assistance of one staff for bathing.<BR/>Record review of the undated shower roster indicated Resident #29 was not named on the shower roster for any scheduled showers.<BR/>Record review of the shower sheets indicated Resident #29 received showers on the following days:<BR/>-5/9/22<BR/>-5/18/22<BR/>-5/23/22<BR/>-5/27/22<BR/>-6/1/22 <BR/>During an observation and interview on 6/6/2022 at 10:15 a.m., Resident #29 had chin hairs and she indicated she had not had a shower since the last Wednesday on 6/1/2022. <BR/>5.Record review of a face sheet dated 6/7/2022 indicated Resident # 31 was [AGE] year-old female with an original admission date of 7/5/2018 and a current admission date of 3/12/2020 with diagnoses of Bipolar Disorder dated 7/05/2018, Major depressive disorder dated 7052018, and generalized anxiety disorder dated 7/05/2018. <BR/>Record review of a comprehensive care plan 10/25/2019 indicated Resident #31 had an ADL self-care deficit with a goal to improve her current level of function. The care plan failed to address the bathing needs of Resident #31.<BR/>Record review of the most recent significant change MDS dated [DATE] indicated Resident #31 was usually understood and understands others. The MDS indicated Resident #31 had a BIMS of 8 indicating moderate cognitive impairment. The MDS indicated Resident #31 required total assistance of 1 staff for bathing. <BR/>Record review of the undated shower rosters indicated Resident #31 was scheduled for a shower on Tuesday-Thursday-Saturday on the 6:00 p.m.- 6:00 a.m.<BR/>Record review of the shower sheets dated 5/19/22 through 6/7/22 indicated Resident #31 received 4 showers out of 9 scheduled opportunities. <BR/>During an observation and interview on 6/6/2022 at 9:40 a.m., Resident #31 said she had one shower since last week. Resident #31 indicated her shower days were Tuesday-Thursday and Saturday. Resident #31 had hairs to her chin, and she voiced she needed them to be shaved off . <BR/>During an observation and interview on 6/7/2022 at 10:32 a.m., Resident #31 said she had not had a shower and nor had her hairs been shaved. Resident #31 said not getting her showers and shaved were normal routine. <BR/>During an observation on 6/7/2022 at 2:00 p.m., Resident #31 continued to have hair to her chin.<BR/>During an interview on 6/7/2022 at 4:12 p.m., CNA F indicated he was responsible for the showers on 100 Hall. CNA F indicated he showered Resident #31 this morning. CNA F indicated he failed to notice the hairs to Resident #31's chin. CNA F said he would take care of them at this time. CNA F said shaving was one of his tasks . <BR/>6.Record review of a face sheet dated 6/8/2022 indicated Resident #32 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of early onset Alzheimer's disease (a memory destroying disease), and difficulty swallowing. <BR/>Record review of a Care plan dated 10/17/2019 indicated Resident #32 indicated she required hands on assistance with most daily care and would have her needs met by the staff providing her showers.<BR/>Record review of a Significant Change MDS dated [DATE] indicated Resident #32 sometimes understood others and was sometimes understood. The MDS indicated Resident #32's daily decision-making abilities were severely impaired. The MDS indicated Resident #32 required extensive assistance with bed mobility, total assistance with dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #32 had no activity in the areas of transfers, walking in room or corridor, locomotion on or off the unit and bathing. <BR/>Record review of the undated resident shower roster indicated Resident #32 would have a shower on Monday-Wednesday-Friday on the 6:00 a.m.- 6:00 p.m. shift.<BR/>Record review of the shower sheets dated 5/9/2022 through 6/8/2022 indicated Resident #32 had 4 showers provided out of 14 scheduled showers.<BR/>During an observation on 6/6/2022 at 10:08 a.m., Resident #32 had long hairs to her chin. <BR/>7.Record review of a face sheet dated 6/7/2022 indicated Resident #47 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnosis of acute respiratory failure with lack of sufficient oxygen difficulty swallowing, and dementia. <BR/>Record review of an Annual MDS dated [DATE] indicated Resident #47 was usually understood and usually could understand others. The MDS indicated Resident #47 required total assistance of one staff member for bathing.<BR/>Record review of the undated comprehensive care plan for Resident #47 failed to address her ADL needs.<BR/>Record review of the resident undated shower roster indicated Resident #47 was scheduled Monday-Wednesday-Friday 6:00 a.m. -6:00 p.m. shift.<BR/>Record review of the resident shower sheets dated 5/9/22 through 6/8/22 indicated Resident #47 was provided 6 showers of the 14 scheduled showers. <BR/>During an interview with the resident council on 6/7/22 at 2:59 p.m., Resident #29 indicated she had not had a shower since the last Wednesday.<BR/>During an interview on 6/7/2022 at 4:16 p.m., LVN A stated the CNAs were responsible for the showers. LVN A said the binder at the nurse's desk had the resident shower roster. LVN A said the CNAs should review the shower roster daily and complete the shower sheets. LVN A the shower sheets were then turned in to the nurse. LVN A said she was responsible for reviewing the shower sheets, signing the shower sheets, and turning them in to the ADON by placing in the 24-hour binder .<BR/>During an observation and interview on 6/8/2022 at 8:32 a.m., CNA G stated she was responsible for ADLs on 100 Hall. CNA G said the shower book contained the shower lists and the shower sheets. CNA G said she completed a shower sheet after the shower and turned it into the nurse. CNA G said shower and shaving were the tasks provided on shower days. CNA G said a female resident would not want to have hairs to their chin, this would be embarrassing. CNA G said she was unable at times to provide showers due to staffing challenges. CNA G said she did not notice Resident #26 and Resident #32's hairs to their chins. CNA G indicated she would shave Resident #26 and 32's hairs to the chins.<BR/>During an interview on 6/8/2022 at 8:52 p.m., LVN K said she was responsible for the residents on Hall 100. LVN K said ensuring a resident received their ADLs were her responsibility. LVN K said the shower roster indicated the days a resident would receive a shower. LVN K said the CNAs would complete a shower sheet and she was required to sign the sheet indicating there were no issues. LVN K indicated shaving was a task completed by the CNAs and should be done with ADLs. LVN K indicated a female resident would feel embarrassed with hairs to their chins. <BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON said the charge nurses were responsible for ensuring the showers and shaving were completed by the CNAs. The DON said there was no auditing tool to ensure residents received their scheduled showers . The DON indicated she would implement a tool to mark showers provided. The DON indicated the lack of showers could affect a resident's skin condition and could cause infections. The DON said facial hair on a woman could affect their self-esteem.<BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator stated she expect a resident's ADLs to be completed in their entirety. She said not having their showers and shaving could impact their health and dignity. The Administrator indicated the ADON was responsible for monitoring the ADLs.<BR/>Record review of the facility's Procedural Guideline #28 indicated shaving the Resident dated 1/2022 indicated the purpose was to shave the resident and maintain appearance and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the environment was free of accident and hazards for 1 of 1 resident reviewed for transfers. (Resident #1) <BR/>The facility failed to ensure Resident #1 was transferred using a gait belt on two separate occasions. <BR/>This failure could place residents at risk of injuries and falls. <BR/>Findings included: <BR/>Record review of a face sheet dated 6/8/2022 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with the diagnoses of muscle weakness, need for assistance with personal care, knee contractures and arthritis. <BR/>Record review of a MDS dated [DATE] indicated Resident #1 was usually understood by others and was usually understood. Resident #1's BIMS was a 6 indicating severe cognition problems. The MDS indicated Resident #1 required total assistance of two staff for transfers. The MDS indicated Resident #1 required extensive assistance of one staff with bed mobility, locomotion, and eating. The MDS in the area of balance indicated Resident #1 was not steady in moving from seated to standing position and surface to surface transfers. <BR/>Record review of a comprehensive care plan dated 12/18/2021 indicated Resident #1 was at risk to fall due to a past stroke with left sided weakness and use of medications. The goal was to remain free from falls. Interventions included restorative therapy to continue to enhance quality of life and staff will assist with transfers. The care plan also indicated Resident #1 had limited physical mobility requiring the assistance of one for all transfers. The interventions indicated were staff to assist Resident #1 with all transfers, staff will encourage to be out of bed and to refer to physical therapy as needed. <BR/>During an observation and interview on 6/7/2022 at 8:25 a.m., CNA E transferred Resident #1 by having Resident #1 place her arms around CNA E's neck then CNA E encircled her arms around Resident #1's back and then pivoted her to the wheelchair. CNA E said she was the float aide assisting on Hall 100 today. CNA E said she should have used a gait belt. CNA E said she had been trained on transferring with a gait belt. CNA E said Resident #1 could suffer a fall if not transferred with a gait belt. <BR/>During an observation and interview on 6/8/22 at 11:59a.m., CNA G applied shoes on Resident #1 and then assisted her with a sitting up on the side of the bed. CNA G placed the wheelchair next to bed and locked the chair. CNA G wrapped her arms around the Resident #1's waist, lifted her off the bed, and pivoted her into the wheelchair. CNA G stated she had a gait belt available, but she never used one on Resident #1 because she was so light, and Resident #1 was able to push up with her feet to assist with the transfer. CNA G said she was unsure when her last in-service was on transferring a resident. CNA G stated she was taught in CNA training to use a gait belt with every transfer. CNA G stated not using a gait belt could result in Resident #1 falling. <BR/>During an interview on 6/8/2022 at 12:07 p.m., the DON stated she was responsible for ensuring residents were transferred appropriately using a gait belt. The DON said the employees have annual checkoffs in July 2022. The DON indicated CNA G had just been certified as a nurse aide and therefore had not had an annual check off with the facility. The DON said she was unaware of new hire check offs, but the new employee receives 3 days of orientation. The DON said she had not conducted a recent in-service on transfers but had made gait belts available for all nursing staff. <BR/>During an interview on 6/8/2022 at 12:36 p.m., the Administrator stated she expected the nursing staff to use a gait belt with transfers. The Administrator stated not using a gait belt with transfers could cause an injury to the resident or the employee. The Administrator stated the DON was responsible for transfer compliance. The Administrator was unsure of a form for checkoffs upon hire to ensure competency. <BR/>Record review of the facility's Procedural Guideline #39-Assisting a Resident to Transfer to Chair or Wheelchair, dated 1/2022 indicated the purpose was to transfer a resident to chair or wheelchair without trauma or avoidable pain. The policy included guidelines and precautions with moving and lifting of residents of knowing the abilities and limitations of the resident to participate in the move, request special instruction from the nurse as needed prior to the move . 4.A. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting fingers under it . E. Grasp the transfer belt with an under-hand grip and move the resident forward so the feet are flat on the floor. F. Lean forward and instruct the resident to place hand on your shoulders. Do not let the resident put their arms around your neck. G. Place your hands on either side of the transfer belt, and on prearranged signal, gradually assist the resident up into a standing position, supporting the knees and feet with your legs and feet as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to respect a resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 (Resident #1) of 5 residents reviewed for resident rights.The facility failed to obtain a valid DNR for Resident #1 which resulted, on [DATE], in Resident #1 receiving CPR when she was found unresponsive. This failure could place residents at risk of their rights to refuse or discontinue treatment being disrespected, being resuscitated against their wishes or placed on life support.Findings included:Record review of Resident #1's face sheet, dated [DATE], revealed an eighty-four-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), fracture of the right femur (a break in the thigh bone, which is the longest and strongest bone in the human body), recurrent depressive disorders (the person has a history of at least two depressive episodes (depressed mood or loss of pleasure or interest in activities) for long periods of time).Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly assessment dated [DATE] revealed a BIMS score of zero indicating severe cognitive issues.Record review of Resident #1's care plan revealed a focus dated [DATE] reflected Resident #1 had an order for Do Not Resuscitate (DNR) with interventions dated [DATE]: 1. All aspects of DNR will be explained to Resident #1 or responsible party.2. In absence of blood pressure, pulse, respiration, CPR will not be initiated.3. Notify MD of change of condition.4. Resident #1 will be maintained at a level of comfort as ordered by physician.5. Social Services to consult with resident and RP regarding their decision to continue DNR.Record review of Resident #1's Out-of-hospital Do-Not-Resuscitate (OOH-DNR) order Texas Department of State Health Services dated [DATE] revealed it was unsigned by a physician. Record review of page 28 of Resident #1's facility admission papers dated [DATE] signed by Resident #1's RP reflected Informed Consent - I have been informed of my rights to make advanced directives for health care decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives such as Directive to Physicians and/or Living Will or Durable Power of Attorney for Health Care. Beig so informed, it is my decision to: I have previously executed a document and will supply copies to the facility for my or my relative's clinical record and physician use. Record review of Resident #1's order dated [DATE] by RN H reflected order summary DNR advance directive status current and verified. Interview on [DATE] 10:47 am with the DON reflected that she was alerted by a CNA (name of CNA unknown) that Resident #1 was unresponsive. A family member of Resident #1 was in the building. The DON said they assumed that Resident #1 was a full code because she did not have a DNR. The DON said the Resident #1 was not on hospice. The DON said she began placing her hands on Resident #1 to do chest compressions, and the family member told her to stop because Resident #1 had a DNR. She said EMS arrived and were informed by the DON that Resident #1 did not have a DNR and they began to attempt to do chest compressions and again the family member told them to stop because Resident #1 had a DNR. She said the family member received a copy of the DNR via his telephone from another family member, but the DNR did not have the signature of a MD. She said EMS received approval from a member of their team to not proceed with compressions. Interview on [DATE] at 3:38 pm with a family member of Resident #1, who was present when she died, reflected the facility did not have the correct DNR because the former nursing facility did not send it when Resident #1 was transferred to the current facility. The family said the MD's name was printed on the DNR, but it had no MD signature. He said the former nursing facility was to forward all the information about Resident #1 to her current facility. Interview on [DATE] at 10:57 am with the ADON reflected she had been the ADON at the facility for 1 (one) month. The ADON did not know the facility policy regarding resident DNRs. She said she did not know if the facility required residents to have either a DNR or full code established when they came into the facility, she stated she would hope so, but she did not know. She said she did not know who was responsible for making sure that the residents had the correct code status information when they were admitted to the facility, her first thought would be the nurse, but she did not know which nurse, she would have to look at the policy. She said it was very important to have the residents correct and complete code status because it was a matter of life and death.Interview on [DATE] at 11:32 am with LVN F reflected the charge nurse upon a residents' admission was responsible for checking the residents' code status. LVN F said the resident code status was documented in PCC (an electronic health record designed for long-term care providers, including nursing homes and senior living communities). She said she thought the admission coordinator and the social worker were responsible for making sure that the residents' code status was accurate, correct, with a completed copy in the residents' file. She said the negative effect of not knowing the residents' code status was you would not know what the resident wanted if they were unresponsive and could be violating their wishes if it was incorrect. Interview on [DATE] at 12:10 pm via phone with LVN G reflected she no longer worked at the facility. LVN G believed that the DON was responsible for making sure that the code status for residents was requested and accurate. LVN G said Hospice was also responsible. She said the negative effect of not having a clear DNR for the residents was it would go against resident rights if staff did the opposite of what the resident wanted; either to be resuscitated or not resuscitated if they coded. Interview on [DATE] at 12:58 pm with the SWD reflected she looked over the DNRs for accuracy then uploaded them into the residents' electronic file. She said sometimes the DNRs were incomplete and did not have a signature and she had to wait to upload it. She said the DON was responsible for making sure it was in the facility. She said if staff did not know a residents' code status, the resident was considered a full code and resuscitation efforts would be attempted. She said if a resident had a DNR, and resuscitation efforts were attempted, staff might go against the residents' rights and that was, a big mess up.Interview on [DATE] at 2:59 pm with the RCD reflected the nurse on admission entered in the eMAR either the residents' full code or DNR code. The admitting nurse could have asked the family what the code was when the resident admitted . She said the DON and the social worker were supposed to follow up and confirm that the facility had the correct paperwork for the code status entered by the admitting nurse. She did not know how this was missing. She said it was a big deal because the resident could have been brought back or placed on life support against her wishes. She said it was the responsibility of the social worker and the DON to confirm code status and obtain complete paperwork. She said the DON personally uploaded the DNRs into the resident's record to make sure they were there. Interview on [DATE] at 3:44 pm with the RDO reflected when a resident was referred to their facility from another facility, they had to have the DNR in hand prior to admitting the resident. The RDO did not know what happened that they did not have a completed signed DNR on hand for Resident #1. She said the nurse should not have placed the DNR order unless there was a complete signed DNR on hand. She said it should have been followed up on chart audits by the DON or the ADON. She said the negative outcome was that the resident received CPR (emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) and it was against the wishes of the resident. It was a resident rights issue.Interview on [DATE] at 4:58 pm with the Administrator reflected nurse managers and the DON had the responsibility of checking the admission orders within the first 24 hours of a resident's admission to make sure all documents and the admission was complete. She said there was a process that began with the charge nurse when the resident was admitted , to the admissions coordinator and the DON. She said the worst-case scenario if there was kink in the process of confirming if a resident had a DNR, was the resident could be resuscitated against their wishes, and when the resident's ultimate wishes were not respected, it was a violation of resident rights.Interview on [DATE] at 6:02 pm with the DON reflected when the charge nurse admitted a resident, the nurse needed a hard copy of the DNR that was signed and executed, and if there was not a fully executed hard copy DNR, the resident was automatically a full code. She said she did not know what happened regarding Resident #1's DNR. The DON said RN H admitted Resident #1 and RN H would have had to have had the DNR in her hand to enter the DNR order for Resident #1. The DON said she never saw a DNR for Resident #1. She said it caused Resident #1's family emotional distress when staff was going to provided Resident #1 CPR. She said a family member threatened bodily harm to the staff if they did not cease CPR because Resident #1 was a DNR.Record review of the facility's policy Do Not Resuscitate Order dated [DATE] revealed Policy Statement - our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation - Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet. The attending physician must be informed of the resident's request to cease the DNR order. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes.