Avir at Caldwell

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: 1. Ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused large papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet.2. Accurately document in Resident #1's EMR regarding the presence of ants/ant bites on his body.3. Ensure Resident #1 was moved to a different room after ants were found on his body on 08/13/25 until 08/15/25.This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/25/25 at 7:10 PM and a template was provided. While the IJ was removed on 08/26/25 at 7:06 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of discomfort, pain, worsening skin impairment issues, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, dysphagia (difficulty swallowing), muscle weakness, and need for assistance with personal care. Review of Resident #1's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 00, indicating he had a severe cognitive deficit. Review of Resident #1's quarterly care plan, dated 07/06/25, reflected he had skin tears related to fragile skin, aging, medication effects, or mobility with an intervention of making sure his environment was safe. Review of Resident #1's NP assessment, dated 08/13/25, reflected the following: [Resident #1] is seen today for a report of possible ant bites to the right arm and right leg. Small red lesions noted to [Resident #1]'s right arm and leg. Review of Resident #1's hospice note, dated 08/13/25 at 12:57 PM and documented by HN D, reflected the following: PC from [LVN A] at (facility) requesting order for Benadryl RN due to ant bites on [Resident #1]'s arm and itching. Verbal order given per s/sx management for Benadryl 25mg 1-2 tablets every 6 hours as needed for itching. Review of Resident #1's progress note, dated 08/13/25 at 3:09 PM and documented by LVN A, reflected the following: [Resident #1] continues with red raised rash to right upper arm and a few patchy areas to the right thigh. He has no complaints of pain or itching at this time. Received PRN order for Benadryl from hospice. Review of Resident #1's physician order, dated 08/13/25, reflected Benadryl Oral Tablet 25 MG - Give 1 tablet by mouth every 6 hours as needed for rash. Review of Resident #1's skin assessment, dated 08/13/25 and completed by LVN A, reflected a rash to his right upper arm. There were no further skin assessments conducted. Review of the facility's pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait was placed in the restroom and bedroom as a precaution. Review of Resident #1's HN B's skin assessment, dated 08/15/25 at 10:44 AM, reflected he had generalized ant bites that were not healing and were pink and beefy red pustules. Review of Resident #1's HN B's progress note, dated 08/15/25 from 10:40 AM - 11:40 AM, reflected the following: [HN B] entered [Resident #1]'s room and found pt awake in bed, [HN B] noted ants crawling on pt's bedding. [HN B] returned to nurses station to tell [LVN C] that the pt needed to be moved to a new room and they needed to contact an exterminator, as ants were in pt's bed. [LVN C] offered for facility aides to change pt bedding. [HN B] stated she would change the bedding, but ants need to be addressed as pt had ant bites on Wednesday (08/13/25). [LVN C] stated the assessment from Wednesday stated pt had a rash. [HN B] went back to pt room, took a picture of ant bites on pt's arm and showed them to [LVN C] who stayed at the nurses station. [HN B] returned to change pt bedding and noted at least 100 ants in pts bed and on pt. [HN B] returned to nurses station to tell [LVN C] that there is a serious issue and pt need to be moved immediately. [HN B] returned to pt room to find [LVN C] had not followed her and was still at nursing station. [HN B] stated loudly that [LVN C] needed to get the DON or the administrator into the patient's room immediately. Multiple HCAs showed up to help [HN B], and eventually [LVN C] did too. [HN B] showed all staff members the multitude of ants in pt's bed. Ants were in between the pt's toes, and on his body from his right leg up to stomach, also removed ants from under pt's scrotum. [LVN C] stated that she was on her first day and was unaware. [The ADM] showed up and said, these [NAME] fire ants, I was told they were fire ants. [HN B] replied, I dont care what they are, this is unacceptable. [The ADM] stated that a pest control person treated the room yesterday and said he left live traps for ants, so it would be normal to see ants going to the live traps. [HN B] asked [The ADM] if the pest control person put live traps in the pt's bed, as that is where the majority of the ants are. [The ADM] did not answer, but stated that the bird feeder outside of the pt's window was a big problem and a cause of ants. [HN B] asked [The ADM] if the facility staff was putting bird feed underneath the pt. Again, [The ADM] did not answer. [HN B] showed everyone in the room the pt's right upper arm, which was covered in ant bites, [LVN C] stated that the patient's arm did not look like that on Wednesday. [HN B] asked [LVN C] how she knows what patient's arm looked like if today was her first day, no one answered. [HN B] stated that staff needed to get the hoyer lift so that pt can be transferred out of his bed to high back WC immediately. WC, in pt's bathroom, also found to have ants on it. [The ADM] left and came back several minutes later stating that pt would be moved to another room, but instructed facility aides to just get pt to high back WC and take him to the cafeteria for lunch, not to move his belongings at this time. SKIN: Skin is thin/fragile with Ecchymosis to BUE, with ruddy BLE. Pt has generalized ant bites all over his body. Pt's right arm from shoulder to elbow is approximately 85% covered in numerous erythematous papules (red lesions on the skin that may resemble elevated rashes) and vesiculopustular lesions that range from 1-5mm in diameter. Many with vesicopustule (a vesicle which is developing pus) formation with erythema (redness or discoloration of the skin) at the base. Similar lesions are present from pt's right hip to mid thigh, covering approximately 30-40% of the surface area and multiple lesions are also present between the toes of bilateral feet. Facility staff reports pt's itching has been controlled with PRN Benadryl and Hydrocortisone cream.Please ensure that pt has been moved to new room and that no ants or other insects are present in pt's bed. I did not leave medihoney in pt room so that Administrator could not blame ants on medihoney. Review of Resident #1's progress note, dated 08/15/25 at 11:09 AM and documented by LVN A, reflected the following: Notified [Resident #1's RP] and [Resident #1] that he is moving to 214 (room) today. Review of Resident #1's HN B's progress note, dated 08/18/25 at 12:07 PM, reflected he had generalized ant bites that were not healing with raised heads. Review of maintenance log requests, from 07/01/25 - 08/20/25, reflected ants were found in resident's rooms on 07/11/25, 07/22/25, 07/24/25, and 07/25/25.Review of a pest control invoice, dated 07/14/25, reflected they spot treated a proximity [sic] a dozen fire ant mounds. Review of a pest control invoice, dated 07/29/25, reflected the following: (Pest control company) responded to an emergency call regarding ant activity in rooms [ROOM NUMBERS]. Upon arrival, I met with the social worker at the front desk. We first inspected room [ROOM NUMBER], where staff reported ant activity throughout the room and restroom. During my inspection, I confirmed the presence of fire ants in the restroom and along the baseboards near the dresser. I applied a liquid treatment around all baseboards in the room and restroom. Next, we proceeded to room [ROOM NUMBER], which previously housed the resident from room [ROOM NUMBER]. Although no live ant activity was observed during the inspection, I performed a preventative treatment by baiting the restroom baseboards and the sink area. Afterward, I met with the [MAINTD], to access the courtyard and inspect for ant mounds near the affected units. Several mounds were located and treated. I recommended a long-term control solution, and the [ADM] requested a quote. I will be contacting my superiors to have this quote forwarded to her.Reported ants in room [ROOM NUMBER]. Facility has made multiple requests for ants. Please evaluate if larger scale of services needed. Review of pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait eas [sic] placed in the restroom and bedroom as a precaution. After this I made my way outside for an exterior inspection and granular perimeter application. Active ant mounds were treated with a bait application. A liquid residual perimeter application was performed on entry ways to aid in control of ants. I spoke with the administrator to wrap up the service. She was notified that our products take a few days to achieve full effect. During an observation on 08/20/25 at 10:52 AM revealed Resident #1 asleep in his bed and was unable to arouse. Visible beneath the right sleeve of his hospital gown revealed approximately 50 dark pink/red ant-like bites on his upper arm/shoulder. There were no visible ants in his bed, room, or bathroom. During a telephone interview on 08/20/25 at 12:04 PM, Resident #1's NP stated she was notified of redness to his arm on 08/13/25. She stated she looked at it but could not determine what it was, it was too difficult to say. She stated she wrote an order for Benadryl for dermatitis (a skin condition that causes redness, irritation, or rash). She stated he was on hospice services, so they oversaw his care. During an interview on 08/2025 at 12:55 PM, CNA E stated Resident #1 had recently been moved to her hall (200) but was not sure why. She stated she was not told what happened. She stated he had redness to his arms and stomach. During an interview on 08/20/25 at 1:03 PM, LVN C stated she was not working the day Resident #1 appeared with a rash. She stated she first saw it the following day, 08/14/25 and was asked if she would describe it. She stated she would not be able to because she was not a doctor. During an interview on 08/10/25 at 1:10 PM, the ADM stated on 08/13/25 she was grabbed by an aide stating Resident #1 had ants in his bed. She stated they had already cleaned up his bed but was shown a picture and they looked like sugar ants and sugar ants did not bite. She stated she told them to get him up and asked the housekeepers to clean his room. She stated she had the NP and her ADON assess his skin and the ADON said it looked more like a rash. She stated the NP looked at it and said she did not think they were ant bites by the way they were raised up from his skin and that it may be a reaction to something or a rash. She stated she contacted pest control, and they came the following day, 08/14/25, to treat his room. She stated on 08/15/25, HN B pulled back his covers on his bed and found ants on his abdomen. She stated she had not moved him rooms because pest control had already treated the room and the ADON and NP had told her it was a rash, not ant bites. She stated she called the pest control company again and they told her it could take up to a week before all the ants were killed. She stated she had not known that before. She stated she had not seen his skin since 08/13/25 and was shown a current picture. When she saw the picture, she stated it did look like they could be bites. During a telephone interview on 08/25/25 at 11:50 AM, HN B stated she found out ants were in Resident #1's bed on 08/13/25 when LVN A contacted their agency requesting Benadryl for ant bites and him itching. She stated on 08/15/25, when she arrived, she could not believe what she saw. She stated there were hundreds of ants all over him actively biting and she had to remove them from his right arm, right leg, abdomen, and under his scrotum. She stated his bites had little white heads and she had no doubt they were from the ants. She stated she even found ants on his wheelchair in his bathroom. She stated she went to tell LVN C who blew her off and kept telling her it was a rash. She stated she finally got the ADM in the room and showed her the ants and told her to get her staff to move him rooms as it was completely unacceptable. She stated her HCAs provided him with a shower and removed his linens to be laundered. During an interview on 08/26/25 11:57 AM, LVN C stated she worked the 6:00 AM - 6:00 PM shift on 08/15/25. She stated when HN B came in to do wound care on Resident #1, she was shown a picture of his skin, and she believed it was a rash. She then stated HN B found the ants on him and in his bed. She stated they then removed all of his linens and took them to the laundry room and moved him to a room on the 200 hall. She stated she did see the ants in his bed but did not perform a skin assessment because she saw one had already been done that day and a rash was noted. She stated the importance of skin assessments was to make sure the skin was good, for skin integrity, and to ensure there was no skin breakdown. During an interview on 08/26/25 at 12:10 PM, the ADM stated the pest control company they used brought up doing extra services on the grounds (outside of facility) but not the inside of the facility. She stated she asked for a quote but never received one. She stated a negative outcome of not following up with the pest control company would be that you could have pests in the building that could contribute to negative outcomes for the residents. She stated they could be a nuisance, could carry germs, or they could bite the residents which could lead to more negative outcomes. She stated the importance of accurate nursing documentation was so there was a clear picture of what was happening with the resident. She stated her expectations on nursing documentation was that all issues and concerns of the residents were documented. She stated if the documentation was not accurate, the resident could have an issue or concern that the nurses were not aware of, and it would not get addressed. She stated a skin assessment should have been conducted by the nurses every day after Resident #1 acquired his rash to ensure they were assessing the area and to ensure the MD was notified if there was a change. During a telephone interview on 08/26/25 at 12:46 PM, the ADON stated he was told by LVN A that Resident #1 had a skin impairment issue (could not remember the date). He stated he went and assessed him but did not see anything visible at that time. He stated he did not see anything that was consistent with bite marks. He stated he had ben out sick so he had not assessed Resident #1 since 08/13/25. He stated even though he was under hospice's care, they (facility staff) were still responsible for the welfare of the resident. He stated the importance of accurate skin assessments were to ensure there were no areas on the residents and to make sure there were no skin issues going unaddressed. During a telephone interview on 08/26/25 at 1:18 PM, LVN A stated she was working on Resident #1's hall on 08/13/25. She stated CNAs F and G came to her and told her he had raised areas to his right arm. She stated there was mention of ant this and ant that but when she inspected his room, she saw no ants. After the NP assessed him and did not note ant bites, she completed her skin assessments and documented a rash to his right arm. During a telephone interview on 08/26/25 at 4:25 PM, CNA G stated she worked on Resident #1's hall on 08/13/25. She stated she had worked with him for 3-4 years and he was unable to use his call light, so when he was in distress or needed something, he would whistle. She stated on 08/13/25, she heard him whistling so she went to his room with CNA F. She stated they pulled back his covers and saw about 15 ants or more crawling on his right thigh. She stated there were bites all over his legs, stomach, and right arm. She stated there the bites were blotchy red spots. She stated she and CNA G told LVN A that they needed to get the ADM to his room. She stated the ADM told them to give him a shower and she would call for pest control to come and treat the room. She stated the HCAs provided the shower while they removed the linens to be laundered. During an interview on 08/26/25 at 4:40 PM, CNA F stated she worked on Resident #1's hall on 08/13/25. She stated she and CNA G uncovered him, and they saw ants and ant bites on his right side, right arm, right upper thigh, and on his stomach. She stated the bites looked red like little dots and she estimated there were 15-20 ants on him. She stated his body was moving in frustrated movements, which was not normal. She stated she and CNA G reported it to LVN A. Review of the facility's Pest Control Policy, revised May 2008, reflected the following: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's Charting and Documentation Policy, dated July 2017, reflected the following: The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the facility's Pressure Injury Risk Assessment, dated March 2020, reflected the following: Documentation:The following information should be recorded in the resident's electronic health record utilizing facility forms.:.4. Any change in the resident's condition, if identified.5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. Review of the facility's Skin System Process Policy, dated May 2025, reflected the following: PCC Skin and Wound Total Body Skin Assessment: assessment is completed weekly until pressure injury or skin issue (skin tears, lacerations, abrasions, surgical incisions, diabetic, arterial, stasis, venous ulcers) is resolved. The ADM was notified on 08/25/25 at 7:10 PM that an IJ had been identified and an IJ template was provided at that time.The following Plan of Removal submitted by the facility was approved accepted on 08/26/25 at 12:30 PM: Resident #1 was assessed for skin alterations by the Director of Nursing on 08/25/2025. An entire building skin sweep was initiated and completed on 8/25/25 by the Director of Nursing to ensure no more residents had skin alterations from possible ant bites. Skin assessments on all residents are documented in the electronic health record of the individual residents. On 8/25/25, the regional nurse consultant educated the administrator, business office manager, and the director of nursing on abuse, neglect, identifying pest control issues, skin abnormalities in regards to insect bites. The Business Office Manager searched all residents' rooms on 08/25/25 for any evidence of ants, no concerns were notes. Interviewable residents were asked if they had noticed any ants or pests in their rooms, on 08/25/25By the Business Office Manager. All residents interviewed stated they had not seen any ants or pests. This was documented on a facility form. The charge nurse that did not report the alleged neglect, was counseled by the director of nursing on 08/25/25 on the Abuse and Neglect policy, documentation, assessment, physician notification of change, skin assessment, immediately moving a resident if pests are found in room, notification of RP for change in condition, rounding, documentation in medical record. Charge nurse signature on in-service indicates understanding. The pest control company was at facility to exterminate inside and outside for ants on 8/14/25. The pest control company was at the facility on 8/26/25 to exterminate inside and outside the facility. This will be documented in the pest control book. All staff were in-serviced on Abuse, Neglect, and Exploitation, and reporting Abuse and Neglect to the abuse coordinator/facility administrator immediately, beginning on 8/25/25 and will be completed on 8/26/2025. In-services were completed per the Director of Nursing. Any new staff or agency staff will be in-serviced by the DON on Abuse, Neglect, and Exploitation policy before the start of their first shift. Verification of education will be completed by administrator/designee, three (3) times a week for thirty (30) days and randomly thereafter. Results will be kept on a facility audit form. Department heads will round in the morning all resident rooms. Focus will be ensuring there is no evidence of ants or pests in the resident rooms, daily M-F X3 months. Dept heads will be educated on this practice by the administrator on 08/26/2025. Results will be kept on a facility rounding form. DON and the Administrator will interview 3 staff daily related to their understanding of the in-service education provided, for the next 4 weeks. Results will be kept on a facility audit form. An Ad Hoc QAPI was held by the Facility Administrator, Director of Nursing, , and Asst. Director of Nurses on 08/25/2025 at 8:30 PM to review the alleged deficiency and plan. The surveyor monitored the POR on 08/26/25 as followed: Observations made on 08/26/25 from 12:45 PM - 1:18 PM revealed six randomly picked resident rooms without any ants/pest sightings. The residents that occupied these rooms denied seeing any pests/ants. During interviews on 08/26/25 from 3:18 PM - 6:20 PM, the following staff were interviewed from all shifts: CNA E, CNA F, CNA G, the DM, HSK H, HSK I, DA J, MA K, CNA L, LVN M, MA N, CNA O, MA P, CNA Q, LVN R, and LVN S. All stated they were in-serviced on abuse and neglect and pest control prior to their shift. The nurses stated they were also interviewed on documentation and skin assessments. All staff stated their ADM was the abuse and neglect coordinator and they should report to her immediately if they heard of or saw any allegation of abuse or neglect. They were able to give examples of abuse such as verbal, physical, or emotional. They all stated if they saw any pests, such as roaches, ants, or flies, they would immediately notify the ADM and MAINTD and fill out the pest control log that was located at the nurse's station. They all stated if a pest was found on a resident they needed to be showered, moved to another room, an all their linens and clothes would need to be laundered. The CNAs stated they would notify the nurses immediately if they saw any bites on a resident during personal care. The nurses stated the importance of skin assessments were to give an accurate depiction of the resident's skin, such as potential bug bites. The nurses stated they were to document all skin impairments along with the size/measurements (if applicable), color, and any other indications. The nurses stated anything that happened to a resident medically or physically should be accurately documented in the resident's chart to paint a clear picture of what was going on with them. All nursing staff stated residents should be rounded on at least every two hours to ensure their safety and health needs were being met. During an interview on 08/26/25 at 3:02 PM, the PCS stated the facility contacted his company on 08/25/25 and requested service as soon as possible. He stated he treated the facility inside and outside on 08/26/25. He stated he did not observe any ants inside the facility. During an interview on 08/26/25 at 4:54 PM, the RNC stated she in-serviced the ADM and DON on 08/25/25 regarding staff rounding, reporting pests, abuse and neglect, skin assessments, nursing documentation, and moving residents to a pest-free room if pests were observed in their room. During an interview on 08/26/25 at 5:14 PM, the ADM stated she and the DON were in-service by the RNC prior to in-servicing staff on pest control, what to do when pests were located, and skin assessments prior to a resident being potentially bitten. She stated they were also in-serviced on abuse and neglect, reporting/investigation time frames, skin assessments, and nursing documentation. She stated when pests/ants were observed in a resident's room, they should be moved immediately, showered, and linens laundered. She stated pest control would be contacted immediately for service. During an interview on 08/26/25 at 5:32 PM, MAINTD stated he completed a thorough assessment of the perimeter and the inside of the facility that day (08/26/25) and he brought up concerns of wasp nests to the attention of the PCS for mitigation. Review of the facility's QAPI meeting agenda, dated 08/25/25, reflected the ADM, the MD, the DON, the ADON, the RVP, and the BOM were in attendance. Review of an in-service entitled Pest Control and Resident Assessment/Safety, dated 08/25/25 and conducted by the RNC, reflected the ADM and DON were in-serviced on the facility's pest control policy. The in-service also covered abuse and neglect, accurate skin assessments, and nursing documentation. Review of Resident #1's skin assessment, on 08/25/25, reflected multiple scabs to his right elbow, abdomen, chest, right thigh, and right antecubital (inner arm). Review of skin assessments conducted on all residents, dated 08/25/25, reflected no new skin issues (including bites). Review of the facility's document for checking for pests, dated 08/25/25 and documented by the BOM, reflected she interviewed 11 residents who were asked if they saw any pests of any kind and all residents stated they had not. Review of room rounds, dated 08/26/25, reflected all residents' rooms were searched for pests and none were observed. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on abuse and neglect. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on safety and supervision of residents. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on moving residents to a pest-free room should pests be identified in their room that could/would bite.[TF1] Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on the facility's pest control policy. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all nurses were in-serviced on skin assessments: Skin assessments should be completed no less than weekly and should reflect all skin impairments and documented in the resident's chart and notification of any new skin impairments should be communicated to the RP, physician, and DON.The ADM was notified on 08/26/25 at 7:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one (Resident #1) of five residents reviewed for physical environment. The facility failed to ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/25/25 at 7:10 PM and a template was provided. While the IJ was removed on 08/26/25 at 7:06 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of discomfort, pain, or infection. Findings included:Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, dysphagia (difficulty swallowing), muscle weakness, and need for assistance with personal care. Review of Resident #1's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 00, indicating he had a severe cognitive deficit. Review of Resident #1's quarterly care plan, dated 07/06/25, reflected he had skin tears related to fragile skin, aging, medication effects, or mobility with an intervention of making sure his environment was safe. Review of Resident #1's NP assessment, dated 08/13/25, reflected the following: [Resident #1] is seen today for a report of possible ant bites to the right arm and right leg. Small red lesions noted to [Resident #1]'s right arm and leg. Review of Resident #1's hospice note, dated 08/13/25 at 12:57 PM and documented by HN D, reflected the following: PC from [LVN A] at (facility) requesting order for Benadryl RN due to ant bites on [Resident #1]'s arm and itching. Verbal order given per s/sx management for Benadryl 25mg 1-2 tablets every 6 hours as needed for itching. Review of Resident #1's progress note, dated 08/13/25 at 3:09 PM and documented by LVN A, reflected the following: [Resident #1] continues with red raised rash to right upper arm and a few patchy areas to the right thigh. He has no complaints of pain or itching at this time. Received PRN order for Benadryl from hospice. Review of Resident #1's physician order, dated 08/13/25, reflected Benadryl Oral Tablet 25 MG - Give 1 tablet by mouth every 6 hours as needed for rash. Review of Resident #1's skin assessment, dated 08/13/25 and completed by LVN A, reflected a rash to his right upper arm. There was no documented evidence of further skin assessments conducted. Review of the facility's pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait was placed in the restroom and bedroom as a precaution. Review of Resident #1's HN B's skin assessment, dated 08/15/25 at 10:44 AM, reflected he had generalized ant bites that were not healing and were pink and beefy red pustules. Review of Resident #1's HN B's progress note, dated 08/15/25 from 10:40 AM - 11:40 AM, reflected the following: [HN B] entered [Resident #1]'s room and found pt awake in bed, [HN B] noted ants crawling on pt's bedding. [HN B] returned to nurses station to tell [LVN C] that the pt needed to be moved to a new room and they needed to contact an exterminator, as ants were in pt's bed. [LVN C] offered for facility aides to change pt bedding. [HN B] stated she would change the bedding, but ants need to be addressed as pt had ant bites on Wednesday (08/13/25). [LVN C] stated the assessment from Wednesday stated pt had a rash. [HN B] went back to pt room, took a picture of ant bites on pt's arm and showed them to [LVN C] who stayed at the nurses station. [HN B] returned to change pt bedding and noted at least 100 ants in pts bed and on pt. [HN B] returned to nurses station to tell [LVN C] that there is a serious issue and pt need to be moved immediately. [HN B] returned to pt room to find [LVN C] had not followed her and was still at nursing station. [HN B] stated loudly that [LVN C] needed to get the DON or the administrator into the patient's room immediately. Multiple HCAs showed up to help [HN B], and eventually [LVN C] did too. [HN B] showed all staff members the multitude of ants in pt's bed. Ants were in between the pt's toes, and on his body from his right leg up to stomach, SN also removed ants from under pt's scrotum. [LVN C] stated that she was on her first day and was unaware. [The ADM] showed up and said, these [NAME] fire ants, I was told they were fire ants. [HN B] replied, I dont care what they are, this is unacceptable. [The ADM] stated that a pest control person treated the room yesterday and said he left live traps for ants, so it would be normal to see ants going to the live traps. [HN B] asked [The ADM] if the pest control person put live traps in the pt's bed, as that is where the majority of the ants are. [The ADM] did not answer, but stated that the bird feeder outside of the pt's window was a big problem and a cause of ants. [HN B] asked [The ADM] if the facility staff was putting bird feed underneath the pt. Again, [The ADM] did not answer. [HN B] showed everyone in the room the pt's right upper arm, which was covered in ant bites, [LVN C] stated that the patient's arm did not look like that on Wednesday. [HN B] asked [LVN C] how she knows what patient's arm looked like if today was her first day, no one answered. [HN B] stated that staff needed to get the hoyer lift so that pt can be transferred out of his bed to high back WC immediately. WC, in pt's bathroom, also found to have ants on it. [The ADM] left and came back several minutes later stating that pt would be moved to another room, but instructed facility aides to just get pt to high back WC and take him to the cafeteria for lunch, not to move his belongings at this time. SKIN: Skin is thin/fragile with Ecchymosis to BUE, with ruddy BLE. Pt has generalized ant bites all over his body. Pt's right arm from shoulder to elbow is approximately 85% covered in numerous erythematous papules (red lesions on the skin that may resemble elevated rashes (and vesiculopustular lesions that range from 1-5mm in diameter. Many with vesicopustule (a vesicle which is developing pus) formation with erythema (redness or discoloration of the skin) at the base. Similar lesions are present from pt's right hip to mid thigh, covering approximately 30-40% of the surface area and multiple lesions are also present between the toes of bilateral feet. Facility staff reports pt's itching has been controlled with PRN Benadryl and Hydrocortisone cream.Please ensure that pt has been moved to new room and that no ants or other insects are present in pt's bed. SN did not leave medihoney in pt room so that Administrator could not blame ants on medihoney. Review of Resident #1's progress note, dated 08/15/25 at 11:09 AM and documented by LVN A, reflected the following: Notified [Resident #1's RP] and [Resident #1] that he is moving to 214 (room) today. Review of Resident #1's HN B's progress note, dated 08/18/25 at 12:07 PM, reflected he had generalized ant bites that were not healing with raised heads. Review of maintenance log requests, from 07/01/25 - 08/20/25, reflected ants were found in resident's rooms on 07/11/25, 07/22/25, 07/24/25, and 07/25/25.Review of a pest control invoice, dated 07/14/25, reflected they spot treated a proximity [sic] a dozen fire ant mounds. Review of a pest control invoice, dated 07/29/25, reflected the following: (Pest control company) responded to an emergency call regarding ant activity in rooms [ROOM NUMBERS]. Upon arrival, I met with the social worker at the front desk. We first inspected room [ROOM NUMBER], where staff reported ant activity throughout the room and restroom. During my inspection, I confirmed the presence of fire ants in the restroom and along the baseboards near the dresser. I applied a liquid treatment around all baseboards in the room and restroom.Next, we proceeded to room [ROOM NUMBER], which previously housed the resident from room [ROOM NUMBER]. Although no live ant activity was observed during the inspection, I performed a preventative treatment by baiting the restroom baseboards and the sink area. Afterward, I met with the [MAINTD], to access the courtyard and inspect for ant mounds near the affected units. Several mounds were located and treated. I recommended a long-term control solution, and the [ADM] requested a quote. I will be contacting my superiors to have this quote forwarded to her. Reported ants in room [ROOM NUMBER]. Facility has made multiple requests for ants. Please evaluate if larger scale of services needed. Review of pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait eas [sic] placed in the restroom and bedroom as a precaution. After this I made my way outside for an exterior inspection and granular perimeter application. Active ant mounds were treated with a bait application. A liquid residual perimeter application was performed on entry ways to aid in control of ants. I spoke with the administrator to wrap up the service. She was notified that our products take a few days to achieve full effect. During an observation on 08/20/25 at 10:52 AM revealed Resident #1 asleep in his bed and was unable to arouse. Visible beneath the right sleeve of his hospital gown revealed approximately 50 dark pink/red ant-like bites on his upper arm/shoulder. There were no visible ants in his bed, room, or bathroom. During a telephone interview on 08/20/25 at 12:04 PM, Resident #1's NP stated she was notified of redness to his arm on 08/13/25. She stated she looked at it but could not determine what it was, it was too difficult to say. She stated she wrote an order for Benadryl for dermatitis (a skin condition that causes redness, irritation, or rash). She stated he was on hospice services, so they oversaw his care. During an interview on 08/2025 at 12:55 PM, CNA E stated Resident #1 had recently been moved to her hall (200) but was not sure why. She stated she was not told what happened. She stated he had redness to his arms and stomach. During an interview on 08/20/25 at 1:03 PM, LVN C stated she was not working the day Resident #1 appeared with a rash. She stated she first saw it the following day, 08/14/25 and was asked if she would describe it. She stated she would not be able to because she was not a doctor. During an interview on 08/10/25 at 1:10 PM, the ADM stated on 08/13/25 she was grabbed by an aide stating Resident #1 had ants in his bed. She stated they had already cleaned up his bed but was shown a picture and they looked like sugar ants and sugar ants did not bite. She stated she told them to get him up and asked the housekeepers to clean his room. She stated she had the NP and her ADON assess his skin and the ADON said it looked more like a rash. She stated the NP looked at it and said she did not think they were ant bites by the way they were raised up from his skin and that it may be a reaction to something or a rash. She stated she contacted pest control, and they came the following day, 08/14/25, to treat his room. She stated on 08/15/25, HN B pulled back his covers on his bed and found ants on his abdomen. She stated she had not moved him rooms because pest control had already treated the room and the ADON and NP had told her it was a rash, not ant bites. She stated she called the pest control company again and they told her it could take up to a week before all the ants were killed. She stated she had not known that before. She stated she had not seen his skin since 08/13/25 and was shown a current picture. She stated what she saw in the picture did look like they could be bites. During a telephone interview on 08/25/25 at 11:50 AM, HN B stated she found out ants were in Resident #1's bed on 08/13/25 when LVN A contacted their agency requesting Benadryl for ant bites and him itching. She stated on 08/15/25, when she arrived, she could not believe what she saw. She stated there were hundreds of ants all over him actively biting and she had to remove them from his right arm, right leg, abdomen, and under his scrotum. She stated his bites had little white heads and she had no doubt they were from the ants. She stated she even found ants on his wheelchair in his bathroom. She stated she went to tell LVN C who blew her off and kept telling her it was a rash. She stated she finally got the ADM in the room and showed her the ants and told her to get her staff to move him rooms as it was completely unacceptable. She stated her HCAs provided Resident #1 a shower and his linens were removed to be laundered. During an interview on 08/26/25 11:57 AM, LVN C stated she worked the 6:00 AM - 6:00 PM shift on 08/15/25. She stated when HN B came in to do wound care on Resident #1, she was shown a picture of his skin by HN B, and she believed it was a rash. She then stated HN B found the ants on him and in his bed. She stated they then removed all of his linens and took them to the laundry room and moved him to a room on the 200 hall. During an interview on 08/26/25 at 12:10 PM, the ADM stated the pest control company they used brought up doing extra services on the grounds (outside of facility) but not the inside of the facility. She stated she asked for a quote but never received one. She stated a negative outcome of not following up with the pest control company would be pests in the building that could contribute to negative outcomes for the residents. She stated they could be a nuisance, could carry germs, or they could bite the residents which could lead to more negative outcomes. During a telephone interview on 08/26/25 at 12:46 PM, the ADON stated he was told by LVN A that Resident #1 had a skin impairment issue (could not remember the date). He stated he went and assessed him but did not see anything visible at that time. He stated he did not see anything that was consistent with bite marks. He stated he was off since the incident and had not assessed his skin since. He stated even though he was under hospice's care, they (facility staff) were still responsible for the welfare of the resident. During a telephone interview on 08/26/25 at 1:18 PM, LVN A stated she was working on Resident #1's hall on 08/13/25. She stated CNAs F and G came to her and told her he had raised areas to his right arm. She stated there was mention of ant this and ant that but when she inspected his room, she saw no ants. After the NP assessed him and did not note ant bites, she completed her skin assessments and documented a rash to his right arm. During a telephone interview on 08/26/25 at 4:25 PM, CNA G stated she worked on Resident #1's hall on 08/13/25. She stated she had worked with him for 3-4 years and he was unable to use his call light, so when he was in distress or needed something, he would whistle. She stated on 08/13/25, she heard him whistling so she went to his room with CNA F. She stated they pulled back his covers and saw about 15 ants or more crawling on his right thigh. She stated there were bites all over his legs, stomach, and right arm. She stated there the bites were blotchy red spots. She stated she and CNA G told LVN A that they needed to get the ADM to his room. She stated the ADM told them to give him a shower and she would call for pest control to come and treat the room. She stated the HCAs provided Resident #1 with a shower and they removed his linens. During an interview on 08/26/25 at 4:40 PM, CNA F stated she worked on Resident #1's hall on 08/13/25. She stated she and CNA G uncovered him, and they saw ants and ant bites on his right side, right arm, right upper thigh, and on his stomach. She stated the bites looked red like little dots and she estimated there were 15-20 ants on him. She stated his body was moving in frustrated movements, which was not normal. She stated she and CNA G reported it to LVN A. Review of the facility's Pest Control Policy, revised May 2008, reflected the following: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.The ADM was notified on 08/25/25 at 7:10 PM that an IJ had been identified and an IJ template was provided.The following Plan of Removal submitted by the facility was accepted on 08/26/25 at 12:30 PM: F925 Pest Control The facility failed to check the other residents' rooms 08/13/25. The facility staff failed to notify management that ants had been discovered 08/13/25. The facility failed to ensure that the unit was free from fire ants. The facility failed to assess other residents on the unit when Resident #1 was identified to have ant bites on 08/13/25. The facility failed to ensure Resident #1 was kept free of harm when they were found to have ants on their body, sheet and room. The facility did not move resident to another room when ants were found on the resident skin on 08/13/25 The facility failed to protect Resident #3 from potential harm as resident was left in the same room on 08/13/25. Identify residents who could be affected All Residents have the potential to be affected. Identify responsible staff/ what action taken The facility administrator requested Pest Control to visit the facility as soon as possible on 8/25/25. On 8/25/25, the regional nurse consultant educated the director of nursing regarding staff rounding, reporting pests in the facility immediately to the administrator/maintenance, skin assessments and notifications to MD/RP, and removing residents from their room if pests are found and showering of the resident who has any evidence of bites from pests. On 8/25/25, the director of nursing began education to direct care staff (RN, LVN, CNA, CMA, RNA), housekeeping, laundry, dietary, maintenance, office staff, and rehabilitation staff. Any agency staff utilized by facility or staff who did not receive the in-service on 8/25/25 will receive in-services prior to starting their assigned shift. The in-service addresses proper notifications when pest/ants are identified inside or outside the facility. Any resident that is identified as exposed to ants will immediately be removed from that area, head to toe assessment completed, will receive a shower and then proper notifications will be made to the responsible party, attending physician, the administrator, the director of maintenance and the director of nursing. The in-service also included conducting proper skin assessments on residents and complete rounds on all rooms/areas that pests or ants have been identified. If the administrator, director of maintenance or director of nursing did not answer the staff must continue to call department managers until they are able to reach someone. This in-service was started on 08/25/25 and will be completed on 08/26/25. Any staff who are unable to attend will receive the in service prior to beginning their shift and will not work until they receive the in service. New hires will receive same in service as part of their onboarding and will not work the floor until in service completed. Resident #1 was moved to another room on 08/15/25. A head-to-toe assessment was completed on 08/25/25 and residents' skin is clear. The maintenance director, completed a thorough assessment of the perimeter of the facility on 08/25/25. Any concerns identified were brought to the attention of pest control for mitigation. This will be documented in the pest control binder. Implementation of Changes Pest Control will service the facility weekly x4 weeks and then monthly and as needed thereafter. The maintenance director/designee will conduct thorough rounds throughout the facility QDay x30days and then prn thereafter to monitor for any pest/ant activity. This will be documented on a form in the pest control binder. The maintenance director/designee will round daily and ensure all food items are stored properly to prevent pest/ant activity daily x 30days and prn. This will be documented on a form in the pest control binder. During morning meeting TELS will be reviewed for any new concerns regarding pest/ant activity and that appropriate interventions have been implemented daily x 30days and prn. Perimeter checks of the facility will be conducted twice a day x 30days and prn to monitor for pest/ant mounds by the maintenance director/designee. This will be documented on a form in the pest control binder. During clinical morning meeting and during clinical stand down the Director of nursing/Assistant Director of Nursing will discuss with each charge nurse regarding any pest/ant activity x30days and prn. This will be documented on the room rounds form. Pest Control will service the facility weekly x4 weeks and then monthly and as needed thereafter. This will be documented in the pest control binder. All monitoring and any negative findings will be reported to QAPI monthly. The Director of Nursing/Assistant Director of Nursing/Designee will conduct five staff interviews, three (3) times a week for thirty (30) days to validate staff knowledge of education. This will be documented on interview questionnaire. Involvement of Medical Director The facility held an ad.hoc QAPI with the medical director to discuss a plan of removal on 08/25/25 at 8:30PM Who is responsible for implementation of process? The Administrator will be responsible for implementation of New Process. The New Process/ system will be started on 08/25/25. Please accept this letter as our plan of removal for the determination of revised Immediate Jeopardy issued on 08/25/25. Starting 8/26/25, education understanding will be completed with 3 staff members, three (3) times a week for one (1) month by the administrator/designee by questioning the facility staff about what they do if ants/pests are observed in the facility, to notify the administrator immediately. The Regional VP of Operations will ensure the administrator understands the directive to notify pest control, move the resident, direct nursing to complete skin assessment and notify the Rp and provider immediately. This will be documented on an audit flow sheet. The Surveyor monitored the POR on 08/26/25 as followed: Observations made on 08/26/25 from 12:45 PM - 1:18 PM revealed six randomly picked resident rooms without any ants/pest sightings. The residents that occupied those rooms denied observing any pests/ants. During interviews on 08/26/25 from 3:18 PM - 6:20 PM, the following staff were interviewed from all shifts: CNA E, CNA F, CNA G, the DM, HSK H, HSK I, DA J, MA K, CNA L, LVN M, MA N, CNA O, MA P, CNA Q, LVN R, and LVN S. All stated they were in-serviced on pest control issues prior to their shift. They all stated if they saw any pests, such as roaches, ants, or flies, they would immediately notify the ADM and MAINTD and fill out the pest control log that was located at the nurse's station. They all stated if a pest was found on a resident they needed to be showered, moved to another room, an all their linens and clothes would need to be laundered. The CNAs stated they would notify the nurses immediately if they saw any bites on a resident during personal care. During an interview on 08/26/25 at 3:02 PM, the PCS stated the facility contacted his company on 08/25/25 and requested service as soon as possible. He stated he treated the facility inside and outside on 08/26/25. He stated he did not observe any ants inside the facility. During an interview on 08/26/25 at 4:54 PM, the RNC stated she in-serviced the ADM and DON on 08/25/25 regarding staff rounding, reporting pests, and moving residents to a pest-free room if pests were observed in their room. During an interview on 08/26/25 at 5:14 PM, the ADM stated she and the DON were in-serviced by the RNC prior to in-servicing staff on pest control, what to do when pests were located (remove the resident from the room, provide a shower, and wash their linens), and skin assessments prior to a resident being potentially bitten. During an interview on 08/26/25 at 5:32 PM, MAINTD stated he completed a thorough assessment of the perimeter and the inside of the facility that day (08/26/25) and he brought up concerns of wasp nests to the attention of the PCS for mitigation. There was no documentation of ant mounds. Review of the facility's QAPI meeting agenda, dated 08/25/25, reflected the ADM, the MD, the DON, the ADON, the RVP, and the BOM were in attendance. Review of an in-service entitled Pest Control, dated 08/25/25 and conducted by the RNC, reflected the ADM and DON were in-serviced on the facility's pest control policy. Review of Resident #1's skin assessment, on 08/25/25, reflected multiple scabs to his right elbow, abdomen, chest, right thigh, and right antecubital (inner arm). Review of skin assessments conducted on all residents, dated 08/25/25, reflected no new skin issues (which included bites). Review of the facility's document for checking for pests, dated 08/25/25 and documented by the BOM, reflected she interviewed 11 residents who were asked if they saw any pests of any kind and all residents stated they had not. Review of room rounds, dated 08/26/25, reflected all residents' rooms were searched for pests and none were observed. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on moving residents to a pest-free room should pests be identified in their room that could/would bite. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on the facility's pest control policy.The ADM was notified on 08/26/25 at 7:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review the facility failed to ensure a quarterly trust fund statement was provided to the resident for 1 (Resident # 6) of 3 residents reviewed for personal funds. <BR/>The facility failed to provide quarterly statements to the resident receiving insurance funds.<BR/>The failed practice had the potential to affect any resident who had a trust fund account managed by the facility.<BR/>Findings included: <BR/>Review of Resident # 6's face sheet dated 10/14/2024 reflected an [AGE] year-old female with an admit date of 12/31/2020 and a re-admittance date of 10/02/2024. Resident # 6 had diagnoses of chronic obstructive pulmonary disease, immunodeficiency (impairment of the immune system function) due to drugs, morbid obesity, acute respiratory failure, hemiplegia and hemiparesis(muscle weakness or partial paralysis) affecting right dominant side following cerebral infarction, muscle weakness, lack of coordination, hypothyroidism (underactive thyroid), hyperlipidemia (high levels of fat particles in the blood), major depressive disorder, anxiety disorder, insomnia, dysarthria (slurred speech), hypertension, pulmonary embolism (blood clot in the lung), chronic kidney disease stage 2, gastro-esophageal reflux disease , and cervical disc degeneration. <BR/>Review of Resident # 6's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated the resident had intact cognition. Resident # 6's MDS revealed no behaviors documented.<BR/>In an interview on 10/14/2024 at 11:36 AM Resident # 6 stated the only concern they had was that they had been asking the BOM for several months for statements on their financial status of their personal trust fund and had not received them. Resident # 6 stated that the BOM came to their room and asked to see the personal records Resident # 6 kept of their financial transactions to see if the resident's records matched the facility records. Resident # 6 stated that the BOM told them they had been working to get them their financial statement but that the BOM had just not had time to complete the statement. <BR/>In an interview on 10/16/2024 at 1:09 PM the BOM stated that Resident # 6 had not received their quarterly financial statement for this last quarter. The BOM stated the statement was printed on 9/30/2024 but had not been given to Resident # 6 because they were still working on it. The BOM said the last statement Resident # 6 received was at the end of July of 2024 and it was not up to date at that time as the company had recently changed ownership and that had made some challenges the facility had not been able to work through yet. The BOM said the expectation was that trust funds were kept current and financial statements were given to the resident quarterly and upon request. The BOM could not give an explanation as to why trust funds statements have not been available to residents quarterly or upon request. The BOM stated there was no reason the residents should not have access to their funds unless she was off for the day. The BOM stated by the residents not having access to their financial statements then the residents could be overdrawn on their account and not be aware of it.<BR/>In an interview on 10/16/2024 at 1:40 PM the ADM stated their expectation was that all residents have access to their money and that the resident trust funds were kept accurate. The ADM stated the residents have the right to receive their financial statements. The ADM stated if the residents did not have access to their financial statements this could negatively affect the residents by the fact that the resident would not know their financial balance in their trust fund. The ADM stated it was the BOM's responsibility to ensure the resident's trust fund financial statements were accurate and available.<BR/>Review of Resident Personal Funds policy undated reflected under heading policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Under heading accounting and records: The individual financial record must be available to the resident through quarterly statements and upon request.<BR/>Review of Resident Rights undated reflected You, the resident, do not give up any rights when you enter a nursing Facility. The Facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing Facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights. <BR/>You have a right:<BR/>13. to access money and property you have deposited with the Facility and to an accounting of your money and property that are deposited with the Facility and of all financial transactions made with or on behalf of you;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #45) reviewed for care plan revision. <BR/>Based on interviews and record review the facility failed to update the care plan of Resident #45 to reflect services to maintain the residents's highest practicable well being.<BR/>The facility failure place Resident #45 at risk for his physical, medical and social needs not being met and risk of further weight loss.<BR/>Findings include:<BR/>Review of the Face sheet for Resident #45 reflected he was admitted on [DATE] with diagnosis of: Unspecified Dementia, Hypothyroidism (thyroid doesn't create and release enough thyroid hormone into your bloodstream), Secondary Parkinsonism (a term used to describe the collection of signs and symptoms found in Parkinson's disease), Mood Disorder, Type 2 Diabetes, History of falls, and Depression Unspecified.<BR/>Review of the MDS admission assessment for Resident #45 dated 5/11/22 reflected a BIMS score of 8, indicating severe cognitive impairment. Review of the functional assessment reflected he required extensive assistance for all ADLs. He was assessed as frequently incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #45 reflected interventions were in place for: Full Code Status, ADL self-performance deficit, Impaired Cognitive Function, Diabetes, Hypothyroidism, An actual fall, Antidepressant medication, Mood disorder (Depression, Parkinson's r/t eating and mobility.)<BR/>In an interview on 6/08/22 at 2:22 pm LVN D stated an updated Care plan should be completed for new developments on the day ordered. She stated nurses would enter the Baseline Care Plan into the computer, print it out and put it in the Resident binder. <BR/>In an interview on 6/09/22 at 9:45 am LVN E stated Resident #45 had lost weight since his admission. She stated a significant weight change should be included in a Resident's Care Plan. She reviewed his records and confirmed his weight change was from 172.0 down to 156.0 lbs. She stated Resident had Med Pass (a protein and high calorie supplement given with his medications) and health shakes. She stated Resident #45 was to be monitored for his oral intake and was checked daily for weight . LVN E stated any charge nurse could alter the Resident's Care Plan. She stated other members of the Care Team can also update interventions. LVN E stated Resident #45 had been cooperative with staff providing his care.<BR/>In an interview on 6/09/22 at 9:50 am the DON stated Resident #45 should have his Care Plan updated to include his weight loss and the measures ordered by his physician . The DON stated Resident #45 was a recent admission [DATE]) and his weight loss was still being evaluated. She stated the weight loss of 9.3 percent was noted and his care updated. The DON stated she was not sure when his next dietary evaluation would be done, one was done on admission .<BR/>In an interview on 6/09/22 at 10:15 CNA K stated in working with Resident #45 the resident had not refused care. He stated Resident #45 was cooperative with his requests .<BR/>In an interview on 6/09/22 at 11:03 am the Administrator stated he would expect staff to follow guidelines and update Care Plans appropriately. He stated the MDS coordinator had been out with serious illness for two weeks and the corporate MDS person was trying to catch up.<BR/>In an interview on 6/09/22 at 1:35 pm the MDS Coordinator stated Resident #45 should have his Care Plan updated when a weight loss was reported. She stated the physician ordered interventions and dietary supplements would be added to his care plan as soon as possible. <BR/>In an interview on 6/09/22 at 1:35 pm the Nurse Practitioner for Resident #45 stated the Resident was just not willing to eat enough. She stated the facility was offering Health Shakes and supplements but he was not taking in enough. The Nurse Practitioner stated the resident's RP was bringing in home cooked food but he was also refusing that. She stated she would continue monitoring Resident #45, but he could not be forced to eat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within seven days after the comprehensive MDS assessment was completed for one (Resident #1) of five residents reviewed for comprehensive care plans.<BR/>The facility failed to complete a comprehensive person-centered care plan to address Resident #1's needs within seven days after the comprehensive MDS assessment was completed.<BR/>This failure could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet dated 06/12/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Intertrochanteric Fracture of Right Femur (type of hip fracture in which the femur is fractured), Malignant Neoplasm of Unspecified Ovary (primary or metastatic malignant tumor involving the ovary), and Chronic Kidney Disease (long-term condition where the kidneys do not work as well as they should). <BR/>Review of Resident #1's MDS admission Assessment, dated 05/22/2024 revealed Resident #1 had a BIMS Score of 6, which indicates severe cognitive impairment. The MDS Assessment revealed that Resident #1 was a new admit from 04. Short-Term General Hospital. The MDS Assessment in Section H - Bladder and Bowel indicated C. Ostomy (including urostomy, ileostomy, and colostomy) related to Resident #1, which required additional care. <BR/>Review of Resident #1's undated electronic health records revealed an initiated Care Plan date of 5/23/2024. Review of the Comprehensive Care Plan file revealed that it contained no information and indicated, No data found.<BR/>Interview on 06/12/2024 at 4:00 PM, the DON stated that the facility did not have an MDS Coordinator and was utilizing an MDS Consultant to assist. The DON stated that she wanted care plans for residents to be completed immediately or within a day of their completed MDS admission Assessment. The DON stated that she is responsible for ensuring that care plans for residents are completed. The DON reviewed the electronic records for Resident #1 and stated that they had failed to complete her Comprehensive Care Plan in the required time. The DON stated that Comprehensive Care Plans are vital to ensure proper care for their residents' needs and to ensure they are met.<BR/>Interview on 06/12/2024 at 4:17 PM, the MDS Consultant stated that she is currently assisting the facility with completion of MDS Assessments. The MDS Consultant stated that once the MDS assessment is complete it is the facility's responsibly to ensure that the Comprehensive Care Plan is completed. The MDS Consultant stated that the Comprehensive Care Plan needs to be completed within 7 days of the resident MDS admission Assessment. The MDS Consultant reviewed the electronic file of Resident #1 and stated that she did not have a completed Comprehensive Care Plan and should have. The MDS Consultant stated that the Comprehensive Care Plan must be completed to ensure that the facility as well as the resident and their families are on the same page. The MDS Consultant stated that failure to complete the Comprehensive Care Plan in a timely manner could result in uninformed / improper care of the resident.<BR/>Interview on 06/12/2024 at 4:23 PM, the Interim Administrator stated that they are currently utilizing consultants to assist with MDS Assessments. The Interim Administrator stated that Care Plans are a team effort and should be completed within 24 hours of the completed MDS Assessment. The Interim Administrator stated that Comprehensive Care Plans are completed to ensure the needs of the resident are met.<BR/>Interview on 06/12/2024 at 4:38 PM, Resident #1 stated that she and her responsible party have not had a meeting with the facility to discuss and approve her Comprehensive Care Plan.<BR/>Review of the facility Comprehensive Care Plan Policy dated 2023 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally - competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessments Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidence in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 6 (Resident is #7, and Residents #32) residents reviewed for pain management. <BR/>The facility failed to ensure Resident #7, and Resident #32 had effective pain management by not evaluating effectiveness of current pain medications.<BR/>This failure could place resident at risk for increased pain causing undo suffering.<BR/>Findings included:<BR/>1) Record review of Resident #7's face sheet, dated 10/14/24, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included osteoarthritis (a chronic disease-causing cartilage to break down over time), restless leg syndrome, and post laminectomy syndrome (a condition where a patient continues to experience pain after spinal surgery).<BR/>Record review of the facility Pain assessment dated [DATE] reflected Resident #7 denied having any pain within the last five days. The assessment also reflected Resident #7 was taking routine pain medications for pain management.<BR/>Record review of Resident #7's Quarterly MDS assessment, dated 08/29/2024, reflected he had a BIMS score of 5, which indicated severe cognitive impairment. Resident #7 required partial/moderate staff assistance with personal hygiene, toileting, and showering. The MDS reflected received scheduled pain medication. <BR/>Record review of Resident #7's care plan dated 01/02/2023 and revised on 09/30/24 reflected he was at risk for pain. Goal: Resident #7 will not have an interruption in normal activities due to pain through the review date. Interventions included Evaluate the effectiveness of pain medications every shift and as needed.<BR/>Record review of Resident #7's medication administration record dated 10/14/24 reflected he was taking Tylenol with Codeine #3 twice a day and Lidocaine 4% external patch daily for pain. <BR/>Record review of the electronic medical records on 10/14/24 reflected there were no assessments evaluating the effectiveness of medications daily for the months of September and October 2024. <BR/>In an interview on 10/15/24 at 09:55 AM Resident #7 stated he occasionally had leg and back pain and he took a pain medication, but he couldn't remember what it was . Resident stated his pain was controlled at this time. <BR/>2) Record review of Resident #32's face sheet, dated 10/14/24, reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included osteoarthritis (a chronic disease- causing cartilage to break down over time), chronic obstructive pulmonary disease (a lung disease restricting airflow), and mild cognitive impairment.<BR/>Record review of facility Pain assessment dated [DATE] reflected Resident #32 denied having any pain within the last five days. <BR/>Record review of Resident #32's Quarterly MDS assessment, dated 08/08/2024, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #32 required set up/supervision staff assistance with personal hygiene, toileting, and showering. The MDS reflected received scheduled pain medication. He had pain within the last 5 days of assessment and rated it at a 4 on numeric rating scale (0-10). <BR/>Record review of Resident #32's care plan dated 02/18/2024 reflected he was at risk for pain related to his medical condition. Goal: Resident #32 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included Monitor /record /report complaints of pain or request for pain treatment.<BR/>Record review of Resident #32's medication administration record dated 10/14/24 reflected he was taking Lidocaine 4% external patch daily for pain in his right hip for the month of October 2024. <BR/>Record review of the electronic medical records on 10/14/24 for Resident #32 reflected there were no assessments evaluating the effectiveness of medications daily. <BR/>In an interview on 10/15/24 at 10:24 AM Resident #32 stated he had occasional phantom pain in his left at the knee amputation area. Resident #32 stated his pain was controlled at this time. <BR/>In an interview with the DON on 10/16/24 at 11:13 AM she stated residents required routine monitoring of pain to ensure pain management was adequate. If pain management was not adequate, staff would need to reach out to the physician to ensure pain was managed. The DON stated nurses were instructed to monitor for pain every shift. The DON stated she was responsible for monitoring to ensure there was an order in place to monitor pain. She stated the negative effects for not monitoring residents' pain or effectiveness of medications for pain would be the pain would be unmanaged. <BR/>In an interview with the ADM on 10/16/24 at 12:48 PM she stated her expectation would be for the residents to be comfortable and given their pain medication as needed. She stated pain should be monitored routinely and the DON was responsible for monitoring the pain management program. The ADM stated the negative effects for not monitoring pain would be more pain increased discomfort for the resident. <BR/>Record review of facility policy titled Pain Management dated 9/1/23 reflected that the facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice the comprehensive person-centered care plan and the residents' goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 4 residents (Resident #38) reviewed for unnecessary medications.<BR/>The facility failed to ensure Resident #38's GDR recommended by the pharmacist consultant was followed up on for 6 months for Resident #38's antipsychotic, antianxiety, and antidepressant medications.<BR/>This failure could place residents receiving antipsychotic medications at risk for adverse health consequences.<BR/>Findings included: <BR/>Review of Resident #38's face sheet dated 10/16/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Huntington's disease (is a rare, inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain) and Major depressive disorder recurrent severe without psychotic features (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.). <BR/>Review of Resident #38's Quarterly MDS dated [DATE] reflected Resident #38 was assessed to have a BIMS score of 6 indicating severe cognitive impairment. Resident #38 was assessed not to have verbal behaviors 1 to 3 days during the assessment period. Resident #38 was assessed to take antipsychotic, antianxiety, and antidepressant medication.<BR/>Review of Resident #38's comprehensive care plan reflected a focus area initiated on 02/08/2023 The resident uses psychotropic medications related to disease process; Resident has diagnosis of Huntington's disease. Goal included the resident will be/remain free of psychotropic drug related complications . Further review reflected a focus area initiated on 08/09/2023 The resident has depression. Intervention included, administer medications as ordered, and monitor for side effects. Another focus area initiated on 02/22/2023 reflected Resident #38 used antianxiety medications. Interventions included, administer medications as ordered and monitor for side effects.<BR/>Review of Resident #38's consolidated physician orders dated 10/01/2024 reflected the following medication orders dated 12/23/2023: Abilify 15 mg QD (antipsychotic), Celexa 30mg QD (antidepressant), and Clonazepam 1mg BID (anti-anxiety).<BR/>Review of Resident #38's consultant pharmacist / provider communication dated 05/21/2024 reflected This resident has been taking Abilify 15mg QD, Celexa 30mg QD, and Clonazepam 1mg BID since 12/23. Please evaluate the current dose and consider a dose reduction. No physician response was noted on the communication.<BR/>Review of Resident #38's consultant pharmacist medication regimen review recommendations pending a final response dated 06/01/2024 reflected his GDR was still pending.<BR/>Review of Resident #38's consultant pharmacist / provider communication dated 07/10/2024 reflected This resident has been taking Abilify 15mg QD, Celexa 30mg QD, and Clonazepam 1mg BID since 12/23. Please evaluate the current dose and consider a dose reduction. No physician response was noted on the communication.<BR/>Review of Resident #38's consultant pharmacist medication regimen review recommendations pending a final response dated 08/01/2024 reflected his GDR was still pending.<BR/>Review of Resident #38's consultant pharmacist / provider communication dated 09/16/2024 reflected This resident has been taking Abilify 15mg QD, Celexa 30mg QD and Clonazepam 1mg BID since 12/23. Please evaluate the current dose and consider a dose reduction. No physician response was noted on the communication.<BR/>In an interview on 10/16/2024 at 10:00 AM the VP of clinical Operations stated the DON was responsible for the pharmacy review recommendations. She stated she did not find the GDR for Resident #38 that had been returned from the MD. The VP of clinical Operations stated it was not done. She stated the facility had 7 days from the time the pharmacy recommendation was received to get a response back from the MD and if not received from the MD it needed to be sent to the medical director. She stated by the facility not following up on the GDRS it could lead to negative outcomes for the resident and the residents potently continuing medication that they do not need.<BR/>In an interview on 10/16/2024 at 10:21 AM the DON stated she had been having trouble getting the recommendations back from the MDs. She stated she was not aware it had been since May that Resident #38's GDR was requested by the pharmacist. She stated there was a MD change in July. The DON stated Resident #38's GDR got missed due to the MD change. She stated the resident was seen by psychiatry in September and his meds were reviewed but the GDR was not reviewed or signed. The DON stated by not following up on the pharmacy recommendations it could lead to negative resident outcomes.<BR/>Review of the facility's policy Medication Monitoring: Medication Regimen Review and Reporting dated 01/2024 reflected .The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information, and information from the nursing care center staff and other health professionals involved in the resident's care . The findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filed with other consultant pharmacist recommendations in the resident's chart . The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. a. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record .

Based on observation, interview, and record review, the facility failed to ensure that menus were developed and followed to meet resident nutritional, religious, cultural, or ethnic needs, and resident choices in accordance with the national guidelines for one of one facility.<BR/>The facility failed to provide residents in the facility with a varied menu, having utilized the same menu for the facility for over a year.<BR/>This failure could place the residents in the facility at risk of reduced appetite resulting in their nutritional needs not being met and / or weight loss. <BR/>Findings included:<BR/>Observation on 08/16/2023 at 9:01 AM, revealed the menu board outside the dining area contained no information as to kitchen menus for the day, week, or month.<BR/>In a confidential group interview on 08/16/2023 at 2:40 PM, all eight resident attendees stated they were tired of the same menu being served in the facility every week. Residents stated that they were given a copy of the menu and that one has not been posted outside the dining area for over a year. Residents stated they were told they would have a new menu provided to them, but the facility has failed to implement one.<BR/>In an interview on 08/17/23 at 11:05 AM, the DM was requested to provide menus that have been served by the facility since 08/17/2022. The DM stated that there has only been one menu in the facility since she started on 10/15/22. The DM provided surveyor with the facility's Patient Menu Regular Diet Nutrition Services Menu. The DM stated that they do have their alternate choices, but the menu has remained unchanged. The DM stated that she has gone to the Administrator and discussed her desire to have the menu updated and changed. The DM stated she was advised the menu was going to change this month but did not. The DM stated the menu they serve at the facility was created for the hospital and should not be the same for the residents of the facility due to the duration of their stay. The DM stated that the kitchen provides food service off the menu for the hospital. The DM stated she was aware that residents have complained and continue to complain about the lack of variety. Surveyor referenced hearing a resident complain on 08/16/2023 about mashed potatoes instead of french fries. The DM stated that mashed potatoes were listed on the menu and that they were providing french fries that were ordered on accident but ran out. <BR/>In an interview on 08/18/2023 at 9:23 AM, the AD stated that the menu in the facility has been brought up numerous times in Resident Council. The AD stated that the current menu being served to residents has been served for more than a year. The AD stated that the menu was supposed to change in June but did not. The AD stated that she was then advised that it would change in August but has not as of this date. The AD stated that she does not believe that facility residents should have the same meals for the length of time they have and felt it was due to a shared menu with the hospital.<BR/>In an interview on 08/18/2023 at 9:40 AM, the Administrator confirmed that they have utilized the same menu for approximately one year. The Administrator stated that use of the current menu was a decision made above him, but he can understand why the residents would be upset eating the same meals every week for as long as they have. <BR/>Review of the undated menu contained a weekly menu for breakfast, lunch, and dinner. Personal Choices were included on the menu, which did not show french fries as a choice. Menu reflected the same dinner of beef stew, dinner roll, green peas, and grapes on Tuesday and Saturday every week. <BR/>Review of Resident Council minutes dated 05/25/2025 at 2:00 PM (seven residents in attendance), indicated for Dietary: changing menus in Aug. Minutes dated 7/26/2023 at 2:00 PM (four residents in attendance), indicated for Dietary: Ready for new menus .food is tolerate sometimes.

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. <BR/>1. The kitchen test tray of the lunch meal on 10/15/2024, the foods were bland, unappealing, and inedible. The kitchen test tray beverages of iced tea and iced water lacked ice. The kitchen test tray's cornbread and cake were both very dry and crumbly. <BR/>2. The facility failed to follow the puree diet recipe. The pureed garlic bread, pureed vanilla cake, pureed meat sauce and pureed pasta were all mixed with water during the puree process for the lunch meal on 10/15/24 and 10/16/2024 instead of something with nutritive value such as broth, milk, or juice. <BR/>These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. <BR/>Findings included:<BR/>Observation on 10/15/2024 at 10:43 AM of DA F revealed DA F pureed the vanilla cake with water instead of milk or something of nutritive value. DA F did not have any recipe out for the pureed food. <BR/>Observation on 10/15/2024 at 12:28 PM of the kitchen test tray revealed the iced tea and iced water both to be without ice. Kitchen test tray consisted of pinto beans with sausage, rice pilaf, collard greens, cornbread, and glazed vanilla cake. The kitchen test tray pinto beans and sausage was warm but lacked flavor. The rice pilaf was warm and had good flavor. The collard greens were warm but lacked flavor and tasted like dirt. The cornbread and cake were both very crumbly and dry.<BR/>Observation on 10/16/2024 at 11:10 AM of [NAME] G revealed [NAME] G pureed the garlic bread, meat sauce and pasta with hot water instead of milk or something of nutritive value. [NAME] G did not have any recipe out for the pureed food. <BR/>In an interview on 10/15/2024 at 10:43 AM DA F stated that they usually thin the pureed products with water or milk depending on what the dessert was. DA F stated when asked as to why they used water instead of milk for the cake, they could not provide an answer. DA F stated they did not know if using water affected the nutritive value of the food. <BR/>In an interview on 10/16/2024 at 11:10 AM [NAME] G stated the reason she used hot water to thin the pureed food was because the milk would make the food products cold. [NAME] G stated they were unsure if using water would affect the nutritive value of the foods. [NAME] G stated they have not seen a list of appropriate liquids to thin the pureed foods with.<BR/>In an interview on 10/16/2024 at 11:22 AM DM H stated the RD told the dietary staff that pureed foods could be thinned with water. DM H said the recipes say water can be used to thin food products. DM H went to the recipe binder to show the state surveyor the recipes. DM H could not provide the pureed recipes. DM H then stated, oh I must not have printed them yet. DM H then went to the computer and printed the pureed recipes. Upon review of the recipes, DM H stated they had never seen the appropriate liquid sheet and it must be new to the recipes. DM H stated using water to thin the pureed food can affect the nutritive value of the food products but that was why we use very small amounts of water. DM H stated they expected the recipes to be followed by the dietary staff. DM H said they provided lots of training and in-services regarding technique. DM H said it was their responsibility to print the recipes for the dietary staff. <BR/>In an interview on 10/16/2024 at 1:40 PM the ADM stated the ADM expected the dietary staff to follow the RD recommendations and to follow recipes for the pureed foods. The ADM stated that not following recipes could affect the nutritive value of the foods. The ADM stated not following the recipes could negatively affect the residents by the residents could choke or not get the nutrients they need. <BR/>Review of recipes undated for garlic bread, meat sauce and pasta, red velvet cake reflected the following: cooking liquid, broth, gravy, or other suitable liquid may be substituted for liquid in recipe when pureeing foods. <BR/>Review of recipes undated appropriate liquid sheet for pureed foods reflected the following: Add the appropriate liquid in the amounts specified in the recipe for the item being pureed. *Entrees - Broth or other appropriate sauce/gravy from menu - tomato sauce, cheese sauce, cream gravy, etc. *Starch - Whole Milk or Sauce from menu Vegetables - Broth, Cooking liquid, or Sauce from menu Dessert - Milk *Bread, crackers, muffins, Pancakes, - Milk or Juice Ensure the liquid selected for pureeing is appropriate for the person's diet order. Ensure the liquid selected for pureeing is appropriate for the person's diet order.<BR/>Review of in-service dated 06/11/2024 reflected topics included recipes and spreadsheets attended by 5 dietary staff members including [NAME] G and DA F.<BR/>Review of in-service dated 08/15/2024 reflected topic of proper foodservice procedures attended by 5 dietary staff members including [NAME] G and DA F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 6 (Resident #11, and Residents #15) residents reviewed for infection control.<BR/>LVN B failed to properly sanitize blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressure for Residents #11 and #15.<BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>1) Record review of Resident #11's face sheet, dated 10/16/24, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included paranoid personality disorder, type 2 diabetes mellitus (too much sugar in the blood), and major depressive disorder.<BR/>Record review of Resident #11's Quarterly MDS assessment, dated 09/30/2024, reflected she had a BIMS score of 9, which indicated moderate cognitive impairment. Resident #11 required staff assistance with eating, personal hygiene, toileting, and showering.<BR/>Record review of Resident #11's care plan dated 06/02/2021 and revised on 09/23/24 reflected she had an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits related to unsteady gait, and hemiparesis (paralysis) to upper extremity. Goal: Resident #11 will maintain current level of function in ADL's, through the next review date. Interventions included Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.<BR/>2) Record review of Resident #15's face sheet reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (a loss in cognitive function thinking reasoning and remembering), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and hemiplegia and Hemiparesis (paralysis) affecting the right dominate side.<BR/>Record review of Resident #15's Quarterly MDS assessment, dated 09/30/2024, reflected she had a BIMS score of 03, which indicating severe cognitive impairment. Resident #15 required staff assistance with eating, personal hygiene, toileting, and showering.<BR/>Record review of Resident #15's care plan dated 06/02/2021 and revised on 09/23/24 reflected she had an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits r/t: dementia, fatigue, and impaired balance. Goal: Resident #15 will maintain current level of function in ADL's, through the next review date. Interventions included Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.<BR/>In an observation on 10/15/24 at 08:57 AM, LVN A did not sanitize the blood pressure cuff when going from resident #15 to Resident #11. <BR/>In an interview on 10/15/24 at 8:56 AM LVN A stated the blood pressure cuff should have been cleaned between residents. She stated staff were in-serviced on infection control routinely. LVN A stated not cleaning the blood pressure cuff would create cross contamination leading to infections. <BR/>In an interview on 10/16/24 at 11:13 AM the DON stated the staff needed to disinfect the blood pressure cuff between residents. She stated the nurses were educated on infection control monthly. The DON stated she was responsible for instruction and monitoring of infection control. She stated the negative effects for not cleaning the blood pressure cuff between usage would be passing organisms from one patient to another. <BR/>In an interview on 10/16/24 at 12:48 PM the ADM stated the nurses were expected to clean the blood pressure cuff between residents. She stated the DON was responsible for management of infection control. The ADM stated negative effects for the resident for not cleaning the blood pressure cuff between residents would be cross contamination and spreading infections.<BR/>Record review of facility policy titled Infection Prevention and Control Program dated 9/1/2023 Revised 1/23/2024 reflected:<BR/>Standard Precautions:<BR/>All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.<BR/>Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department.<BR/> Equipment Protocol: <BR/>All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

Based on observation, interview, and record review the facility failed to ensure that medications were stored in a locked compartment for 2 (300 Hallway) of 4 medication carts reviewed for medication storage in the facility.<BR/>The facility failed to ensure that both medication carts for the 300-hallway remained locked at all times when not in use and direct view of staff.<BR/>This failure could result in harm due to unauthorized access to medications by residents and visitors.<BR/>Findings included:<BR/>Observation on 06/12/2024 at 9:02 AM, revealed a multi-drawer, rollable medication cart that was left unlocked in front of the nurse's station in the 300 hallway. LVN A was seated in a chair behind the nurses' station working at a computer and RN C was present viewing paperwork. Two residents were seated in a common area watching television approximately twenty feet from the cart.<BR/>Observation on 06/12/2024 at 9:39 AM, revealed that the cart observed at 9:02 AM was still in the same location unlocked and now a second multi-drawer, rollable medication cart was next to it in front of the nurses' station that was also unlocked. Two staff members were present on the opposite side of the counter discussing paperwork.<BR/>Observation and interview on 06/12/2024 at 10:09 AM, revealed that both medication carts observed at 9:39 AM in front of the nurses' station in the 300 hallway were still unlocked and no staff or residents were present around them. LVN A approached the original unlocked cart and looked over at the second unlocked medication cart. LVN A engaged the lock on the second cart to secure it and then obtained medication from the first cart before locking it. LVN A stated that the two carts should not have been unlocked prior to her securing them. LVN A stated that medication carts are to be always locked if not in direct view and actively being used by staff. LVN A stated that both observed carts were considered the 300 hallway medication carts. LVN A stated that they are to keep the medication carts locked at all times to ensure that residents do not gain access to medications, which could result in illness if ingested. LVN A stated that she and RN C utilized the two 300 hallways carts this morning.<BR/>Interview on 06/12/2024 at 10:17 AM, the DON was notified of the unlocked medications carts for the 300 hallway. The DON stated that if staff are not directly in front of the medication cart they are to be locked at all times. The DON stated that the facility has residents with Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) as well as visitors who could gain unauthorized access to medications if the carts are not locked. The DON stated that if someone ingested medications that were not theirs it could result in medical side effects. <BR/>Interview on 06/12/2024 at 10:45 AM, RN C stated that she did assist LVN A with medication pass this morning between 6:45 AM and 7:00 AM. RN C stated that she knew she locked the cart she used before turning it over to LVN A. RN C stated that medication carts were to be locked at all times when not in use or their direct view. RN C stated that the medication carts are to be locked even if they are in the area of them. RN C stated that medication carts must be locked to ensure that no residents gain access to medications, which could result in an adverse reaction. <BR/>Interview on 06/12/2024 at 2:40 PM, MA D stated that they are trained that medication carts are to be locked at all times if they are not directly in front of them working. MA D stated that as soon as they obtain the medications they need for a resident they are to close the computer screen and lock the medication cart. MA D stated that failure to do so could result in a resident getting into the cart and taking some medications, which could cause an adverse effect. <BR/>Interview on 06/12/2024 at 2:50 PM, LVN B stated that they are trained that medication carts are to be locked at all times when not directly in front of them. LVN B stated that medication carts have to remain locked to ensure that residents do not gain access to medications that are not theirs, which could lead to an allergic reaction. <BR/>Follow-up interview on 06/12/2024 at 4:00 PM, the DON stated that the facility has four medications carts, which contain medications for their residents. The DON stated that the 300 hallway does have two of the four medication carts, which she audited after notification and found no evidence of drug diversion.<BR/>Interview on 06/12/2024 at 4:23 PM, the Interim Administrator stated that medication carts are to be locked immediately after use and if not directly in front of staff. The Interim Administrator stated that failure to lock medication carts could lead to a resident gaining access to medications resulting in a possible adverse reaction.<BR/>Review of the facility's Drug Diversion Policy dated 2024 revealed, Policy: This facility recognizes the risks for contamination and infection associated with diversion of injectable medications and monitors staff with access to injectable controlled substances to prevent transmission of infections. Definitions: Drug diversion refers to the theft or other deviation that removes a prescription drug from its intended path from the manufacturer to the patient. Policy Explanation and Compliance Guidelines: 1. All drugs and biologicals, including controlled substances, are stored in locked compartments and only authorized personnel have access to the keys to locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). 2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications, including documentation and disposition of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor the residents right to choose his or her attending physician for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) and the entire facility reviewed for resident rights.<BR/>The facility did not honor any residents right to choose his/her primary care physician as his/her attending physician after the facility terminated their Medical Director agreement and changed the attending physician without notice to the residents or their representatives effective 07/04/24.<BR/>This deficient practice could place residents at risk of decreased quality of care and treatment due to their lack of free choice for their attending physician care while in the facility.<BR/>Findings included:<BR/>Resident #1<BR/>Record review of Resident #1's face sheet dated 07/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of unspecified dementia-unspecified severity-without behavioral disturbance- psychotic disturbance- mood disturbance- and anxiety (a group of symptoms that affects memory, thinking, and interferes with daily life), hypothyroidism-unspecified (a condition resulting from decreased production of thyroid hormone), hyperlipidemia-unspecified (high cholesterol, or condition in which the blood contains a high level of fats), chronic ischemic heart disease (occurs from reduced blood flow to the heart muscle from blocked arteries), and unspecified chronic atrial fibrillation (irregular and often rapid heartbeat). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03 indicating severe cognitive impairment. <BR/>An interview on 07/19/24 at 11:20 AM with Resident #1 she stated she was always encouraged to see a doctor as needed by the facility. Resident #1 stated she was not informed of having her doctor changed but recalled meeting with the new attending physician who introduced himself to her. Resident #1 was observed sitting in her recliner at bedside, was well groomed, and her mood appeared well; she was able to answer other questions at the time of the interview coherently and appeared to understand the questions being asked. She stated she did not have any concerns with the new attending physician. <BR/>Resident #2<BR/>Record review of Resident #2's face sheet dated 07/19/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease- unspecified (a gradual decline in memory, thinking, and reasoning skills), wheezing, dysphagia-oropharyngeal phase (a condition with difficulty in swallowing food or liquid), edema-unspecified (swelling caused due to excess fluid accumulation in the body tissues), chronic obstructive pulmonary disease (chronic lung disease that causes breathing difficulty, cough, mucus production and wheezing), hyperlipidemia (high cholesterol, or condition in which the blood contains a high level of fats), depression (mood disorder that causes persistent sadness and loss of interest), and heart failure (a condition where the heart cant pump enough blood to meet the body's needs). <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score was not assessed.<BR/>An interview on 07/19/24 at 11:50 AM with Resident #2 and [family member] in the room, they stated they were not notified of the attending physician change that took place. The [family member] stated she was the responsible party for Resident #2 and in the past has received letters in advance notifying her when there was a change in physician, but she did not receive notification this time neither by mail nor in person by facility staff. The [family member] stated they also did not have a say in selecting any other physician, one was just assigned which she did not like as she was not given the option. Resident #2 stated she was not informed in advance of the decision to change the attending physician via letter or in advance by the facility nor was she given an option on who to choose. The [family member] said it was the residents right to be informed and not given the right was upsetting. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 07/19/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture without routine healing (type of hip fracture), edema (swelling caused due to excess fluid accumulation in the body tissues), primary hypertension (high blood pressure), and chronic kidney disease. <BR/>Record review of Resident #3's significant change MDS assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. <BR/>An interview on 07/19/24 at 12:09 PM with Resident #3's [family member] he stated he was the responsible party for Resident #3 and participated in managing the care for Resident #3 such as attending the care plan meetings when possible. The [family member] stated he did not get notified of the change in attending physician, he said he did not receive a letter from the facility nor was he informed about it over the phone or in person and given options in providers. An attempt was made to interview Resident #3, however, due to a decline in health and hospice pain medications that were administered Resident #3 was unable respond to interview questions as she was in a sedative state.<BR/>Resident #4<BR/>Record review of Resident #4's face sheet dated 07/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of unspecified dementia-severe-with other behavioral disturbance (a group of symptoms that affects memory, thinking, and interferes with daily life), disorder of kidney and ureter-unspecified, repeated falls, dysuria (pain or burning sensation while passing urine), localized edema (swelling caused due to excess fluid accumulation in the body tissues), and delusional disorders. <BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score was not assessed. <BR/>An interview on 07/19/24 at 12:20 PM with Resident #4's [family member] she stated she was the responsible party for Resident #4 and would participate in the care plan meetings as needed. The [family member] stated she was concerned because Resident #4's attending physician was changed without notifying her as the responsible party. The [family member] said she was extremely upset by this because Resident #4 has had APH A as the attending physician for years; she said APH A had an established relationship and knew the care and goals of Resident #4. The [family member] said they did not get a choice in selecting the new attending physician that one was just assigned. The [family member] stated she was so upset by this she did her own research to discover this was a resident rights issue. The [family member] stated she also learned of the change in attending physician by another family member who was upset about the change after the change had already taken place, she stated she never heard it from the facility. The [family member] stated that since the change took place at the beginning of July 2024, the new attending physician has made his rounds and introduced himself however she would like to have a different attending physician assigned. <BR/>An interview on 07/19/24 at 11:28 AM with MA B she stated the change in attending physician was a surprise to both staff and residents. MA B stated she was spoken to by numerous residents' family members when the change took place as well as residents who were not notified that the attending physician was changing. MA B stated she recalled seeing a note at the nurse's station when the change took place was not formally notified in advance and was not aware of any of the residents being notified of the change in advance.<BR/>An interview on 07/19/24 at 12:56 PM with APH A she stated she was the attending physician for the facility prior to the change that took effect July 4th of 2024. APH A said she managed care along with NP C for 100% of the facility census prior to the change. APH A stated that she was shocked when she found out that she was no longer the attending physician to the facility; she said she was not given a 30 day notice which was standard practice and also was not aware of who the new attending physician would be so she was unable to meet with them in advance in order to participate in a transfer of care which would have included updating the new physician all the residents current conditions. APH A stated this change affected all the residents in the facility because it was her license number that was used when admitting residents, adding orders, and she oversaw the care of them all. APH A stated she was made aware of the changes on 7/04/24 because NP C attempted to call the facility to give orders and the facility told her they no longer had access to the residents' records. NP C stated to her knowledge the new physician took over on 7/04/24 as the new attending physician and medical director. APH A said the only notice that was provided was a 30-day notice given on 6/3/24, terminating the contract with the medical director, she stated that the attending physician relationship was different and that notice given and contract terminated would not have had any change to the patient/ physician relationship with the residents. She said the residents, or their representatives should have been provided with their own 30-day notice of change. APH A stated she believed it did not happen however because multiple families reached out to her expressing their concern and anger of the change without notification. APH A stated she did not believe there was a negative outcome that resulted in harm to any of the residents from the change, but she believed they should have been notified because it was a resident right to choose their attending physician. <BR/>An interview on 07/19/24 at 01:42 PM with NP C she stated she contacted the facility on 7/4/24, in order to give an updated order for a resident but was told by the charge nurse that she did not have access to the residents' medical records as a new company had taken over and they were provided a new medical director/ attending physician. NP C stated that prior to this change she along with APH A cared for 100% of the residents in the facility. NP C stated she was not notified in advance that this change was taking place and was surprised; she also stated that the charge nurse also seemed confused in the matter and thought the facility failed to also notify the staff, residents, and their representatives appropriately of the change of attending physician. NP C stated that by failing to notify her and APH A they were not able to do an appropriate transfer of care' with the new attending physician. She also stated it was a resident right to choose who their doctor was, and they should have been notified in advance of the change, she said many of the residents in the facility have had APH A as the attending physician for many years and she believed the residents opinions and choices were not heard or respected. NP C stated in the end she was able to speak with the DON about the residents she was calling about and did not believe a lapse in care took place that caused harm to any of the residents as a result of this change. <BR/>An interview on 07/19/24 at 01:49 AM with the DON she stated the change in attending physician that covered all the residents took effect 7/4/24. She stated she was new in her role but to her knowledge the residents or their representatives were made aware of the changes via a postal letter sent out by corporate a month before the changes took place. The DON stated the previous attending physician should have been made aware of the changes as well. The DON stated to her knowledge there was not a lapse in care and the new attending physician was able to start making rounds right away. The DON said it was a resident right to be able to choose their own doctor and to be informed of who is providing care. She stated a negative outcome of not being informed of a change in attending physician was the resident would not know who was treating them or their treatment plan. She stated if the previous attending physician was not notified, they would also not be able to do a transfer of care and the providers would be trying to follow up on a resident they did not have care over. <BR/>An interview and record review on 07/19/24 at 02:38 PM, the contract with the previous MDR was reviewed which specified it was for the role of the Medical Director. The ADM provided an email thread of communication between corporate and MDR dated 06/03/24.<BR/>Record review of an email thread between corporate and MDR dated 06/03/24 revealed a 30-day notice was emailed to the MDR indicating the contract for the role as Medical Director would be terminated with the last effective date 06/02/24. A follow up email in the thread from corporate dated 06/24/24 to the MDR then clarified if services from MDR would be provided through 06/03/24 to which MDR confirmed. The email thread and contract specified the termination of services for the Medical Director but did not refer to services being provided by APH A as attending physician or termination of those services. <BR/>In an interview with MDR on 07/19/24 at 03:15 PM, he stated he communicated with the facility's corporate office both via email and phone call. The MDR stated that in their communication it was the agreement for the role of Medical Director which was terminated 06/03/24 not any relationship between the attending physician and the residents. The MDR stated that was a separate patient/ doctor relationship that has no contract and if changes are made the resident or their representative should be made aware and should have a right to choose. The MDR stated he was not informed by the facility that they would be changing the attending physician and did not believe the residents were notified appropriately. <BR/>An interview and record review on 07/19/24 at 03:29 PM the ADM provided an untitled copy dated 06/04/24of what the letter that corporate would have sent out to the families. The ADM stated to her knowledge that was the letter that would have gone out to the families, she was unable to provide evidence to support to whom, where, or when the letters were mailed. The letter also only specified that the facility would be receiving a new medical director effective 07/04/24, it did not say that the attending physician would be changed or give the residents or their representatives a choice in attending physician. The ADM stated the residents always have a right to choose their attending physician and have a right to be notified of changes in their care. The ADM stated by not being informed of those changes it could have caused the residents to be confused and that it was important they know who was providing care. <BR/>Record review of the facility Resident Rights policy dated 09/01/23 revealed:<BR/>The resident has a right to be informed of and participate in his or her treatment including: the right to be informed in advance of the care to be furnished and the type of care giver or professional that will furnish care.<BR/>Choice of attending physician. The resident has the right to choose his or her attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within seven days after the comprehensive MDS assessment was completed for one (Resident #1) of five residents reviewed for comprehensive care plans.<BR/>The facility failed to complete a comprehensive person-centered care plan to address Resident #1's needs within seven days after the comprehensive MDS assessment was completed.<BR/>This failure could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet dated 06/12/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Intertrochanteric Fracture of Right Femur (type of hip fracture in which the femur is fractured), Malignant Neoplasm of Unspecified Ovary (primary or metastatic malignant tumor involving the ovary), and Chronic Kidney Disease (long-term condition where the kidneys do not work as well as they should). <BR/>Review of Resident #1's MDS admission Assessment, dated 05/22/2024 revealed Resident #1 had a BIMS Score of 6, which indicates severe cognitive impairment. The MDS Assessment revealed that Resident #1 was a new admit from 04. Short-Term General Hospital. The MDS Assessment in Section H - Bladder and Bowel indicated C. Ostomy (including urostomy, ileostomy, and colostomy) related to Resident #1, which required additional care. <BR/>Review of Resident #1's undated electronic health records revealed an initiated Care Plan date of 5/23/2024. Review of the Comprehensive Care Plan file revealed that it contained no information and indicated, No data found.<BR/>Interview on 06/12/2024 at 4:00 PM, the DON stated that the facility did not have an MDS Coordinator and was utilizing an MDS Consultant to assist. The DON stated that she wanted care plans for residents to be completed immediately or within a day of their completed MDS admission Assessment. The DON stated that she is responsible for ensuring that care plans for residents are completed. The DON reviewed the electronic records for Resident #1 and stated that they had failed to complete her Comprehensive Care Plan in the required time. The DON stated that Comprehensive Care Plans are vital to ensure proper care for their residents' needs and to ensure they are met.<BR/>Interview on 06/12/2024 at 4:17 PM, the MDS Consultant stated that she is currently assisting the facility with completion of MDS Assessments. The MDS Consultant stated that once the MDS assessment is complete it is the facility's responsibly to ensure that the Comprehensive Care Plan is completed. The MDS Consultant stated that the Comprehensive Care Plan needs to be completed within 7 days of the resident MDS admission Assessment. The MDS Consultant reviewed the electronic file of Resident #1 and stated that she did not have a completed Comprehensive Care Plan and should have. The MDS Consultant stated that the Comprehensive Care Plan must be completed to ensure that the facility as well as the resident and their families are on the same page. The MDS Consultant stated that failure to complete the Comprehensive Care Plan in a timely manner could result in uninformed / improper care of the resident.<BR/>Interview on 06/12/2024 at 4:23 PM, the Interim Administrator stated that they are currently utilizing consultants to assist with MDS Assessments. The Interim Administrator stated that Care Plans are a team effort and should be completed within 24 hours of the completed MDS Assessment. The Interim Administrator stated that Comprehensive Care Plans are completed to ensure the needs of the resident are met.<BR/>Interview on 06/12/2024 at 4:38 PM, Resident #1 stated that she and her responsible party have not had a meeting with the facility to discuss and approve her Comprehensive Care Plan.<BR/>Review of the facility Comprehensive Care Plan Policy dated 2023 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally - competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessments Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidence in the clinical record.

Based on observation, interview, and record review the facility failed to ensure that medications were stored in a locked compartment for 2 (300 Hallway) of 4 medication carts reviewed for medication storage in the facility.<BR/>The facility failed to ensure that both medication carts for the 300-hallway remained locked at all times when not in use and direct view of staff.<BR/>This failure could result in harm due to unauthorized access to medications by residents and visitors.<BR/>Findings included:<BR/>Observation on 06/12/2024 at 9:02 AM, revealed a multi-drawer, rollable medication cart that was left unlocked in front of the nurse's station in the 300 hallway. LVN A was seated in a chair behind the nurses' station working at a computer and RN C was present viewing paperwork. Two residents were seated in a common area watching television approximately twenty feet from the cart.<BR/>Observation on 06/12/2024 at 9:39 AM, revealed that the cart observed at 9:02 AM was still in the same location unlocked and now a second multi-drawer, rollable medication cart was next to it in front of the nurses' station that was also unlocked. Two staff members were present on the opposite side of the counter discussing paperwork.<BR/>Observation and interview on 06/12/2024 at 10:09 AM, revealed that both medication carts observed at 9:39 AM in front of the nurses' station in the 300 hallway were still unlocked and no staff or residents were present around them. LVN A approached the original unlocked cart and looked over at the second unlocked medication cart. LVN A engaged the lock on the second cart to secure it and then obtained medication from the first cart before locking it. LVN A stated that the two carts should not have been unlocked prior to her securing them. LVN A stated that medication carts are to be always locked if not in direct view and actively being used by staff. LVN A stated that both observed carts were considered the 300 hallway medication carts. LVN A stated that they are to keep the medication carts locked at all times to ensure that residents do not gain access to medications, which could result in illness if ingested. LVN A stated that she and RN C utilized the two 300 hallways carts this morning.<BR/>Interview on 06/12/2024 at 10:17 AM, the DON was notified of the unlocked medications carts for the 300 hallway. The DON stated that if staff are not directly in front of the medication cart they are to be locked at all times. The DON stated that the facility has residents with Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) as well as visitors who could gain unauthorized access to medications if the carts are not locked. The DON stated that if someone ingested medications that were not theirs it could result in medical side effects. <BR/>Interview on 06/12/2024 at 10:45 AM, RN C stated that she did assist LVN A with medication pass this morning between 6:45 AM and 7:00 AM. RN C stated that she knew she locked the cart she used before turning it over to LVN A. RN C stated that medication carts were to be locked at all times when not in use or their direct view. RN C stated that the medication carts are to be locked even if they are in the area of them. RN C stated that medication carts must be locked to ensure that no residents gain access to medications, which could result in an adverse reaction. <BR/>Interview on 06/12/2024 at 2:40 PM, MA D stated that they are trained that medication carts are to be locked at all times if they are not directly in front of them working. MA D stated that as soon as they obtain the medications they need for a resident they are to close the computer screen and lock the medication cart. MA D stated that failure to do so could result in a resident getting into the cart and taking some medications, which could cause an adverse effect. <BR/>Interview on 06/12/2024 at 2:50 PM, LVN B stated that they are trained that medication carts are to be locked at all times when not directly in front of them. LVN B stated that medication carts have to remain locked to ensure that residents do not gain access to medications that are not theirs, which could lead to an allergic reaction. <BR/>Follow-up interview on 06/12/2024 at 4:00 PM, the DON stated that the facility has four medications carts, which contain medications for their residents. The DON stated that the 300 hallway does have two of the four medication carts, which she audited after notification and found no evidence of drug diversion.<BR/>Interview on 06/12/2024 at 4:23 PM, the Interim Administrator stated that medication carts are to be locked immediately after use and if not directly in front of staff. The Interim Administrator stated that failure to lock medication carts could lead to a resident gaining access to medications resulting in a possible adverse reaction.<BR/>Review of the facility's Drug Diversion Policy dated 2024 revealed, Policy: This facility recognizes the risks for contamination and infection associated with diversion of injectable medications and monitors staff with access to injectable controlled substances to prevent transmission of infections. Definitions: Drug diversion refers to the theft or other deviation that removes a prescription drug from its intended path from the manufacturer to the patient. Policy Explanation and Compliance Guidelines: 1. All drugs and biologicals, including controlled substances, are stored in locked compartments and only authorized personnel have access to the keys to locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). 2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications, including documentation and disposition of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 3 of 9 residents (Resident #21, Resident #31, and Resident # 41) reviewed for call lights in that: <BR/>Resident #21's, and Resident #31's call lights were on the floor and Resident #41's call light was in drawer and not in reach. <BR/>This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. <BR/>Findings included:<BR/>1. Record review of Resident #21's face sheet, dated 08/17/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included heart failure (leads to serious and life-threatening complications), altered mental status ( a change in mental function that stems from illnesses, disorders and injuries affecting your brain), and chronic obstructive pulmonary disease ( a group of diseases that cause airflow blockage and breathing-related problems). <BR/>Record review of Resident #21's Significant Change MDS assessment, dated 06/28/2023, reflected Resident # 21 had a BIMS score of 1 which indicated residents' cognition was severely impaired. Resident #21 was assessed to require assistance with ADLs. <BR/>Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2023, reflected Resident #21 had an ADL self-care performance deficit and required staff assistance. Resident #21 was at risk for falls related to weakness. Intervention: ensure the call light within reach and encourage to use the call light for assistance as needed.<BR/>Observation on 08/16/2023 at 9:40 AM revealed Resident #21 was awake and lying-in bed. Resident #21's call light was on the floor. The call button was partially under the bed. <BR/>2. Record review of Resident #31's face sheet, dated 08/11/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with muscle weakness ( when full effort does not produce a normal muscle movement), and cognitive communication deficit ( difficulty with thinking and how someone uses language), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). <BR/>Record review of Resident #31's Quarterly MDS Assessment, dated 06/28/2023, reflected Resident #31 had a BIMS score of 7 which indicated residents' cognition was severely impaired. Resident #31 was assessed to require assistance with ADLs. <BR/>Record review of Resident #31's Comprehensive Care Plan, start date of 08/11/2023, reflected Resident #31 had an ADL self-care performance deficit and required staff assistance. Resident was at risk for falls related to unsteady gait, and balance. Intervention: ensure the call light within reach and encourage to use the call light for assistance as needed.<BR/>Observation/Interview on 08/16/2023 at 10:16 AM revealed Resident #31 was lying in bed watching television. Resident #31's call light was on the floor toward the head of the bed. Resident #31 mumbled when responded to questions. <BR/>3. Record review of Resident #41's face sheet, dated 08/17/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute pulmonary embolism ( a sudden blockage in a lung artery), type two diabetes mellitus ( your body does not use insulin properly), and acute kidney failure (kidney damage that happens within a few hours or few days). <BR/>Record review of Resident #41's Quarterly MDS Assessment, dated 05/24/2023, reflected Resident #41 had a BIMS score of 8 which indicated residents' cognition was moderately impaired. Resident #41 was assessed to require assistance with dressing, walk in corridor, locomotion on and off unit, toileting, dressing, personal hygiene, and bathing. <BR/>Record review of Resident #41's Comprehensive Care Plan, dated 06/12/2023, reflected Resident #41 had an ADL self-care performance deficit related to fatigue and impaired balance. Resident was at risk for falls related to unsteady gait, and balance. Intervention: ensure the call light within reach and encourage to use the call light for assistance as needed.<BR/>Observation/Interview on 08/16/2023 at 11:10 AM revealed Resident #41 was lying in bed. His call light was on the floor between the head of bed and the wall Resident #41 stated he used the call light whenever he needed the nurses for anything. Resident stated the call light had been on floor since last night. He stated he did not need assist from the nurses last night or this morning, however, if he did require assistance, he was unable to reach the call light. <BR/>In an interview on 8/17/2023 at 2:15 PM, CNA C stated all staff were responsible to check call lights when they entered a resident's room. She stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. CNA C stated a resident may have an emergency such as choking and possibly could die. She stated the resident would not be able to yell for help. She stated there was a possibility a resident may break a bone if the resident fell during the attempt of reaching the call light. <BR/>In an interview on 8/17/2023 at 2:45 PM, LVN A stated if a resident call light was on the floor and the resident was unable to reach the call light there was a possibility a resident may fall attempting to reach the call light and break a bone. She stated it was everyone's responsibility to place the call light in reach if they observed the call light not in reach of the resident when they enter a resident's room. She stated it was difficult for residents to yell out for help if the staff was not near the residents' room. <BR/>In an interview on 8/17/2023 at 3:00 PM, CNA D stated if a residents call light was not in reach there was a possibility a resident may need assistance with anything and may attempt to reach for the call light and fall. She stated if a resident fell there was a possibility of the resident breaking a bone or hitting their head on the floor and have a bump on their head or cut on their head. <BR/>In an interview on 08/17/2023 at 3:20 PM, The Director of Nurses she expected the call lights be within reach of all residents. She stated if a call light was not in reach when a resident was in their room, the residents would not have any device to use if they needed any type of assistance. She stated some residents were able to yell, however, this was not the appropriate protocol for residents to yell for help. She also stated it was a greater risk for harm if the residents did not have the call light within reach such as falling and breaking a bone. The Director of Nurses stated the nurse supervisor was responsible to monitor CNAs and to ensure call lights were within reach. <BR/>In an interview on 08/17/2023 at 3:50 PM the Administrator stated all staff were responsible for checking call lights whey they entered a resident's room. He stated he expected all call lights placed within reach of the residents. He stated if the resident was lying in bed and the call light was on the floor the resident had a potential of falling and breaking a bone or have some type of head injury if the resident attempted to reach for the call light. The Administrator stated a resident may need immediate help from the staff and would not be able to call for help by using the call light. He also stated not all residents could yell for assistance. <BR/>Record Review of the facility's Policy on Call Lights dated 02/23 reflected when a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of fifteen residents (Resident # 21, Resident #18, Resident #31 and Resident #13) reviewed for quality of life. <BR/>The facility failed to ensure Resident#21s, Resident #18's, Resident #31's, and Resident #13's fingernails were trimmed and cleaned.<BR/>These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life.<BR/>Findings included: <BR/>1. Record review of Resident #21's face sheet, dated 08/17/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis was characterized by one-sided weakness, but without complete paralysis), altered mental status ( a change in mental function that stems from illnesses, disorders and injuries affecting your brain), and unspecified convulsions ( rapid involuntary muscle contractions). <BR/>Record review of Resident #21's Significant Change MDS assessment, dated 06/28/2023, reflected Resident # 21 had a BIMS score of 1 which indicated residents' cognition was severely impaired. Resident #21 was assessed to require assistance with ADLs. He required extensive assistance with two person assist with personal hygiene. Resident #21 did not reject care.<BR/>Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2023, reflected Resident #21 had an ADL self-care performance deficit and required staff assistance. Intervention: Resident #21 required staff assistance with personal hygiene. Resident #21 had impaired cognitive function. <BR/>Observation on 08/16/2023 at 9:40 AM revealed Resident #21 was awake and lying-in bed. Resident #21 had long jagged fingernails on his left and right hands. <BR/>2. Record review of Resident #18's face sheet, dated 08/17/2023, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included type two diabetes mellitus (high levels of sugar in the blood), hemiplegia unspecified (involved one sided paralysis- the loss or the ability to move), muscle weakness (lack of muscle strength), and unspecified dementia (experiencing memory loss, poor judgement, and confusion).<BR/>Record review of Resident #18's assessment, dated 07/19/2023, reflected Resident # 18 was rarely/ never understood. Resident #18's cognition was assessed by the staff. She had poor short- and long-term memory recall. Resident #18's decision making ability was severely impaired. She did not reject care. Resident #18 was assessed to be totally dependent on staff for personal hygiene, toileting, dressing, and bed mobility.<BR/>Record review of Resident #18's Comprehensive Care Plan, dated 08/09/2023, reflected Resident #18 had an ADL self-care performance deficit. Intervention: Check nail length. Trim and clean on bath day and as necessary. Report any changes to the nurse. Resident #18 required staff assistance with personal hygiene. Resident #18 had impaired cognitive function; impaired thought process related to dementia. Resident #18 had a potential for skin tears related to fragile skin. <BR/>Observation on 08/16/2023 at 10:00 AM revealed Resident #18 was lying in bed. Her fingernails on her middle, forefinger, and ring finger on both hands were jagged. There was a blackish substance underneath her middle and ring finger on her left hand. <BR/>3. Record review of Resident #31's face sheet, dated 08/17/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease ( paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without paralysis), muscle weakness ( when full effort does not produce a normal muscle movement), and cognitive communication deficit ( difficulty with thinking and how someone uses language). <BR/>Record review of Resident #31's Quarterly MDS Assessment, dated 06/28/2023, reflected Resident #31 had a BIMS score of 7 which indicated residents' cognition was severely impaired. Resident #31 was assessed to require assistance with ADLs. He required extensive assistance with two person assist with personal hygiene. Resident #31 did not reject care.<BR/>Record review of Resident #31's Comprehensive Care Plan, start date of 08/17/2023, reflected Resident #31 had an ADL self-care performance deficit and required staff assistance. Intervention: Resident #31 required staff assistance with personal hygiene. Resident #31 had impaired cognitive function. <BR/>Observation/Interview on 08/16/2023 at 10:16 AM revealed Resident #31 was lying in bed watching television. His fingernails on right and left hand were jagged. Resident #31's fore finger, middle finger, and ring finger on both hands had blackish/brownish substance underneath the nails. Resident #31 was not interview able. Resident #31 mumbled when responded to questions.<BR/>4. Record review of Resident #13's face sheet, dated 08/17/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type two diabetes mellitus (high levels of sugar in the blood), muscle weakness (when full effort does not produce a normal muscle movement), and osteoarthritis, unspecified site (inflammation of one or more joints. It is the most common of arthritis that affects joints in the hand, spine, knees, and hips). <BR/>Record review of Resident #13's Quarterly MDS Assessment, dated 06/14/2023, reflected Resident #13 had a BIMS score of 2 which indicated residents' cognition was severely impaired. Resident #13 was assessed to require one staff assistance with ADLs. Resident #13 did not reject care.<BR/>Record review of Resident #13's Comprehensive Care Plan, dated 06/23/2023, reflected Resident #13 had an ADL self-care performance deficit related to fatigue, and impaired balance. Intervention: check nail length, trim and clean nails on bath day and as necessary. Report any changes to the nurse. Resident #13 required staff assistance with personal hygiene. Resident #13 had impaired through processes related to dementia (the loss of thinking, remembering and reasoning).<BR/>Observation/Interview on 08/16/2023 at 10:45 AM revealed Resident #13 was sitting in the dining room at a table by himself and was watching people. He agreed to exit the dining room and meet in a private area. Resident #13's fingernails on right and left hand were jagged and had thick blackish substance underneath each nail on both hands. Resident #13 stated my nails are dirty and he stated he did not know what the black substance was underneath his nails. Resident #13 stated it looked like feces. He stated when he tries to clean himself, he gets feces on his hands, and he was unable to clean his nails. He stated he did ask someone to clean them, but he did not recall the person's name. Resident #13 said he asked someone several times last week and this week. <BR/>Observation/Interview on 08/17/2023 at 1:15 PM revealed Resident #13 was sitting in the dining room. Resident #13's nails on his right and left hand had a hard blackish substance underneath each nail. Resident #13 smiled and stated, I got my toenails cut you want to see them. Resident #13 stated the doctor cut his toenails today and he stated he asked the doctor if they would cut his fingernails and clean them and the doctor stated he did not cut or clean fingernails only toenails. He stated he did ask someone today but could not recall their name to clean his fingernails and cut them and the person said his nails would be clean and cut tomorrow. <BR/>In an interview on 8/17/2023 at 2:15 PM, CNA C stated the nurses were responsible for diabetic nail care. She stated the CNAs were responsible for all other resident's nail care such as cleaning , trimming and possibly filing the nails. She stated nail care was usually completed during showers or as needed. She stated nail care was to be completed daily if a resident's nails were dirty or needed to be trimmed. She stated if a resident had a blackish/brownish substance underneath their nails it could be any type of bacteria. CNA C stated there was a possibility a resident may eat with their hands and the blackish substance may transfer from residents' hands to the food. She stated the resident may become physically ill with some type of stomach problems such a vomiting or diarrhea. She stated it was a possibility a resident may need to be assessed at a hospital if it was severe. CNA C stated if a residents' nails were rough there was a possibility a resident may scratch themselves and develop a skin tear or could scratch their eyes. She stated there was a potential a resident may develop and infection in their eyes. She stated she had been in serviced to clean and trim residents' nails in the shower and/or as needed except for diabetic nails. She stated she did not recall when the last in-service on nail care was given by nurse supervisors. <BR/>In an interview on 8/17/2023 at 2: 30 PM, CNA /MA E stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed, and cleaned nails during showers , however, the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA/MA E stated the nursing staff was expected to clean and trim residents' nails immediately if there were blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. She stated if the nursing staff waited until shower the resident had potential of skin tears because of the residents scratching themselves. said it was a possibility the resident may get an infection from the skin tear. said the blackish substance possibly may be fecal matter underneath the residents' nails. She stated a resident may become physically ill with an intestinal problem and may need to be admitted to the hospital.<BR/>In an interview on 8/17/2023 at 2:45 PM, LVN A stated it was the nurses and CNAs responsibility to trim, cut and clean residents' fingernails. She stated only the nurses can trim and clean residents with diagnosis of diabetes. LVN A stated if a resident's nails were jagged there was a possibility a resident my infect their skin if the resident scratched themselves and develop a skin tear. LVN A stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. She stated if a resident placed their finger in their mouth the feces could transfer from their fingers to their mouth. LVN A also stated if the resident swallowed the feces or other bacteria a resident may develop a stomach infection such as E coli (eating contaminated food) and the resident would require to be hospitalized . She stated the symptoms of a stomach infection may include the following: diarrhea, vomiting and/or loss of appetite. <BR/>In an interview on 8/17/2023 at 3:00 PM, CNA D stated the nurses was responsible to trim and clean all diabetics nails. She stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated the CNAs usually did nail care when residents received a shower or as needed. CNA D stated if anyone observed a brownish and/or blackish substance underneath residents nails the staff was expected to clean the residents' nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the residents' nails. CNA D stated if a resident swallowed the bacteria there was a possibility a resident may become very ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. CNA D stated if a residents' nails were long or rough a resident may scratch themselves or another resident and cause a skin tear or they could get their nails caught on something and pull the nail off and cause an infection on the finger. She stated she had been assigned to in the past . She did not recall how many times she had been assigned to these residents. Resident # 21, Resident #18, Resident #31, and Resident #13. CNA D stated she was not aware of any of these residents refusing nail care. <BR/>In an interview on 08/17/2023 at 3:20 PM, the Director of Nurses stated if a resident had dirty nails there was a possibility bacteria could be on their fingers and/or underneath the resident's nails. She stated there was a potential a resident could ingest bacteria from their fingernails into their mouth. She stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. The Director of Nurses stated a resident potentially could become ill with stomach issues or any type of infection. She also stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection if the residents' nails were not trimmed properly. She stated it was the nurse supervisor responsibility to monitor nursing staff to ensure residents were receiving proper nail care.<BR/>In an interview on 08/17/2023 at 3:50 PM, the Administrator stated the residents' nail care was the CNAs responsibility. He stated if a resident was a diabetic it was the nurse's responsibility. The Administrator stated nail care was expected to be taken care of when nails were visibly dirty or needed to be trimmed. He stated if the blackish substance was a certain type of bacterial a resident may become physically ill. He stated there was a possibility a resident may require medical care from the hospital and that depended on what type of bacteria a resident may ingest. He said it was the nurse supervisor's responsibility to monitor residents nail care. <BR/>Record Review of the facility's Policy on The Care of Fingernails/Toenails dated 4/23 reflected the purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Only licensed personnel can perform nail care on a resident with diabetes. <BR/>1. Nail care includes daily cleaning and regular trimming.<BR/>2. Proper nail care can aid in the prevention of skin problems around the nail bed.<BR/>3. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 2 of 2 Residents (Resident #20 and #29) reviewed for respiratory care.<BR/>The facility failed to ensure that Resident #29's suction equipment was properly cleaned and dated.<BR/>1. Failed to date suction tubing and canister. <BR/>2. Failed to bag yaunker.<BR/>3. Failed to clean suction tubing.<BR/>The facility failed to replace Resident #20's oxygen tubing.<BR/>These failures could place residents at risk for respiratory compromise and infection.<BR/>Findings included:<BR/>Review of Resident #29's Face Sheet dated 08/17/2023 revealed that he was a [AGE] year old male, with an initial admit date of 10/15/2018 and secondary admission date of 10/20/2022. His diagnoses included Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), Dysphagia (difficulty swallowing - taking more time and effort to move food or liquid from your mouth to your stomach), Pneumonitis (inflammation of lung tissue), Dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Cough. <BR/>Review of Resident #29's MDS Quarterly Assessment, dated 07/06/2023 revealed Resident #29 had a BIMS Score of 12, which indicated his cognitive status was moderately impaired.<BR/>Review of Resident #29's Care Plan, dated 10/20/22 indicated, Focus - Resident to have suction machine at bedside. Goal - Resident to remain free of increase secretions. Interventions / Tasks - Suction Resident as needed for increase secretions. <BR/>Review of Resident #29's Order Summary Report dated 08/18/2023, indicated that the suction canister and tubing were to be changed every three days when in use by night shift. Order was made and started on 08/18/2023. <BR/>Review of Resident #29's TAR from 08/01/2023 - 08/17/2023 through the facility's Point Click Care indicated no documentation in reference to the cleaning / documentation for Resident #29's suction machine. Review indicated there was no order for cleaning / changing suction canister / tubing prior to surveyor intervention. <BR/>Review of physician's orders for Resident #29 dated 8/01/23 reflected no mention of cleaning/changing suction canister, tubingh or Yaunkauer prior to questions from surveyor.<BR/>Review of the face sheet dated 8/11/23 for Resident #20 reflected she was admitted on [DATE] with diagnoses of Multiple Sclerosis, Anemia, other specified Anxiety Disorders, Intracerebral Hemorrhage, Asthma, Neuropathic bladder, Scoliosis and Repeated Falls.<BR/>Review of the MDS annual assessment for Resident #20 dated 5/17/23 reflected a BIMS score of 4 which indicated her cognitive function was severely impaired. Her functional assessment reflected the resident required extensive assistance for all ADLs except mobilizing in her wheelchair and eating. The assessment of her bowel and bladder function reflected she was frequently incontinent.<BR/>Review of the Care Plan dated 8/05/23 for Resident #20 reflected interventions were in place for: DNR status, Insomnia, ADL self-care deficits, Hospice Care, Fall Risk, Psychotropic Medications, MS and Scoliosis. Her plan reflected she should have oxygen therapy of 2 L/min to keep her saturation above 95 %.<BR/>Review of Daily Oxygen Saturation levels for Resident #20 dated from 8/11/23 to 5/31/23 reflected her saturation varied from 96 to 97 %.<BR/>Review of physician's orders for Resident #20 reflected she had oxygen therapy ordered at 2L/min as needed for shortness of breath dated 8/02/23.<BR/>Observation on 08/16/2023 at 9:59 AM, Resident #29's suction machine was uncovered on a tray table to right of the resident's bed. There was no date located on the tubing or cannister, the yankauer (rigid suction tip used to aspirate secretions from the oropharynx) was not bagged, and there was visible black and green substance growing in several locations on the inside of the tubing. <BR/>Observation on 08/17/2023 at 9:22 AM, Resident #29's suction machine was still uncovered, with no date located on the tubing or cannister, the yankauer remain uncovered, and a black and green substance was still present in the tubing.<BR/>Observation on 8/16/23 at 9:45 AM revealed Resident #20's oxygen tubing was dated and labeled 7/10/23. Resident #20 was wearing her oxygen tubing while sitting up in bed. In an interview Resident #20 stated she was comfortable but was unable to answer most questions appropriately.<BR/>In an interview on 8/16/23 at 10:10 AM, LVN E stated Resident #20's oxygen use was periodic, she stated Resident #20 had periodic drops in her oxygen saturation level.<BR/>Observation on 8/17/23 at 9:15 AM revealed Resident #20's oxygen tubing had been exchanged and was now dated 8/16/23.<BR/>In an interview on 08/17/2023 at 1:14 PM, LVN A, stated that she has worked at the facility for over four years in total. LVN A observed the suction machine in the room of Resident #29. LVN A stated that the yankauer should be bagged. LVN A stated that the suction tubing should be dated and changed weekly. LVN A stated that the cannister and tubing to the machine should be dated and changed monthly. LVN A stated that the tubing was supposed to be checked daily and that this obviously slipped through the cracks. LVN A stated that checks of the resident's suction machine were to be logged weekly in the TAR (Treatment Administration Record) . LVN A stated that this failure could result in respiratory infection.<BR/>In an Interview on 08/17/2023 at 2:04 PM, LVN A pulled up the TAR for Resident #29. LVN A checked the system and stated that she was incorrect and that it was not documented. LVN A stated that it would not be logged because it was PRN (as needed) by Resident #29.<BR/>In an interview on 08/17/2023 at 1:22 PM, the DON observed the suction machine in the room of Resident #29. The DON immediately stated that it was not correct. The DON stated that it should be bagged and that both the cannister and tubing were supposed to be dated. The DON stated that the suction tubing should be dated and replaced weekly, with the cannister begin dated and replaced monthly. The DON observed the green and black substance in the suction line and stated that procedures had not been followed. The DON stated that the suction machine was being removed immediately and cleaned. The Resident #29 indicated that he needed the suction machine and was advised that it would be returned in clean condition shortly. <BR/>In an interview on 08/18/2023 at 8:00 AM, the DON approached surveyor and stated that the cleaning of Resident #29's suction machine was not being logged in the TAR. <BR/>In an interview on 8/18/23 at 8:35 am, LVN G stated since she had been working at the facility Resident #20 had not needed to use her Oxygen prescribed. LVN G stated Resident #20 was up and about every day without supplemental Oxygen. She stated Resident #20 had not required Oxygen to keep her saturation levels up to normal (95 percent or higher) since she started working at the facility.<BR/>In an interview on 08/18/2023 at 8:38 AM, Resident #29 (cognitive with limited speech) acknowledged that he was aware that the suction machine was dirty. Resident #29 indicated that he did not notify medical staff of its condition.<BR/>Review of the facility's policy, Health for Respiratory Care Equipment Use, dated 10/22, Procedures: 5. Disposable respiratory care supplies will be used whenever possible. If disposable equipment is not available, all reusable equipment will e sterilized or disinfected according to manufacturer's instructions. 6. All non-disposable equipment should be cleaned and decontaminated or sterilized according to the manufacturer's instructions. 7. Re-usable equipment will be cleaned according to manufacturer's instructions. 8. All clean equipment should be covered when to in use for protection against contaminants.

Based on observation, interview, and record review the facility failed to ensure that medications were stored in a locked compartment for 2 (300 Hallway) of 4 medication carts reviewed for medication storage in the facility.<BR/>The facility failed to ensure that both medication carts for the 300-hallway remained locked at all times when not in use and direct view of staff.<BR/>This failure could result in harm due to unauthorized access to medications by residents and visitors.<BR/>Findings included:<BR/>Observation on 06/12/2024 at 9:02 AM, revealed a multi-drawer, rollable medication cart that was left unlocked in front of the nurse's station in the 300 hallway. LVN A was seated in a chair behind the nurses' station working at a computer and RN C was present viewing paperwork. Two residents were seated in a common area watching television approximately twenty feet from the cart.<BR/>Observation on 06/12/2024 at 9:39 AM, revealed that the cart observed at 9:02 AM was still in the same location unlocked and now a second multi-drawer, rollable medication cart was next to it in front of the nurses' station that was also unlocked. Two staff members were present on the opposite side of the counter discussing paperwork.<BR/>Observation and interview on 06/12/2024 at 10:09 AM, revealed that both medication carts observed at 9:39 AM in front of the nurses' station in the 300 hallway were still unlocked and no staff or residents were present around them. LVN A approached the original unlocked cart and looked over at the second unlocked medication cart. LVN A engaged the lock on the second cart to secure it and then obtained medication from the first cart before locking it. LVN A stated that the two carts should not have been unlocked prior to her securing them. LVN A stated that medication carts are to be always locked if not in direct view and actively being used by staff. LVN A stated that both observed carts were considered the 300 hallway medication carts. LVN A stated that they are to keep the medication carts locked at all times to ensure that residents do not gain access to medications, which could result in illness if ingested. LVN A stated that she and RN C utilized the two 300 hallways carts this morning.<BR/>Interview on 06/12/2024 at 10:17 AM, the DON was notified of the unlocked medications carts for the 300 hallway. The DON stated that if staff are not directly in front of the medication cart they are to be locked at all times. The DON stated that the facility has residents with Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) as well as visitors who could gain unauthorized access to medications if the carts are not locked. The DON stated that if someone ingested medications that were not theirs it could result in medical side effects. <BR/>Interview on 06/12/2024 at 10:45 AM, RN C stated that she did assist LVN A with medication pass this morning between 6:45 AM and 7:00 AM. RN C stated that she knew she locked the cart she used before turning it over to LVN A. RN C stated that medication carts were to be locked at all times when not in use or their direct view. RN C stated that the medication carts are to be locked even if they are in the area of them. RN C stated that medication carts must be locked to ensure that no residents gain access to medications, which could result in an adverse reaction. <BR/>Interview on 06/12/2024 at 2:40 PM, MA D stated that they are trained that medication carts are to be locked at all times if they are not directly in front of them working. MA D stated that as soon as they obtain the medications they need for a resident they are to close the computer screen and lock the medication cart. MA D stated that failure to do so could result in a resident getting into the cart and taking some medications, which could cause an adverse effect. <BR/>Interview on 06/12/2024 at 2:50 PM, LVN B stated that they are trained that medication carts are to be locked at all times when not directly in front of them. LVN B stated that medication carts have to remain locked to ensure that residents do not gain access to medications that are not theirs, which could lead to an allergic reaction. <BR/>Follow-up interview on 06/12/2024 at 4:00 PM, the DON stated that the facility has four medications carts, which contain medications for their residents. The DON stated that the 300 hallway does have two of the four medication carts, which she audited after notification and found no evidence of drug diversion.<BR/>Interview on 06/12/2024 at 4:23 PM, the Interim Administrator stated that medication carts are to be locked immediately after use and if not directly in front of staff. The Interim Administrator stated that failure to lock medication carts could lead to a resident gaining access to medications resulting in a possible adverse reaction.<BR/>Review of the facility's Drug Diversion Policy dated 2024 revealed, Policy: This facility recognizes the risks for contamination and infection associated with diversion of injectable medications and monitors staff with access to injectable controlled substances to prevent transmission of infections. Definitions: Drug diversion refers to the theft or other deviation that removes a prescription drug from its intended path from the manufacturer to the patient. Policy Explanation and Compliance Guidelines: 1. All drugs and biologicals, including controlled substances, are stored in locked compartments and only authorized personnel have access to the keys to locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). 2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications, including documentation and disposition of medications.

Based on observation, interview, and record review, the facility failed to ensure that menus were developed and followed to meet resident nutritional, religious, cultural, or ethnic needs, and resident choices in accordance with the national guidelines for one of one facility.<BR/>The facility failed to provide residents in the facility with a varied menu, having utilized the same menu for the facility for over a year.<BR/>This failure could place the residents in the facility at risk of reduced appetite resulting in their nutritional needs not being met and / or weight loss. <BR/>Findings included:<BR/>Observation on 08/16/2023 at 9:01 AM, revealed the menu board outside the dining area contained no information as to kitchen menus for the day, week, or month.<BR/>In a confidential group interview on 08/16/2023 at 2:40 PM, all eight resident attendees stated they were tired of the same menu being served in the facility every week. Residents stated that they were given a copy of the menu and that one has not been posted outside the dining area for over a year. Residents stated they were told they would have a new menu provided to them, but the facility has failed to implement one.<BR/>In an interview on 08/17/23 at 11:05 AM, the DM was requested to provide menus that have been served by the facility since 08/17/2022. The DM stated that there has only been one menu in the facility since she started on 10/15/22. The DM provided surveyor with the facility's Patient Menu Regular Diet Nutrition Services Menu. The DM stated that they do have their alternate choices, but the menu has remained unchanged. The DM stated that she has gone to the Administrator and discussed her desire to have the menu updated and changed. The DM stated she was advised the menu was going to change this month but did not. The DM stated the menu they serve at the facility was created for the hospital and should not be the same for the residents of the facility due to the duration of their stay. The DM stated that the kitchen provides food service off the menu for the hospital. The DM stated she was aware that residents have complained and continue to complain about the lack of variety. Surveyor referenced hearing a resident complain on 08/16/2023 about mashed potatoes instead of french fries. The DM stated that mashed potatoes were listed on the menu and that they were providing french fries that were ordered on accident but ran out. <BR/>In an interview on 08/18/2023 at 9:23 AM, the AD stated that the menu in the facility has been brought up numerous times in Resident Council. The AD stated that the current menu being served to residents has been served for more than a year. The AD stated that the menu was supposed to change in June but did not. The AD stated that she was then advised that it would change in August but has not as of this date. The AD stated that she does not believe that facility residents should have the same meals for the length of time they have and felt it was due to a shared menu with the hospital.<BR/>In an interview on 08/18/2023 at 9:40 AM, the Administrator confirmed that they have utilized the same menu for approximately one year. The Administrator stated that use of the current menu was a decision made above him, but he can understand why the residents would be upset eating the same meals every week for as long as they have. <BR/>Review of the undated menu contained a weekly menu for breakfast, lunch, and dinner. Personal Choices were included on the menu, which did not show french fries as a choice. Menu reflected the same dinner of beef stew, dinner roll, green peas, and grapes on Tuesday and Saturday every week. <BR/>Review of Resident Council minutes dated 05/25/2025 at 2:00 PM (seven residents in attendance), indicated for Dietary: changing menus in Aug. Minutes dated 7/26/2023 at 2:00 PM (four residents in attendance), indicated for Dietary: Ready for new menus .food is tolerate sometimes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review the facility failed to ensure 1 of 12 residents (Resident #25) was treated with dignity and respect.<BR/>The facility failed to protect the dignity of Resident #25 by taking him to the dining room dressed only in a hospital gown without any other covering or clothing.<BR/>This failure exposed the resident to decreased feelings of self-worth, increased risk of mental health issues and psychosocial harm. <BR/>Findings include:<BR/>Review of the Face Sheet for Resident #25 reflected he was admitted on [DATE] with diagnosis of: cerebral infarction (Also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Anxiety disorder, other stimulant abuse, Hyperlipidemia (high cholesterol), hemiplegia (paralysis of one side of the body), toxic encephalopathy ( brain dysfunction caused by toxic exposure), dysphagia (difficulty swallowing), gastrostomy (a surgical operation for making an opening in the stomach), HTN (elevated blood pressure). <BR/>Review of the quarterly MDS assessment dated [DATE] for Resident #25 reflected a BIMS score of 3 indicating severe cognitive impairment. His functional assessment reflected he required extensive assistance for all ADLs. He was assessed as always incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #25 reflected interventions were in place for: Full Code Status, ADL performance Deficit, Confusion/Impaired Cognitive status following stroke, Behavior Problems- kicking, biting, aggressive behavior r/t severe confusion, Actual Falls, Tube Feedings, Anticoagulant Therapy, Psychotropic Medications.<BR/>In an observation on 6/07/2022 at 11:40 AM during lunchtime in the dining room reflected Resident #25 to be in the dining room in geriatric chair (a large, padded chair that is designed to help seniors with limited mobility) and hospital gown with no blanket to cover his legs. At 12:08 pm Resident #25 was observed pushing his chair away from table. <BR/>An observation and interview on 06/07/2022 at 12:15 PM reflected Resident #25 returned to his room by DON. The DON stated Resident requested to return to his room to eat.<BR/>An observation on 06/07/2022 at 12:24 PM reflected Resident #25 seated in his room in geriatric chair with no tray served.<BR/>An observation on 06/07/2022 at 12:28 PM reflected a tray delivered to Resident #25's room and DON assisted with set up. Resident #25 remained dressed in hospital gown.<BR/>In an interview on 6/07/22 at 1:09 PM LVN D stated she did not know why Resident #25 was dressed in a hospital gown. She stated he was uncooperative with care at times and would refuse care. <BR/>In an interview on 6/08/22 at 2:22 PM LVN F stated she had experienced different behaviors when providing care for Resident #25. She stated he had never refused to wear clothing or get dressed. She stated he would be aggressive or resist care if it was opposite of what he wanted. She stated when he was sliding down in his chair he did not want to be pulled up. LVN F stated Resident #25 needed a lot of assistance with ADLs except eating, he could feed himself with a spoon.<BR/>In an interview on 6/08/22 at 2:27 PM CNA S stated she had never experienced Resident #25 refusing to get dressed. CNA S stated Resident #25 would be ready to go to the dining room the moment you asked him if he wanted to eat. She stated he really likes food. She stated he could be aggressive when he did not want care, he would refuse to get back to bed and refuse showers. She stated when she told him it was time to get dressed, he normally cooperated.<BR/>In an interview on 6/09/22 at 7:50 AM LVN E stated Resident #25 had not refused or resisted care for her. She stated Resident #25 liked to stay in his room and did not want people bothering him. She stated he was easy to work with. <BR/>In an interview on 6/09/22 at 8:37 AM Resident #25's RP stated she had a few concerns with staff when he was first admitted . She stated nurses were stand-off-ish and not as caring. RP stated Resident #25 had been dressed on her visits to the facility and she would normally inform the facility in advance she was coming to visit. The RP stated she hoped to move Resident #25 closer to home in another facility soon.<BR/>In an interview on 6/09/22 at 9:50 AM the DON stated Resident #25 should not have been brought to the dining room in a hospital gown. She stated by lunch time he should have been appropriately dressed for the day. She stated he had no behaviors of refusing to get dressed, he had behaviors of crying and looking for his family.<BR/>In an interview on 6/09/22 at 11:03 AM the Administrator stated Resident #25 had his dignity violated when he was taken to the dining room in a hospital gown. He stated staff could not give an explanation for why Resident #25 was dressed only in a hospital gown and Resident #25 was not interviewable. He stated there was no excuse for the lapse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #45) reviewed for care plan revision. <BR/>Based on interviews and record review the facility failed to update the care plan of Resident #45 to reflect services to maintain the residents's highest practicable well being.<BR/>The facility failure place Resident #45 at risk for his physical, medical and social needs not being met and risk of further weight loss.<BR/>Findings include:<BR/>Review of the Face sheet for Resident #45 reflected he was admitted on [DATE] with diagnosis of: Unspecified Dementia, Hypothyroidism (thyroid doesn't create and release enough thyroid hormone into your bloodstream), Secondary Parkinsonism (a term used to describe the collection of signs and symptoms found in Parkinson's disease), Mood Disorder, Type 2 Diabetes, History of falls, and Depression Unspecified.<BR/>Review of the MDS admission assessment for Resident #45 dated 5/11/22 reflected a BIMS score of 8, indicating severe cognitive impairment. Review of the functional assessment reflected he required extensive assistance for all ADLs. He was assessed as frequently incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #45 reflected interventions were in place for: Full Code Status, ADL self-performance deficit, Impaired Cognitive Function, Diabetes, Hypothyroidism, An actual fall, Antidepressant medication, Mood disorder (Depression, Parkinson's r/t eating and mobility.)<BR/>In an interview on 6/08/22 at 2:22 pm LVN D stated an updated Care plan should be completed for new developments on the day ordered. She stated nurses would enter the Baseline Care Plan into the computer, print it out and put it in the Resident binder. <BR/>In an interview on 6/09/22 at 9:45 am LVN E stated Resident #45 had lost weight since his admission. She stated a significant weight change should be included in a Resident's Care Plan. She reviewed his records and confirmed his weight change was from 172.0 down to 156.0 lbs. She stated Resident had Med Pass (a protein and high calorie supplement given with his medications) and health shakes. She stated Resident #45 was to be monitored for his oral intake and was checked daily for weight . LVN E stated any charge nurse could alter the Resident's Care Plan. She stated other members of the Care Team can also update interventions. LVN E stated Resident #45 had been cooperative with staff providing his care.<BR/>In an interview on 6/09/22 at 9:50 am the DON stated Resident #45 should have his Care Plan updated to include his weight loss and the measures ordered by his physician . The DON stated Resident #45 was a recent admission [DATE]) and his weight loss was still being evaluated. She stated the weight loss of 9.3 percent was noted and his care updated. The DON stated she was not sure when his next dietary evaluation would be done, one was done on admission .<BR/>In an interview on 6/09/22 at 10:15 CNA K stated in working with Resident #45 the resident had not refused care. He stated Resident #45 was cooperative with his requests .<BR/>In an interview on 6/09/22 at 11:03 am the Administrator stated he would expect staff to follow guidelines and update Care Plans appropriately. He stated the MDS coordinator had been out with serious illness for two weeks and the corporate MDS person was trying to catch up.<BR/>In an interview on 6/09/22 at 1:35 pm the MDS Coordinator stated Resident #45 should have his Care Plan updated when a weight loss was reported. She stated the physician ordered interventions and dietary supplements would be added to his care plan as soon as possible. <BR/>In an interview on 6/09/22 at 1:35 pm the Nurse Practitioner for Resident #45 stated the Resident was just not willing to eat enough. She stated the facility was offering Health Shakes and supplements but he was not taking in enough. The Nurse Practitioner stated the resident's RP was bringing in home cooked food but he was also refusing that. She stated she would continue monitoring Resident #45, but he could not be forced to eat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received food that accommodates resident preferences for one resident (Residents #6) out of four reviewed for food preferences. <BR/>The facility failed to provide Resident #6 with full portions at meals which resulted in Resident #6 experiencing increased hunger symptoms and feelings of starvation while Resident #6 was being treated for a health problem that required treatment with a high dose appetite stimulant from January 2022 to June 2022. <BR/>This failure could place residents at risk for denial of food preferences, increased hunger and dissatisfaction.<BR/>Findings included:<BR/>Review of Resident #6 face sheet dated 06/08/2022 revealed Resident #6 to be a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of asthma, diabetes mellitus, high blood pressure, edema of lower limbs (swelling), schizophrenia (a psychological disorder that affects a person's ability to think, feel, and behave clearly) and other uterine bleeding. <BR/>Review of Resident #6 quarterly MDS assessment dated [DATE] revealed Resident #6 had a BIMS score of 14 to indicate resident was cognitively intact. Resident #6 required supervision and set-up assistance with eating. Resident #6 was noted to require a therapeutic diet. <BR/>Review of Resident #6 Care Plan dated 06/08/2022 revealed Resident #6 to receive diet per MD order. See current orders with a goal the resident will maintain adequate nutritional status through the review date. Interventions included proved provide and serve diet as ordered, RD to evaluate and make diet change recommendations as needed and weigh per order. <BR/>Review of Resident #6 physician orders dated 12/05/2021 revealed Resident #6 diet order to be low concentrated sweets, regular texture, regular consistency with no additional instructions or modifications. Resident #6 physician ordered diet order was had not changed since admission on [DATE].<BR/>Review of Resident #6 admission Nutrition Assessment completed by RD dated 12/09/2021 revealed Resident #6 to consume greater than 75% meals and Resident #6 would greatly benefit from weight loss. It was noted Resident #6 was on Megace which is typically an appetite stimulant, however is prescribed for other health reasons. Shame it increases appetite in this instance. It noted the goal: weight loss of two pounds per week to BMI less than 30.<BR/>Review of Resident #6 Monthly Nutrition Assessment completed by RD dated 01/06/2022 revealed RD has asked kitchen manager if calorie cap can be placed on LCS diet. For now, recommend current POC with goal of slow weight loss to BMI less than 30. <BR/>Review of Resident #6 Monthly Nutrition Assessment completed by RD dated 02/03/2022 revealed Resident #6 to have stable weight would greatly benefit from weight loss. Recommend continue current POC for weight loss. It was noted Resident #6 was on Megace, not as a supplement but definitely keeps up appetite.<BR/>Review of Resident #6 Monthly Nutrition Assessment completed by RD dated 02/22/2022 revealed RD noted Resident #6 to have gained 12.2 pounds in 1 month and Resident #6 was on &frac34; portion size per the kitchen. The assessment further noted edema is noted, but oral intake is also always consumed at greater than 75% (likely 100%) and per kitchen, patient is always asking for extra snacks. For now recommend current POC. If weight continues to increase perhaps &frac12; serving sizes would be better. <BR/>In an interview on 06/07/2022 at 10:30 AM, Resident #6 stated she did not get enough to eat and was hungry all the time. She said they started giving her less food and now she eats a lot of snacks because she was hungry all the time. She said she mainly eats graham crackers all day and then a sandwich before bed. She said she needed 5 small meals per day and not three small meals with snacks in between. She said she needed surgery for a hernia and a hysterectomy for bleeding from her uterus. She said she was waiting to be cleared by her cardiologist and pulmonologist before she could have the surgeries. <BR/>In an observation and record review on 06/07/2022 at 12:40 PM, Resident #6's meal tray observed to be empty of food with no residuals from the meal. Resident #6's meal ticket observed on the tray with the diet order listed as low concentrated sweets regular, small portions for lunch Tuesday 06/07/2022. Portions were as follows for the lunch meal:<BR/>Balsamic Chicken breast &frac34; each<BR/>Baked Potato 4/10 each<BR/>Buttered Zucchini 3 Fl Oz<BR/>Whole Wheat Dinner Roll 1 each portion control<BR/>Margarine 1 each portion control<BR/>Banana Cream Pie &frac12; each portion control<BR/>2% milk 8 Fl Oz portion control<BR/>Unsweetened Iced Tea 8 Fl Oz portion control<BR/>Sour Cream 2 &frac14; tsp dipper<BR/>In an interview on 06/07/2022 at 12:45 PM, RP G stated Resident #6 received small portions at all meals and the portions were tiny. She said she ate lunch with her frequently and would request a meal from the hospital which has the same food as the nursing facility. She said the portion she received was double the portion Resident #6 received. She said one day Resident #6 received a half a piece of lasagna, small side salad like five leaves of lettuce and a half a piece of bread. She said it was not enough food to feed a small child much less an adult. She said Resident #6 had a heart attack and needed to eat healthier but starving her was not the answer especially since Resident #6 ate more snacks because she was not receiving enough food. She said they had not spoken with anyone at facility regarding portion sizes. She did not know why Resident #6 had smaller portions compared with her roommate's tray. <BR/>In an interview on 06/07/2022 at 12:48 PM, Resident #6 stated she felt hungry after eating and did not feel full. She said she would probably be eating graham crackers all afternoon. <BR/>In an interview on 06/07/22 at 12:52 PM CNA B stated Resident #6 did complain about feeling hungry a lot. She said they gave her snacks like graham crackers, cheese and fruit. She said she was aware of her having smaller portions to help her lose weight but was not sure who ordered the smaller portions and when the smaller portions started. She said she did not tell anyone or alert anyone to Resident #6 feeling hungry a lot, she said the nurse's were aware of it and would give her snacks too. <BR/>Record review of physician orders dated 03/04/2022 revealed Resident #6 ordered Megestrol Acetate Tablet 40 MG with instructions to give four tablets by mouth two times per day due to uterine bleeding. <BR/>In an interview on 06/07/2022 at 3:30 PM, the DON stated after reviewing Resident #6's EMR that she did not see a physician order for the smaller portions for Resident #6. She stated she would look for the handwritten order and figure out why it was not in the EMR. She stated the Megestrol Acetate was an appetite stimulant as well used to stop uterine bleeding. She said she did not know why portions sizes were reduced while Resident #6 was being treated for the uterine bleeding with an appetite stimulant. <BR/>In an interview on 06/08/2022 at 8:50 AM DON stated she spoke with NP C who told the DON, she did not order the smaller portions and that the dietitian made the change. She said they changed her back to full portions today. She said the DM said he received the order for smaller portions from the RD.<BR/>In an interview on 06/08/2022 at 2:35 PM NP C said she did not write an order for reduced portions and neither did Resident #6's attending physician. She said she believed the RD wrote in recommendations at one point for reduced portions and the DM made the change. She said she did not order the reduced portions due to Resident #6 being treated with Megace and it is an appetite stimulant. She said Resident #6 would continue the Megace until she had the hysterectomy. She said the priority was to stop Resident #6 from bleeding not lose weight until after the hysterectomy. She said the Megace and decreased portions would have caused Resident #6 to experience increased hunger symptoms and discomfort from it. <BR/>In an interview on 06/08/22 at 3:00 PM LVN A stated the process for diet order change was after the MD or NP gave an order they write it on a triplicate form (used by the kitchen) and give the yellow slip to the DM. She said they make the diet order change in the EMR and file the form in the resident's chart. She said she did not see a written diet order form change for Resident #6 in her paper chart and there was no change in the EMR regarding the smaller portions. She said Resident #6 did ask for snacks sometimes and reported being hungry in between meals. She said she did not know who made the change for Resident #6 for smaller portions. <BR/>In an interview on 06/09/2022 at 10:50 AM, DM said RD called him and told him to reduce portions for Resident #6 a few months ago. He said he made the change and had not heard any complaints from Resident #6. He said he had not spoken with Resident #6 regarding her diet order or the smaller portions. He said he would normally receive the yellow slip from the dietary form with order changes from the nurse . He made the change in the dietary system. He said he conducted dietary assessments with residents to ensure their preferences were honored as much as possible. He stated he was not aware that Resident #6 required snacks between meals due to smaller portions or that Resident #6 was on a medication that increased her appetite. <BR/>In an interview on 06/09/2022 at 11:00 AM the ADMIN stated the RD can make diet order changes like reducing portions and it would have been his expectation for either the DM or RD to check effectiveness of the intervention with Resident #6. He stated Resident #6's increased hunger and preference for larger portions should have been honored. <BR/>In an interview on 06/09/2022 at 11:32 AM the RD stated she was concerned about Resident #6 after admission because of her increase in weight. She said she was brainstorming with DM and kitchen staff about interventions for Resident #6. She suggested reduced portions because that patient (Resident #6) really needs less food. She said she did not complete an order change form or notify nursing because she did not realize DM was going to make the change. She said she didn't know why a doctor would put an obese patient on megace and had to research it to find out it was for Resident #6's uterine bleeding. She said she tried to show a list of healthier options for Resident #6 but Resident #6 ate what she wants. She said she wished the nursing staff would not give her snacks because it defeated the purpose of smaller portions to help with weight loss. She said she was not sure when the smaller portions started for Resident #6, possibly February 2022. She stated after reviewing her documentation, she wrote a note on 02/22/2022 for half portions recommended. She said this facility offers so much food on their tray and Resident #6 was still gaining weight in March 2022 and would have cut back Resident #6's portions more since the first reduction in portions was not effective. She had not spoken with Resident #6 since the portion change and did not know about the increased snacks due to increase hunger for Resident #6. She would not have recommended returning Resident #6 to full portions. She said no one at the facility told her Resident #6 was always starving or hungry all the time. She covered five facilities and the DM at each facility was supposed to follow-up with residents after interventions for concerns or complaints. She said she very rarely speaks to patients and will only speak with them directly if they or their RP requests it. She stated the DM communicates resident issues to her as needed. She makes recommendations and if an order change was needed she would communicate that to the nursing staff and MD/NP and they would change the order in the EMR. She said she could see how smaller portions for a resident on an appetite stimulant would be an ineffective intervention for Resident #6 and result in increased hunger symptoms in Resident #6. <BR/>In an interview on 06/09/2022 at 2:04 PM, the DON said the RD should have communicated to nursing staff and Resident #6's NP or MD before a change was made for Resident #6 to smaller portions. Nursing staff should have noticed the smaller portions on her meal ticket and when Resident #6 was asking for more food they should have checked whether this intervention was appropriate and effective. She said they should have taken her preference for larger portions into consideration especially with Resident #6 being prescribed the appetite stimulant for uterine bleeding. She said the DM should have followed up with Resident #6 regarding the decreased portions. She said if a resident has an issue or wanted a change in their diet order, they speak with the RD and MD and make changes as needed. <BR/>Review of Resident #6 Nutrition task amount eaten dated 05/12/2022 - 06/09/2022 revealed Resident #6 consistently ate 76-100% of meals. <BR/>Review of Nutritional Assessment policy dated April 2022 revealed the nutritional assessment as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Included in the assessment would be resident food preferences and dislikes and preferred portion sizes. Individualized care plans shall address to the extent possible the resident's personal preferences. <BR/>Review of Therapeutic Diets Policy dated April 2022 revealed therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Diet will be determined in accordance with resident's informed choices, preferences, treatment goals and wishes. The resident has the right not to comply with therapeutic diets. If the resident or the resident's representative declines the recommended therapeutic diet, the IDT team will collaborate with the resident to identify possible alternatives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide special eating equipment and utensils for residents who needed them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 (Resident #58) of 1 resident reviewed for assistive devices.<BR/>The facility failed to provide Resident #58 with built up silverware for meal consumption. <BR/>This failure put the resident at risk for inadequate intake, weight loss and malnutrition. <BR/>Findings included:<BR/>Review of Resident #58 face sheet revealed Resident #58 to be an [AGE] year old male admitted to the facility on [DATE] with a diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), high blood pressure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dysphagia (difficulty swallowing), heart disease, muscle wasting and other lack of coordination disorder (decreased strength and weakening of muscles resulting in decreased ability to move and complete tasks). <BR/>Review of Resident #58 quarterly MDS assessment dated [DATE] revealed Resident #58 to have a BIMS score of 12 to indicate moderately impaired cognition. The assessment reflected Resident #58 to require supervision and one-person physical assist when eating. <BR/>Review of Resident #58 care plan dated 06/08/2022 revealed Resident #58 to required assistance from staff with eating. Resident #58 was noted to have unplanned/unexpected weight loss related to poor food intake with interventions to include provide a divided plate with sides to assist with scooping. There was not an intervention documented to include a built-up fork and spoon on the care plan. <BR/>Review of Resident #58 physician orders dated 06/08/2022 revealed Resident #58 did not have a physician order for built-up spoon and fork. Resident #58 had a diet order dated 11/15/2018 for regular diet, regular texture and regular consistency. Resident #58 had an order dated 09/05/2020 for resident to have a divided plate with high sides to assist with scooping every day and night shift related to Parkinson's disease. <BR/>An observation on 06/07/2022 at 12:28 PM in the dining room reflected revealed Resident #58 struggled to stab a piece of chicken and a chunk of baked potato with a regular fork. Resident #58 attempted to eat a bite of chicken and the piece fell off his fork and into his lap. He attempted to stab another piece of chicken and after three tries was able to stab the piece of chicken with the fork. There was unmodified silverware observed on Resident #58's tray with a divided plate. <BR/>Review of Resident #58 meal ticket dated 06/07/2022 reflected Resident #58 required a divided plate with built-up fork and spoon. <BR/>In an interview on 06/07/2022 at 12:30 PM Resident #58 stated it was difficult to stab meat and potatoes with the unmodified fork because of Parkinson's disease. He said he had a special fork and spoon in his room and he would have to ask someone to go get them if he wanted them, but the staff were busy and he did not want to trouble them. He said if he ate in his room he had the thicker handled fork and spoon but they were sometimes not washed in between meals. He said he rarely had the built-up fork and spoon if he ate in the dining room and he ate lunch in the dining room almost every day. He said using the built-up fork and spoon made it easier and faster to eat. <BR/>In an interview on 06/07/2022 at 12:32 PM LVN E stated Resident #58's meal ticket was correct, and he was supposed to have the built-up fork and spoon at each meal. She said she would find his set and get them to him as soon as possible . She said the kitchen staff and the nurse checking the meal tickets prior to trays being passed should have ensured Resident #58 had the built-up fork and spoon. <BR/>In an observation on 06/07/2022 at 12:40 PM LVN E returned with a built-up fork and spoon with white/gray handles. She placed the fork in Resident #58's left hand. Resident #58 stabbed a piece of chicken with the built-up fork and ate it. Resident #58 stated well that was a lot easier. He was observed to finish his plate of food in less than 5 minutes. <BR/>In a follow-up interview on 06/07/2022 at 12:50 PM LVN E stated the nurse checking the diet orders and meal tickets for correct orders should have ensured the built-up fork and spoon were on his tray prior to his tray being delivered. She said she was unsure of which nurse was checking trays during lunch service today. She stated Resident #58 not having his built-up fork and spoon could result in him having decreased intake and weight loss. She said it could also cause him to have less independence in that he would need more assistance with eating. <BR/>In an interview on 06/09/2022 at 1:58 PM OTA F stated she evaluated Resident #58 in June 2021 and determined he needed the built-up fork and spoon due to his Parkinson's disease making it more difficult for him to eat. She said the extra weight and grip of the devices assisted with manipulating food to increase intake and allow for more independence. She said she had observed his tray to not have the built fork and spoon in the past. She said she had to remind staff to make sure he had them at each meal. She said she did not know why there was not a physician order for them but they were on Resident #58's meal ticket. She said after she made the recommendation the doctor or nurse practitioner signed the order and nursing staff would have added it to his physician orders and notified dietary staff of the change. She said she had checked in with him to ensure they were effective. She said she did not know why they were not on his care plan. She said not having the built-up fork and spoon available to Resident #58 could result in decreased oral intake and weight loss. <BR/>In an interview on 06/09/2022 at 2:04 PM, the DON stated it was her expectation that Resident #58 be provided the built-up fork and spoon at each meal, and it should have been included in physician orders. The DON stated to not have the devices would put Resident #58 at risk for decreased oral intake and weight loss. She said it should have been listed as an intervention on his care plan too . She said the kitchen staff were responsible for ensuring the built-up fork and spoon were on his tray and the nurse verifying the correct diet order should have checked it too. <BR/>Review of Resident #58 hand-written OT Clarification Order dated 06/29/2021 and signed by the physician on 07/01/2021 revealed [Resident #58] to use divided plate and built-up curved spoon for all meals beginning 06/29/2021. <BR/>Review of Resident #58 occupational daily treatment note dated 06/23/2021 to 06/29/2021 revealed Resident #58 was able to self-feed with moderate difficulty, assistance required to load spoon due to poor fine motor control and Resident #58 noted with significant spilling of food and missing mouth with tremors. It further noted orders written for divided plate and built-up curved spoon for self-feeding. <BR/>Review of Assistance with Meals Policy dated March 2022 revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards and/or specialized cups. Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's kitchen ice machine that provided ice for three out of three hallways and the dining room. <BR/>The facility failed to clean and sanitize the kitchen ice machine which resulted in the ice machine having a pink bacterial mold present in the ice bin and provided ice for the facility lunch service and ice for resident cups on three out of three resident hallways and dining room. <BR/>These failures could place residents who used ice from the ice machine at risk of foodborne illness.<BR/>Findings included:<BR/>An observation on 06/07/2022 at 9:20 AM revealed an ice chute in the ice machine to have red/orange black biofilm growth along the entire chute touching ice cubes. <BR/>In an interview on 06/07/2022 at 9:22 AM, the DM stated he saw the bio-film and the staff must have forgotten to wipe down the ice chute when they cleaned the machine a week ago. The DM said the ice machine was scheduled to be cleaned by a local company [COMPANY] this week. He stated the kitchen staff clean the ice machine completely on a monthly basis by disposing of the ice and sanitizing the entire machine, then on a weekly basis they wipe the machine down on the inside and outside. <BR/>In a follow-up interview on 06/07/2022 at 1:25 PM, the DM stated the ice machine was cleaned of the biofilm and the local company would still be coming to do a deep clean and disinfection as well as staff training for the ice machine. When asked if the ice in the ice chests for the resident hallways and lunch service was the ice used when the machine had biofilm, he said yes. He said when they clean the ice bin they remove the ice and melt it, but they did not clean the ice bin and the same ice was left in the ice bin that had been exposed to the bio-film. He said they would dispose of the ice now and bring in ice for the ice chests until the new ice could be generated. He said the residents that drank ice water in their rooms received ice from the ice machine and they were exposed to ice that had contact with the bio-film. The resident who had ice in their drinks at lunch were also exposed to ice that had contact with the bio-film on the ice chute. <BR/>In an interview on 06/09/2022 at 11:00 AM, the ADMIN stated the facility had the ice machine deep cleaned and all of the ice that was exposed to the bio-film was disposed of and the machine had since generated new ice. He stated it was his expectation that no bio-film be present in the ice machine as it could expose the residents to food borne illness. <BR/>Review of Ice Machine cleaning Log dated 2022 revealed it was cleaned by staff at facility on 06/01/2022 and each month since January 2022. <BR/>Review of Ice Machine and Filter Change Procedures dated March 2015 revealed the facilities maintenance department shall be responsible for performing inspections, electrical/safety test and preventive maintenance on ice machines at [FACILITY]. Procedures for maintenance and cleaning included clean the water spout, actuator plate, cylindrical storage bin, end plate assembly, ice auger and bin stationary bottom parts, using a solution of approved cleaner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #45) reviewed for care plan revision. <BR/>Based on interviews and record review the facility failed to update the care plan of Resident #45 to reflect services to maintain the residents's highest practicable well being.<BR/>The facility failure place Resident #45 at risk for his physical, medical and social needs not being met and risk of further weight loss.<BR/>Findings include:<BR/>Review of the Face sheet for Resident #45 reflected he was admitted on [DATE] with diagnosis of: Unspecified Dementia, Hypothyroidism (thyroid doesn't create and release enough thyroid hormone into your bloodstream), Secondary Parkinsonism (a term used to describe the collection of signs and symptoms found in Parkinson's disease), Mood Disorder, Type 2 Diabetes, History of falls, and Depression Unspecified.<BR/>Review of the MDS admission assessment for Resident #45 dated 5/11/22 reflected a BIMS score of 8, indicating severe cognitive impairment. Review of the functional assessment reflected he required extensive assistance for all ADLs. He was assessed as frequently incontinent of bowel and bladder.<BR/>Review of the Care Plan for Resident #45 reflected interventions were in place for: Full Code Status, ADL self-performance deficit, Impaired Cognitive Function, Diabetes, Hypothyroidism, An actual fall, Antidepressant medication, Mood disorder (Depression, Parkinson's r/t eating and mobility.)<BR/>In an interview on 6/08/22 at 2:22 pm LVN D stated an updated Care plan should be completed for new developments on the day ordered. She stated nurses would enter the Baseline Care Plan into the computer, print it out and put it in the Resident binder. <BR/>In an interview on 6/09/22 at 9:45 am LVN E stated Resident #45 had lost weight since his admission. She stated a significant weight change should be included in a Resident's Care Plan. She reviewed his records and confirmed his weight change was from 172.0 down to 156.0 lbs. She stated Resident had Med Pass (a protein and high calorie supplement given with his medications) and health shakes. She stated Resident #45 was to be monitored for his oral intake and was checked daily for weight . LVN E stated any charge nurse could alter the Resident's Care Plan. She stated other members of the Care Team can also update interventions. LVN E stated Resident #45 had been cooperative with staff providing his care.<BR/>In an interview on 6/09/22 at 9:50 am the DON stated Resident #45 should have his Care Plan updated to include his weight loss and the measures ordered by his physician . The DON stated Resident #45 was a recent admission [DATE]) and his weight loss was still being evaluated. She stated the weight loss of 9.3 percent was noted and his care updated. The DON stated she was not sure when his next dietary evaluation would be done, one was done on admission .<BR/>In an interview on 6/09/22 at 10:15 CNA K stated in working with Resident #45 the resident had not refused care. He stated Resident #45 was cooperative with his requests .<BR/>In an interview on 6/09/22 at 11:03 am the Administrator stated he would expect staff to follow guidelines and update Care Plans appropriately. He stated the MDS coordinator had been out with serious illness for two weeks and the corporate MDS person was trying to catch up.<BR/>In an interview on 6/09/22 at 1:35 pm the MDS Coordinator stated Resident #45 should have his Care Plan updated when a weight loss was reported. She stated the physician ordered interventions and dietary supplements would be added to his care plan as soon as possible. <BR/>In an interview on 6/09/22 at 1:35 pm the Nurse Practitioner for Resident #45 stated the Resident was just not willing to eat enough. She stated the facility was offering Health Shakes and supplements but he was not taking in enough. The Nurse Practitioner stated the resident's RP was bringing in home cooked food but he was also refusing that. She stated she would continue monitoring Resident #45, but he could not be forced to eat.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's kitchen ice machine that provided ice for three out of three hallways and the dining room. <BR/>The facility failed to clean and sanitize the kitchen ice machine which resulted in the ice machine having a pink bacterial mold present in the ice bin and provided ice for the facility lunch service and ice for resident cups on three out of three resident hallways and dining room. <BR/>These failures could place residents who used ice from the ice machine at risk of foodborne illness.<BR/>Findings included:<BR/>An observation on 06/07/2022 at 9:20 AM revealed an ice chute in the ice machine to have red/orange black biofilm growth along the entire chute touching ice cubes. <BR/>In an interview on 06/07/2022 at 9:22 AM, the DM stated he saw the bio-film and the staff must have forgotten to wipe down the ice chute when they cleaned the machine a week ago. The DM said the ice machine was scheduled to be cleaned by a local company [COMPANY] this week. He stated the kitchen staff clean the ice machine completely on a monthly basis by disposing of the ice and sanitizing the entire machine, then on a weekly basis they wipe the machine down on the inside and outside. <BR/>In a follow-up interview on 06/07/2022 at 1:25 PM, the DM stated the ice machine was cleaned of the biofilm and the local company would still be coming to do a deep clean and disinfection as well as staff training for the ice machine. When asked if the ice in the ice chests for the resident hallways and lunch service was the ice used when the machine had biofilm, he said yes. He said when they clean the ice bin they remove the ice and melt it, but they did not clean the ice bin and the same ice was left in the ice bin that had been exposed to the bio-film. He said they would dispose of the ice now and bring in ice for the ice chests until the new ice could be generated. He said the residents that drank ice water in their rooms received ice from the ice machine and they were exposed to ice that had contact with the bio-film. The resident who had ice in their drinks at lunch were also exposed to ice that had contact with the bio-film on the ice chute. <BR/>In an interview on 06/09/2022 at 11:00 AM, the ADMIN stated the facility had the ice machine deep cleaned and all of the ice that was exposed to the bio-film was disposed of and the machine had since generated new ice. He stated it was his expectation that no bio-film be present in the ice machine as it could expose the residents to food borne illness. <BR/>Review of Ice Machine cleaning Log dated 2022 revealed it was cleaned by staff at facility on 06/01/2022 and each month since January 2022. <BR/>Review of Ice Machine and Filter Change Procedures dated March 2015 revealed the facilities maintenance department shall be responsible for performing inspections, electrical/safety test and preventive maintenance on ice machines at [FACILITY]. Procedures for maintenance and cleaning included clean the water spout, actuator plate, cylindrical storage bin, end plate assembly, ice auger and bin stationary bottom parts, using a solution of approved cleaner.

Based on observation , interview, and record review the facility failed to ensure residents had the right to personal privacy of his or her personal male and right to send and promptly receive unopened mail and other letters, packages, materials delivery to the facility for residents for one of one facility. <BR/>The facility failed to implemet a system for delivering mail received on Saturdays to residents the date of receipt and instead of distributed mail received Saturday on Mondays.<BR/>This failure could place the residents in facility at risk of not receiving mail in a prompt manner and could result in a decline in the residents' psychosocial well-being and cause them to feel disconnected from family, friends, and current events. <BR/>Findings included:<BR/>In a group confidential interview on 08/16/2023 at 2:40 PM, all eight resident attendees stated they do not receive mail on Saturdays at the facility because there was no one in the office on Saturdays. Residents stated that mail was provided to them by the AD Monday through Friday. <BR/>In an interview on 08/18/2023 at 9:23 AM, the AD stated that she has worked for the facility for over three years. The AD stated that she works Monday through Friday and that she was responsible for distribution of the mail. The AD stated that they do not distribute mail on Saturdays and the residents were aware. The AD was asked if she knew mail was supposed to be distributed on Saturday and she stated that this was how it has always worked. The AD stated that they do not have an exterior mailbox, so mail was not delivered to the facility on Saturdays.<BR/>In an interview on 08/18/2023 at 9:40 AM, the Administrator stated that mail was delivered to the facility on Saturdays. The Administrator stated that the mail was brought into the facility and placed in the mail slot of the BOM's area. The Administrator stated that they have discussed nurses distributing the mail on Saturdays, but he was unaware if it was distributed. <BR/>In an interview on 08/18/2023 at 10:12 AM, the AD stated that she was corrected and informed that the mail was delivered on Saturdays through a slot into the BOM's area. The AD was asked if this area was accessible to others on the weekend and she advised it was not. <BR/>In an interview on 08/18/2023 at 10:29 AM, the BOM stated that the mail was delivered through the slot into her locked office area. The BOM stated that the delivered mail from Saturday stays in her office area until she gathers it on Monday morning and provides it to AD for distribution. The BOM stated that the residents mail has not been delivered on Saturday since at least January of 2023.<BR/>In Review of facility Resident Rights Policy, revised 10/2021, which includes the Texas Health and Human Service Residents Rights poster available in English and Spanish. Rights under privacy and confidentiality state Send and receive unopened mail and to receive help in reading or writing correspondence. Facility advised that there was no other reference or policy that related directly to mail and the distribution thereof.