Monument Rehabilitation and Nursing Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. On 04/08/2025, Resident #1 eloped from the facility through a side door and was later found by a neighbor in a grassy area approximately 219 feet away from the facility. This failure placed the resident at risk for serious harm.The non-compliance was identified as past non-compliance. The immediate jeopardy began on 04/08/2025 and ended on 04/14/2025. The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began.This failure had the potential to affect other residents and could result in residents not receiving appropriate supervision, placing them at risk for serious injury, harm, or death. Upon entry to the facility, on 07/01/2025 an observation was conducted on all exit doors. The observations revealed that all doors were locked and equipped with functioning alarms. Additionally, it was observed that the side door in the activity room provided access to the area where Resident #1 had eloped. Resident #1 walked/used her wheelchair to ambulate to a grassy area across the way from the facility. Resident #1 is believed to have crossed a side driveway to the facility and then a street entering a neighborhood.Record Review of Resident #1's electronic facility face sheet dated 07/01/2025, revealed she was a [AGE] year-old female admitted to the facility originally on 08/08/2022 with the most recent admission on [DATE]. Her diagnoses included Cognitive communication Deficit(thinking and speaking difficulty), Repeated Falls, Unspecified Dementia with agitation(memory decline with acting out), Hypertension(high blood pressure), and Hypothyroidism unspecified(underactive thyroid).Record Review of Resident #1's MDS Assessment, dated 04/14/2025, reflected Resident #1 was unable to complete brief interview for mental status. Resident #1 had poor short-term memory recall. Her decision-making ability was severely impaired. Record review of Resident #1's care plan with a closed date of 04/25/2025 due to discharge indicated: Resident had an actual elopement: Fall occurred on 4/8/2025 during elopement attempt interventions included: Monitor 1:1 until resident is stable, Psychiatric NP will complete a medication review. Make recommendations as needed, and UA and Labs collected .Record review of Resident #1's wandering risk assessment dated [DATE] indicated a wander score of 05 which was a low wandering risk category.Record review of Resident #1's wandering risk assessment dated [DATE] indicated not a wandering risk category.Record review of Resident #1's wandering risk assessment dated [DATE] indicated Resident was a wandering risk. The assessment indicated an intervention of : Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of hospital discharge records dated 04/9/2025 indicated Resident #1 fell out of her wheelchair. There was no injury to head or neck. There were no fractures noted anywhere. They put an Ace wrap on her right wrist for comfort and support.Interview with ex-maintenance director, 07/01/2025 revealed he was terminated when the door to the exterior in the activities room was left unlocked and Resident #1 was able to elope from the facility. He stated the door was unlocked and the alarm did not sound from what he heard from staff. He stated he worked earlier that day and was not at the facility when resident eloped. He stated he locked the door in the Activity room that leads to the courtyard and left the activity room from the door that led to the hallway. He stated another staff member must have left the door unlocked. He stated the resident was found at night in a grassy area next to the facility by a neighbor who then called EMS and the administrator of the facility. Ex-maintenance director stated the facility blamed him for this incident, but he was not working nor in charge of the resident.Interview with AD, 07/01/2025 revealed she was not working when Resident #1 eloped from the facility. AD just returned to work 2 days ago. AD stated the activity room door stayed locked when there was no activity. She stated the door leading to the courtyard, locked automatically from the outside. AD could not recall when the alar was installed on the activity room door.Interview with MA, 07/01/2025, revealed she was working the night Resident #1 eloped from the facility. She reported she administered Resident #1's nighttime medications at 8:30 PM. She stated she later heard Resident #1 had been found across the facility driveway in a grassy area outside the nearby neighborhood. She stated Resident #1 typically only walked when agitated so staff were surprised by the location where Resident #1 was found with her wheelchair beside her.Interview with LVN , 07/01/2025 revealed she last saw around 9:00 PM on hall 200 (which is not Resident #1's hallway). She stated Resident #1 was sundowning and disturbing two residents on the hallway. She redirected Resident #1 back to Resident #1's hallway at that time. She said Resident #1 was not exit seeking at that time. She stated the next thing she heard was that Resident #1 was outside thefacility and had exited through the activity room exterior door. She stated she did not hear any alarms sound to indicate a resident was outside. She stated she immediately grabbed resident roster to ensure everyone else was in the building. Interview with CNA A, 07/01/2025 revealed she worked with Resident #1 the night she eloped. CNA A stated she was working the night Resident #1 eloped from the facility. She last observed the resident around 9:00 p.m. in the hallway. CNA A reported that the resident was attempting to enter and exit multiple rooms, and she redirected the resident several times. She described the night as very busy, noting that she was assisting with bedtime routines for multiple residents and that there was an actively dying resident on the same hallway.According to CNA A, the resident did not allow staff to place her in bed that evening. She explained that it typically takes two staff members to assist the resident into bed when she is active. She stated that another CNA performed one round with her, then left. CNA A noted that the resident tends to be active at night and does not usually sleep through the night. She recalled that the resident often sat near the front door during nighttime hours. CNA A stated she provided her statement to the charge nurse on duty.Attempted interview with Resident #1's hallway CNA C, 07/01/2025, called twice and received no response.Interview with Administrator, 07/01/2025 revealed he was contacted by a neighbor of the facility on 4/8/25 that Resident #1 was outside the facility near the entrance to the neighbor's neighborhood. He spoke to LVN D, the charge nurse, over the phone and had her check the doors and alarms. He stated the only door unlocked and alarm not working was the activity room exterior door. He did not know why the alarm was malfunctioning on the door. He stated the maintenance director was held responsible for the door being unlocked and the alarm malfunctioning and was terminated as a result. He stated the resident was placed on 1:1 supervision immediately and then transferred to a secure facility. He stated he made rounds with all residents to ensure they felt safe. He stated new elopement assessments were completed on 4/9/25 on all residents with no other residents at high risk. He stated they conducted in-services with all staff regarding elopements, securing doors/alarms, supervision, and abuse and neglect. Elopement drills were completed on all shifts on 4/9/25. He stated an ad hoc QAPI meeting was held on 4/9/25 with the medical director. He stated they also added a coded lock onto the activity room interior door so that a wandering resident would not be able to enter the room and use exit. He stated all doors, locks and alarms were evaluated on 4/9/25 and none were malfunctioning. Record Review of facility incident report dated 04/08/2025, revealed that Resident #1 eloped from the facility on that date. The facility ADM was notified by a neighbor of the facility that Resident #1 was observed outside in a grassy area left of the facility. Upon investigation, it was determined that the activity room door had been left unlocked, and the gate leading to the driveway area was open, which may have led to the resident's exit from the premises. Emergency Medical Services (EMS) assessed Resident #1 at the scene, after which the resident was transported to the hospital for further evaluation. The resident's physician and responsible party (RP) were notified on April 8, 2025. Following the incident and upon the resident's return to the facility, Resident #1 was placed on 1:1 supervision to ensure safety and prevent further incidents.Record Review of EMS report dated, 04/09/2025 reflected Resident #1 was found lying on the ground at 10:25 PM, 3 bystanders were with Resident #1 when EMS arrived. The report further stated, the bystanders stated they found Resident #1 lying in the grass, they noted Resident #1's wheelchair was found sitting upright a few feet away from resident and the resident possibly wandered outside the nursing home and then fell from her wheelchair into the grass. The resident was transferred to hospital.Attempted interview with Charge Nurse 07/02/2025, received no response.Interview with CNA B, 07/02/2025 revealed she was working the night Resident #1 eloped from the facility. She stated the administrator contacted the facility and spoke with the charge nurse. Upon noticing a concerning expression on the charge nurse's face during the call, CNA B stated she immediately exited through the front door. She observed EMS personnel near the facility and ran over to assist them in helping Resident #1 stand up. CNA B stated the resident was found on the ground in a grassy area, with her wheelchair positioned against a fence. She reported that she was unsure how the resident exited the facility. Although staff believe Resident #1 may have left through the activity room door, CNA B noted that the door is typically locked. She also stated that no door alarms sounded that night. CNA B recalled that Resident #1 was able to tell EMS her name and age. Interview with Resident #1 RP revealed Resident #1 was supervised with 1:1 staff prior to Resident #1 being transferred to secure facility. RP stated he had no concerns regarding Resident #1 care while at the facility. RP stated Resident #1 is doing well at the new facility.Record Review of Elopement Assessments dated 04/09/2025, revealed all current residents were assessed for elopement /wandering risk. No new residents were identified to be at high risk.On 07/02/2025 at 3:45 PM, the acting Administrator was informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 04/08/2025 and ended on 04/14/2025. The facility had corrected the noncompliance before the investigation began. The interventions and plan for correction included:Review of Resident #1 discharge paperwork revealed she was discharged on 04/14/25 to a secure facility.Review of Resident #1 EMR revealed Resident #1 was on 1:1 supervision with a caregiver until she was transferred to the new facility.Review of facility in-services dated 04/09/25 revealed all staff were educated regarding elopements, securing doors and activating alarms, abuse and neglect and supervision of residents. Staff were instructed to notify DON, Admin regarding any attempts of elopement or resident who may have increased confusion and attempt to exit. Staff were to ensure all exit gates are closed.Review of Elopement drills dated 04/09/25-04/11/25 revealed a drill was completed on all shifts. Review of Ad Hoc QAPI meeting held on 4/9/25 revealed an QAPI meeting was held to discuss the elopement of Resident #1.Review of Elopement Assessments dated 4/9/25 revealed current residents were assessed for elopement/wandering risk. No newresidents were identified to be at high risk.Observations at facility on 7/1/25 did not reveal observations of exit seeking or wandering residents.Interviews with facility staff on 7/1/25-7/2/25 revealed they were educated on elopements, securing doors and alarms, supervision ofresidents, abuse and neglect, and reinforcement of monitoring procedures.Interview with the facility's new maintenance supervisor revealed he is checking the locks and alarms each day to ensure they are working properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for 1 of 3 discharged residents (Resident #29) reviewed for closed records. The facility failed to complete and transmit a discharge MDS assessment for Resident #29, who discharged on [DATE], within 14 days of the discharge date . This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings included: Record review of Resident # 29's admission face sheet undated reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, hypertension (high blood pressure), hyperlipidemia (fat particles in the blood), major depressive disorder, adjustment disorder, dehydration, insomnia, shortness of breath, hypokalemia, anxiety disorder, edema, muscle wasting and atrophy, dysphagia, acute upper respiratory infection, edema, dyspnea, and cognitive communication deficit. Record review of Resident # 29's nursing progress note dated [DATE] reflected Resident # 29 expired on [DATE] at 7:52 AM. Record review of Resident # 29's MDS list in PCC on [DATE] reflected Resident # 29's last transmitted MDS was her Annual MDS dated [DATE]. Review of the warnings associated with Resident # 29's MDS transmission reflected Death-ARD complete by [DATE]-93 days overdue. Interview on [DATE] at 11:39 AM with LVN A, when asked who was responsible for completing the resident MDS assessment LVN A stated they were responsible for completing the resident MDS assessment. LVN A stated each resident should have a discharge MDS assessment completed upon discharge. LVN A stated it was important for residents to have discharge MDS assessments conducted because it was a record keeping tool for the state, and it was a cut off or end Date for CMS purposes. LVN A stated there was not a reason that the discharge MDS assessment was not completed for Resident # 29 other than it was just overlooked and missed, and it was a mistake. LVN A stated it was her expectation that MDS assessments were to be completed on time and accurately. Interview on [DATE] at 11:45 AM with the DON revealed LVN A was responsible for completing resident MDS assessments. The DON stated all residents discharged should have discharge MDS completed. The DON stated it was important to complete a discharge MDS, so the plan of care is documented of who the providers are, what services are provided to the resident, and any upcoming appointments. The DON stated for a death MDS it was important those were completed to be able to know where the resident discharged to and what they expired from and to let CMS know to stop any payments to the facility. The DON stated it was their expectation that MDS assessments were completed timely and accurately. Interview on [DATE] at 11:50 AM with the ADM revealed that LVN A was responsible for completing resident MDS assessments. The ADM stated all residents discharged should have a discharge MDS completed. The ADM stated it was important to have a discharge MDS completed so documentation can be shown that a safe discharge was provided to the family. The ADM stated in the event of death he was unsure if a MDS assessment was needed. The ADM stated he was also unsure if not having a death MDS completed could affect CMS funding. The ADM stated it was his expectation that MDS assessments are completed timely and accurately to protect resident care and overall well-being.Attempted record review of facility MDS policy reflected policy requested from ADM on [DATE] at 5:15 PM. The ADM replied on [DATE] at 10:17 AM that the facility follows the RAI manual.Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated [DATE], revealed OBRA Discharge assessments -Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 8 residents reviewed for infection control (Resident #30).<BR/>The facility failed to ensure the needle used on Resident #30, remained sterile during the procedure for intramuscular injection of the antibiotic Ceftriaxone.<BR/>This failure could place residents at risk of infection, decline in health and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #30's face sheet revealed a [AGE] year-old male admitted to the facility 02/21/2021 and initially admitted on [DATE]. His diagnoses included atrial fibrillation (abnormal heart rhythm), Parkinson's disease, muscle wasting, pain in joints, age related debility, behavioral and emotional disorder, depression, non-cancerous tumor of the salivary gland, HTN and contractures of the hips and of the knees.<BR/>Record review of Resident #30's quarterly MDS dated [DATE] revealed he had short term and long term memory problem. He had moderately impaired cognitive skills for daily decision making. He required extensive assistance with ADLs and was always incontinent of bowel and bladder. Further review revealed he was receiving antibiotics and IV medications. <BR/>Record review of Resident #30's undated care plan revealed the resident had an infection of swollen lymph nodes to the right cheek/jaw area, date initiated was 06/05/2023. The goal was for resident to be free of complications related to infection. Interventions included nurses to administer antibiotics as per MD orders.<BR/>Record review of Resident #30's active physician orders revealed an order to start Ceftriaxone sodium solution reconstituted 1gm, inject 1 gm IM every 24 hours for swollen lymph nodes with fever on start date 06/07/2023 and end date of 06/10/2023.<BR/>Observation and interview on 06/07/2023 at 9:10AM, RN A prepared Ceftriaxone 1gm vial. RN A reconstituted the Ceftriaxone 1gm by adding 2.1 ml of Lidocaine 1%. RN A put on clean gloves, cleansed the stopper on the Ceftriaxone vial with an alcohol prep pad, removed the cap of the needle, set the cap down on the med cart, withdrew the liquid using a 3ml syringe and 22 g needle. RN A walked to Resident #30's bedside, explained the procedure to Resident #30, opened a small alcohol prep pad, placed the pad on top of the outer package of the prep pad and placed the syringe with exposed needle on top of the alcohol pad. RN A removed gloves and donned clean gloves then disinfected Resident #30's dorsogluteal site (left hip area) with an alcohol prep pad. RN A picked up the syringe with needle and wiped the needle using the alcohol prep pad. RN A injected the content of the syringe and needle into Resident #30's dorsogluteal site, swabbed the site with a new alcohol pad and disposed of the syringe with the needle in a sharps container. RN A stated he did not recap the needle d/t the potential of a needle stick. RN A stated he wiped the needle with alcohol to clean and disinfect it. RN A was asked if wiping the needle with alcohol was facility policy. RN A stated it was the way he learned how to do injections.<BR/>Interview on 06/07/2023 at 4:30PM, the DON stated after drawing up the injectable medication she expected the nurse to cover the needle with the cap in a way to prevent a needle stick. The DON stated the cap did not necessarily need to be tightly secured. The DON stated it was not policy to wipe down the needle. The DON stated the risk would be an infection control issue and potential needle stick. The DON stated she would monitor Resident #30's injection site for infection keeping in mind the Ceftriaxone may cause redness by itself.<BR/>Interview on 06/08/2023 at 8:30AM RN A stated he had been working at the facility about 1.5 years now and had an inservice regarding administration of medication about one week ago.<BR/>Interview on 06/08/2023 at 8:35AM, the DON stated the DON or the corporate nurse was responsible to conduct nursing staff inservices for medication administration.<BR/>Interview on 06/08/2023 at 10:10AM, the DON stated the records for Nursing Administration of Medications inservices were completed through the online learning courses provided by the facility. The DON stated RN A had signed an inservice on 2/6/2023.<BR/>Record review of the online learning transcript included RN A's completion of the one-hour course for Medication Administration in Acute Care on 2/06/2023, with a final score of 100.<BR/>Record review of the facility policy and procedure manual, section: Medication Administration, Injectable Administration revised on 10/01/2009 read in part: Policy: to administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate and effective manner. Equipment Required .2. Sterile syringe capable of holding the medication volume. 3. Sterile safety needle .Procedure .Sites for Administration: .Intramuscular .withdraw the medication; create air lock. Do not recap needle, remove air bubbles .Sanitize hands with approved sanitizer .put on gloves .prepare skin for injection, remove air from syringe and insert the needle . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 3 of 5 residents reviewed for immunizations. (Residents #14, #28 and #5) A) The facility failed to document in Resident #14's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. B) The facility failed to document in Resident #28's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects (VIS-Vaccine information sheet), for the influenza immunization and the pneumococcal immunization. C) The facility failed to document in Resident #5's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, for the influenza immunization and the pneumococcal immunization. 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: A) Review of Resident #14's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), cognitive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.), and diabetes mullites type II (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #14's quarterly MDS dated [DATE] reflected Resident #14 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #14 was further assessed to receive the influenza vaccine on 09/29/2024. Resident #14 was assessed to not have the pneumococcal vaccination with stated reason offered and declined. Review of Resident #14's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #14's EMR on 09/11/2025 reflected under the immunizations tab in PCC that Resident #14 received the influenza vaccination on 09/29/2024, no other immunizations were recorded. Review of Resident #14's admission paperwork dated 12/18/2023 reflected no informed consent or vaccination information sheet (VIS) for the pneumonia vaccination. B) Review of Resident #28's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), peripheral vascular disease (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and aphasia(A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.). Review of Resident #28's quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #28 was assessed to have the influenza vaccine dated 09/29/2024. Resident #28 was assessed to not be up to date on the pneumococcal. Review of Resident #28's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #28's resident admission agreement dated 09/07/2023 reflected Resident #28 refused the influenza and pneumococcal. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP regarding influenza and pneumococcal vaccinations. C) Review of Resident #5's face sheet dated 09/11/2025 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion.) and malignant neoplasm of pancreas (cancer). Review of Resident #5's Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #5 was assessed to not receive influenza, pneumococcal, offered and declined. Review of Resident #5's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #5's resident admission agreement dated 09/03/2024 reflected last known pneumococcal vaccination question was blank. Review of the consent reflected the RP wanted the resident to receive the pneumococcal and influenza vaccinations. Review of Resident #5's resident informed consent for influenza immunization dated 09/29/2024 reflected Resident #5 refused the influenza immunization. The consent was signed by the resident. In an interview on 09/11/2025 at 1:02 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. She stated the facility did not have a policy for immunizations that they used the CDC guidelines. In an interview on 09/11/2024 at 1:15 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the IP but since the current IP was not yet certified the DON who is certified was doing it and had not yet come up with a system to keep track of the immunizations. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the CDC guidelines on the www.cdc.gov website reflected Pneumococcal conjugate vaccine helps protect against bacteria that cause pneumococcal disease. There are several pneumococcal conjugate vaccines (PCVs). The specific PCV and number of doses recommended are based on a person's age, vaccination history, and medical status. Adults 50 years or older who have not previously received PCV should receive a PCV vaccine. Some adults in this group who have already received PCV might be recommended to receive another dose. CDC recommends everyone 6 months and older get vaccinated every flu season. Children 6 months through 8 years of age may need 2 doses during a single flu season. Everyone else needs only 1 dose each flu season.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 3 of 5 residents who were reviewed for immunizations. (Residents #14, #28 and #5) The facility failed to document in Resident #14, #28 and #5's medical records for having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: Review of Resident #14's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), cognitive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.), and diabetes mullites type II (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #14's quarterly MDS dated [DATE] reflected Resident #14 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #14's MDS did not address her current COVID-19 status. Review of Resident #14's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #14's EMR on 09/11/2025 reflected under the immunizations tab in PCC that Resident #14 received the influenza vaccination on 09/29/2024, no other immunizations were recorded. Review of Resident #14's admission paperwork dated 12/18/2023 reflected no informed consent or vaccination information sheet (VIS) for the COVID-19 vaccination. Review of Resident #28's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), PVD (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and aphasia(A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.). Review of Resident #28's quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #28 MDS did not address her current COVID-19 status. Review of Resident #28's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #28's resident admission agreement dated 09/07/2023 reflected no entry regarding the COVID-19 vaccination. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP the COVID-19 vaccination. Review of Resident #5's face sheet dated 09/11/2025 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion.) and malignant neoplasm of pancreas (cancer). Review of Resident #5's Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #5's MDS did not address her current COVID-19 status. Review of Resident #5's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #5's resident admission agreement dated 09/03/2024 reflected no entries related to COVID-19 vaccinations. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP the COVID-19 vaccination. In an interview on 09/11/2025 at 1:02 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. She stated the facility did not have a policy for immunizations that they used the CDC guidelines. In an interview on 09/11/2024 at 1:15 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the IP but since the current IP is not yet certified the DON who is certified is doing it and had not yet come up with a system to keep track of the immunizations. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the CDC guidelines on the www.cdc.gov website reflected CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older. Parents of children ages 6 months to 17 years should discuss the benefits of vaccination with a healthcare provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (1) of five (5) residents reviewed for abuse.<BR/>The facility failed to protect Resident #1 from abuse when staff yelled at her when asking for assistance via call light. <BR/>The noncompliance was identified as Past Noncompliance 07/30/24. The noncompliance began on 07/22/24 and ended on 07/29/24. The facility had corrected the noncompliance before the survey began.<BR/>These failures placed residents at risk of experiencing and enduring abuse by facility staff causing decreased quality of life. <BR/>Findings Included:<BR/>Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: Hemiplegia to left side, Metabolic encephalopathy, Hx of Traumatic Brain Injury, Muscle wasting and atrophy, epilepsy, Unspecified convulsions, need for personal care.<BR/>Review of the quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #1 reflected interventions were in place for: Full Code status, ADL performance deficit, History of Falls/Hemiplegia, Antidepressant medication, Anticoagulant medication, Chronic Pain r/t pelvic fracture and vertebrae fractures.<BR/>Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: Myopathy, Morbid Obesity, Hypothyroidism, Congestive Heart Failure, Muscle wasting and atrophy and Peripheral Vascular disease.<BR/>Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self performance deficit, a history of falls, a UTI, Chronic back pain, Psych history related to sexual assault.<BR/>In an interview on 7/29/24 at 9:10 am Resident #1 stated she felt fine, and she got along well with facility staff. She stated the one aide was the only one that had ever spoken badly to her. She stated she did not like to discuss the matter because the aide was disrespectful to her and talked to her like a child.<BR/>In an interview on 7/29/24 at 9:15 am Resident #21 stated she had overheard the conversation between the CNA and Resident #1. She stated when Resident #1 first pushed her call light it was for assistance to the toilet. She stated the aide came in and said she would be right back. Resident #21 stated Resident #1 then pushed the call light about five more times. She stated the aide came back and yelled and cussed at Resident #1. She stated she didn't hear everything, but the aide was mean and warned Resident #1 not to push the call light anymore.<BR/>In an interview on 7/30/24 at 1:36 pm the Administrator stated the employee named in the Abuse/Neglect allegation involving Resident #1 and her roommate Resident #21. The Administrator stated the employee was terminated for inappropriate behavior towards a resident. He stated he interviewed Resident #1, and she confirmed the staff was rude. The Administrator stated the Resident's room-mate Resident #21 stated she overheard and felt the aide had a bad attitude and was disrespectful. The Administrator stated no other reports of bad behavior were found in interviews with other residents. He stated in his interview with the can she denied speaking inappropriately or using cuss words. The Administrator stated no harm was assessed to either resident.<BR/>In an interview on 7/30/24 at 3:15 pm the DON stated the incident involving Resident #1 and #21 had been investigated. She stated the facility had an aide who was not always polite with residents. She stated Resident #1 informed her the aide talked down to her like she was a child. The DON stated the roommate, Resident #21, confirmed the aide was grouchy with Resident #1. The DON stated no psychological harm was assessed. The DON stated the social worker did a Harm Survey with all able residents and no other residents had any complaints related to the allegations.<BR/>In an interview on 7/30/24 at 4:00 pm LVN L stated neither Residents #1 nor #21, had any changes in behavior after the incident involving the aide. LVN L stated Resident #21 had complained about the aide stating she yelled at Resident #1 and cussed at her to stop using her call light.<BR/>Review of the investigation report by the facility completed on 7/29/24 reflected the facility had substantiated the CNA was verbally inappropriate or abusive. The investigation started on 7/22/24 when Resident #1's family member reported via telephone that the Resident was treated ugly and disrespectfully by the CNA. The aide was suspended, and the physician, RP, and Sheriff department were notified. A head-to-toe assessment reflected no new injuries. Resident #1 denied any psychological stress. Interviews with other residents were conducted. Residents #1 and her roommate, Resident #21, were interviewed by the administrator. The interviews reflected the CNA was loud, inappropriate, and yelled at Resident #1 for putting her call light on too many times. The Administrator interviewed the alleged perpetrator who denied doing anything wrong. She stated Resident #1 put on her call light multiple times and she told her after getting her up she was going to keep her in her wheelchair. She stated she did not yell, the resident took it wrong.<BR/>Review of the CNA's written statement dated 7/22/24 reflected she went to answer Resident #1's call light and she asked for a pain pill. She stated she would inform the nurse, and the nurse stated it would be 45 more minutes before she could have a pain pill per her physician's orders. The CNA stated Resident #1 put on the call light five more times asking for a pain pill. The CNA stated she took Resident #1 to the bathroom and placed her in a regular wheelchair as Resident #1's electric chair was still charging. Her statement also reflected she had informed Resident #1 the nurse wanted her to sit up in the wheelchair for a while after her lunch.<BR/>Review of the Abuse Neglect and Exploitation Policy dated 8/15/22 reflected a definition of Verbal Abuse which included the use of disparaging or derogatory terms to residents. The CNA had completed training on abuse neglect at the time of her employment.<BR/>Review of the facility policy Promoting Resident Dignity dated 1/13/23 reflected the employees were to protect and promote Resident rights and treat each resident with respect and dignity. Resident requests will be responded to in a timely manner. Staff were to speak respectfully to residents, discussions should not be overheard by others.<BR/>The noncompliance was identified as Past Noncompliance 07/30/24. The noncompliance began on 07/22/24 and ended on 07/29/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 9 and Resident #47) out of 8 residents reviewed for call lights.<BR/>The facility failed to ensure Resident #9 and Resident #47's call light was within reach.<BR/>This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.<BR/>Findings included:<BR/>Record review of Resident #9's Face Sheet, dated 07/31/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of history of falling (balance issues or other health conditions that increase the risk of falling), unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), and abnormal posture ( rigid body movements and chronic abnormal positions of the body.).<BR/>Record review of Resident #9's Annual MDS Assessment, dated 06/04/2024, reflected the Resident had a BIMS score of a 6 indicating her cognition was severely impaired. Resident #9 was assessed to require assistance with the following ADLs: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, putting on /taking off footwear, and personal hygiene. She also required assistance with transfers. <BR/>Record review of Resident #9's Comprehensive Care Plan, dated 06/17/2024 reflected Resident #9 had an ADL self-care deficit related to cognitive loss and limited mobility. Intervention: Resident #9 required assistance with transfers, bed mobility, dressing, eating, toileting, dressing, and grooming. Resident #9 had actual falls with no injury related to poor balance and unsteady gait. Intervention: keep in highly visible areas. <BR/>Record review of Resident # 47's face sheet dated 7/31/24 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of respiratory failure ( a condition that occurs when the lungs can't get enough oxygen into the blood or remove enough carbon dioxide from the body), traumatic brain injury ( brain dysfunction caused by an outside force, usually a violent blow to the head), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), quadriplegia (a type of paralysis that causes severe or complete loss of motor function in all four limbs and the body from the neck down), altered mental status (a general term for a change in mental function that can range from slight confusion to coma), chronic pain syndrome (persistent pain that lasts weeks to years), need for assistance with personal care, hypertension (high blood pressure), contracture to both left and right hands ( a permanent tightening of the muscles, tendons, skin, and surrounding tissue that causes the joints to shorten and stiffen and a decrease in ROM in both hands), muscle wasting and atrophy (the loss of muscle mass and strength), neuromuscular dysfunction of bladder (a urinary tract condition that occurs when the nerves and muscles of the urinary system don't work together properly due to damage to the nervous system), cognitive communication deficit (a communication problem that's caused by a cognitive deficit rather than a language or speech deficit), aphasia ( a comprehension and communication (reading, speaking, writing) disorder resulting from damage or injury to a specific area in the brain), complete amputation at right hip joint, and gastronomy status (the presence of a gastrostomy, which is a surgical opening into the stomach for nutritional support or gastric decompression)<BR/>Record review of Resident # 47's care plan revised on 1/4/24 reflected the resident was a high risk for falls related to spasticity and traumatic brain injury interventions reflect to be sure resident's call light was within reach and encourage resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. The care plan also reflected the resident had a communication problem related to head injury. Resident was nonverbal most of the time but will occasionally speak to staff and family. Will blink eyes yes and no and nod head no in response to questions. Interventions included anticipate and meet needs revised 5/6/24. Care plan reflected the resident has oxygen therapy PRN related to respiratory distress, decreased oxygen level revised 4/1/24 with interventions to include provide reassurance and allay anxiety. Have an agreed upon method for the resident to call for assistance (e.g. call light, bell). Stay with resident during episode of respiratory distress. Care plan reflected the resident had an ADL self-care performance deficit related to TBI interventions include resident to be totally dependent on staff for all aspects of ADL's revision on 2/16/24.<BR/>Observation on 07/29/2024 at 9:41 AM to 9:47 AM Resident #9 was in her room sitting in her wheelchair. She had both feet propped up on her recliner. She had an overhead rolling table approximately 3 feet from where she was sitting. On the rolling table her call light was hanging over the table and the call button was not near her. The call button was hanging from the rolling table on the right side of the table and Resident #9 was sitting on the left side of the rolling table. Resident #9 attempted to reach for the call light. She was not able to reach the call light from where she was sitting in her wheelchair.<BR/>Observation on 07/29/2024 at 9:45 AM Resident #9 attempted to reach for the call light and she was not able to reach it from where she was sitting in her wheelchair. <BR/>Observation on 7/30/24 at 4:02 pm of Resident # 47's room revealed Resident # 47 to be in bed resting looking out the window. Further observation revealed Resident # 47's call light and soft pad call device both to be hung on the opposite wall not within reach of Resident # 47. Resident # 47 asked if he needed any assistance. Resident # 47 shook his head no. Resident # 47 asked if he was ok currently and Resident # 47 shook head yes as Resident # 47 is primarily nonverbal and this is his primary way to communicate. <BR/>Interview on 07/29/2024 at 9:43 to 9:47 AM Resident #9 stated no when she was asked if she knew where her call light was located. She began to look for the call light in her wheelchair and she looked around the room and saw it on the overhead rolling table. She stated she could not reach it but she saw it on the table ( she pointed to the overhead rolling table and to the call light). Resident #9 stated she did use her light when she needed help. <BR/>In an interview on 07/29/2024 at 9:50 AM CNA Q entered Resident #9's room and stated the call light was not within reach of Resident #9. She stated the resident would not be able to use the call light if she had an emergency or needed anything from the staff. CNA Q stated Resident #9 had fallen in the past attempting to get out of her chair. She stated there was a possibility Resident #9 could fall or have an emergency and would not be able to call out for help. She stated she had been in-serviced on call lights and to place the call light near the resident when in their room. She stated she did not recall when she received the in-service. <BR/>Interview on 7/30/24 at 1:00 pm with CNA A revealed that residents should have their call lights within reach so they could have their needs met. CNA A said most residents have a regular call light except Resident # 47 who has a soft pad call device that he used be he has contractures of both arms. CNA A said Resident # 47 was mainly nonverbal so he needed frequent checks to make sure his needs were met.<BR/>In an interview on 07/31/2024 at 9:08 AM the Administrator stated all call lights were expected to be within reach of the resident when the resident was in their room. He stated there was a possibility if the call light were not in reach the resident may need nursing assistance and would not be able to call out for help. <BR/>In an interview on 07/31/2024 at 10:06 AM LVN P stated if a resident's call light was not within reach of the resident there was a possibility a resident may fall and break a hip or hit their head on the floor attempting to reach the call light. He stated if the resident had an emergency, the resident may be able to yell for help but there were some residents that would not be able to yell very loud. It would be difficult to hear those residents. LVN P stated Resident #9 would be difficult to hear if staff were not near their rooms. He stated it was the responsibility of all staff in the facility to check call lights when they entered a resident room to ensure the call light was attached where the residents had easy access to use the call light. He stated he had been in-serviced on call lights and placing the call light within reach of the resident when they were in their room. LVN P did not recall the last time he received the in-service.<BR/>In an interview on 07/31/2024 at 11:09 AM the DON stated it was all the staff's responsibility when they entered a resident room to ensure the call light was within reach of the resident. She stated if the call light were not within reach, it would be difficult for a resident to obtain the help they may need in a timely manner. She stated some residents were able to yell for help and some residents would not be able to yell loud enough. She stated a resident had a potential to fall if the resident attempted to reach for their call light. She stated a resident may fracture their hip, break their leg, or arm. The DON stated it was safe practice for all staff to ensure call lights were within reach of all residents. She stated an in-service had been given to all staff on call light placement. She stated she did not recall the date when the in-service was given to the staff.<BR/>In an interview on 07/31/2024 at 11:40 AM CNA B stated all staff were responsible to check call lights when they entered a resident's room. She stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. CNA B stated a resident may break a bone or gain a laceration on their head if they fell. She stated all call lights were expected to be within reach of all residents when they were in their room. CNA B stated it would be difficult to hear Resident #9 if she attempted to yell for help and the staff were not standing near her room. She stated she had been in-serviced on call lights and attach call lights where residents can reach it when in their room. CNA B did not recall the date of the last in-service she had on call lights.<BR/>Record review of the Facilities Policy on Call Lights: Accessibility and Timely Response, dated 10/13/2022 reflected the following:<BR/>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. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. <BR/>Policy Explanation and Compliance Guidelines: <BR/>1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. <BR/>2. Staff will ensure the call light is within reach of resident and secured, as needed. <BR/>3. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. <BR/>4. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. <BR/>5. Ensure the call system alerts staff members directly or goes to a centralized staff work area. <BR/>6. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observations, interviews, and record review the facility failed to place the most recent survey readily accessible to residents in a place most frequented by residents for 9 of 9 residents reviewed for resident group meeting.<BR/>The facility failed to have the survey manual readily accessible for residents to view the surveys. <BR/>This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history.<BR/>Findings included: <BR/>Observation on 07/29/2024 at 3:00 PM revealed that the facility did not locate the survey book in common areas of the facility. There was no sign seen that reflected where the survey book was located. <BR/>Observation on 07/30/2024 at 9:30 AM revealed that the state surveyor was unable to locate the survey book in common areas of the facility. There was no sign seen that reflected where the survey book was located. <BR/>Record review of the Resident Council Minutes on 07/30/2024 from 8:30 AM to 8:50 AM revealed that during the Resident Council Meetings from 04/2024 to 07/2024 the residents were not explained that the resident had a right to view any surveys or investigations from the state. The Resident Council was not informed where the survey book was located. <BR/>In a confidential group interview on 07/30/2024 from 10:00 AM to 10:35 AM, seven residents stated they did not know where or how to access the survey results in the facility. They did not understand or have the knowledge this manual existed in the facility. The residents in the group stated they would like to have access to this information, because the staff did not tell them anything about visits from the state. The residents in the group did not know the state sent a report to the facility of any type of visits. The residents in the group did not know where a sign was located informing the residents about the survey book. The five residents in the group stated if they reviewed the reports in a manual, they would prefer to be able to reach it themselves, and not have to ask for it. The five residents stated they would prefer the staff did not know they were wanting to review the reports from the state. <BR/>In an interview on 07/30/2024 at 10:25 AM the Administrator stated the facility did have a survey binder and it was behind the nurse desk. He stated there was a sign that stated that the Annual State Inspection could be located at the Nursing Station. <BR/>Observation on 07/30/2024 at 10:28 AM the Administrator had to reveal where the sign was located in the facility. The sign was not facing the area where people walk. It was not noticeable, and it was located in a cubby area on the side of the small wall located in the cubby area near the nurse's desk. The Administrator was observed removing the State survey binder from behind the nurse's desk. The binder was mixed with approximately eight other binders on the middle shelf behind nurse's station. <BR/>In an interview on 07/31/2024 at 9:08 AM the Administrator stated the residents had a right to know they had access to the state survey binder. He stated one of the resident rights were to view the survey book. The Administrator stated the survey book was not readily accessible to the residents. He stated the residents had the right to view the survey binder without having to ask someone to get it for them. He stated the residents were not allowed behind the nurse's station. He stated the Activity Director reviewed resident rights during Resident Council. He stated the Activity Director was responsible for reviewing the resident rights. <BR/>In an interview on 07/30/2024 at 11:49 AM the Activity Director V stated the survey binder was not discussed in Resident Council of where it was located or the availability of the binder. She stated she did not know at this time where the survey binder was located. She also stated she would need to check the resident rights about the state survey binder and verify if it was one of the resident rights. She stated she did review one resident right in the Resident Council meetings. The Activity Director V also stated she did not specify on the Resident Council Minutes what she reviewed. She stated she was not aware the residents did not understand what she was saying during the meetings ( Resident Council Meetings). She stated she only reviewed resident rights with the residents in Resident Council and she did not review resident rights with other residents . She stated all residents needed to know their resident rights in the facility. She stated if a resident did not know their resident rights it was a possibility it could affect their quality of life at the facility. <BR/>Record review of Facility Policy on Resident Rights , dated November 2021, reflected informed of state survey reports and the nursing facility's plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment; including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Resident #1) of 8 residents reviewed for homelike environment. <BR/>The facility failed to ensure two bedside tables were cleaned daily for three days observed during annual survey.<BR/>This failure placed residents at risk for infections, injuries, and demoralization.<BR/>The findings included:<BR/>Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: hemiplegia to left side ( paralysis of limbs on the left side of body), metabolic encephalopathy (problem of the brain, history of traumatic brain injury (disruption in the normal function of the brain, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), epilepsy, unspecified convulsions ( a group of disorders marked by problems in the normal functioning of the brain), and need for personal care.<BR/>Review of the Quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene, and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #1 reflected interventions were in place for: full code status, ADL performance deficit, history of falls/hemiplegia, antidepressant medication, anticoagulant medication, chronic pain r/t pelvic fracture, and vertebrae fractures.<BR/>Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: myopathy (disorder of the skeletal muscles), morbid obesity, hypothyroidism ( when the thyroid gland does not make enough thyroid hormones to meet your body's needs), congestive heart failure ( weakened heart condition that causes fluid buildup in the feet, arms, lungs and other organs), muscle wasting and atrophy ( decrease in size of muscles) and peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel.<BR/>Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming, and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self- performance deficit, a history of falls, a urinary tract infection( infection in any part of the urinary system), Chronic back pain, and psych history related to sexual assault.<BR/>In an interview on 7/30/24 at 8:20 am Resident #21 stated no one had ever cleaned the surface of her bedside table as far back as she could remember. She stated no one cleaned the table in between meals and incontinence care. She stated no one cleaned the table before setting her meal tray on it and no one helped to wash her hands.<BR/>Observation of lunch service on 7/30/24, starting at 12:10 pm.<BR/>At 12:15 pm Resident #21 stated her tray table or bedside table had not been cleaned. She also stated she had not been assisted to wash her hands.<BR/>At 12:20 pm trays for 500 Hall exited the dining room and were checked by a nurse.<BR/>At 12:22 pm trays were served to the first two rooms, Resident #10 and Resident #50 by Aides CNA M and CNA N. Neither resident was observed to be assisted with handwashing or cleaning their table.<BR/>At 12:30 pm Resident #21 was not assisted to wash her hands and her tray table was not cleaned prior to being served her lunch tray.<BR/>At 12:35 Resident #44 was served his lunch tray with a urinal containing approximately 300 mls of clear yellow urine sitting on the bedside table and left behind alongside his food.<BR/>In an interview on 7/30/24 at 3:25 pm Housekeeper P stated each room in the facility was to be cleaned daily. He stated all touch surfaces were to be cleaned daily. He stated staff should be sure to follow policy during the current increase in Covid-19 infections in the facility . He stated there was a possibility if residents' rooms were not sanitized a resident may become ill with some type of virus. <BR/>In an interview on 7/30/24 at 4:00 pm LVN L stated Residents should be assisted to wash their hands multiple times a day by aides and nurses. She stated caregivers should be wearing PPE when in Covid-19 rooms. She stated housekeeping was responsible for wiping down high touch surfaces once a day . She stated if not sanitized a resident may become ill.<BR/>In an interview on 7/31/24 at 8:12 am Resident #21 stated no one cleaned her bedside table or helped her wash her hands before breakfast today.<BR/>In an interview on 7/31/24 at 8:50am Resident #1 stated the staff did not help her wash her hands before breakfast today and did not help her wash her hands after getting up to the bathroom at 8:30 am.<BR/>In an interview on 7/31/24 at 12:20 pm CNA A stated she assisted all the residents on 500 Hall to wash their hands this morning. She stated she can't speak for other aides, but she made sure everyone got help when they needed it. She stated tabletops and bedside tables were to be cleaned by housekeeping each day . She stated if a room was not sanitized a resident may become ill with breathing problems.

Based on observation, interview, and record review, the facility failed to have sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for one cook (Cook G) of three dietary cooks reviewed for qualified dietary staff in that:<BR/>Cook G had not received onboarding training with the appropriate competencies and skills to carry out the functions of the food and nutrition services department. <BR/>This failure could place residents at risk of not having their nutritional needs met and place them at risk of food borne illness. <BR/>Findings included:<BR/>During an interview on 7/29/24 at 9:00 am the DD said all her staff including herself had the Texas Food Handlers License except for [NAME] G who was new and just started in the early part of July 2024. The DD said [NAME] G will be coming in to take her Texas Food Handlers course this week and get their food handlers license . The DD said [NAME] G had recently transitioned from the housekeeping department to dietary department. The DD said [NAME] G has worked several shifts since starting and was being trained by the DD, [NAME] E, and [NAME] F. The DD said [NAME] G has never prepared a meal by themselves and they have never been left in the kitchen without a team member present who has their Texas Food Handlers certification. <BR/>During an observation and interview on 7/31/24 at 12:30 pm revealed [NAME] G to be in the DD office taking the Texas Food Handler online course. [NAME] G said they started in the dietary department on 7/11/24. [NAME] G said their normal shift was 12:00 pm-8:00 pm. [NAME] G said they have been receiving training from the DD, [NAME] E, and [NAME] F. [NAME] G said they have never worked in food service prior to this position. [NAME] G said they do not have a Texas Food Handlers certification, and which was why the DD requested they come in early today to be able to take the course today. [NAME] G said they have received Hands on training from the DD and the other cooks. [NAME] G said they have been allowed to assist in preparing the resident meals, wash dishes independently, serve tray line independently. [NAME] G said they have been trained on the different types of diets offered, menus and alternate meal options available. [NAME] G said they have not received or were unsure if they had received training on cross contamination, infection control, time temperature control, HACCP , recipes, and production records. [NAME] G said they had never received a job description to sign or nay other paperwork documents for this current position.<BR/>Record review of dietary schedule for 7/15/24 - 8/12/24, revealed [NAME] G had worked 11 shifts in the dietary department as a cook. <BR/>Record review of [NAME] G personnel file revealed a hire date of 3/1/24 with a job title of housekeeper signed by [NAME] G on 3/4/24. Job description of housekeeper in employee file dated 3/4/24. <BR/>Interview on 7/29/24 at 9:00 am, DD was asked for the training documentation for [NAME] G. No training documents for [NAME] G provided prior to exit.<BR/>Record review of the cook job description undated revealed under Licensing requirements: Texas Food Handler Certificate<BR/>And under Experience requirements: Knowledge of food preparation, sanitation, and hygienic methods. Knowledge of Universal Precautions and rules that govern hazardous waste. Previous experience in skilled nursing facility is preferred. Ability to follow oral and written directions.

Based on observations, interviews, and record review, the facility failed to provide the physician prescribed therapeutic diet to 11 of 13 residents (Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207) reviewed for therapeutic diets, in that:<BR/>Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207did not receive a mechanical soft diet as ordered. <BR/>This failure could place residents at risk for choking and causing further health issues. <BR/>Findings included: <BR/>A record review of Resident # 3's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 9's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # !0's diet order dated 7/10/24 reflected an order for Regular diet mechanical sift texture, regular liquids consistency.<BR/>A record review of Resident # 12's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 13's diet order dated 12/14/23 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 22's diet order dated 3/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 23's diet order dated 4/22/24 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 25's diet order dated 9/25/23 reflected an order for Reduced Concentrated Sweets mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 36's diet order dated 8/10/23 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 156's diet order dated 7/16/24 reflected an order for Regular diet mechanical soft texture, regular liquids consistency.<BR/>A record review of Resident # 207's diet order dated 7/16/24 reflected and order for Renal-Liberalized diet mechanical soft texture, regular liquids consistency.<BR/>Observation of kitchen lunch preparation on 7/29/24 at 11:00 am revealed tray line to be set up with chopped lettuce for beef soft tacos. <BR/>Observation of lunch tray line service on 7/29/24 at 12:00 pm revealed mechanical soft diets receiving chopped lettuce on meal trays.<BR/>Observation of lunch meal tray on 7/29/24 at 12:45 pm of Resident # 13's meal tray and meal ticket with order of Regular diet mechanical soft texture. Resident # 13's meal tray consisted of ground beef and tortilla mixture with shredded cheese as garnish on top of beef mixture with a side of chopped lettuce. Observation of Resident # 13 to be eating some of the lettuce.<BR/>Record review of week 2-day 8 recipe for soft beef taco reflected under notes: 3. For ground and puree texture modifications, omit lettuce and tomatoes.<BR/>Record review of week 2-day 8 production records signed by Dietary Director and RD reflected mechanical soft texture to receive &frac12; cup of shredded lettuce.<BR/>Interview on 7/29/24 at 12:33 pm the Dietary Director said the cooks follow the production records when preparing the meals and the production records stated mechanical soft diets can have chopped lettuce. The Dietary Director was asked about the recipe for soft beef tacos indicating to omit the lettuce and tomato and modify with substitution, the Dietary Director reiterated the staff follow the production records for meal preparation. The Dietary Director was unsure about the policy concerning diet texture modifications and stated they would ask the RD and Administrator about the policy.<BR/>Interview on 7/30/24 at 9:22 am reflected the Registered Dietician (RD) said the company and the facility followed the National Dysphasia Diet Level 3: Advanced protocol for their mechanical soft diets. The RD said this protocol allowed for residents to receive shredded lettuce. The RD said this protocol was the policy the facility follows. The RD said the recipes come from their grocery supplier and the facility follows the facility procedure/protocol if the recipe has a discrepancy and states differently than the facility policy/protocol.<BR/>Interview with Dietary Director on 7/31/24 at 9:15 am reflected Dietary Director said the facility received whole heads of lettuce and they chop it themselves as receiving pre-shredded lettuce in was more expensive and usually does not have a long shelf life.<BR/>Record review of mechanical soft diet textures in-service dated 6/3/24 presented by Dietary Director reflected 5 staff members signatures of attendance. In-service training documentation reflected <BR/>Under heading What is a Mechanical Soft diet texture? An altered diet texture for residents who cannot safely chew or swallow regular/hard food textures but may still chew softer foods. Foods should be soft, moist. Meats are ground or minced, moist, and no larger than &frac14; inch pieces.<BR/>Under heading Not approved foods: raw vegetables<BR/>Record review of National Dysphagia Diet Level 3: Advanced policy provided by facility RD undated reflected mech soft to be handwritten in parenthesis at the top of the document next to the word advanced. Under heading considerations for specific food items: Raw fruits and vegetables-shredded lettuce is underlined, sliced tomatoes, and finely chopped tomatoes/salads as tolerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive device when consuming meals and snacks for 1 resident (Resident # 2) of 8 residents reviewed for assistive devices.<BR/>The facility failed to provide Residents# 2's physician ordered handled cup with lid for lunch.<BR/>This failure put resident at risk for decreased fluid intake, dehydration, and decreased quality of life.<BR/>Findings included:<BR/>A record review of Residents # 2's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (A congenital disorder of movement, muscle tone, or posture.), intellectual disabilities (A neurodevelopmental condition that affects a person's intellectual functioning and adaptive behavior.), muscle wasting and atrophy (The loss of muscle mass and strength), dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus.), ataxia (Impaired balance or coordination can be due to damage to the brain), need for assistance with personal care,, cognitive communication deficit (A communication problem that's caused by a cognitive deficit rather than a language or speech deficit), and age related physical debility.<BR/>A record review of Resident # 2's care plan last revised on 1/26/2024 reflected she has potential nutritional problems related to cerebral palsy. Diet order RCS diet, mech soft, regular liquids consistency, Handled cup. Interventions reflected Resident # 2 will get a no spill handled cup with her meals to help aid with her drinking abilities. Provide serve diet as ordered. Monitor intake and record meal.<BR/>A record review of Resident # 2's diet order dated 1/25/2024 reflected Reduced Concentrated Sweets diet, Mechanical Soft texture, Regular liquid consistency, handled cup with lid, divided plate, built up utensils, can have salads per speech therapy.<BR/>Observation on 7/29/24 at 12:40 pm the Activity Director in dining room assisting Resident # 2 with their drink. Resident # 2 had a diet coke being poured into handled cup with lid by the Activity Director. The drink foamed over cup lid was applied to cup and given to Resident # 2. Cup slipped from Resident # 2's hands onto floor and spilled contents on floor. The Activity Director put Resident # 2 handled cup in the dirty dish area of dining room. The Activity Director went to Resident # 2's room got Resident # 2 another diet coke opened it then went to get straw to put inside can for Resident # 2. The Activity Director gave Resident # 2 the can of Diet coke with straw. A new clean handled spill proof cup was never provided to Resident # 2 during lunch meal service.<BR/>Interview and observation on 7/29/24 at 2:00 pm with the Dietary Director reflected Resident # 2 has an order for a handled spill proof cup with all meals. The Dietary Director showed the kitchen had a quantity of 2 handled cups in the clean dish storage area that Resident# 2 used.<BR/>Record review of Meal Service policy dated 10/1/2018 reflected under heading policy: The facility believes that all residents should be always treated with dignity and respect. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. 8. Assistive devices will be provided as ordered and documented in residents' care plans.

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 one of one kitchen reviewed for sanitation. <BR/>1. <BR/>The facility failed to ensure all items were labeled and dated.<BR/>2. <BR/>The facility failed to ensure all items were covered and stored properly.<BR/>3. <BR/>The facility failed to ensure sanitation practices were occurring in kitchen.<BR/>4. <BR/>The facility failed to ensure temperature logs were being completed.<BR/>These failures placed residents at risk of foodborne illness.<BR/>Findings included:<BR/>Observation of the kitchen's ice machine on 7/29/24 at 7:00 am revealed the inside of the machine to have black debris and growth growing on the upper inside of the machine near the door.<BR/>Observation of ice scoop receptacle on wall next to ice machine on 7/29/24 at 7:05 am revealed inside of receptacle to have dried brown appearing substance at the bottom of the receptacle. <BR/>Observation of kitchen prep area worktable on 7/29/24 at 7:08 am revealed a staff member had a Styrofoam cup of coffee uncovered in work prep area near toaster, robot coupe blender, and block of butter unwrapped with butcher knife on wrapper next to it. <BR/>Observation on 7/29/24 at 7:10 am in the clean dish storage area, there were steam table lids with dried particles on them. The lids were stored in bin with other clean steam table lids.<BR/>Observation of walk-in refrigerator on 7/29/24 at 7:13 am revealed the following: <BR/>*A cut unwrapped undated cucumber sitting on a tray with health shakes and chocolate syrup bottles.<BR/>*A thawing brisket on bottom shelf on sheet pan undated.<BR/>Observation of walk-in freezer on 7/29/24 at 7:16 am revealed the following:<BR/>*A bag of frozen chicken breast that had been torn open with 1 single chicken breast remaining undated and unsealed.<BR/>*A steam table pan of mixed vegetable blend with red peppers, green beans, broccoli, and mushrooms uncovered and undated on shelf.<BR/>*A package with half of an angel food cake undated and unsealed.<BR/>Observation of dry storage area on 7/229/24 at 7:20 am revealed the following:<BR/>*A container of brown sugar with the lid sitting on top of container with a gap of approximately 2-centimeter opening.<BR/>*A container of flour with lid sitting on top of container with a gap of approximately 1-centimeter.<BR/>*A gallon Ziploc bag with penne pasta inside unlabeled and undated.<BR/>*An open storage bin with individually wrapped saltine crackers unlabeled and undated on bin.<BR/>*An open storage bin with individually packaged ketchup packets with a label stating contents were flour and date of 10/20/23.<BR/>*An opened storage bin with individually packaged mustard packets undated and unlabeled.<BR/>*An opened box of tea bags undated unlabeled and with box partially torn open with part of box missing.<BR/>*An undated container of unopened oatmeal.<BR/>*An undated container of parsley flakes.<BR/>Observation of kitchen prep drink station on 7/29/24 at 7:30 am revealed the following:<BR/>*An undated gallon container of orange juice without lid approximately &frac14; full. <BR/>*6 juice glasses full of orange juice without lids on table. A stack of lids were present next to glasses that had been filled.<BR/>Observation of temperature logs on 7/29/24 at 7:33 am revealed the following:<BR/>*The daily dish machine temperature and sanitizer log had not been completed for lunch on 7/10/24, breakfast on 7/25/24, and breakfast and lunch on 7/26/24.<BR/>*The walk-in freezer temperature log had not been completed for 4/30/24, 7/27/24, and 7/28/24.<BR/>*The walk-in refrigerator temperature log had not been completed for 7/27/24 and 7/28/24.<BR/>*The pot/sink sanitizer test strip log had not been completed for dinner 7/25/24, breakfast 7/26/24, and lunch 7/26/24.<BR/>*The daily meal/ food temperature log had not been completed for dinner 7/21/24 and breakfast 6/10/24.<BR/>Observation of three-compartment sink on 7/29/24 at 7:38 am revealed dried particles, dirt, grime, and a single hair black in color on the dish drain side of the sink.<BR/>Observation of dish machine rack storage dolly on 7/29/24 at 7:40 am revealed dirt, grime, dried particles, and paper scraps on storage dolly surface where dish machine racks are stored.<BR/>Observation of lunch tray line on 7/29/24 at 12:15 pm revealed the 400 hall cart trays being loaded into meal cart with charro beans in bowls uncovered and bowls of soup uncovered. <BR/>Observation of breakfast meal cart on 7/30/24 at 7:50 am revealed the 200 hall meal cart doors open in hallway with bowls of oatmeal on resident trays uncovered. Meal cart unattended at time of observation.<BR/>Observation on 7/30/24 at 9:15 am Dietary Aide I was in kitchen with his beard guard down under chin not covering beard.<BR/>Observation on 7/30/24 at 9:22 am of kitchen revealed large 55-gallon trash can in kitchen without lid.<BR/>Observation on 7/30/24 at 12:05 pm Dietary Aide I was in kitchen working the lunch tray line with beard guard under chin not covering beard.<BR/>Observation on 7/31/24 at 9:20 am of kitchen revealed large 55-gallon trash can in kitchen without lid.<BR/>Observation on 7/31/24 at 9:21 am of kitchen revealed spatula hanging in clean utensil storage area with dried particles on surface. <BR/>Observation on 7/31/24 at 9:24 am of kitchen revealed inside of juice dispenser nozzle to be caked with red and orange slimy buildup.<BR/>Observation on 7/31/24 at 12:19 pm of Dietary Aide J in kitchen prepping mayonnaise cups for lunch meal service. Observation further revealed mayonnaise cups to be put on meal trays uncovered and loaded onto meal cart.<BR/>Interview on 7/29/24 at 9:00 am the Dietary Director said the cleaning logs are posted on the cooler and each staff member has different parts of the kitchen they are responsible for cleaning. The Dietary Director said the cleaning schedule was posted on the cooler right next to the cleaning logs. The Dietary Director said all staff are trained in kitchen sanitation in part of their new hire onboarding training. The Dietary Director said everyone who comes into the kitchen was required to wear hair restraints and beard restraints for the males. The Dietary Director said when items are received, they are dated with the receipt date and stored using the First In First Out method. DD said once items are opened or prepared, they are dated with the open/preparation date and the discard date.<BR/>Record review of dietary cleaning schedule posted for week of 6/24/24 revealed the following: <BR/>*cleaning task of toaster completed 6/24/24, <BR/>*cleaning task of microwave completed 6/24/24 by Dietary Aide K, <BR/>*cleaning task of can opener completed 6/24/24 by Dietary Director and 6/25/24 by Dietary Aide K, <BR/>*cleaning task of cook shelves and steam table completed by [NAME] F undated, <BR/>*cleaning task of storeroom completed by [NAME] F undated, and <BR/>*cleaning task of dish machine completed by [NAME] F undated. <BR/>Record review of weekly dietary cleaning schedule posted for week of 7/1/24-7/8/24 with cleaning task of:<BR/>*dry storage completed 7/1/24 by Dietary Aide I, <BR/>*cleaning task of walk-in freezer completed on 7/1/24 by [NAME] E,<BR/>* cleaning task of walk-in cooler completed on 7/1/24 by Dietary Director, <BR/>*cleaning task of reach-in cooler completed 7/10/24 by Dietary Director, <BR/>*cleaning task of mop under/between ovens, fryer and steamer completed on 7/1/24 by Dietary Director, and on 7/2/24 by Dietary Aide I, and<BR/>*cleaning task of dish room completed on 7/1/24 and 7/2/24 by [NAME] F.<BR/>Record review of general kitchen sanitation policy dated 10/1/2018 reflected under heading policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US food codes to minimize the risk of infection and food borne illness. Under heading procedure:<BR/>1. <BR/>Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all food-contact surfaces of equipment.<BR/>4. <BR/>Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food-contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation.<BR/>5. <BR/>After cleaning and until use, store and handle all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants<BR/>6. <BR/>Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition.<BR/>Record review of the dietary food handling policy undated under heading purpose: The purpose of this procedure is to provide guidelines for the d=safe preparation, handling, and storage of perishable food and proper environmental cleaning. Under heading general guidelines 13. Clean uniforms, hairnets or caps should be worn daily. All facial hair should be covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 8 residents reviewed for infection control (Resident #30).<BR/>The facility failed to ensure the needle used on Resident #30, remained sterile during the procedure for intramuscular injection of the antibiotic Ceftriaxone.<BR/>This failure could place residents at risk of infection, decline in health and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #30's face sheet revealed a [AGE] year-old male admitted to the facility 02/21/2021 and initially admitted on [DATE]. His diagnoses included atrial fibrillation (abnormal heart rhythm), Parkinson's disease, muscle wasting, pain in joints, age related debility, behavioral and emotional disorder, depression, non-cancerous tumor of the salivary gland, HTN and contractures of the hips and of the knees.<BR/>Record review of Resident #30's quarterly MDS dated [DATE] revealed he had short term and long term memory problem. He had moderately impaired cognitive skills for daily decision making. He required extensive assistance with ADLs and was always incontinent of bowel and bladder. Further review revealed he was receiving antibiotics and IV medications. <BR/>Record review of Resident #30's undated care plan revealed the resident had an infection of swollen lymph nodes to the right cheek/jaw area, date initiated was 06/05/2023. The goal was for resident to be free of complications related to infection. Interventions included nurses to administer antibiotics as per MD orders.<BR/>Record review of Resident #30's active physician orders revealed an order to start Ceftriaxone sodium solution reconstituted 1gm, inject 1 gm IM every 24 hours for swollen lymph nodes with fever on start date 06/07/2023 and end date of 06/10/2023.<BR/>Observation and interview on 06/07/2023 at 9:10AM, RN A prepared Ceftriaxone 1gm vial. RN A reconstituted the Ceftriaxone 1gm by adding 2.1 ml of Lidocaine 1%. RN A put on clean gloves, cleansed the stopper on the Ceftriaxone vial with an alcohol prep pad, removed the cap of the needle, set the cap down on the med cart, withdrew the liquid using a 3ml syringe and 22 g needle. RN A walked to Resident #30's bedside, explained the procedure to Resident #30, opened a small alcohol prep pad, placed the pad on top of the outer package of the prep pad and placed the syringe with exposed needle on top of the alcohol pad. RN A removed gloves and donned clean gloves then disinfected Resident #30's dorsogluteal site (left hip area) with an alcohol prep pad. RN A picked up the syringe with needle and wiped the needle using the alcohol prep pad. RN A injected the content of the syringe and needle into Resident #30's dorsogluteal site, swabbed the site with a new alcohol pad and disposed of the syringe with the needle in a sharps container. RN A stated he did not recap the needle d/t the potential of a needle stick. RN A stated he wiped the needle with alcohol to clean and disinfect it. RN A was asked if wiping the needle with alcohol was facility policy. RN A stated it was the way he learned how to do injections.<BR/>Interview on 06/07/2023 at 4:30PM, the DON stated after drawing up the injectable medication she expected the nurse to cover the needle with the cap in a way to prevent a needle stick. The DON stated the cap did not necessarily need to be tightly secured. The DON stated it was not policy to wipe down the needle. The DON stated the risk would be an infection control issue and potential needle stick. The DON stated she would monitor Resident #30's injection site for infection keeping in mind the Ceftriaxone may cause redness by itself.<BR/>Interview on 06/08/2023 at 8:30AM RN A stated he had been working at the facility about 1.5 years now and had an inservice regarding administration of medication about one week ago.<BR/>Interview on 06/08/2023 at 8:35AM, the DON stated the DON or the corporate nurse was responsible to conduct nursing staff inservices for medication administration.<BR/>Interview on 06/08/2023 at 10:10AM, the DON stated the records for Nursing Administration of Medications inservices were completed through the online learning courses provided by the facility. The DON stated RN A had signed an inservice on 2/6/2023.<BR/>Record review of the online learning transcript included RN A's completion of the one-hour course for Medication Administration in Acute Care on 2/06/2023, with a final score of 100.<BR/>Record review of the facility policy and procedure manual, section: Medication Administration, Injectable Administration revised on 10/01/2009 read in part: Policy: to administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate and effective manner. Equipment Required .2. Sterile syringe capable of holding the medication volume. 3. Sterile safety needle .Procedure .Sites for Administration: .Intramuscular .withdraw the medication; create air lock. Do not recap needle, remove air bubbles .Sanitize hands with approved sanitizer .put on gloves .prepare skin for injection, remove air from syringe and insert the needle . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents has the right to be informed of, and participate in, their treatment for one (Resident #17) of four residents reviewed for resident rights. <BR/>-The facility failed to ensure Resident #17'ss wishes to discontinue use of Estradiol (estrogen).<BR/>This failure could place residents at risk of not being part of the decision-making process for their care. <BR/>The findings included:<BR/>Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE]. Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size or wasting away of a body part or tissue arrested development), lack of coordination, type 2 diabetes mellitus (a condition results from insufficient production of insulin, causing high blood sugar), polyneuropathy (damage to multiple peripheral nerves), hypertension (high pressure in the arteries), hemiplegia (paralysis of one side of the body) and hemiparesis (is weakness on one side of the body) of the right side, dysphagia (difficulty in swallowing food or liquid difficulty in swallowing food or liquid), and chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes and fluids). <BR/>Record review of Resident #17's quarterly MDS dated [DATE] with an ARD of 5/12/2023 revealed a BIMS of 11 indicating minimal cognitive impairment. The MDS revealed he had no indications of psychosis, behaviors affecting others, or wandering or elopement behaviors, and he rejected care between one and three days in the seven days prior to the assessment. The MDS documented Resident #17 required extensive assistance from one or more caregivers with bed mobility, transfers, locomotion, dressing, personal hygiene, and toileting, and minimal assistance with set-up for eating. The MDS noted he was always incontinent of bladder and bowel, but he was not on a toileting program. The MDS revealed he was at risk of developing pressure ulcers or injuries, had two venous (typically shallow with irregular sloping edges) and/or arterial (deep and has a 'punched out' appearance) ulcers (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal) of the feet, and was receiving treatment for the injuries. The MDS documented Resident #17 received anticoagulant and diuretic medication seven days of the seven days prior to the assessment. The MDS noted he received no therapeutic services. <BR/>Record review of the Resident #17's care plan, updated 3/7/2023, revealed a focus on his propensity to curse at staff and make inappropriate comments to female staff members with interventions including anticipation of his needs, positive interactions, discussion of inappropriate behaviors.<BR/>Record review of Resident #17's medication record revealed he was prescribed Estradiol (a female hormone that regulates many functions in the body, such as reproduction, mood, and bone health) 1mg tablet, one tablet daily, for inappropriate sexual behaviors. The prescription was ordered on 4/11/2023 and initiated on 4/12/2023. <BR/>Record review of Resident #17's medication record revealed prescriptions for Estradiol 1mg tablet one time daily for inappropriate sexual behaviors.<BR/>Record review of a nurse's note dated 4/11/2023 documented Resident #17 was being sexually inappropriate with CNA's during bed bath today. Record review of a nurse's noted dated 4/11/2023 revealed Resident #17 was prescribed Estradiol 1mg for inappropriate sexual behaviors. <BR/>Record review of a nurse's note dated 5/24/2023 created by the DON revealed Resident #17 refused to sign a consent for Estradiol and informed the nurse he did not want to take it. <BR/>Record review of Resident #17's May 2023 MAR revealed he had been administered Estradiol 5/25/2023 through 5/31/2023 daily at 9:00 AM. <BR/>Record review of Resident #17's June 2023 MAR revealed he had been administered Estradiol 6/1/2023 through 6/8/2023 daily at 9:00 AM. <BR/>Observation on 6/6/2023 at 9:09 AM of Resident #17 revealed he was lying in his bed watching television. Resident #17 appeared clean and appropriately groomed.<BR/>Interview on 6/7/2023 at 8:02 AM with Resident #17, he said he did not know the names of all the medications he took. Resident #17 said he did not know if he was prescribed, administered, or took Estradiol. Resident #17 said he did not know what Estradiol would treat. <BR/>Interview on 6/8/2023 at 12:18 PM with Resident #17, he said he had spoken with the Admin regarding his Estradiol on 6/8/2023. Resident #17 said he wanted to take the estradiol because it calmed him down. Resident #17 said he had not known he was taking it in the past. Resident #17 said the facility and staff had not informed him of the medications he takes. Resident #17 said the staff would administer the medication and tell him to take it without explaining what he was taking. <BR/>Interview on 6/7/2023 at 1:14 PM with CNA A, she said she had been employed as a CNA since December of 2022. CNA A said her primary duties as a CNA were to assist residents with showers, other ADL's, weigh the residents, and assist the residents with what they needed. CNA A said Resident #17 did not appear to have a problem with her. CNA A said Resident #17 preferred specific CNA's and nurses. CNA A said Resident #17 routinely refused care. CNA A said Resident #17 had acted inappropriately with her. CNA A said he had made inappropriate jokes and had attempted to touch her bottom. CNA A said she had informed the facility management about her concerns. CNA A said Resident #17's inappropriate behaviors had decreased since she informed management of the issues. <BR/>Interview on 6/8/20 at 8:14 AM with The MDS, she said Resident #17's Estradiol was not on his care plan. The MDS said it was not on his care plan because he had come to the facility with the prescription. The MDS said she thought the Estradiol was controlling Resident #17's inappropriate sexual behaviors and that was why she had not included it as an intervention on the care plan. The MDS reviewed the EHR and said the Estradiol was prescribed on 4/11/2023. The MDS said the Estradiol should have been included on the care plan as an intervention for the Resident #17's focus on inappropriate sexual behaviors. The MDS said she was unsure if Resident #17 had received any psychiatric or social work intervention to address the inappropriate sexual behaviors. <BR/>Telephone interview on 6/8/2023 with Resident #17's PCP at 10:34 AM, he said he thought he was aware Resident #17 was prescribed Estradiol. Resident #17's PCP said Estradiol was not a common medication, but it may have been used for sexually inappropriate behaviors. Resident #17's PCP said if Resident #17 was his own responsible party, he could choose to refuse and/or discontinue the medication. <BR/>Telephone interview on 6/8/2023 with Resident #17's NP at 10:42 AM, she said Resident #17 was prescribed Estradiol for inappropriate sexual behaviors. Resident #17's NP said she had prescribed Estradiol in the past to residents with inappropriate sexual behaviors and it had decreased the behaviors. Resident #17's NP said the estradiol could decrease Resident #17 grabbing behaviors. Resident #17's NP said the estradiol helps the nurses to work with Resident #17 and would stop him from grabbing their lady parts. Resident #17's NP said she had not been informed Resident #17 had refused to take the Estradiol. Resident #17's NP said he could refuse his medication if he was his own responsible party. <BR/>Interview on 6/8/2023 at 11:17 AM with the DON, she said if a resident had inappropriate verbal behaviors, she would address the concern and move on. She said if the behaviors were physical, she would move the resident's hand, speak to the resident, and move on. The DON said if the behaviors continued or became invasive the facility progress to medication reviews, possible referral to an inpatient geriatric psychiatric hospital, or obtaining physician's orders for medication to address the behaviors. The DON said it was not her decision to determine if Resident #17 should have begun the medication after what was documented as a one-time occurrence, it was the prescribers. The DON said she did speak to Resident #17, on 5/24/2023, where he expressed a desire to discontinue his use of Estradiol. The DON said she did not discuss the discontinuation of the orders with the physician. The DON said at that time there was another interim DON who would have contacted the physician. The DON said if Resident #17 verbally refused to take the Estradiol a discontinuation of orders should have been obtained from the physician. <BR/>Interview on 6/8/2023 at 12:05 PM with the Admin, he said he had spoken to Resident #17 regarding his prescription for Estradiol. The Admin said he had chosen to continue taking the medication. <BR/>Record review of the facility's Medication Administration policy date 10/1/2019 read in part medications are administered as prescribed in accordance with good nursing principles and practices ., .the patient has the right to know exactly what they are taking, people taking medication have the right to refuse medications ., .residents may actively refuse medications ., and medication refusal must be reported to the prescriber or mid-level practitioner after every vital medication is refused and after every 3rd dose of a nonvital medication and there must be documentation of prescriber notification of such .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 6 residents (Resident#17) reviewed for unnecessary drugs.<BR/>The facility failed to ensure Estradiol (a female hormone that regulates many functions in the body, such as reproduction, mood, and bone health) was appropriate for Resident #17. Estradiol was prescribed for one documented incident of sexualized behavior which is an off-label use.<BR/>This failure could place residents receiving medications at risk of a possible inappropriate drug use or adverse drug reaction. hospitalization.<BR/>Findings included:<BR/>Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE]. Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size or wasting away of a body part or tissue arrested development), lack of coordination, type 2 diabetes mellitus (a condition results from insufficient production of insulin, causing high blood sugar), polyneuropathy (damage to multiple peripheral nerves), hypertension (high pressure in the arteries), hemiplegia (paralysis of one side of the body) and hemiparesis (is weakness on one side of the body) of the right side, dysphagia (difficulty in swallowing food or liquid difficulty in swallowing food or liquid), and chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes and fluids). <BR/>Record review of Resident #17's quarterly MDS dated [DATE] with an ARD of 5/12/2023 revealed a BIMS of 11 indicating minimal cognitive impairment. The MDS revealed he had no indications of psychosis, behaviors affecting others, or wandering or elopement behaviors, and he rejected care between one and three days in the seven days prior to the assessment. The MDS documented Resident #17 required extensive assistance from one or more caregivers with bed mobility, transfers, locomotion, dressing, personal hygiene, and toileting, and minimal assistance with set-up for eating. The MDS noted he was always incontinent of bladder and bowel, but he was not on a toileting program. The MDS revealed he was at risk of developing pressure ulcers or injuries, had two venous (typically shallow with irregular sloping edges) and/or arterial (deep and has a 'punched out' appearance) ulcers (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal) of the feet, and was receiving treatment for the injuries. The MDS documented Resident #17 received anticoagulant and diuretic medication seven days of the seven days prior to the assessment. The MDS noted he received no therapeutic services. <BR/>Record review of the Resident #17's care plan, updated 3/7/2023, revealed a focus on his propensity to curse at staff and make inappropriate comments to female staff members with interventions including anticipation of his needs, positive interactions, discussion of inappropriate behaviors.<BR/>Record review of Resident #17's medication record revealed he was prescribed Estradiol (a female hormone that regulates many functions in the body, such as reproduction, mood, and bone health) 1mg tablet, one tablet daily, for inappropriate sexual behaviors. The prescription was ordered on 4/11/2023 and initiated on 4/12/2023. <BR/>Record review of Resident #17's medication record revealed prescriptions for Estradiol 1mg tablet one time daily for inappropriate sexual behaviors.<BR/>Record review of a nurse's note dated 4/11/2023 documented Resident #17 was being sexually inappropriate with CNA's during bed bath today. Record review of a nurse's noted dated 4/11/2023 revealed Resident #17 was prescribed Estradiol 1mg for inappropriate sexual behaviors. <BR/>Observation on 6/6/2023 at 9:09 AM of Resident #17 revealed he was lying in his bed watching television. Resident #17 appeared clean and appropriately groomed.<BR/>Interview on 6/8/2023 at 12:18 PM with Resident #17, he said he had spoken with the Admin regarding his Estradiol on 6/8/2023. Resident #17 said he wanted to take the estradiol because it calmed him down. Resident #17 said he had not known he was taking it in the past. Resident #17 said the facility and staff had not informed him of the medications he takes. Resident #17 said the staff would administer the medication and tell him to take it without explaining what he was taking. Resident #17 did not recall any psychiatric care services. <BR/>Interview on 6/7/2023 at 1:14 PM with CNA A, she said she had been employed as a CNA since December of 2022. CNA A said her primary duties as a CNA were to assist residents with showers, other ADL's, weigh the residents, and assist the residents with what they needed. CNA A said Resident #17 did not appear to have a problem with her. CNA A said Resident #17 preferred specific CNA's and nurses. CNA A said Resident #17 routinely refused care. CNA A said Resident #17 had acted inappropriately with her. CNA A said he had made inappropriate jokes and had attempted to touch her bottom. CNA A said she had informed the facility management about her concerns. CNA A said Resident #17's inappropriate behaviors had decreased since she informed management of the issues. <BR/>Interview on 6/8/20 at 8:14 AM with the MDS, she said the Estradiol should have been included on the care plan as an intervention for the Resident #17's focus on inappropriate sexual behaviors. <BR/>Telephone interview on 6/8/2023 with Resident #17's PCP at 10:34 AM, he said he thought he was aware Resident #17 was prescribed Estradiol. Resident #17's PCP said Estradiol was not a common medication, but it may have been used for sexually inappropriate behaviors. <BR/>Telephone interview with on 6/28/2023 Resident #17's NP at 10:42 AM, she said Resident #17 was prescribed Estradiol for inappropriate sexual behaviors. Resident #17's NP said she had prescribed Estradiol in the past to residents with inappropriate sexual behaviors and it had decreased the behaviors. Resident #17's NP said the estradiol could decrease Resident #17 grabbing behaviors. Resident #17's NP said the estradiol helps the nurses to work with Resident #17 and would stop him from grabbing their lady parts. <BR/>Interview on 6/8/2023 at 11:17 AM with the DON, she said if a resident had inappropriate verbal behaviors, she would address the concern and move on. She said if the behaviors were physical, she would move the resident's hand, speak to the resident, and move on. The DON said if the behaviors continued or became invasive the facility progress to medication reviews, possible referral to an inpatient geriatric psychiatric hospital, or obtaining physician's orders for medication to address the behaviors. The DON said it was not her decision to determine if Resident #17 should have begun the medication after what was documented as a one-time occurrence, it was the prescribers. The DON said she did not know Resident #17's history with the prescriber, but in general the least restrictive approach should be utilized for inappropriate behaviors, and medication may not be the least restrictive. <BR/>Record review of the FDA's medication label for estradiol revealed it's typical uses included treatment of moderate to severe vasomotor symptoms associated with the menopause, treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause, treatment of hypoestrogenism due to hypogonadism, castration or primary ovarian failure, treatment of breast cancer (for palliation only) in appropriately selected women and men with metastatic disease, treatment of advanced androgen-dependent carcinoma of the prostate (for palliation only), and prevention of osteoporosis. The label documented estradiol was contraindicated for undiagnosed abnormal genital bleeding, known, suspected, or history of cancer of the breast, known or suspected estrogen-dependent neoplasia, active deep vein thrombosis, pulmonary embolism or history of these conditions, active or recent (e.g., within the past year) arterial thromboembolic disease (e.g., stroke, myocardial infarction), and liver dysfunction or disease. The label further documented estradiol should not be used in patients with known hypersensitivity to its ingredients, and estradiol 2 mg, contain FD&C Yellow No. 5 (tartrazine) which may cause allergic-type reactions (including bronchial asthma) in certain susceptible individuals. <BR/>Record review of the FDA's boxed warnings for Estradiol revealed estrogen therapy has been associated with an increased risk of cardiovascular events such as myocardial infarction and stroke, as well as venous thrombosis and pulmonary embolism, and should any of these occur or be suspected, estrogens should be discontinued immediately. The boxed warnings documented an increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving estrogens had been reported. The boxed warning further revealed estrogen administration may lead to severe hypercalcemia in patients with breast cancer and bone metastases. Per the boxed warnings retinal vascular thrombosis had been reported in patients receiving estrogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 8 residents reviewed for infection control (Resident #30).<BR/>The facility failed to ensure the needle used on Resident #30, remained sterile during the procedure for intramuscular injection of the antibiotic Ceftriaxone.<BR/>This failure could place residents at risk of infection, decline in health and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #30's face sheet revealed a [AGE] year-old male admitted to the facility 02/21/2021 and initially admitted on [DATE]. His diagnoses included atrial fibrillation (abnormal heart rhythm), Parkinson's disease, muscle wasting, pain in joints, age related debility, behavioral and emotional disorder, depression, non-cancerous tumor of the salivary gland, HTN and contractures of the hips and of the knees.<BR/>Record review of Resident #30's quarterly MDS dated [DATE] revealed he had short term and long term memory problem. He had moderately impaired cognitive skills for daily decision making. He required extensive assistance with ADLs and was always incontinent of bowel and bladder. Further review revealed he was receiving antibiotics and IV medications. <BR/>Record review of Resident #30's undated care plan revealed the resident had an infection of swollen lymph nodes to the right cheek/jaw area, date initiated was 06/05/2023. The goal was for resident to be free of complications related to infection. Interventions included nurses to administer antibiotics as per MD orders.<BR/>Record review of Resident #30's active physician orders revealed an order to start Ceftriaxone sodium solution reconstituted 1gm, inject 1 gm IM every 24 hours for swollen lymph nodes with fever on start date 06/07/2023 and end date of 06/10/2023.<BR/>Observation and interview on 06/07/2023 at 9:10AM, RN A prepared Ceftriaxone 1gm vial. RN A reconstituted the Ceftriaxone 1gm by adding 2.1 ml of Lidocaine 1%. RN A put on clean gloves, cleansed the stopper on the Ceftriaxone vial with an alcohol prep pad, removed the cap of the needle, set the cap down on the med cart, withdrew the liquid using a 3ml syringe and 22 g needle. RN A walked to Resident #30's bedside, explained the procedure to Resident #30, opened a small alcohol prep pad, placed the pad on top of the outer package of the prep pad and placed the syringe with exposed needle on top of the alcohol pad. RN A removed gloves and donned clean gloves then disinfected Resident #30's dorsogluteal site (left hip area) with an alcohol prep pad. RN A picked up the syringe with needle and wiped the needle using the alcohol prep pad. RN A injected the content of the syringe and needle into Resident #30's dorsogluteal site, swabbed the site with a new alcohol pad and disposed of the syringe with the needle in a sharps container. RN A stated he did not recap the needle d/t the potential of a needle stick. RN A stated he wiped the needle with alcohol to clean and disinfect it. RN A was asked if wiping the needle with alcohol was facility policy. RN A stated it was the way he learned how to do injections.<BR/>Interview on 06/07/2023 at 4:30PM, the DON stated after drawing up the injectable medication she expected the nurse to cover the needle with the cap in a way to prevent a needle stick. The DON stated the cap did not necessarily need to be tightly secured. The DON stated it was not policy to wipe down the needle. The DON stated the risk would be an infection control issue and potential needle stick. The DON stated she would monitor Resident #30's injection site for infection keeping in mind the Ceftriaxone may cause redness by itself.<BR/>Interview on 06/08/2023 at 8:30AM RN A stated he had been working at the facility about 1.5 years now and had an inservice regarding administration of medication about one week ago.<BR/>Interview on 06/08/2023 at 8:35AM, the DON stated the DON or the corporate nurse was responsible to conduct nursing staff inservices for medication administration.<BR/>Interview on 06/08/2023 at 10:10AM, the DON stated the records for Nursing Administration of Medications inservices were completed through the online learning courses provided by the facility. The DON stated RN A had signed an inservice on 2/6/2023.<BR/>Record review of the online learning transcript included RN A's completion of the one-hour course for Medication Administration in Acute Care on 2/06/2023, with a final score of 100.<BR/>Record review of the facility policy and procedure manual, section: Medication Administration, Injectable Administration revised on 10/01/2009 read in part: Policy: to administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate and effective manner. Equipment Required .2. Sterile syringe capable of holding the medication volume. 3. Sterile safety needle .Procedure .Sites for Administration: .Intramuscular .withdraw the medication; create air lock. Do not recap needle, remove air bubbles .Sanitize hands with approved sanitizer .put on gloves .prepare skin for injection, remove air from syringe and insert the needle . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for four (Resident #1, Resident #2, Resident #3, and Resident #4) out of five residents reviewed for ADLs, in that:<BR/>The facility failed to provide showers to Resident #1, Resident #2, Resident #3, and Resident #4 in compliance with their shower schedules.<BR/>This deficient practice placed residents at risk of a decline in hygiene, at risk of skin breakdown, and reduced feelings of self-worth.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture), major depressive disorder, age-related physical debility, and muscle wasting and atrophy. <BR/>Review of Resident #1's quarterly care plan, dated 03/01/23, reflected she had an ADL self-care performance deficit related to impaired balance and cerebral palsy with an intervention of requiring assistance of two staff members with bathing/showering.<BR/>Review of Resident #1's quarterly MDS assessment, dated 12/06/22, reflected a BIMS of 5, indicating a severe cognitive impairment. Section G (Functional Status) reflected she required physical help with bathing.<BR/>Review of Resident #1's bathing tasks in her EMR, from 02/13/23 - 03/13/23, reflected she had not received a shower/bath. No refusals were documented.<BR/>During an observation and interview on 03/13/23 at 11:55 AM, Resident #1 was laying in her bed. Her face and hair were greasy. She stated she could not remember the last time she had been showered, but it had been a long time. She stated it made her feel bad and gross. <BR/>Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, muscle wasting and atrophy, and unspecified pain.<BR/>Review of Resident #2's quarterly care plan, dated 01/04/23, reflected she had an ADL self-care performance deficit related to activity intolerance, fatigue, and limited mobility with an intervention of requiring extensive assistance with 1-2 staff with bathing/showering.<BR/>Review of Resident #2's quarterly MDS assessment, dated 01/04/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section G (Functional Status) reflected she required physical help with bathing.<BR/>Review of Resident #2's bathing tasks in her EMR, from 02/13/23 - 03/13/23, reflected she had received a shower on 02/23/23 and 02/25/23. No refusals were documented.<BR/>During an observation and interview on 03/23/23 at 12:05 PM, Resident #2 was sitting in the dining room waiting for lunch to be served. She stated it had been forever since she had been showered. She stated she always felt so good when she did receive one. She stated when she asked for one, she was always told they were too short staffed. She stated she almost had not gone to the dining room for lunch that day because she felt dirty.<BR/>Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia, and muscle weakness.<BR/>Review of Resident #3's initial care plan, dated 03/09/23, reflected no mention of assistance required for ADL care /bathing.<BR/>Review of Resident #3's admission MDS assessment, dated 03/10/23, reflected a BIMS had not been conducted. Section G (Functional Status) reflected the activity of bathing had not occurred over the entire 7-day period.<BR/>Review of Resident #3's bathing tasks in her EMR, from 03/06/23 - 03/13/23, reflected she had not received a shower/bath.<BR/>During an observation and interview on 03/13/23 at 12:11 PM, Resident #3 was pacing in her room. The front of her shirt had brown stains on it. She stated she had not been bathed since she was admitted to the facility (03/06/23). She stated she felt dirty, and the staff kept putting off giving her a shower day after day and she just could not live like that.<BR/>Review of Resident #4's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including muscle weakness, tremors (a type of involuntary movement of the body, distinct from a muscle spasm or twitch), major depressive disorder, and muscle wasting and atrophy.<BR/>Review of resident #4's quarterly care plan, dated 02/27/23, reflected he had an ADL self-care performance deficit related to generalized weakness, seizures, tremors, hypertension (high blood pressure), incontinence, vertigo, impaired cognition, and impaired mobility with no interventions in regard to bathing.<BR/>Review of Resident #4's quarterly MDS assessment, dated 02/26/23, indicated a BIMS of 6, indicating a severe cognitive impairment. Section G (Functional Status) reflected the activity of bathing had not occurred over the entire 7-day period.<BR/>Review of Resident #4's bathing tasks in his EMR, from 02/26/23 - 03/13/23, reflected he had received a shower on 02/27/23 and 03/08/23. A refusal was documented on 03/03/23.<BR/>During an observation and interview on 03/13/23 at 12:16 PM, Resident #4 was in bed watching television with his FM sitting in a chair next to him. Resident #4's face was greasy, and his hair was matted on the back of his head. Resident #4 stated he rarely got showered and he hated it. Resident #3's FM stated he went at least a week without receiving a shower and she normally had to go ask an aide herself for it to get done, and she did not feel like that was okay.<BR/>During an interview on 03/13/23 at 2:20 PM, the DON stated it was her expectation that residents received at least three showers a week. She stated it was ultimately up to her to ensure they were being done regularly. She stated the aidesaide's documented showers in their care tracker (which was reflected in the residents' EMR). The DON stated she had not looked at showers in the EMR's recently but had not heard any complaints of not receiving them. She stated not receiving showers regularly could lead to skin break down and infections. <BR/>During an interview on 03/13/23 at 2:00 PM, the ADM stated the residents had the right to be cleaned appropriately and as often as they wanted. He stated not receiving regular showers could lead to bad hygiene.<BR/>Review of the facility's Activities of Daily Living Policy, dated 10/24/22, reflected the following:<BR/>Care and services will be provided for the following activities of daily living:<BR/>1. Bathing<BR/> .<BR/>3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for three (Nurse Cart 2B Hall, Med Aide Cart 1A Hall, Nurse cart 2A Hall) of four medication carts reviewed for storage of medications.<BR/>Nurse Cart 2B Hall, Med Aide Cart 1A Hall and Nurse cart 2A Hall had punctured protective seals on the back of multiple narcotic medication blister pill cards.<BR/>This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion.<BR/>Findings included:<BR/> Nurse Cart 2B Hall:<BR/>Observation on 05/31/2023 at 10:00am revealed the narcotic storage of Lorazepam 0.5mg tablets #5 and #6 of 9 tablets had torn protective seals. A second blister card of Lorazepam 0.5mg, tablet #3 of 4 tablets had a torn protective seal. A third blister card of Lorazepam, tablet #6 of 30 tablets had a torn protective seal. <BR/>In an interview on 05/31/2023 at 10:00AM, LVN E stated if the resident needed a dose of Lorazepam, he would use the tablets with the broken seal first. LVN E stated if the seal was broken there would be an infection control issue, or someone could remove the pills. LVN E stated he will waste the tablets with another nurse.<BR/>Med Aide Cart 1A Hall: <BR/>Observation on 05/31/2023 at 10:43AM revealed the narcotic storage of Lorazepam 0.5mg, tablet #10 of 10 tablets had a torn seal that was taped over with paper tape. <BR/>In an interview with RN B and DON on 05/31/2023 at 10:43AM, RN B stated the Lorazepam tablet may fall out, get lost and the resident will not have any pills available when needed. RN B stated it should not have been taped, it should be wasted. The DON stated it should not have tape and will be wasted. <BR/>Nurse Med Cart 2A Hall:<BR/>Observation on 06/01/2023 at 12:45PM revealed the narcotic storage of Tramadol 50mg (1/2tabs), tablets #2, #3, #5 of 6 tablets had torn protective seals. A blister card of Lorazepam 0.5mg, had 16 tablets; blister seal #3 was torn, #15 had a puncture, #6 and #8 were torn and taped over with paper tape. A second blister card of Lorazepam 0.5mg tabs had 14 tablets and seal #8 was torn. A third Lorazepam 0.5mg blister card had 34 tablets and blister seal #6 was torn. <BR/>In an interview on 06/01/2023 at 12:45PM, LVN D stated it was not correct to tape up the seals that were broken. LVN D stated the risk would be infection, loss of the drug, depletion of the resident's supply and the tablet may not be the same that was originally in the package. LVN D stated she would notify the ADON, waste the meds with another nurse and place reorders. <BR/>In an interview on 06/01/2023 at 12:50PM, LVN E said all nurses in charge of medication carts were responsible for checking the integrity of blister seals on all packaging.<BR/>In an interview on 06/01/2023 at 4:40PM, the Administrator stated she expected the nurses to be responsible for checking the integrity of the packaging since they are the ones who count it daily. The Administrator stated she expected nurses to waste the meds if the seals are broken as the tablets could fall out and picked up by anyone. The Administrator then stated, I don't know, I would probably tape it if the seal was broken only slightly then label it, do not use, or waste it later.<BR/>Record review of the facility policy for storage of medications, revised April 2007 read in part: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe and sanitary manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing <BR/>Record review of the facility policy for Controlled Substances, revised December 2012 read in part: Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances <BR/>Record review of the undated facility policy for Drug Diversion revealed in part: .Goal, to support the health and safety of its employees, patients and visitors. Policy: Drug diversion (theft) is prohibited. Suspected drug diversion will be investigated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for four (Resident #1, Resident #2, Resident #3, and Resident #4) out of five residents reviewed for ADLs, in that:<BR/>The facility failed to provide showers to Resident #1, Resident #2, Resident #3, and Resident #4 in compliance with their shower schedules.<BR/>This deficient practice placed residents at risk of a decline in hygiene, at risk of skin breakdown, and reduced feelings of self-worth.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture), major depressive disorder, age-related physical debility, and muscle wasting and atrophy. <BR/>Review of Resident #1's quarterly care plan, dated 03/01/23, reflected she had an ADL self-care performance deficit related to impaired balance and cerebral palsy with an intervention of requiring assistance of two staff members with bathing/showering.<BR/>Review of Resident #1's quarterly MDS assessment, dated 12/06/22, reflected a BIMS of 5, indicating a severe cognitive impairment. Section G (Functional Status) reflected she required physical help with bathing.<BR/>Review of Resident #1's bathing tasks in her EMR, from 02/13/23 - 03/13/23, reflected she had not received a shower/bath. No refusals were documented.<BR/>During an observation and interview on 03/13/23 at 11:55 AM, Resident #1 was laying in her bed. Her face and hair were greasy. She stated she could not remember the last time she had been showered, but it had been a long time. She stated it made her feel bad and gross. <BR/>Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, muscle wasting and atrophy, and unspecified pain.<BR/>Review of Resident #2's quarterly care plan, dated 01/04/23, reflected she had an ADL self-care performance deficit related to activity intolerance, fatigue, and limited mobility with an intervention of requiring extensive assistance with 1-2 staff with bathing/showering.<BR/>Review of Resident #2's quarterly MDS assessment, dated 01/04/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section G (Functional Status) reflected she required physical help with bathing.<BR/>Review of Resident #2's bathing tasks in her EMR, from 02/13/23 - 03/13/23, reflected she had received a shower on 02/23/23 and 02/25/23. No refusals were documented.<BR/>During an observation and interview on 03/23/23 at 12:05 PM, Resident #2 was sitting in the dining room waiting for lunch to be served. She stated it had been forever since she had been showered. She stated she always felt so good when she did receive one. She stated when she asked for one, she was always told they were too short staffed. She stated she almost had not gone to the dining room for lunch that day because she felt dirty.<BR/>Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia, and muscle weakness.<BR/>Review of Resident #3's initial care plan, dated 03/09/23, reflected no mention of assistance required for ADL care /bathing.<BR/>Review of Resident #3's admission MDS assessment, dated 03/10/23, reflected a BIMS had not been conducted. Section G (Functional Status) reflected the activity of bathing had not occurred over the entire 7-day period.<BR/>Review of Resident #3's bathing tasks in her EMR, from 03/06/23 - 03/13/23, reflected she had not received a shower/bath.<BR/>During an observation and interview on 03/13/23 at 12:11 PM, Resident #3 was pacing in her room. The front of her shirt had brown stains on it. She stated she had not been bathed since she was admitted to the facility (03/06/23). She stated she felt dirty, and the staff kept putting off giving her a shower day after day and she just could not live like that.<BR/>Review of Resident #4's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including muscle weakness, tremors (a type of involuntary movement of the body, distinct from a muscle spasm or twitch), major depressive disorder, and muscle wasting and atrophy.<BR/>Review of resident #4's quarterly care plan, dated 02/27/23, reflected he had an ADL self-care performance deficit related to generalized weakness, seizures, tremors, hypertension (high blood pressure), incontinence, vertigo, impaired cognition, and impaired mobility with no interventions in regard to bathing.<BR/>Review of Resident #4's quarterly MDS assessment, dated 02/26/23, indicated a BIMS of 6, indicating a severe cognitive impairment. Section G (Functional Status) reflected the activity of bathing had not occurred over the entire 7-day period.<BR/>Review of Resident #4's bathing tasks in his EMR, from 02/26/23 - 03/13/23, reflected he had received a shower on 02/27/23 and 03/08/23. A refusal was documented on 03/03/23.<BR/>During an observation and interview on 03/13/23 at 12:16 PM, Resident #4 was in bed watching television with his FM sitting in a chair next to him. Resident #4's face was greasy, and his hair was matted on the back of his head. Resident #4 stated he rarely got showered and he hated it. Resident #3's FM stated he went at least a week without receiving a shower and she normally had to go ask an aide herself for it to get done, and she did not feel like that was okay.<BR/>During an interview on 03/13/23 at 2:20 PM, the DON stated it was her expectation that residents received at least three showers a week. She stated it was ultimately up to her to ensure they were being done regularly. She stated the aidesaide's documented showers in their care tracker (which was reflected in the residents' EMR). The DON stated she had not looked at showers in the EMR's recently but had not heard any complaints of not receiving them. She stated not receiving showers regularly could lead to skin break down and infections. <BR/>During an interview on 03/13/23 at 2:00 PM, the ADM stated the residents had the right to be cleaned appropriately and as often as they wanted. He stated not receiving regular showers could lead to bad hygiene.<BR/>Review of the facility's Activities of Daily Living Policy, dated 10/24/22, reflected the following:<BR/>Care and services will be provided for the following activities of daily living:<BR/>1. Bathing<BR/> .<BR/>3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**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 be treated with respect and dignity for one (Resident # 11) of eight residents reviewed for dignity.<BR/>Resident # 11 waited 14 minutes staring at her meal tray before a staff member set down to assist with feeding Resident # 11.<BR/>This failure placed residents at risk of not being treated with dignity.<BR/>Findings included:<BR/>A record review of Residents # 11's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), traumatic subarachnoid hemorrhage (bleeding on the brain), wedge compression fracture of the T5-T6 vertebra (spinal fracture), major depressive disorder ( A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life.), cervicalgia (Neck pain),and anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.)<BR/>A record review of Resident # 11's care plan last revised on 5/09/2024 reflected she had ADL self-care performance deficit related to dementia, limited mobility, and terminal illness. Resident # 11's interventions reflected she needed total assistance by 1 staff to eat.<BR/>An observation of meal service on 7/29/2024 at 1:00 pm revealed Resident # 11 lunch meal tray was sat in front of her. The Activity director came over and set up Resident # 11 meal tray without performing hand hygiene prior to touching meal tray and food items. After meal tray was set up the Activity Director walked away. Resident # 11 sat staring at her meal tray for 14 minutes before a staff member came over and sat down to assist with feeding Resident # 11 her meal tray.<BR/>Interview with the Dietary Director on 7/29/2024 at 2:00 pm reflected the dining room trays are served after the hall trays go out. The Dietary Director said the meal tickets are in the order they are printed but they try to serve all residents at one table at a time. The Dietary Director said as for the trays of residents who need assistance those are not separated, they just come out in the normal order as they are printed. <BR/>Record review of Meal Service policy dated 10/1/2018 reflected under heading policy: The facility believes that all residents should be always treated with dignity and respect. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. 7.Residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining.