DIBOLL NURSING AND REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment 1 of 3 halls (room [ROOM NUMBER]) reviewed for environment.The facility failed to repair the window in Resident #8's room [ROOM NUMBER] that had a broken frame that was frayed and splintered on 8/26/2025 and 8/27/2025.This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.Findings include:Record review of a face sheet for Resident #8 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of severe intellectual disabilities (delay in language, motor, and social skills), expressive aphasia (difficulty speaking), and hypotension (low blood pressure). Record review of the maintenance log dated 7/30/2025 indicated that the window frame in Resident #8's room was reported and initialed by Maintenance. Record review of a care plan for Resident #8 dated 7/23/2025 indicated she had impaired functional abilities related to severe intellectual disabilities and she was dependent on staff for all adl's. Record review of a Quarterly MDS Assessment for Resident #8 dated 7/18/2025 indicated she was rarely/never understood and did not have a BIMS score. She was dependent on staff for all adl's. During an observation and interview on 8/26/2025 at 8:19 AM in Resident #8's room revealed she was in bed visiting with a friend . The window frame was frayed and splintered with pieces of wood sticking out. The friend said she had been working with Resident #8 for two weeks and had not noticed the window frame. She said the window frame was splintered it could be a hazard to the resident and said she was sure they would get it fixed. During an observation and interview on 8/26/2025 at 8:21 AM, CNA A was standing in the hallway of hall 100. She said she had been employed at the facility since April 2025. She said she reported the window frame in Resident #8's room last month to Maintenance. She said she had Maintenance go in the room and look at the window frame. She said she did not know if there was a logbook to report maintenance issues. She said she would report issues verbally to the nurse or would find Maintenance and report to him directly. She said the resident could get splinters, cuts, or injuries if the window frame was not repaired. During an observation on 8/27/2025 at 8:19 AM, Resident #8 was in bed resting with her eyes closed. The window frame was still not repaired and was splintered with pieces of wood sticking out. During an observation and interview on 8/27/2025 at 8:46 AM, the Maintenance Supervisor said he had been employed at the facility for three months. He said staff reported things that needed repair to him verbally but would log in the maintenance book that was kept outside of his office door. He said he checked the maintenance log daily. He observed the window in Resident #8's room and said it was splintered and needed to be repaired. He said he thought the staff were raising the bed too close to the window frames that was causing the frames to break. He said he was not aware of the window frame in Resident #8's room but would get it repaired. He said residents could get hurt if it was not repaired. During an interview on 8/27/2025 at 9:20 AM, the Administrator said he was aware of the windowsills in some of the resident rooms that needed repair. He said the Maintenance Supervisor had been working to repair them. He was not aware the window in Resident #8's room had been on the log for about a month. He said the Maintenance Supervisor would get the window repaired. He said there could be a risk for injury if the window was not repaired. Record review of a facility policy titled Homelike Environment revised February 2021, .Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 4 of 8 residents (Residents #9, #1, #4, and #21) reviewed for ADL care. 1.The facility failed to clean/groom Resident #9's fingernails that had a dark brown substance underneath them on 8/25/25 and 8/26/25.2.The facility failed to trim, clean/groom Resident #21's fingernails that were about 1/2 inch in length and had a dark, brown substance underneath them on 8/25/2025.3. The facility failed to trim, clean/groom Resident #4's fingernails that were about 1/2 inch in length on 8/25/2025 and 8/26/2025.4. The facility failed to trim, clean/groom Resident #1's fingernails that were about 1/2 inch in length and had a brown substance underneath them on 8/25/2025 and 8/26/2025. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care.Findings included:1. Record review of a facility face sheet dated 8/26/25 for Resident #9 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (uncontrolled blood sugar). Record review of Resident #9's Quarterly MDS assessment dated [DATE] indicated a BIMS score of 3 which indicated a severe cognitive impairment. She required maximum assistance with most ADLs. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 7/23/25 for Resident #9 indicated she had an ADL self-care performance deficit and had an intervention for substantial/maximal assistance with personal hygiene. Record review of a Point of Care History flowsheet dated 8/23/25 to 8/26/25 for Resident #9 indicated she was to have nail care done once a day on Monday, Wednesday, and Friday.During an observation and interview on 8/25/25 (a Monday) at 9:27 am Resident #9 was observed lying in bed. Her 2nd and 3rd fingernails on her left hand were observed with a dark brown, caked substance underneath them. She was asked when the last time her nails were cleaned and groomed, and she said she thought they trimmed them last week but could not say when the last time they were cleaned. She said she would like to have them cleaned. During an observation on 8/26/25 (a Tuesday) at 8:20 am Resident #9 was observed in bed finishing her breakfast. Her nails on her left hand were observed to still have a dark brown, cakey substance underneath them. 2. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he readmitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (wound at the bottom of the spine that extends through the skin into the tissue and fat), diabetes mellitus, and malignant neoplasm of upper lobe of lung (lung cancer).Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 10. He required substantial/maximal assistance with personal hygiene. Record review of a care plan for Resident #1 dated 10/28/2024 indicated he had an approach for nail care to be performed once a day on Monday, Wednesday, and Friday.During an observation and interview on 8/25/2025 at 1:41 PM, Resident #1 was in bed awake. His fingernails were about 1/2 inch in length and had a brown substance underneath them. He said the staff had cut and cleaned his nails before, but it had been a while. He said he would like to have his nails trimmed and cleaned.During an observation on 8/26/2025 at 9:07 AM, Resident #1 was in bed awake. His fingernails were still long in length and had a brown substance underneath them.3. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction (Stroke) affecting left non-dominant side (paralyzed on one side of the body), type 2 diabetes, heart failure and GERD (acid reflux disease).Record review of a care plan for Resident #21 dated 8/18/2025 indicated nail care to be done once a day on Monday, Wednesday, and Friday from 6 am-6 pm. She had impaired functional abilities related to hemiplegia with an approach for personal hygiene that indicated she was dependent on staff.Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene.During an observation and interview on 8/25/2025 at 1:19 PM, Resident #21 was in her room in bed. Her fingernails were about 1/2 inch in length and had a brown substance underneath them. She said the staff cut and cleaned her nails about once a month. She said she did not like long nails and liked to keep them short and clean.During an observation on 8/26/2025 at 2:58 PM, Resident #21 was sitting up in a wheelchair in her room watching tv. Her nails were still long and had a brown substance underneath them.4. Record review of a Face Sheet for Resident #4 dated 8/26/2025 indicated the resident admitted to the facility on [DATE] and was [AGE] years old with diagnoses of moderate intellectual disabilities (developmental delay that affects thinking) expressive language disorder (inability to use language and communicate effectively), and schizoaffective disorder (a mental illness that combines symptoms of mood disorders).Record review of a care plan for Resident #4 dated 7/23/2025 indicated nail care to be completed once a day on Tuesday, Thursday, and Saturday.Record review of an Annual MDS Assessment for Resident #4 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She was dependent on staff for personal hygiene.During an observation on 8/25/2025 at 9:52 AM, Resident #4 was sitting by the front entrance in a wheelchair. She was staring out the front door and did not answer when she was spoken to. Her fingernails were about 1/2 inch in length. During an observation and interview on 8/26/2025 at 2:59 PM, Resident #4 was sitting by the front entrance in a wheelchair with a visitor present. Resident #4 did not respond when she was spoken to. Resident #4 still had long fingernails. Her visitor said she had been with the resident for about 5 months and the resident had never refused to allow the staff to trim her nails. She said the Activity Director or Treatment nurse would trim the resident's fingernails. She said residents could scratch themselves or injure others if their nails were long.During an interview on 8/26/2025 at 3:01 PM, the Activity Director said she was responsible for nail care along with the nurse aides. She said the nurse aides were to clean and trim nails on the resident's shower days and she provided nail care on Monday during activities that included cleaning, trimming, and painting. She said the nurse aides would try to cut Resident #1's his nails but he would refuse at times. She said for the dependent residents who stayed in bed she would trim or file their nails as a 1:1 activity. She said if resident's nails were dirty and long, they could spread infections.During an interview on 8/26/2025 at 3:13 pm, LVN B said the treatment nurse was responsible for nail care for the residents in the facility and her last day working at the facility was one day last week. She said the treatments had been split up between management staff that included the ADON and MDS who would all rotate days during the week to perform treatments that started the week of 8/25/2025. She said she was not aware of any residents' nails in the facility being long or that needed to be cleaned.During an interview on 8/26/2025 at 3:17 PM, CNA A said nail care included cutting/cleaning and was the responsibility of the nurse aides and it was to be done on shower days and as needed. She said if the resident was diabetic, then the nurses were responsible for cutting the resident's nails. She said Resident #21 and Resident #1 were both diabetic residents and she did not cut their nails. She said she was not sure about Resident #4 if she was diabetic or not. She said she had cleaned her nails in the past but never trimmed them. During an interview on 8/27/2025 at 9:00 am, the DON said nail care was the responsibility of the nurse aides and the person who was responsible for completing skin assessments. She said nail care should be done weekly three times a week and as needed. Staff should trim, cut, file or clean as needed. She said nail care was taken care of on yesterday 8/26/2025 for the residents in the facility. She said residents could scratch themselves if nails were long and could get infections if not cleaned.During an interview on 8/27/2025 at 9:20 AM, the Administrator said nail care was the responsibility of the nurses and nurse aides. He said nail care should be done as needed. He said he planned to assign staff to perform nail care and have the administrative staff monitor daily during rounds. He said not having proper nail care could be a dignity issue and the residents could possibly scratch themselves or get ill from not having clean nails.Record review of a facility policy titled Nail Care dated 7/2025 indicated, .The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 1 of 5 residents reviewed for respiratory care (Residents #21).The facility failed to ensure the external filters of Resident #21's oxygen concentrators was free of dust build up from 8/25/2025-8/27/2025.These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.Findings included:Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction affecting left non-dominant side (paralyzed on left side of the body following a stroke), type 2 diabetes, heart failure (heart not able to pump effectively) and GERD (acid reflux). Record review of active physician orders for Resident #21 dated 8/26/2025 indicated an order to clean the oxygen concentrator filter weekly on Sundays with a start date of 6/12/2023. Record review of a care plan for Resident #21 dated 8/18/2025 indicated she needed oxygen therapy related to shortness of breath in an approach to administer oxygen as needed per MD orders. Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. Special Treatments, Procedures, and Programs during the 14 day look back period, she did not use oxygen therapy. During an observation on 8/25/2025 at 9:58 AM in the room of Resident #21, she was on oxygen via a nasal cannula at 2 L/min, the external oxygen concentrator filter had a large amount of white dust buildup. During an observation on 8/26/2025 at 2:58 PM, Resident #21 was in her room sitting up in a wheelchair not wearing oxygen. The external filter on the oxygen concentrator still had a large amount of white dust buildup. Resident #21 said the staff changed the oxygen tubing weekly on Sundays but had never seen anyone clean the filter on the concentrator. During an observation on 8/27/2025 at 8:21 AM, in the room of Resident #21, the external oxygen concentrator filter still had dust buildup. Resident #21 was in bed resting with her eyes closed. During an observation and interview on 8/27/2025 at 8:51 AM, LVN B said the oxygen concentrator filters were designated to get cleaned by the weekend nursing staff on Sundays. LVN B observed the concentrator of Resident #21 and said the filter was dusty and needed to be cleaned. She said if the filters were not kept clean, the residents could get infections, or the concentrator may not work properly. During an observation and interview on 8/27/2025 at 9:00 AM, the DON said the weekend supervisors were responsible for cleaning the oxygen concentrator filters on Sundays. The DON observed the concentrator for Resident #21 and said the filter was dusty. She said residents could be at risk for infections. She checked the filters and said they were hard to remove and would get the resident another concentrator to use. During an interview on 8/27/2025 at 9:20 AM, the Administrator said nursing staff were responsible for cleaning the oxygen concentrator filters when they changed the tubing weekly and as needed. He said if the filters were not cleaned it could inhibit the flow of oxygen to the resident. Record review of a facility policy titled Oxygen Concentrator dated 7/2025 indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. 5. Care of the concentrator: a. Follow manufacture recommendations for the frequency of cleaning filter and servicing the device .

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 12 months (February 2023, and May 2023) reviewed for pharmacy services. <BR/>The facility did not have a licensed pharmacist and two witnesses initial the attached pages of the controlled medication destruction inventory sheets. <BR/>This failure could put residents at risk for misappropriation and drug diversion.<BR/>Findings:<BR/>During a record review of the facility's drug destruction log for the last 12 months (June 2022 to May 2023), revealed the drug destructions for controlled drugs dated 02/15/23 and 05/15/23 indicated that the attached pages of medication destruction were ot numbered and did not include the initials of the consultant pharmacist and two witnesses.<BR/>During an interview on 06/13/23 at 9:50 a.m., the ADON said there was no DON currently employed at the facility, and she was unaware that the cover page had to be signed by the Pharmacist and another witness and that there had to be two witnesses initialing each page and that she thought the cover sheet was all that was needed. She said she took this position three weeks ago and would implement a new system that would ensure the cover sheets and all attachment pages were numbered and signed/ witnessed appropriately going forward. She said she did not think a drug diversion could happen, but anything might be possible if the correct procedure was not followed.<BR/>During an interview on 06/1/23 at 2:03 p.m., the Regional Nurse said there was no DON currently employed at the facility, and she was unaware there had to be two witnesses initialing each page of the listed drugs and each page should be numbered. She said that she thought the signed cover sheet was all that was needed. She said she would ensure the cover sheets were signed as required and all attachment pages were numbered and witnessed appropriately going forward. She said the risk could be a possible drug diversion.<BR/>During an interview on 06/13/23 at 4:00 p.m., the Interim ADMIN said she would check the regulations with the Pharmacist to ensure the drug destruction occurred appropriately and said that going forward she expected her staff to follow correct policy regarding drug destruction. <BR/>Record review of facility policy titled Discarding and Destroying Medications revised October 2014 indicated .Schedule II, II and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. The facility may contract with a DEA registered collector for proper disposal of non-hazardous schedule II, III, IV and V controlled substances.<BR/>Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and regulations <BR/>Record review of 22 TAC &sect;303.1 Destruction of Dispensed Drugs accessed online 06/07/2023 at https://texreg.sos.state.tx.us/ indicated.<BR/>(a) Drugs dispensed to patients in health care facilities or institutions.<BR/>(1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. <BR/>(A) A written agreement exists between the facility and the consultant pharmacist. <BR/>(B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: <BR/>(i) name and address of the facility or institution. <BR/>(ii) name and pharmacist license number of the consultant pharmacist. <BR/>(iii) date of drug destruction. <BR/>(iv) date the prescription was dispensed. <BR/>(v) unique identification number assigned to the prescription by the pharmacy. <BR/>(vi) name of dispensing pharmacy. <BR/>(vii) name, strength, and quantity of drug. <BR/>(viii) signature of consultant pharmacist destroying drugs. <BR/>(ix) signature of the witness(es); and <BR/>(x) method of destruction. <BR/>C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet , provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es).<BR/>v) any two individuals working in the following capacities at the facility: <BR/>(I) facility administrator. <BR/>(II) director of nursing. <BR/>(III) acting director of nursing; or <BR/>(IV) licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services.<BR/>1. The Dietary Aide failed to properly wear hair net while in the kitchen on 7/15/2024.<BR/>2. Dietary Staff failed to check and log the dishwasher temperature and sanitation for month of July 2024.<BR/>3. Dietary Staff failed to properly label and dispose of leftovers from the refrigerator.<BR/>4. Facility staff failed to clean Resident #7's water pitcher. <BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>Findings:<BR/>During an observation on 7/15/24 at 6:45 am the dietary aide had hair out of his hair net on his neck and had facial hair with no beard guard net.<BR/>During an observation on 7/15/24 at 6:50 am there was a dishwasher temperature and sanitation log located on the side of the refrigerator. The log had no temperatures or sanitation levels listed. The log was not dated with the month and only included staff initials. <BR/>During an observation on 7/15/24 at 7:00 am the refrigerator located in the kitchen had two containers of ready care thickened water dated 7/01/24 and 1 container of ready care thickened orange juice dated 7/01/24. Directions on the ready care container read to use within 7 days of opening. There were leftovers in plastic containers with labels that read: smothered chicken dated 7/9/24, chicken patties dated 7/9/24, spiced apples dated use by 7/12/24, chicken dated 7/13/24, meatballs dated use by 7/14/24, rice dated use by 7/12/24, meatloaf dated use by 7/13/24, red beans and sausage dated use by 7/12/24, beef stew use by 7/13/24, and white gravy dated 7/9/24.<BR/>During an interview on 7/15/24 at 6:57 am the dietary aide said he had been at the facility for 5 weeks. He said he initialed the dishwasher log but was not sure about the temperature and sanitizer sections. He said the log posted was for July 2024 and he checked the temperatures and sanitation every day, but he was not sure what temperature the dishwasher needed to be. He said the previous dietary manager may or may not have told him and would make sure the water was steaming when he washed the dishes . He said he thought his hair was short enough on his beard and applied a beard guard and tucked his hair in the back under the hair net. He said that not washing dishes at the proper temperature could cause illness and not having his hair covered was unsanitary. <BR/>During an interview on 7/15/24 at 7:10 am [NAME] G said she had been at the facility 1 year. She said all leftovers were to be labeled with name, date and use by date and should be discarded after 3 days. She said the ready care thickened beverages were to be dated when opened and discarded after 7 days. She said the cooks were responsible for checking and removing items from the refrigerator at least every other day. She said if residents were to consume expired foods it could make them sick. <BR/>Record review of a facility face sheet dated 7/16/24 indicated Resident #7 was an [AGE] year-old female that admitted on [DATE] with diagnosis of Alzheimer's.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7had a BIMS of 04 indicating severely impaired cognition was dependent with all activities of daily living.<BR/>During an observation on 7/15/24 at 10:05 am Resident #7 had a water pitcher at her bedside with thickened water and on inspection the water had a slimy green substance floating in the water. <BR/>During an interview on 7/15/24 at 10:20 am CNA F said she had worked at the facility 1 year. She said she passed water to her residents every morning and afternoon. She said Resident # 7 was on thickened liquids and received her hydration in a cup from the kitchen . She said she was not aware there was a water pitcher in her room and would remove it. She said that water pitchers were to be changed out every night on the night shift and washed by the kitchen staff. She said if water pitchers were not cleaned it could cause residents to get sick.<BR/>During an interview on 7/16/24 at 9:30 am [NAME] G said that the aides were to collect the water pitchers and bring them to the kitchen to wash. She said she was not sure if there was a schedule and could not recall the last time water pitchers were washed. She said that water pitchers that were not cleaned regularly could cause a resident to get sick.<BR/>During an interview on 7/16/24 at 10:32 am the DON said that Resident #7 was on thickened liquids and the CNAs provide the already thickened liquids in individual cups and was not sure how she got a water pitcher at her bedside. She said the water pitchers should be changed nightly on the evening shift but there was no process in place to ensure the pitchers were being cleaned. She said dirty water pitchers could cause sickness and she expected all water pitchers to be cleaned and changed daily. <BR/>During an interview on 7/17/24 at 9:10 am the Administrator said he was responsible for oversight of the kitchen and made rounds in the kitchen with staff for training weekly. He said he was between dietary managers and in the process of finding a new manager. He said that the staff were responsible for their daily duties and the dietary aides were to fill out the dishwasher log daily and ensure the temperature and sanitation was appropriate to prevent illness. He said leftovers should be discarded after 3 days because old food could make someone sick if it was served. He said water pitchers should be changed daily but there had not been a monitoring system in place. He said dirty water pitchers could cause illness. He said he expected the kitchen to be always maintained in a sanitary kitchen and water pitchers are cleaned and changed daily. <BR/>Record review of a facility policy titled Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment dated 2018 indicated, . the facility will follow the cleaning and sanitizing requirements of the state. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. the temperature of the wash water must be at least 120F.<BR/>Record review of a facility policy titled Food Storage dated 2018 indicated, .to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US food codes and guidelines. 2. Refrigerators e. use all leftovers within 72 hours. Discard items that are over 72 hours old .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food safety (Resident #3 and Resident #14).The facility failed to ensure the refrigerator for Resident #3 did not contain expired cheddar cheese bars or canned sausage. The facility failed to ensure the refrigerator for Resident #14 did not contain expired pineapple tidbits, fruit cups or pineapple juice. This failure could place resident at risk for food borne illnesses.Findings include:1.Record review of Resident #3's electronic medical record and face sheet undated reflected she was admitted to the facility on [DATE]. Her diagnoses included: radiculopathy, cervical region (pain, weakness or numbness), cellulitis and abscess of mouth (bacterial infection of the skin and the deeper tissues beneath the skin), psychotic disorder with hallucinations (severe mental illness with false perceptions of things not there and false beliefs). Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected She could understand others and be understood. She scored a 13 on her BIMS which signified she was cognitively intact. She could ambulate with a walker 10 feet with maximum assistance. Resident #3 required partial to moderate assistance from staff with his ADLs. Record review of Resident #3's comprehensive care plan date initiated 8/05/2025 indicated had impaired functional abilities related to chronic obstructive pulmonary disease with interventions that included: eating: set up and clean up assistance.During an observation and interview on 8/25/2025 at 10:51 AM, Resident #3 said her personal fridge was usually cleaned by her and the facility staff. Resident #3 said she gets items out of the fridge herself. Resident #3 said she did not know that the observed 4 cans of 4.6-ounce canned sausage that expired on 8/9/2025 sitting on top of the refrigerator had expired. She said she also did not know the bag containing 6 cheddar cheese bars of 2.75 ounce inside the refrigerator had also expired on 7/20/2025. She said she also did not know the observed container of 5.3-ounce Greek yogurt had expired on 7/22/2025. She said her family member had just brought the cheddar cheese to her last week. 2. Record review of Resident #14's electronic medical record and face sheet undated reflected he was admitted to the facility on [DATE] with the most recent readmission [DATE]. His diagnoses included: intestinal adhesions (scar tissue on the intestines), alcohol induced persisting dementia (brain damage resulting from long term heavy alcohol use), hypertension (high blood pressure).Record review of Resident #14's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 11 on his BIMS which signified he had mild cognitive impairment. He could ambulate independently without devices or assistance. Resident #14 was independent with his ADLs. Record review of Resident #14's comprehensive care plan date initiated 3/28/2025 indicated he had impaired functional abilities with interventions that included: eating: set up and clean up assistance. During and observation and interview on 8/25/2025 at 10:21 AM, Resident #14 said he and the staff takes care of his personal refrigerator. He said he did not know that the 3 pineapple tidbits 4-ounce cups had expired on 8/21/2024. He said he did not know the 3 mixed fruit 3.23-ounce cups had expired on 3/23/2024. He said he did not know the 1.4 ounce can of pineapple juice had expired on 6/29/2025. He said could get food out of his refrigerator himself. During an interview on 08/27/2025 at 8:31 AM the Housekeeping supervisor said her and the Maintenance Director clean the residents' personnel refrigerators. She said they clean the fridges about twice a week and check for expired foods. She said they did not have a set schedule for cleaning the personal refrigerators. She said the nursing department helped with checking the temperatures. She said it had been about a month since Resident #14's refrigerator had been cleaned. She said Resident #3's refrigerator was cleaned last week, and they had thrown away milk and other expired foods and said these items must have just been missed. She said the potential hazard to resident by consuming foods would be stomach poisoning. During an interview on 08/27/2025 at 8:44 AM the Maintenance Director said housekeeping cleans the residents' personal refrigerators. He said he only moves them if needed. During an interview on 08/27/2025 8:56 AM the DON said it was housekeeping's responsibility to clean residents' personal refrigerators. She said she would have to check but assumed they would be cleaned 1 time a week. She said nursing will throw away food if they notice its expired, but housekeeping was responsible. She said it could make residents sick at their stomach by consuming expired food. During an interview on 08/27/2025 10:13 AM the Administrator said it was housekeeping's responsibility to clean residents' personal refrigerators. He said nursing should had not been designated to clean residents' personal refrigerators. He said they should be cleaned as needed. He said the residents could potentially get sick by consuming expired food. Record review of the facility policy Personal Resident Refrigerators dated 9/11/2023 indicated: The facility does not provide a refrigerator in the resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident owned refrigerators. 3. Housekeeping and/or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are not in compliance.

**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 6 residents (Resident #34) reviewed for infection control. <BR/>TNA B failed to wash or sanitize her hands when changing gloves while performing incontinent care to Resident #34.<BR/>TNA B failed to change her gloves when going from dirty to clean while performing incontinent care to Resident #34.<BR/>This failure could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings included:<BR/>Record review of an undated face sheet for Resident #34 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage (weakness on one side after a brain bleed), chronic kidney disease (loss of kidney function), depression (sadness or loss of interest in activities), and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS Assessment for Resident #34 dated 4/28/2023 indicated she had moderate impairment in thinking with a BIMS score of 10. She required extensive to total dependence in ADL's with one to two person assist. She was always incontinent of bowel and bladder. <BR/>Record review of a Care Plan dated 4/27/2023 for Resident #34 indicated she had ADL functional status with an approach of bathing/hygiene and required assistance.<BR/>During an observation on 6/11/2023 at 1:50 PM, revealed the Activity Director and TNA B were present in the room of Resident #34. Both washed their hands in the bathroom and applied gloves. Resident #34 was transferred from a wheelchair to her bed using a mechanical lift with both the Activity Director and TNA B assisting. The Activity Director left the room and TNA B provided incontinent care. TNA B pulled the resident's pants down to her legs and opened her brief and placed it between Resident #34's thighs. TNA B removed wipes from a plastic bag and wiped Resident #34's perineal area from front to back and placed the wipes in the trash. TNA B rolled Resident #34 to her left side and a large amount of feces was observed. TNA B removed wipes and wiped Resident #34's rectal area from front to back multiple times and placed the wipes in the trash. TNA B ran out of wipes and removed her gloves and placed them in the trash and did not wash or sanitize her hands. TNA B pulled the privacy curtain and left the room to get more wipes. TNA B entered the room after about a minute with more wipes in a plastic bag and placed the bag on the bed and went into the restroom to wash her hands. TNA B placed gloves on both hands and proceeded with incontinent to Resident #34. TNA B cleaned Resident #34's buttocks with wipes and placed them in the trash along with the dirty brief. TNA B placed a clean brief underneath Resident #34 buttocks with dirty gloves on and then removed the gloves and placed them in the trash. TNA B applied another pair of gloves to both hands without washing or sanitizing them and secured the brief on Resident #34 who was then repositioned in the bed and her pants were pulled back up. TNA B went to the door to get the Activity Director to come back in the room to assist with transferring Resident #34 from her bed to the wheelchair using a mechanical lift. Resident #34 was safely transferred by both staff to the wheelchair. TNA B removed her gloves and placed them in the trash and sanitized her hands.<BR/>During an interview on 6/11/2023 at 2:10 PM, TNA B said she had only been employed at the facility for 3 weeks as a temporary nurse aide. She said she had taken her skills examination but still needed to take the written test for certification as a nurse aide. She said she should have had more supplies in the room when she was providing care to Resident #34. She said she should have washed or sanitized her hands when she changed her gloves. She said she touched a clean brief with dirty gloves and should have had clean gloves on before applying the brief. She said she had only had a few days of training with staff and was trained by other CNAs in the facility. She said she had not received any training from the ADON or DON. She said the CNAs showed her how to perform incontinent care. She said a resident could be at risk of infection if hands were not washed or sanitized in between gloves changes and contamination of clean items with dirty gloves. <BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 4 weeks. She said the facility had not had a DON or Administrator since the end of May 2023. She said the DON was responsible for training staff on infection control. She said staff should wash or sanitize hands between glove changes and should not use dirty gloves to touch anything clean. She said there was a risk for infection control to the residents along with cross contamination. She said going forward she would look at the facility's policy and procedures to educate staff. She said she would conduct a skills check off with TNA B.<BR/>During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said she had been employed with the company for 2 years. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. She said the ADON started an in-service with all staff on handwashing and perineal care on 6/13/2023. She said any time staff changed gloves, they should wash or sanitize their hands before putting on new gloves. She said staff should take gloves off when going from dirty to clean. <BR/>During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said staff should take gloves off when going from dirty to clean. She said staff should wash or sanitize hands when gloves are changed. She said they started in-services with staff on pericare, handwashing, and infection control on 6/13/2023. She said they put a PIP in place for the issues on 6/13/2023. She said the TNAs started skills check offs yesterday, 6/13/2023. She said going forward direct staff would have competency check offs before providing care. She said residents could be at risk of infections by staff not washing or sanitizing their hands when changing gloves.<BR/>Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of 1/20/2023 indicated .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections, 5. Hand hygiene must be performed prior to donning and after doffing gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 4 of 5 residents (Residents #1, #4, #7, and #21) reviewed for immunizations.The facility failed to document education was offered for the influenza and pneumococcal vaccinations to Residents #1, #4, #7 and #21.These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.Findings include: 1. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (wound a the bottom of the spine that extends through the skin and tissue), diabetes mellitus, and malignant neoplasm of upper lobe of lung (lung cancer). Record review of a comprehensive care plan dated 7/3/2025 for Resident #1 indicated that he did not have any interventions for flu and pneumonia vaccinations. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated that he had moderate impairment in thinking with a BIMS score of 10. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive his influenza vaccine in the facility for this year's influenza season because it was offered and declined. He was not up to date on the pneumonia vaccination because it was offered and declined. Record review of Resident #1's electronic health record undated revealed on 10/4/2024 the influenza vaccine was refused by family. On 4/3/2024 the pneumonia vaccine was refused by the resident. 2. Record review of a Face Sheet for Resident #4 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of moderate intellectual disabilities, expressive language disorder, and schizoaffective disorder. Record review of a comprehensive care plan dated 7/23/2025 for Resident #4 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of an Annual MDS assessment dated [DATE] for Resident #4 indicated that she had moderate impairment in thinking with a BIMS score of 11. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She was not up to date on the pneumonia vaccination. She was up to date on the pneumonia vaccine. Record review of Resident #4's electronic health record undated revealed on 10/4/2024 the influenza was refused by family. She received the pneumonia vaccine on 11/19/2021. 3. Record review of a face sheet for Resident #7 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Raynaud's syndrome (a condition that causes areas such as fingers and toes to feel numb and cold in response to cold temperatures), bipolar disorder (mood swings), and hypertension (high blood pressure). Record review of a Quarterly MDS Assessment for Resident #7 dated 8/12/2025 indicated she did not have any impairment in thinking with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She did not receive the pneumonia vaccine because it was not offered. Record review of a care plan for Resident #7 dated 7/23/2025 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of the electronic health record for Resident #7 undated revealed the influenza vaccine was offered on 10/4/2024 and the resident refused. On 4/13/2024 the pneumonia vaccine was offered and the resident refused. 4. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction affecting left non-dominant side (paralyzed on left side of the body following a stroke), type 2 diabetes, heart failure (heart not able to pump effectively) and GERD (acid reflux). Record review of a care plan for Resident #21 dated 8/25/2025 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She did not receive the pneumonia vaccine because it was offered and declined. Record review of an electronic health record for Resident #21 undated revealed on 10/4/2024 the influenza vaccine was offered and the family refused. On 10/25/2023 the pneumonia vaccine was offered and declined by the resident. During an interview on 8/27/2025 at 9:00 AM, the DON said the ADON was responsible for ensuring the residents received immunizations. She said when immunizations were given education was provided to the resident/family. She said she was not aware there was not any documentation for the refusals of the vaccines that were offered. She said residents could be at risk of not knowing what they were refusing if they were not provided education. During an interview on 8/27/2025 at 9:18 AM, the ADON said she was responsible for resident immunizations. She said she did not have any record of the declinations that were provided to the residents or families. She said they were in a binder somewhere but could not locate them and they were not in the electronic record. She said education was provided to the resident/family at the time vaccines were given along with information from the CDC. She said if they declined, they should be given the VIS statement detailing the risks of vaccine refusal and she would let them know that they could change their mind at any time and provided education to them. During an interview on 8/27/2025 at 9:20 AM, the Administrator said declinations for vaccines should include education on the pros and cons of getting immunizations along with proof of verbal educations. He said he was not sure of the regulations regarding the documentation that should be provided to the resident/family. Record review of a facility policy titled General Immunization/Vaccination dated 6/2025 indicated, .It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases. 10. The resident's medical record or staff/volunteer's medical file will include documentation that the staff, volunteer, resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization(s), and that the resident received or did not receive the immunization(s) due to medical contraindication or refusal . Record review of a facility policy titled Infection Prevention and Control Program dated 6/2025 indicated, .7. Influenza and Pneumococcal Immunization: c. Education will be provided to the residents and/or representative regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 6 residents (Residents # 6, #22, #26, and #27) reviewed for resident call system.1.The facility failed to ensure Residents #6, #22, and #26 had a call light within reach on 8/25/25 and 8/26/2025.2.The facility failed to ensure Resident #27 had a call light that was functional. Resident #27 did not have a pull cord attached to the call box on 8/25/25.This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1.Record review of a facility face sheet dated 8/26/25 for Resident #6 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 11, which indicated she had moderate cognitive impairment. She was always incontinent to bowel and bladder. She required maximum to total assistance with all ADLs. Record review of a comprehensive care plan dated 6/4/25 for Resident #6 indicated she was at risk for falls and had an intervention to keep the call light within reach. Record review of a facility face sheet dated 8/26/25 for Resident #22 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (uncontrolled blood sugar). Record review of a Quarterly MDS assessment dated [DATE] for Resident #22 indicated a BIMS score of 6, which indicated the resident had severely impaired cognition. She was always incontinent to bowel and bladder. She required maximal assistance with most ADLs. Record review of a comprehensive care plan dated 6/3/25 for Resident #22 indicated she was at risk for falls and had an intervention to keep the call light within reach. Record review of a facility face sheet dated 8/26/25 for Resident #26 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #26 indicated a BIMS assessment should not be conducted due to the resident being rarely/never understood. She had severely impaired cognition. She was totally dependent with all ADLs. She had an indwelling urinary catheter and was always incontinent of bowel. Record review of a comprehensive care plan dated 8/25/25 for Resident #26 indicated she was at risk for falls and had an intervention to keep the call light within reach. 2. Record review of a facility face sheet dated 8/26/25 for Resident #27 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (trouble breathing due to not having enough oxygen in the blood). Record review of a comprehensive MDS assessment dated [DATE] for Resident #27 indicated a BIMS score of 11, indicating moderate cognitive impairment. She was dependent with most all ADLs. She was always incontinent to bowel and bladder. Record review of a comprehensive care plan dated 6/18/25 for Resident #27 indicated she was incontinent of urine and had an intervention to keep the call light in reach. During an observation on 8/25/25 at 9:31 am Resident #6 was observed lying in bed sleeping. She did not speak when attempted to awaken. Her call light was observed on the floor between the bed and the wall, out of her reach. During an observation on 8/25/25 at 9:45 am Residents #22 and #26 were observed in their room. Resident #22 was observed lying in bed and her call light was observed on the floor behind the head of her bed, out of her reach. She did not answer questions appropriately. Resident #26 was observed lying in her bed. She did not speak. Her call light was observed on the floor out of her reach. During an observation and interview on 8/25/25 at 9:57 am Resident #27 was observed lying in bed. She said she did not use the call light very often, staff took care of her needs, and she said she had no complaints. No call light was observed within her reach and upon inspection, it was observed that there was no call light cord attached to the box on the wall for her. During an observation and interview on 8/25/25 at 2:00 pm Resident #27 was observed in bed awake and talking, but did not answer questions appropriately, she just kept repeating My name is and saying her name. There was still no call light cord from the box to her side of the room. No call light was observed within her reach. During an observation on 8/26/25 at 8:00 am Resident #22 was observed lying in bed, sleeping. Her call light was again observed lying on the floor at the head of the bed, out of her reach. During an observation on 8/26/25 at 8:05 am Resident #6 was observed in bed sleeping and her call light was observed clipped to the cord next to the box on the wall, out of her reach. During an observation on 8/26/25 at 8:15 am Resident #27 was observed in her room, lying in bed with the head of the bed elevated being assisted with breakfast by the COTA. Her call light was observed on her nightstand at the time the COTA was assisting with breakfast. During an observation on 8/26/25 at 9:15 am Resident #6 was observed lying in bed with her call light still clipped out of her reach. During an observation on 8/26/25 at 9:47 am Resident #27 was observed lying in bed with her call light still observed on the nightstand, out of her reach. During an observation and interview on 8/26/25 at 10:19 am the ADON was observed in Resident #27's room providing care. Upon exiting the resident room, the ADON did not place the call light within reach of the resident. After exiting the room with the ADON, she was asked if there was anything else that needed to be done. She walked back into the resident's room and looked around, and it was then she noticed the call light on the nightstand and she placed the call light within reach of Resident #27. She said residents should always have access to their call lights so they can call for help if needed. She said residents could be at risk of not being able to call for help and possibly dehydration if they could not ask for water, or skin breakdown if they could not call for help with incontinent care or repositioning. During an interview on 08/27/2025 at 12:03 pm the COTA said she was assisting Resident #27 with her breakfast yesterday on 8/26/25 and when she was done, her roommate needed something, so she then helped staff change the roommate and just must have forgotten to replace the call light within reach of Resident #27 when she left the room. She said residents could be hurt if they needed help and could not reach the call light to call for assistance. During an interview on 8/27/25 at 1:30 pm the DON said residents could not call for help if they needed assistance if they did not have access to call lights. During an interview on 8/27/25 at 1:35 pm the Administrator said residents may not get the help they need if they could not call for help. Record review of a facility policy titled Call Lights: Accessibility and Timely Response dated 7/1/25 read: .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . and .staff will ensure the call light is within reach of resident and secured, as needed . and .The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #9, Resident #22 and Resident #139) reviewed for beneficiary notice.<BR/>The facility failed to ensure Resident #9, Resident #22 and Resident #139 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted.<BR/>This failure could place the residents who were discharged at risk of not having knowledge of changes to services in a timely manner to allow the resident or their representative the option of appealing the denial of services.<BR/>Findings include:<BR/>Record review of a facility face sheet dated 7/16/24 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] after a qualifying hospital stay 1/11/24 through 1/16/24 with diagnoses including: metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), and thrombocytopenia (an abnormally low level of platelets). <BR/>Record review of a facility census report for Resident #9 indicated that she had been admitted to Medicare A skilled services on 1/17/24 and discharged from Medicare A skilled services on 3/17/24. The facility failed to issue a NOMNC or a SNF ABN.<BR/>Record review of a facility face sheet dated 7/16/24 for Resident #22 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and his last qualifying hospital stay was from 12/29/23 through 1/12/24. His diagnoses included: intestinal adhesions (bands), unspecified as to partial versus complete obstruction (a disease of the intestines and digestive system that can lead to obstructions); hypertension (high blood pressure); and type 2 diabetes (uncontrolled blood sugar).<BR/>Record review of a facility census report for Resident #22 indicated that he was admitted to Medicare A skilled services on 1/12/24 and discharged from Medicare A skilled services on 3/14/24. The facility issued a NOMNC on 3/11/24 indicating that Medicare would not cover services after 3/13/24 but failed to issue a SNF ABN.<BR/>Record review of a facility face sheet dated 7/16/24 for Resident #139 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] after a qualifying hospital stay of 10/4/23 to 10/30/23. His diagnoses included: Acute respiratory failure with hypoxia (a condition where the lungs cannot provide enough oxygen to the blood); bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows); and dysphagia (difficulty in swallowing).<BR/>Record review of a facility census report for Resident #139 indicated that he was admitted to Medicare A skilled services on 10/30/23 and discharged from Medicare A skilled services on 2/10/24. The facility failed to issue a NOMNC or a SNF ABN.<BR/>Record review of SNF Beneficiary Notice indicated Residents #9, Resident #22, and Resident #139 remained in the facility at the end of Medicare part A stay and did not receive the SNF ABN notification form.<BR/>During an interview on 7/16/24 at 11:00 am DORC said she did not have the forms required because the facility did not complete them. <BR/>During an interview on 7/17/24 at 9:33 am the Administrator said that Residents #3, #22, and #139 had been on Medicare A and the facility did not have an MDS nurse at the time. He said since they did not use all their 100 days, they should have received the notices. He said it was a lack of education and communication, and he would ensure better education and communication going forward. He said he had hired a new MDS nurse and BOM and they would both be expected to do things correctly going forward. He said residents may not be aware of any benefits remaining if they were not given the appropriate notices. <BR/>Record review of Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 provided by the facility read .The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily .<BR/>Record review of Form Instructions Advance Beneficiary Notice of Non-Coverage (ABN) OMB Approval Number: 0938-0566 provided by the facility read .The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice .<BR/>Record review of a facility policy titled Medicare and Medicaid Benefits dated 2001 and revised in April of 2021 read .When changes are made to items and services covered by Medicare or Medicaid plans, residents are informed of these changes as soon as possible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 1 courtyard reviewed for accident hazards.<BR/>The facility failed to store laundry detergent and bleach away from residents.<BR/>These failures could place the residents at risk of accidents hazrds in the environment in which they live.<BR/>Findings included:<BR/>Record review of the Face Sheet dated 06/13/23, indicated Resident #24, admitted to the facility on [DATE], was [AGE] years old with diagnoses of End Stage Heart Disease (heart no longer pumps effectively), essential (primary) hypertension (high blood pressure) and Depress (mood disorder). <BR/>Record review of a Quarterly MDS assessment for Resident #24 dated 4/27/23 indicated he had a moderate impairment in thinking with a BIMS score of 12 (A BIMS of 8-12 indicates the resident is moderately impaired.)<BR/>During an observation on 6/12/2023 at 08:45 AM of the courtyard and smoking area revealed upon exit at the door near the laundry area, there were 5 3-gallon containers filled with liquid detergent and one damaged 3-gallon container filled with liquid bleach labeled caustic/hazard (clear liquid was visible through a hole in the container and cigarette butts were floating in the liquid ).<BR/>During an observation and interview on 6/12/2023 at 9:09 AM, revealed the Laundry Supervisor was aware of the containers on the stoop of the exit door. She said she had been employed at the facility since February 2022. She opened the door leading out to the courtyard and smoking area and looked at the containers of detergent and damaged container of bleach. The Laundry Supervisor said the containers had been there since she started to work at the facility, and she wasn't concerned about them. When asked if the bleach could cause harm if a resident tampered with it, she said the caustic chemicals in the bleach could harm a resident if it was spilled on them or was ingested and the detergent could make them sick also. She stated the resident that came out to the courtyard walked by the containers and they could pose a safety hazard if they stumbled on them or the bleach splashed on them.<BR/>During an interview on 06/12/23 at 10:00 AM with Resident #24 he said he uses the exit at the door next to the laundry room multiple times to smoke and the other 4to 6 smokers use the exit door also. Resident 24 said some of the smoker are confused but there is a staff member that goes out with them. Resident #24 said there are some resident that come outside that have trouble walking and they could fall on the bleach container that was cracked. Resident #24 said the residents could fall over the stacked containers of detergent since they were close to the door and if the fell on the cracked container of bleach it might get on them. <BR/>During an observation on 06/12/23 at 10:15 AM of the smoking area at the Gazebo revealed there appeared to be multiple ash marks on the bricks, and concrete near the exit door. Cigarette butts were in a coffee can and a damaged 3-gallon plastic bleach container (labeled-Hazard Caustic) filled with bleach at the doorway leading out to the Gazebo.<BR/>During an interview on 6/12/2023 at 3:45 PM, the Maintenance Director said he had been employed at the facility since 09/2020. He said he was responsible for anything that was broken and needed repair in the facility. He said his supplies were in the two metal buildings in the courtyard and he frequently used the exit door where the detergent and bleach had been stored for a long time. He said the bleach and detergent had been placed outside because a new vendor was under contract to supply cleaning products and the 6 containers were scheduled to be picked up by the old vendor but they never came to get them. When asked if the bleach or detergent could cause harm if a resident tampered with it, he said the caustic chemicals in the bleach could harm a resident if it was spilled on them or ingested and the detergent also. He said he would dispose of them immediately.<BR/>During an Interview on 6/13/2023 at 7:45 AM, the Interim Administrator said she had been at the facility for a week, and the last Administrator left at the end of May 2023. She said she was not aware of the detergent and bleach being outside next to the laundry exit door, that the resident use to go outside and the smokers use to go to the smoking Gazebo. She said the bleach and detergent sitting outside the door in the resident courtyard were a hazard and posed a risk of poisoning or burns if a resident came in contact or ingested the contents of the containers.<BR/>During an observation on 6/14/2023 at 9:00 AM revealed the containers of bleach and detergent were no longer by the exit doorway.<BR/>Record review of a facility policy titled Maintenance Service with a revised date of December 2022 indicated, .1. Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times 2. A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents for one resident (Resident #16) of six residents reviewed for medication storage.<BR/>The facility failed to ensure topical medications and skin cleanser were stored in a manner to prevent possible diversion or contamination.<BR/>This failure could place residents at risk for drug diversion and access to medications that could cause harm, sickness, or hospitalization.<BR/>Findings included:<BR/>Review of Resident #16's face sheet dated 07/14/2024 reflected an eighty-three-year-old female admitted on [DATE] with diagnoses that included: Senile Degeneration of Brain (gradual loss of thinking ability), Diaper dermatitis (skin rash to the diaper area) Pressure-induced deep tissue damage of right ankle, (open skin break on the right foot), and Pressure ulcer of left ankle, stage 3 (open skin break of the left ankle).<BR/>During an observation and interview on 07/15/2024 at 07:00 AM Resident #16 is lying in bed in her room, wound cleanser was on the bedside table, Zinc Oxide tube and 3 small packets of Zinc Oxide were on the bedside table, skin barrier cream and antifungal skin powder on bedside table. All containers are labeled keep out of reach from Children. Resident #16 said the staff use the products on her and they must have left them there after providing her wound care and care to her peri-area.<BR/>During an observation on 07/15/20/24 at 01:26 PM revealed Resident #16, sleeping in her room. Wound cleanser at bedside table. Zinc Oxide tube and 3 small packets of Zinc Oxide are on the bedside table, skin barrier cream and antifungal skin powder on bedside table.<BR/>During a record review of a physician order summary dated 7/15/2024, Resident # 16 had orders with an origin date of 06/24/2024 for Calmoseptine (menthol-zinc oxide) ointment; 0.44-20.6 %; amount- dime size; topical three times a day and apply Zinc Oxide to buttocks & coccyx every shift, origin date 03/01/24 twice a day. <BR/>During an interview on 07/15/2024 at 01:30 PM LVN C, said that medications should not be keep in residents' room, including medications for wound care. He said that he will remove the barrier cream, antifungal powder and zinc oxide ointment and place them in a bag for storage in the wound care cart. LVN C said that the items could harm residents if they used them incorrectly or ingested topicals labeled keep away from children. He said the topical medications could be contaminated if the resident or family opened them with unclean hands.<BR/>During an Interview on 07/15/2024 01:45 PM the DON she said the residents are not allowed to keep medications at bedside, unless they have a doctor's order and arrangements for safe storage are developed for that specific resident. The DON said it was unsafe to have any medications or substances labeled to keep out of reach from children at bedside and topicals could become contaminated if not handled correctly by the resident or family.<BR/>During an interview on 07/16/2024 03:30 PM the Administrator said the DON is responsible for oversight of medication storage and will start an Inservice for all staff safe storage of medications. The Administrator said leaving topical medications or cleanser at bedside pose a risk to residents for possible ingestion and contamination.<BR/>Record review of a facility policy titled Storage of Medications Policy . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation<BR/>1. <BR/>Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .<BR/> The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.<BR/>2. <BR/>Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing dressings and biologicals are locked when not in use. Unlocked medication carts are not left unattended.<BR/>Record Review of a facility policy dated 06/01/2022 titled Administrative Procedures for all Medications To administer medications in a safe and effective manner. <BR/>A. <BR/>Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services.<BR/>1. The Dietary Aide failed to properly wear hair net while in the kitchen on 7/15/2024.<BR/>2. Dietary Staff failed to check and log the dishwasher temperature and sanitation for month of July 2024.<BR/>3. Dietary Staff failed to properly label and dispose of leftovers from the refrigerator.<BR/>4. Facility staff failed to clean Resident #7's water pitcher. <BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>Findings:<BR/>During an observation on 7/15/24 at 6:45 am the dietary aide had hair out of his hair net on his neck and had facial hair with no beard guard net.<BR/>During an observation on 7/15/24 at 6:50 am there was a dishwasher temperature and sanitation log located on the side of the refrigerator. The log had no temperatures or sanitation levels listed. The log was not dated with the month and only included staff initials. <BR/>During an observation on 7/15/24 at 7:00 am the refrigerator located in the kitchen had two containers of ready care thickened water dated 7/01/24 and 1 container of ready care thickened orange juice dated 7/01/24. Directions on the ready care container read to use within 7 days of opening. There were leftovers in plastic containers with labels that read: smothered chicken dated 7/9/24, chicken patties dated 7/9/24, spiced apples dated use by 7/12/24, chicken dated 7/13/24, meatballs dated use by 7/14/24, rice dated use by 7/12/24, meatloaf dated use by 7/13/24, red beans and sausage dated use by 7/12/24, beef stew use by 7/13/24, and white gravy dated 7/9/24.<BR/>During an interview on 7/15/24 at 6:57 am the dietary aide said he had been at the facility for 5 weeks. He said he initialed the dishwasher log but was not sure about the temperature and sanitizer sections. He said the log posted was for July 2024 and he checked the temperatures and sanitation every day, but he was not sure what temperature the dishwasher needed to be. He said the previous dietary manager may or may not have told him and would make sure the water was steaming when he washed the dishes . He said he thought his hair was short enough on his beard and applied a beard guard and tucked his hair in the back under the hair net. He said that not washing dishes at the proper temperature could cause illness and not having his hair covered was unsanitary. <BR/>During an interview on 7/15/24 at 7:10 am [NAME] G said she had been at the facility 1 year. She said all leftovers were to be labeled with name, date and use by date and should be discarded after 3 days. She said the ready care thickened beverages were to be dated when opened and discarded after 7 days. She said the cooks were responsible for checking and removing items from the refrigerator at least every other day. She said if residents were to consume expired foods it could make them sick. <BR/>Record review of a facility face sheet dated 7/16/24 indicated Resident #7 was an [AGE] year-old female that admitted on [DATE] with diagnosis of Alzheimer's.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7had a BIMS of 04 indicating severely impaired cognition was dependent with all activities of daily living.<BR/>During an observation on 7/15/24 at 10:05 am Resident #7 had a water pitcher at her bedside with thickened water and on inspection the water had a slimy green substance floating in the water. <BR/>During an interview on 7/15/24 at 10:20 am CNA F said she had worked at the facility 1 year. She said she passed water to her residents every morning and afternoon. She said Resident # 7 was on thickened liquids and received her hydration in a cup from the kitchen . She said she was not aware there was a water pitcher in her room and would remove it. She said that water pitchers were to be changed out every night on the night shift and washed by the kitchen staff. She said if water pitchers were not cleaned it could cause residents to get sick.<BR/>During an interview on 7/16/24 at 9:30 am [NAME] G said that the aides were to collect the water pitchers and bring them to the kitchen to wash. She said she was not sure if there was a schedule and could not recall the last time water pitchers were washed. She said that water pitchers that were not cleaned regularly could cause a resident to get sick.<BR/>During an interview on 7/16/24 at 10:32 am the DON said that Resident #7 was on thickened liquids and the CNAs provide the already thickened liquids in individual cups and was not sure how she got a water pitcher at her bedside. She said the water pitchers should be changed nightly on the evening shift but there was no process in place to ensure the pitchers were being cleaned. She said dirty water pitchers could cause sickness and she expected all water pitchers to be cleaned and changed daily. <BR/>During an interview on 7/17/24 at 9:10 am the Administrator said he was responsible for oversight of the kitchen and made rounds in the kitchen with staff for training weekly. He said he was between dietary managers and in the process of finding a new manager. He said that the staff were responsible for their daily duties and the dietary aides were to fill out the dishwasher log daily and ensure the temperature and sanitation was appropriate to prevent illness. He said leftovers should be discarded after 3 days because old food could make someone sick if it was served. He said water pitchers should be changed daily but there had not been a monitoring system in place. He said dirty water pitchers could cause illness. He said he expected the kitchen to be always maintained in a sanitary kitchen and water pitchers are cleaned and changed daily. <BR/>Record review of a facility policy titled Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment dated 2018 indicated, . the facility will follow the cleaning and sanitizing requirements of the state. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. the temperature of the wash water must be at least 120F.<BR/>Record review of a facility policy titled Food Storage dated 2018 indicated, .to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US food codes and guidelines. 2. Refrigerators e. use all leftovers within 72 hours. Discard items that are over 72 hours old .

**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 6 residents (Resident #34) reviewed for infection control. <BR/>TNA B failed to wash or sanitize her hands when changing gloves while performing incontinent care to Resident #34.<BR/>TNA B failed to change her gloves when going from dirty to clean while performing incontinent care to Resident #34.<BR/>This failure could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings included:<BR/>Record review of an undated face sheet for Resident #34 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage (weakness on one side after a brain bleed), chronic kidney disease (loss of kidney function), depression (sadness or loss of interest in activities), and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS Assessment for Resident #34 dated 4/28/2023 indicated she had moderate impairment in thinking with a BIMS score of 10. She required extensive to total dependence in ADL's with one to two person assist. She was always incontinent of bowel and bladder. <BR/>Record review of a Care Plan dated 4/27/2023 for Resident #34 indicated she had ADL functional status with an approach of bathing/hygiene and required assistance.<BR/>During an observation on 6/11/2023 at 1:50 PM, revealed the Activity Director and TNA B were present in the room of Resident #34. Both washed their hands in the bathroom and applied gloves. Resident #34 was transferred from a wheelchair to her bed using a mechanical lift with both the Activity Director and TNA B assisting. The Activity Director left the room and TNA B provided incontinent care. TNA B pulled the resident's pants down to her legs and opened her brief and placed it between Resident #34's thighs. TNA B removed wipes from a plastic bag and wiped Resident #34's perineal area from front to back and placed the wipes in the trash. TNA B rolled Resident #34 to her left side and a large amount of feces was observed. TNA B removed wipes and wiped Resident #34's rectal area from front to back multiple times and placed the wipes in the trash. TNA B ran out of wipes and removed her gloves and placed them in the trash and did not wash or sanitize her hands. TNA B pulled the privacy curtain and left the room to get more wipes. TNA B entered the room after about a minute with more wipes in a plastic bag and placed the bag on the bed and went into the restroom to wash her hands. TNA B placed gloves on both hands and proceeded with incontinent to Resident #34. TNA B cleaned Resident #34's buttocks with wipes and placed them in the trash along with the dirty brief. TNA B placed a clean brief underneath Resident #34 buttocks with dirty gloves on and then removed the gloves and placed them in the trash. TNA B applied another pair of gloves to both hands without washing or sanitizing them and secured the brief on Resident #34 who was then repositioned in the bed and her pants were pulled back up. TNA B went to the door to get the Activity Director to come back in the room to assist with transferring Resident #34 from her bed to the wheelchair using a mechanical lift. Resident #34 was safely transferred by both staff to the wheelchair. TNA B removed her gloves and placed them in the trash and sanitized her hands.<BR/>During an interview on 6/11/2023 at 2:10 PM, TNA B said she had only been employed at the facility for 3 weeks as a temporary nurse aide. She said she had taken her skills examination but still needed to take the written test for certification as a nurse aide. She said she should have had more supplies in the room when she was providing care to Resident #34. She said she should have washed or sanitized her hands when she changed her gloves. She said she touched a clean brief with dirty gloves and should have had clean gloves on before applying the brief. She said she had only had a few days of training with staff and was trained by other CNAs in the facility. She said she had not received any training from the ADON or DON. She said the CNAs showed her how to perform incontinent care. She said a resident could be at risk of infection if hands were not washed or sanitized in between gloves changes and contamination of clean items with dirty gloves. <BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 4 weeks. She said the facility had not had a DON or Administrator since the end of May 2023. She said the DON was responsible for training staff on infection control. She said staff should wash or sanitize hands between glove changes and should not use dirty gloves to touch anything clean. She said there was a risk for infection control to the residents along with cross contamination. She said going forward she would look at the facility's policy and procedures to educate staff. She said she would conduct a skills check off with TNA B.<BR/>During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said she had been employed with the company for 2 years. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. She said the ADON started an in-service with all staff on handwashing and perineal care on 6/13/2023. She said any time staff changed gloves, they should wash or sanitize their hands before putting on new gloves. She said staff should take gloves off when going from dirty to clean. <BR/>During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said staff should take gloves off when going from dirty to clean. She said staff should wash or sanitize hands when gloves are changed. She said they started in-services with staff on pericare, handwashing, and infection control on 6/13/2023. She said they put a PIP in place for the issues on 6/13/2023. She said the TNAs started skills check offs yesterday, 6/13/2023. She said going forward direct staff would have competency check offs before providing care. She said residents could be at risk of infections by staff not washing or sanitizing their hands when changing gloves.<BR/>Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of 1/20/2023 indicated .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections, 5. Hand hygiene must be performed prior to donning and after doffing gloves

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 4 hallways (north hallway and south hallway) reviewed for environment, in that.<BR/>1. <BR/>The nursing supply storage room on the south hallway was open and accessible to visitor or resident tampering/contamination of sterile products and supplies kept in the nursing supply storage room.<BR/>2. <BR/>The shower room on the north hallway (100 hallway) was open and accessible to residents and staff staff allowing access to toxic cleaners.<BR/>These failures could place residents at risk for unsafe environment resulting in injury or unsafe conditions due access to toxic cleaners and visitor or resident tampering/contamination of sterile products and supplies kept in the shower room and nursing supply room. <BR/>Findings included:<BR/>1. <BR/>During an observation on 07/15/2024 at 06:55 AM Nursing supply storage room on the end of the south hallway was observed to be open. Upon entrance to the nursing supply storage room there are sterile supplies in the room, sterile foley catheters, lancets for skin punctures, gastric tube feeding supplies, wound cleanser, sterile dressing supplies no staff in area. Resident walking down the hallway nearby. <BR/>2. <BR/>During an observation on 7/15/24 at 7:30 AM Shower room door on end of north hallway (100 hallway) was observed to be open. Upon entrance to shower room, observation revealed a supply closet in shower room was also open. There was a bottle of spray disinfectant inside supply closet. <BR/>During an interview on 07/15/2024 at 07:30 AM LVN C said he had just gotten to the facility when the surveyors arrived. He was not aware the nursing supply closet was propped open, but he would go shut it. He said the door had a lock and it should be always locked to prevent resident or visitors from accessing to room. LVN C said nursing staff had a key to the door, but the night shift probably left it open for convenience.<BR/> During an observation and interview 07/15/2024 at 07:43 AM, the door to the nursing supply room remained propped open. LVN B said the door should be closed and locked. LVN B said residents and visitors would have assess and could possibly tamper with supplies if the door is left open. She said that if the resident or visitors tampered with supplies include wound supplies and cleansers, sterile foley catheters, lancets glucometer supplies, and supplements they could become contaminated. <BR/>During an interview on 07/15/2024 at 11:30 AM the DON said she was aware that the supply room was sometimes being left open. The door had a lock, and the nurses have the key. She said she has in-serviced the staff and ordered a punch key lock for the door. The DON said when the lock arrives the maintenance man will install it. The DON said there was a risk of theft or contamination to the supplies if a visitor or resident accessed the supply room and tampered with them.<BR/>During an interview on 07/17/24 09:00 AM the Administrator said a punch lock had been installed on the door to the nursing supply to facilitate easy access for the staff and protect the supplies from contamination or theft.<BR/>Record review of a facility policy titled Storage of Medications Policy .<BR/>The facility stores all drugs and biologicals in a safe, secure, and orderly manner.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .<BR/>6. <BR/>Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing dressings and biologicals are locked when not in use. Unlocked medication carts are not left unattended.<BR/>Record review of a facility policy revision date February 2021 titled Homelike Environment . Policy Statement:<BR/>Residents are provided with a safe, clean, comfortable, and home environment and encouraged to use their personal belongings to the extent possible.<BR/>Policy Interpretation and Implementation: Staff provides person-centered care that emphasizes the residents comfort, independence and personal needs and preferences.<BR/>2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.<BR/> These characteristics include:<BR/>a. <BR/>clean, sanitary, and orderly environment . <BR/>. <BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 1 of 5 residents (Resident #1) reviewed for abuse.<BR/>1. CNA B failed to immediately report when TNA A was observed scrubbing Resident #1's body roughly, TNA A said to Resident #1 that she would choke her and called her a bitch, and TNA A kept saying it was disgusting. CNA B failed to report an allegation of abuse within 2 hours to the abuse coordinator.<BR/>2. The facility did not conduct thorough investigations which allowed 2 incidents to occur with Resident #1 and TNA A with an allegation of abuse.<BR/>These deficient practices could affect any resident and contribute to further abuse or neglect.<BR/>Findings included:<BR/>Record review of a face sheet for Resident #1 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), pulmonary hypertension (high blood pressure that affects the blood vessels in the lungs and the right side of the heart), manic episode with psychotic symptoms (delusions, disorder thinking and a lack of awareness of reality), and major depressive disorder (persistent feeling of sadness and loss of interest).<BR/>Record review of an admission MDS assessment dated [DATE] for Resident #1 indicated she did not have any impairment in thinking with a BIMS score of 15. She required extensive assistance with one-person physical assist with personal hygiene. She was always incontinent of bowel. Section H of the MDS indicated her urinary incontinence was not rated because she had an indwelling foley catheter (a tube placed in the bladder that drains urine into a collection bag). <BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated she did not have any impairment in thinking with a BIMS score of 13. She required extensive assistance with one-person physical assist with personal hygiene. She was always incontinent of bowel. Section H of the MDS indicated her urinary incontinence was not rated because she had an indwelling foley catheter (a tube placed in the bladder that drains urine into a collection bag).<BR/>Record review of a progress note dated 2/15/2023 at 10:40 PM by LVN E for Resident #1 indicated, .An allegation of verbal abuse toward resdient by staff member are currently under investigation at this time. Alleged incident has been reported to Administration, Steps are being taken to prevent further incidence including inservice for staff, and alleged staff member had been suspended until further investigation .<BR/>Record review of a Provider Investigation Report dated 2/16/2023 indicated an incident occurred at the facility on 2/14/2023 at 2:00 AM with TNA A and Resident #1. CNA B reported she observed TNA A being verbally and physically abusive to Resident #1 when she provided care. That incident was investigated by the state agency and was unsubstantiated (not proven by evidence).<BR/>Record review of a Provider Investigation Report dated 4/23/2023 indicated an incident occurred at the facility on 4/22/2023 at 9:00 PM with TNA A and Resident #1. LVN E reported she observed TNA A being rough with Resident #1 while providing care. That incident was investigated by the state agency and was unsubstantiated. <BR/>During an interview on 5/17/2023 at 8:11 AM, CNA B said she worked at the facility prn (as needed) since January 2022. She said she observed the incident that occurred on 2/14/2023 with TNA A and Resident #1. CNA B said Resident #1 had a bowel accident on the floor in her room. CNA B said TNA A provided care to Resident #1 and TNA A said she was going to show her how she provided care when she worked at a psychiatric facility in the past. CNA B said TNA A started scrubbing Resident #1's body roughly. CNA B said Resident #1 was saying TNA A was hurting her and Resident #1 hit TNA A. CNA B said TNA A said to Resident #1 that she would choke her and called her a bitch in a low tone but it was louder than a whisper. CNA B said TNA A kept saying it was disgusting out loud. CNA B said she tried to help TNA A but she refused and was told to stand by. CNA B said she was going to report the incident at the time it occured but started feeling sick and ended up with an infection. She said she gave her statement to the Administrator a few days later after the incident. She said she had training on abuse/neglect at the facility. She said abuse should be reported immediately to someone at the facility such as the Administrator.<BR/>During an observation and interview on 5/17/2023 at 8:43 AM, Resident #1 was lying in bed awake, confused and said she had been at the facility for a few months. She said she remembered when TNA A worked at the facility and said she was never mean or verbally abusive towards her. She said TNA A was good to her. <BR/>During an interview on 5/17/2023 at 10:52 AM, the Corporate Nurse said she had been employed with the facility for 2 years. She said the incident with Resident #1 and TNA A on 2/14/2023 was reported to her on 2/16/2023 by the previous Administrator C when the allegation was received from CNA B. She said Administrator C did not complete a thorough investigation following the incident. She said Administrator C only took a statement from CNA B and terminated TNA A without conducting a thorough investigation. She said she immediately started an investigation and submitted to the state agency at that time. She said the facility conducted safe surveys with residents and also had character witness statements from staff who all said TNA A was a good aide and residents denied her being mean or verbally abusive towards them. She said the decision was made after the investigation to hire TNA A back on 3/13/2023. She said CNA B should have reported the incident immediately to the Administrator. She said the incident that occurred on 4/22/2023 with Resident #1 and TNA A was reported to her on 4/23/2023 by the DON. She said the second incident occurred on 4/22/2023 when LVN E reached out to the DON and reported an allegation of abuse on 4/23/2023. She said the state agency was notified on 4/23/2023 of that incident. SHe said TNA A was immediately terminated following the second incident. She said any abuse/neglect allegation should be reported to the abuse coordinator which was the Administrator immediately. She said any allegations of abuse should be reported to the state agency within 2 hours of the allegation taking place. She said the staff received education in-services on abuse/neglect and to whom to report. She said going forward, any allegation of abuse would be reported timely. She said a delay in reporting any allegation of abuse could put residents at risk of further harm.<BR/>Attempted several phone calls with LVN E on 5/17/2023 and 5/18/2023 with no returned phone call. <BR/>Attempted several phone calls with TNA A on 5/17/2023 and 5/18/2023 with no returned phone call.<BR/>During an interview on 5/18/2023 at 9:20 AM, Administrator C said she was only employed at the facility for about 8 weeks from 1/6/2023 until 2/28/2023. She said the incident that occurred on 2/14/2023 was reported to her on 2/16/2202 by CNA B and that was when she reported to the state agency the allegation of abuse. She said CNA B told her that she was sick after the incident and did not report it immediately as she should have reported to the abuse coordinator who was the Administrator. She said residents could be at risk of jeopardy and staff should not try to make the decision if they should report or not as that should be left up to the Administrator or abuse coordinator. She said staff were in-serviced on abuse/neglect following the reporting of the incident and when to report any allegations of abuse along with who to report to and their contact phone numbers. She said they posted signs in the facility to indicate who to contact for abuse/neglect allegations. She said staff should report any suspicion of abuse to her immediately. She said the incident should have been reported within 2 hours to the state agency. She said on a regular basis the facility conducted education on abuse/neglect as that was key to having staff understanding the importance of abuse and who the abuse coordinator was. <BR/>During an interview on 5/18/2023 at 10:58 AM, the DON said she started at the facility on 4/3/2023. She said she was not aware of the incident that occurred in February that was reported to the state agency with Resident #1 and TNA A. She said LVN E called her on the night of 4/22/2023 at the end of her shift. She said LVN E told her she felt TNA A needed some customer service training and she said she told her to write a statement and slide it under her door. She said on the morning of 4/23/2023 when she read the statement, she immediately notified the Administrator. She said they started investigating and Administrator D notified the state agency at that time. She said staff received education on abuse/neglect, staff burnout, and residents with behaviors. She said abuse allegations should be reported immediately to the abuse coordinator who was the Administrator. She said abuse allegations should be reported to the state agency within 2 hours. She said going forward, any abuse allegation would be reported immediately to the abuse coordinator and would make sure residents were safe. She said residents could be potentially harmed by delaying reporting timely.<BR/>During an interview on 5/18/2023 at 11:15 AM, Administrator D said she started at the facility on 3/16/2023. She said she was not aware of the incident that occurred with Resident #1 and TNA A in February 2023 until a little while after she was hired. She said she was involved in reporting to the state agency following an incident that occurred on 4/22/2023 with Resident #1 and TNA A. She said on the morning of 4/23/2023. she was notified by the DON of a possible reportable incident of abuse. She said LVN E reported to the DON an incident with TNA A and Resident #1 that occurred on the night of 4/22/2023. She said she reported the incident to the state agency at the time of notification on 4/23/2023. She said she immediately started an investigation and in-serviced staff on abuse/neglect, staff burn out, resident rights, and privacy when providing care. She said going forward they would continue to educate on the importance of reporting sooner rather than later. She said any delay in reporting allegations of abuse could be detrimental to the residents. She said they are advocates for the residents and must keep them safe. <BR/>Record review of a personnel file for TNA A indicated she hired at the facility on 1/9/2023. Review of previous employment hisory indicated no record of any work at a psychiatrist facility.<BR/>Record review of a facility policy titled Abuse Prevention Program with a revised date of 1/9/2023 indicated, .1. The Administrator is responsible for the overall and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reports to local, state, and federal agencies. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than 2 hours if the alleged violation involves abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to self-administer medications if the IDT determined that the practice was clinically appropriate for 1 of 1 resident (Resident #238) reviewed for medication self-administration.<BR/>The facility failed to assess, obtain physician orders and IDT approval for Resident #238 to self-administer his own bolus G-tube feedings. <BR/>This failure could place residents at risk of infection and aspiration.<BR/>Findings include:<BR/>Record review of a face sheet for Resident #238 dated 6/13/23 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Gastrostomy status (an opening in the stomach for feeding and treatment), viral hepatitis C without hepatic coma (a viral infection that causes liver inflammation, sometimes leading to serious liver damage), Malignant neoplasm of mandible (mouth cancer), Malignant neoplasm of head, face and neck (head and neck cancer), and Pneumonia (an infection in the lungs).<BR/>Record review of Resident #238's electronic medical record indicated that he had not been in facility long enough for a comprehensive MDS assessment and had no BIMS score on his chart. <BR/>Record review of the care plan for Resident #238 dated 6/11/23 indicated that there was no care plan developed for resident to self-administer medications. <BR/>Record review of the physician orders for Resident #238 dated 6/12/23 indicated that resident had the following order: Jevity 1.5 Bolus 6 times a day. One bolus feed every 4 hours. First 5 bolus feeds at 237 ml and last feed at 107 ml. <BR/>During an observation on 06/11/23 at 10:20 am a plastic cup with a glove over the top of it was noted on Resident #238's overbed table. It had a thick, tan colored liquid in it. Resident #238 was non-verbal and unable to say what liquid was but did point to his G-tube.<BR/>During an observation on 6/12/23 at 7:22 am, there were 2 plastic cups containing thick, tan colored liquid with gloves over the top of them along with 2 plastic cups of what appeared to be water on Resident #238's overbed table.<BR/>During an interview with LVN A on 6/12/23 at 8:30 am, she said that Resident #238 refused to allow staff to administer his G-tube feedings and would administer them himself. She said that the tan liquid in the cups was his feeding formula. She said that she would leave them in his room for him to administer himself. The gloves were over the cups to protect them from getting contaminated. She said the thought that it was care planned for this resident and that it was fine because they had been doing this since he was admitted a little over a week ago. She was unsure as to any assessment documentation. <BR/>During an interview with the Regional Nurse on 6/12/23 at 11:30 am, she said that staff were not supposed to be allowing Resident #238 to self-administer his G-tube feedings because he had not been properly assessed and did not have the proper orders and approval. She said that she was not aware that this was happening. She said that the charge nurses should have come to her with this issue as she was only in the facility 2-3 times per week.<BR/>During an interview with the ADON on 6/12/23 at 8:30 am, she said that she had only been here for 3 weeks and was overwhelmed due there being no DON, no Administrator, and she was having to cover the floor for staffing call-ins. She said that Resident #238 could be at risk for aspiration, and aspiration pneumonia if he was not competent to self-administer. She said she just had not had time to ensure all the proper paperwork and assessments were in place to allow him to self-administer his own G-tube feedings. <BR/>During an interview with the Regional Nurse on 6/14/23 at 11:10 am she said that going forward she would expect her staff to follow proper policy and procedures regarding resident's self-administering medications or G-tube feedings. She said that she would ensure that all staff were properly trained on this. She said that without the proper assessments, residents administering their own G-tube feedings could be at risk for infection, and all feedings would be in labeled containers for safety reasons.<BR/>Record review of facility policy titled Administering Medications dated 2001 with revision date of April 2019 indicated:<BR/> .Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . and <BR/> .Residents may self-administer their own medication only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .<BR/>Record review of facility policy titled Enteral Nutrition dated 2001 with a revision date of November 2018 indicated:<BR/> .14. Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as: a. Aspiration; b. Tube misplacement or migration; c. Skin breakdown around insertion site; d. Perforation of the stomach or small intestine leading to peritonitis; e. Esophageal swelling, strictures, fistulas; and f. Clogging of the tube . and <BR/> .15. Staff caring for residents with feeding tubes are trained on how to recognize and report complications relating to the administration of enteral nutrition products, such as: a. Nausea, vomiting, diarrhea, and abdominal cramping; b. Inadequate nutrition; c. Metabolic abnormalities; d. Interactions between feeding formula and medications; and e. Aspiration . and<BR/> .16. Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan. Risk of aspiration may be affected by: a. Diminished level of consciousness; b. Moderate to severe swallowing difficulties; c. Improper positioning of the resident during feeding; and d. Failure to confirm placement of the feeding tube prior to initiating the feeding .<BR/>Record review of facility policy titled Self-Administration of Medication dated 2001 with a revision date of February 2021 indicated:<BR/> .Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . and <BR/> .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #35) of 8 residents reviewed for parameters to notify Physician of critical lab levels <BR/>The facility failed to notify Resident # 35's primary care physician of critical low blood sugar readings of (46 mg/dl on 05/17/23 and 44mg/dl, on 05/21/23).<BR/>The facility failed to train the staff of when to report changes to the physician.<BR/>An Immediate Jeopardy (IJ) situation was identified on 06/13/23 at 3:00 PM. The IJ template was provided to the facility on [DATE] at 3:03pm. While the IJ was removed on 06/14/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. <BR/>This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death.<BR/>Findings included: <BR/>Record review of Resident # 35's face sheet dated 04/25/23 indicated Resident #35 admitted [DATE]. and was a 59-year- old-female with diagnosis: Bacteremia (blood infection, sepsis), Diabetes Mellitus a disease that occurs when your blood glucose, also called blood sugar, is too high (abnormal blood sugars) due to underlying condition with neuropathy, chronic viral hepatitis C, (liver disease),neuromuscular dysfunction of the bladder,(bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation, (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus, (pressure sore).<BR/>Record review of the Physician Orders for Resident #35 dated 04/25/2023: Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicated, there were no physician orders to check resident #35's BS even though nurses were checking BS before administering Insulin. Resident #35 had no parameters for notification of critical BS values to be reported to the physician.<BR/> Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS (activities of daily living), and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident was able to feed herself with set up assistance from staff. Resident had a foley catheter due to diagnosis of neuromuscular bladder, (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx and was incontinent of bowel. <BR/>Record review of a care plan dated 05/31/23 indicated Resident #35 had diagnosis of Diabetes Mellitus, and intervention of: medications as ordered.<BR/>Record review of Resident #35's progress note dated 05/17/23 at 10:44PM completed by CCM, (previous MDS coordinator) indicated CMS entered room for routine check, resident complained of, my sugar is dropping. Resident #53's Accucheck, (blood glucose monitor) Blood Sugar was 46mg/dl, glass of apple juice with sugar and bowl of cereal with milk given at this time, assisted resident to reposition in bed, Resident requested fan at the foot of the bed to be turned on, this nurse turned on fan as requested, hob elevated and snack set up, resident sitting up in bed eating cereal and drinking juice at this time. The progress note did not indicate that the Physician was notified of critical low blood sugar levels. <BR/>11:00 PM Entered room for follow up Accucheck BS 66. Noted to be lying in bed, awake and alert, respiration even and unlabored, skin warm/dry. Offered and accepted package of peanut butter crackers. No signs/symptoms of distress noted, resident states I feel a lot better now, just hungry, but I really like these crackers. Resident encouraged to consume package of crackers and assisted to reposition self and linens in bed for comfort.<BR/>11:29PM Repeat Accucheck BS level 82. Noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. No s/s of distress noted. Arouses easily to verbal stimuli, Resident stated, Thank you for everything, I feel better.<BR/> Record review of a progress note dated 05/21/23 at 10:00AM indicated the Treatment Nurse was called to Resident #35's room to check blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes BS 80mg/dl. WCTM. Wound treatment provided this shift. PRN Tylenol #4 administered prior to treatment. Resident tolerated well no complaints. <BR/>Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, results 130. Stated her thanks to this writer and Good, it should not drop much lower <BR/>Record review of a progress note dated 05/24/23 at 2:15AM Called to room by resident requesting this nurse, (CCM) to, check my sugar, Accucheck BS level 66. Resident offered and accepted small package of peanut butter crackers at this time. No s/s of distress noted.<BR/>Record Review of Consultant Pharmacist's Medication Regimen review dated 5/23 indicated there were no recommendations from the Pharmacist for Glucagon, (Hormone, it can treat severe low blood sugar) or parameters for notification to the Physician of critical values. <BR/>During an interview 06/12/23 at 3:45 PM, Resident # 35 said she had tried to get the nurses to not give her full dosage of Insulin and to only give half, because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar dropping. <BR/>A Record Review of Residents #35 progress notes dated 06/12/23 at 4:11 PM, order received for blood sugar checks BID, but still no parameters to hold Insulin, notify the Physician or Glucagon Orders.<BR/>During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had worked for corporation for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at documentation. She was not aware there were no orders for blood sugars or parameters to hold Insulin on Resident #35. She said she had texted the Physician regarding the Resident's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed by her this morning with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility was for the nurses to follow morning meeting process, monitor vital signs, blood sugars and if out of range notify the Physician. She said she would monitor this when she comes to the facility twice a week. She said she would join the meeting through TEAMS. She said everyone taking Insulin will have BS checks, and parameters to hold Insulin if BS was to low or high and orders to notify the Physician. <BR/>During a phone interview on 06/13/23 at 9:44 AM, the Physician said, (the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl). The Physician said he would call orders to the facility to notify him if blood sugars were below 100mg/dl. <BR/>During an interview 06/13/23 at 10:03AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident has a critical lab value. She said resident #35 had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at nursing facility were not aware of sliding scale order. She said she had texted the Doctor multiple times since yesterday when they became aware of no parameters, and physician has not replied. LVN A, said she had notified Physician regarding Resident #35's scheduled Humulin Insulin at bedtime to see if facility could get orders for <BR/>The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures.<BR/>The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included:<BR/>Notification of Changes.<BR/>Resident #35: Resident's physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 5/17/23 and 5/21/23. New orders received for labs to include hemoglobinA1C, one time order, and accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. Date: 6/12/2023. <BR/>Resident on 6/13/2023 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. Medical Director, was consulted regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar check orders to: <BR/>Accuchecks BID, Special Instructions: **NOTIFY MD FOR BLOOD SUGARS &lt;80 OR &gt;400** Twice A Day 06:30 AM, 08:00 PM<BR/>Blood sugar prn for symptoms of hyperglycemia or hypoglycemia. Special Instructions: Notify MD of results &lt;80 or &gt;400 As Needed PRN 1, PRN 2, PRN 3<BR/>Notification parameters have added to all residents with finger stick blood sugar orders per the MD's request. <BR/>Action 1: Educate all nurses regarding physician notification and change of condition.<BR/>The licensed nursing staff will have an understanding to report out of range (less than 80 and higher than 400)/critical blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per physician order). <BR/>Staff will have an understanding on when to report changes to the physician through the above education physician notification and change of condition. <BR/>All current, new and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. Out of range, per the Medical Director, that he would like notified about, is lower than 80 and higher than 400. These parameters have been added to the accucheck orders. <BR/>Date of Completion: 6/14/2023 by 11AM<BR/>Staff Responsible for Completion: Assistant Director of Nursing and/or Designee<BR/>Action 2: Clinical Resource Nurse and/or Clinical Company Leader to perform blood sugar audit to check for out of range blood sugars for previous 30-days. Any blood sugars identified outside the Physician Prescribed range per his order(s) will be reported to the Medical Director and any new orders received will be entered and followed. <BR/>Date of Completion: 6/13/2023 <BR/>Staff Responsible for Completion: Clinical Resource Nurse and/or Clinical Company Leader<BR/>Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. <BR/>Clinical Resource Nurse and Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results &lt;80 or &gt;400 has been added to all residents with finger stick blood sugar orders. Per the Medical Director he would like to be notified of blood sugar outside the range of 80-400, this reflects in the order set inputted for residents receiving accuchecks. <BR/>Date of Completion: 6/13/2023 <BR/>Staff Responsible for Completion: Clinical Resource Nurse <BR/>Action 4: Adhoc QAPI meeting performed with interim administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents.<BR/>Date of Completion: 6/13/2023<BR/>Staff Responsible for Completion: Administrator and Clinical Resource Nurse<BR/>On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by:<BR/>Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test.<BR/>Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. <BR/>On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to:<BR/>Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. <BR/>Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results &lt; 80 or &gt; 400 AS NEEDED <BR/> During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl.<BR/>On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 3 of 6 residents (Residents #21, #34, and #238) reviewed for baseline care plans. <BR/>The facility failed to develop a baseline care plan or comprehensive care plan within 48 hours of admission for Residents #21, #34, and #238. <BR/>These failures could place residents at risk of not receiving care and services to meet their needs. <BR/>Findings include: <BR/>Record review of Resident #21, #34, and #238's electronic medical records indicated no baseline care plans were implemented.<BR/>Record review of a face sheet dated 6/14/23 for Resident #21 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypertension (high blood pressure), and dysphagia (difficulty in swallowing food or liquid). <BR/>Record review of a face sheet dated 6/14/23 for Resident #34 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hemiplegia (paralysis of one side of the body), cerebral infarction (stroke), chronic kidney disease (a gradual loss of kidney function), and hypertension (high blood pressure). <BR/>Record review of a face sheet for Resident #238 dated 6/13/23 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Gastrostomy status (an opening in the stomach for feeding and treatment), viral hepatitis C without hepatic coma (a viral infection that causes liver inflammation, sometimes leading to serious liver damage), Malignant neoplasm of mandible (mouth cancer), Malignant neoplasm of head, face and neck (head and neck cancer), and Pneumonia (an infection in the lungs).<BR/>During an interview on 6/12/23 at 3:40 pm the Regional Nurse said that she was aware that there were no baseline care plans being done. She said that the ADON did the care plans and had been doing all of this by herself. There was no DON currently, and she said that it was just a lot to keep up with. She said that she expected going forward that her staff would discuss all new admissions in the morning meetings and would do baseline care plans timely. She said that in their system it was too time consuming for the charge nurse to do with admissions.<BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she was not formally shown how to staff the facility and has been doing the best she can. She said the facility had been without a DON since 5/26/2023 but the regional nurse did come to the facility a couple times a week as needed. She said there were no baseline care plans being done at admission due to LVN's needing training. She said the nursing staff needed training on the admission process and had not been shown how to accurately complete an admission. <BR/>During an interview on 6/14/2023 at 8:47 AM, the previous ADON said she had worked at the facility from the beginning of January 2023 until sometime in April 2023. She said she was responsible for staffing, completing MDS assessments and care plans. She said she was new to completing MDS assessments, but she was being trained by corporate staff. She said she would generate a baseline care plan when a new resident entered the facility, and the DON was supposed to look over the care plans to make changes as needed. She said the baseline care plan would be generated within the first 24-48 hours of admission. She said if a resident admitted to the facility on a Friday, she would not generate the baseline care plan until the following Monday and the DON would make changes. <BR/>During an interview on 6/14/23 at 11:10 am, the Regional Nurse said that not having baseline care plans done within 48 hours of admission could put the residents at risk of not receiving appropriate medical treatments. She said that going forward, she would ensure that all staff were properly trained. She said that she has been with company 2 years, has 4 buildings to cover, 2 of which currently have no DON. She would expect her staff going forward to be properly trained, and to notify her with any questions or concerns. She said that she would do TEAMS meetings with staff when she was not able to be in the building to help ensure nothing was missed.<BR/>Record review of the facility policy titled Care Plans - Baseline dated 2001 with revision date of December 2016 indicated .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #7 and #34) reviewed for care plans.<BR/>The facility failed to ensure Resident #7's care plan accurately reflected her hospice status.<BR/>The facility failed to ensure Resident #34's care plan accurately reflected her ADL status. <BR/>This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs.<BR/>Findings include: <BR/>Record review of a face sheet for Resident #7 dated 6/13/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction, dysphagia, and hypertension. <BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. Section O of same MDS assessment indicated that she had received hospice care within the last 14 days while a resident of the facility. <BR/>Record review of a care plan for Resident #7 with last care conference date of 9/9/22 indicated that hospice status was not addressed on care plan. <BR/>Record review of physician orders for Resident #7 dated 6/13/23 indicated that she had a physician order dated 2/6/23 stating the following: Admit to Heart-to-Heart Hospice; Primary Hospice Diagnosis: CVA <BR/>Record review of a face sheet for Resident #34 undated indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage, chronic kidney disease, depression, and hypertension.<BR/>Record review of a Quarterly MDS Assessment for Resident #34 dated 4/28/2023 indicated she had a BIMS score of 10, indicating that she had moderately impaired cognition. She required extensive to total dependence in most ADLs with one to two-person assist. She was always incontinent of bowel and bladder and required extensive assist of one person with toileting and personal hygiene.<BR/>Record review of a Care Plan dated 4/27/2023 for Resident #34 indicated she had ADL functional status with an approach of bathing/hygiene amount of assist and toileting amount of assist dated 4/7/2023 that was incomplete.<BR/>During an interview on 6/12/23 at 3:40 pm, the Regional Nurse said that the ADON was responsible for care plan updates and revisions, and she was currently out sick. She said that ADON was currently overwhelmed without a DON, administrator and covering staffing. <BR/>During an interview on 6/13/23 at 8:10 am, the ADON said that she had been employed at the facility for 3 weeks. She said she has not had a DON or Administrator since the end of May 2023. She said that a resident's hospice status and ADL status should be addressed on their care plan. She said that residents could be at risk of staff not getting a complete picture of resident and resident could possibly not get appropriate care. She said that going forward, she would hope to have a full time DON, administrator, and leadership to help with getting care plans initiated and training of staff.<BR/>Record review of facility policy titled Care Plan, Comprehensive Person-Centered dated 2001, with revision date of December 2020 indicated: .The comprehensive, person-centered care plan will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the person-centered care plans to reflect the current condition for 3 of 5 residents of the facility (Residents #7, #17, and #18).<BR/>The facility failed to ensure Residents #7, #17, and #18 care plans conferences and reviews were held quarterly.<BR/>This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. <BR/>Findings:<BR/>Record review of a face sheet for Resident #7 dated 6/13/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction (stroke), dysphagia (trouble swallowing), and hypertension. <BR/>Record review of a Quarterly MDS Assessment for Resident #7 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. <BR/>Record review of Resident #7's medical record indicated that last care conference was held on 9/9/22.<BR/>Record review of the facility face sheet dated 6/13/2023 for Resident #17 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (A group of symptoms that affects memory, thinking and interferes with daily life), anxiety, Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), and congestive heart failure (when your left ventricle can't pump blood efficiently). <BR/>Record review of a Quarterly MDS dated [DATE] for Resident #17 indicated that she had a BIMS score of 11, indicating that she had moderately impaired cognition. <BR/>Record review of Resident #17's medical record indicated that last care conference was held on 9/26/22.<BR/>Record review of face sheet dated 6/14/23 for Resident #18 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, cerebral infarction, and hypertension. <BR/>Record review of a Quarterly MDS for Resident #18 dated 5/16/23 indicated that BIMS assessment should not be conducted due to resident being rarely/never understood.<BR/>Record review of Resident #18's medical record indicated that the last care plan conference was held on 9/26/22. <BR/>During an interview on 6/13/23 at 8:30 am, the ADON said that she had been employed here for approximately 3 weeks and was overwhelmed trying to everything by herself. She said she had no administrator, no DON, and no one to cover staffing, so she had also been trying to cover all the call-ins. She said that care plan conferences and reviews were not being done, at least since she has been here, as she has had no training on this. She said that going forward, she would hope to have an administrator, a DON, and additional help to cover everything that needs to be done in the facility. <BR/>During an interview on 6/14/23 at 11:10 am, the Regional Nurse said that she knew care plan conferences were not being done properly in the facility, but that they just did not have the staff. She said that residents could be at risk of not receiving proper care without care plans being implemented and reviewed appropriately. She said that going forward she would expect staff to address in morning meetings all residents who had care plan reviews coming up in the following week. She said she would ensure proper training for all staff, have the MDS corporate nurses training the current ADON and hold TEAMS meetings with staff when she could not be in the facility to ensure that things were done correctly, and things did not get missed. <BR/>Record review of the facility policy titled Care Plan, Comprehensive Person-Centered dated 2001, with revision date of December 2020 indicated: .The Interdisciplinary Team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 of 8 residents (Resident #35), reviewed for quality of care. <BR/>The facility failed to obtain orders for finger stick blood sugars for resident #35 and to follow their policy on Management of Hypoglycemia, (low blood sugar), when resident # 35's blood sugar reading was at critical levels of 46mg/dl on 05/17/23 and 44mg/dl on 05/23/23 and hold parameter for Insulin if blood sugar reading is at a critical level of below 70mg/dl. Resident #35 experienced sweating and shakiness when her blood sugar fell below 80mg/dl. Resident #35 had no orders for finger stick blood sugars and no parameters for holding Insulin for blood sugar levels below 70mg/dl. <BR/>An Immediate Jeopardy (IJ) situation was identified on 06/13/23. The IJ template was provided to the facility on [DATE] at 3:03pm, while the IJ was removed on 06/14/23. The facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm, due to the facility's need to evaluate the corrective actions. <BR/>This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death.<BR/>Findings included: <BR/>Record review of Resident #35's face sheet dated 04/25/23 indicated Resident #35 admitted to the facility on [DATE] and was a 59-year- old-female with diagnoses: Bacteremia (blood infection, sepsis), Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), (abnormal blood sugars) due to underlying condition with neuropathy, (dysfunction of peripheral nerves), (chronic viral hepatitis C (liver disease), neuromuscular dysfunction of the bladder (bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus (pressure sore).<BR/>Record review of Physician Orders dated 04/25/2023 Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicates, there were no physician orders to check resident's BS and no parameters for notification of abnormal values to be reported to the physician.<BR/>Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS, and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident #35 was able to feed herself with set up assistance from staff. Resident #35 had a Foley catheter due to diagnosis of neuromuscular bladder (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx (small triangular bone at the base of the spine) and was incontinent of bowel. <BR/>Record review of a care plan dated 05/31/23 indicated Resident #35 had a diagnosis of Diabetes Mellitus, and intervention of: medications as ordered.<BR/>Record Review of Physician orders dated 04/25/23 through 06/12/23 indicated Resident #35 had no orders for routine finger stick blood sugars, no parameters to hold insulin if blood sugar reading below 70mg/dl, and no orders to notify the physician of critical blood sugar levels of below 70mg/dl and above 250 mg/dl. <BR/>Record review of MAR (medication administration record) indicates nurses were checking residents BS twice a day before Insulin administration but had no Physician orders to check Resident's BS and no parameters to hold Insulin or parameters to notify the Physician of critical values. <BR/>Record review of Resident #35's progress note dated 05/17/23 at 10:44 PM completed by the CCM (previous MDS coordinator) indicated the CCM entered the room for a routine check and the resident complained of, my sugar is dropping. Resident #35's Accucheck (blood glucose monitor) Blood Sugar was 46mg/dl. A glass of apple juice with sugar and a bowl of cereal with milk was given at that time. The resident was assisted to reposition in bed. The resident requested a fan at the foot of the bed to be turned on, and the nurse turned on the fan as requested. The head of bed was elevated, and a snack was set up. The resident was sitting up in bed eating cereal and drinking juice at this time. At 11:00 PM, CCM entered room for follow up Accucheck, BS at 66. Resident noted to be lying in bed, awake and alert, respiration even and unlabored, skin was warm/dry. The resident was offered and accepted a package of peanut butter crackers. There were no signs/symptoms of distress noted, and the resident stated she felt a lot better now, was just hungry, but he really like the crackers. The resident was encouraged to consume package of crackers and was assisted to reposition self and linens in bed for comfort. At11:29 PM a repeat Accucheck, BS level 82. The resident was noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. There was no signs/symptoms of distress noted. The resident aroused easily to verbal stimuli. The resident stated, Thank you for everything, I feel better.<BR/>Record review of a progress note dated 05/21/23 at 10:00 AM indicated the Treatment Nurse was called to Resident #35's room to check his blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes and BS 80mg/dl. WCTM. Wound treatment was provided on shift. PRN Tylenol #4 was administered prior to treatment. The resident tolerated well no complaints. <BR/>Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, and results were 130mg/dl. Stated her thanks to this writer (CCM) and Good, it should not drop much lower. <BR/>Record review of a progress note dated 05/24/23 at 2:15 AM CCM called to resident #35's room by resident, requesting this nurse, (CCM) to, check my sugar, Accucheck BS was level 66. The resident was offered and accepted a small package of peanut butter crackers at the time. There were no signs/symptoms of distress noted.<BR/>Record Review of the Consultant Pharmacist's Medication Regimen Review dated May 2023 indicated there were no recommendations from the Pharmacist for Glucagon, (hormone, it can treat severe low blood sugar,) parameters to hold insulin, or parameters for notification to the Physician of critical values. <BR/>During an interview on 06/12/23 at 3:45 PM, Resident #35 said she had tried to get the nurses to not give her a full dosage of Insulin 20mg/dl and to only give half (10mg/dl) because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar dropping. She said she has seen the Physician but didn't think to tell him. Resident #35 said she experienced sweating and shakiness when her blood sugar fell below 80mg/dl. <BR/>During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had notified the Physician regarding the Resident #35's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed with no signs or symptoms of Hypoglycemia. The Regional Nurse said she had worked for corporate for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at nursing documentation. She was not aware there were no orders for blood sugars or parameters to hold insulin for Resident #35. <BR/>During an interview 6/12/23 a 4:10 PM, the Regional nurse said Resident #35 had been assessed today with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility is for the nurses to follow the morning meeting process, (look at documentation, monitor vital signs, blood sugars and if out of range to notify the Physician). She said she would join the meeting through TEAMS. (Messaging APP). She said everyone taking insulin will have BS checks, and parameters to hold Insulin if BS is to low or high.<BR/>Record Review of a Progress notes dated 06/12/23 at 4:11 PM revealed, new order for HbA1C (blood test for diabetes determines the three-month average blood sugar level), next lab draw and Accuchecks twice a day. <BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she [NAME] formally been shown how to do an admission but said the nurses should have known to get blood sugar checks and parameters with insulin orders. She said the facility had been without a DON since 5/26/2023 but the Regional Nurse did come to the facility a couple times a week as needed. She said she was often called to work the floor and was doing the best she could. <BR/>During a phone interview on 06/13/23 at 9:44 AM the Physician said, the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl. Physician said he had not been notified of Resident #35's critical low blood sugar levels or her requesting to have Insulin dosage lowered. <BR/>During an interview 06/13/23 at 10:03 AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident had a critical lab value. She said the resident had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at the nursing facility were not aware of the sliding scale order. She said she had texted the Physician multiple times since yesterday when they became aware of no parameters, and the physician has not replied. LVN A said she had notified the Physician regarding Resident #35's scheduled Humulin 70/30 U-100 Insulin (NPH and regular Human) [OTC] suspension; 100 unit/ml (70-30); Amount to Administer: 20 units; subcutaneous twice a day, to see if the facility could get orders for parameters. LVN A notified the Physician that Resident #35 was requesting to get half of her insulin dosage when her blood sugar is low. <BR/>During an interview 06/13/23 at 10:15 AM, the Treatment Nurse said she had worked at the facility for two years. She said if the facility was short staff she got pulled from doing treatments to work the floor. She said Resident # 35 was a very brittle diabetic and her blood sugars were hard to control. She said they do check the resident's blood sugar before giving her insulin. She said there were no physician's orders to check her blood sugar or parameters as to when to notify the physician. She said she had to give her orange juice and sugar before and a snack to bring her bloodsugar up. She said once the blood sugar was stable she did not think to notify the Physician. <BR/>During an interview 06/13/23 at 10:34 AM the Interim Administrator said she expected her staff to notify the Physician of any change in the resident including low or high blood sugars. She said she expects her staff to be trained and have competency checks offs regarding Hypoglycemia or Hyperglycemia and to know when to notify the Physician. The Administrator said the resident could have gone into a coma if her BS is not controlled. She said she expects her staff to follow protocol for hypoglycemia, and the Regional Nurse was inservicing the staff on the policy today, she hopes to improve education for the staff. She said she will meet with families during care conference meetings and make sure they are doing everything they can to take care of the residents <BR/>During an interview 06/13/23 at 10:47 AM Resident #35 said she didn't always get her snacks at bedtime, and that her blood sugar would drop. She said she could feel her blood sugar dropping sometimes and would call the nurse to come check it. She said the nurse would give her orange or apple juice with sugar and give her snacks to bring it up. She said she tried to keep snacks in her room. Resident #35 said she had tried to get the night nurse to only give her half of her insulin dosage because she kept dropping. <BR/>The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures.<BR/>The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included:<BR/>Resident #35: The resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day with hold parameters to hold insulin if blood sugar is less than 100. <BR/>On 06/13/23 Resident #35 was assessed by the Clinical Resource Nurse and there were no signs or symptoms of hypo or hyperglycemia (low or high blood sugar). The Medical Doctor was consulted regarding current orders. The Medical Director has changed Resident #35's finger stick blood sugar; changed orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl; and Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results &lt; 80 or &gt; 400 AS NEEDED PRN 1 PRN 2, PRN 3.<BR/>Action 1: Educate all nurses regarding the diabetic/managing hypoglycemia policy, physician notification, and change of condition (to include blood sugars out of range per the Physician's prescription below 80 and above 400). <BR/>The licensed nursing staff will have an understanding to report out of range blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per the Physician's preference below 80 and above 400). Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference. <BR/>The facility will ensure competency of licensed nursing staff and ensure licensed nursing staff understand our management of hypoglycemia policy through the above education.<BR/>The charge nurses will notify the doctor immediately if the blood sugar reading is above or below the parameters set by the residents' physician (the MD would like to be notified if blood sugar is outside 80-400), the charge nurse at that time will follow the MD's orders. The updated orders read as follows per the physician: Special Instructions: Notify MD of results &lt;80 or &gt;400 has been added to all residents with finger stick blood sugar orders. Policy Managing Hypoglycemia has been updated to reflect follow provider orders/instructions for blood sugars under 80 and over 400 and/or to administer oral glucose/glucagon/call emergency services per policy. Orders will reflect PRN oral glucose/glucagon per policy and MD orders for residents receiving accuchecks. All nurses will be educated regarding the policy and policy changes. <BR/>All current, new, and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. <BR/>Date of Completion 6/14/23 @ 12 PM <BR/>Staff Responsible for Completion: Assistant Director of Nursing and/or Designee<BR/>Action 2: Perform Blood Sampling- Capillary (Finger Stick) Competency competencies on all licensed nurses. <BR/>All new and temporary (agency) nurses shall be checked off on Blood Sampling- Capillary (Finger Stick) Competency prior to working their next shift/first shift. <BR/>Date of Completion: 6/14/2023 @ 12 PM<BR/>Staff Responsible for Completion: Assistant Director of Nursing and/or Designee<BR/>Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. <BR/>The Clinical Resource Nurse and the Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results &lt;80 or &gt;400 has been added to all residents with finger stick blood sugar orders. Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference and physician's order/instruction upon notification of blood sugars lower than 80 and higher than 400.<BR/>Date of Completion: 6/13/2023<BR/>Staff Responsible for Completion: Clinical Resource Nurse <BR/>Action 4: Adhoc QAPI meeting performed with the Interim Administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents.<BR/>Date of Completion: 6/13/2023<BR/>Staff Responsible for Completion: Administrator and Clinical Resource Nurse<BR/>These interventions were completed based on staff (Interim Administrator, ADON, Clinical Resource Nurse, and 4 LVNs (Treatment Nurse, Nurse A, Nurse G, Nurse H) on the morning and evening shift, were interviewed to ensure these interventions had been completed. Nursing staff were able to appropriately indicate they would follow the policy, Management of Hypoglycemia, the parameters of notification. <BR/>A policy, Management of Hypoglycemia-Diboll Specific, updated 06/14/23 was reviewed by Surveyors.<BR/>MANAGEMENT of HYPOGLYCEMIA:<BR/>The following is a suggested protocol thaat should be implemented without the approval of the Medical Director and Director of Nursing. If there is already a protocol in place, disregard this and follow the existing approved protocol instead.<BR/>1. <BR/>Classification of hyperglycemia:<BR/>a. <BR/>Level 1 hypoglycemia:blood glucose &lt;80 mg/dl and &gt;54 mg/dl<BR/>b. <BR/>Level 2 hypoglycemia: blood glucose is &lt;54mg/dl: and<BR/>c. <BR/>Level 3 hypoglycemia: altered mental and or physical status requiring assistance for hypoglycemia. <BR/>2. <BR/>For Level 1 hypoglycemia (&lt;80mg/dl<BR/>a. <BR/>Give resident an oral form of rapidly absorbed glucose 1tube/15grams<BR/>Notify the Physician immediately.<BR/>b. <BR/>Remain with the resident<BR/>c. <BR/>Recheck blood sugar in 15 minutes:<BR/>1. <BR/>If blood glucose within establish reference range, pprovide the resident with a meal or snack. <BR/>2. <BR/>If blood sugar is greater than established reference range (rebound Hyperglycemia) administer diabetic medication as ordered or<BR/>3. <BR/>If blood sugar remains &lt;80mg/dl, repeat oral glucose and notify physician for further orders.<BR/> 3. For Level 2 hypoglycemia (&lt;54mg/dl)<BR/> a. Administer glucagon 1 vial/1mg I<BR/> b. Notify the Physician Immediately<BR/> c. Remain with the Resident<BR/> d. Place resident in a comfortable and safe place (bed or chair)<BR/> e. Monitor vital signs and <BR/> f. Recheck blood glucose in 15 minutes (as Above)<BR/> 4. If a resident has a Level 3 hypoglycemia and is unresponsive <BR/> a. Call 911(in accordance with resident's advance directives<BR/> b. Administer Glucagon 1 vial/1mg IM. <BR/> c. Notify the Physician immediately<BR/> d. Remain with the resident<BR/> e. Place the resident in a comfortable and safe place (bed or chair); and <BR/> f. Monitor vital signs<BR/>During an interview on 6/14/2023 at 4:00 PM, the Interim Administrator said she had been at the facility since Monday 6/12/23. She said they had no DON, and the last DON left two weeks ago. She said her expectations were for the staff to be in-serviced on the Management of Diabetes. She said the Regional Nurse had audited the physician's orders on all resident to be ensure BS checks, and parameters to hold Insulin, and to notify the Physician of abnormal values, BS &lt;80 and &gt;400mg/dl had been implemented on all diabetics. <BR/>On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test.<BR/>Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. <BR/>On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to:<BR/>Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. <BR/>Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results &lt; 80 or &gt; 400 AS NEEDED <BR/>During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl.<BR/>On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 1 courtyard reviewed for accident hazards.<BR/>The facility failed to store laundry detergent and bleach away from residents.<BR/>These failures could place the residents at risk of accidents hazrds in the environment in which they live.<BR/>Findings included:<BR/>Record review of the Face Sheet dated 06/13/23, indicated Resident #24, admitted to the facility on [DATE], was [AGE] years old with diagnoses of End Stage Heart Disease (heart no longer pumps effectively), essential (primary) hypertension (high blood pressure) and Depress (mood disorder). <BR/>Record review of a Quarterly MDS assessment for Resident #24 dated 4/27/23 indicated he had a moderate impairment in thinking with a BIMS score of 12 (A BIMS of 8-12 indicates the resident is moderately impaired.)<BR/>During an observation on 6/12/2023 at 08:45 AM of the courtyard and smoking area revealed upon exit at the door near the laundry area, there were 5 3-gallon containers filled with liquid detergent and one damaged 3-gallon container filled with liquid bleach labeled caustic/hazard (clear liquid was visible through a hole in the container and cigarette butts were floating in the liquid ).<BR/>During an observation and interview on 6/12/2023 at 9:09 AM, revealed the Laundry Supervisor was aware of the containers on the stoop of the exit door. She said she had been employed at the facility since February 2022. She opened the door leading out to the courtyard and smoking area and looked at the containers of detergent and damaged container of bleach. The Laundry Supervisor said the containers had been there since she started to work at the facility, and she wasn't concerned about them. When asked if the bleach could cause harm if a resident tampered with it, she said the caustic chemicals in the bleach could harm a resident if it was spilled on them or was ingested and the detergent could make them sick also. She stated the resident that came out to the courtyard walked by the containers and they could pose a safety hazard if they stumbled on them or the bleach splashed on them.<BR/>During an interview on 06/12/23 at 10:00 AM with Resident #24 he said he uses the exit at the door next to the laundry room multiple times to smoke and the other 4to 6 smokers use the exit door also. Resident 24 said some of the smoker are confused but there is a staff member that goes out with them. Resident #24 said there are some resident that come outside that have trouble walking and they could fall on the bleach container that was cracked. Resident #24 said the residents could fall over the stacked containers of detergent since they were close to the door and if the fell on the cracked container of bleach it might get on them. <BR/>During an observation on 06/12/23 at 10:15 AM of the smoking area at the Gazebo revealed there appeared to be multiple ash marks on the bricks, and concrete near the exit door. Cigarette butts were in a coffee can and a damaged 3-gallon plastic bleach container (labeled-Hazard Caustic) filled with bleach at the doorway leading out to the Gazebo.<BR/>During an interview on 6/12/2023 at 3:45 PM, the Maintenance Director said he had been employed at the facility since 09/2020. He said he was responsible for anything that was broken and needed repair in the facility. He said his supplies were in the two metal buildings in the courtyard and he frequently used the exit door where the detergent and bleach had been stored for a long time. He said the bleach and detergent had been placed outside because a new vendor was under contract to supply cleaning products and the 6 containers were scheduled to be picked up by the old vendor but they never came to get them. When asked if the bleach or detergent could cause harm if a resident tampered with it, he said the caustic chemicals in the bleach could harm a resident if it was spilled on them or ingested and the detergent also. He said he would dispose of them immediately.<BR/>During an Interview on 6/13/2023 at 7:45 AM, the Interim Administrator said she had been at the facility for a week, and the last Administrator left at the end of May 2023. She said she was not aware of the detergent and bleach being outside next to the laundry exit door, that the resident use to go outside and the smokers use to go to the smoking Gazebo. She said the bleach and detergent sitting outside the door in the resident courtyard were a hazard and posed a risk of poisoning or burns if a resident came in contact or ingested the contents of the containers.<BR/>During an observation on 6/14/2023 at 9:00 AM revealed the containers of bleach and detergent were no longer by the exit doorway.<BR/>Record review of a facility policy titled Maintenance Service with a revised date of December 2022 indicated, .1. Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times 2. A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards .

Based on observation, interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 5 of 5 months reviewed. (January 2023-May 2023)<BR/>The facility did not have RN coverage for 4 days in January 2023.<BR/>The facility did not have RN coverage for 17 days in February 2023.<BR/>The facility did not have RN coverage for 17 days in March 2023. <BR/>The facility did not have RN coverage for 3 days in April 2023.<BR/>The facility did not have RN coverage for 2 days in May 2023.<BR/>This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.<BR/>Findings included:<BR/>Record review of the CMS Payroll Based Journal report for the 2nd quarter of 2023 (January 1, 2023 through March 31, 2023) indicated there were no RN hours for the following dates: <BR/>01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/07 (SA); 01/08 (SU); 01/09 (MO); 01/10 (TU); 01/11(WE); 01/12 (TH); 01/13 (FR); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/23 (MO);01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/28 (SA); 01/29 (SU); 01/30 (MO); and 01/31 (TU). <BR/>02/01 (WE); 02/02 (TH); 02/03 (FR); 02/06 (MO); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/11(SA); 02/12 (SU); 02/13 (MO); 02/14 (TU); 02/15 (WE); 02/16 (TH); 02/17 (FR); 02/20 (MO); 02/21 (TU);02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); 02/26 (SU); 02/27 (MO); and 02/28 (TU). <BR/>03/01 (WE); 03/02 (TH); 03/03 (FR); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11(SA); 03/12 (SU); 03/13 (MO); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/20 (MO); 03/21 (TU);03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25 (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); and 03/31 (FR).<BR/>Record review of the daily nurse staffing sheets for January 2023 indicated there were no RN hours worked on the following dates: 01/07 (SA); 01/08; 01/28 (SA); and 01/29 (SU). <BR/>Record review of the daily nurse staffing sheets for February 2023 indicated there was no RN hours worked on the following dates: 02/01 (WE); 02/02 (TH); 02/03 (FR); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/11 (SA); 02/12 (SU); 02/15 (WE); 02/16 (TH); 02/17 (FR); 02/21 (TU); 02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); and 02/26 (SU).<BR/>Record review of the daily nurse staffing sheets for March 2023 indicated there was no RN hours worked on the following dates: 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11 (SA); 03/12 (SU); 03/20 (MO); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25 (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); and 03/31 (FR).<BR/>Record review of the daily nurse staffing sheets for April 2023 indicated there was no RN hours worked on the following dates: 04/11 (TU); 04/12 (WE); and 04/13 (TH).<BR/>Record review of the daily nurse staffing sheets for May 2023 indicated there was no RN hours worked on the following dates: 05/10 (WE); and 05/11 (TH). <BR/>During an observation and interview on 6/11/2023 at 10:00 AM, revealed RN K was in the facility by the nurse station and said she was one of the weekend RN's who worked at the facility. She said she had been employed since August 2022 and alternated weekends with another RN. She said she only worked weekends at the facility.<BR/>During an interview on 6/12/2023 at 2:00 PM, HR said she had been employed at the facility since August 2022. She said she was responsible for making sure hours were submitted to payroll. She said she was not responsible for submitting anything to the PBJ system. She said the ADON was responsible for staffing and the facility did utilize agency staff at times. She said if agency staff worked at the facility, she was not able to access their time sheets and would have to reach out of corporate to get them. She said the facility always had a nurse in the facility and was never without a nurse any day but a RN was not always there. She said she was not aware the facility triggered for no RN hours in January 2023 to March 2023. She said the only RNs who clocked in or out were the RNs who worked the weekends. She said the DON or the Regional Nurse when she visited did not clock in or out either because they were salary employees. She said the nurse staffing sheets that were posted by the nurse station daily would reflect if they had RN coverage on the specific dates and she was responsible for updating the sheet daily according to the staffing schedule. She said the facility had a DON who left on 1/31/2023 who had been employed full time since 9/1/2022. She said the facility did not have another DON until 4/1/2023 and she left 5/26/2023. She said the facility did not currently have a full time DON but the Regional Nurse would come to the facility about twice a week. She said the facility always had a licensed nurse in the facility to take care of the residents.<BR/>During an interview on 6/12/2023 at 9:55 AM, the Regional Nurse said the facility had been without a full time DON since 5/26/2023. She said she had been going to the facility about two times a week. She said the last DON was employed at the facility from 4/1/2023 to 5/26/2023. She said the DON worked Monday-Friday 8 hours a day which provided coverage for the RN hours. She said the facility had weekend RNs who worked alternating weekends. She said the ADON was responsible for staffing at the facility. She said while the facility did not have a DON, she would cover and work 8 hours days on the days she visited the facility. She said the facility did not have a RN in the facility 8 hours a day 7 days a week at this time.<BR/>During an interview on 6/12/2023 at 2:20 PM, the Compliance Officer said he was the person who was responsible for the PBJ submissions. He said he had been in that position for the last two quarters of the fiscal year 2023 that was submitted to CMS. He said the facility utilized their payroll system which pulled time punch detail hours for employees except for corporate staff that was submitted to PBJ. He said the hours did not include the DON and Regional Nurse who was paid salaries and clocking in and out was not required for them. He said the time punch detail hours that was submitted for the second quarter of 2023 were the hours for the RN's that were not salaried. He said he had not received any training on PBJ submissions and how to get the data from the different payroll systems. He said corporate was looking into getting another system in place for time reporting. He said the current system was not collecting accurate hours worked for the RN coverage. <BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she was not shown how to staff the facility and had been doing the best she could. She said the facility had been without a DON since 5/26/2023 but the Regional Nurse did come to the facility a couple times a week as needed but did not stay at the facility for the 8 hours that was required. She said the facility had never been without nurse coverage since her employment started. She said a RN must be in the facility to provide guidance for the nursing staff and not having a fulltime RN present could affect the resident's overall quality of care. She said the facility did not have a RN in the facility 8 hours a days 7 days a week at this time.<BR/>During an interview on 6/14/2023 at 8:30 AM, the Treatment Nurse said she had been employed at the facility for 2 years but only 2 months as the treatment nurse. She said the facility had weekend RNs that worked. She said after 1/31/2023 the facility was without a DON until the beginning of April 2023. She said the Regional Nurse would come to the facility a couple of days a week. She said when a RN was not in the facility if the charge nurses had issues or concerns, they would report to the ADON, and the ADON would contact the Regional Nurse if needed. She said the ADON was responsible for staffing and made sure the facility had nurse coverage in the facility. <BR/>During an interview on 6/14/2023 at 8:47 AM, the previous ADON said she worked at the facility from the beginning of January 2023 until sometime in April 2023. She said she was responsible for staffing. She said from February 1, 2023, to April 1, 2023, the facility did not have a fulltime DON or Administrator. She said the Regional Nurse would come to the facility a few days a week. She said if the staff had an issue or situation that required a RN, then she would contact the Regional Nurse. She said the residents could be at risk of having a medical condition that would require a RN. <BR/>During a follow up interview on 6/14/2023 at 10:40 AM, the Regional Nurse said they had two applicants that would be interviewed for the DON position this week. She said RNs were critical thinkers and should be in the facility 8 hours a day 7 days a week as required and without them present it could impact the residents' medical conditions. She said going forward she would review the clock hours each day to ensure hours were met for nursing hours. She said the facility had weekend RNs that worked. She said she would review with the ADON on a weekly basis for RN coverage.<BR/>During an interview on 6/14/2023 at 11:00 AM, the Interim Administrator said she had been employed with the company for years but 6/12/2023 was her first day at the facility. She said she was not aware of the facility having days that triggered for no RN hours from January 2023 to March 2023 according to the PBJ submission report. She said the facility should have an RN in the facility 8 hours a day 7 days a week. She said a resident could be at risk of not receiving needed nursing care. She said the facility did not have a policy for RN hours.<BR/>Record review of the Facility Assessment Tool dated 7/28/2022 with next review date for the QAPI committee review date of 8/23/2022 indicated an average census was thirty-two. Their plan for staff indicated one RN for days and one LVN for days, evenings and nights and a DON 24/7.

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 12 months (February 2023, and May 2023) reviewed for pharmacy services. <BR/>The facility did not have a licensed pharmacist and two witnesses initial the attached pages of the controlled medication destruction inventory sheets. <BR/>This failure could put residents at risk for misappropriation and drug diversion.<BR/>Findings:<BR/>During a record review of the facility's drug destruction log for the last 12 months (June 2022 to May 2023), revealed the drug destructions for controlled drugs dated 02/15/23 and 05/15/23 indicated that the attached pages of medication destruction were ot numbered and did not include the initials of the consultant pharmacist and two witnesses.<BR/>During an interview on 06/13/23 at 9:50 a.m., the ADON said there was no DON currently employed at the facility, and she was unaware that the cover page had to be signed by the Pharmacist and another witness and that there had to be two witnesses initialing each page and that she thought the cover sheet was all that was needed. She said she took this position three weeks ago and would implement a new system that would ensure the cover sheets and all attachment pages were numbered and signed/ witnessed appropriately going forward. She said she did not think a drug diversion could happen, but anything might be possible if the correct procedure was not followed.<BR/>During an interview on 06/1/23 at 2:03 p.m., the Regional Nurse said there was no DON currently employed at the facility, and she was unaware there had to be two witnesses initialing each page of the listed drugs and each page should be numbered. She said that she thought the signed cover sheet was all that was needed. She said she would ensure the cover sheets were signed as required and all attachment pages were numbered and witnessed appropriately going forward. She said the risk could be a possible drug diversion.<BR/>During an interview on 06/13/23 at 4:00 p.m., the Interim ADMIN said she would check the regulations with the Pharmacist to ensure the drug destruction occurred appropriately and said that going forward she expected her staff to follow correct policy regarding drug destruction. <BR/>Record review of facility policy titled Discarding and Destroying Medications revised October 2014 indicated .Schedule II, II and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. The facility may contract with a DEA registered collector for proper disposal of non-hazardous schedule II, III, IV and V controlled substances.<BR/>Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and regulations <BR/>Record review of 22 TAC &sect;303.1 Destruction of Dispensed Drugs accessed online 06/07/2023 at https://texreg.sos.state.tx.us/ indicated.<BR/>(a) Drugs dispensed to patients in health care facilities or institutions.<BR/>(1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. <BR/>(A) A written agreement exists between the facility and the consultant pharmacist. <BR/>(B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: <BR/>(i) name and address of the facility or institution. <BR/>(ii) name and pharmacist license number of the consultant pharmacist. <BR/>(iii) date of drug destruction. <BR/>(iv) date the prescription was dispensed. <BR/>(v) unique identification number assigned to the prescription by the pharmacy. <BR/>(vi) name of dispensing pharmacy. <BR/>(vii) name, strength, and quantity of drug. <BR/>(viii) signature of consultant pharmacist destroying drugs. <BR/>(ix) signature of the witness(es); and <BR/>(x) method of destruction. <BR/>C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet , provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es).<BR/>v) any two individuals working in the following capacities at the facility: <BR/>(I) facility administrator. <BR/>(II) director of nursing. <BR/>(III) acting director of nursing; or <BR/>(IV) licensed nurse.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the second quarter January 1, 2023 to March 31, 2022)<BR/>The facility failed to submit accurate licensed nursing coverage 24 hours a day for 1/3/2023, 1/27/2023, 3/2/2023 and 3/7/2023.<BR/>These failures could place residents at risk for personal needs not being identified and met.<BR/>The findings included:<BR/>Record review of the CMS PBJ report for the second quarter of 2023 (January 1, 2023 through March 31, 2023) indicated there was no licensed nursing coverage 24 hours/day for the following dates: 1/3/2027, 1/27/2023, 3/2/2023 and 3/7/2023.<BR/>During an interview on 6/12/2023 at 2:00 PM, HR said she had been employed at the facility since August 2022. She said she was responsible for making sure hours were submitted to payroll. She said she was not responsible for submitting anything to the PBJ system. She said the ADON was responsible for staffing and the facility did utilize agency staff at times. She said if agency staff worked at the facility, she was not able to access their time sheets and would have to reach out to corporate to get them. She said the facility always had a nurse in the facility and was never without a nurse any day. She said she was not aware the facility triggered for 4 days in the second quarter for licensed nurse coverage 24 hours a day.<BR/>During an interview on 6/12/2023 at 2:20 PM, the Compliance Officer said he was the person who was responsible for the PBJ submissions. He said the facility utilized their payroll system which pulled time punch detail hours for employees except for corporate staff that included the regional nurses and DONs that was submitted to the PBJ system. He said the hours did not include the DON and the regional nurse who were paid salaries and clocking in and out was not required for them. He said the time punch detail hours that were submitted for the second quarter of 2023 were the hours for the RNs that were not salaried. He said he had not received any formal training on PBJ submissions and how to get the data from the different payroll systems. He said corporate was looking into getting another system in place for time reporting. He said the current system was not collecting accurate hours that was worked for all staff. <BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she was not shown how to staff the facility and had been doing the best she could. She said the facility had a lot of call in's and it had been difficult to get shifts covered. She said since the facility had been short staffed, and she implemented a nurse coming in to work 4 pm to 10 pm to work and help administer medications to the residents since she started at the facility. She said the facility had never been without nurse coverage since her employment started. <BR/>During an interview on 6/14/2023 at 8:30 AM, the Treatment Nurse said she had been employed at the facility for 2 years but only 2 months as the Treatment Nurse. She said her hours to work were usually from 8 am until 5 pm. She said the ADON was responsible for staffing and made sure the facility had nurse coverage in the facility. She said the ADON would cover for the nurses if there was only one nurse in the facility so they could take a break. She said on 3/2/2023 she came in to work that day at her normal time at 8 am because that was her schedule since being the Treatment Nurse at the facility. She said when she arrived, someone must have called in and she had to work as a charge nurse, and she also provided wound care and treatments to the residents that day. She said she clocked out at 6:20 pm and that would have indicated she worked as a charge nurse that day because the nurses worked 12 hours shifts from 6 am to 6 pm on the day shift.<BR/>During an interview on 6/14/2023 at 8:47 AM, the previous ADON said she was a LVN who worked at the facility from the beginning of January 2023 until sometime in April 2023. She said she was responsible for staffing. She said the facility always had numerous nurses in the facility all the time and was never without one. She said if the facility was short a nurse, then she would cover the shift if she could not get coverage from agency staffing. <BR/>During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said she had been employed with the company for 2 years. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. She said going forward she would review the clock hours for each day to ensure hours were met for nursing hours. She said she was not aware of the facility having days that triggered for licensed nurse coverage 24 hours a day according to the PBJ submission report.<BR/>During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said she had been employed with the company for years but 6/12/2023 was her first day at the facility. She said she was not aware of the facility having days that triggered for licensed nurse coverage 24 hours a day according to the PBJ submission report. She said a nurse would not leave or take a break without another nurse being present and if a licensed nurse was not in the facility, they were to notify her immediately. She said a resident could be at risk of not receiving needed nursing care. She said the facility did not have a policy for licensure nurse coverage for 24 hours a day.<BR/>Record review of the Facility Assessment Tool dated 7/28/2022 with next review date for the QAPI committee review date of 8/23/2022 indicated an average census was thirty-two. Their plan for staff indicated one RN for days and one LVN for days, evenings and nights and a DON 24/7.

**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 6 residents (Resident #34) reviewed for infection control. <BR/>TNA B failed to wash or sanitize her hands when changing gloves while performing incontinent care to Resident #34.<BR/>TNA B failed to change her gloves when going from dirty to clean while performing incontinent care to Resident #34.<BR/>This failure could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings included:<BR/>Record review of an undated face sheet for Resident #34 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage (weakness on one side after a brain bleed), chronic kidney disease (loss of kidney function), depression (sadness or loss of interest in activities), and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS Assessment for Resident #34 dated 4/28/2023 indicated she had moderate impairment in thinking with a BIMS score of 10. She required extensive to total dependence in ADL's with one to two person assist. She was always incontinent of bowel and bladder. <BR/>Record review of a Care Plan dated 4/27/2023 for Resident #34 indicated she had ADL functional status with an approach of bathing/hygiene and required assistance.<BR/>During an observation on 6/11/2023 at 1:50 PM, revealed the Activity Director and TNA B were present in the room of Resident #34. Both washed their hands in the bathroom and applied gloves. Resident #34 was transferred from a wheelchair to her bed using a mechanical lift with both the Activity Director and TNA B assisting. The Activity Director left the room and TNA B provided incontinent care. TNA B pulled the resident's pants down to her legs and opened her brief and placed it between Resident #34's thighs. TNA B removed wipes from a plastic bag and wiped Resident #34's perineal area from front to back and placed the wipes in the trash. TNA B rolled Resident #34 to her left side and a large amount of feces was observed. TNA B removed wipes and wiped Resident #34's rectal area from front to back multiple times and placed the wipes in the trash. TNA B ran out of wipes and removed her gloves and placed them in the trash and did not wash or sanitize her hands. TNA B pulled the privacy curtain and left the room to get more wipes. TNA B entered the room after about a minute with more wipes in a plastic bag and placed the bag on the bed and went into the restroom to wash her hands. TNA B placed gloves on both hands and proceeded with incontinent to Resident #34. TNA B cleaned Resident #34's buttocks with wipes and placed them in the trash along with the dirty brief. TNA B placed a clean brief underneath Resident #34 buttocks with dirty gloves on and then removed the gloves and placed them in the trash. TNA B applied another pair of gloves to both hands without washing or sanitizing them and secured the brief on Resident #34 who was then repositioned in the bed and her pants were pulled back up. TNA B went to the door to get the Activity Director to come back in the room to assist with transferring Resident #34 from her bed to the wheelchair using a mechanical lift. Resident #34 was safely transferred by both staff to the wheelchair. TNA B removed her gloves and placed them in the trash and sanitized her hands.<BR/>During an interview on 6/11/2023 at 2:10 PM, TNA B said she had only been employed at the facility for 3 weeks as a temporary nurse aide. She said she had taken her skills examination but still needed to take the written test for certification as a nurse aide. She said she should have had more supplies in the room when she was providing care to Resident #34. She said she should have washed or sanitized her hands when she changed her gloves. She said she touched a clean brief with dirty gloves and should have had clean gloves on before applying the brief. She said she had only had a few days of training with staff and was trained by other CNAs in the facility. She said she had not received any training from the ADON or DON. She said the CNAs showed her how to perform incontinent care. She said a resident could be at risk of infection if hands were not washed or sanitized in between gloves changes and contamination of clean items with dirty gloves. <BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 4 weeks. She said the facility had not had a DON or Administrator since the end of May 2023. She said the DON was responsible for training staff on infection control. She said staff should wash or sanitize hands between glove changes and should not use dirty gloves to touch anything clean. She said there was a risk for infection control to the residents along with cross contamination. She said going forward she would look at the facility's policy and procedures to educate staff. She said she would conduct a skills check off with TNA B.<BR/>During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said she had been employed with the company for 2 years. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. She said the ADON started an in-service with all staff on handwashing and perineal care on 6/13/2023. She said any time staff changed gloves, they should wash or sanitize their hands before putting on new gloves. She said staff should take gloves off when going from dirty to clean. <BR/>During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said staff should take gloves off when going from dirty to clean. She said staff should wash or sanitize hands when gloves are changed. She said they started in-services with staff on pericare, handwashing, and infection control on 6/13/2023. She said they put a PIP in place for the issues on 6/13/2023. She said the TNAs started skills check offs yesterday, 6/13/2023. She said going forward direct staff would have competency check offs before providing care. She said residents could be at risk of infections by staff not washing or sanitizing their hands when changing gloves.<BR/>Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of 1/20/2023 indicated .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections, 5. Hand hygiene must be performed prior to donning and after doffing gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow established policy regarding smoking, smoking areas, and smoking safety for 2 (back porch smoking area and gazebo smoking area) of 2 smoking areas. <BR/>The facility failed to keep cigarette butts out of the plastic trash can containing paper and plastic in the smoking area (back porch smoking area), and there were no red metal trash cans (fire-proof) available for residents to extinguish their cigarettes. The residents were putting their cigarettes out on the bricks of the building at the exit door next to the laundry (Gazebo smoking area). The residents were then placing the cigarettes in a coffee can and plastic bleach container at the doorway.<BR/>This failure could place residents who smoke at risk of physical harm, burns, fires and lead to an unsafe smoking environment.<BR/>Findings included: <BR/>Record review of the Face Sheet dated 06/13/23, indicated Resident #24, admitted to the facility on [DATE], was [AGE] years old with diagnoses of End Stage Heart Disease (heart no longer pumps effectively), essential (primary) hypertension (high blood pressure) and Depress (mood disorder). <BR/>Record review of a Quarterly MDS assessment for Resident #24 dated 4/27/23 indicated he had a moderate impairment in thinking with a BIMS score of 12 (A BIMS of 8-12 indicates the resident is moderately impaired.)<BR/>Record review of the care plan for Resident #24 dated 5/04/23 indicated Problem: Resident is a daily cigarette smoker and keeps his personal cigarettes at bedside. Staff and Administration are aware that resident keeps personal cigarettes at bedside.<BR/>During an observation on 06/12/23 at 8:45 AM revealed the back porch of the facility was designated as a smoking area. There were no ash trays or red metal trash cans available for residents to extinguish their cigarettes. There was a large plastic trash can with cigarette butts and paper in the trash can. <BR/>During an interview on 06/12/23 at 10:00 AM with Resident #24 he said they only smoked out back on the porch when it rained, otherwise they use the smoking gazebo, located out back. He said when residents use the smoking Gazebo a staff member goes with them, and they exit at the door next to the laundry room. <BR/>During an observation on 06/12/23 at 10:15 AM of the smoking area at the Gazebo revealed there appeared to be multiple ash marks on the bricks, and concrete near the exit door. Cigarette butts were in a coffee can and a damaged 3-gallon plastic bleach container (labeled-Hazard Caustic) filled with bleach at the doorway leading out to the Gazebo.<BR/>During an interview on 6/12/23 at 3:45 PM, the Maintenance Director said the back porch area was used for smoking by staff, residents, and visitors when it rained. He said there was a fire extinguisher out on the back porch . He said he was not aware that cigarettes were being put out on the side of the building, butts were being put in a coffee can or that butts where being kept in a plastic bleach container at the exit door near the laundry room leading the Gazebo and courtyard. He said he was not aware that there where cigarette butts and flammable trash (paper and plastic items) in the plastic trash can on the back porch. He said he would immediately remove the plastic trash can and replace with a metal one. The maintenance man said he would remove the bleach container and the coffee can. He said there was a risk of fire and injury if the cigarettes were not extinguished properly.<BR/>During an interview on 6/13/23 at 8:30 AM, the Interim Administrator said she had just started at the facility 3 days ago. She said the back porch area was used for smoking by staff, residents, and visitors. She said she was not aware that cigarettes were being put out on the side of the building, that the coffee can was being used to contain butts or the bleach container was being used to extinguish butts at the doorway near the laundry room leading out to the Gazebo. She said there was a risk of fire and injury if the cigarettes were not extinguished properly.<BR/>During an observation on 6/14/2023 at 9:00 AM revealed the container of bleach and coffee can were no longer by the exit doorway.<BR/>Record review of a facility smoking policy-Residents dated August 2019<BR/>Policy Statement: This facility shall establish and maintain safe resident smoking practices .2. Smoking is only permitted in designated resident smoking areas, which are located outside of the facility. Smoking is not allowed inside the facility under any circumstances .6. Metal containers with a self-closing cover device, are available in smoking areas. 7. Ashtrays are only emptied into designated receptables

Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for all new and existing staff consistent with their expected roles, that included but are not limited to the mandatory training topics of communication, resident rights, abuse, infection control, dementia, and behavioral health for 9 of 13 employees (ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, CNA F) reviewed for training.<BR/>The facility failed to ensure required trainings were provided to: ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, and CNA F.<BR/>These failures could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>The findings were :<BR/>Record review of the personnel file for the ADON indicated she was hired at the facility on 4/24/2023. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health.<BR/>Record review of the personnel file for LVN G indicated she hired at the facility on 3/6/2023. She received training on abuse on hire. She had an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia.<BR/>Record review of the personnel file for the Activity Director indicated she was hired at the facility on 8/16/2019. She received training on abuse on hire. She had an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia.<BR/>Record review of the personnel file for the FSS indicated she was hired at the facility on 9/1/2020. She received training on abuse on hire. She received an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia.<BR/>Record review of the personnel file for the Rehab Director indicated she was hired at the facility on 7/31/2019. She received training on abuse on hire. She received an in-service training on resident rights and behavioral health on 4/23/2023. There was no record of trainings on communication, infection control, or dementia.<BR/>Record review of the personnel file for TNA C indicated she was hired at the facility on 5/8/2023. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health<BR/>Record review of the personnel file for CNA D indicated she was hired at the facility on 9/19/2022. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health.<BR/>Record review of the personnel file for CNA E indicated she was hired at the facility on 2/17/2023. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health.<BR/>Record review of the personnel file for CNA F indicated she was hired at the facility on 11/21/2022. She received abuse training on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health.<BR/>During an interview on 6/14/2023 at 10:15 AM, HR said she had been employed at the facility since August 2022. She said she was responsible for the training at the facility for staff. She said new staff were supposed to receive training on resident rights and abuse/neglect. She said staff were supposed to complete the required trainings through an online training program or during in-service training at the facility She said staff were supposed to complete the required training through an online training program. She said the program did not show any enrollment for the staff in the facility and did not know why. She said staff were given specific trainings during the in-services that were conducted at the facility. She said she did not know what trainings were required on hire or annually. She said going forward, she would make a packet and start training staff on resident rights, abuse, and neglect, dementia care/behavioral health, and infection control . She said residents could be at risk of abuse/neglect and staff not being taught how to take care of the residents for situations. <BR/>During an interview on 6/14/2023 at 10:40 AM, the Regional Nurse said the trainings should include infection control, resident rights, abuse/neglect and be given the first 3 days of orientation. She said going forward the staff would receive the required training and she would conduct an in-service with the ADON and HR to go over the required trainings to ensure they knew what trainings was required for all staff . She said they were unable to find any in-services on dementia care, behavioral health, and communication.<BR/>During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said the twelve mandatory trainings should be scheduled when staff were hired, and the abuse/neglect should be given before staff were allowed to provide direct patient care. She said all mandatory in-services would be provided to the staff going forward. She said the potential risk to residents would be staff providing care without updated education.<BR/>Record review of a facility policy titled Staff Development Program with a revised date of June 2021 indicated, .All personnel must participate in initial orientation and regularly scheduled in-service training classes. 2. The primary objective of our Center's Staff Development Program is to ensure that staff have the knowledge, skills, and critical thinking necessary to provide excellent resident care. 5. Training topics may include: a. Effective communication with residents and family (direct care staff), b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, or misappropriation of property; dementia management, e. the infection prevention and control program standards, policies, and procedures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 15 residents reviewed for MDS assessment accuracy. (Resident #17)<BR/>The facility incorrectly coded Resident #17 as having not received oxygen in previous 14 days while a resident on her MDS.<BR/>This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. <BR/>Findings Include:<BR/>Record review of the facility face sheet dated 6/13/2023 for Resident #17 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Unspecified dementia (A group of symptoms that affects memory, thinking and interferes with daily life), anxiety, Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), Shortness of breath, and Acute systolic (congestive) heart failure (when your left ventricle can't pump blood efficiently). <BR/>Record review of a Quarterly MDS dated [DATE] for Resident #17 indicated that she had a BIMS score of 11, indicating that she had moderately impaired cognition. Section O, question O0100, 2c indicated that resident had not received oxygen in the previous 14 days.<BR/>Record review of the medication administration record for Resident #17 for the month of April 2023 indicated that she had received oxygen continuously for the look-back period (previous 14 days) of the MDS.<BR/>Record review of Resident #17's care plan dated 6/13/23 indicated problem: Decreased cardiac output related to changes in myocardial contractility, CHF (Congestive Heart Failure), with intervention: Administer oxygen (O2) as prescribed.<BR/>Record review of Resident #17's physician orders dated 6/13/23 indicated that she had the following order: Oxygen @ 3 liters per minute by nasal cannula continuously for hypoxia every shift, with a start date of 1/4/23.<BR/>During an observation and interview on 06/11/23 at 10:15 am Resident #17 was observed with oxygen on as ordered by nasal cannula at a rate of 3 liters per minute. Resident #17 said that she always wore her oxygen. <BR/>During an interview with Regional Nurse on 6/12/23 at 3:40 pm, she said that the ADON was responsible for doing the MDS's and she was currently out sick today. <BR/>During an interview with the ADON on 6/13/23 at 8:30 am, she said that she had been here for 3 weeks and had been so overwhelmed with no administrator, no DON, and covering staffing that corporate nurses were helping her to complete the MDS's. ADON said that she felt like she still needed training on MDS's. She said that she had been trying to do everything that she could to ensure that the residents were taken care of and keep the facility afloat by herself. She was unable to say why oxygen was not captured on Resident #17's MDS, but that it most likely just fell through the cracks. She said that going forward, she hoped to receive proper training herself, and have a full time DON and administrator to help lighten her load. <BR/>During an interview with the Regional Nurse on 6/14/23 at 11:10 am, she said that she would ensure the ADON was properly trained on MDS completion and accuracy of assessments by the corporate nurses. She also said that going forward she would expect the facility staff to be properly trained, notify her with questions/concerns, and follow proper processes and policies. <BR/>Record review of facility policy titled Certifying Accuracy of the Resident Assessment dated 2001 with revision date of November 2019 indicated .The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #7 and #34) reviewed for care plans.<BR/>The facility failed to ensure Resident #7's care plan accurately reflected her hospice status.<BR/>The facility failed to ensure Resident #34's care plan accurately reflected her ADL status. <BR/>This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs.<BR/>Findings include: <BR/>Record review of a face sheet for Resident #7 dated 6/13/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction, dysphagia, and hypertension. <BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. Section O of same MDS assessment indicated that she had received hospice care within the last 14 days while a resident of the facility. <BR/>Record review of a care plan for Resident #7 with last care conference date of 9/9/22 indicated that hospice status was not addressed on care plan. <BR/>Record review of physician orders for Resident #7 dated 6/13/23 indicated that she had a physician order dated 2/6/23 stating the following: Admit to Heart-to-Heart Hospice; Primary Hospice Diagnosis: CVA <BR/>Record review of a face sheet for Resident #34 undated indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage, chronic kidney disease, depression, and hypertension.<BR/>Record review of a Quarterly MDS Assessment for Resident #34 dated 4/28/2023 indicated she had a BIMS score of 10, indicating that she had moderately impaired cognition. She required extensive to total dependence in most ADLs with one to two-person assist. She was always incontinent of bowel and bladder and required extensive assist of one person with toileting and personal hygiene.<BR/>Record review of a Care Plan dated 4/27/2023 for Resident #34 indicated she had ADL functional status with an approach of bathing/hygiene amount of assist and toileting amount of assist dated 4/7/2023 that was incomplete.<BR/>During an interview on 6/12/23 at 3:40 pm, the Regional Nurse said that the ADON was responsible for care plan updates and revisions, and she was currently out sick. She said that ADON was currently overwhelmed without a DON, administrator and covering staffing. <BR/>During an interview on 6/13/23 at 8:10 am, the ADON said that she had been employed at the facility for 3 weeks. She said she has not had a DON or Administrator since the end of May 2023. She said that a resident's hospice status and ADL status should be addressed on their care plan. She said that residents could be at risk of staff not getting a complete picture of resident and resident could possibly not get appropriate care. She said that going forward, she would hope to have a full time DON, administrator, and leadership to help with getting care plans initiated and training of staff.<BR/>Record review of facility policy titled Care Plan, Comprehensive Person-Centered dated 2001, with revision date of December 2020 indicated: .The comprehensive, person-centered care plan will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily for 1 of 5 residents (Resident #1) reviewed for abuse. <BR/>The facility did not report to the state agency within 2 hours when an allegation of abuse occurred on 2/14/2023 that involved Resident #1. The state agency was notified of the allegation of abuse on 2/16/2023.<BR/>The facility did not report to the state agency within 2 hours when an allegation of abuse occurred on 4/22/2023 that involved Resident #1. The state agency was notified of the allegation of abuse on 4/23/2023. <BR/>This failure could place vulnerable residents at risk of harm due to delays in reporting an allegation of abuse.<BR/>Findings included:<BR/>Record review of a face sheet for Resident #1 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), pulmonary hypertension (high blood pressure that affects the blood vessels in the lungs and the right side of the heart), manic episode with psychotic symptoms (delusions, disorder thinking and a lack of awareness of reality), and major depressive disorder (persistent feeling of sadness and loss of interest).<BR/>Record review of an admission MDS assessment dated [DATE] for Resident #1 indicated she did not have any impairment in thinking with a BIMS score of 15. She required extensive assistance with one-person physical assist with personal hygiene. She was always incontinent of bowel. Section H of the MDS indicated her urinary incontinence was not rated because she had an indwelling foley catheter (a tube placed in the bladder that drains urine into a collection bag). <BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated she did not have any impairment in thinking with a BIMS score of 13. She required extensive assistance with one-person physical assist with personal hygiene. She was always incontinent of bowel. Section H of the MDS indicated her urinary incontinence was not rated because she had an indwelling foley catheter (a tube placed in the bladder that drains urine into a collection bag).<BR/>Record review of a progress note dated 2/15/2023 at 10:40 PM by LVN E for Resident #1 indicated, .An allegation of verbal abuse toward resdient by staff member are currently under investigation at this time. Alleged incident has been reported to Administration, Steps are being taken to prevent further incidence including inservice for staff, and alleged staff member had been suspended until further investigation .<BR/>Record review of a Provider Investigation Report dated 2/16/2023 indicated an incident occurred at the facility on 2/14/2023 at 2:00 AM with TNA A and Resident #1. CNA B reported she observed TNA A being verbally and physically abusive to Resident #1 when she provided care. That incident was investigated by the state agency and was unsubstantiated (not proven by evidence).<BR/>Record review of a Provider Investigation Report dated 4/23/2023 indicated an incident occurred at the facility on 4/22/2023 at 9:00 PM with TNA A and Resident #1. LVN E reported she observed TNA A being rough with Resident #1 while providing care. That incident was investigated by the state agency and was unsubstantiated. <BR/>During an interview on 5/17/2023 at 8:11 AM, CNA B said she worked at the facility prn (as needed) since January 2022. She said she observed the incident that occurred on 2/14/2023 with TNA A and Resident #1. CNA B said Resident #1 had a bowel accident on the floor in her room. CNA B said TNA A provided care to Resident #1 and TNA A said she was going to show her how she provided care when she worked at a psychiatric facility in the past. CNA B said TNA A started scrubbing Resident #1's body roughly. CNA B said Resident #1 was saying TNA A was hurting her and Resident #1 hit TNA A. CNA B said TNA A said to Resident #1 that she would choke her and called her a bitch in a low tone but it was louder than a whisper. CNA B said TNA A kept saying it was disgusting out loud. CNA B said she tried to help TNA A but she refused and was told to stand by. CNA B said she was going to report the incident at the time it occured but started feeling sick and ended up with an infection. She said she gave her statement to the Administrator a few days later after the incident. She said she had training on abuse/neglect at the facility. She said abuse should be reported immediately to someone at the facility such as the Administrator.<BR/>During an observation and interview on 5/17/2023 at 8:43 AM, Resident #1 was lying in bed awake, confused and said she had been at the facility for a few months. She said she remembered when TNA A worked at the facility and said she was never mean or verbally abusive towards her. She said TNA A was good to her. <BR/>During an interview on 5/17/2023 at 10:52 AM, the Corporate Nurse said she had been employed with the facility for 2 years. She said the incident with Resident #1 and TNA A on 2/14/2023 was reported to her on 2/16/2023 by the previous Administrator C when the allegation was received from CNA B. She said Administrator C did not complete a thorough investigation following the incident. She said Administrator C only took a statement from CNA B and terminated TNA A without conducting a thorough investigation. She said she immediately started an investigation and submitted to the state agency at that time. She said the facility conducted safe surveys with residents and also had character witness statements from staff who all said TNA A was a good aide and residents denied her being mean or verbally abusive towards them. She said the decision was made after the investigation to hire TNA A back on 3/13/2023. She said CNA B should have reported the incident immediately to the Administrator. She said the incident that occurred on 4/22/2023 with Resident #1 and TNA A was reported to her on 4/23/2023 by the DON. She said the second incident occurred on 4/22/2023 when LVN E reached out to the DON and reported an allegation of abuse on 4/23/2023. She said the state agency was notified on 4/23/2023 of that incident. SHe said TNA A was immediately terminated following the second incident. She said any abuse/neglect allegation should be reported to the abuse coordinator which was the Administrator immediately. She said any allegations of abuse should be reported to the state agency within 2 hours of the allegation taking place. She said the staff received education in-services on abuse/neglect and to whom to report. She said going forward, any allegation of abuse would be reported timely. She said a delay in reporting any allegation of abuse could put residents at risk of further harm.<BR/>Attempted several phone calls with LVN E on 5/17/2023 and 5/18/2023 with no returned phone call. <BR/>Attempted several phone calls with TNA A on 5/17/2023 and 5/18/2023 with no returned phone call.<BR/>During an interview on 5/18/2023 at 9:20 AM, Administrator C said she was only employed at the facility for about 8 weeks from 1/6/2023 until 2/28/2023. She said the incident that occurred on 2/14/2023 was reported to her on 2/16/2202 by CNA B and that was when she reported to the state agency the allegation of abuse. She said CNA B told her that she was sick after the incident and did not report it immediately as she should have reported to the abuse coordinator who was the Administrator. She said residents could be at risk of jeopardy and staff should not try to make the decision if they should report or not as that should be left up to the Administrator or abuse coordinator. She said staff were in-serviced on abuse/neglect following the reporting of the incident and when to report any allegations of abuse along with who to report to and their contact phone numbers. She said they posted signs in the facility to indicate who to contact for abuse/neglect allegations. She said staff should report any suspicion of abuse to her immediately. She said the incident should have been reported within 2 hours to the state agency. She said on a regular basis the facility conducted education on abuse/neglect as that was key to having staff understanding the importance of abuse and who the abuse coordinator was. <BR/>During an interview on 5/18/2023 at 10:58 AM, the DON said she started at the facility on 4/3/2023. She said she was not aware of the incident that occurred in February that was reported to the state agency with Resident #1 and TNA A. She said LVN E called her on the night of 4/22/2023 at the end of her shift. She said LVN E told her she felt TNA A needed some customer service training and she said she told her to write a statement and slide it under her door. She said on the morning of 4/23/2023 when she read the statement, she immediately notified the Administrator. She said they started investigating and Administrator D notified the state agency at that time. She said staff received education on abuse/neglect, staff burnout, and residents with behaviors. She said abuse allegations should be reported immediately to the abuse coordinator who was the Administrator. She said abuse allegations should be reported to the state agency within 2 hours. She said going forward, any abuse allegation would be reported immediately to the abuse coordinator and would make sure residents were safe. She said residents could be potentially harmed by delaying reporting timely.<BR/>During an interview on 5/18/2023 at 11:15 AM, Administrator D said she started at the facility on 3/16/2023. She said she was not aware of the incident that occurred with Resident #1 and TNA A in February 2023 until a little while after she was hired. She said she was involved in reporting to the state agency following an incident that occurred on 4/22/2023 with Resident #1 and TNA A. She said on the morning of 4/23/2023. she was notified by the DON of a possible reportable incident of abuse. She said LVN E reported to the DON an incident with TNA A and Resident #1 that occurred on the night of 4/22/2023. She said she reported the incident to the state agency at the time of notification on 4/23/2023. She said she immediately started an investigation and in-serviced staff on abuse/neglect, staff burn out, resident rights, and privacy when providing care. She said going forward they would continue to educate on the importance of reporting sooner rather than later. She said any delay in reporting allegations of abuse could be detrimental to the residents. She said they are advocates for the residents and must keep them safe. <BR/>Record review of a personnel file for TNA A indicated she hired at the facility on 1/9/2023. Review of previous employment hisory indicated no record of any work at a psychiatrist facility.<BR/>Record review of a facility policy titled Abuse Prevention Program with a revised date of 1/9/2023 indicated, .1. The Administrator is responsible for the overall and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reports to local, state, and federal agencies. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than 2 hours if the alleged violation involves abuse .

Based on interview and record review, the facility failed to ensure that the designated individual responsible for the infection control program was certified in infection prevention . <BR/>This failure has the potential to affect all 36 residents of the facility due to potential outbreaks infections. (There was no full time Infection Preventionist at the facility.)<BR/>Findings include:<BR/>During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks and was not a Certified Infection Preventionist. She said the facility did not currently have a DON/IP and the DON/IP's last day was 5/26/2023. She said if an infection control nurse was not certified they could have an outbreak of infections at the facility, and that could have an adverse effect on the 36 residents.<BR/>During an interview on 6/13/2023 at 2:15 PM, the Regional Nurse said she had been employed with the company for 2 years and was not a Certified Infection Preventionist. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON/IP from 2/1/2023 to 4/1/2023 and then from 5/26/2023 to the present. <BR/>During an interview on 06/13/32 at 2:15 PM the Regional Nurse Consultant acknowledged the facility was to have a certified individual who was responsible for the infection control program at all times. The Consultant Nurse Consultant was able to confirm there was no other nurse that was certified in infection control employed at the facility as required by regulation.<BR/>During an interview on 6/14/2023 at 11:00 AM, the interim Administrator said she had been at the facility since 6/13/23. She said she had obtained certification in Infection Prevention as of 6/14/2023 through TRAIN. <BR/>A policy was requested on 6/14/2023 at 12:30 PM concerning the Infection Preventionist Role and employment in the facility. None was provided at time of exit.<BR/>Record review of the facility's infection control policy titled, Antimicrobial Stewardship, dated 2019, reflected in part licensed nursing staff will receive training related to antibiotic stewardship, the facilities criteria for initiating antibiotics .this training will occur as part of the nurse's orientation.<BR/>Record review of the facility's infection control plan titled, Infection Control Plan: Overview, dated 2019, reflected in part The facility will establish and maintain an Infection Control Program designed to .help prevent the development and transmission of disease and infection.<BR/>Record review of a facility policy titled Employee Training on Infection Control with a revised date of January 2022 indicated .The facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs . 2. The Infection Preventionist and Administrator will identify those disciplines or individuals who need task or job specific infection control training, 3. Infection control training topics will include at least a. Standard precautions, including hand hygiene .

Based on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for essential equipment.<BR/>The facility did not ensure the gas stove was in working order. One of six gas stove burners (back right) had excessive carbon buildup and the burner did not fully light on 7/16/2024.<BR/>This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. <BR/>Findings:<BR/>During an observation on 7/16/24 at 10:53 am, 1 of 6 burners on the stove located in the kitchen did not light completely. The burner had carbon build up to the right side of the burner. <BR/>During an interview on 7/16/24 at 10:54 am [NAME] H said she was the cook for the day, and it was her first day back from a month break. She said she was not sure who was responsible for burners on the stove, but the cooks cleaned the covers and grill daily. She said that the burner not lighting correctly could cause an injury, <BR/>During an interview on 7/16/24 at 11:15 am the maintenance director said he was not sure who was responsible for the stove burners and could not recall anyone coming to clean them. He said he was not sure what could happen if the burners did not light correctly.<BR/>During an interview on 7/16/24 at 12:10 pm the administrator said he was not sure who was to clean the burners on the stove. He said the cooks clean daily after meals but the actual removal of carbon buildup he was not sure who was responsible but would get someone to the facility to clean them. He was not sure what could happen if the burners did not work correctly and would advise staff to not use that burner until it was cleaned. <BR/>Record review of a facility a facility policy titled Range and Grill dated 2018 indicated, .the facility will maintain the range and grill in a clean manner to minimize the risk of food hazards .

Based on interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 1 resident group (resident council) reviewed for quality of life. <BR/>The facility failed to ensure that staff were not talking on their cell phones while providing care to residents.<BR/>The facility failed to ensure that staff did not speak rudely to residents.<BR/>This failure could place residents at risk of decreased feelings of self-worth.<BR/>Findings include:<BR/>During an anonymous group interview, 6 of 12 residents in attendance of resident council meeting voiced the following concerns:<BR/>1. <BR/>Staff members had been providing care while using their personal cell phones. One resident said that a staff member had given her a shower recently and was on her cell phone using ear buds the entire time she showered her, and it made her feel very uncomfortable, almost like the person on the other end of the phone could see me. She said she had already reported it to administration but it was still happening. Other residents said that staff would commonly be talking on their phones while providing personal care to them. <BR/>2. <BR/>Staff members often speaking rudely to them and being disrespectful to them. <BR/>Residents would not give staff member's names.<BR/>During an interview on 07/16/24 at 03:58 PM Administrator said he was aware of some residents complaining of staff being rude and using cell phones while providing care. He said the Resident Council president had told him. He said staff should not be talking on their phones while providing care. He said it could make the residents feel bad about themselves. He said the residents had not given him specific employee names, but he would be holding in-services because that was unacceptable to him. He said that CNAs being rude to the residents was inhospitable. He said this was their home and they should be treated with respect.<BR/>During an interview on 07/17/24 at 09:55 AM DON said that she would be providing education to staff regarding respect and not talking on their phones while providing care. She said it could make the residents feel bad about themselves.<BR/>Record review of a facility policy titled Cell Phones dated December 2019 read .Use of these devices will be restricted to the employee break room or outside of the facility .<BR/>Record review of a facility policy titled Dignity dated 2001 and revised in February 2021 read .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .