UVALDE HEALTHCARE AND REHABILITATION CENTER

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.<BR/>Findings included:<BR/>Record Review of the Employee Service List, dated 02/07/2024, revealed Employee A was listed as the Dietary Manager with a hire date of 08/02/2023.<BR/>In an interview on 02/08/2024 at 12:20 p.m. Employee A revealed she had been hired as a cook in August of 2023 and when the previous supervisor left sometime in October [2023] she had moved into the DM role. Employee A further revealed she did not have any certification or degrees as a nursing home DM and stated she was previously in a management position at a local restaurant. Employee A revealed she was signed up for classes when she took the DM position in October of 2023 and would complete the course in October of 2024.<BR/>In an interview on 02/08/2024 at 2:47 p.m., the BOM/Assistant Administrator confirmed she had enrolled Employee A in a dietary manager training course when she was moved into the new position however she had not completed a dietary manager training course at this point. The BOM/AA stated she felt the DM was doing an excellent job and the facility had a consultant dietitian who was available to Employee A as needed and in the facility one to two days each month.<BR/> Record review of the job description for Dietary Service Manager, provided by the facility revealed a section, Base Knowledge: Current certification by state as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 (Resident #101) residents in that: <BR/>LVN T did not use hand hygiene between cleaning Resident #101's plate/tray and touching an unknown resident's dessert plate. <BR/>This could affect all residents that use plates from kitchen and could result in bacteria and cross contamination. <BR/>The findings were: <BR/>Record review of Resident #101's face sheet dated 3/11/2024 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of Parkinson's disease, (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves. Symptoms start slowly. The first symptom may be a barely noticeable tremor in just one hand. Tremors are common, but the disorder may also cause stiffness or slowing of movement), diabetes II, osteoarthritis (type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone) and pain. <BR/>Observation on 3/11/24 at 12:53 PM revealed Resident # 101 sitting in his wheelchair in the main dining room. LVN T served Resident # 101 his food tray, placed food items in front of him, then went to the other side of the room to put down his tray and throw things away. Then LVN T went over to pick up an unknown resident's dessert plate, then left the dining room. LVN T did not use hand hygiene after putting unknown residents' tray down and picking up unknown resident's dessert plate. <BR/>Interview on 3/11/24 at 1:04 PM with LVN T stated she had served food to Resident #101, threw the trash from his tray away, then lifted an unknown residents' dessert tray to see if they were in the dining area. LVN T stated she was helping to serve in the dining room, then went back to her station to wash her hands and return to the nurse's station. LVN T stated her hand sanitizer was in her pocket, but she did not use it between resident food items. LVN T stated she did not serve the dessert tray, since the resident was not in the dining room. <BR/>Interview on 3/11/24 at 01:38 PM with DON stated staff should use good hand hygiene (washing/disinfecting hands in between resident food items), in between touching resident food trays. <BR/>Interview on 3/12/24 at 9:03 AM with Administrator discussed hand hygiene with LVN T touching the dessert plate, without hygiene between resident care. The Administrator had no response the infection control observation. <BR/>Interview on 3/12/24 at 9:21 AM with DON stated the risk of staff not using good hand hygiene was cross contamination.<BR/>Record review of policy Handwashing/Hand Hygiene dated August 2019 revealed The facility considers hand hygiene the primary means to prevent the spread of infections. Before and after eating or handling food, and before and after assisting a resident with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 kitchen reviewed for pests.<BR/>The facility failed to have pest control effectively treat the kitchen for roaches.<BR/>This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.<BR/>The findings include:<BR/>During an observation and interview on 04/10/2025 at 06:07 a.m., revealed a live roach on the floor in the clean pots and pan storage room. This observation was pointed out to DA A, who immediately got a broom, swept the roach up, and removed it from the kitchen. DA A stated the roach was alive. DA A stated he knew that someone came and sprayed the kitchen twice a month for bugs. <BR/>During an interview on 04/10/2025 at 02:39 p.m., the DS stated she was told about the water roach seen this morning. She stated that the facility kitchen did have stragglers but did not know how the water roach got in. She stated the kitchen had pest control treatment every month. <BR/>During an interview on 04/10/2025 at 02:57 p.m., the Maint Dir stated the facility had monthly pest control services. He stated that the facility had recently changed pest control companies due to a concern that the prior company's chemical spray was not strong enough. He stated that the new company appeared to be working better for the facility's needs. He stated the new company had been treating the kitchen with a new chemical that seemed to be working. He stated he believed the small bug found that morning possibly entered the kitchen due to a clean out area that had flooded during the night by the kitchen grease trap. He stated that the clean out area and flooding were addressed and fixed that same morning. <BR/>During an interview on 04/10/2025 at 04:05 p.m., the ADMIN stated the facility changed pest control companies recently due to a concern brought by the maintenance department regarding the prior company's solution not having been effective. The ADMIN stated the facility had not had pest control concerns reported since the change in companies. She stated pests in the kitchen would be an infection control concern and the bug found that morning was brought to her attention. She stated it was due to a backing up of the drainage system, which did not occur very often. She stated the facility maintenance and dietary department do regular rounds to check the environment and would report any concerns they found. <BR/>Record review of Pest Control Service Proposal, dated as signed 03/18/2025, revealed: <BR/>PESTS TO BE CONTROLLED: Ants, Centipedes, American Roaches, Silverfish, Pill Bugs Earwigs, Millipedes, [NAME] Bugs, Spiders and Scorpions. <BR/>NOTE: Rodents including Mice & Rats, [NAME]/Ticks, [NAME] Destroying Insects, Flying Insects, Bed Bugs, German Roaches and Lawn Treatments require different procedures and are not covered by this agreement.<BR/>[Pest Control Company Name] will provide all materials and labor to perform Monthly Pest Control Service at the above location .<BR/> Roach Clean-Out Control (2 services 30 days apart) .<BR/> Monthly Commercial Pest Control Charge (Includes roach bating).<BR/>Record review of Pest Control Invoice, dated 03/19/2025, revealed the following service, ROACH CLEAN OUT (1 of 2 trips) NO WARRANTY FOR SERVICE. Under Target Pest: American Roach, Ant, German Roach, and Spider were marked. Remarks: German Roaches in the Dietary was noted on the invoice document. <BR/>Record review of Pest Control Invoice, dated 03/25/2025, revealed the following service, MONTHLY COMMERCIAL SERVICE. Under Target Pest: American Roach, Ant, and Spider were marked. Remarks: German Roaches in the Dietary was noted on the invoice document. <BR/>Record review of facility policy, Pest Control, dated as revised May 2008, revealed under Policy Statement, Our facility shall maintain an effective pest control program. Under Policy Interpretation and Implementation, 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 20 Residents (Resident #30) reviewed for comprehensive care plans, in that:<BR/>The facility failed to ensure Resident #30's care plan addressed services that were to be provided by hospice and the facilities responsibilities.<BR/>This failure could place residents at risk of not receiving care and services needed and a diminished quality of life. <BR/>The findings were:<BR/>Record review of Resident #30's face sheet, dated 2/2/2023, revealed the resident was initially admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses which included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease stage 3 (kidneys have mild to moderate damage and they are less able to filter waste and fluid out of your blood), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone, which can disrupt such things as heart rate, temperature and all aspects of metabolism), gastroesophageal reflux disease (Gerd-a digestive disease in which the stomach acid or bile irritates the food pipe lining) and cognitive communication deficit.<BR/>Record review of Resident #30's Quarterly MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 4 which indicated the resident had severe impaired cognitive status and was receiving hospice services.<BR/>Record review of Resident #30's Physician Orders revealed the resident was admitted to hospice services on 10/14/2021.<BR/>Record review of Resident #30's care plan revealed a care plan with a start date of 4/12/2021 revealed the problem, Potential for sig (significant) weight loss due to nutrition and potential for aspiration R/T (related to) hypothyroidism, GERD (Gastroesophageal reflux disease), on hospice services for end stage heart failure, and he has broken/chipped teeth. Further review of the care plan revealed the goal addressed the resident would receive adequate nutrition and the approaches addressed the resident's prescribed diet, oral care, monitoring for aspiration and offering substitutes if the resident ate less than 50% of meals. Further review of the resident's care plans revealed there was not a care plan that addressed the specific goal and interventions and services provided by hospice. <BR/>In an interview on 2/2/2023 at 3:38 p.m. with RN/MDS E revealed she worked for the facility about a month. RN/MDS E reported care plans were created to address resident care to know what the resident needed. RN/MDS E reported a hospice care plan should note the resident was on hospice services and that basic needs were addressed. RN/MDS E revealed she knew what to care plan by looking at the face sheet diagnoses, orders, the Resident Assessment Instrument (RAI) and any records from a hospital. RN/MDS E reported she would normally care plan hospice as a problem on its own, and provide goals and interventions related to hospice services and not combine it in another care plan. RN/MDS E reported care plans were necessary for staff to do care the residents needed and to know who was on hospice services.<BR/>Record review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for respiratory care.<BR/>The facility failed to ensure Resident #1's oxygen concentrator filter was cleaned and free of debris. <BR/>This deficient practice could place residents at risk for an increase in respiratory complications. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 4/4/25, revealed a [AGE] year-old male admitted on [DATE] with diagnoses wheezing, cough, end stage renal disease, and atherosclerotic heart disease native coronary artery (accumulation of plaque within the arterial walls, leading to narrowed or blocked arteries) without angina pectoris (chest pain that comes and goes). <BR/>Record review of Resident #1's Annual MDS assessment, dated 1/2/25, revealed the resident's cognition was moderately impaired for daily decision making. <BR/>Record review of Resident #1's care plan, dated 4/4/25, revised 4/1/25 revealed the resident was at risk for ineffective breathing related to congestion to lung fields with approach to notify MD of shortness of breath (SOB) not relieved by oxygen, nebulizers, or medications. <BR/>Record review of Resident #1's physician order summary, dated 4/3/25, revealed an order for oxygen at 2-3 liters per minute via nasal cannula as needed for SOB/Dyspnea, with an order date of 6/23/24, and no end date. <BR/>During an observation on 4/1/25 at 12:00 p.m. Resident #1 had an oxygen concentrator in his room. A layer of built-up lint/dust was noted on the filter. <BR/>During an interview on 4/1/25 at 12:01 p.m. Resident #1 stated he used the oxygen sometimes and had never seen anyone clean it. <BR/>During an interview on 4/3/25 at 4:55 p.m. LVN C stated there was dust on the oxygen concentrator filter in Resident #1's room. LVN C stated she was unsure if maintenance or housekeeping was responsible for cleaning the oxygen filters. <BR/>During an interview on 4/3/25 at 4:59 p.m. the Housekeeping Supervisor stated housekeeping staff was expected to clean the oxygen filters daily when they cleaned the resident rooms. The Housekeeping Supervisor stated the filter on Resident #1's concentrator looked dirty and looked like it had not been cleaned recently. The Housekeeping Supervisor stated the resident could breathe in the dust and have breathing issues from it. <BR/>During an interview on 4/3/25 at 5:12 p.m. the DON stated nursing staff should be checking the oxygen concentrators and can clean them. The DON stated a resident is at risk for a respiratory infection if they do not keep the filters clean. <BR/>Record review of the facility's policy titled Departmental (Respiratory Therapy)- Prevention of Infection, dated 2001, revised 11/2011, stated The Purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff . Steps in the Procedure .9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #20) reviewed for dialysis:<BR/>The facility failed to fully complete the dialysis communication forms for Resident #20 on 3/24/25 and 3/31/25.<BR/>This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. <BR/>The findings included:<BR/>Record review of Resident #20's face sheet, dated 4/4/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic (lack of oxygen) brain injury, end stage renal disease (ESRD) (your kidneys can no longer support your body's needs), and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic neuropathy (nerve damage that affects people with diabetes. The most common type is peripheral neuropathy, which often affects your feet.). <BR/>Record review of Resident #20's quarterly MDS assessment, dated 1/22/25, revealed Resident #20's cognition was moderately impaired for daily decision making. Section O revealed Resident #20 received dialysis. <BR/>Record review of the Resident #20's Care Plan, dated 4/3/25, last revised 4/1/25 revealed she required dialysis related to ESRD with approaches to obtain vital signs/weight as needed. Report significant changes in pulse, respiration, and blood pressure immediately. <BR/>Record review of Resident #20's physician orders, dated 4/3/25, revealed orders for:<BR/>- [dialysis center] .chair time 11:15 a.m.once a day on Monday, Wednesday, and Friday, with a start date of 12/17/24, and no end date. <BR/>-Left AV (arteriovenous fistula) shunt (a passage or anastomosis between two natural channels, especially between blood vessels): Monitor for +bruit (the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery) and thrill (An abnormal vibration that is felt on the skin overlying a loud cardiac murmur or an arteriovenous fistula.) every shift day and night, with a start date of 4/29/23, and no end date. <BR/>Record review of Resident #20's dialysis communication forms revealed: <BR/>-On 3/24/25 the post dialysis section did not have vitals and a line was drawn through the area for vitals. The section was signed by LVN D. <BR/>-On 3/31/25 the post dialysis section to be completed by the nursing facility was blank. There was no vitals, assessment for presence of bruit or thrill, assessment for infection or bleeding, and assessment of the dressing. There was no nurse signature. <BR/>Record review of Resident #20's vitals, dated 4/3/25, revealed vitals from the previous 30 days. No vitals were found for dates 3/24/25 and 3/31/25 at the time the resident returned from dialysis in the afternoon. <BR/>During an interview on 4/4/25 at 10:26 a.m. LVN D stated he worked the 6 a.m. shift to 6 p.m. shift. LVN D stated he would assess residents before dialysis and upon return from dialysis which included assess for thrill, bruit, assesses the access site, and obtaining vitals. LVN D stated the dialysis center would let the nursing facility know if there was a change in status for the resident during dialysis. LVN D stated he should also take the residents vitals upon return from dialysis to see there was no changed in the residents status. LVN D stated he forgot to mark the vitals on the communication form from 3/24/25. LVN D stated it was important to assess the resident upon return from dialysis to make sure the resident was stable. <BR/>During an interview on 4/4/25 at 10:32 a.m. the DON stated nursing staff should take vitals before a resident goes to dialysis and upon return and document it on the dialysis communication form. The DON stated they assess the resident and take vitals to make sure their blood pressure if not dropping and to see how they feel after. <BR/>Record review of the facility's policy titled Hemodialysis Catheters- Access and Care of, dated 2001, revised 2/23, stated Purpose Hemodialysis catheters will only be accessed by medical staff who have received training and demonstrated clinical competency regarding use of this catheter. Guidelines .Care of AVFs .3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 4. To prevent infection and/ or clotting .d. check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing routine care and at regular intervals .g. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. h. Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access .Documentation. The nurse should document in the resident's medical records every shift as follows: 1. Location of the catheter. 2. The condition addressing (interventions if needed). 3. If dialysis is done during shift. 4. Any part of the report from dialysis nurse post dialysis being given. 5. Observations post dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed the facility failed to ensure correct use of bed rails including but not limited to the following elements. Assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation for 1 of 8 Residents (Resident #20) whose records were reviewed for bed rails. <BR/>The facility failed to ensure staff obtained informed consent (the facility has explained to the resident or RP the risk and benefits of using bedrails) for the use of 1/4 bed rails for Resident #20.<BR/>These deficient practices could affect residents who used bed rails and could put the residents at risk for potential injuries. <BR/>Findings Included:<BR/>Record review of Resident #20's face sheet, dated 4/4/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic (lack of oxygen) brain injury, muscle weakness, and rheumatoid arthritis (chronic, condition that causes pain, swelling and irritation, called inflammation, in the joints). <BR/>Record review of Resident #20's quarterly MDS assessment, dated 1/22/25, revealed Resident #20's cognition was moderately impaired for daily decision making. Section P revealed Resident #20 used bed rails. <BR/>Record review of the Resident #20's Care Plan, dated 4/3/25, last revised 4/1/25 revealed she used side rails and was at risk for injury with approach assess for the use of side rails quarterly and as needed. <BR/>Record review of Resident #20's physician orders, dated 4/3/25, revealed an orders for &frac14; rails x2 to promote independence, aid in repositioning. Special instructions: &frac14; rails x2 to promote independence with repositioning, with a start date of 10/31/24, and no end date. <BR/>Record review of Resident #20's side rails assessment and consent, dated 4/27/21 showed the side rails were not in use and had no resident or family signature for consent. <BR/>During an observation on 4/1/25 at 12:33 p.m. Resident #20's bed had &frac14; rails on it. <BR/>During an interview on 4/4/25 at 11:22 a.m. the MDS nurse stated nursing staff would normally fill out a consent form at the time the side rail order was initiated. The MDS nurse stated there should be a consent for Resident #20's side rails. The MDS nurse stated it was important to obtain a consent to show the family and resident were aware of the risk of using side rails. <BR/>Record review of the facility's policy titled Bed Safety and Bed Rails, dated 2001, revised 8/22, stated use of bed rails is prohibited unless the criteria for use of bed rails have been met .The Use of Bed Rails .8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with use of bed rails; b. The resident's risk from the use of bed rails and how these will be mitigated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.67% based on 2 out of 30 opportunities, which involved 2 of 3 Residents (Resident #1 and Resident #35) reviewed for medication administration, in that:<BR/>1. The facility failed to ensure LVN C administered Resident #1's insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) correctly. <BR/>2. The facility failed to ensure MA B administered the full dose of Resident #35's polyethylene glycol 3350 (osmotic laxative that attracts water into the colon to ease, hydrate, and soften stool). <BR/>These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. <BR/>The findings included:<BR/>1. Record review of Resident #1's admission Record, dated 4/4/25, revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, wheezing, cough, end stage renal disease, and atherosclerotic heart disease native coronary artery (accumulation of plaque within the arterial walls, leading to narrowed or blocked arteries) without angina pectoris (chest pain that comes and goes). <BR/>Record review of Resident #1's Annual MDS assessment, dated 1/2/25, revealed the resident's cognition was moderately impaired for daily decision making. <BR/>Record review of Resident #1's care plan, dated 4/4/25, revised 4/1/25 revealed the resident was at risk for S&A of hyper/hypoglycemia [refer to blood sugar levels that are too low or too high] related to diagnosis of diabetes mellitus with approaches to monitor blood sugar as ordered by the MD. <BR/>Record review of Resident #1's physician order summary, dated 4/3/25, revealed an order for insulin lispro pen, 100 unit/mL, amount 10 units, subcutaneous. Hold if blood sugar less than 100 mg/dL before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m., with a start date of 7/11/24, and no end date. <BR/>During an observation on 4/3/25 at 10:37 a.m. LVN C cleaned Resident #1's insulin pen with an alcohol swab, turned the pen to 10 units, placed the needle on the pen, went into the resident's room, removed the needle cover, and administered the insulin into the resident right side of his abdomen. LVN C did not prime the insulin pen prior to administration. <BR/>During an interview on 4/3/25 at 10:44 a.m. LVN C stated she did not prime the insulin pen prior to administering the insulin to the resident. LVN C stated she had not had any training on using insulin pens and was not aware they needed to be primed. <BR/>During an interview on 4/3/25 at 12:11 p.m. the DON stated it was recommended staff prefill or prime an insulin pen prior to administering it. The DON stated she had not gone over any training with nursing staff because she was waiting on new training books to come in and had not had an opportunity to use them yet. The DON stated they did not have a specific policy for insulin pen administration. <BR/>2. Record review of Resident #35's admission Record, dated 4/4/25, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of dementia, other lack of coordination, and chronic pain. <BR/>Record review of Resident #35's Quarterly MDS assessment, dated 3/10/25, revealed the resident's cognition was moderately impaired for daily decision making. <BR/>Record review of Resident #35's MAR, dated 4/3/25, revealed an order for 1 cap or 17 grams of polyethylene glycol once a day. <BR/>During an observation on 4/3/25 at 8:03 a.m. MA B pour the polyethylene glycol for Resident #35 into a cap from the bottle. The cap had one line halfway and a second line at the top of the cap for 17 grams. MA B pour to the first line in the cap and only poured half the dose. MA B then mixed the polyethylene glycol with water and administered it to the resident. <BR/>During an interview on 4/3/25 at 9:01 a.m. MA B stated she thought she poured a cap full. MA B stated she should pour to the top of the white cap to ensure the resident gets the full dose of medication so he can have normal bowels. <BR/>During an interview on 4/3/25 at 12:07 p.m. the DON stated aides could use a graduated cup to measure the medication amount. The DON stated if staff only pour half the dose, they would not be administering the full amount for full effect, so they would need to notify the doctor and follow any recommendations. <BR/>Record review of the facility's policy titled Administering medications, dated 2001, revised 4/19, stated medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . <BR/>Record review of manufacturer instructions for (insulin lispro) Instructions for Use, dated 8/2023, stated .Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the needle, and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal reviewed for food and nutrition services in that:<BR/>The facility failed to ensure Resident #1 received a health shake with his lunch meal on 10/3/24.<BR/>This failure could place residents at risk for dissatisfaction, poor intake, weight loss, and diminished quality of life.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 10/3/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acute gastritis (sudden inflammation or swelling of the stomach lining causing acid to irritate and inflame the lining) with bleeding, esophageal obstruction (blockage or narrowing of the esophagus, the tube that carries food and liquids from the mouth to the stomach), heartburn (burning sensation or discomfort in the chest or throat often caused by acid reflux), gastro-esophageal reflux disease (backward flow of stomach acid or contents into the esophagus), abnormal weight loss, and protein-calorie malnutrition (condition caused by a deficiency of both protein and calories in the diet leading to a range of health issues).<BR/>Record review of Resident #1's most recent annual MDS assessment, dated 7/30/24 revealed the resident was moderately cognitively intact for daily decision-making skills, was diagnosed with malnutrition and received a mechanically altered diet texture.<BR/>Record review of Resident #1's Physician Order Report, dated 8/1/24 to 10/3/24 revealed the following:<BR/>-Diet: LCS/Pureed diet/Thin liquids, Special Instructions: HOUSE SHAKES WITH MEALS [DX: Esophageal obstruction] Three Times A Day; 0800 AM, 12:00 PM, 05:00 PM, with order date 8/6/24 and no stop date<BR/>Record review of Resident #1's comprehensive care plan, with review date 8/27/24 revealed the resident was on a planned weight gain program related to history of significant weight loss and low BMI, with approaches that included to Provide supplements: house shakes with meals and TID.<BR/>During an observation on 10/3/24 at 11:32 a.m., during the lunch meal, revealed the [NAME] and Dietary Aide C preparing the lunch trays. Dietary Aide C was overheard saying, we just got the shakes delivered this morning, but won't get to serve them at lunch because they are still frozen. <BR/>During an interview on 10/3/24 at 11:58 a.m., Dietary Aide C revealed, Resident #1 would be getting two cartons of milk and a serving of apple sauce instead of the milk shakes he was supposed to get because they ran out of milk shakes last night. Dietary Aide C further stated the shipment of milk shakes were delivered to the facility earlier that morning but would not be served because they were frozen. <BR/>During an observation and interview on 10/3/24 at 12:15 p.m., revealed Resident #1 sitting up in bed eating his lunch and there were no milk shakes on the tray. Resident #1's meal ticket revealed he received a regular, pureed diet and supplements that included 1 carton of vanilla milk shake, and a note that stated, HOUSE SHAKE WITH EVERY MEAL. Further review of the meal ticket revealed 2 milk was handwritten with a black marker. Resident #1 stated he did not get a house shake, they ain't got none. The last time I got a shake maybe day before last. They're out of shakes and I get 2 with every meal. <BR/>During an interview on 10/3/24 at 12:43 p.m., the DS stated Resident #1 always asked for 2 milk shakes and 2 milks. The DS stated, We can give him an extra milk and at dinner he will be served his house shake. The DS stated the facility received a delivery earlier that morning that included the house shakes but because they were delivered frozen, they were not served to the resident at lunch, but he will get it at dinner because it should be thawed by then. The DS stated the facility ran out of house shakes the night before and was not served during dinner.<BR/>During an interview on 10/3/24 at 1:31 p.m., LVN D revealed she had checked Resident #1's lunch tray and was aware the resident was supposed to receive a house shake with meals, but confirmed the resident received a carton of milk instead. LVN D stated since the resident did not have a milk shake on the lunch tray when she checked it, she assumed the kitchen didn't have any, so I didn't ask them. LVN D stated, I wouldn't call the doctor about getting a substitution for the milk shake, that would be up to the kitchen staff.<BR/>During an interview on 10/3/24 at 1:45 p.m., the DON revealed Resident #1 had a physician's order for a house shake with every meal. The DON further stated the kitchen staff could offer an alternative, but it was ultimately up to the physician to order a substitute if the resident did not receive it because it was not available, then the doctor should have been notified. <BR/>Record review of the facility policy and procedure titled, Food Preparation and Food Service, undated, revealed in part, .The primary purpose of the dietary department of this facility is to prepare and serve meals in a way to ensure that the food and nutrition service is operating in a safe, sanitary and efficient matter. The menus are prepared in accordance with the physician's orders and to meet the Recommended Dietary Allowance of the Food and Nutrition Board, National Research Council .

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food handling sanitation. <BR/>1. The facility failed to ensure the kitchen ice machine was clean.<BR/>2. The facility failed to ensure the kitchen handwashing sink was supplied with hot water.<BR/>These failures could place residents at risk for cross-contamination and foodborne illnesses. <BR/>The findings include:<BR/>Observation on 01/31/23 at 1:42 PM revealed the designated handwashing sink within the kitchen to only provide cold water.<BR/>Observation on 02/01/23 at 11:14 AM revealed several large black spots along the inside of the ice machine.<BR/>Interview on 02/01/23 at 11:21 AM, the DS stated the ice maker was serviced approximately 1 month ago (January 2023) and should have been cleaned thoroughly. The DS stated the black substance observed was mold. The DS stated the protocol for maintaining the cleanliness of the ice maker was to observe the ice maker from the inside on a regular basis and submit a work order to the MS when they observed it needed to be cleaned. The DS stated the ice maker was cleaned regularly by a third-party vendor. The DS stated she did not know the frequency of cleaning and approximated quarterly. The DS stated the reason the ice maker was not currently free of mold was due to an incomplete work order by the third-party vendor. The DS additionally stated the designated handwashing sink did not have cold water, so staff would use the 3-compartment sink. The DS stated staff were not able to use the 3-compartment sink when it was in operation to wash their hands. The DS stated she submitted a work request to fix the handwashing sink approximately 3 months ago (November 2022) but the problem had not been corrected.<BR/>Interview on 02/02/23 at 12:19 PM, the Maintenance Supervisor stated a request to look at the hot water in the handwashing sink was submitted to him when he started in his position about 4 months ago (October 2022). The MS stated he knew hot water was operating in the 3-compartment sink but was not aware of the handwashing sink. The MS stated he was trying to fix the handwashing sink himself without the help of a vendor. The MS stated the previous MS tried to fix the handwashing sink and completed the repair improperly. The MS stated he attempted to clean the ice maker by himself by cleaning the front face of the unit and cleaning the filters. The MS stated a vendor came to work on the ice maker about a month ago (January 2023) to clean the ice maker by emptying the ice, defrost, and cleaned the inside of the unit. The MS stated he did not check the ice maker after the vendor completed the work and had not cleaned the inside of the unit himself. The MS stated ensuring the cleanliness of the ice maker was the responsibility of the dietary staff.<BR/>Interview on 1/02/2023 at 3:15 PM, the DON stated it was her expectation food provided to the residents was prepared in accordance with professional standards. The DON stated it her expectation for the ice maker that provided ice to the residents was clean and free of mold. The DON stated it was her expectation that staff who prepared food for the residents washed their hands properly while in the kitchen. The DON stated a risk of the ice maker containing mold and dietary staff not washing their hands properly would be the residents could contract foodborne illness.<BR/>Interview on 2/03/2023 at 9:39 AM, the ADM stated she was not aware the ice maker had not been cleaned or the designated handwashing sink was not operating properly. The ADM stated it was her expectation food provided to the residents was prepared in accordance with professional standards. The ADM stated it was her expectation for the ice maker that provided ice to the residents was cleaned and free of mold. The ADM stated it was her expectation that staff who prepared food for the residents washed their hands properly while in the kitchen. The ADM stated a risk of the ice maker containing mold and dietary staff not washing their hands properly would be the residents could contract foodborne illness.<BR/>Record review of the facility's, undated, policy titled Cleaning Schedulereflected ice maker to be listed within the section Weekly (Thorough Cleaning).<BR/>Record review of the facility's, undated, policy titled Sanitizing Ice Machine and Scoops reflected Sanitize inside [with] clean saturated with sanitizing solution.<BR/>Record review of facility's, undated, policy titled Handwashingreflected wet hands with warm running water.<BR/>Record review of the US Food Code, dated 2017, revealed 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38oC (100oF) through a mixing valve or combination faucet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 20 Residents (Resident #30) reviewed for comprehensive care plans, in that:<BR/>The facility failed to ensure Resident #30's care plan addressed services that were to be provided by hospice and the facilities responsibilities.<BR/>This failure could place residents at risk of not receiving care and services needed and a diminished quality of life. <BR/>The findings were:<BR/>Record review of Resident #30's face sheet, dated 2/2/2023, revealed the resident was initially admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses which included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease stage 3 (kidneys have mild to moderate damage and they are less able to filter waste and fluid out of your blood), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone, which can disrupt such things as heart rate, temperature and all aspects of metabolism), gastroesophageal reflux disease (Gerd-a digestive disease in which the stomach acid or bile irritates the food pipe lining) and cognitive communication deficit.<BR/>Record review of Resident #30's Quarterly MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 4 which indicated the resident had severe impaired cognitive status and was receiving hospice services.<BR/>Record review of Resident #30's Physician Orders revealed the resident was admitted to hospice services on 10/14/2021.<BR/>Record review of Resident #30's care plan revealed a care plan with a start date of 4/12/2021 revealed the problem, Potential for sig (significant) weight loss due to nutrition and potential for aspiration R/T (related to) hypothyroidism, GERD (Gastroesophageal reflux disease), on hospice services for end stage heart failure, and he has broken/chipped teeth. Further review of the care plan revealed the goal addressed the resident would receive adequate nutrition and the approaches addressed the resident's prescribed diet, oral care, monitoring for aspiration and offering substitutes if the resident ate less than 50% of meals. Further review of the resident's care plans revealed there was not a care plan that addressed the specific goal and interventions and services provided by hospice. <BR/>In an interview on 2/2/2023 at 3:38 p.m. with RN/MDS E revealed she worked for the facility about a month. RN/MDS E reported care plans were created to address resident care to know what the resident needed. RN/MDS E reported a hospice care plan should note the resident was on hospice services and that basic needs were addressed. RN/MDS E revealed she knew what to care plan by looking at the face sheet diagnoses, orders, the Resident Assessment Instrument (RAI) and any records from a hospital. RN/MDS E reported she would normally care plan hospice as a problem on its own, and provide goals and interventions related to hospice services and not combine it in another care plan. RN/MDS E reported care plans were necessary for staff to do care the residents needed and to know who was on hospice services.<BR/>Record review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 22 residents (Residents #18 and #35) reviewed for accidents and hazards in that: <BR/>The facility failed to ensure Residents #18 and #35 did not have two disposable razors in their rooms. <BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents.<BR/>The findings were:<BR/>1. Record review of Resident #18's Face sheet, dated 02/03/23, revealed an admission date of 09/28/22 and readmission date of 01/02/23 with diagnoses which included seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), lack of coordination, and unspecified dementia with behavioral disturbances (Dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life). <BR/>Record review of for Resident #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 4 which indicated severe impaired cognition. <BR/>Record review of Resident #18's Care Plan dated 02/01/23 revealed the resident experienced wandering moved with no rational purpose, seemingly oblivious to needs or safety, with a goal for the Resident to wander safely within specified boundaries. Wander-guard in place (a device that is worn by residents designed for Alzheimer's and dementia patients allowing them to have freedom within their resident facilities and will alert staff if they go beyond allowed boundaries). <BR/>Record review of Resident #18's Physician order summary, dated 02/03/23, revealed an order for a wander guard to the right lower extremity, with a start date of 01/05/23 and an end date of 01/07/23. <BR/>2. Record review of Resident #35's Face sheet, dated 02/03/23, revealed an admission date of 01/04/23, with a diagnoses which included: vascular dementia and dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (A group of symptoms that affects memory, thinking and interferes with daily life), muscle wasting and atrophy (muscle weakness), poisoning by local antifungal, anti-infective and anti-inflammatory drugs, and other lack of coordination. <BR/>Record review of Resident #35's Quarterly MDS dated [DATE] revealed a BIMS of 02 which indicated the resident had severe impaired cognition. <BR/>Record review of Resident #35's Care Plan dated 01/12/23 revealed alterations in ADL self-performance and mobility related to weakness. Resident #35 required x1 assist with personal hygiene. <BR/>During an observation on 02/01/23 at 10:37 a.m., Resident #18 and Resident #35 had a basket of toiletries on top of a counter next to the sink in their shared room. The basket contained two disposable razors. <BR/>A second observation on 02/02/23 at 2:13 p.m. revealed the basket still contained two disposable razors. <BR/>During an interview on 02/07/23 at 4:01 p.m. LVN A stated there was a list of items that were prohibited in residents' rooms. She stated razors were not allowed in the residents' rooms. She stated she knew of one resident, Resident #37, who was allowed to shave themselves. LVN A stated the CNAs watched Resident #37 while shaving and removed the razor when the resident was done shaving. LVN A stated staff should not leave any razors in resident rooms and razors were locked up in the central supply closet. <BR/>During an interview on 02/02/23 at 4:30 p.m. the DON stated Residents #18 and #35 were shaved by the CNAs. The DON confirmed there were two razors in Resident #18 and #35's room at that time. The DON removed the razors from the room at that time. The DON stated razors were kept locked up because they could be a danger to residents who got a hold of them and were not competent to be using a sharp object. The DON stated the only resident she was aware of that shaved by themselves was Resident #37. The DON stated staff should be checking the rooms for items that were not allowed. <BR/>Record review of an undated document titled Nursing Home List of Items Not Allowed in Resident Rooms, stated the following is a list of items which are either specifically controlled by code, standards, regulations or have been determined by this facility as having an adverse effect on the health and safety of our residents. upon removal of any of these non-allowed items from the resident's room, family will be notified, and the item will be held until the family claims them . safety hazard . aerosol cans: of any product are combustible, glass items: which can be broken and cost cut, razors and blades: these must be left at the nurses station . <BR/>Record review of the Facility's policy, undated, titled Free of Accident Hazards/Supervision/Devices, stated Intent: it is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with each resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: 1. the facility must ensure that: a. the resident environment remains as free of accident hazards as is possible; and b. each resident receives adequate supervision and assistance devices to prevent accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 16 residents (Resident #14) reviewed for advance education for medication benefits versus risks.<BR/>The facility administered medroxyprogesterone, a type of hormone (progestin), from June 2023 to March 2024 to Resident #14 without Resident #14 and/or Resident #14's representative receiving education on the rationale for the prescription, the benefits vs. the risks of medroxyprogesterone and offered options for treatment. <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.<BR/>This failure denied the resident their right to participate in their care and treatment and placed other residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed.<BR/>The findings included :<BR/>A review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. The admission record revealed Resident #14 had two representatives. <BR/>A record review of Resident #14' quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment .<BR/>A record review of Resident #14's physicians orders, dated 03/14/2024, revealed the physician prescribed medroxyprogesterone (a hormone which help other hormones start and stop the menstrual cycle) 10 mg once a day at bedtime. <BR/>A review of Resident #14's medication Administration Records for June, July, August, September, October, November, December 2023, and January, February, March 2024 revealed Resident #14 was receiving medroxyprogesterone daily. <BR/>Record review of Resident #14's medical record revealed no evidence Resident #14 and or his representatives received any education on the rationale for the prescription, benefits vs risks, or potential adverse reactions of the prescribed medroxyprogesterone.<BR/>A record review of the National Library of Medicine's website, https://www.ncbi.nlm.nih.gov/books/NBK559192/ , Medroxyprogesterone .Last Update: June 30, 2022 revealed, Continuing Education Activity: This article highlights medroxyprogesterone .This activity discusses the mechanism of action, adverse effects, monitoring, and contraindications for medroxyprogesterone. Also, it highlights the important role that providers play in administering medroxyprogesterone and regularly monitoring patients for side effects . Off-Label Indications: Paraphilia/hypersexuality . Both genders reported experiencing changes in breast and sexual function . Patients currently using medroxyprogesterone for paraphilia/hypersexuality, LFTs (liver function tests), CBC (complete blood count), serum testosterone (male hormone), LH, FSH (a lab for decreased functional activity of the gonads (ovaries or testes)), and glucose require regular monitoring. Also, if serum testosterone shows a marked decrease, consider an annual bone scan.<BR/>A record review of Resident #14's medical records revealed no evidence Resident #14 received monitoring and or lab studies for the potential adverse effects of the female hormone medroxyprogesterone he was prescribed and administered for 9.5 months. <BR/>During an interview on 03/13/24 at 02:29 PM LVN K stated she had been the charge nurse for Resident #14. LVN K stated Resident #14 had a history of aggressive sexual harassment behaviors towards staff and Resident s. LVN K stated Resident #14 had been prescribed medroxyprogesterone. LVN K stated the medication aide had administered Resident #14's medroxyprogesterone. LVN K stated there had been no monitoring measures for testosterone levels or breast tenderness .<BR/>During an interview on 03/14/2024 at 03:00 PM Dr. Y stated he was the primary care physician for Resident #14. Dr. Y stated he had received reports from nursing staff, in June of 2023, that Resident #14 was developing unwanted sexual behaviors towards staff, and he prescribed medroxyprogesterone, a hormone prescribed to reduce Resident #14's unwanted sexual harassment behaviors. Dr. Y stated he had trust and faith the nursing staff would have advised Resident #14 and his representatives of the new medication to include rationale for the prescription, risks versus benefits, and potential adverse reactions. Dr. Y stated since June 2023 he had not received any reports from the nursing staff for any signs and or symptoms of adverse effects from the medroxyprogesterone . <BR/>During an interview on 03/15/2024 at 02:44 PM Resident #14's 2 representatives stated Resident #14 occasionally had behaviors where he would become upset and would be calmed by the facility when offered non-alcoholic beer, he doesn't know the difference, and the representatives would call and further calm Resident #14. Resident #14's representatives stated Resident #14 was not able to receive education on the rationale, benefits vs risks of any prescribed medications. Resident #14's representatives stated they were unaware of Resident #14's inappropriate sexual behaviors towards female residents. Resident #14's representatives stated they were not informed Resident #14 was prescribed and administered a hormone to reduce his sexual inappropriate behaviors. Resident #14's representatives stated they had not received any education on the rationale, benefits vs risks of the prescribed medroxyprogesterone, and stated We have no idea what the drug is and what it does. The facility called us today to schedule a meeting next week, but they did not report to us any information on any drugs and or past sexual behaviors.<BR/>During an interview on 03/18/24 at 02:20 PM LVN N stated she was the charge nurse who reported in June 2023 Resident #14's sexual harassment behaviors and received from Dr. Y the order for medroxyprogesterone. LVN N stated she had not clarified Resident #14's medroxyprogesterone order for monitoring for adverse effects of the medroxyprogesterone, breast tenderness and or laboratory test for monitoring Resident #14's testosterone blood levels, because it did not occur to her. LVN N stated she had not consulted with Resident #14 and or his representatives to provided informed consent to include the rationale for the medroxyprogesterone, the benefits versus the risk, and the potential adverse effects of the medroxyprogesterone prior to the administration of the medroxyprogesterone. LVN N stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. <BR/>During an interview on 03/18/24 at 03:50 PM the MDS Nurse stated a review of Resident #14's medical record revealed no evidence for laboratory studies for testosterone, no monitoring for adverse effects medroxyprogesterone, no evidence for education for benefits vs risks of medroxyprogesterone, no care plan summaries to reveal Resident #14 and or the representatives received education for benefits vs risks of medroxyprogesterone. The MDS Nurse stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. <BR/>During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for residents to receive informed consent prior to the initial dose of any medication and or treatment. The Administrator stated going forward he would ensure residents received from the physician and or nursing staff the rational for the new prescription and or treatment, the risks versus benefits, and potential adverse reactions. The Administrator stated not having provided Resident #14, or any resident, the opportunity to receive education for benefits vs risks of a medication and or treatment would deny their rights to participate in their plan of care and to consent or refuse the care.<BR/>During an interview on 03/18/2024 at 05:31 PM the ADON stated a review of Resident #14's medical record revealed no evidence for laboratory studies for testosterone, no monitoring for adverse effects medroxyprogesterone, no evidence for education for benefits vs risks of medroxyprogesterone, no care plan summaries to reveal Resident #14 and or representatives received education for benefits vs risks of medroxyprogesterone. The ADON stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. <BR/>A record review of the facility's Resident Participation - Assessment/Care Plans policy dated February 2021, revealed, the Resident/representatives right to participate in the development and implementation of his or her plan of care includes the right to: participate in the planning process; identify individuals to be included in the planning process; request meetings; request revisions to the plan of care; participate in the establishing his or her goals and expected outcomes of care; participate in the type, amount, frequency, and duration of care; receive the services and or items included in the care plan; be informed, in advance, of changes to the plan of care; refuse, request changes to and or discontinued care or treatment offered or proposed; be informed, in advance by the physician more professionals, of the risks and benefits of the care or treatment proposed .<BR/>The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM.<BR/>POR Verification<BR/>Problem: F552 Failure to ensure resident had the right to be informed of, and participate in, his or her treatment<BR/>Interventions:<BR/>o Resident #14's Responsible Party was notified, according to progress notes, again of orders for Resident #14 to be prescribed medroxyprogesterone.<BR/>Record review of progress note, dated 03/17/2024 at 1:12 PM, reflected that the MDS Coordinator, spoke with Resident #14's responsible parties to include educating on risk vs benefits of medroxyprogesterone. The progress notes further revealed that the responsible party voiced their understanding of the medication and its side effects and agreed that it was beneficial for the resident to remain on the medication. <BR/>Interview on 3/18/2024 at 1:06 PM, the Administrator stated that Resident #14's responsible party was notified of the orders for medroxyprogesterone on 3/17/2024. <BR/>o Resident #14's care plan was updated to reflect responsible party's notification of the medication being prescribed.<BR/>Record review of the care plan, dated 3/15/2024, reflected Problem: Resident #14 is taking hormone medroxyprogesterone with Approach: Education provided to family as to risk vs benefit of medication. <BR/>o Any new medication or treatment that Resident #14 (or any other resident) is prescribed will be assessed by nurse staff for a minimum of 72 hours.<BR/>Record review of Resident #14 progress notes reflected an assessment of adverse reactions by nursing staff on medications. <BR/>Interview on 3/18/2024 at 1:09 PM, the Administrator stated the assessments of adverse reactions of the new medication or treatments for Resident #14 were in the progress notes. <BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift , were interviewed to confirm receiving in-services and training on recognizing the side effects of the medication Medroxyprogesterone. <BR/>o The need for education regarding adverse effects, risks vs. benefits, etc. of treatment before treatment begins, was identified, and in-servicing has begun by administrator; in-servicing will be completed by the end of business on 3/17/2024. This in-service is to include all nurses, and any nurse not in-serviced will not be allowed to perform duties until they are in-serviced.<BR/>Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that nursing staff who had not been in-serviced would be allowed to perform duties until they had been in-serviced. <BR/>Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff as having completed the in-service. <BR/>o The following in-services were initiated on 3/14-16/2024: All available nursing staff will begin being in-serviced on 3/15/2024. Any nursing staff member not present or in-serviced, will not be allowed to assume their duties until in-serviced. Administrator/Designee to ensure that in service training has been done for all nurse staff.<BR/>o AII Nurse Staff) nurses, CNA, MA) <BR/>o Abuse/Neglect<BR/>o The importance of reporting events to physicians and responsible parties<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care. <BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care.<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care.<BR/>Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. <BR/>Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff reported to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. <BR/>Record review of a document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service.<BR/>Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. <BR/>Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. <BR/>Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff. <BR/>Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported.<BR/>Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. <BR/>Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. <BR/>Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. <BR/>Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to.<BR/>Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. <BR/>Monitoring:<BR/>o DON/Designee will perform a weekly audit of EMR to ensure that resident and/or responsible parties are being notified and educated with regard to any treatment changes, including but not limited to, any possible adverse effects, risks and benefits, or any alternative treatments that might be available BEFORE any changes are made<BR/>Record review reflected a facility activity report, detailing each residents EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. <BR/>Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON would be performing a weekly audit of the EMR. <BR/>o This weekly audit will be monitored on an ongoing weekly basis, to be integrated into the normal work routine of the nurse management team. Initial audit to be performed on 3/16/2024 by DON/Designee.<BR/>Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON will be performing a weekly audit of the EMR. <BR/>Record review reflected a facility activity report, detailing each residents EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. <BR/>o The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed<BR/>Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 2 of 18 residents (Residents #14 and #23) reviewed for physician notification of changes.<BR/>1 . The facility failed to inform Resident #14's physician when Resident #14 made sexual lewd comments towards female residents and entered Resident #23's shower room while she was showering on 02/06/2024 and again on 03/12/2024 and unsuccessfully attempted to enter Resident #23's shower room on 02/15/2024. <BR/>2. The facility failed to inform Resident #23's physician when Resident #14 entered Resident #23's shower room while she was showering on 02/06/2024, again on 03/12/2024, and unsuccessfully attempted to enter Resident #23's shower room on 02/15/2024. <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.<BR/>This failure denied residents and their physicians accurate and timely assessments so the physician could intervene with care.<BR/>The findings included :<BR/>1. A record review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. Resident #14's admission record revealed Resident #14 had two representatives.<BR/>A record review of Resident #14' quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment .<BR/>A record review of Resident #14's care plan dated 03/14/2024 revealed, Resident has episodes of inappropriate behaviors AEB (As Evidenced By) disrobes in public areas, sexual innuendos/gestures .Problem Start Date: 06/26/2023 . Behavioral episodes will be reduced to less than daily over the next 90 days . Monitor and chart behaviors and report to MD .<BR/>A record review of Resident #14's nursing progress notes revealed LVN A documented on 06/07/2023, Resident urinated in shower room. Redirected resident to room and told resident that was not appropriate. Resident resting in bed . we'll continue to monitor. <BR/>A record review of Resident #14's nursing progress notes revealed the DON documented on 08/18/2023, Resident sitting in dining room having non-alcoholic beverage. Activity director states that he was having a behavior issue earlier. He kept signaling to female resident to go to shower with him to shower . asked him to stop, he replied she wants to. Resident was redirected and asked to stop behavior .<BR/>A record review of Resident #14's nursing progress note dated 08/28/2023 revealed LVN A documented, . resident had sexual behaviors this evening was blowing kisses and saying I love you to this writer when providing care - when resident started rubbing his private area through shorts, he was told that was inappropriate and this writer lowered the bed, close the curtain, and stepped out of room. call light within reach.<BR/>A record review of Resident #14's nursing progress note dated 09/19/2023 revealed LVN AA documented, resident is showing sexual behaviors with aides, continues to tell aides to touch him down there, stating that he likes it, and throws kisses, blinking his eye.<BR/>A record review of Resident #14's nursing progress note dated 02/06/2024 revealed LVN A documented, this writer was paged to station 1 where this resident was standing in the middle of the shower room while there was already a female resident using it (Resident #23). This resident refused to leave the Shower room after being told several times there was a female showering. The resident did not leave until an aide agreed to shower him in a different room once she was done with her round. <BR/>A record review of Resident #14's nursing progress note dated 02/15/2024 revealed LVN A documented, resident came to station one and started calling this writer a 'pendeja' ([NAME] -a derogatory name in Spanish ) and demanding that this writer take him into the shower (in Spanish) writer told resident to go back to his room and would let his nurse know. Difficult to redirect. resident kept shaking shower door handle on station 1 after being told several times there was a female resident using the shower. this is not the first-time resident becomes aggressive. resident does not belong to station one but will still come to this station to yell and demand to be showered.<BR/>A record review of Resident #14's nursing progress note dated 03/12/2024 revealed LVN A documented, ad 0015 (15 minutes past midnight) Resident (#14) walked into station one shower while a female Resident (Resident #23) was using it and refused to leave. Resident (#14) became angry when asked to leave and walked to 700 hall and started opening several rooms - Resident (#14) kept stating he wanted to leave the facility (Spanish speaking). Resident (#14) was cussing and doing sexual gestures to staff. Resident (#14) was repeatedly told that was inappropriate and to stop. Resident (#14) replied I don't give a F*** I'm leaving (Spanish speaking). Resident (#14) walked to front hallway and started shaking door handles and running shoulder into door to force it open. Resident (#14) went to front door and pushed it open - this writer and CNA we're trying to hold it closed as resident repeatedly pushed on it. This writer called [Resident #14] representative and she was able to talk resident down. Resident stated to representative he wanted to be showered - [Resident #14's] representative was told tomorrow is Resident's shower day. [Resident #14's] representative was still on the phone while Resident (#14) was making sexual gestures to staff and was made aware. [Resident #14's] representative told Resident (#14) she would come to facility tomorrow to speak with him . attempted to call the DON and the ADON no answer. called the administrator made aware. <BR/>A record review of Resident #14's medical record, on 03/14/2024, revealed no evidence for providing the physician with reports where Resident #14 had increased sexual harassment behaviors towards residents since June 2023. <BR/>During an interview on 03/13/24 at 04:15 PM the BOM stated Resident #23 had complained in early February about Resident #14 trying to get into her shower room. The BOM stated the previous DON reported Resident #14 attempted to enter the room and was unsuccessful and redirected, I did not know [Resident #14] entered [Resident #23's] shower room.<BR/>During an interview on 3/14/24 at 03:00 PM, Dr. Y stated he was the primary care physician for Resident #14 and, over the span of several months, had received multiple reports Resident #14 was sexually inappropriate with staff . Dr. Y stated he continued with resident #14's drug regiment to allow time for the therapies to progress. Dr. Y stated he had not received any reports Resident #14 was sexually inappropriate toward any resident. Dr. Y stated, I would have recalled a report of him getting in a female resident's shower. Dr. Y stated, if he had received such a report, he would have ordered for a 1 to 1 staff level of supervision for Resident #14 and ordered a psychiatric evaluation. The medical director stated he had received reports of Resident #14's inappropriate sexual behaviors however the reports were limited to staff harassment and not resident harassment. The reports were incomplete and lacking the scope of Resident #14's behaviors towards female residents. Dr. Y stated he was concerned for the behavior towards residents and would have considered further interventions for Resident #14's safety and the safety of residents. <BR/>During an interview on 03/15/2024 at 09:30 AM Resident #14 stated he was wanting beer, a dance party, and a sexual partner. He stated, I have not been drunk, had sex in a long time .there are no dances here and they only have church! Resident #14 stated he enjoyed female CNAs assisting him with showers and they didn't shower him when he demanded. Resident #14 denied he was in any females shower room.<BR/>2. A record review of Resident #23's admission record, dated 03/14/2024, revealed an admission date of 09/09/2016 with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance and anxiety. <BR/>A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment.<BR/>A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions avoidance of over-stimulation and avoidance of aggressive peer residents.<BR/>During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her) and now wished to avoid showers and stay in her room.<BR/>During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would yell and scream at him until staff intervened and re-directed him away. Resident #23 stated she had increased anxiety and insomnia due to the fear of resident #14 entering her room and or shower.<BR/>A record review of Resident #23's medical record, on 03/14/2024, revealed no evidence for providing the physician with reports where Resident #14 had increased sexual harassment behaviors towards Resident #23 since February 2024.<BR/>During an interview on 03/14/24 at 08:28 AM the Medical Director stated he was unsure if he received a report from the nursing staff that Resident #23 was involuntary secluded in the shower. The medical Director stated if he had he could have assessed resident for psychiatric evaluation. <BR/>During an interview on 03/15/2024 at 02:00 PM the Medical Director stated he was Resident #23's physician, and he was unaware Resident #14 had on 2 occasions entered Resident #23's shower room. The Medical Director stated had he known he may have assessed Resident #23 for anxiety and may have intervened with a psychiatric evaluation. The physician stated at a minimum he would have expected a report from nursing for Resident #14's sexual harassment behaviors and Resident #23's potential anxiety and fear.<BR/>During an interview on 03/18/24 at 03:50 PM the MDS Nurse stated a review of Resident #14's medical record revealed no evidence for reports to the physician that Resident #14 was having sexual harassment behaviors towards residents . <BR/>During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for nursing staff to timely report to Resident's physicians any changes in residents' health status to include increased and or decreased behaviors and or responses to therapies. The Administrator stated nursing staff should have reported to the physician and himself Resident #14's sexual harassment episodes towards residents. The Administrator stated nursing staff had not reported Resident #14 had made sexual harassment behaviors towards residents. <BR/>During an interview on 03/18/2024 at 05:31 PM the ADON stated a review of Resident #14's and Resident #23's medical record revealed no evidence for reports to the residents' physicians for any of Resident #14's sexual harassment episodes towards residents and or Resident #23. <BR/>A record review of the facility's Accidents and Incidents - Investigating and Reporting, dated July 2017, revealed, all accidents or incidents involving residents, employees, visitors, vendors, etcetera, occurring on our premises shall be investigated and reported to the Administrator .the following data, as applicable, shall be included on the report of incident accident form; the date and time the accident or incident took place; the nature of the injury illness; where the accident or incident took place; the names of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's attending physician was notified, as well as the time the position responded and his or her instruction . <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. <BR/>The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM.<BR/>Plan of Removal Verification <BR/>Problem: F580 Notification of physicians and responsible parties Interventions:<BR/>o Responsible parties of both Resident #14 and Resident #23 notified of incident as of 3/16/2024.<BR/>Record review of Resident #23's progress note dated 3/15/2024 at 11:43 AM, made by the Worker reflected, SW spoke with resident today, via a Spanish translator, and asked if she had any lingering emotional distress or anxiety related to the 2/6/24 incident and if so does she want to be seen by psych. services/counseling. Resident stated she is o.k. and did not want any type of counseling/psych. services. SW also had a conversation with her MPOA regarding the incident on 2/6/24 and asked if she wanted resident to have counseling/psych. services and she stated no she doesn't want that for resident at this time as resident seems fine. SW let her know that counseling/psych. services is available if she ever changes her mind and that she may always speak to SW as needed.<BR/>Record review of a progress note dated 3/15/2024 at 6:21 PM reflected the Social Worker, and Administrator spoke with Resident #14's RP of the resident's incidents. <BR/>Interview on 3/18/2024 at 1:10 PM, the Administrator stated that each incident was discussed with Resident #14's responsible parties. The Administrator then confirmed Resident #23's responsible party had been notified of the incidents. The Administrator also confirmed the medication and its adverse effects were discussed with Resident #14's responsible parties. <BR/>Record review of Resident #14's Progress Note, dated 3/17/2024 at 1:12 PM and written by the MDS Coordinator reflected that education was provided to the RP of risks vs benefits of taking the medication medroxyprogesterone and went on to list risks and benefits. <BR/>o Evidence of deficiencies in notification of physicians and responsible parties was found to exist in the facility.<BR/>Interview on 3/18/2024 at 10:55 AM, the Administrator stated that the evidence of deficiencies in notification were found during the survey process and no other evidence of deficiencies in notification were found during the facilities audit after notification of the initial deficiencies. <BR/>o The following in-services were initiated on 3/14-16/2024: All available staff will begin being in serviced on 3/15/2024, to be completed on or before 3/16/2024. Any staff member not present or in-serviced by this time will not be allowed to assume their duties until they have been in serviced. Administrator/Designee to ensure that in-service training has been done for all staff.<BR/>O All Staff<BR/>o Abuse/Neglect<BR/>o Incident reporting, to include behaviors, to Admin/Physicians<BR/>o The importance of reporting events to physicians and responsible parties<BR/>A record review of the facility's all discipline employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 71, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician. <BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician.<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician.<BR/>Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed all disciplines, 46 of 71 staff signed off as having completed the in-service. <BR/>Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator stated that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. <BR/>Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service.<BR/>Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. <BR/>Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. <BR/>Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff. <BR/>Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported.<BR/>Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. <BR/>Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. <BR/>Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. <BR/>Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to.<BR/>Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. <BR/>Monitoring<BR/>o DON/Designee will perform a weekly audit of EMR (electronic medical record) to ensure that physicians and responsible parties are being notified with regard to any scenarios outlined in, but not limited to, CMS F580, to include medication changes, changes in condition, and critical labs. <BR/>Record review reflected a facility activity report, detailing each residents' EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. <BR/>Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON will be performing a weekly audit of the EMR. <BR/>o Facility will be monitoring this by weekly EMR audits. Nurses will chart items in progress notes, and flagged on 24 hour report which will be discussed Monday - Friday by IDT. <BR/>Interview on 3/18/2024 at 10:36 AM, the Administrator stated that they will be discussing the 24-hour report during the morning meeting to see if there need to be any changes made to any care for the residents based on what is on the 24 hour report. <BR/>o The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed<BR/>Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they followed a template relating to the deficiencies and discussed any changes or suggestions related to any changes in care for residents with all members of the QAPI committee. <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure Residents had the right to be free from abuse, neglect, and involuntary seclusion for 3 (Resident #23, #43, and #1) of 16 residents reviewed for abuse and neglect. <BR/>1. The facility failed to ensure Resident #23 was not neglected when she was left in a dark, locked, shower room alone. <BR/>2. The facility failed to protect Resident #23 from abuse by allowing a male resident access to her while in the shower. <BR/>3. The facility failed to protect Resident #1 when she wandered into Resident #43's room and Resident #43 hit her (Resident #1) on the head.<BR/>An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.<BR/>This failure denied residents their rights for freedom from abuse, neglect, and involuntary seclusion. <BR/>The findings included:<BR/>A record review of Resident #23's admission record, dated 03/14/2024, revealed an admission date of 09/09/2016 with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety, and Onchocerciasis with glaucoma (a disease where a parasite destroyed parts of the eye). <BR/>A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. Section G of the MDS assessment revealed resident #23 used a wc independently and was Setup or clean-up assistance - for transfers and showers.<BR/>A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions for avoidance of over-stimulation and avoidance of aggressive peer residents and, Problem Start Date: 07/17/2020 .ADLs (activities of daily life) . Presents with alteration in ADL self-performance & mobility R/T hx (related to history) of Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death) & failure to thrive, Dementia, stiff left shoulder, muscle weakness, lack of coordination, muscle wasting and atrophy AEB (as evidenced by) requires staff assistance with all ADL's . Approach Start Date: 01/21/202 1; Resident requires supervision and set up by staff with showers.<BR/>A record review of Resident #23's nursing notes revealed LVN K documented on 02/06/2024 at 01:12 AM, an incident where Resident #23 was in the shower room bathing alone. LVN K documented she heard screams and shouts and discovered Resident #23 in the darkened shower room and on the floor. LVN K also documented Resident #23 was locked in the shower by another LVN (LVN A) who was re-directing Resident #14 from entering the shower room, while unknowing Resident #14 was in the shower, resident (#23) propel self in wheelchair to shower room. Another Resident (#14) wanting to take a shower and kept wanting to go in shower. Staff (LVN A) unknowing that resident was in shower turned light off and locked door so that other resident would not go into the shower by himself. Resident (#23) calling for help from the shower room and was sitting on the floor. asst. x2 to wheelchair. moving all extremities, refused writer to take vitals and/or check head. resident wanted to be left alone so that she could take her shower. Resident (#23) upset because she could hear other Resident (#14) wanting to go into shower. took other Resident to 200 hall shower room and showered.<BR/>A record review of the facility's incident reports from June 2023 to March 2024 revealed no evidence for the incident on 02/06/2024 where Resident #23 was showering and Resident #14 attempting to enter the shower room while Resident #23 was bathing. <BR/>During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her).<BR/>During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would, pull the shower curtain closed, yell and scream at him until staff intervened and re-directed him away. <BR/>During an interview on 03/13/24 at 02:29 PM LVN K stated she and LVN A were the charge nurses on 02/06/2024 from 06:00 PM to 06:00 AM. LVN K stated Resident #23 had a preference to bathe herself in the shower room early in the mornings around midnight to 01:00 AM. LVN K stated Resident #23's routine was she would gather her clothes and bathing supplies and self-ambulate in her wheelchair to the shower room. LVN K stated on 02/06/2024 around 01:00 AM screams and shouting were heard coming from the shower room. LVN K stated she ran to the shower room and discovered Resident #23 in the dark on the floor. Resident #23 was upset and claimed she was locked in the shower with the lights off. LVN K stated Resident #23 stated she fell in the dark attempting to get out of her wheelchair trying to get to the light switch or door. LVN K stated she spoke with LVN A and learned Resident #14 was attempting to get into the shower room with Resident #23 when LVN A redirected Resident #14 away and LVN A did not recognize Resident #23 was in the shower room. LVN A turned off the light and locked the shower room door to prevent Resident #14 from entering. LVN K stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents.<BR/>During an interview on 03/15/24 at 10:59 AM LVN A stated on the early morning of 02/06/2024 around midnight Resident #14 entered the shower room while Resident #23 was showering; although LVN A did not know Resident #23 was in the shower room. LVN A stated she heard Resident #23 in the shower room and entered and redirected him out and away from the shower room and turned off the shower room light and locked the door. LVN A stated she did not check for other residents in the shower room and did not see Resident #23 possibly due to the shower curtain was pulled shut. LVN A stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents.<BR/>A record review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. <BR/>A record review of Resident #14's quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment.<BR/> During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for facility staff to ensure residents were supported in their rights to be free from abuse and or neglect, including Resident #23's rights for safety. The Administrator stated he expected a report for all incidents involving resident #23 being secluded and harassed by resident #14 in her shower room. The Administrator stated not having provided any Resident, supports for ensuring their rights could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment. <BR/>3. A record review of Resident #43's admission record dated 03/15/2024 revealed an admission date of 04/26/2023 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.). <BR/>A record review of Resident #43's quarterly MDS assessment, dated 02/21/2024, revealed Resident #43 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment .<BR/>A record review of Resident #43's care plan dated 03/15/2024 revealed Resident #43 had a history of physical aggression towards staff and peer residents in areas of increased stimulation. Resident #43's care plan revealed interventions for monitoring for early signs of aggression and encouragement to attend social activities. <BR/>A record review of Resident #1's admission record revealed an admission date of 12/14/2014 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.).<BR/>A record review of Resident #1's quarterly MDS assessment, dated 02/06/2024, revealed Resident #1 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 99 which indicated Resident #1 could not participate in the assessment and may be severely cognitively impaired .<BR/>A record review of Resident #1's care plan dated 03/15/2024 revealed Resident #1 had a history of unsafely wandering in her wheelchair. Further review revealed interventions which included, .Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents) . Remove resident from other resident's rooms and unsafe situations .<BR/>A record review of Resident #43's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:35 AM, Resident (#43) in his room watching television (Resident #1) wandered into his room via wheelchair was asked to leave she did not - then he hit her in head just above left ear - resident is forgetful at times - and does not like people going into his room re-educated on importance of not hitting people and keeping his hands to himself - verbalized understanding stated she shouldn't be in my room.<BR/>A record review of Resident #1's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:32 AM, Resident (#1) propelling self in and out of other residents room went into room (Resident #43's room) was in room and she would not leave and (Resident #42) hit in head just above left ear - no apparent injuries noted resident moved from area and placed in main dining room to participate in activities.<BR/>A record review of the Texas Unified Licensure Information Portal on 03/18/2024 revealed no evidence for reporting the alleged incident of abuse on 01/01/2024 between Residents #43 and #1.<BR/>A record review of the facility's incidents and accidents log for the review dates of June 2023 through March 2024 revealed no reporting for the 01/01/2024 alleged peer to peer physical abuse between Resident #1 and Resident #43. <BR/>During an interview on 03/12/2024 at 10:10 AM LVN N stated on 01/01/2024 at around 10:00 am Resident #1, who was pleasant and confused wandered into Resident #43's room when he began yelling at Resident #1 to get out of his room. LVN N stated she received a report from the CNA who saw Resident #43 hit Resident #1 on the side of the head. LVN N stated she assessed both residents for injuries and or pain and none were evidenced. Resident #43 was counseled and redirected to not hit anyone and Resident #1 was redirected to the living room to participate in activities. LVN N stated she had not generated an incident report, nor documented the incident on the 24-hour report but had documented the incident on the residents nursing progress notes. LVN N stated she had not reported the incident to the physician since there was no injuries . <BR/>During an interview on 03/15/24 at 10:10 AM the DON stated the facility policy and her expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, the Administrator, herself (the DON), and document on the facility's incident report, and the 24-hour report. The DON stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43's aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident . <BR/>During an interview on 03/15/24 at 11:00 AM the Administrator stated the facility policy, and his expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, (himself), and documented on the facility's incident report, and the 24-hour report. The Administrator stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43 aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident .<BR/> A record review of the facility's Abuse / Neglect policy dated 01/08/2003, revealed, The Resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents should not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff, of other agencies serving the Resident, family members or legal guardians, friends, or other Residents .the facility will provide and ensure the promotion and protection of Resident rights. It is each individuals' responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any Resident in the facility .<BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. <BR/>The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM.<BR/>Plan of Removal Verification<BR/>Problem: F600 Sexual Inappropriateness allegation<BR/>Interventions:<BR/>Resident #14 placed in 1:1 observation and continues currently<BR/>Record review of Resident #14's Orders reflected, One on one care d/t behaviors. with a start date of 3/14/2024. <BR/>Observation and interview on 03/16/2024 at 11:25 AM revealed CNA M was assigned to monitor Resident #14 and has monitored him most of the day. She stated she must document on a sheet of paper every 15 minutes. <BR/>During an observation on 03/16/2024 at 04:00 PM revealed Resident #14 was asleep in his bedroom while CNA M monitored Resident #14 for safety.<BR/>Observation on 03/16/2024 at 5:10 PM revealed resident #14 in the dining room being observed by staff while eating a meal. <BR/>Record review of Resident #14's 1 to 1 documentation sheet, dated 03/16/2024, revealed Resident #14 was continuously monitored for safety and documented every 15 minutes. <BR/>Interview on 3/18/2024 at 12:49 PM, the Administrator stated that Resident #14 is on 1:1 observation and will continue to be pending further evaluation by physician for effectiveness and necessity. <BR/>Immediate psychiatric services via telehealth initiated on 3/14/2024<BR/>Record review of psychiatric evaluation dated 3/14/2024 at 06:06 PM.<BR/>Record review of consolidated orders dated March 2023 revealed to be evaluated and treated by Psychiatric Services as needed, dated 3/14/2024. <BR/>Record review of revealed Resident #14 RP verbally consented over the phone on 3/14/2024 to resident receiving psychiatric services. <BR/>Interview on 3/18/2024 at 10:59 AM, the Administrator stated that Resident #14 had been seen by psychiatric services. <BR/>Record review of Progress Note, dated 3/14/2024, reflected that Resident #14 was seen by a psychiatric NP with plan based on residents' diagnosis. <BR/>STAT CBC, CMP, BMP, TSH, Ammonia level, and UA ordered by Primary Care Provider on 3/14/2024<BR/>Record review of Resident #14's orders reflected STAT CBC, CMP, UA ordered by the resident's physician on 3/14/2024. <BR/>Record review of Resident #14's orders reflected Draw blood for TSH and Ammonia level ordered by the resident's physician on 3/15/2024. <BR/>Record review of Resident #14's lab drawn on 3/14/2024 reflected CBC UA CMP, TSH and Ammonia with no recommendations signed Administrator/DON on 3/17/2024. <BR/>New order for Sertraline, ordered by psychiatric services NP on 3/14/2024<BR/>Record review of telephone order dated 3/14/2024, start date for 3/22/2024 Sertraline 50 mg, 1 tablet once a day, oral for insomnia, ordered by the resident's PCP. <BR/>Record review of telephone order dated 3/14/2024, start date 3/14/2024, end date 3/21/2024 for Sertraline 25 mg 1 tablet once a day by mouth with diagnosis of insomnia, ordered by the resident's PCP. <BR/>Record review of telephone order dated 3/16/2024, start date 3/16/2024, with no end date for Risperidone 1 mg 1 tablet twice a day by mouth with diagnosis of anxiety disorder. <BR/>Record review of telephone order dated 3/16/2024, start date 3/16/2024, with no end date for Melatonin 5 mg 2 tablets once daily at bedtime with diagnosis of insomnia. <BR/>Psychiatric services to be offered to Resident #23 in order to provide for any mental or emotional anguish created by any interactions with Resident #14<BR/>Record review of progress note dated 3/16/2024 at 4:29 PM, LVN K spoke with Resident #23's RP regarding the incident on 2/6/2024 as well as the incident on 3/12/2024. <BR/>Record review of progress note dated 3/15/2024 at 11:43 AM revealed the Social Worker, spoke with Resident #23 who declined psychiatric services. Further review of the progress note revealed the Social Worker spoke with the MPOA regarding the incident on 2/6/2024 and the MPOA stated she did not want the resident to receive psychiatric services at this time.<BR/>Abuse and Neglect prevention in-service for all facility staff initiated and completed by Admin/DON/Compliance Nurse on 3/14/2024<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed 74 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F600.<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 74 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600.<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 74 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600. <BR/>Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. <BR/>Interview on 3/18/2024 at 12:54 PM, the Administrator stated most staff have been in-serviced and those who have not will be in-serviced before resuming duties. <BR/>The following in-services were initiated on 3/14/2024: All available staff will be in-serviced by close of 3/15/2024 mandatory staff meeting, to be held at 1400 . Any staff member not present or in-serviced at close of mandatory meeting, will not be allowed to assume their duties until in-serviced. Administrator/Designee to ensure that in-service training has been done for all staff.<BR/>oAll Staff<BR/>Abuse/Neglect<BR/>Abuse/Neglect Reporting<BR/>Who to Report Abuse/Neglect to<BR/>Incident reporting, to include behaviors, to Admin/Physicians.<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation.<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation.<BR/>A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation. <BR/>Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. <BR/>Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. <BR/>Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service.<BR/>Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. <BR/>Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. <BR/>Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers.<BR/>Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported.<BR/>Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. <BR/>Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect. <BR/>Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents complaints were recognized and grievances were filed. <BR/>Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to.<BR/>Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors. <BR/>Interview on 3/18/2024 at 12:54 PM, the Administrator stated most staff have been in-serviced and those who have not will be in-serviced before resuming duties. <BR/>Monitoring<BR/>Administrator/DON to review findings of psychiatric NP and ensure implementation of treatment plan if found to be necessary. DON to ensure care plans have been updated for resident #14 as well as resident #23.<BR/>Record review of Progress Note, dated 3/14/2024, reflected that Resident #14 was seen by a psychiatric NP. Further review reveals the DON and Administrator signed the document as Reviewed on 3/14/2024. <BR/>Interview on 3/18/2024 at 10:59 AM, the Administrator stated that Resident #14 had seen the psychiatric NP and that he and the DON had reviewed the findings. He further stated that he, along with the DON, reviewed the psychiatric services progress note and will continue to do so after any psychiatric services appointment. <BR/>Administrator will work with social services to develop a plan of action to find suitable placement for resident #14 in order to provide a better, more appropriate level of care, to provide a safer environment for resident #14 as well as all others residing in the facility <BR/>Interview on 3/18/2024 at 12:58 PM, the Administrator stated that the social worker has put in referrals for 3 places and continues to search for placement. The residents RP's have declined some placements for the resident. <BR/>Record review of Resident #14's care plan revealed, Problem: Administrator issued 30 Day Discharge Notice has been issued effective from 3/15/24. with interventions of Social services to send referrals to facilities that will meet Resident #14's needs. <BR/>Thirty-Day Notice of discharge to be issued to resident #14, resident #14's representative, and representative of long-term care ombudsman program on 3/15/2024<BR/>Record review of document titled 30 Day Discharge Notice reflected a 30 day discharge notification provided to the residents representative on 3/15/2024. <BR/>Record review of email to Ombudsman reflected notification of 30-day discharge notice on 3/15/2024. <BR/>Record review of Resident #14's care plan revealed, Problem: Administrator issued 30 Day Discharge Notice has been issued effective from 3/15/24. with interventions of Social services to send referrals to facilities that will meet Resident #14 's needs. <BR/>Interview on 3/18/2024 at 1:04 PM, the Administrator stated the family was provided with a 30-day notice to Resident #14, and the ombudsman was provided with the 30-day notice as well. <BR/>The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed<BR/>Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. <BR/>An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations which involved abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 3 of 16 Residents (Residents #1, #23, and #43) reviewed for reporting of alleged Abuse, Neglect, exploitation, and or mistreatment. <BR/>1.The facility failed to ensure staff reported to the Administrator and or the state agency Resident #43's alleged physical aggression towards Resident #1. <BR/>2. The facility failed to report to the state agency that Resident #23 was left in a dark, locked, shower room alone and failed to report abuse by allowing a male resident access to her while in the shower. <BR/>These deficient practices could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment. <BR/>The findings included:<BR/>1.A record review of Resident #43's admission record dated 03/15/2024 revealed an admission date of 04/26/2023 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.). <BR/>A record review of Resident #43's quarterly MDS assessment, dated 02/21/2024, revealed Resident #43 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment .<BR/>A record review of Resident #43's care plan dated 03/15/2024 revealed Resident #43 had a history of physical aggression towards staff and peer residents in areas of increased stimulation. Resident #43's care plan revealed interventions for monitoring for early signs of aggression and encouragement to attend social activities. <BR/>A record review of Resident #1's admission record revealed an admission date of 12/14/2014 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.).<BR/>A record review of Resident #1's quarterly MDS assessment, dated 02/06/2024, revealed Resident #1 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 99 which indicated Resident #1 could not participate in the assessment and may be severely cognitively impaired .<BR/>A record review of Resident #1's care plan dated 03/15/2024 revealed Resident #1 had a history of unsafely wandering in her wheelchair. Further review revealed interventions which included, .Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents) . Remove resident from other resident's rooms and unsafe situations .<BR/>A record review of Resident #43's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:35 AM, Resident (#43) in his room watching television (Resident #1) wandered into his room via wheelchair was asked to leave she did not - then he hit her in head just above left ear - resident is forgetful at times - and does not like people going into his room re-educated on importance of not hitting people and keeping his hands to himself - verbalized understanding stated she shouldn't be in my room.<BR/>A record review of Resident #1's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:32 AM, Resident (#1) propelling self in and out of other residents room went into room (Resident #43's room) was in room and she would not leave and (Resident #42) hit in head just above left ear - no apparent injuries noted resident moved from area and placed in main dining room to participate in activities.<BR/>A record review of the Texas Unified Licensure Information Portal on 03/18/2024 revealed no evidence for reporting the alleged incident of abuse on 01/01/2024 between Residents #43 and #1.<BR/>A record review of the facility's incidents and accidents log for the review dates of June 2023 through March 2024 revealed no reporting for the 01/01/2024 alleged peer to peer physical abuse between Resident #1 and Resident #43. <BR/>During an interview on 03/12/2024 at 10:10 AM LVN N stated on 01/01/2024 at around 10:00 am Resident #1, who was pleasant and confused wandered into Resident #43's room when he began yelling at Resident #1 to get out of his room. LVN N stated she received a report from the CNA who saw Resident #43 hit Resident #1 on the side of the head. LVN N stated she assessed both residents for injuries and or pain and none were evidenced. Resident #43 was counseled and redirected to not hit anyone and Resident #1 was redirected to the living room to participate in activities. LVN N stated she had not generated an incident report, nor documented the incident on the 24-hour report but had documented the incident on the residents nursing progress notes. LVN N stated she had not reported the incident to the physician since there was no injuries . <BR/>During an interview on 03/15/24 at 10:10 AM the DON stated the facility policy and her expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, the Administrator, herself (the DON), and document on the facility's incident report, and the 24-hour report. The DON stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43's aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident . <BR/>During an interview on 03/15/24 at 11:00 AM the Administrator stated the facility policy, and his expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, (himself), and documented on the facility's incident report, and the 24-hour report. The Administrator stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43 aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident .<BR/>2. A record review of Resident #23's admission record, dated 03/14/2024, revealed an admission date of 09/09/2016 with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety, and Onchocerciasis with glaucoma (a disease where a parasite destroyed parts of the eye). <BR/>A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. Section G of the MDS assessment revealed resident #23 used a wc independently and was Setup or clean-up assistance - for transfers and showers.<BR/>A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions for avoidance of over-stimulation and avoidance of aggressive peer residents and, Problem Start Date: 07/17/2020 .ADLs (activities of daily life) . Presents with alteration in ADL self-performance & mobility R/T hx (related to history) of Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death) & failure to thrive, Dementia, stiff left shoulder, muscle weakness, lack of coordination, muscle wasting and atrophy AEB (as evidenced by) requires staff assistance with all ADL's . Approach Start Date: 01/21/202 1; Resident requires supervision and set up by staff with showers.<BR/>A record review of Resident #23's nursing notes revealed LVN K documented on 02/06/2024 at 01:12 AM, an incident where Resident #23 was in the shower room bathing alone. LVN K documented she heard screams and shouts and discovered Resident #23 in the darkened shower room and on the floor. LVN K also documented Resident #23 was locked in the shower by another LVN (LVN A) who was re-directing Resident #14 from entering the shower room, while unknowing Resident #14 was in the shower, resident (#23) propel self in wheelchair to shower room. Another Resident (#14) wanting to take a shower and kept wanting to go in shower. Staff (LVN A) unknowing that resident was in shower turned light off and locked door so that other resident would not go into the shower by himself. Resident (#23) calling for help from the shower room and was sitting on the floor. asst. x2 to wheelchair. moving all extremities, refused writer to take vitals and/or check head. resident wanted to be left alone so that she could take her shower. Resident (#23) upset because she could hear other Resident (#14) wanting to go into shower. took other Resident to 200 hall shower room and showered.<BR/>A record review of the facility's incident reports from June 2023 to March 2024 revealed no evidence for the incident on 02/06/2024 where Resident #23 was showering and Resident #14 attempting to enter the shower room while Resident #23 was bathing. <BR/>During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her).<BR/>During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would, pull the shower curtain closed, yell and scream at him until staff intervened and re-directed him away. <BR/>During an interview on 03/13/24 at 02:29 PM LVN K stated she and LVN A were the charge nurses on 02/06/2024 from 06:00 PM to 06:00 AM. LVN K stated Resident #23 had a preference to bathe herself in the shower room early in the mornings around midnight to 01:00 AM. LVN K stated Resident #23's routine was she would gather her clothes and bathing supplies and self-ambulate in her wheelchair to the shower room. LVN K stated on 02/06/2024 around 01:00 AM screams and shouting were heard coming from the shower room. LVN K stated she ran to the shower room and discovered Resident #23 in the dark on the floor. Resident #23 was upset and claimed she was locked in the shower with the lights off. LVN K stated Resident #23 stated she fell in the dark attempting to get out of her wheelchair trying to get to the light switch or door. LVN K stated she spoke with LVN A and learned Resident #14 was attempting to get into the shower room with Resident #23 when LVN A redirected Resident #14 away and LVN A did not recognize Resident #23 was in the shower room. LVN A turned off the light and locked the shower room door to prevent Resident #14 from entering. LVN K stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents.<BR/>During an interview on 03/15/24 at 10:59 AM LVN A stated on the early morning of 02/06/2024 around midnight Resident #14 entered the shower room while Resident #23 was showering; although LVN A did not know Resident #23 was in the shower room. LVN A stated she heard Resident #23 in the shower room and entered and redirected him out and away from the shower room and turned off the shower room light and locked the door. LVN A stated she did not check for other residents in the shower room and did not see Resident #23 possibly due to the shower curtain was pulled shut. LVN A stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents.<BR/>A record review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. <BR/>A record review of Resident #14's quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment.<BR/> During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for facility staff to ensure residents were supported in their rights to be free from abuse and or neglect, including Resident #23's rights for safety. The Administrator stated he expected a report for all incidents involving resident #23 being secluded and harassed by Resident #14 in her shower room. The Administrator stated not having provided any Resident, supports for ensuring their rights could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment.<BR/>A record review of the facility's Abuse / Neglect policy dated 01/08/2003, revealed, The Resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents should not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff, of other agencies serving the Resident, family members or legal guardians, friends, or other Residents .the facility will provide and ensure the promotion and protection of Resident rights. It is each individuals' responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any Resident in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 3 of 16 residents (Residents #1, #23 and #43) reviewed for investigation to prevent further potential abuse, neglect, exploitation, or mistreatment.<BR/>1. The facility failed to investigate and report the findings to the state agency for Resident #43's alleged physical aggression towards Resident #1. <BR/>2. The facility failed to investigate and report the findings to the state agency that Resident #23 was left in a dark, locked, shower room alone and failed investigate and report the findings of alleged abuse by allowing a male resident access to her while in the shower. <BR/>These deficient practices could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment. <BR/>The findings included :<BR/>1. A record review of Resident #43's admission record dated 03/15/2024 revealed an admission date of 04/26/2023 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.). <BR/>A record review of Resident #43's quarterly MDS assessment, dated 02/21/2024, revealed resident #43 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment.<BR/>A record review of Resident #43's care plan dated 03/15/2024 revealed Resident #43 had a history of physical aggression towards staff and peer residents in areas of increased stimulation. Resident #43's care plan revealed interventions for monitoring for early signs of aggression and encouragement to attend social activities. <BR/>A record review of Resident #1's admission record revealed an admission date of 12/14/2014 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.).<BR/>A record review of Resident #1's quarterly MDS assessment, dated 02/06/2024, revealed resident #1 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 99 which indicated Resident #1 could not participate in the assessment and may be severely cognitively impaired.<BR/>A record review of Resident #1's care plan dated 03/15/2024 revealed Resident #1 had a history of unsafely wandering in her wheelchair. Further review revealed interventions which included, .Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents) . Remove resident from other resident's rooms and unsafe situations .<BR/>A record review of Resident #43's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:35 AM, Resident (#43) in his room watching television (Resident #1) wandered into his room via wheelchair was asked to leave she did not - then he hit her in head just above left ear - resident is forgetful at times - and does not like people going into his room re-educated on importance of not hitting people and keeping his hands to himself - verbalized understanding stated she shouldn't be in my room.<BR/>A record review of Resident #1's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:32 AM, Resident (#1) propelling self in and out of other residents room went into room (Resident #43's room) was in room and she would not leave and (Resident #42) hit in head just above left ear - no apparent injuries noted resident moved from area and placed in main dining room to participate in activities.<BR/>A record review of the Texas Unified Licensure Information Portal on 03/18/2024 revealed no evidence for reporting the alleged incident of abuse on 01/01/2024 between residents #43 and #1.<BR/>A record review of the facility's incidents and accidents log for the review dates of June 2023 through March 2024 revealed no reporting for the 01/01/2024 alleged peer to peer physical abuse between Resident #1 and Resident #43. <BR/>During an interview on 03/12/2024 at 10:10 AM LVN N stated on 01/01/2024 at around 10:00 am Resident #1, who was pleasant and confused wandered into Resident #43 room when he began yelling at Resident #1 to get out of his room. LVN N stated she received a report from the CNA who saw Resident #43 hit Resident #1 on the side of the head. LVN N stated she assessed both residents for injuries and or pain and none were evidenced. Resident #43 was counseled and redirected to not hit anyone and Resident #1 was redirected to the living room to participate in activities. LVN N stated she had not generated an incident report, nor documented the incident on the 24-hour report but had documented the incident on the residents nursing progress notes. LVN N stated she had not reported the incident to the physician since there was no injuries. <BR/>During an interview on 03/15/24 at 10:10 AM the DON stated the facility policy and her expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, the Administrator, herself (the DON), and documented on the facility's incident report, and the 24-hour report. The DON stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43 aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident. <BR/>During an interview on 03/15/24 at 11:00 AM the Administrator stated the facility policy, and his expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, (Himself), and documented on the facility's incident report, and the 24-hour report. The Administrator stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43 aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident.<BR/>2. A record review of Resident #23's admission record, dated 03/14/2024, revealed an admission date of 09/09/2016 with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety, and Onchocerciasis with glaucoma (a disease where a parasite destroyed parts of the eye). <BR/>A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. Section G of the MDS assessment revealed resident #23 used a wc independently and was Setup or clean-up assistance - for transfers and showers.<BR/>A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions for avoidance of over-stimulation and avoidance of aggressive peer residents and, Problem Start Date: 07/17/2020 .ADLs (activities of daily life) . Presents with alteration in ADL self-performance & mobility R/T hx (related to history) of Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death) & failure to thrive, Dementia, stiff left shoulder, muscle weakness, lack of coordination, muscle wasting and atrophy AEB (as evidenced by) requires staff assistance with all ADL's . Approach Start Date: 01/21/202 1; Resident requires supervision and set up by staff with showers.<BR/>A record review of Resident #23's nursing notes revealed LVN K documented on 02/06/2024 at 01:12 AM, an incident where Resident #23 was in the shower room bathing alone. LVN K documented she heard screams and shouts and discovered Resident #23 in the darkened shower room and on the floor. LVN K also documented Resident #23 was locked in the shower by another LVN (LVN A) who was re-directing Resident #14 from entering the shower room, while unknowing Resident #14 was in the shower, resident (#23) propel self in wheelchair to shower room. Another Resident (#14) wanting to take a shower and kept wanting to go in shower. Staff (LVN A) unknowing that resident was in shower turned light off and locked door so that other resident would not go into the shower by himself. Resident (#23) calling for help from the shower room and was sitting on the floor. asst. x2 to wheelchair. moving all extremities, refused writer to take vitals and/or check head. resident wanted to be left alone so that she could take her shower. Resident (#23) upset because she could hear other Resident (#14) wanting to go into shower. took other Resident to 200 hall shower room and showered.<BR/>A record review of the facility's incident reports from June 2023 to March 2024 revealed no evidence for the incident on 02/06/2024 where Resident #23 was showering and Resident #14 attempting to enter the shower room while Resident #23 was bathing. <BR/>During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her).<BR/>During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would, pull the shower curtain closed, yell and scream at him until staff intervened and re-directed him away. <BR/>During an interview on 03/13/24 at 02:29 PM LVN K stated she and LVN A were the charge nurses on 02/06/2024 from 06:00 PM to 06:00 AM. LVN K stated Resident #23 had a preference to bathe herself in the shower room early in the mornings around midnight to 01:00 AM. LVN K stated Resident #23's routine was she would gather her clothes and bathing supplies and self-ambulate in her wheelchair to the shower room. LVN K stated on 02/06/2024 around 01:00 AM screams and shouting were heard coming from the shower room. LVN K stated she ran to the shower room and discovered Resident #23 in the dark on the floor. Resident #23 was upset and claimed she was locked in the shower with the lights off. LVN K stated Resident #23 stated she fell in the dark attempting to get out of her wheelchair trying to get to the light switch or door. LVN K stated she spoke with LVN A and learned Resident #14 was attempting to get into the shower room with Resident #23 when LVN A redirected Resident #14 away and LVN A did not recognize Resident #23 was in the shower room. LVN A turned off the light and locked the shower room door to prevent Resident #14 from entering. LVN K stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents.<BR/>During an interview on 03/15/24 at 10:59 AM LVN A stated on the early morning of 02/06/2024 around midnight Resident #14 entered the shower room while Resident #23 was showering; although LVN A did not know Resident #23 was in the shower room. LVN A stated she heard Resident #23 in the shower room and entered and redirected him out and away from the shower room and turned off the shower room light and locked the door. LVN A stated she did not check for other residents in the shower room and did not see Resident #23 possibly due to the shower curtain was pulled shut. LVN A stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents.<BR/>A record review of Resident #14's admission record dated 03/14/2024, revealed an admission date of 05/10/2023 with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. <BR/>A record review of Resident #14's quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment.<BR/> During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for facility staff to ensure residents were supported in their rights to be free from abuse and or neglect, including Resident #23's rights for safety. The Administrator stated he expected a report for all incidents involving resident #23 being secluded and harassed by Resident #14 in her shower room. The Administrator stated not having provided any Resident, supports for ensuring their rights could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment.<BR/>A record review of the facility's A record review of the facility's Abuse / Neglect policy dated 01/08/2003, revealed, The Resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents should not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff, of other agencies serving the Resident, family members or legal guardians, friends, or other Residents .the facility will provide and ensure the promotion and protection of Resident rights. It is each individuals' responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any Resident in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 21 (Resident #20) reviewed in that:<BR/>Resident #20 did not have an order for his colostomy, urostomy, urinary catheter, or his pacemaker.<BR/>The failure could place residents at risk of not receiving care as needed. <BR/>The findings were:<BR/>Record review of #20's face sheet dated 3/13/2024 revealed he was admitted on [DATE], re-admitted on 12/12023, resident was [AGE] years old. with diagnoses of personal history of malignant neoplasm of bladder, overactive bladder, retention of urine, persona history of urinary infections.<BR/>Record review of consolidated physician orders for March 2024 revealed colostomy ,since 9/9/2023 (An opening into the colon from the outside of the body. A colostomy provides a new path for waste material to leave the body after part of the colon has been removed.), ostomy, urinary catheter, (uses a tube (created out of your own intestines) to help you pass urine when your bladder has been removed or isn't working correctly) or his pacemaker, since 9/11/2023. The urostomy since 9/9/2023.<BR/>Record review of Resident #20's Quarterly MDS dated on 12/13/2023 revealed Section C BIMs score was 11/15 (moderate cognitive impairment). Section H Bladder and Bowel reflected he had, and ostomy checked off, that included urostomy and colostomy. The MDS revealed in section I Active Diagnosis reflected he had a cardiac pacemaker.<BR/>Observation on 3/11/2024 at 11:13 AM with Resident #20 revealed he was sitting in a wheelchair and had a catheter bag, catheter tubing, and privacy bag was over the catheter bag. <BR/>Observation on 3/18/24 at 1:52 PM in Resident #20's room revealed he had a pacemaker, urostomy, colostomy, urinary catheter bag and were clean.<BR/>Record review of Resident # 20 consolidated orders for March 2024 revealed no order for urinary catheter, colostomy, and Urostomy. Order for pacemaker to left upper chest wall start date 3/12/2024 (surveyor intervention). Orders for Urostomy every day and every shift. Change colostomy dressing every 3 days May use 2-piece system (wafer and pouch). Stoma powder. Stoma paste or ring seal if available. Skin prep. Adhesive wipes once daily dated on 10/6/2023. Order for urostomy output every shift started on 9/9/2023. Order for follow up appointment with physician office to check pacemaker dated for 4/25/2024. Order for Colostomy to left lower abdominal area every shift start date 3/12/2024. Order to change urostomy dressing every 4 days may use stoma powder, adhesive remover wipes, skin prep, wafer, and drainage pouch once a day started on 10/12/2023. Order Change colostomy dressing as needed may use 2-piece system, stoma paste or ring seal if available, skin prep, adhesive wipes as needed start date 9/9/2023. Facility had orders for treatment. <BR/>Record review of Resident #20's care plan dated on 9/16/22, last review 12/13/2024. The pacemaker dated 9/11/23 revealed changed serial number, next pacemaker checks 4/25/2024, colostomy/ostomy-9/16/22.<BR/>Interview on 3/13/24 at 5:22 PM with the DON stated it was important to have an order resident needs such as colostomy, so the nursing staff could follow and provide care to residents.<BR/>Interview on 3/18/24 at 1:47 PM LVN N stated Resident #20 had a pacemaker, urostomy, colostomy and catheter. LVN N stated Resident #20's cardiologist next check for his pacemaker at the office was 4/25/2024. LVN N stated she worked with ostomies and catheters before and was experienced. <BR/>Interview 3/18/24 at 1:59 PM Resident #20 stated he had no issues with pacemaker, urostomy or colostomy and urinary catheter. <BR/>Interview on 3/18/24 at 5:36 PM with RN R revealed it was detrimental to have a care plan for resident to make sure the staff followed the physicians' orders to provide residents with care. <BR/>Record review of the policy Physician Services dated February 2021 revealed The medical care of each resident is supervised by a licensed physician. 2. Once a resident is admitted , orders for the residents' immediate care and needs can be provided by a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 22 residents (Residents #18 and #35) reviewed for accidents and hazards in that: <BR/>The facility failed to ensure Residents #18 and #35 did not have two disposable razors in their rooms. <BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents.<BR/>The findings were:<BR/>1. Record review of Resident #18's Face sheet, dated 02/03/23, revealed an admission date of 09/28/22 and readmission date of 01/02/23 with diagnoses which included seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), lack of coordination, and unspecified dementia with behavioral disturbances (Dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life). <BR/>Record review of for Resident #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 4 which indicated severe impaired cognition. <BR/>Record review of Resident #18's Care Plan dated 02/01/23 revealed the resident experienced wandering moved with no rational purpose, seemingly oblivious to needs or safety, with a goal for the Resident to wander safely within specified boundaries. Wander-guard in place (a device that is worn by residents designed for Alzheimer's and dementia patients allowing them to have freedom within their resident facilities and will alert staff if they go beyond allowed boundaries). <BR/>Record review of Resident #18's Physician order summary, dated 02/03/23, revealed an order for a wander guard to the right lower extremity, with a start date of 01/05/23 and an end date of 01/07/23. <BR/>2. Record review of Resident #35's Face sheet, dated 02/03/23, revealed an admission date of 01/04/23, with a diagnoses which included: vascular dementia and dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (A group of symptoms that affects memory, thinking and interferes with daily life), muscle wasting and atrophy (muscle weakness), poisoning by local antifungal, anti-infective and anti-inflammatory drugs, and other lack of coordination. <BR/>Record review of Resident #35's Quarterly MDS dated [DATE] revealed a BIMS of 02 which indicated the resident had severe impaired cognition. <BR/>Record review of Resident #35's Care Plan dated 01/12/23 revealed alterations in ADL self-performance and mobility related to weakness. Resident #35 required x1 assist with personal hygiene. <BR/>During an observation on 02/01/23 at 10:37 a.m., Resident #18 and Resident #35 had a basket of toiletries on top of a counter next to the sink in their shared room. The basket contained two disposable razors. <BR/>A second observation on 02/02/23 at 2:13 p.m. revealed the basket still contained two disposable razors. <BR/>During an interview on 02/07/23 at 4:01 p.m. LVN A stated there was a list of items that were prohibited in residents' rooms. She stated razors were not allowed in the residents' rooms. She stated she knew of one resident, Resident #37, who was allowed to shave themselves. LVN A stated the CNAs watched Resident #37 while shaving and removed the razor when the resident was done shaving. LVN A stated staff should not leave any razors in resident rooms and razors were locked up in the central supply closet. <BR/>During an interview on 02/02/23 at 4:30 p.m. the DON stated Residents #18 and #35 were shaved by the CNAs. The DON confirmed there were two razors in Resident #18 and #35's room at that time. The DON removed the razors from the room at that time. The DON stated razors were kept locked up because they could be a danger to residents who got a hold of them and were not competent to be using a sharp object. The DON stated the only resident she was aware of that shaved by themselves was Resident #37. The DON stated staff should be checking the rooms for items that were not allowed. <BR/>Record review of an undated document titled Nursing Home List of Items Not Allowed in Resident Rooms, stated the following is a list of items which are either specifically controlled by code, standards, regulations or have been determined by this facility as having an adverse effect on the health and safety of our residents. upon removal of any of these non-allowed items from the resident's room, family will be notified, and the item will be held until the family claims them . safety hazard . aerosol cans: of any product are combustible, glass items: which can be broken and cost cut, razors and blades: these must be left at the nurses station . <BR/>Record review of the Facility's policy, undated, titled Free of Accident Hazards/Supervision/Devices, stated Intent: it is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with each resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: 1. the facility must ensure that: a. the resident environment remains as free of accident hazards as is possible; and b. each resident receives adequate supervision and assistance devices to prevent accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for 1 of 8 Residents (Resident #13) reviewed for nutritional status in that: <BR/>The facility failed to initiate timely intervention to prevent weight loss when Resident #13 experienced continuous significant weight loss of -10.84% (13.8 pounds) between the dates 12/01/2023 and 01/04/2024. <BR/>These failures could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life. <BR/>Findings included:<BR/>Record review of Resident #13's Face Sheet, dated 3/18/2024, reflected an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including unspecified dementia (group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and osteoporosis (A condition in which bones become weak and brittle). <BR/>Record review of Resident #13's MDS assessment, dated 3/1/2024, reflected a BIMS score of 10, indicating moderate cognitive impairment. Further review reflected that Resident #13 required setup or clean-up assistance while eating and had no swallowing disorders. <BR/>Record review of Resident #13's Care Plan, dated 2/28/2024, reflected Resident #13 had unplanned weight loss of over 10% in 6 months with a start date of 1/9/2024. Interventions listed included: registered dietician to review residents medical record and make recommendations with nursing staff to follow up . There is no evidence to suggest the care plan intervention was implemented, or that the dietitian reviewed the medical record with nursing staff. <BR/>Record review of Resident #13's weight record reflected that on 12/01/2023, she weighed 127.3 lbs.; on 1/04/2024, she weighed 113.5 lbs.; on 2/06/2024 she weighed 102.5 lbs.; and on 3/5/2024 she weighed 100.3 lbs. <BR/>Record review of document, titled Communication between the Dietitian and Attending Physician reflected that on 1/16/2024, the facility's registered dietician recommended house shake qd @ lunch and snack bid b/t meals for Resident #13. Further review reflected that the resident's physician reviewed this document on 2/8/2024, 23 days after the recommendation from the dietitian. <BR/>Record review of Resident #13's orders reflected a doctor's order for house shake daily for lunch and a snack between meals twice daily with a start date of 2/8/2024. <BR/>Observation on 3/11/2024 at 12:35 PM, Resident #13 was observed in her room eating lunch. A house shake was on the resident's meal tray. Interview attempt was not successful, as the resident declined to speak to surveyor. <BR/>Interview on 3/15/2024 at 5:00 PM, LVN W stated that the CNA's take weights of residents and usually tell nursing staff if the resident seems to be losing weight based on any other factors throughout the month and they would notify the doctor if the weight was a significant amount. <BR/>Interview on 3/15/2024 at 5:15 PM, the DON stated that the LVN's should document dietary intake and keep track of weights and inform DON of any significant changes so they can inform the physician. The DON stated that if there is a significant weight loss and/or any dietary recommendations, the expectation is that the physician is informed within a week so that they can begin any dietary recommendations or orders the physician may recommend. The DON stated that the risk to residents for not acting quickly on dietary recommendations or significant weight loss could include not preserving nutritional status or being able to investigate the cause for the weight loss.<BR/>Interview on 3/16/2024 at 11:25 AM, CNA M stated that CNA's weigh residents monthly and discuss with nursing staff if a resident seems to be eating less or if the resident looks like they have lost weight. CNA M stated they were not aware on the resident's weight loss status and would only know if they noticed significant weight loss based on the residents appearance. <BR/>Record review of policy titled, Food and Nutritional Services, dated 10/2017, reflected, The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on interview and record review the facility failed to ensure residents are free of any significant medication errors for 2 of 2 (#9, #47) residents reviewed in that:<BR/>1. Resident #9 was administered Midodrine (a blood pressure medication) 9 times in February and March 2024 above parameters when it should have been held.<BR/>2. Resident #47 was administered Midodrine more than 39 times (2/13/2024 to 3/9/2024) in February and March 2024 without parameters (orders from the physician to determine where to give the medication or not based upon the blood pressure). <BR/>This failure could result in residents having risk of heart attacks, strokes, blood clots, and risk of hospitalizations. <BR/>Findings include: <BR/>1. Record review of Resident #9's face sheet dated 3/15/2024 revealed he was admitted on [DATE] and re-admitted on [DATE] with diagnosis of hypotension (low blood pressure).<BR/>Record review of Resident #9's consolidated orders for March 2024 revealed he had an order for Midodrine tablet 2.5 milligrams, oral, special instructions: Hold if systolic blood pressure is greater than 110 mm/Hg (millimeters of mercury) medications is used to treat low blood pressure (hypotension), three times a day.<BR/>Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed Section C Cognitive Pattern BIMS score was 8/15 (moderate cognitive impairment), and Section I Active diagnosis reflected he had a diagnosis of hypotension. <BR/>Record review of Resident #9's care plan dated 3/16/2024 revealed he was diagnosed with Cardiovascular, disease and the intervention was to monitor vitals for hypotension. <BR/>Record review of Resident #9's MAR revealed administered Midodrine tablet 2.5 mg, 1 tablet, oral three times a day, HOLD if systolic blood pressure is greater than 110mm/Hg medications is used to treat low blood pressure (hypotension), diagnoses hypotension with a start date of 1/9/2024. <BR/>Record review of MAR legend revealed initial parenthesized meant not administered or not charted. These dates below did not have parenthesis and show they were administered. Resident #9's February and March 2024 MARs indicated the Midodrine was administered on <BR/>Dated: <BR/>2/15/2024 at 7- 10 PM B/P was 112/65 and was administered by MA H.<BR/>2/17/2024 at 1-2 PM B/P was 123/65 and was administered by MA H.<BR/>2/20/2024 at 7-10 PM B/P was 113/64 and was administered by MA H.<BR/>2/23/2024 at 1-2 PM B/P was 134/65 and was administered by MA H.<BR/>2/26/2024 at 1-2 PM B\P was 116/68 and was administered by MA X.<BR/>2/28/2024 at 1-2 PM B/P was 142/76 and was administered by MA H.<BR/>2/29/2024 at 1-2 PM B/P was 141/67 and was administered by MA H.<BR/>3/2/2024 at 1-2 PM B/P was 128/80 and was administered by MA X.<BR/>3/6/2024 at 1-2 PM B/P was 120/63 and was administered by MA H.<BR/>Interview on 3/14/2024 at 10 AM with CMA H stated the Midodrine should not be administered if B/P was greater than 110 for Resident #9. CMA H stated she did not remember administering the Midodrine when his B/P was above 110. CMA H stated Resident #9 did not have side effects. <BR/>Interview on 3/15/24 at 04:19 PM at 4 PM with CMA H stated she did Administer the medications as ordered and within the parameters to Resident # 9. CMA stated she had not noticed any adverse side effects and would notify the nurse. <BR/>Interview on 3/14/2024 at 10:25 AM with LVN N stated the Midodrine was for low blood pressure and the CMA's administered that medication. LVN stated the CMA's had not notified her of any side effects and any change of condition.<BR/>Interview on 3/14/2024 at 10:37 AM with the DON stated Midodrine was administering for low blood pressure and should not be administered by staff if Residents have a high B/P. DON stated the nursing staff had not let her know about administering Midodrine when B/P was high. DON stated she had been working as a DON for a week. <BR/>Interview on 3/14/2024 at 10:42 AM with CMA X stated she missed it the Midodrine and thought it was for another medication with parameters. CMA X stated Resident #9 did not have adverse effects. <BR/>2. Record review of Resident #47's face sheet dated 3/18/2024 revealed she was admitted on [DATE] with diagnoses of Malignancy in colon, and non-specific low blood pressure reading. <BR/>Record review of #47's consolidated orders for March 2024 revealed midodrine tablet; 5 mg (milligrams); 2 tablets oral Special Instructions: Hold if systolic blood pressure is more than 120.<BR/>Record review of Resident #47's admission MDS assessment dated [DATE] revealed Section C Cognitive Patterns BIMs score was 11/15 (moderate cognitive impairment), and Section I Active Diagnoses was cancer, and non-specific low blood pressure reading. <BR/>Record review of Resident #47's Care Plan for Cardiovascular, reflected resident was at risk for sign and symptoms of hypotension (low blood pressure)/hyper (high blood pressure) related to diagnoses of hypertension. The interventions were to monitor resident's blood pressure per physician orders, and abnormal readings.<BR/>Record review of Resident #47's February and March 2024 MAR revealed CMA Z administered Midodrine tablet 5 mg, 2 tablets three times a day, for diagnoses of low blood pressure reading, with start date 2/3/2024-3/9/2024. Record review reflected from 2/13/2024 to 3/9/2024 no vitals were documented with the administering of the Midodrine medication. <BR/>Interview on 3/15/24 at 4:22 PM with CMA Z stated Midodrine did not have parameters from 2/13/2024 to 3/9/2024 and she would administer Midodrine as ordered with no parameters. The CMA Z stated Resident #47 did not have any adverse effects. CMA Z stated Resident #47 had not been feeling well lately, since her health had declined. <BR/>Interview on 3/16/24 at 1:08 PM DON stated the CMAs were trained to administer medications, and no nursing staff had notified her of adverse effects with residents taking Midodrine. The DON stated she was not sure of the process because she was a new DON. DON stated she did not have any formal training and started 3/1/2024. The DON stated CMAs were not able to assess residents and should notify the nurse to assess the resident with any change of conditions. The DON stated the CMAs can take vitals. The DON stated the risk of not ensuring the staff had followed physic orders for Midodrine, would be heart rate goes up, stroke, and heart attack.<BR/>Attempted interview on 3/18/24 at 5:09 PM with MD. Left a message and did not receive a return call. <BR/>Interview on 03/18/24 at 05:10 PM with LVN K stated she did not remember the Midodrine orders. LVN K stated in her recent training, now nurses were to administrator Midodrine medication.<BR/>Interview on 3/18/24 at 5:36 PM with RN R stated Midodrine was to treat hypotension, and the medication raised the blood pressure. RN R stated residents on Midodrine risked fainting, dizziness, having sensations in lower extremities and elevated pulse. RN R stated the CMA's should be notifying the nurse if any change of condition with medications. <BR/>Record review of policy dated April 2019 was documented Administering Medications, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 20 Residents (Resident #30) reviewed for comprehensive care plans, in that:<BR/>The facility failed to ensure Resident #30's care plan addressed services that were to be provided by hospice and the facilities responsibilities.<BR/>This failure could place residents at risk of not receiving care and services needed and a diminished quality of life. <BR/>The findings were:<BR/>Record review of Resident #30's face sheet, dated 2/2/2023, revealed the resident was initially admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses which included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease stage 3 (kidneys have mild to moderate damage and they are less able to filter waste and fluid out of your blood), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone, which can disrupt such things as heart rate, temperature and all aspects of metabolism), gastroesophageal reflux disease (Gerd-a digestive disease in which the stomach acid or bile irritates the food pipe lining) and cognitive communication deficit.<BR/>Record review of Resident #30's Quarterly MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 4 which indicated the resident had severe impaired cognitive status and was receiving hospice services.<BR/>Record review of Resident #30's Physician Orders revealed the resident was admitted to hospice services on 10/14/2021.<BR/>Record review of Resident #30's care plan revealed a care plan with a start date of 4/12/2021 revealed the problem, Potential for sig (significant) weight loss due to nutrition and potential for aspiration R/T (related to) hypothyroidism, GERD (Gastroesophageal reflux disease), on hospice services for end stage heart failure, and he has broken/chipped teeth. Further review of the care plan revealed the goal addressed the resident would receive adequate nutrition and the approaches addressed the resident's prescribed diet, oral care, monitoring for aspiration and offering substitutes if the resident ate less than 50% of meals. Further review of the resident's care plans revealed there was not a care plan that addressed the specific goal and interventions and services provided by hospice. <BR/>In an interview on 2/2/2023 at 3:38 p.m. with RN/MDS E revealed she worked for the facility about a month. RN/MDS E reported care plans were created to address resident care to know what the resident needed. RN/MDS E reported a hospice care plan should note the resident was on hospice services and that basic needs were addressed. RN/MDS E revealed she knew what to care plan by looking at the face sheet diagnoses, orders, the Resident Assessment Instrument (RAI) and any records from a hospital. RN/MDS E reported she would normally care plan hospice as a problem on its own, and provide goals and interventions related to hospice services and not combine it in another care plan. RN/MDS E reported care plans were necessary for staff to do care the residents needed and to know who was on hospice services.<BR/>Record review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility must ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (Resident #35) reviewed for pressure sores, in that: <BR/>LVN D failed to sanitize her hands between glove changes while providing wound care to Resident #35.<BR/>This failure could place residents at risk for infections and cross contamination.<BR/>The findings were:<BR/>Record review of Resident #35's Face sheet, dated 02/03/23, revealed an admission date of 01/04/23, with a diagnosis which included: unspecified urinary incontinence, vascular dementia and dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (A group of symptoms that affects memory, thinking and interferes with daily life), muscle wasting and atrophy (muscle weakness), and poisoning by local antifungal, anti-infective and anti-inflammatory drugs, intentional self-harm. <BR/>Rcord review of the Quarterly MDS dated [DATE] for Resident #35 revealed a BIMS of 02 which indicated the resident had severe impaired cognition. Under section G functional status for toilet use revealed total dependence on staff. Under section H bladder and bowel revealed the resident was always incontinent. <BR/>Record review of Resident #35's Care Plan dated 01.12.23 revealed alterations in ADL self-performance and mobility related to weakness. Resident #35 required x1 assist with personal hygiene.<BR/>Record review of Resident #35's Physician order summary, dated 02/03/23, revealed an order for nystatin powder; 100,000 unit/gram topical apply to peri wound to left buttock, left groin, and right groin, with a start date of 01/23/23 and no end date. <BR/>Record review of Resident #35's Physician order summary, dated 02/03/23, revealed an order for buttocks clean wound with wound cleanser, pat dry, apply collagen powder and calcium alginate and cover with gauze, with a start date of 01/30/23 and no end date.<BR/>Record review of Resident #35's Physician order summary, dated 02/03/23, revealed an order for right and left groin clean area with wound cleanser, pat dry, apply collagen powder and calcium alginate cover with dry dressing twice a day, with a start date of 01/30/23 and no end date.<BR/>During an observation on 02/01/23 at 4:33 p.m. revealed LVN D provided wound care to Resident #35's left and right groin area and buttocks area. LVN D did not sanitize her hands in between glove changes during the wound care treatment. LVN D changed her gloves approximately 6 times with out sanitizing her hands between glove changes. <BR/>During an interview on 02/01/23 at 4:57 p.m. LVN D stated she should sanitize her hands between glove changes during wound care. She stated she did not have any hand sanitizer on her tray during wound care to use. She stated she did have some in the nurse treatment cart, but she forgot it. She stated she should sanitize her hands for infection control. <BR/>During an interview on 02/01/23 at 5:01 p.m. the DON stated staff were expected to sanitize their hands between glove changes to prevent infections during wound care. She stated they had bottles of hand sanitizer available for them to use. She stated they should also wash their hands with soap and water after they were done with wound care.<BR/>Record review of the Facility's Policy titled Clean Dressing Change, dated 01/27/21, stated Intent: it is the policy of the facility to ensure change dressings in accordance with state and federal regulations, and national guidelines. Procedure: 1. Verify and review physician's order before procedure 2. Perform hand hygiene and assemble equipment and supplies needed for dressing change .5. Put on gloves. adjust bedside table to waste off. Clean bedside table with germicide disposable cloth. Establish a clean field . 7. Remove gloves and perform hand hygiene .12. Remove dressing and place in the residence trash can. 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Clean wound with gauze and prescribed cleaning solutions using single outward strokes. Use separate guys for each cleansing wipe .17. Remove gloves and perform hand hygiene. 18. Put on clean gloves. 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene . <BR/>Record review of the Facility's policy titled Fundamentals of Infection Control Precautions, dated 02/14/02, stated a variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the LTCF. These measures make up the fundamentals of infection control precautions. 1. Hand washing and gloving, 1. hand washing is the most important measure to reduce the risk of transmitting organisms from one person to another or from one site to another on the same resident. 2 . in addition to hand washing gloves play an important role in reducing the risk of transmission of microorganisms. C. gloves are worn for three important reasons .4. Wearing gloves does not replace the need for hand washing because gloves may have small and inapparent defect or be torn during use, and hands can become contaminated during removal of gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 22 residents (Residents #18 and #35) reviewed for accidents and hazards in that: <BR/>The facility failed to ensure Residents #18 and #35 did not have two disposable razors in their rooms. <BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents.<BR/>The findings were:<BR/>1. Record review of Resident #18's Face sheet, dated 02/03/23, revealed an admission date of 09/28/22 and readmission date of 01/02/23 with diagnoses which included seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), lack of coordination, and unspecified dementia with behavioral disturbances (Dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life). <BR/>Record review of for Resident #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 4 which indicated severe impaired cognition. <BR/>Record review of Resident #18's Care Plan dated 02/01/23 revealed the resident experienced wandering moved with no rational purpose, seemingly oblivious to needs or safety, with a goal for the Resident to wander safely within specified boundaries. Wander-guard in place (a device that is worn by residents designed for Alzheimer's and dementia patients allowing them to have freedom within their resident facilities and will alert staff if they go beyond allowed boundaries). <BR/>Record review of Resident #18's Physician order summary, dated 02/03/23, revealed an order for a wander guard to the right lower extremity, with a start date of 01/05/23 and an end date of 01/07/23. <BR/>2. Record review of Resident #35's Face sheet, dated 02/03/23, revealed an admission date of 01/04/23, with a diagnoses which included: vascular dementia and dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (A group of symptoms that affects memory, thinking and interferes with daily life), muscle wasting and atrophy (muscle weakness), poisoning by local antifungal, anti-infective and anti-inflammatory drugs, and other lack of coordination. <BR/>Record review of Resident #35's Quarterly MDS dated [DATE] revealed a BIMS of 02 which indicated the resident had severe impaired cognition. <BR/>Record review of Resident #35's Care Plan dated 01/12/23 revealed alterations in ADL self-performance and mobility related to weakness. Resident #35 required x1 assist with personal hygiene. <BR/>During an observation on 02/01/23 at 10:37 a.m., Resident #18 and Resident #35 had a basket of toiletries on top of a counter next to the sink in their shared room. The basket contained two disposable razors. <BR/>A second observation on 02/02/23 at 2:13 p.m. revealed the basket still contained two disposable razors. <BR/>During an interview on 02/07/23 at 4:01 p.m. LVN A stated there was a list of items that were prohibited in residents' rooms. She stated razors were not allowed in the residents' rooms. She stated she knew of one resident, Resident #37, who was allowed to shave themselves. LVN A stated the CNAs watched Resident #37 while shaving and removed the razor when the resident was done shaving. LVN A stated staff should not leave any razors in resident rooms and razors were locked up in the central supply closet. <BR/>During an interview on 02/02/23 at 4:30 p.m. the DON stated Residents #18 and #35 were shaved by the CNAs. The DON confirmed there were two razors in Resident #18 and #35's room at that time. The DON removed the razors from the room at that time. The DON stated razors were kept locked up because they could be a danger to residents who got a hold of them and were not competent to be using a sharp object. The DON stated the only resident she was aware of that shaved by themselves was Resident #37. The DON stated staff should be checking the rooms for items that were not allowed. <BR/>Record review of an undated document titled Nursing Home List of Items Not Allowed in Resident Rooms, stated the following is a list of items which are either specifically controlled by code, standards, regulations or have been determined by this facility as having an adverse effect on the health and safety of our residents. upon removal of any of these non-allowed items from the resident's room, family will be notified, and the item will be held until the family claims them . safety hazard . aerosol cans: of any product are combustible, glass items: which can be broken and cost cut, razors and blades: these must be left at the nurses station . <BR/>Record review of the Facility's policy, undated, titled Free of Accident Hazards/Supervision/Devices, stated Intent: it is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with each resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: 1. the facility must ensure that: a. the resident environment remains as free of accident hazards as is possible; and b. each resident receives adequate supervision and assistance devices to prevent accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 3 of 10 residents (Residents #24, #40, and #50) reviewed for medication administration in that:<BR/>The facility failed to ensure the Station 2 medication cart contained an accurate narcotic log for Residents #25, #40, and #50. <BR/>This deficient practice could place residents at risk of inaccurate care due to improper procedures. <BR/>The findings were:<BR/>1. Record review of Resident #25's Face sheet, dated 02/03/23, revealed an admission date of 09/05/22, and a readmission date of 10/19/22, with diagnoses which included epilepsy (A neurological disorder that causes seizures or unusual sensations and behaviors). <BR/>Record review of Resident #25's Physician orders, dated 02/03/23, revealed an order for lacosamide (a controlled substance used to prevent and control seizures) 200 mg tablet oral twice a day at 9:00 a.m. and 9:00 p.m. with an order date of 04/18/22 and no end date.<BR/>Record review of Resident #25's MAR, dated 02/03/23, revealed lacosamide was administered on 02/02/23 at 9:00 a.m. by MA C. <BR/>Record review of a document titled individual Patient's Antibiotic/Narcotic Record , dated 01/17/23, revealed 1 tab of lacosamide 200 mg tabs were last administered on 02/01/23 at 8:00 p.m. with a quantity of 36 remaining in the package. <BR/>During an observation on 02/02/23 at 10:13 a.m. revealed a blister pack contained 35 pills of lacosamide 200 mg tablets for Resident #25. <BR/>2. Record review of Resident #40's Face sheet, dated 02/03/22, revealed the resident was admitted to the facility on [DATE], with diagnoses which included anxiety (mind and body's reaction to stressful, dangerous, or unfamiliar situations, it's the sense of uneasiness, distress, or dread you feel) and bipolar disorder (condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)). <BR/>Record review of Resident #40's Physician orders, dated 02/03/23, revealed an order for lorazepam (a controlled substance used to treat anxiety) 1 mg tab oral give 30 or 60 minutes before dialysis on Monday, Wednesday, and Friday at 9:00 a.m. with an order date 08/08/22 and no end date.<BR/>Record review of Resident #40's MAR, dated 02/03/23, revealed lorazepam was not available to be administered on 02/02/23. It was only to be administered on Mondays, Wednesdays, and Fridays before dialysis. 02/02/23 was a Thursday. <BR/>Record review of a document titled individual Patient's Antibiotic/Narcotic Record , dated 01/14/23, revealed 1 tablet of lorazepam 1 mg tablets was administered on 02/02/23 at 8:49 a.m. with a quantity of 6 remaining in the package. MA C initialed the log. <BR/>During an observation on 02/02/23 at 10:13 a.m. revealed a blister pack contained 7 pills of lorazepam 1 mg tablets for Resident #40. <BR/>3. Record review of Resident #50's admission Record, dated 02/03/23, revealed an admission date of 12/07/22 and a readmission date of 12/29/22, with diagnoses which included epilepsy (A neurological disorder that causes seizures or unusual sensations and behaviors).<BR/>Record review of Resident #50's Physician orders for September 2022 revealed an order for phenobarbital (a controlled used to prevent and control seizures) 64.6 mg tab 2 orally once a day at 7:00 a.m., with an order date 12/29/22 and no end date.<BR/>Record review of Resident #50's MAR, dated 02/03/23, revealed 2 tabs of phenobarbital were administered on 02/02/23 at 7:00 a.m. by MA C. A note was added by MA C on 02/02/23 at 8:08 a.m. which stated, late administration: charted late. <BR/>Record review of a document titled individual Patient's Antibiotic/Narcotic Record , dated 01/28/23, revealed 2 tablets of phenobarbital 64.8 mg tablets were administered on 02/01/23 at 7:00 a.m. with a quantity of 24 remaining in the package.<BR/>During an observation on 02/02/23 at 10:13 a.m. revealed a blister pack contained 22 pills of phenobarbital 64.8 mg tablets for Resident #50. <BR/>During an interview on 02/03/23 at 10:33 a.m. MA C stated she should have documented the removal of medications from the packages right after they were administered. She stated because it was a narcotic, they must document it right away. She stated if the count was off on the narcotic log they must investigate where the medication went. She stated she accidentally documented she gave one medication on another Resident's log and that was why 2 of the logs were incorrect. She stated she would go find someone to help her correct them at that time. <BR/>During an interview on 02/02/23 at 4:39 p.m. the DON stated when a narcotic medication was popped out of the blister package it should be documented in the narcotic log at that time. The DON stated even if the medication was not administered and was refused by the resident later it should be documented at the time it was removed from the package. She stated the logs were checked between shifts to make sure no one was taking the medications and to prevent drug diversion. The DON stated the residents were at risk of missing a medication dose or being over dosed if medications were not documented properly in the narcotic log. <BR/>Record review of the facility's policy titled Storage and documentation of schedule II controlled medications, dated 2003, stated all schedule two controlled medication will be stored under double lock and checked for accountability at each change of shift by the nurse going off duty and the nurse coming on duty. Documentation of the audit will be completed on the appropriate form . disposition of controlled substance is maintained on a sheet supplied by the pharmacy with each scheduled to controlled substance, and the controlled substance in schedule III and IV provided in counters. Entries are to be made in pen each time it controlled substances used. Then the nurse administering the medication will record the following information: date and time drug is administered, amount of drug administered, remaining balance of drug, and signature of the nurse administering drug .

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food handling sanitation. <BR/>1. The facility failed to ensure the kitchen ice machine was clean.<BR/>2. The facility failed to ensure the kitchen handwashing sink was supplied with hot water.<BR/>These failures could place residents at risk for cross-contamination and foodborne illnesses. <BR/>The findings include:<BR/>Observation on 01/31/23 at 1:42 PM revealed the designated handwashing sink within the kitchen to only provide cold water.<BR/>Observation on 02/01/23 at 11:14 AM revealed several large black spots along the inside of the ice machine.<BR/>Interview on 02/01/23 at 11:21 AM, the DS stated the ice maker was serviced approximately 1 month ago (January 2023) and should have been cleaned thoroughly. The DS stated the black substance observed was mold. The DS stated the protocol for maintaining the cleanliness of the ice maker was to observe the ice maker from the inside on a regular basis and submit a work order to the MS when they observed it needed to be cleaned. The DS stated the ice maker was cleaned regularly by a third-party vendor. The DS stated she did not know the frequency of cleaning and approximated quarterly. The DS stated the reason the ice maker was not currently free of mold was due to an incomplete work order by the third-party vendor. The DS additionally stated the designated handwashing sink did not have cold water, so staff would use the 3-compartment sink. The DS stated staff were not able to use the 3-compartment sink when it was in operation to wash their hands. The DS stated she submitted a work request to fix the handwashing sink approximately 3 months ago (November 2022) but the problem had not been corrected.<BR/>Interview on 02/02/23 at 12:19 PM, the Maintenance Supervisor stated a request to look at the hot water in the handwashing sink was submitted to him when he started in his position about 4 months ago (October 2022). The MS stated he knew hot water was operating in the 3-compartment sink but was not aware of the handwashing sink. The MS stated he was trying to fix the handwashing sink himself without the help of a vendor. The MS stated the previous MS tried to fix the handwashing sink and completed the repair improperly. The MS stated he attempted to clean the ice maker by himself by cleaning the front face of the unit and cleaning the filters. The MS stated a vendor came to work on the ice maker about a month ago (January 2023) to clean the ice maker by emptying the ice, defrost, and cleaned the inside of the unit. The MS stated he did not check the ice maker after the vendor completed the work and had not cleaned the inside of the unit himself. The MS stated ensuring the cleanliness of the ice maker was the responsibility of the dietary staff.<BR/>Interview on 1/02/2023 at 3:15 PM, the DON stated it was her expectation food provided to the residents was prepared in accordance with professional standards. The DON stated it her expectation for the ice maker that provided ice to the residents was clean and free of mold. The DON stated it was her expectation that staff who prepared food for the residents washed their hands properly while in the kitchen. The DON stated a risk of the ice maker containing mold and dietary staff not washing their hands properly would be the residents could contract foodborne illness.<BR/>Interview on 2/03/2023 at 9:39 AM, the ADM stated she was not aware the ice maker had not been cleaned or the designated handwashing sink was not operating properly. The ADM stated it was her expectation food provided to the residents was prepared in accordance with professional standards. The ADM stated it was her expectation for the ice maker that provided ice to the residents was cleaned and free of mold. The ADM stated it was her expectation that staff who prepared food for the residents washed their hands properly while in the kitchen. The ADM stated a risk of the ice maker containing mold and dietary staff not washing their hands properly would be the residents could contract foodborne illness.<BR/>Record review of the facility's, undated, policy titled Cleaning Schedulereflected ice maker to be listed within the section Weekly (Thorough Cleaning).<BR/>Record review of the facility's, undated, policy titled Sanitizing Ice Machine and Scoops reflected Sanitize inside [with] clean saturated with sanitizing solution.<BR/>Record review of facility's, undated, policy titled Handwashingreflected wet hands with warm running water.<BR/>Record review of the US Food Code, dated 2017, revealed 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38oC (100oF) through a mixing valve or combination faucet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure, in accordance with professional standards and practices, medical records were maintained for each resident that were complete and accurately documented for 2 of 22 residents (Resident #33 and Resident #104) reviewed for accurate and complete medical records, in that: <BR/>1. The facility failed to ensure Resident #33's dietary orders were correct in the resident's clinical record.<BR/>2. The facility failed to ensure Resident #104's EHR reflected the correct code status. <BR/>These failures could place residents at risk for errors in care and treatment.<BR/>Findings included:<BR/>1. Record review of Resident #33's face sheet, dated 2/2/2023, revealed the resident was admitted to the facility on [DATE] and had diagnoses which included end stage renal disease (the kidneys no longer filter wastes and excess fluids from the blood), Hemiplegia (partial or total paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it which can cause parts of the brain to die), essential hypertension (a type of blood pressure that has no clearly identifiable cause, but thought to be linked to genetics, poor diet, lack of exercise and obesity) and dysphagia (swallowing difficulties). <BR/>Record review of Resident #33's Quarterly MDS dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated mild cognitive loss. <BR/>Record review of Resident #33's physician orders, with a start date of 11/19/2022 and revised 1/21/2023, revealed he had an order for a Liberal Renal Diet, with no salt on tray, limit citrus fruit, bananas, chocolate, potatoes, beans and tomatoes, breakfast taco for every breakfast meal. Further review of Resident #33's medical record revealed he had an order for NPO (nothing by mouth) with a start date of 12/5/2021. <BR/>Record review of Resident #33's care plan dated 6/2/2021 revealed the resident had a care plan to provide diet as ordered and monitor intake. <BR/>In an observation on 2/1/2023 at 12:20 p.m. revealed an unidentified CNA took Resident #33 a meal tray, into his room, then exited his room and reported to the nurse the resident's mother was going to bring him lunch today. Further observation revealed the resident did not eat his meal served by the facility . <BR/>In an interview on 2/1/2023 at 9:58 a.m., during initial rounds, Resident #33 reported the food at the facility did not taste good. <BR/>In an interview on 2/02/2023 at 11:52 a.m. with LVN F revealed Resident #33 received Bolus feedings (a type of feeding where a syringe is used to send formula through a feeding tube) if he ate less than 50% of his meal. The LVN stated the resident was NPO a while back and was on a feeding pump (an electronic medical device that controls the timing and amount of nutrition delivered to a resident during enteral feeding by feeding tube), but now Resident #33 received a tray and bolus feeding, if needed. The LVN reported the physician or Speech Therapist usually wrote orders if a resident was to be NPO or not .<BR/>In an interview on 2/2/2023 at 12:00 p.m. with the DON revealed both she and RN E reviewed the resident's physician orders for accuracy. The DON reported Resident #33 received a diet tray from the kitchen and received feedings via gastrostomy tube (a surgical placed device used to give direct access to the stomach for supplemental feeding) if the resident consumed less than 50% of his meal. <BR/>In an interview on 2/2/2023 at 12:08 p.m. with RN E revealed Resident #33 was on a renal diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with chronic kidney disease) and received a meal tray from the kitchen. The RN revealed the resident was not NPO and the NPO order should have been removed. The RN stated if a nurse had seen both orders and was confused about whether to give the resident a meal tray or not the RN stated she, hoped the nurse would check with the doctor and just not let him have food. The RN stated Resident #33 was particular about his food, so his mother frequently brought him food.<BR/>2. Record review of Resident #104's physician's orders dated 12/9/2021 reflected an active order which indicated Full Code.<BR/>Record review of Resident #104's comprehensive care plan dated 1/29/23 reflected a care goal of DNR.<BR/>Record review of Resident #104's DNR revealed the form was signed by the resident, witnesses and physician.<BR/>Interview on 02/02/23 at 11:41 AM LVN F stated Resident #104 did have an active DNR but it might not have been uploaded to the EHR. LVN F stated the DNR was in the paper file for Resident #104. LVN F stated medical records uploaded the DNR forms into the EHR for new admissions but the medical records staff member was on leave for the last several weeks. LVN F stated she was not aware of what staff member took over the role of medical records while she was on leave. LVN F stated the physician's orders for Resident #104 must reflect the will of the resident and must be a mistake as the resident wished to not be resuscitated in that instance.<BR/>Interview on 02/02/23 at 01:49 PM, the DON stated Resident #104's EHR should reflect she had an active DNR and requested to not be resuscitated. The DON stated she was not sure why the EHR was inconsistent for Resident #104 or why the physician's orders reflected a Full Code order. The DON stated the concern and risk with having conflicting information related to the code status for a resident would be staff would potentially not respect the resident's wishes in the instance of a code.<BR/>Interview on 2/03/2023 at 9:39 AM, the ADM stated she was not aware of Resident #104's EHR reflecting a Full Code physician order while Resident #104 had a completed and executed DNR. The ADM stated it was her expectation resident's EHR's reflected the will of the resident the same as their paper records for all residents. The ADM stated the risk associated with having inconsistent records for resident's code status could cause the resident's rights to not be respected during the instance of a code.

**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 a safe, clean, comfortable, and homelike environment which included but not limited to receiving treatment and supports for daily living for 2 of 5 resident rooms (Rooms #809 and #811) reviewed for environmental conditions and for 2 of 8 Residents (Residents #16 and #49) reviewed for safe and clean environment in that: <BR/>1. The facility failed to ensure Resident #16's bed was not broken.<BR/>2. The facility failed to ensure Resident #49's bed was not broken. <BR/>These failures could place residents at risk of living in an unsafe, unclean, uncomfortable, and un-homelike environment.<BR/>Findings include: <BR/>1. Record review of Resident #16's face sheet dated 2/1/2023 revealed the resident was admitted on [DATE] and had diagnoses which included essential hypertension (a type of high blood pressure that has no clearly identifiable cause), cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it, which can cause parts of the brain to die), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting of left non-dominant side, and cognitive communication deficit.<BR/>Record review of Resident #16's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate impaired cognitive status and required extensive assistance of 2 staff for bed mobility, transfers, dressing and toileting. <BR/>Observation on 2/1/2023 at 9:10 a.m. reflected Resident #16 in his room in Bed A, the bed was by the door, and there was another bed, Bed B, that was in the room but was unoccupied. Further observation of Bed B revealed there was a sign on the bed that read, Maintenance with a picture of a wrench and hammer on the sign.<BR/>2. Record review of Resident #49's face sheet dated 2/2/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included dementia (a progressive loss of intellectual functioning, especially with impaired memory and abstract thinking, resulting from organic disease of the brain) with anxiety, essential hypertension (high blood pressure that does not have a known secondary cause), chronic obstructive pulmonary disease (a type of progressive characterized by long-term respiratory symptoms and airflow limitation), and other chronic pain.<BR/>Record review of Resident #49's admission MDS dated [DATE] revealed the resident had a BIMS score of 14 which indicated the resident was cognitively intact, and required extensive assistance of 1 staff member for bed mobility, transfers, dressing, toileting, and personal hygiene.<BR/>Observation on 2/1/2023 at 9:15 a.m. reflected Resident #49 occupied Bed B in his room, by the window and bed A, by the door, was unoccupied. Further observation of Bed A revealed there was a sign on the bed that read, Maintenance with a picture of a wrench and hammer on the sign.<BR/>In an interview on 2/2/2023 at 9:55 p.m. with the Maintenance Director he reported the signs were on the beds because the beds were broken, and he was waiting for parts. The Maintenance Director stated the beds were power beds and used hydraulics to raise and lower the bed. He stated parts to the hydraulics needed to be replaced and were on back order. He stated he left the broken beds in the room because that was where they were when they broke. He said there was no other reason why he did not move the broken beds out of the rooms.<BR/>In an interview on 2/3/2023 at 12:40 p.m. with the Administrator, she reported she asked the Maintenance Director to put the signs on the beds because they kept assigning residents to them. <BR/>Record review of the facility policy entitled, Homelike Environment, revised February 2021, revealed, 3. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics included: c. institutional signage (for example, labeled storage closets and work rooms in common areas).

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.<BR/>Findings included:<BR/>Record Review of the Employee Service List, dated 02/07/2024, revealed Employee A was listed as the Dietary Manager with a hire date of 08/02/2023.<BR/>In an interview on 02/08/2024 at 12:20 p.m. Employee A revealed she had been hired as a cook in August of 2023 and when the previous supervisor left sometime in October [2023] she had moved into the DM role. Employee A further revealed she did not have any certification or degrees as a nursing home DM and stated she was previously in a management position at a local restaurant. Employee A revealed she was signed up for classes when she took the DM position in October of 2023 and would complete the course in October of 2024.<BR/>In an interview on 02/08/2024 at 2:47 p.m., the BOM/Assistant Administrator confirmed she had enrolled Employee A in a dietary manager training course when she was moved into the new position however she had not completed a dietary manager training course at this point. The BOM/AA stated she felt the DM was doing an excellent job and the facility had a consultant dietitian who was available to Employee A as needed and in the facility one to two days each month.<BR/> Record review of the job description for Dietary Service Manager, provided by the facility revealed a section, Base Knowledge: Current certification by state as required.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.<BR/>Findings included:<BR/>Record Review of the Employee Service List, dated 02/07/2024, revealed Employee A was listed as the Dietary Manager with a hire date of 08/02/2023.<BR/>In an interview on 02/08/2024 at 12:20 p.m. Employee A revealed she had been hired as a cook in August of 2023 and when the previous supervisor left sometime in October [2023] she had moved into the DM role. Employee A further revealed she did not have any certification or degrees as a nursing home DM and stated she was previously in a management position at a local restaurant. Employee A revealed she was signed up for classes when she took the DM position in October of 2023 and would complete the course in October of 2024.<BR/>In an interview on 02/08/2024 at 2:47 p.m., the BOM/Assistant Administrator confirmed she had enrolled Employee A in a dietary manager training course when she was moved into the new position however she had not completed a dietary manager training course at this point. The BOM/AA stated she felt the DM was doing an excellent job and the facility had a consultant dietitian who was available to Employee A as needed and in the facility one to two days each month.<BR/> Record review of the job description for Dietary Service Manager, provided by the facility revealed a section, Base Knowledge: Current certification by state as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 20 Residents (Resident #30) reviewed for comprehensive care plans, in that:<BR/>The facility failed to ensure Resident #30's care plan addressed services that were to be provided by hospice and the facilities responsibilities.<BR/>This failure could place residents at risk of not receiving care and services needed and a diminished quality of life. <BR/>The findings were:<BR/>Record review of Resident #30's face sheet, dated 2/2/2023, revealed the resident was initially admitted to the facility on [DATE], readmitted on [DATE], and had diagnoses which included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease stage 3 (kidneys have mild to moderate damage and they are less able to filter waste and fluid out of your blood), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone, which can disrupt such things as heart rate, temperature and all aspects of metabolism), gastroesophageal reflux disease (Gerd-a digestive disease in which the stomach acid or bile irritates the food pipe lining) and cognitive communication deficit.<BR/>Record review of Resident #30's Quarterly MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 4 which indicated the resident had severe impaired cognitive status and was receiving hospice services.<BR/>Record review of Resident #30's Physician Orders revealed the resident was admitted to hospice services on 10/14/2021.<BR/>Record review of Resident #30's care plan revealed a care plan with a start date of 4/12/2021 revealed the problem, Potential for sig (significant) weight loss due to nutrition and potential for aspiration R/T (related to) hypothyroidism, GERD (Gastroesophageal reflux disease), on hospice services for end stage heart failure, and he has broken/chipped teeth. Further review of the care plan revealed the goal addressed the resident would receive adequate nutrition and the approaches addressed the resident's prescribed diet, oral care, monitoring for aspiration and offering substitutes if the resident ate less than 50% of meals. Further review of the resident's care plans revealed there was not a care plan that addressed the specific goal and interventions and services provided by hospice. <BR/>In an interview on 2/2/2023 at 3:38 p.m. with RN/MDS E revealed she worked for the facility about a month. RN/MDS E reported care plans were created to address resident care to know what the resident needed. RN/MDS E reported a hospice care plan should note the resident was on hospice services and that basic needs were addressed. RN/MDS E revealed she knew what to care plan by looking at the face sheet diagnoses, orders, the Resident Assessment Instrument (RAI) and any records from a hospital. RN/MDS E reported she would normally care plan hospice as a problem on its own, and provide goals and interventions related to hospice services and not combine it in another care plan. RN/MDS E reported care plans were necessary for staff to do care the residents needed and to know who was on hospice services.<BR/>Record review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the facility policy titled, Comprehensive Care Plans revised 5/12/2015 revealed, The care plan must describe the following: a. Services/interventions that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible, for 1 of 1 Residents (Resident #35) reviewed for perineal/incontinent care, in that:<BR/>The facility failed to ensure CNA B provided proper incontinent care to Resident #35.<BR/>This deficient practice could place residents at risk of increased urinary tract infections due to improper care.<BR/>The findings were:<BR/>Record review of Resident #35's Face sheet, dated 02/03/23, revealed an admission date of 01/04/23. Resident #35 had diagnoses which included unspecified urinary incontinence, vascular dementia and dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (A group of symptoms that affects memory, thinking and interferes with daily life), muscle wasting and atrophy (muscle weakness), and other lack of coordination. <BR/>Record review of Resident #35's Quarterly MDS dated [DATE] revealed a BIMS of 02 which indicated the resident had severe impaired cognition. Under section G functional status for toilet use revealed total dependence on staff. Under section H bladder and bowel revealed the resident was always incontinent. <BR/>Record review of Resident #35's Care Plan dated 01/12/23 revealed alterations in ADL self-performance and mobility related to weakness. Resident #35 required x1 assist with personal hygiene.<BR/>During an observation on 02/01/23 at 4:12 p.m. CNA B provided incontinent care to Resident #35 in the order of in between the residents thighs, scrotum, buttocks, and then penis. <BR/>During an interview on 02/01/23 at 4:30 p.m. CNA B stated she should have cleaned Resident #35 penis instead of his bottom first. She stated she was taught to clean in the order of groin area, then penis, then the bottom. She stated she messed up and forgot to wash the penis and moved on to clean his bottom then came back to wash his penis. She stated she should clean from an area of clean to dirtiest to prevent a urinary tract infection for the resident. <BR/>During an interview on 02/01/23 at 5:01 p.m. the DON stated incontinent care for a male resident should be done in the order of the penis, scrotum, and back area. She stated if the CNA cleaned the buttocks area and then the penis this would not be the correct order. She stated they should clean from the front to back, cleanest to dirtiest because you did not want to move the germs to the clean area. <BR/>Record review of the, undated, facility document of a check off list revealed an area titled Peri care- male and stated Help resident flex knees and spread legs apart, wash upper thighs using one stroke method, washing down leg towards knee, gently grasp shaft of penis & if uncircumcised retract foreskin, wash tip of penis at urethral meatus (the opening of the urethra) first. Using circular motion, cleanse from meatus outward & down shaft. One stroke method. Gently cleanse scrotum, lift carefully & wash underlining skin folds & groin, change gloves & pat dry, lower legs & resume side lying position, wash by wiping from front towards anus with one stroke. Repeat using clean wipe, change gloves, dry area using one stroke method.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 8 resident rooms (Resident #41) reviewed for storage of drugs, in that: <BR/>An over-the-counter dietary supplement was found on a nightstand in a resident's room.<BR/>This failure could place residents at risk of medication misuse and diversion.<BR/>The findings included:<BR/>Record review of Resident #41's face sheet, dated 3/18/2024, revealed a [AGE] year-old resident admitted on [DATE] with diagnosis including hypertension (high blood pressure), and urinary tract infection. <BR/>Record review of Resident #41's care plan did not reflect any information related to self-administering medications or supplements. <BR/>Record review of Resident #41's MDS Assessment reflected a BIMS score of 12, indicating moderate cognitive impairment. <BR/>Interview and Observation on 3/11/2024 at 10:39 AM revealed a blister pack of medication on Resident #41's nightstand. Further observation revealed a box of medication with identical blister packs inside of it, with the box reading, AZO Cranberry Urinary Tract Health. Resident #41's husband entered the room, and stated he was happy with the care at the facility and had brought in the blister pack of the medication due to his wife's predisposition to contract urinary tract infections. Resident #41's husband stated his wife was at physical therapy and was unable to be interviewed, and that he had not been told he was not able to bring her medication that she could keep bedside. <BR/>Interview on 3/15/2024 at 5:00 PM, LVN W stated if they see medication in a resident room, they are required to remove them, tell the DON, and tell the physician. LVN W stated the risks to medications being in resident rooms could include side effects from other medications possibly interacting with the medication in the resident's room. LVN W stated it was likely that the medication was brought in by the resident's family member, and further stated that they ensure any medications are stored by discussing medications with residents and ensure resident family members are informed of the risks of residents having access to medications. <BR/>Interview on 3/15/2024 at 5:16 PM, the DON stated that supplements, vitamins, or any sort of over-the-counter medication should not be in resident rooms and if staff find them, they are to inform the DON so they can inform the physician. The DON stated risks of over-the-counter medication being unregulated by nursing staff could include accidental ingestion of medication a resident should not take. The DON stated that the staff regularly go in and out of resident rooms and are taught to ensure there are no hazardous items such as over-the-counter medication available to residents.<BR/>Record review of the facility policy and procedure titled, Storage of Medication, revealed, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.

Based on interviews and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 6 (1/18/25, 1/19/25, 1/25/25, 1/26/25, 2/8/25, and 2/9/25) of 90 days reviewed for RN hours reviewed, for the months January 1st, 2025, through March 31st, 2025.<BR/>The facility failed to have RN coverage for 6 days on Saturday 1/18/25, Sunday 1/19/25, Saturday 1/25/25, Sunday 1/26/25, Saturday 2/8/25, and Sunday 2/9/25.<BR/>This failure could place residents at risk for harm by denying residents the advanced critical thinking skills a registered nurse could provide. <BR/>The findings were:<BR/>Review of the facility's RN timesheets, no date, revealed there were no RN hours for Saturday 1/18/25, Sunday 1/19/25, Saturday 1/25/25, Sunday 1/26/25, Saturday 2/8/25, and Sunday 2/9/25.<BR/>During an interview on 4/3/25 at 2:45 p.m. the BOM stated there were gaps on the weekend where they did not have RN coverage. <BR/>During a joint interview on 4/3/25 at 4:07 p.m. the DON and Administrator stated it was difficult to find RNs. They stated they now had an RN who was working weekends and the DON filled in when needed. They stated the DON was working weekends previously when there was no RN but did not clock in to document those days. They stated no resident went without care on the times no RN hours were logged. They both stated the facility did not have a policy for RN coverage and went by CMS guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 (Resident #101) residents in that: <BR/>LVN T did not use hand hygiene between cleaning Resident #101's plate/tray and touching an unknown resident's dessert plate. <BR/>This could affect all residents that use plates from kitchen and could result in bacteria and cross contamination. <BR/>The findings were: <BR/>Record review of Resident #101's face sheet dated 3/11/2024 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of Parkinson's disease, (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves. Symptoms start slowly. The first symptom may be a barely noticeable tremor in just one hand. Tremors are common, but the disorder may also cause stiffness or slowing of movement), diabetes II, osteoarthritis (type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone) and pain. <BR/>Observation on 3/11/24 at 12:53 PM revealed Resident # 101 sitting in his wheelchair in the main dining room. LVN T served Resident # 101 his food tray, placed food items in front of him, then went to the other side of the room to put down his tray and throw things away. Then LVN T went over to pick up an unknown resident's dessert plate, then left the dining room. LVN T did not use hand hygiene after putting unknown residents' tray down and picking up unknown resident's dessert plate. <BR/>Interview on 3/11/24 at 1:04 PM with LVN T stated she had served food to Resident #101, threw the trash from his tray away, then lifted an unknown residents' dessert tray to see if they were in the dining area. LVN T stated she was helping to serve in the dining room, then went back to her station to wash her hands and return to the nurse's station. LVN T stated her hand sanitizer was in her pocket, but she did not use it between resident food items. LVN T stated she did not serve the dessert tray, since the resident was not in the dining room. <BR/>Interview on 3/11/24 at 01:38 PM with DON stated staff should use good hand hygiene (washing/disinfecting hands in between resident food items), in between touching resident food trays. <BR/>Interview on 3/12/24 at 9:03 AM with Administrator discussed hand hygiene with LVN T touching the dessert plate, without hygiene between resident care. The Administrator had no response the infection control observation. <BR/>Interview on 3/12/24 at 9:21 AM with DON stated the risk of staff not using good hand hygiene was cross contamination.<BR/>Record review of policy Handwashing/Hand Hygiene dated August 2019 revealed The facility considers hand hygiene the primary means to prevent the spread of infections. Before and after eating or handling food, and before and after assisting a resident with meals.