Avir at Lubbock

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from neglect for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that:<BR/>1) The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. <BR/>This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated.<BR/>The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration.<BR/>These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. <BR/>The findings include:<BR/>Resident #1<BR/>Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder).<BR/>Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; <BR/>If Blood Sugar is less than 60, call MD. <BR/>If Blood Sugar is 61 to 150, give 0 Units. <BR/>If Blood Sugar is 151 to 250, give 3 Units. <BR/>If Blood Sugar is 251 to 350, give 5 Units. <BR/>If Blood Sugar is 351 to 450, give 7 Units. <BR/>If Blood Sugar is 451 to 500, give 10 Units. <BR/>If Blood Sugar is greater than 500, call NP/PA. <BR/>Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A.<BR/>Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . <BR/>Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. <BR/>Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON.<BR/>Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin:<BR/>Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank.<BR/>Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested, and it was 203 and 3 units of insulin was administered prior to dinner - admission Observation by LVN C.<BR/>Further record review of the MAR revealed the following:<BR/>On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B.<BR/>On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. <BR/>On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B.<BR/>Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following:<BR/>04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B.<BR/>04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B<BR/>Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . <BR/>Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization <BR/>Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. <BR/>Labs. <BR/>Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. <BR/>Specimen: blood. <BR/>Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L .<BR/>carbon dioxide 8 on a normal scale of 21-32 mmol/L. <BR/>Glucose 1,030 on a normal scale of 74-106 mg/dL. <BR/>Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. <BR/>Blood, urine moderate. <BR/>Glucose, urine 100 mg/dL. <BR/>Ketones, urine 40 mg/dL. <BR/>Disposition. <BR/>Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. <BR/>Comment. <BR/>Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety.<BR/>Expected patient class: in patient.<BR/>Level of service: ICU. <BR/>Discharge summary note. <BR/>Discharge summary. <BR/>Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM)<BR/>Cause of death: renal failure, metabolic acidosis, lactic acidosis.<BR/>Other contributing factors: <BR/>Principal problem: acute metabolic encephalopathy.<BR/>Active problems: . diabetes myelitis. DKA (diabetic keto acidosis) . <BR/>Hospital Course:<BR/>(Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . <BR/>Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows:<BR/>Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: [DATE]. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. <BR/>Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. <BR/>Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused.<BR/>Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility.<BR/>On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to the ER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500.<BR/>On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. <BR/>On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter.<BR/>On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care.<BR/>On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B.<BR/>On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23.<BR/>On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. <BR/>On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. <BR/>On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022.<BR/>On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in.<BR/>On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. <BR/>On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high.<BR/>On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own.<BR/>On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin.<BR/>On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. <BR/>Resident #2<BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD.<BR/>If blood sugar is 150 to 200 give two units.<BR/>If blood sugar is 201 to 250 give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, give 12 units.<BR/>If blood sugar is greater than 450, give zero units.<BR/>If blood sugar is greater than 450, call MD. Subcutaneous. <BR/>[DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] <BR/>Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM <BR/>Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days.<BR/>Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 .<BR/>Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. <BR/>Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #3 <BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD. <BR/>If blood sugar is 150 to 200, give two units.<BR/>If blood sugar is 201 to 250, get four units.<BR/>If blood sugar is 251 to 300, gives six units. <BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is greater than 400, call NP/PA. Subcutaneous <BR/>[DX: type two diabetes mellitus without complications] <BR/>Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM.<BR/>Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: <BR/>Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank.<BR/>Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days.<BR/>Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 .<BR/>Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #4 <BR/>Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. <BR/>Further record review of the Physician Order Report revealed the following orders:<BR/>Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro <BR/>Insulin pen; 100 unit/ML; AMT: per sliding scale; <BR/>If blood sugar is less than 70, call NP/PA.<BR/>If blood sugar is 70 to 150, give 0 units.<BR/>If blood sugar is 151 to 200, give two units.<BR/>If blood sugar is 201 to 250, give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 300 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, gives 12 units.<BR/>If blood sugar is 450 to 500, give 14 units. <BR/>If blood sugar is greater than 501, called NP/PA. Subcutaneous.<BR/>[DX: type two diabetes myelitis without complications]<BR/>Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM <BR/>Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications]<BR/>Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM<BR/>Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. <BR/>Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes.<BR/>Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM.<BR/>Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime.<BR/>Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals and missing documentation for the residents listed on the MAR chart audit until the facility conducted a chart [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 5 residents (Resident #1) of five residents whose records were reviewed for abuse.<BR/>Facility staff did not implement facility policy and immediately notify administration when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. <BR/>This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. <BR/>Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition. <BR/>Record review of Resident #1's care plan dated 5/2/24 indicated Resident #1 had a history of pain with a start date of 4/29/24. Staff are instructed to handle gently and try to eliminate any environmental stimuli. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. FM #1 stated that when Resident #1 returned from the hospital on 6/23/24 after she had been hospitalized for fractured ribs. FM#1 stated she observed that CNA B was rough with Resident #1 when she jerked her up to change her. FM#1 stated she told CNA B that she (FM#1) would change Resident #1 herself. FM #1 stated she reported to LVN A that CNA B was rough with Resident #1. FM#1 stated she was concerned about Resident #1's safety and wellbeing.<BR/>During an interview on 6/25/24 at 2:50 p.m. LVN A stated that when Resident #1 returned from the hospital and was in her room with FM #1. LVN A stated that FM #1 reported to him that CNA B was real rough with Resident #1. LVN A stated that FM #1 told him that [CNA B] was rough with her and made her get out of bed. LVN A stated that he was not in the room when CNA B assisted Resident #1 and did not think CNA B was the type of person to be abusive. LVN A stated that he had been trained on Abuse and Neglect and trained to report allegations of abuse immediately to the Administrator. LVN A stated that the facility had routine in-services on Abuse and Neglect and to report allegations to the ADM. LVN A stated he did not think CNA B had abused Resident #1 and had FM #1 stated that CNA B hit or punched Resident #1 he then would have reported it.<BR/>During an interview on 6/25/24 at 3:15 p.m. with the ADM; he stated that when the FM told LVN A that CNA B was rough with the resident, it should had been reported to him. The ADM stated that if the family member had not used the word abused that LVN A may not have thought it was reportable. The ADM stated that had LVN A reported it to him, the facility would have investigated the reported incident. The ADM stated that I just gave in services on ANE and reporting two weeks ago. It is posted all over the building to report to me and my phone number is listed. The ADM confirmed that nothing had been reported to him by LVN A. <BR/>During an interview on 6/25/24 at 3:24 p.m. with the DON, she stated that if a FM told LVN A that CNA B was rough with Resident #1, LVN A should have reported it to her or the ADM so it could be investigated. The DON stated that rough is not gentle and if someone reported that a staff was rough with a resident, she would have investigated it as the staff was being not gentle and either grabbing or pulling, rushing. The DON stated had it been reported to her, she would report it to the ADM and then report to the state. The DON stated that LVN A had been trained to report suspected abuse or neglect. The DON stated that the person making the complaint would not have to use the word abused and the word rough would be a reportable incident. The DON stated she had not been informed of this incident until now. <BR/>During an interview on 6/25/24 at 3:53 p.m. with CNA C, stated that if a family member or staff member stated that a staff member was rough with a resident, she would immediately report to the charge nurse and to the Administrator. CNA C stated that she believed the term rough could mean tearing skin, pulling an arm out of socket and if a family member thinks a staff is being rough, they are rough, and it had to be reported. <BR/>During a phone interview on 6/27/24 at 3:45 p.m. with CNA B; stated that when Resident #1 returned from the hospital her FM (#1) notified her that Resident #1 was sitting on the edge of the bed and the floor was wet. CNA B stated she entered Resident #1's room and found Resident #1 sitting on the edge of her bed with pants around her ankles. CNA B stated the floor was wet under Resident #1's feet and the pants were the roommates' pants as they were too small for Resident #1. CNA B stated that Resident #1 had been in the hospital and had fractured ribs. CNA B stated she stepped out of the room to get a pull-up for Resident #1. CNA B stated she removed the pants from Resident #1; s ankles, put a pull-up and pants on Resident #1 and then assisted Resident #1 to stand up to pull up the pull up and pants. CNA B stated she put her arms under Resident #1's arms to assist her to stand up and did not use any force nor was rough. CNA B stated after she dressed Resident #1, she assisted Resident #1 back onto her bed and realized that Resident #1's socks were wet. CNA B stated she attempted to remove the socks and the FM told her she would do it herself because she did not want Resident #1 to stand up again. CNA B stated that she had been trained on abuse/neglect and to report any allegations of abuse/neglect immediately to the abuse coordinator, the Administrator. CNA B stated that if someone told her that a staff member had been rough with a resident, she would immediately notify her charge nurse and then immediately would notify the Administrator that an allegation had been made. <BR/>Record review of the facility's Abuse Prevention policy revised on 10/2023 revealed in part, the facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect: <BR/>- Include training for new and existing staff on activities that constitute abuse, neglect, reporting procedures. <BR/>- Indicators of abuse include, but are not limited to: Resident, staff, or family report of abuse. <BR/>-Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately but not later than 2 hours of after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. <BR/>Record review of the facility's In-service on Abuse and Neglect for LVN A dated and signed 11/4/22 revealed in part: The facility during its orientation program and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive plan must be prepared by an interdisciplinary team to the extent practicable, the participation of the resident and the resident's representative(s)of the care plan conference for 2 of 22 residents (Resident #33 and Resident #43) reviewed for comprehensive resident centered care plans.<BR/>The facility failed to invite Resident #33 and Resident #43 or the representatives to attend their care plan conferences.<BR/>These failures placed the residents at risk for unmet care needs and a decreased quality of life. <BR/>Findings included:<BR/>Resident #33<BR/>Record review of Resident #33's face sheet, dated 02/07/24, revealed a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Benign neoplasm of pineal gland (central nervous system tumors, which begin in the brain), Reduced mobility (unsteadiness while walking, difficulty getting in and out of a chair, or falls), Symptomatic epilepsy (a type of seizure) (repeated seizures-defined as a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain) & epileptic syndromes with complex partial seizures (most common type of epilepsy in adults -can last as long as 30 seconds to 2 minutes), anxiety disorder (persistent excessive worry that interfere with daily activities), conversion disorder with seizures or convulsions (a condition where a mental health issue disrupts how the brain works, physical symptoms that a person cannot control), hypotension (low blood pressure), cognitive communication deficit (difficulty with thinking and how someone uses language), pain (physical suffering or discomfort caused by illness or injury), oropharyngeal phase dysphagia (difficulty swallowing food & liquids), and lack of coordination (muscle control problem that causes an inability to coordinate movements; leads to jerky, unsteady, to-and-fro motion). <BR/>Record review of quarterly MDS assessment dated [DATE] revealed Resident #33 had a staff assessment for mental status revealed short-term and long-term memory problems, memory/recall ability was none, and cognitive skills for daily decision making was 03 (severely impaired-never/rarely made decisions). The MDS further revealed Resident #33 required substantial/maximal assistance with eating; oral, toilet, personal hygiene; bathing; upper and lower dressing; putting on/off footwear; partial/moderate assistance with rolling right & left, sit to lying, lying to sitting on side of bed; sit to stand; chair/bed-to-chair transfer; always incontinent of bladder and bowel; receives 51% or more nutrition by tube feeding seven days a week. <BR/>In an interview on 02/07/2024 at 5:54 PM, Resident #33's family member stated the only care plan meetings that had been attended were with the local authority for PASRR.<BR/>Record review of care conference report for Resident #33 revealed a quarterly care planning meeting dated 12/05/2023 with the social worker, the activity director and the MDS coordinator. <BR/>Record review of care conference report for Resident #33 revealed a quarterly care planning meeting dated 01/24/2024 with ADON A, the DON, the social worker, the activity director, the administrator, the MDS coordinator, and ADON B. <BR/>Record review of Resident #33's progress notes dated 04/23/2023 - 02/07/2024 revealed no documentation that Resident #33 or Resident #33's representative was invited to the care plan meeting. <BR/>Resident #43<BR/>Record review of Resident #43's face sheet, dated 02/06/24, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia (mental disorder), rhabdomyolysis (rare muscle injury) and pain. <BR/>Record review of Resident #43's comprehensive MDS assessment, dated 09/18/23, revealed Resident #43 was understood and had a BIMS score of 04 which indicated his cognition was severely impaired.<BR/>During a phone interview on 02/07/24 at 11:28 AM, Resident #43's RP stated she had not been invited to a care plan meeting since the beginning of last year (2023). <BR/>Record review of Resident #43's care conference report revealed a quarterly meeting was held on 02/14/23 and Resident #43's RP was listed as one of the attendees. <BR/>Record review of Resident #43's care conference report revealed a quarterly meeting was held on 10/26/23 and Resident #43's RP was not listed as one of the attendees.<BR/>Record review of Resident #43's progress notes dated 08/01/2023 - 02/07/2024 revealed no documentation that Resident #43 or Resident #43's RP was invited to the care plan meeting. <BR/>During an interview on 02/08/24 at 2:16 PM, the SW stated she was responsible for inviting residents and their RP to care plan meetings. The SW stated Resident #43 had a care plan meeting on 10/26/23 and she confirmed Resident #43's RP was not at the meeting. The SW stated she remembered calling Resident #43's RP to invite her to the care plan meeting and stated she usually did a progress note about it. The SW stated she was not able to locate the progress report and she did not document it anywhere else. The SW stated she understands if something was not documented, there was no way to prove it was done. The SW stated the potential negative outcome to the resident and their RP was they would not know what was current in the residents' care and they would not know about any new orders. <BR/>During an interview on 02/08/24 at 2:53 PM, the ADM stated the SW was responsible for inviting residents' and their RP to care plan meetings. The ADM stated he did not know why Resident #33 and Resident #43's RPs were not invited to their care plan meetings. The ADM stated he expected the SW to document all invitations to care plan meetings. The ADM stated the potential negative outcome to the residents' and their RP was families may not know what was going on with the resident and families would not have a chance to address all members of the team. <BR/>In an interview on 02/08/2024 at 5:15 PM, the social worker stated Resident #33 has had care plan meetings with the local authority for PASRR and she was documenting on her side of the quarterly meetings when PASRR met. She agreed there were no notes in the care conference reports prior to 12/05/2023 of care plan meetings and no documentation of invitations to the resident representative. She stated if it was not documented, it did not happen. She stated the negative outcome of not having care plan meetings were that the resident's care could not have continuity for all departments: nursing, dietary, activities, and psychosocial.<BR/>Record review of the facility policy titled, Comprehensive Care Plans with a revised date of 01/26/24, reflected the following:<BR/>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, mental and psychosocial needs that are identified in the resident's comprehensive assessment.<BR/>Policy Explanation and Compliance Guidelines:<BR/> .4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to:<BR/>a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan.<BR/>b. A registered nurse with responsibility for the resident.<BR/>c. A nurse aide with responsibility for the resident.<BR/>2 d. A member of the food and nutrition services staff.<BR/>e. The resident and the resident's representative, to the extent practicable.<BR/>f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by 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 received adequate supervision to prevent accidents and/or hazards as possible for 2 of 5 residents (Resident #1, Resident #2) reviewed for supervision. The facility failed to ensure Resident #1, and Resident #2 received supervision to prevent Resident #2, who had a history of sexual behaviors, from sexually abusing Resident #1, when she put her hand in her panties. Resident #1 was on one to one (1:1) supervision due to a previous incident of aggression with a different resident; however, she was allowed to alone in her room with Resident #2. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm, due to lack of supervision.Findings include: <BR/>Resident #2<BR/>Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression).<BR/>*Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: <BR/>Section C Brief Interview for Mental Status (BIMS) score revealed a score of 1 which indicated the resident's cognition was severely impaired.<BR/>Section E-Behavior:<BR/>Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days.<BR/>Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days.<BR/>Functional Abilities-Mobility: Walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. <BR/>*Record review of Resident #2's Care Plan, dated 08/24/25 revealed her inappropriate sexual activity was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25.<BR/>Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary.<BR/>Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection.<BR/>*Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma.<BR/>On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. <BR/>On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzheimer's late onset to Resident #2's diagnosis. <BR/>Resident #1:<BR/>Record review of Resident #1's Face Sheet current as 0f 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), insomnia (trouble sleeping).<BR/>*Record review of Resident #1's admission Comprehensive Minimum Data Set, dated [DATE] revealed: <BR/>Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired.<BR/>Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. <BR/>Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited.<BR/>Functional Abilities-Mobility, walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper.<BR/>*Record review of Resident #1's Care Plan dated 08/12/25 included:<BR/>Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety.<BR/>Problem, on 08/12/25 the plan included that she had been physically aggressive towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others.<BR/>*Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1 was assessed and she had no signs of trauma. <BR/>*Record review of Resident #1's Progress Notes indicated the following:<BR/>On 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. 08/23/35 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma.<BR/>During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. <BR/>During an interview on 09/03/25 at 10:46 am, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the living/dining area and saw Resident #2 go into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. <BR/> During an interview on 9/04/25 at 1:34 PM CNA P stated that prior to 08/23/25, she had never done 1:1 observation. She stated she was working on 08/23/25. She stated she did not recall anyone specifically telling her that they were leaving, and they were the 1:1 staff for Resident # 1. She stated on 08/23/25 she was the person to get Resident #1 dressed and she sat her at the dining room table.<BR/>During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody had hurt her and she could not recall being touched on her body by Resident #2.<BR/>During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #1 had a history of inappropriate sexual behavior.<BR/>During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and CNP replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall a night CNA informing her that she was leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table.<BR/>During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. The admission Coordinator said she did not review Resident #2's notes in the admission packet; and then confirmed Resident #2's admission transfer notes did include 3 incidents of inappropriate sexual behavior 08/03/25 - two incidents, and one incident on 07/16/25.<BR/>During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation.<BR/>During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission.<BR/>During an interview on 09/04/25 at 1:19 PM, the FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. <BR/>During an interview on 09/04/21 at 1:41 PM, the DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggressor on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle, and he had to move her hand away. The DON said he asked LVN F to supervise his assessment of Resident #2's and nothing else happened. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #1's pants, and that Resident #1 did not have a 1:1 observation at the time of this incident.<BR/>During an interview on 9/04/25 at 1:40 PM CNA E stated that she has never been any resident's 1:1 staff. She stated they are typically informed by the DON or the previous shift staff may tell them if a resident is on 1:1 supervision. She stated the DON would tell them if a resident was off 1:1 supervision. She stated she had been trained by the facility staff that they stay until relief comes. She stated she did not know when, but the training had occurred since she had been at the facility.<BR/>During an interview on 09/04/25 at 2:18 PM, the Administrator indicated that the facility's investigation included that LVN F witnessed said she witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff.<BR/>During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 AM on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left.<BR/>During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2.<BR/>During an interview on 09/05/25 at 10:35 PM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days, and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because you don't know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties.<BR/>During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25, Resident #2 was not assigned special observation; however, Resident #1 was on 1:1 observation due to an incident of aggression on 08/21/25. On 08/23/25 LVN F said she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs &ldquo;come get them&rdquo; and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she was not informed CNA O was not starting her shift at 6 AM, had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON.<BR/>The facility's policy and procedure, Observation Levels, dated 04/2024 indicated &ldquo;It is the policy of the facility that staff monitoring is instituted to maintain the safety of each resident and provided by a system of progressive intensity of resident observation and oversight. The use of the level that provide each resident with optimal level of safety in the least restrictive manner will be utilized. Resident will be routinely observed in compliance with physician orders and/or clinical protocols.&rdquo; <BR/>The level of supervision included:<BR/>Standard observation (assess and document at no less than every two hours). Minimum level of observation for all residents.<BR/>Line of sight (assess and document at 15-minute intervals). A level of observation wherein the resident remains in staff view. A specific staff member may be assigned, and the line-of-sight observation is maintained by staff in person and not through video monitoring.<BR/>One to one (staff member constantly with the resident and documents at 15-minute intervals). Consist of One-to-one with a resident never farther away than 10 or less feet. The residents must remain within this parameter. A licensed nurse my place a resident ton line-of-sight or one-on-one and increase the level of observation at any time as clinically necessary. In all cases the least restrictive clinically appropriate intervention will be implemented. The license nurse my not decrease the level of observation until conferring with the director of nursing/designee and/or physician.<BR/>The procedure includes three levels of resident observation are used. The levels are designated to provide increasing intensity of observation, precaution, and oversight commensurate with physician and staff. The appropriate observation level is implemented:<BR/>After evaluation and assessment, a level of observation may be instituted by the attending physician or registered nurse.<BR/>If a registered nurse institutes an observation level, the attending physician is notified as soon as possible.<BR/>The physician's order shall include the Observation Level and the reason for the monitoring.<BR/>The charge nurse will assign staff to perform the standard observation level on a designated set of residents. Resident online of sight or one on one will be assigned specific staff.<BR/>The charge nurse will assign staff to perform the standard observation level on a specific designated set of residents. Resident online of sight or one on one will be assigned specific staff. The nurse will arrange for staff to be relieved for breaks and meals. <BR/>Assigned staff will complete the resident observations as rounds are made and document on the rounds from. Staff will observe the resident's location and note the residents' behavior. Rounds are not to be documented in advance.<BR/>In addition to recording the whereabouts of resident at ordered intervals, the purpose of observation is to provide a system of progressive intensity of resident observation, precaution and oversight based on resident acuity, severity and type of symptoms, and overall needs.<BR/>The order of observation level is communicated to all staff.<BR/>Staff must hand-off responsibility for maintaining observation of assigned resident of any break or potential interruption in completing assigned rounds.<BR/>The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided.<BR/>The following Plan of Removal was accepted on 09/05/2025 at 10:46AM:<BR/>&ldquo;Plan of Removal<BR/>09/05/2025<BR/>The facility failed to provide the &ldquo;planned&rdquo; or &ldquo;scheduled&rdquo; 1:1 supervision for resident #1 that resulted in exposing her to a hazard of being inappropriately / sexually touched by resident #2.<BR/>1. On 08/23/25 Resident #2, who was the aggressor that put her hand inside Resident #1's panties, was placed on 1:1 observation. Resident #1, who was supposed to be on 1:1 observation when Resident #2 put her hand in her panties, was returned to 1:1 observation. On 08/26/25, Resident #2 was taken off of 1:1 observation after IDT's review.Person(s) Responsible: Administrator, Director of Nursing, and/or DesigneeDate: 8/26/2025<BR/>2. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designeeDate: 8/23/2025<BR/>3. Education was provided to the Administrator and the Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and the Resident-to-Resident Policy.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse ConsultantDate: 9/4/2025<BR/>4. All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 9/4/2025<BR/>5. When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025<BR/>6. QAPI&mdash;<BR/>Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time.Person(s) Responsible: AdministratorDate: 9/4/2025<BR/>7. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. <BR/>On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Observation on 09/05/25 at 7:55 AM revealed CNAs B, C and DON were working on the memory unit. The DON, who was monitoring, said he was filling in because CNA M was not able to work her shift, and ADON, would also fill in as needed. The DON said there was not a resident in this unit, who was on 1:1 observation or a special level of observation. The staff were expected to monitor and prevent Resident #2 from entering a resident's room. The memory unit had a 3-foot-tall wall that is approximately 12 feet wide and separates the living/dining area from the hallway, which allowed staff to see the residents in the living/dining area and the hallway. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 8:05 AM, revealed Resident #2 was observed walking around the living/dining area and the CNAs were in the hallway and living/dining area observing approximately 9 Residents, including Residents #1 and #2. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 10:06 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 11:21 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 11:23 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was standing near the CNAs. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 2:10 PM, CNAs, B, C, and LVN F, who was monitoring, were on duty, and Resident #2 was walking in the living/dining area. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 4:55 PM, CNAs B and C, and MA G, who was monitoring, were in the memory care unit, and Resident #2 was walking in the hallway. Resident #2 did not enter a resident's room. <BR/>Interview on 09/05/25 at 12:57 PM, the DON indicated Resident #2 was the only one identified with sexual behaviors; however, since 08/23/25 she had not made any attempts to touch a resident or staff inappropriately. <BR/>*Record Review of Resident #2's Event Report dated 09/03/25 indicated:<BR/>On 08/24/25 at 10:54 AM. Resident #2 was being monitored on the memory unit on, and she was wandering among the common areas with 1:1 assigned staff member. She exhibits no signs of agitation or pain. She has minimal verbal exchanges and has been minimal in complete thoughts and sentences. <BR/>On 08/24 at 4:22 PM Resident #2 only makes visual contact nonverbal, in good spirit, affect appropriate, and can't assist with questions to complete any SW admission assessments. <BR/>On 08/26/25 at 10:56 AM revealed Resident #2's Interdisciplinary Team met and discontinued her 1:1 observation. <BR/>On 09/02/05 LVN F received orders from FNP T, who was in the facility, to complete Resident #2 a CBC, CMP, TSH, A1C, senior psych referral, and Aricept 5mg q hs. This report included that on <BR/>On 09/02/25 at 10:37 AM LVN F received orders from PNP to change Remeron to HS, change Paxil to AM, monitor for over sedation, and add history of Alzheimer's late onset. <BR/>*Review Resident #2's FNP T's Progress Note dated 09/02/25 indicated Resident #2 was taking Aricept 5 mg at bedtime orally once a day. This assessment indicated Resident #2 required memory care unit, Aricept, and psych consult. <BR/>During interview conducted with staff on duty on 09/05/25 from 10:06 PM until 5:01 PM that worked on the 6 AM to 6 PM shift (FNP T at 10:06 PM, LVN F at 10:35 AM , DON at 11:09 PM, ADON at 11:32 PM, CNA H at 1:06 pm, LVN I at 1:36 PM, CNA HH at 1:56 PM, LVN F at 1:49 PM, SW at 2:12 PM, CNA P at 2:32 PM, Activity Director at 2:50 PM, MA J at 2:58 PM, CNA II, at 3:23 PM, Admissions Coordinator at 3:29 PM, HK Supervisor at 4:45 PM, MA G at 5:42 PM), and 6 pm to 6 am shifts (RN Z at 5:51 PM, and CNA and CNA D at 1:28 PM). These staff were in-serviced on preventing Abuse, Neglect, and Exploitation, Levels of Observation, and Resident to Resident Altercat

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 22 residents reviewed for medications (#11 and #18 ).<BR/>1)The facility failed to accurately acquire and administer medications as ordered for two residents (Residents #11 and #18). Resident #11 missed doses of ordered Plavix (antiplatelet medication) and Resident #18 missed doses of hydralazine (blood pressure medication) and hydrocortisone eye ointment (anti-inflammatory medication).<BR/>These failures could place residents at risk of experiencing missed medications which could result in the exacerbation of their medical conditions and a decline in health status. <BR/>The findings included:<BR/>Resident #18<BR/>Record review of the undated face sheet for Resident #18 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of cerebral infarction, unspecified (stroke), unspecified inflammation of eyelid (history of), other specified glaucoma (vision disorder), palpitations (irregular heart beat), essential hypertension (high blood pressure), personal history of transient ischemic attack (TIA - mini stroke), dependence on renal dialysis (procedure to remove waste from blood when kidney function has declined), type two diabetes mellitus, without complications (blood sugar disorder), and end stage renal disease (kidney disease). <BR/>Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #18 had a BIMS score of 15 indicating that the resident was cognitively intact. Further record review of the MDS revealed active diagnoses of hypertension, renal insufficiency, renal failure, or end stage renal disease, diabetes mellitus, cerebral vascular accident, transient ischemic, attack, or stroke. Additional review of the MDS revealed that the resident was on dialysis while a resident.<BR/>Record review of the significant change MDS assessment dated [DATE] revealed that Resident #18 also had an active diagnosis of glaucoma, cataracts, or macular degeneration.<BR/>Record review of the current care plan for Resident #18 last reviewed/revised: 1/22/24 revealed that there was a problem documented as follows, Problem start date: 1/9/24. Problem end date 3/9/24. Category: visual function. Resident has impaired vision related to aging process. Edited: 1/22/24. The documented goal was as follows, long-term goal target date: 4/24/24. Resident will not experience negative consequences of vision loss as evidence by remaining physically safe and participating in social and self-care activities. Edited: 1/22/24. Approaches included, Approach start date: 1/9/24. Administer eye medication as ordered. Evaluate/record/report effectiveness, and any adverse side effects. Edited: 1/9/24. Approach start date: 1/9/24. Arrange ophthalmologist/optometrist consult. Implement recommendations. Edited: 1/9/24 . <BR/>Record review of the current care plan for Resident #18, last reviewed/revise: 1/22/24, revealed there was no specific care plan regarding hypertension or administration of medications related to hypertension. <BR/>During an interview on 2/6/24 at 5:50 PM Resident #18 stated the facility wase waiting on a blood pressure pill to come in for her. She further stated they were having problems with getting her medications in. <BR/>During an interview on 2/7/24 at 9:36 AM Resident #18 stated she had two blood pressure medicines. One was nifedipine which she got, but hydralazine was not in and it had been over a week . <BR/>Record review of the current physician orders for Resident #18, dated 2/6/24 revealed the following orders, Hydralazine tablet; 50 mg; amount: 50 mg; oral. Three times a day. Morning 6 AM - 10 AM, midday 11 AM - 2 PM, bedtime 7 PM - 10 PM. Start date 12/31/22. Open ended . [blood pressure medication]<BR/>Record review of the MAR for January 2024 for Resident #18, from 1/15/24 through 1/31/24 revealed that the resident was administered hydralazine on 40 of 51 opportunities. Between that time, the resident was not available on a Tuesday, Thursday, or Saturday for the midday dose on seven of seven occasions. This was the resident's dialysis days. On those seven days, the resident only received the medication two of the three ordered times daily .<BR/>Record review of the February 2024 MAR for Resident #18 from 2/1/24 through 2/7/24 revealed that the resident received the medication on eight of 21 opportunities. it was documented that the medication was unavailable/not in stock on nine opportunities from 2/4/24 midday dose through 2/7/24 morning dose. It was also noted that on Thursday (dialysis day), 2/1/24, the resident was documented as unavailable and did not receive a midday dose. The resident only received two of the three ordered doses . <BR/>Record review of the current physician orders for Resident #18 dated 2/6/24 revealed the following order, Hydrocortisone, ophthalmic ointment; 1%; amount: one; both eyes. Twice a day. Morning 7 AM - 10 AM, bedtime 7 PM - 10 PM. Start date 10/16/23. Open ended . [anti-inflammatory medication]<BR/>Record review of the MAR for Resident #18 for December 2023 revealed that the hydrocortisone 1% ophthalmic ointment was given 24 times of the 62 opportunities. It was also documented that the resident was unavailable eight times and the medication was unavailable 30 times . <BR/>Record review of the January 2024 MAR for Resident #18 revealed that the resident was given the hydrocortisone ophthalmic ointment 16 times of the 62 opportunities. It was further documented that the resident was unavailable two times and the medication was unavailable 45 times .<BR/>Record review of the MAR for Resident #18 for February 2024 revealed that from 2/1/24 through 2/7/24. The resident was given the hydrocortisone ophthalmic ointment medication five or 14 opportunities. It was further documented that the resident was unavailable two times, and the medication was unavailable on seven times .<BR/>Record review of the pharmacy consultant reports for Resident #18 for December 2023, and January 2024 revealed a recommendation on 12/18/23 to indicate diagnoses for the residents' drugs. On 1/25/24, the consultant pharmacist recommendation to physician was regarding the timing of the administration of the resident's Carafate, which was ordered four times a day since 6/2023. There was no documentation regarding the residents missed hydrocortisone ophthalmic ointment or missed dosages of hydralazine. <BR/>Resident #11 <BR/>Record review of the current undated face sheet for female Resident #11 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), essential hypertension (high blood pressure), unspecified systolic (congestive) heart failure (heart failure), cerebral infarction, unspecified (stroke), and other persistent atrial fibrillation (irregular heart rhythm). <BR/>Record review of the quarterly MDS assessment for Resident #11 dated 12/2/23 revealed that the resident had a BIMS score of 14 indicating that she was cognitively intact. Further record review of the MDS revealed active diagnoses of coronary artery disease, heart failure, hypertension, cerebral vascular accident, transient ischemic attack, or stroke . <BR/>Record review of the progress notes for a Resident #11 dated 2/22/23 at 5:45 PM revealed the following documentation, resident will be going to the dentist Tuesday (2/28/23). Her Plavix will be (discontinued) until then awaiting the dentist orders. Plavix 75 mg. [Plavix - antiplatelet medication]<BR/>Record review of the progress notes for Resident #11 revealed the following progress note dated 12/19/2023, 4:38 PM, resident back from urology doctor appointment and requesting information regarding the Plavix prescription she was previously taking. Resident came back from doctor appointment and wanted to know why she wasn't taking Plavix. After researching Plavix was to be held for a dental appointment on 2/22/23 but never restarted. Order reactivated. Reviewed with DON and provider <BR/>Record review of the current physician orders for Resident #11 dated 2/6/24 revealed the following order, Clopidogrel tablet: 75 mg; amount; 75; oral. Once a morning. Morning 7 AM - 10 AM. Start date 1/24/24. Open ended. <BR/>Record review of the December 2023 MAR for Resident #11 revealed the following order, clopidogrel tablet; 75 mg; amount to administer: one tablet; oral, once a morning, start date, 12/19/23 - end date 1/3/24, (DC date). Diagnosis: Atherosclerotic heart disease of native coronary artery without angina pectoris. <BR/>Record review of the January 2024 MAR for Resident #11 revealed her order for Plavix was restarted with a start date of 1/3/24 through 1/5/24. There was an additional order for the Plavix that had a start date 1/10/24 through 1/19/24 as an end date. There was also an additional current order for the resident's Plavix that had a start date of 1/24/24, which was open ended.? <BR/>Record review of the care plan for Resident #11 last reviewed/revised 1/25/24 revealed no care plan related to the administration of Plavix (clopidogrel). <BR/>During an interview with Resident #11 on 2/7/24 at 9:03 AM she stated she had missed medications in the past, but the facility had straightened it out. She stated at the time of the incident she had a procedure and was taken off Plavix. She stated she was off the medication for several months, but the facility had gotten her back on it. She added it was restarted approximately 3 months ago. <BR/>On 2/8/24 at 11:36 AM an interview was conducted with Resident #11. She stated she had not experienced any adverse effects from being off the Plavix. She added she had stents and her physician told her she would need Plavix the rest of her life. [Note: Stent - metal mesh used to keep an artery open.] <BR/>On 2/8/24 at 3:15 PM an interview was conducted with Nurse Practitioner A for residents, #11 and #18. Regarding Resident #11's missed Plavix she stated, generally it should be resumed after a procedure. She stated, I guess it was slipped. She further stated regarding Resident #11, She needs it (Plavix). She should be back on it. Regarding Resident #18's missed hydralazine and hydrocortisone ophthalmic ointment, she stated she saw that both medications were ordered. She stated Resident #18 had an ophthalmologist and she (Nurse Practitioner) lets the ophthalmologist order what was needed for her. She added, The hydralazine is given to keep blood pressure under control. The hydralazine should have been given. I don't understand why it was not. She further stated regarding Resident #18's missed doses of hydralazine that the facility should administer the medication to her when she comes back from dialysis. She stated this situation could be an oversight problem. I'm not sure . <BR/>On 2/8/ 24 at 3:23 PM an interview and observation were conducted with CMA B regarding the missed medications for Resident #18. She stated, the hydralazine, she thought, ran out and the pharmacy did not send it. She stated that staff tell the nurse or re-order the medication on the computer. She stated, the pharmacy says they will send medications and then they do not send them. She stated she had reported to the nurses that the medications were not available. She stated a resident's blood pressure could go up and down and have a stroke if she did not receive her blood pressure medication. She stated that she was not present when the medication error occurred for Resident #11. She stated that she had worked in the facility only three months as medication aid. She stated Resident #18's hydralazine order had just come in Tuesday or Wednesday. Observation of the pill card at this time from the medication cart revealed that two pills were missing of the 30-pill pack. CMA B stated the hydrocortisone ophthalmic ointment for Resident #18 was not present.<BR/>On 2/8/24 at 3:30 PM an interview was conducted with LVN B regarding the missed Plavix for Resident #11. She stated, she was not present when it stopped. She stated she understood she went to the doctor and had a procedure, and the Plavix was stopped. Regarding Resident #18's hydrocortisone eye ointment, she stated at one time the resident kept the medications in her room. Family would bring medications also. She stated that she was unsure why the resident did not have her eye ointment. Regarding the missed doses of hydralazine, she stated sometimes the resident was at dialysis and not present for a dose. She thought the resident received a dose when she was at dialysis. She added that staff did not have any instructions related to medications missed when residents were gone to dialysis. She stated the facility does not send medications with her to dialysis. She stated It depended on when she returned from dialysis as to if she received the medication. She stated the resident would usually receive a bedtime dose, but the missed doses were not replaced. Regarding delays in receiving medications, she stated sometimes staff wait on medications and then pass the information on to the next shift. She stated staff were waiting on the eye ointment for Resident #18 and that medication delays were an ongoing issue. She added if it has been a long time, and the medication was not here, the staff would call the pharmacy and let the DON know. She stated she could not remember if she informed the DON about the eye ointment for Resident #18. She stated the resident's blood pressure could go up if the resident did not receive her medication as ordered. She further stated she had not considered this situation as not following the physician orders.<BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON regarding Resident #11's missed Plavix. She stated, she was not employed in the facility then. She stated at an appointment, medical staff at the appointment reviewed the resident's medications and found the error. She stated she was not sure why Plavix was taken off her physician orders. She stated, We fixed the error. She stated the facility's medication system could not place a medication on hold like other systems. She added that she could see how someone in a hurry, stopped the medication, and did not start it up again. She stated that she expected staff to have started the order and to give the medication. She stated nurses and the medication aids were responsible for ensuring that medications were given accurately to residents. She stated, staff monitored medication orders by pulling up the MAR and pulling up a medication report. She stated with Plavix, the resident could develop a blood clot and have a stroke if the medication was missed. Regarding Resident #18's medication situation, she stated, she was not sure about the hydralazine. She added, staff had access to the stock safe and did not give the medication. She stated she had conducted in-services on the stock safe. She stated at times if the medication was not on the cart, staff did not give it. She stated the nurses were not aware of missed medications for Residents #11 and #18. She added that the CMAs said they did not tell the nurse about the hydralazine. She stated that she was still investigating the issue on the eye ointment for Resident #18 and stated, I'm not sure what happened there. She stated staff should be informing if they were out of medications. She stated medications could have been purchased locally. She stated she felt the situation occurred due to poor communication and not letting the nurses and the DON know. She stated she expected staff to have provided the medication and notified the nurses. She stated the CMA should report medication issues to the nurse, and if the medication was not in the safe to then contact the DON. She stated that the DON and nurse were responsible for ensuring that residents received their medication's. She stated the resident's eye situation could have worsen and her blood pressure could have led to a stroke as a result of the missed medications.<BR/>On 2/8/24 at 5:10 PM an interview was conducted with the Administrator regarding missed medications for Resident #11 and Resident #18. He stated he felt there was a break in communication that caused the situation to occur. He stated his staff should communicate. He added, the first day the medication was not there, they should have told the nurse. He stated that the nurses, the DON and the ADON were responsible for residents receiving their medications. He stated without Plavix, the stent could have clotted. The resident (that missed hydralazine) could have experienced an increase in blood pressure and the missed eye ointment, it would not help her vision.<BR/>Record review of the in-service, titled E Kit, instructor DON, dated 11/15/23 revealed the following documentation, Topic: if out of medication or meds not received, we need to be sure to check the E kit for every med before charting Drug Unavailable. This in-service was given to staff in the nursing department. <BR/>Record review of the facility policy, titled Pharmacy Services, Overview, Revised April 2007, revealed the following documentation, Policy Statement. The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication, and biologicals, and the services of a licensed pharmacist. Policy Interpretation and Implementation. <BR/>3. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support resident's needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but it's not limited to, collaborating with the facility and Medical Director to . <BR/>f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers. <BR/>h. Collaborate with the staff and practitioners to address and resolve medication related needs or problems. <BR/>l. Help the facility develop a process for receiving, transcribing, and recapitulating medication orders. <BR/>Based on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications for 1/2 medication carts and 1/2 medication storage rooms reviewed for pharmaceutical services in that: <BR/>MA B had expired aspirin 325 mg on cart of 02/23. <BR/> Seven bottles of Geri-Care Geri-Lanta 355 ml (12 fl oz.) was found to be expired on 12/23 <BR/>These failures could place residents at risk of taking medications that are expired causing medication to be ineffective or having adverse reactions. <BR/>Findings include: <BR/>Observation made of medication storage room on south hall (wing 1) on 02/07/2024 at 2:33 pm with LVN C revealed seven bottles of Geri-Care Geri-Lanta 355 ml (12 fl oz.) expired on 12/23. Observed LVN C dispose of the expired medication by taking it to the DON to discard. <BR/>Observation made of medication storage room on south hall (wing 1) on 02/07/2024 at 2:33 pm with LVN C revealed seven bottles of Geri-Care Geri-Lanta 355 ml (12 fl oz.) expired on 12/23. Observed LVN C dispose of the expired medication by taking it to the DON to discard. <BR/>Interview with the DON on 02/07/2024 at 1:53 pm. revealed the DON stated that she expects the staff to keep the carts and storage clean. The DON stated that the medication aides are responsible for checking the carts prior to the beginning of their shift. The DON stated that the ADON will do random cart checks to make sure that the cart is cleaned, and expiration dates are checked approximately weekly. The DON stated that for an expired medication is that the resident could metabolize the medication differently cause ineffective medication. The DON stated that an in-service will be completed. The DON stated that staff have been trained on expired medications through in-services and in-services occur approximately bi-weekly. <BR/>Interview with the Administrator on 02/07/2024 at 2:01 pm., the Administrator stated that he expects medication aides to check the carts and to make sure there are no expired medications in the carts or in the medication storage rooms. The Administrator stated that the negative potential outcome for expired medications is that it could cause the resident to not get the correct dosage of medications or it being ineffective. The Administrator stated that the negative potential outcome for loose medications on the cart could cause a resident to have a missed medication because not enough medication left. The Administrator stated that the staff will get in-serviced on loose medications and expired medications. <BR/>Interview with LVN C about the expired medications on 02/07/2024 at 2:37 pm revealed LVN C stated that it is the responsibility of all staff to check the medication storage for expired medications. LVN C stated that the room is just randomly checked when the staff have time. LVN C stated that the negative potential outcome for expired medications or supplements is it not working, medication error, and adverse reactions. LVN C stated that they have had in-services and it is just randomly, not a set time. <BR/>Interview with LVN B (charge nurse) on 02/07/2024 at 2:48 pm, LVN B stated that it is the responsibility of the staff member that is assigned to that cart to make sure cart is cleaned. LVN B stated that all staff are responsible to check the medication room. LVN B stated that the negative potential outcome for expired medications is ineffective medication or overdose, resident could get sick, adverse reactions, or not the desired effect. LVN B stated that the negative potential outcome for loose medications is if the cart is left unlocked then a resident could get the wrong medication or with the loose medication a resident could have a missed medication. LVN B stated that in-services are completed and are held approximately monthly. LVN B stated that the DON, ADON, and Pharmacist will check the medication room randomly but is not sure how often. <BR/>Record Review of facility provided policy, labeled, Storage of Medications, provided on 02/08/2024 date Revised November 2020, revealed: <BR/>Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. <BR/>Policy Interpretation and Implementation: <BR/>2. Drugs and Biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. <BR/>4. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 2 of 12 (Resident #4 and Resident #6) reviewed for unnecessary medications.The facility failed to ensure that Resident #4 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date.The facility failed to ensure that Resident #6 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date.This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health.Findings included:Resident #4 Record review of Resident #4's face sheet, dated 09/0325, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis of generalized anxiety disorder (increased worry), psychosis (mental health condition characterized with by false contact with reality. Record review of Resident #4's Comprehensive MDS, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section N Medications revealed Resident #4 took the following high-risk medications: Anti-anxietyResident #4's care plan, dated 6/19/25 revealed the following:Resident #4 had a focus for psychotropic drug use specifically that Resident #4 had potential for complications related to antidepressant medications, specifically Lorazepam. (initiated 7/9/25) The goal was for Resident #4 to be free from side effects to the medication and to not exhibit side effects from taking antianxiety medications. Staff should monitor resident's functional status each shift. Staff should monitor resident's mood and response to medication. Staff should monitor side effects such as sedation, drowsiness, dizziness, nausea and vomiting. The staff should have a pharmacy review monthly. Record review of Resident #4's physician orders, undated, revealed the following:*Lorazepam .5 mg/ML; .25 ML every 6 hours prn diagnosis: generalized anxiety; order start date: 12/18/24 and end date: open ended.Record review of #4's medication consent, dated 08/28/24, revealed Resident #4's MAR for July 2025 revealed that Resident #4 was not administered Lorazepam .5 mg/ML: .25 ML prn.Resident #4's MAR for August 2025 revealed that Resident #4 was administered Lorazepam .5 mg/ML: .25 ML prn on the following dates:*08/01/25 at 11:27 AM by LVN W *08/01/25 at 6:29 PM by RN Y (doses effective), *08/05/25 at 2:46 PM by LVN F (dose effective), and *08/25/25 at 4:06 PM by LVN L (dose effective).Resident #4's MAR for September 2025 revealed that Resident #4 was not administered Lorazepam .5 mg/ML.Record review of Resident #4's Consultant Pharmacist Recommendation, dated 08/28/24, signed by the Pharmacy Consultant revealed:In accordance with state and federal guidelines, psychotropic drugs, PRN, orders for psychotropic drugs are limited to 14 days, except when the attending position or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then here she should document the rationale in the resident medical record and indicate the duration for the PRN order. Response: Continue PRN use for 90 days, as the benefit outweighs the risk.Record review of Resident #4's progress notes, dated 06/01/25-09/03/25, revealed the following:*08/01/25 at 4:33 PM, LVN W documented Resident #4 was witnessed rolling himself from the edge of the bed onto his fall mat and appeared to be confused. The resident was given .25 ml of lorazepam to help with anxiety and agitation. Further review reviewed there were no additional progress notes regarding lorazepam, medication administration or anxiety. During an interview on 09/05/25 at 10:31 AM, Resident #4 did not contribute any information related to the specific failure. Resident #6 Record review of Resident #6's face sheet, dated 09/19/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), generalized anxiety (increased worry) and cognitive communication deficit (difficulty communicating). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed: *Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Section N Medications revealed Resident #6 did not take high-risk medications, to include anti-anxiety. Record review of Resident #6's physician orders, undated, revealed the following:*Lorazepam 2 mg/ ML;.25 ML Every 4 hours PRN; diagnosis: pain: 08/03/25 and end date: open ended.Record review of Resident #6's updated prescription order, dated 09/09/25, revealed:*Lorazepam 2 mg/ ML;.25 ML Every 4 hours PRN; diagnosis: Generalized anxiety: 09/09/25 and end date: 09/23/25Record review of Resident #6's MAR for August and September 2025 revealed that Resident #6 was not administered Lorazepam .5 mg/ML.Record review of Resident #6's Consultant Pharmacist Recommendation, dated 08/25/25, signed by the Pharmacy Consultant revealed:In accordance with state and federal guidelines, psychotropic drugs, PRN, orders for psychotropic drugs are limited to 14 days, except when the attending position or prescribing practitioner believes that it is appropriate for the PR in order to be extended beyond 14 days. Then here she should document the Russian now and the resident medical record and indicate the duration for the PRN order. Response (no response documented)Record review of Resident #6's care plan, dated 5/22/25 revealed Resident #6 did not have a care plan regarding prn medications and or anti-anxiety (Lorazepam) medication administration. Record review of Resident #6's progress notes, dated 08/3/25 at 1:31 PM written by LVN W revealed Resident #6 hospice nurse came and evaluated her (Resident #6). LVN W stated Resident #6 was transitioning and the hospice nurse would order comfort medications (specific medication was not indicated). During an interview on 09/05/25 at 10:27 AM, Resident #6 was unable to participate in an interview as she was sleep.During an interview on 09/05/25 at 5:10 PM, Resident #6 did not answer the investigator's questions. She blinked at the investigator and the investigator thanked her for her time and exited the room. During an interview on 9/05/25 at 9:56 AM the FNP T stated she was unaware that Resident #4 and Resident #6 did not have a 14 day stop date for their PRN Lorazepam. She stated she generally does not order that medication but hospice or the psychiatric provider would order Lorazepam. FNP T stated she was not very fond of benzodiazepines. She stated it was a medication that was on the high-risk list for elderly residents. FNP T stated Lorazepam was not used for pain but given for anxiety. FNP T stated she did not have any information regarding Resident #4 having a 90 day stop date and the physician order not being updated. She stated the purpose of having a 14 day stop date was to ensure that they followed guideline, and it was a standard for PRN medications in that class. During an interview on 9/05/25 at 11:50 AM Hospice RN DD stated she was unaware that Resident #6 did not have a 14 day stop date. Hospice RN DD stated she was familiar with the concept that PRN antianxiety and antipsychotic should not exceed the 14 days stop date. She stated she was unsure of the purpose of the 14 day stop date for PRN antianxiety and antipsychotic medications. Hospice RN DD stated facility staff may have told her about the 14 day stop date but she did not remember. She stated she was aware that antianxiety and antipsychotics could cause excessive sleepiness, sedation or increase agitation in elderly patients. Hospice RN DD stated she was aware the same medications could cause hallucinations. Hospice RN DD stated the Lorazepam prescribed to Resident #6 was not for pain but should have been for anxiety. During an interview on 9/05/25 at 12:59 PM the DON stated he was familiar with the facility's Antipsychotic Medication policy. The DON stated that the purpose of a 14 day stop date on PRN antianxiety or antipsychotics was so that they could reference if there was a need for the medication or if the medication needed to be changed. He stated after the 14 day stop date they could assess the resident and determine if there was a need for a GDR. The DON stated the potential negative outcome for not ensuring that there were 14 day stop date for antianxiety and antipsychotic medications was the resident could experience a nontherapeutic outcome from the medication. He said for example, the resident may not be comfortable as the medication was intended for. The DON stated he was unaware that Resident #4 and Resident #6 PRN Lorazepam did not have a 14 day stop date. He stated it was brought to his attention by the ADON. He stated he was told the ADON that it was still the facility's responsibility to ensure that there was a 14 day stop date even if the medication was added by hospice. He stated there was not a system in place to monitor PRN antianxiety and antipsychotic medications, but it would take staff teaching and training. The DON stated he had been trained that PRN antianxiety and antipsychotic medications should have a 14 day stop date. He stated had not received a formal training, but it was apart of nursing standard practice. The DON stated all his staff have not been trained. He stated he did not have a physical list of who had not or had been trained. The DON stated he expected PRN antianxiety and antipsychotics to have a 14 day stop date and after the 14 days the resident to be evaluated by a physician, medication changes implemented if necessary and medication to be ordered timely. He stated he did not have a reason why Resident #4 and Resident #6 PRN Lorazepam did not have a 14 day stop date but that he was responsible for ensure the appropriate stop date was implemented and reflected in the resident's physician orders. He stated he was unaware there had been a 90-day recommendation for Resident #4 but expected the recommendation of the doctors to be reflected in the resident's physician's order. During an interview on 9/05/25 at 2:07 PM the ADM stated he was familiar with the facility's policy, Antipsychotic Medications, and the purpose of having a 14 day stop date on PRN antianxiety and antipsychotics was to make sure there was a review on the necessity of the medications. He stated the potential negative outcome of not have the required 14 day stop date for the PRN antianxiety or antipsychotic was could potentially receive a medication that they do not need. The ADM stated he was unaware Resident #4 and Resident #6 PRN Lorazepam did not have a 14 day stop date. He stated he was unaware that Resident #4 had a recommendation for a 90 day stop date and his physician order was not updated. He stated his staff had been trained on the requirement of a 14 day stop date and he knew about the requirement because of his nursing experience. The ADM stated he expected a 14 day stop date to be implemented and if the medication was ordered by hospice the nurse needed to ask for the 14 day stop date. He stated he did not have a reason why there was not a 14 day stop date for Resident #4 and Resident #6 but whoever took the orders were responsible. During an interview on 9/05/25 at 3:54 PM the ADON stated she was familiar with the facility's Antipsychotic Medication Policy. She stated the purpose of having a 14 day stop date for PRN antipsychotics and antianxiety medications was to monitor if the medication was still needed for the resident. The ADON stated they do not want to snow their residents. The ADON stated using the term snow means that the resident would be either too groggy or overly sedated. The ADON stated the potential negative outcome for not having the 14 day stop date for PRN antipsychotic and antianxiety was the residents could potentially be overly sedated. The ADON stated she was unaware that Resident #4 and Resident #6 did not have a 14 day stop date for their PRN Lorazepam. She stated the system to monitor PRN antipsychotics and antianxiety medications was they should run reports and stay on top of them and let the hospice providers know. The ADON stated she would have to let the PNP know about the 14 day stop date. The ADON stated prior to the date of the interview (09/05/25) they did not have a system in place to monitor. The ADON stated she had been trained that PRN antipsychotics and antianxiety medications should have a 14 day stop date. The ADON stated her nurses should also know as it was apart of nursing in long term care. The ADON stated she or her nurses had not had any specific formal training from the facility. The ADON stated she did not think anything of the 14 day stop date as she thought since it was prescribed and apart of hospice it would be considered apart of palliative care. The ADON stated she expected her nurses to pay attention to the stop date when the medication was ordered. She stated the nurse receiving the order should ensure that the PRN medication had the 14 day stop date and should be reordered timely. The ADON stated there was no reason why Resident #4 and #6 PRN Lorazepam did not have a 14 day stop date. The ADON stated she assumed it was hospice that ensured there was a 14 day stop date but that it should be whichever nurse enters the order in the resident's EMR. The ADON stated she would follow up with the HHSC investigator on the purpose of the Lorazepam for Resident #6. The ADON stated Lorazepam was not typically used for pain. The ADON stated she did not have a reason why Resident #4's physician order was not updated to reflect the 90 day stop date that was indicated on the pharmacy recommendation from 2024, but that she expected the resident's physician order to be updated and reflect the recommendation from the Pharmacy Consultant and the assigned doctor. The ADON stated she would have expected the hospice provider to update the resident's EMR. She stated she is unsure if the hospice provider had access to the facility's EMR system. During an interview on 9/10/25 at 11:07 AM the Pharmacy Consultant stated he was unsure if he had already identified the lack of a 14 day stop date for Resident #4 and Resident #6. He stated he would have look at his notes and he was not where he could access the notes. He stated any documentation needed would have to be requested from the facility. He stated he does regimen reviews and if he identified there was a PRN antianxiety or antipsychotic, he generally would let the facility and doctor know through written notification. The Pharmacy Consultant stated the potential negative outcome for not having a 14 day stop date was the resident could receive the medication longer than he or she needed. Record review of the facility's policy, Use of Psychotropic Medications, dated July 2025, revealed:PolicyIt is the intent of this policy to ensure that residents only receive psychotropic medication's when other non-pharmacological interventions are clinically contraindicated. Additionally, this medication should only be used to treat the residence, Medical Center, and not used for discipline or staff convenience, which would deem it as a chemical restraint.Psychotropic medication's use on a PRN basis must have a diagnose specific condition and indication for the PRN use document in the residence medical record in a subjected to the limitations as noted: PRN orders for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner, believes it is appropriate to extend the order beyond the 14 days. The medical records should include documentation from the physician or prescriber for the rationale for the extended time. And indicate a specific duration. PRN orders for antipsychotic medication's only, shall be limited to 14 days with no exception. If the attending physician or prescribing practitioner, believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 2 medication carts (med cart on South Hall). <BR/>MA B had loose pills in the medication cart assigned to her on South Hall. <BR/>This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. <BR/>The findings include: <BR/>Record Review of Resident #42's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, depression, anxiety, urgency of urination, allergic rhinitis, type 2 diabetes with high blood sugar, congestive heart failure, irritable bowel syndrome with constipation, cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver, muscle wasting and atrophy, high blood pressure, reduced mobility. <BR/>Record Review of Resident #50's face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, anxiety, aphasia (loss or difficulty to understand or express speech), muscle weakness, depression, muscle spasm, constipation, high blood pressure, type 2 diabetes, hyperlipidemia, hyperthyroidism, pulmonary hypertension. <BR/>Record Review of Resident #56's face sheet reflected he was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of: end stage renal disease, fluid overload, gastrointestinal hemorrhage (a sign of a disorder in the digestive tract), hypotension, allergic rhinitis, thrombocytopenia (low platelets), depression, difficulty swallowing, bipolar disorder, type 2 diabetes, muscle weakness, renal dialysis (is a treatment for people whose kidneys are failing), muscle wasting and atrophy, acid reflux, hyperlipidemia, hypothyroidism, chronic kidney disease. <BR/> Observation and interview on 02/07/2024 at 1:28 pm during a medication cart check with MA B, revealed 6 loose medications in the medication cart in which MA B was responsible for. The medications that were found were as listed: glyburide 5 mg (1 pill) belonging to Resident #50, atorvastatin 20 mg (2 pills) belonging to Resident #50, hydroxyzine hydrochloride 25 mg (2) pill belonging to Resident #42, and carvedilol 6.25 mg belonging to Resident #56. The medications were identified by MA B by locating the medication cards and locating the missing medications. MA B observed the loose medications in her cart. MA B stated that it had been her responsibility to check her cart upon taking responsibility of the cart for the day. MA B stated that the charge nurse is also responsible for checking the carts and carts are usually checked before every shift. MA B stated that she had been trained in medication storage through in-services and the facility will hold in-services approximately monthly. MA B stated that the negative potential outcome for having loose medications in the cart is that the resident could not have enough medication and the pharmacy may not refill their medications causing a missed medication. <BR/>Interview with the Clinical Resource Nurse on 02/07/2023 at 1:42 pm revealed the Clinical Resource Nurse was informed of the loose medications found on the cart during the medication cart check. The Clinical Resource Nurse stated that he expects all staff that is responsible for the cart to check the cart prior to shift. The Clinical Resource Nurse stated that the negative potential outcome for loose medications on the cart is that it could cause a resident to miss a dose of medication because they have to dispose of that medication. The Clinical Resource Nurse stated that he will be in-serviced on loose medications. <BR/>Interview with the DON on 02/07/2024 at 1:53 pm. revealed the DON stated that she expects the staff to keep the carts and storage clean. The DON stated that the medication aides are responsible for checking the carts prior to the beginning of their shift. The DON stated that the ADON will do random cart checks to make sure that the cart is cleaned and are checked approximately weekly. The DON stated that the negative potential outcome for loose medications is that the wrong resident could get the medication, or it could cause a missed medication. The DON stated that an in-service will be completed. The DON stated that staff have been trained on expired medications and loose pills through in-services and in-services occur approximately bi-weekly. <BR/>Interview with the Administrator on 02/07/2024 at 2:01 pm., The Administrator stated that the negative potential outcome for loose medications on the cart could cause a resident to have a missed medication because not enough medication left. The Administrator stated that the staff will get in-serviced on loose medications and expired medications. <BR/>Record Review of facility provided policy, labeled, Storage of Medications, provided on 02/08/2024 date Revised November 2020, revealed: <BR/>Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. <BR/>Policy Interpretation and Implementation: <BR/>2. Drugs and Biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined the facility failed to provide ADL (Activities of Daily Living) care for 7 of 7 residents (Resident#1, #10, #11, #12, #13, #14, and #15)) observed for ADL care to ensure they were receiving appropriate hygiene in that:<BR/>The facility failed to provide showers for Residents #1, #10, #11, #12, #13, #14, and #15, on a routine basis. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. <BR/>The findings include: <BR/>Resident #1:<BR/>Record review of an admission Record dated for Resident #1 shows a [AGE] year-old female with an original admission date of 12/18/2024 and a readmission date of 1/6/2025 with diagnoses of transient ischemic attack (TIA) (mini stroke), and cerebral infarction (stroke), Paranoid schizophrenia , Metabolic encephalopathy (a problem with the brain caused by a chemical imbalance in the blood), Urinary tract infection, Tachycardia (fast heart rate), Wheezing, Nausea, Dysuria (discomfort when urinating), Edema (inflammation), Pressure-induced deep tissue damage of right ankle, Depression, gastro-esophageal reflux disease without esophagitis (acid reflux), gastroenteritis and colitis (is inflammation of the stomach and intestines and colitis is the inflammation of the colon), Pressure ulcer of left ankle, stage 4, Spondylosis (age-related wear and tear of the spinal disks), Pain in unspecified limb, acute osteomyelitis (inflammation of bone caused by infection), neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should), anxiety disorder, Quadriplegia (paralysis that affects all of the limbs), viral hepatitis C without hepatic coma, Tinea unguium (a nail fungus), Anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Hypokalemia (low potassium).<BR/>Record review of an annual MDS (Minimum Data Set) 11 #1 indicated a BIM (Brief Interview for Mental Status) of 15 meaning Resident #1 was cognitively intact. <BR/>There was no record of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an Interview on 1/17/2025 at 11:44 AM, Resident #1 stated that she had not had a bed bath but once since she had been in the facility. Resident #1 stated that she did not remember what day she had the one bed bath but would like to have a shower or bed bath on a routine basis. Resident #1 stated that she had asked staff for a shower, but they do not give her a shower. Resident #1 stated that she had told the CNA's because they were the ones who gave the showers. Resident #1 showed frustration that she had not had a shower. <BR/>Resident #10:<BR/>Record review of an admission Record review for Resident #10 showed a [AGE] year-old female with an original admission date of 11/10/2022 and a readmission date of 7/9/2023 with diagnoses of traumatic subdural hemorrhage without loss of consciousness, lack of coordination, anorexia nervosa, dementia, hyperlipidemia, primary open-angle glaucoma, left eye, unsteadiness on feet, anxiety disorder, intermittent explosive disorder-clarified, bipolar disorder, current episode mixed, moderate-clarified, pain, major depressive disorder, severe protein-calorie malnutrition, bacterial pneumonia, muscle weakness acute skin changes due to ultraviolet radiation, contact dermatitis, panic disorder, major depressive disorder, hypothyroidism, dysphagia, abnormalities of gait and mobility, altered mental status, unspecified, cognitive communication deficit, contusion of scalp, contusion of left eyelid and periocular area, contusion of left eyelid and periocular area, poisoning by unspecified drugs, hypo-osmolality and hyponatremia (produced by retention of water, by loss of sodium or both). <BR/>Record review of a Quarterly MDS (Minimum Data Set) #10 indicated a BIMS (Brief Interview for Mental Status) score of 5 meaning Resident #10 was severely cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 3:08 PM, Resident #10 stated that she had not had a shower recently. Resident #10 stated that the staff did not come around to check to see if she needed a shower. Resident #10 stated that the staff would barely change her brief half the time much less give her a shower. Resident #10 stated that if staff did not help her with a shower, then she would have to do without a shower. Resident #10 stated that she had brought up to the staff before that she needed a shower, and they usually did not come back. Resident #10 stated that this had been going on for months. Resident #10 showed frustration when talking about not having a shower. <BR/>Resident #11:<BR/>Record review of an admission Record review or Resident #11 showed a [AGE] year-old female with an admission date of 10/31/2023 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, urinary tract infection, dysphagia (difficulty swallowing), abnormal posture, cognitive communication deficit, nausea with vomiting, muscle weakness, reduced mobility, unspecified lack of coordination, retention of urine, gastro-esophageal reflux disease without esophagitis, hypotension, type 2 diabetes mellitus with diabetic polyneuropathy, insomnia, flaccid hemiplegia affecting right nondominant side, essential (primary) hypertension, cerebral infarction due to embolism of left middle cerebral artery, long term (current) use of anticoagulants, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), aphasia (difficulty swallowing), and pain.<BR/>Record review of a Quarterly MDS (Minimum Data Set) #11 indicated a BIMS (Brief Interview for Mental Status) score of 12 meaning Resident #10 was mildly cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 4:15 PM, Resident #11 stated that she was supposed to take a shower today (1/17/2024) but the staff had not given her a shower. Resident #11 stated that she had not had a shower in several days. Resident #11 stated that she would like to shower and did not like to miss taking a shower because she will smell. Resident #11 stated that she had not told the staff to give her a shower because she stated that she did not want to burden anyone. <BR/>Resident #12:<BR/>Record review of an admission Record dated for Resident #12 shows a [AGE] year-old female with an original admission date of 8/16/2024 with a readmission date of 11/6/2024 with a diagnosis of Chronic systolic (congestive) heart failure, insomnia, Muscle weakness, Major depressive disorder, Vitamin deficiency, seasonal allergic rhinitis, Urinary tract infection, Cognitive communication deficit, lack of coordination, Age-related cognitive decline, Dyspnea, Primary osteoarthritis, Peripheral vascular disease, Morbid (severe) obesity due to excess calories, Hypothyroidism, Generalized anxiety disorder, seizures, Essential (primary) hypertension, Pain, Age-related physical debility, Permanent atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). <BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 12/27/2024 for Resident #12 indicated a BIM (Brief Interview for Mental Status) of 9 meaning Resident #12 was mildly cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 3:27 PM, Resident #12 stated that she had not had a shower all week. Resident #12 stated that if she needed a shower, she had to go tell the staff and sometimes they would give her a shower and sometimes they were too busy to give her a shower. Resident #12 stated that staff will not change her sheets or make her bed most of the time. <BR/>Resident #13:<BR/>Record review of an admission Record dated for Resident #13 shows a [AGE] year-old male with an 8/16/2024 with a admission date of 8/27/2024 with a diagnosis of End stage renal disease, Otalgia of left ear (ear pain), Shortness of breath, Nasal congestion, Pain, Depression, abnormalities of gait and mobility, lack of coordination, Muscle weakness, Acute kidney failure, Chest pain, Essential (primary) hypertension (high blood pressure), Acute diastolic (congestive) heart failure, Gangrene (dead tissue caused by an infection or lack of blood flow), acute appendicitis (a condition in which the appendix becomes inflamed and filled with pus), Noninfective gastroenteritis and colitis involves inflammation of your stomach and intestines), unspecified, Methicillin susceptible Staphylococcus aureus infection (is a type of staph bacteria that's resistant to many antibiotics used to treat regular staph infections), Anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), Type 2 diabetes mellitus with foot ulcer, protein-calorie malnutrition, Hyperlipidemia (a condition in which there are high levels of fat particles in the blood), Hyperkalemia (a high level of the electrolyte potassium in the blood), Cognitive communication deficit, absence of limb, Acute appendicitis with perforation (a condition in which the appendix becomes inflamed and filled with pus), Chronic kidney disease, Acute metabolic acidosis (a condition in which too much acid accumulates in the body), Ventricular tachycardia (a condition in which the lower chambers of the heart (ventricles) beat very quickly).<BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 10/10/2024 for Resident #13 indicated a BIM (Brief Interview for Mental Status) of 11 meaning Resident #13 was mildly cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 1:53 PM, Resident #13 stated that he would like a shower but had not had one for a while. Resident #13 stated that the showers were not consistent. Resident #13 showed agitation in voice when talking about not being able to get a shower. <BR/>Resident #14:<BR/>Record review of an admission Record dated for Resident #14 shows a [AGE] year-old female with an original admission date of 7/21/2024 and a readmission date of 1/13/2024 with a diagnosis of (congestive) heart failure, malignant neoplasm of breast (a cancer that forms in the cells of the breasts), End stage renal disease (kidney failure), Vitamin D deficiency, lack of coordination, Hemorrhage of anus and rectum, Muscle weakness, Anemia in chronic kidney disease, Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Type 2 diabetes mellitus with diabetic nephropathy (a type of nerve damage that occur with diabetes), Iron deficiency, Morbid (severe) obesity due to excess calories, Hyperkalemia (high potassium), insomnia, chronic pain, Essential (primary) hypertension (high blood pressure), seasonal allergic rhinitis, Acute respiratory failure with hypoxia (a condition in which you do not have enough oxygen in your body), Gastro-esophageal reflux disease without esophagitis (acid reflux), Constipation, Chronic kidney disease, stage 4 (severe), Cellulitis (a common and potentially serious bacterial skin infection), Muscle wasting and atrophy, Neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain do not work the way they should), Difficulty in walking, Unsteadiness on feet, Pain, Weakness, Spinal stenosis (the spaces inside the bones of the spine get too small), lumbar region without neurogenic claudication, Depression, Other reduced mobility, lack of coordination, Repeated falls, Heart failure.<BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 11/1/2024 for Resident #14 indicated a BIM (Brief Interview for Mental Status) of 15 meaning Resident #14 was cognitively intact. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 2:45 PM, Resident #14 stated that showers were not being provided most of the time because they did not have enough staff to provide the showers for residents. Resident #14 stated she had to ask several times and then she would still not be given a shower. Resident #14 stated that staff would act like they did not want to mess with it, or it was too hard when she asked. Resident #14 stated that she had not told the Administrator yet because he was new and had only been in the facility a couple of days. Resident #14 stated that she knew that she was not the only resident that had not gotten a shower because she talked to many of the residents, and they all complained about it. <BR/>Resident #15:<BR/>Record review of an admission Record review for Resident #15 showed a [AGE] year-old female with an original admission date of 8/28/2022 and a readmission date of 10/30/2024 with diagnoses of atherosclerotic heart disease, fracture of right wrist and hand, urinary tract infection, edema, insomnia, glaucoma, abnormalities of gait and mobility, presence of cardiac pacemaker, bradycardia (slower than expected heart-rate) shortness of breath, tremor, chronic cough, unsteadiness on feet, painful micturition, dizziness, pain in left leg, arthritis, pain in right shoulder, difficulty in walking, overactive bladder, muscle weakness (generalized), open-angle glaucoma, hypothyroidism, essential (primary) hypertension, systolic (congestive) heart failure, cerebral infarction, persistent atrial fibrillation, depression, unspecified, fractures of lower end of right radius, subsequent encounter for closed fracture with routine healing, repeated falls, and fracture of right wrist and hand.<BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 9/1/2024 for Resident #15 indicated a BIMS (Brief Interview for Mental Status) score of 15 meaning Resident #15 was cognitively intact. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed. <BR/>During an interview on 1/17/2025 at 3:25 PM, Resident #15 stated that she had not had a shower in several weeks and it was like that a lot. Resident #15 stated that she had finally gotten tired of asking for a shower and not getting one that she took her stuff, went to the nursing station, and sat there and kept asking for a shower until she had finally gotten a shower. Resident #15 stated that it should not take that, and the residents were supposed to get a shower on schedule, but the staff did not go by the schedule. Resident #15 showed frustration at not being able to get a shower. <BR/>During an interview on 1/17/2025 at 3:50 PM, CNA A stated that she had not given any showers yet and had not seen any of the resident's getting a shower for today. CNA A stated that they were short staffed and stay busy. CNA A stated that if a resident missed a shower, it could make them feel embarrassed because they may be dirty. CNA A stated that each resident had a schedule and would normally get a shower a few times a week. <BR/>During an interview on 1/17/2025 at 5:58 PM, the DON stated that he expected that all resident's would receive a shower on a routine basis. The DON stated that he would make sure that shower sheets were to be completed. The DON stated that a prn CNA failed to provide showers on the night before shift (1/16/2024) and there would be education provided to the employee because this was not acceptable. The DON stated that he had not known that showers were not being provided because he was a new DON in the facility. The DON stated that the policy stated to provide showers to promote cleanliness and promote healing of the resident's skin. <BR/>During an interview on 1/17/2025 at 6:07 PM, the Administrator stated that he was going to hire a shower aide and that would be their only job daily. The Administrator stated that he had only been in this facility for a few days and noticed that there were many things to correct. The Administrator stated that he had not been aware that showers were not being provided. The Administrator stated that the residents should not have to do without a shower, and he was going to make sure that this was corrected. <BR/>Record review of grievance list dated 11/8/2024 with Council listed as name stated showers with no resolution listed. <BR/>Record review of grievance list dated 11/18/2024 with resident name listed stated showers with no resolution listed. <BR/>Record review of grievance list dated 11/26/2024 with resident name listed stated showers with no resolution listed. <BR/>Record review of Resident Council Minutes dated 1/3/2024, with seven residents in attendance, stated, shower schedule is not followed.<BR/>Record review of Resident Council Minutes dated 11/8/2024, with eight residents in attendance, stated, short-handed with staff and shower schedules.<BR/>Record review of Resident Council Minutes dated 10/11/2024, with eleven residents in attendance, stated, Residents have concerns with shower schedules.<BR/>Record review of Resident Council Minutes dated 9/6/2024, with eleven residents in attendance, stated, Residents have concerns with shower schedules.<BR/>Record review of Resident Council Minutes dated 8/9/2024, with ten residents in attendance, stated, Residents have concerns with shower schedules.<BR/>Review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, date revised March 2018, revealed: <BR/>Policy Statement: <BR/>Residents will provide with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). <BR/>Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.<BR/>1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. <BR/>a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. <BR/>2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: <BR/>a. Hygiene (bathing, dressing, grooming, and oral care). <BR/>3. Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. <BR/>4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. <BR/>Review of the facility's policy and procedure titled, Bath, Shower/Tub, date revised February 2018, revealed: <BR/>Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.<BR/>Documentation<BR/>1. The date and time the shower/tub bath was performed.<BR/>2. The name and title of the individual(s) who assisted the resident with the shower/tub bath.<BR/>3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath.<BR/>4. How the resident tolerated the shower/tub bath.<BR/>5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken.<BR/>6. The signature and title of the person recording the data.<BR/>Reporting<BR/>1. Notify the supervisor if the resident refuses the shower/tub bath.<BR/>2. Notify the physician of any skin areas that may need to be treated.<BR/>3. Report other information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for ADL care in that:<BR/>1. <BR/>The facility failed to accurately document ADL services for Resident #1. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.<BR/>The findings include: <BR/>Record review of Resident #1's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had a medical history of cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die), muscle weakness, and reduced mobility. <BR/>Record review of Resident #1's admission MDS revealed Section C- Cognitive patterns a BIMs score of 0 which indicated resident is rarely/never understood. Section GG- Functional Abilities revealed resident was dependent, helper does ALL of the effort, with shower/bathe, dressing, and toileting. Record review of Resident #1's progress notes revealed on 2/19/2025 and 2/20/2025 resident refused the social workers assessment, and no BIMS score was obtained. <BR/>During an interview and observation on 3/5/2025 at 4:30pm, Resident #1 was in bed with family at bedside. Resident stated he did not want a bed bath because he did not want to wet the bed. Resident #1's family explained they would not be getting the bed wet, but he needed a bed bath. Resident #1 continued to refuse his bed bath. CNA A stated she had offered him a bed bath throughout the day, and he had refused multiple times. <BR/>Record review of Resident #1's progress notes revealed on 3/5/2025 at 4:58pm RN B documented Resident refused shower today with family present. Resident stated that he did not want to get the bed wet and all of that mess. <BR/>Record review of Resident #1's point of care history titled Functional Abilities Shower/Bath self, revealed on 3/5/2025 at 10:04AM CNA A documented a shower/bath as dependent for Resident #1. On 3/6/2025 at 10:08AM CNA A documented a shower/bath as dependent for Resident #1. <BR/>During an interview with CNA A on 3/06/2025 at 2:29pm, she stated she normally documents ADLs after she had done them but sometimes, she would document before they were completed. She stated her training on documentation of ADLs was brief and she had not had an in-service. She stated if she documents she gave someone a bath/shower, but they refuse, or she was unable to complete the shower, she does not go back to change it to a refusal or as not completed. She stated the potential negative outcome of documenting ADLs incorrectly could be neglect with resident ADLs and the resident's needs not being met. <BR/>During an interview with the DON on 3/06/2025 at 3:29pm, he stated his expectation of staff is for them to perform the duty first and then document right after. He stated they were planning to implement an easier charting system for the CNAs to utilize. He stated the potential negative outcome of residents not receiving ADL care or showers could be skin breakdown, infection control issues or new wounds. He stated he had not provided any training on documentation since he was hired at the facility in January 2025 and is not sure when the last staff training was done. <BR/>During an interview with the ADM on 3/06/2025 at 3:52pm he stated staff should be performing the ADLs and then document what they did as accurately as possible. He stated he is not sure when the last training for documentation of ADLs was. He stated the potential negative outcome of inadequate ADL documentation could be residents not receiving that proper care. He stated residents could also be at risk for skin breakdown, immobility, or wounds. <BR/> Record review of facility policy titled Guidelines for Charting and Documentation last revised on April 2012 revealed: The purpose of charting and documentation is to provide: <BR/>A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care .<BR/>8. <BR/>All entries must reflect the date, the time and the signature and title of the person recording the data.<BR/>f. <BR/>Documentation each time the resident refuses his/her treatment, the resident's condition, and any adverse effects due to such refusal.

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 1 of 1 facility observed for pest control.<BR/>1. <BR/>The facility failed to follow the instructions from the pest control company to have multiple holes fixed in the facility that rodents potentially used for access into the building between 1/10/2025 and 2/25/2025. <BR/>The noncompliance was identified as PNC . The noncompliance began on 1/10/2025and ended on 3/3/2025. The facility had corrected the non-compliance before the survey began. <BR/>These failures could place residents at risk for the spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings included:<BR/>Record review of facility's document titled Service inspection Report dated 1/10/2025 revealed:<BR/>After speaking with [Maintenance Man A] and [ADM ], there is a good plan for getting all the holes fixed which ultimately will fix the mouse issue. Spoke with ADM and taking a day to focus on getting the holes fixed and also mentioned hiring a contractor that can come out and just knock it out. I walked with Maintenance Man A and was able to show him the holes and even found a couple new ones. <BR/>Record review of facility's document titled Service inspection Report dated 2/25/2025 revealed:<BR/>Inspected and found the same holes that were listed previously still have not been fixed. These need to be fixed along with several other holes listed previously. The [administrator and DON] are going to try and have these fixed, but they do not have a maintenance person. As a tech I can fix these holes along with a helper it will not be professional, but the holes will be fixed a proposal has been sent out in the past but have not gotten a response for this. <BR/>During an interview with Resident #2 on 3/4/2025 at 12:07pm, she stated she had not had any more mice concerns since they patched up the holes in her room. Resident #2 was unable to recall when they patched the holes up in her room. Resident #2 stated before the holes had been fixed, she had some papers that had been chewed up. <BR/>During an interview with Resident #3 family member on 3/4/2025 at 5:30pm, she stated she had brought Resident #3 some candy bars. Resident #3's family member stated on 2/21/2025, she went to open the candy bar and she noticed the candy had been bitten into and there were mouse dropping in the drawer where the candy bars had been kept in. Resident #3's family member stated, when she notified a staff member their response to her was that the facility had a rat problem. Resident #3's family member was unable to name the staff member and Resident #3 was discharged on 2/26/2025. <BR/>During an interview with RMM on 3/05/2025 at 10:16AM, he stated the building had been without a maintenance man for a while and the last one wasn't doing his job correctly, so they had let him go. He stated they had hired a new maintenance man and he had started working at the facility two days ago [3/3/2025]. He stated he has been working with the new maintenance man and they had made some good progress and most, if not all, of the holes had been fixed. He currently stated the pest control program consisted of the Pest Control company coming out once a week until the problem is resolved and then it would go back to a monthly schedule. He stated he had also been working with housekeeping in making sure the rooms are being kept clean. He stated any mouse droppings that have been found in the past week appear old and not fresh. RMM stated he had contacted the city code enforcement in regard to the restaurant they shared an alley with. He stated the field had been unkept and there was trash pilling up which was contributing to their rodent problems. <BR/>During observations made on 3/05/2025 between 10:20AM and 11:21 AM, Rooms 8, 9,12,14, 17, 30, 45, 46, entrance lobby and halls 1 and 2 were inspected with RMM for holes. Multiple holes below the sinks had been repaired. The entrance lobby of the facility had two large holes where drywall had been replaced and sealed. Exterior campus of the facility had multiple rodent traps placed along the edges of the building. No open holes were observed. <BR/>During an interview with the DON on 3/06/2025 at 3:29pm, he stated the plan for the pest control had been to set out traps and to fix the holes. He stated the maintenance man they had, reported he had fixed all the holes, but they later learned he had not. He stated when they did a walk through about two weeks ago, they had noticed there were still holes that needed to be repaired. He stated they did find two mouse nests, one between room eight and one by the front lobby, and they were disposed of. He stated at this point all the holes should be fixed. He stated the facility did not hire an external entity for facility repairs. He stated he felt the steps the facility had taken had been adequate. He stated the potential negative outcome of rodents being in the facility could be infection control or people getting sick. <BR/>During an interview with the ADM on 3/06/2025 at 3:52pm, he stated he believed the lack of a maintenance man was the reason they were unable to address the issues with the rodents. He stated now that they had repaired most of the holes and they had a new maintenance man , they would be monitoring for new holes and any signs of continued rodent issues. He stated they have at this time increase the visits from the Pest control Company to weekly visits. He stated they would continue to remove any unnecessary clutter from the facility because that can also draw them in. He stated the potential negative outcome of not having an adequate pest control program was an infestation and infection control issues. <BR/>Record review of facility document titled Plan of Action- Rodents undated revealed: <BR/> .Proposal<BR/>Observations/Reports: rodent activity has been reported in resident rooms. Recommend service escalation to mitigate theses issues. <BR/>Temporary escalation Recommended- until issues subside- weekly.<BR/>Record review of facility document titled Pest Management Service Agreement dated 2/2/22 revealed:<BR/>Services to be performed.<BR/>a. <BR/>Perform monthly pest control services .<BR/>b. <BR/>Inspecting and treating exterior pest issues .<BR/>c. <BR/>Inspecting and treating interior pest issues .<BR/>d. <BR/>Monitoring and maintain any equipment use to bait and or eliminate pest inside and outside the building <BR/>e. <BR/>When requested, treat specific areas that are experiencing a particular problem .<BR/>f. <BR/>Providing suggestions and advice to the staff that would help alleviate any existing pest issues and prevent future issues.<BR/>Record review of facility document titled Pest Control last revised May 2008 revealed:<BR/>Our facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents <BR/>6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 1 of 1 resident was reviewed for privacy (Resident #8). <BR/>1. LVN B left Resident #8's information up on the screen while her computer cart was on the other side of the nurse's station, and she was at the nurse's station. The computer screen was left up with Resident #8's information up and residents were walking by, putting Resident #8's information at risk.<BR/>This failure could place residents at risk of having medical information exposed to others and misuse of personal information. <BR/>Findings Included: <BR/>Resident #8:<BR/>Record review of an admission Record review for Resident #8 showed a [AGE] year-old male with an original admission date of 7/21/2022 and a readmission date of 11/23/2024 with diagnoses of end stage renal disease, fluid overload, atrial fibrillation, insomnia, lesions of oral mucosa, muscle spasm, edema, nausea, difficulty in walking, lack of coordination, abnormal posture, pain, muscle weakness, encephalopathy, pleural effusion, pneumonia, severe sepsis with septic shock, dependence on renal dialysis, depressive disorders, acute kidney failure, respiratory failure with hypoxia, essential (primary) hypertension, type 2 diabetes mellitus without complications, unspecified with intoxication with perceptual disturbance, metabolic encephalopathy, chronic obstructive pulmonary disease, and right heart failure.<BR/>Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #8 indicated a BIMS (Brief Interview for Mental Status) score of 10 meaning Resident #8 was moderately cognitively impaired. <BR/>An observation was made of an exposed medical record for Resident #8 on 1/17/2025 at 4:18 PM. While making observations for call lights, it was observed that LVN B was sitting at the nurse's station behind the desk while her computer was on the medication cart on the opposite side of the nurse's station. The computer was left open and exposed while residents were walking by the exposed chart. <BR/>During an interview on 1/17/2025 at 4:27 PM, LVN B stated that she should have minimized the screen, but she had thought that if she were at the nurse's station it would be good. LVN B stated that she was not by the open medical record. LVN B stated that she had been trained in privacy. LVN B stated that she had not had any recent training in privacy due to new management. LVN B stated that the negative potential outcome of not providing privacy for resident's medical records was that the wrong person could get ahold of the resident information and misuse their information. LVN B stated that she should have locked the screen. <BR/>During an interview on 1/17/2025 at 5:53 PM, the DON stated that he expected all staff to abide by HIPAA. The DON stated that he expected the staff to minimize the screen or lock the screen to provide privacy to all residents. The DON stated that it was the responsibility of all staff to provide privacy to all residents and to protect their personal and medical information. The DON stated that the negative potential outcome could be that it could cause extortion and stealing resident information. <BR/>During an interview on 1/17/2025 at 6:01 PM, the Administrator stated that he expected that anytime the staff walked away from the kiosk, then the screen was to be locked or minimized. The Administrator stated that he was getting an in-service together. The Administrator stated that it could cause a resident's information to get stolen and cause identity theft and sometimes it takes years for someone to be able to correct that situation. <BR/>Record Review of facility provided policy, Labeled, Electronic Medical Records, date Revised in June 2019, stated: <BR/>Policy Statement: Electronic medical records may be used in lieu of paper records when approved by the Administrator.<BR/>Policy Interpretation: <BR/>3. <BR/>Only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system.<BR/>4. <BR/>The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure.<BR/>8. <BR/>Our electronic medical records system has safeguards to prevent unauthorized access of electronic protected health information (e-PHI). These safeguards include administrative, technical, and physical safeguards that are appropriate for:<BR/>a. <BR/>The probability and criticality of risks to e-PHI based on a thorough risk analysis conducted by this facility.<BR/>b. <BR/>The size, complexity, and capabilities of this organization; and<BR/>c. <BR/>The technical infrastructure, hardware, software, and security capabilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined the facility failed to provide ADL (Activities of Daily Living) care for 7 of 7 residents (Resident#1, #10, #11, #12, #13, #14, and #15)) observed for ADL care to ensure they were receiving appropriate hygiene in that:<BR/>The facility failed to provide showers for Residents #1, #10, #11, #12, #13, #14, and #15, on a routine basis. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. <BR/>The findings include: <BR/>Resident #1:<BR/>Record review of an admission Record dated for Resident #1 shows a [AGE] year-old female with an original admission date of 12/18/2024 and a readmission date of 1/6/2025 with diagnoses of transient ischemic attack (TIA) (mini stroke), and cerebral infarction (stroke), Paranoid schizophrenia , Metabolic encephalopathy (a problem with the brain caused by a chemical imbalance in the blood), Urinary tract infection, Tachycardia (fast heart rate), Wheezing, Nausea, Dysuria (discomfort when urinating), Edema (inflammation), Pressure-induced deep tissue damage of right ankle, Depression, gastro-esophageal reflux disease without esophagitis (acid reflux), gastroenteritis and colitis (is inflammation of the stomach and intestines and colitis is the inflammation of the colon), Pressure ulcer of left ankle, stage 4, Spondylosis (age-related wear and tear of the spinal disks), Pain in unspecified limb, acute osteomyelitis (inflammation of bone caused by infection), neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should), anxiety disorder, Quadriplegia (paralysis that affects all of the limbs), viral hepatitis C without hepatic coma, Tinea unguium (a nail fungus), Anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Hypokalemia (low potassium).<BR/>Record review of an annual MDS (Minimum Data Set) 11 #1 indicated a BIM (Brief Interview for Mental Status) of 15 meaning Resident #1 was cognitively intact. <BR/>There was no record of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an Interview on 1/17/2025 at 11:44 AM, Resident #1 stated that she had not had a bed bath but once since she had been in the facility. Resident #1 stated that she did not remember what day she had the one bed bath but would like to have a shower or bed bath on a routine basis. Resident #1 stated that she had asked staff for a shower, but they do not give her a shower. Resident #1 stated that she had told the CNA's because they were the ones who gave the showers. Resident #1 showed frustration that she had not had a shower. <BR/>Resident #10:<BR/>Record review of an admission Record review for Resident #10 showed a [AGE] year-old female with an original admission date of 11/10/2022 and a readmission date of 7/9/2023 with diagnoses of traumatic subdural hemorrhage without loss of consciousness, lack of coordination, anorexia nervosa, dementia, hyperlipidemia, primary open-angle glaucoma, left eye, unsteadiness on feet, anxiety disorder, intermittent explosive disorder-clarified, bipolar disorder, current episode mixed, moderate-clarified, pain, major depressive disorder, severe protein-calorie malnutrition, bacterial pneumonia, muscle weakness acute skin changes due to ultraviolet radiation, contact dermatitis, panic disorder, major depressive disorder, hypothyroidism, dysphagia, abnormalities of gait and mobility, altered mental status, unspecified, cognitive communication deficit, contusion of scalp, contusion of left eyelid and periocular area, contusion of left eyelid and periocular area, poisoning by unspecified drugs, hypo-osmolality and hyponatremia (produced by retention of water, by loss of sodium or both). <BR/>Record review of a Quarterly MDS (Minimum Data Set) #10 indicated a BIMS (Brief Interview for Mental Status) score of 5 meaning Resident #10 was severely cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 3:08 PM, Resident #10 stated that she had not had a shower recently. Resident #10 stated that the staff did not come around to check to see if she needed a shower. Resident #10 stated that the staff would barely change her brief half the time much less give her a shower. Resident #10 stated that if staff did not help her with a shower, then she would have to do without a shower. Resident #10 stated that she had brought up to the staff before that she needed a shower, and they usually did not come back. Resident #10 stated that this had been going on for months. Resident #10 showed frustration when talking about not having a shower. <BR/>Resident #11:<BR/>Record review of an admission Record review or Resident #11 showed a [AGE] year-old female with an admission date of 10/31/2023 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, urinary tract infection, dysphagia (difficulty swallowing), abnormal posture, cognitive communication deficit, nausea with vomiting, muscle weakness, reduced mobility, unspecified lack of coordination, retention of urine, gastro-esophageal reflux disease without esophagitis, hypotension, type 2 diabetes mellitus with diabetic polyneuropathy, insomnia, flaccid hemiplegia affecting right nondominant side, essential (primary) hypertension, cerebral infarction due to embolism of left middle cerebral artery, long term (current) use of anticoagulants, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), aphasia (difficulty swallowing), and pain.<BR/>Record review of a Quarterly MDS (Minimum Data Set) #11 indicated a BIMS (Brief Interview for Mental Status) score of 12 meaning Resident #10 was mildly cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 4:15 PM, Resident #11 stated that she was supposed to take a shower today (1/17/2024) but the staff had not given her a shower. Resident #11 stated that she had not had a shower in several days. Resident #11 stated that she would like to shower and did not like to miss taking a shower because she will smell. Resident #11 stated that she had not told the staff to give her a shower because she stated that she did not want to burden anyone. <BR/>Resident #12:<BR/>Record review of an admission Record dated for Resident #12 shows a [AGE] year-old female with an original admission date of 8/16/2024 with a readmission date of 11/6/2024 with a diagnosis of Chronic systolic (congestive) heart failure, insomnia, Muscle weakness, Major depressive disorder, Vitamin deficiency, seasonal allergic rhinitis, Urinary tract infection, Cognitive communication deficit, lack of coordination, Age-related cognitive decline, Dyspnea, Primary osteoarthritis, Peripheral vascular disease, Morbid (severe) obesity due to excess calories, Hypothyroidism, Generalized anxiety disorder, seizures, Essential (primary) hypertension, Pain, Age-related physical debility, Permanent atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). <BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 12/27/2024 for Resident #12 indicated a BIM (Brief Interview for Mental Status) of 9 meaning Resident #12 was mildly cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 3:27 PM, Resident #12 stated that she had not had a shower all week. Resident #12 stated that if she needed a shower, she had to go tell the staff and sometimes they would give her a shower and sometimes they were too busy to give her a shower. Resident #12 stated that staff will not change her sheets or make her bed most of the time. <BR/>Resident #13:<BR/>Record review of an admission Record dated for Resident #13 shows a [AGE] year-old male with an 8/16/2024 with a admission date of 8/27/2024 with a diagnosis of End stage renal disease, Otalgia of left ear (ear pain), Shortness of breath, Nasal congestion, Pain, Depression, abnormalities of gait and mobility, lack of coordination, Muscle weakness, Acute kidney failure, Chest pain, Essential (primary) hypertension (high blood pressure), Acute diastolic (congestive) heart failure, Gangrene (dead tissue caused by an infection or lack of blood flow), acute appendicitis (a condition in which the appendix becomes inflamed and filled with pus), Noninfective gastroenteritis and colitis involves inflammation of your stomach and intestines), unspecified, Methicillin susceptible Staphylococcus aureus infection (is a type of staph bacteria that's resistant to many antibiotics used to treat regular staph infections), Anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), Type 2 diabetes mellitus with foot ulcer, protein-calorie malnutrition, Hyperlipidemia (a condition in which there are high levels of fat particles in the blood), Hyperkalemia (a high level of the electrolyte potassium in the blood), Cognitive communication deficit, absence of limb, Acute appendicitis with perforation (a condition in which the appendix becomes inflamed and filled with pus), Chronic kidney disease, Acute metabolic acidosis (a condition in which too much acid accumulates in the body), Ventricular tachycardia (a condition in which the lower chambers of the heart (ventricles) beat very quickly).<BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 10/10/2024 for Resident #13 indicated a BIM (Brief Interview for Mental Status) of 11 meaning Resident #13 was mildly cognitively impaired. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 1:53 PM, Resident #13 stated that he would like a shower but had not had one for a while. Resident #13 stated that the showers were not consistent. Resident #13 showed agitation in voice when talking about not being able to get a shower. <BR/>Resident #14:<BR/>Record review of an admission Record dated for Resident #14 shows a [AGE] year-old female with an original admission date of 7/21/2024 and a readmission date of 1/13/2024 with a diagnosis of (congestive) heart failure, malignant neoplasm of breast (a cancer that forms in the cells of the breasts), End stage renal disease (kidney failure), Vitamin D deficiency, lack of coordination, Hemorrhage of anus and rectum, Muscle weakness, Anemia in chronic kidney disease, Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Type 2 diabetes mellitus with diabetic nephropathy (a type of nerve damage that occur with diabetes), Iron deficiency, Morbid (severe) obesity due to excess calories, Hyperkalemia (high potassium), insomnia, chronic pain, Essential (primary) hypertension (high blood pressure), seasonal allergic rhinitis, Acute respiratory failure with hypoxia (a condition in which you do not have enough oxygen in your body), Gastro-esophageal reflux disease without esophagitis (acid reflux), Constipation, Chronic kidney disease, stage 4 (severe), Cellulitis (a common and potentially serious bacterial skin infection), Muscle wasting and atrophy, Neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain do not work the way they should), Difficulty in walking, Unsteadiness on feet, Pain, Weakness, Spinal stenosis (the spaces inside the bones of the spine get too small), lumbar region without neurogenic claudication, Depression, Other reduced mobility, lack of coordination, Repeated falls, Heart failure.<BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 11/1/2024 for Resident #14 indicated a BIM (Brief Interview for Mental Status) of 15 meaning Resident #14 was cognitively intact. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed.<BR/>During an interview on 1/17/2025 at 2:45 PM, Resident #14 stated that showers were not being provided most of the time because they did not have enough staff to provide the showers for residents. Resident #14 stated she had to ask several times and then she would still not be given a shower. Resident #14 stated that staff would act like they did not want to mess with it, or it was too hard when she asked. Resident #14 stated that she had not told the Administrator yet because he was new and had only been in the facility a couple of days. Resident #14 stated that she knew that she was not the only resident that had not gotten a shower because she talked to many of the residents, and they all complained about it. <BR/>Resident #15:<BR/>Record review of an admission Record review for Resident #15 showed a [AGE] year-old female with an original admission date of 8/28/2022 and a readmission date of 10/30/2024 with diagnoses of atherosclerotic heart disease, fracture of right wrist and hand, urinary tract infection, edema, insomnia, glaucoma, abnormalities of gait and mobility, presence of cardiac pacemaker, bradycardia (slower than expected heart-rate) shortness of breath, tremor, chronic cough, unsteadiness on feet, painful micturition, dizziness, pain in left leg, arthritis, pain in right shoulder, difficulty in walking, overactive bladder, muscle weakness (generalized), open-angle glaucoma, hypothyroidism, essential (primary) hypertension, systolic (congestive) heart failure, cerebral infarction, persistent atrial fibrillation, depression, unspecified, fractures of lower end of right radius, subsequent encounter for closed fracture with routine healing, repeated falls, and fracture of right wrist and hand.<BR/>Record review of a Quarterly MDS (Minimum Data Set) dated 9/1/2024 for Resident #15 indicated a BIMS (Brief Interview for Mental Status) score of 15 meaning Resident #15 was cognitively intact. There was no record review of shower sheets being completed. Record review of shower sheets were left incomplete and blank. No documentation completed. <BR/>During an interview on 1/17/2025 at 3:25 PM, Resident #15 stated that she had not had a shower in several weeks and it was like that a lot. Resident #15 stated that she had finally gotten tired of asking for a shower and not getting one that she took her stuff, went to the nursing station, and sat there and kept asking for a shower until she had finally gotten a shower. Resident #15 stated that it should not take that, and the residents were supposed to get a shower on schedule, but the staff did not go by the schedule. Resident #15 showed frustration at not being able to get a shower. <BR/>During an interview on 1/17/2025 at 3:50 PM, CNA A stated that she had not given any showers yet and had not seen any of the resident's getting a shower for today. CNA A stated that they were short staffed and stay busy. CNA A stated that if a resident missed a shower, it could make them feel embarrassed because they may be dirty. CNA A stated that each resident had a schedule and would normally get a shower a few times a week. <BR/>During an interview on 1/17/2025 at 5:58 PM, the DON stated that he expected that all resident's would receive a shower on a routine basis. The DON stated that he would make sure that shower sheets were to be completed. The DON stated that a prn CNA failed to provide showers on the night before shift (1/16/2024) and there would be education provided to the employee because this was not acceptable. The DON stated that he had not known that showers were not being provided because he was a new DON in the facility. The DON stated that the policy stated to provide showers to promote cleanliness and promote healing of the resident's skin. <BR/>During an interview on 1/17/2025 at 6:07 PM, the Administrator stated that he was going to hire a shower aide and that would be their only job daily. The Administrator stated that he had only been in this facility for a few days and noticed that there were many things to correct. The Administrator stated that he had not been aware that showers were not being provided. The Administrator stated that the residents should not have to do without a shower, and he was going to make sure that this was corrected. <BR/>Record review of grievance list dated 11/8/2024 with Council listed as name stated showers with no resolution listed. <BR/>Record review of grievance list dated 11/18/2024 with resident name listed stated showers with no resolution listed. <BR/>Record review of grievance list dated 11/26/2024 with resident name listed stated showers with no resolution listed. <BR/>Record review of Resident Council Minutes dated 1/3/2024, with seven residents in attendance, stated, shower schedule is not followed.<BR/>Record review of Resident Council Minutes dated 11/8/2024, with eight residents in attendance, stated, short-handed with staff and shower schedules.<BR/>Record review of Resident Council Minutes dated 10/11/2024, with eleven residents in attendance, stated, Residents have concerns with shower schedules.<BR/>Record review of Resident Council Minutes dated 9/6/2024, with eleven residents in attendance, stated, Residents have concerns with shower schedules.<BR/>Record review of Resident Council Minutes dated 8/9/2024, with ten residents in attendance, stated, Residents have concerns with shower schedules.<BR/>Review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, date revised March 2018, revealed: <BR/>Policy Statement: <BR/>Residents will provide with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). <BR/>Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.<BR/>1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. <BR/>a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. <BR/>2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: <BR/>a. Hygiene (bathing, dressing, grooming, and oral care). <BR/>3. Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. <BR/>4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. <BR/>Review of the facility's policy and procedure titled, Bath, Shower/Tub, date revised February 2018, revealed: <BR/>Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.<BR/>Documentation<BR/>1. The date and time the shower/tub bath was performed.<BR/>2. The name and title of the individual(s) who assisted the resident with the shower/tub bath.<BR/>3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath.<BR/>4. How the resident tolerated the shower/tub bath.<BR/>5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken.<BR/>6. The signature and title of the person recording the data.<BR/>Reporting<BR/>1. Notify the supervisor if the resident refuses the shower/tub bath.<BR/>2. Notify the physician of any skin areas that may need to be treated.<BR/>3. Report other information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 2 of 24 resident reviewed for resident rights. (Resident #40 and Resident #32) <BR/>1. <BR/>The facility failed to obtain consent from Resident #40 or the responsible party for Lorazepam (medication used to treat anxiety disorders). <BR/>2. <BR/>The facility failed to obtain consent from Resident #32 or the responsible party for Lorazepam (medication used to treat anxiety disorders).<BR/>This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects. <BR/>The findings include: <BR/>Record review of Resident #40's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #40 had a medical history of paranoid schizophrenia (a chronic mental illness characterized by disruptions in thought, perception, emotion, and behavior), rhabdomyolysis (serious condition where damaged skeletal muscle breaks down rapidly), and generalized anxiety disorder. Resident #40 had a legal responsible party listed in the face sheet. <BR/>Record review of Resident #40's quarterly MDS Section C- Cognitive Patterns dated 2/8/2025 revealed no BIMS score which indicates Resident #40 was rarely/never understood. <BR/>Record review of Resident #40's physician orders revealed an order for lorazepam - Schedule IV tablet: 0.5 mg . Every 6 Hours - PRN, start date 12/18/2024 with no end date. Physician orders revealed an order for Lorazepam Intensol (lorazepam) - Schedule IV concentrate; 2 mg/mL; amt:0.25mL; oral Every 2 Hours - PRN, start date 1/03/2025 with no end date. <BR/>Record review of Resident #40s medication administration revealed Lorazepam 0.25mL PRN every 2 hours was administered on the following dates 1/3, and 1/31/2025. Lorazepam 0.5mg tablet every 6 hours was administered on the following dates 1/ 2, 1/9, 1/15 and 2/12/2025. <BR/>Record review of Resident #40's medical record did not reveal a signed consent form for the Lorazepam orders by Resident #40 or the responsible party.<BR/>Record review of Resident #32's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #32 had a medical history of unspecified dementia (a decline in cognitive function that cannot be attributed to a specific known cause), panic disorder (a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, eventually leading to the inability to perform simple daily tasks). Resident #32 had a legal responsible party listed in the face sheet <BR/>Record review of Resident #32's admission MDS Section C- Cognitive Patterns dated 12/24/2024 revealed a BIMs score of 00 which indicates Resident #32 had severe cognitive impairment. <BR/>Record review of Resident #32's physician orders revealed an order for lorazepam - Schedule IV tablet; 0.5 mg; oral Every 6 Hours, start date 12/16/2024 with no end date. <BR/>Record review of Resident #32s medication administration revealed Lorazepam 0.5mg every 6 hours PRN was administered on the following dates 2/1/2025 and 2/5/2025. <BR/>Record review of Resident #32's medical record did not reveal a signed consent form for the Lorazepam orders by Resident #32 or the responsible party. <BR/>During an interview with the DON on 3/13/2025 at approximately 12:15pm, he stated the nurses receiving the physician orders and the ADONs were responsible to ensuring the consent forms are completed. He stated the DON would review and confirm the consent form is signed. He stated they monitor compliance with consent being signed by doing audits monthly and quarterly reviews. He stated the potential negative outcome of not obtaining consent forms were the residents not being informed of potential side effects such as drowsiness, sedation, or increased risk of falls. He stated he was not sure why Resident #32 or Resident #40 did not have the signed consent forms. <BR/>During an interview with the ADM on 3/13/2025 at 12:55pm, he stated the nurse who takes the initial order should be making sure the consent forms were signed before beginning that medication therapy. He stated the consent form not being signed could cause the residents to have a medication they do not want or against the responsible party's wishes. He stated compliance was monitored monthly with the DON. <BR/>Record review of facility policy titled Psychoactive Medications dated July 2024 revealed: <BR/>Definition <BR/>A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics .<BR/>3. <BR/>Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions .<BR/>9. <BR/>Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication (excluding an emergency).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 9.38% based on 3 errors out of 32 opportunities, which involved 2 of 7 residents (Resident #6 and Resident #10) reviewed for medication administration. <BR/>1. LVN A failed to administer Resident #6's Certizine medication according to physician orders, resulting in Resident #6 receiving the medication late. <BR/>2. LVN A failed to verify the dosage on Resident #6's Simethicone 125 mg medication order prior to administering the medication, resulting in Resident #6 being underdosed. <BR/>3. LVN A failed to verify the dosage on Resident #10's vitamin D3 125 mcg medication order prior to administering the medication, resulting in Resident #10 being underdosed. <BR/>These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.<BR/>Findings included:<BR/>Resident #6<BR/>Record review of Resident #6's face sheet dated 03/12/25 revealed an [AGE] year-old female with an admission date of 06/12/22 with the following diagnoses: neuropathy (nerve damage), congestive heart failure (condition where the heart does not pump adequately), and gastroparesis (digestive condition).<BR/>Record review of Resident #6's current physicians orders revealed an order with a start date of 01/23/25 for Certizine 10 mg; amount: 1 tablet; oral; once a morning at 07:00 AM. Further record review revealed an order with a start date of 06/12/22 for Simethicone chewable tablet 125 mg; amount 1 tablet four times daily.<BR/>During a medication administration observation on 03/12/25 at 8:59 AM for Resident #6, LVN A dispensed one Cirtizine 10 mg tablet and one Simethicone 80 mg tablet into a medication cup and administered the medications to Resident #6. <BR/>Resident #10<BR/>Record review of Resident #10's face sheet dated 03/12/25 revealed an [AGE] year-old female with an admission date of 01/22/21 with the following diagnoses: metabolic encephalopathy (a change in brain function due to an underlying condition), protein-calorie malnutrition (change in body composition due to reduced nutrients, and hypertension (high blood pressure). <BR/>Record review of Resident #10's current physicians orders revealed an order with a start date of 08/16/23 for Cholecalciferol (vitamin D3) 125 mcg tablet (5,000 unit); amount: 1 tablet; oral once a morning 07:00 AM-10:00 AM.<BR/>During a medication administration observation on 03/12/25 at 9:13 AM for Resident #10, LVN A dispensed one vitamin D3 25 mcg tablet into a medication cup and administered the medication to Resident #10. <BR/>During an interview and observation on 03/12/25 at 12:32 PM, LVN A stated she was asked by nursing administration to take over medication pass for another staff member after 8:00 AM, which caused Resident #6's 7:00 AM medication to be administered late. LVN A pulled the bottle of Simethicone 80 mg from the top drawer of the medication cart and compared it to the physicians order for Resident #6. She stated, The order was for Simethicone 125 mg. The correct dosage was not given. LVN A pulled the bottle of vitamin D3 25 mcg from the top drawer of the medication cart and compared it to the physicians order for Resident #10. She stated, The order was for vitamin D3 125 mcg. I didn't read the order right. LVN A stated her protocol for a medication error was to report the error to her nurse manager and notify the physician. She stated she had been trained on accuracy of medication administration in her nursing education by verifying the right medication, right patient, right dosage, right time and right route. LVN A stated a potential negative outcome for failure to give medication at the right time was that it could interact with other medications. LVN A stated a potential negative outcome for failure to give the correct dosage of medication was that it could lower the therapeutic value and cause a resident to become sick. <BR/>During an interview on 03/13/25 at 9:28 AM, ADON A stated she was notified by LVN A of the medication errors for Resident #6 and Resident #10. She stated the physicians were notified and orders were clarified in the electronic medical record for each resident. She stated staff were trained to verify dosage with medication orders prior to administration of medications and to report medication errors immediately to nursing administration.<BR/>During an interview on 03/13/25 at 10:42 AM, the DON stated he was not aware that medication errors were made during the observation of medication pass. He stated staff were trained on accuracy of medication administration through competency checks conducted by the facility educator. He stated accuracy of medication administration was monitored through computer-based reconciliations of physicians orders and through periodic staff competency checks. The DON stated he was responsible to assure staff were properly trained on accurate medication administration. He stated a potential negative outcome for failure to administer medications according to physicians orders would be harm to the resident on multiple levels, such as death, depending on which medication is given. <BR/>During an interview on 03/13/25 at 10:42 AM, the ADM stated he was not aware that medication errors were made during the observation of medication pass. He stated it was the DON's responsibility to assure staff were trained on accurate medication administration. He stated his expectation of staff for accurate medication administration was that medications were given on time and according to physician's orders. The ADM stated a potential negative outcome for medication errors was adverse reactions for residents. <BR/>Record review of the facility-provided policy titled Specific Medication Administration Procedures, revised January 2018 revealed:<BR/>Policy<BR/>To administer medication in a safe and effective manner.<BR/>Procedures<BR/> .<BR/>C. Review 5 Rights (3) times:<BR/>1) Prior to removing the medication package/container from the cart/drawer;<BR/> a. Check MAR/TAR for order.<BR/>2) Prior to removing the medication from the container<BR/> a. Check the label against the order on the MAR.<BR/>3) After the dose has been prepared and before returning the medication to storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 2 medication carts (med cart on South Hall). <BR/>MA B had loose pills in the medication cart assigned to her on South Hall. <BR/>This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. <BR/>The findings include: <BR/>Record Review of Resident #42's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, depression, anxiety, urgency of urination, allergic rhinitis, type 2 diabetes with high blood sugar, congestive heart failure, irritable bowel syndrome with constipation, cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver, muscle wasting and atrophy, high blood pressure, reduced mobility. <BR/>Record Review of Resident #50's face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, anxiety, aphasia (loss or difficulty to understand or express speech), muscle weakness, depression, muscle spasm, constipation, high blood pressure, type 2 diabetes, hyperlipidemia, hyperthyroidism, pulmonary hypertension. <BR/>Record Review of Resident #56's face sheet reflected he was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of: end stage renal disease, fluid overload, gastrointestinal hemorrhage (a sign of a disorder in the digestive tract), hypotension, allergic rhinitis, thrombocytopenia (low platelets), depression, difficulty swallowing, bipolar disorder, type 2 diabetes, muscle weakness, renal dialysis (is a treatment for people whose kidneys are failing), muscle wasting and atrophy, acid reflux, hyperlipidemia, hypothyroidism, chronic kidney disease. <BR/> Observation and interview on 02/07/2024 at 1:28 pm during a medication cart check with MA B, revealed 6 loose medications in the medication cart in which MA B was responsible for. The medications that were found were as listed: glyburide 5 mg (1 pill) belonging to Resident #50, atorvastatin 20 mg (2 pills) belonging to Resident #50, hydroxyzine hydrochloride 25 mg (2) pill belonging to Resident #42, and carvedilol 6.25 mg belonging to Resident #56. The medications were identified by MA B by locating the medication cards and locating the missing medications. MA B observed the loose medications in her cart. MA B stated that it had been her responsibility to check her cart upon taking responsibility of the cart for the day. MA B stated that the charge nurse is also responsible for checking the carts and carts are usually checked before every shift. MA B stated that she had been trained in medication storage through in-services and the facility will hold in-services approximately monthly. MA B stated that the negative potential outcome for having loose medications in the cart is that the resident could not have enough medication and the pharmacy may not refill their medications causing a missed medication. <BR/>Interview with the Clinical Resource Nurse on 02/07/2023 at 1:42 pm revealed the Clinical Resource Nurse was informed of the loose medications found on the cart during the medication cart check. The Clinical Resource Nurse stated that he expects all staff that is responsible for the cart to check the cart prior to shift. The Clinical Resource Nurse stated that the negative potential outcome for loose medications on the cart is that it could cause a resident to miss a dose of medication because they have to dispose of that medication. The Clinical Resource Nurse stated that he will be in-serviced on loose medications. <BR/>Interview with the DON on 02/07/2024 at 1:53 pm. revealed the DON stated that she expects the staff to keep the carts and storage clean. The DON stated that the medication aides are responsible for checking the carts prior to the beginning of their shift. The DON stated that the ADON will do random cart checks to make sure that the cart is cleaned and are checked approximately weekly. The DON stated that the negative potential outcome for loose medications is that the wrong resident could get the medication, or it could cause a missed medication. The DON stated that an in-service will be completed. The DON stated that staff have been trained on expired medications and loose pills through in-services and in-services occur approximately bi-weekly. <BR/>Interview with the Administrator on 02/07/2024 at 2:01 pm., The Administrator stated that the negative potential outcome for loose medications on the cart could cause a resident to have a missed medication because not enough medication left. The Administrator stated that the staff will get in-serviced on loose medications and expired medications. <BR/>Record Review of facility provided policy, labeled, Storage of Medications, provided on 02/08/2024 date Revised November 2020, revealed: <BR/>Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. <BR/>Policy Interpretation and Implementation: <BR/>2. Drugs and Biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability.<BR/>1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/8/24 lunch). <BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. <BR/>The findings included:<BR/>During confidential individual interviews 6 of 16 residents voiced concerns related to food palatability.<BR/>One resident stated The food is always cold. It's all meals. Another resident stated, The foods are hard. One other resident stated, It sucks. It's not good. The hamburger buns are hard occasionally, and it has poor flavor. A resident stated that the food was so bad that she had to buy her food somewhere else. The resident added that the food was so bad that it made her throw up. Another resident stated, The food is cold and Does not taste good. <BR/>Record review of the Resident Council Minutes dated 11/10/23 revealed resident comments related to the food served in the facility. It was documented, They would like for dietary to put bread in Ziploc bags so bread would not get soggy.<BR/>Record review of the Resident Council Minutes dated 1/5/24 revealed residents had concerns regarding the food served. It was documented, . residents mentioned that the potatoes are rotten. The bread has mold on it. <BR/>- The following interviews and observations were made during a kitchen tour on 2/7/24 that began at 10:51 AM and concluded at 12:04 PM:<BR/>On 2/7/24 at 10:51 AM the Dietary Manager was informed of a request for a test tray for the noon meal.<BR/>On 2/7/24 at 11:26 AM an observation was made of the steam table. Dietary Staff C took temperatures of the foods on the steamtable with the following results:<BR/>Mixed vegetables at 156&deg;F<BR/>Noodles 176&deg;F <BR/> Pork tips 191&deg;F <BR/>Ground pork tips 171&deg;F<BR/>Pur&eacute;ed mixed vegetables and 170&deg;F. <BR/>Pur&eacute;ed pork 177&deg;F <BR/>Pur&eacute;ed bread 108.3&deg;F <BR/>Pur&eacute;e noodles 163.2&deg;F<BR/>Fortified mashed potatoes 155.7&deg;F.<BR/>Hamburger patty 168&deg;F<BR/>Rolls room temperature<BR/>Meal service started at 11:37 AM with the memory unit cart.<BR/>The memory unit cart service ended at 11:45 AM and left the kitchen.<BR/>The Station 1 cart tray prep began at 11:45 AM.<BR/>At 12:01 PM the last tray for Station 1 was prepared and at 12:01 PM they started preparing the sample tray. The preparation for the sample tray was completed at 12:03 PM and at 12:04 PM the cart for Station 1 left the kitchen. At 12:06 PM the cart arrived on Station 1 and staff began serving from the cart at 12:06 PM with the assistance of five staff and serving the Station 1 dining room first. At 12:10 PM the staff started serving residents on Station 1 hall and there were three staff serving the hallway. At 12:15 PM the last tray was served to Resident #35. The resident started eating at 12:16 PM.<BR/>At 12:17 PM the test trays arrived at the conference room and sampling began at 12:19 PM with the following results:<BR/>Beef patty 98.6&deg;F, cold<BR/>Mashed potatoes, 106&deg;F and tasted like instant potatoes and cold.<BR/>Ground pork, 108&deg;F and lukewarm<BR/>Pork tips 109&deg;F, lukewarm<BR/>Noodles 94.5&deg;F, cold and gummy<BR/>Mix vegetables 100&deg;F, cold<BR/>Pur&eacute;ed meat 113.2&deg;F, cold<BR/>Pur&eacute;ed vegetables 109&deg;F, cold and had poor flavor unlike vegetables <BR/>Pur&eacute;ed noodles 106.9&deg;F cold, gummy and had poor flavor unlike noodles <BR/>On 2/7/24 at 12:40 PM an observation and interview were conducted in the kitchen with Dietary Staff C. She stated one of two in use plate warmer bins was not operable. She further stated the bottom plates were hot but not the top ones. Observation of the third plate warmer bin revealed that it was not operable. Only one of three plate warmer bins were operable.<BR/>On 2/8/24 at 9:30 AM an interview was conducted with the Dietary Manager. He stated the speed on the line and the plate warmers was why the palatability issues occurred. He stated that the last time that the plate warmers worked on was two years ago in August (2022). He stated staff should have transferred plates over to the hot plates and picked up the speed on the service line. He also expected staff to pass the trays faster on the halls. He stated he tasted the foods in order to monitor the palatability of foods. He stated that all staff were responsible for ensuring that the foods were palatable. He further stated that residents could become sick, angry, and call the state if their foods were not palatable. He stated that residents had not stated to him that the foods were cold. He stated he attended menu reviews every Friday with residents and activities staff.<BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated most days he ate the facility food and it was fine. He stated their monitoring method was test trays. He stated the food had improved and he gave feedback. He stated that he expected residents to inform staff if the seasoning was not acceptable. He stated that the kitchen staff, Dietary Manager, and everyone were responsible for food palatability. He stated that as a result of unpalatable food residents may not eat, lose weight, or experience malnutrition. <BR/>Record review of the facility policy, titled Food and Nutrition Services, Revised September 2021, revealed the following documentation, Policy Statement. Each resident is provided with a nourishing, palatable, well-balanced, diet that meets his or her daily nutritional and special dietary needs, taking in consideration the preferences of each resident. Policy Interpretation, and Implementation. <BR/>2. A resident centered diet and nutrition plan will be based on this assessment. <BR/>6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the meal appears palatable and attractive, and it is served at a safe and appetizing temperature. <BR/>a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the dietary staff, so that a new food tray can be issued

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services.<BR/>1) The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions.<BR/>2) The facility failed to ensure food and non-food contact surfaces were clean. <BR/>3) The facility failed to ensure staff stored personal items in a manner that prevented contamination. <BR/>4) The facility failed to ensure food was accurately dated and labeled. <BR/>5) The facility failed to protect foods from potential contamination. <BR/>6) The facility failed to ensure staff wore hair restraints in food areas.<BR/>7) The facility failed to ensure sanitizer were at recommended concentrations and used according to manufacturer recommendations, <BR/>8) The facility failed to rapidly reheat potentially hazardous hot food to 165 degrees F prior to placing on the steam table. <BR/>9) The facility failed to ensure that potentially hazardous cold foods were maintained at 41 degrees F or below.<BR/>10) The facility failed to ensure staff used good hygienic practices.<BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings included :<BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 8:54 AM and concluded at 9:45 AM:<BR/>Dietary staff D was observed washing his hands. He turned off the water with his bare hand and then dried them with paper towels. He then donned a pair of gloves and then handled soiled dish trays in the dishwasher area. He then move to the clean dishes and put away trays from the clean side of the dishwasher. <BR/>Observation on 2/6/24 at 9:05 AM, revealed as the Dietary staff D was observed wearing gloves, he was going back-and-forth from soiled dishes to putting away clean lids at the dishwasher and not washing his hands and changing gloves between the soiled and clean operations.<BR/>There was a plastic headband stored on top of the toaster next to a covered thermometer. <BR/>Observation on 2/6/24 at 9:13 AM, revealed the Dietary staff D was wearing gloves and went from handling soiled to clean equipment at the dishwasher area without washing his hands between the soiled and clean operation. He handled soiled dishes and then put away pitchers and cups that were clean.<BR/>Observation on 2/6/24 at 9:18 AM revealed the three compartment sink quaternary sanitizer level was tested at 100 ppm by Dietary staff A. At that time Dietary staff A stated It needs to be a little stronger .<BR/>The front area produce refrigerator had three thawed cartons of vanilla Ready Care shakes on a tray. The cartons reflected Use within 14 days of thawing. There was no label or date to determine if the 14 days had passed. <BR/>The magnetic lid trim was pulling away from the lid on the chest freezer. <BR/>Observation on 2/6/24 at 9:26 AM, revealed Dietary staff A was observed taking food equipment out of the quaternary sink, three compartment sink sanitizer basin where he had just cleaned food equipment. He tested the level of sanitizer in the sanitizing sink, and it was 100 ppm quat. He stated at this time, Maybe I need to drain it and refill it. <BR/>Observation on 2/6/24 at 9:30 AM revealed Dietary staff A stated, he did not add any fresh quaternary sanitizer to the basin after he had initially tested it at 9:18 AM.<BR/>Two of two sets of fluorescent lights in the pantry had no shield. <BR/>Observation on 2/6/24 at 9:40 AM revealed Dietary staff A refilled the sanitizing sink for the three compartment sink and the level of quaternary sanitizer was tested at 200 ppm.<BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 11:21 AM and concluded at 1:16 PM:<BR/>A large ice scoop was hanging in a metal holder on the wall but the handle and top area of the ice scoop had a buildup of dirt/brown substance in the creased areas.<BR/>Observation of the steam table revealed the following with temperatures were taken by Dietary staff A:<BR/>Broccoli 192.4&deg;F <BR/>White gravy 186.4&deg;F. <BR/>Fortified potatoes 178.9&deg; <BR/>Rolls no temperature taken and served room temperature. <BR/>Chicken fingers 205&deg; out of the oven.<BR/>Pur&eacute;e chicken was 153.5&deg;F. Not reheated to 165 degrees F. after cooling during the pureeing process.<BR/>Pur&eacute;e broccoli 154&deg;F <BR/>Mechanical altered chicken 152&deg;F. Not reheated to 165 degrees F. after cooling during the pureeing process.<BR/>Pur&eacute;ed bread no temperature taken. <BR/>There was a plastic headband stored on top of the toaster next to an uncovered cup of white crystal substance that had no label.<BR/>The ceiling vent above the dishwasher was thick with a buildup of fluffy dust and dirt.<BR/>There was a portable fan placed on the clean side of the dishwasher and was turned on and the intake vent of the fan had a buildup of dirt. The fan was blowing across a rack of clean glasses.<BR/>Dietary staff D was observed washing his hands at the hand sink, then turning off the water using a paper towel. He then dried his hands and arms with the same paper towel. He donned, a pair gloves, and then re-gloved and continued with dietary duties.<BR/>MA A entered the kitchen and did not have on a hair restraint. Her hair was pulled up into a loose top knot type bun with loose hair .<BR/>At the service line, there was a box of 20 thawed vanilla Ready Shakes, and there was no date on the boxed indicating when the vanilla shakes were thawed. The shakes were not on any source of refrigeration.<BR/>Interview on 2/6/24 at 11:46 AM, Dietary staff D stated the shakes had been stored in the produce refrigerator.<BR/>Observation on 2/6/24 at 10:50 AM, revealed the pur&eacute;e processing was conducted by Dietary staff A. He was about to pur&eacute;ed broccoli. Observation of the blade and processor pot interior revealed they were wet and soiled with debris. Also, the lid shoot had debris. The surveyor intervened and he washed the processor parts in the three compartments sink. After washing them, he took his wet hands and handled the blade and assemble the processor parts that were dripping wet. He then pur&eacute;ed the broccoli in the processor. Dietary staff A then placed the pur&eacute;e in a pan and placed it on the steam table. He then washed the parts in the three-compartment sink, the lid, the blade and processor pot. He only dipped the parts in the sanitizer basin for approximately two seconds, and then placed the parts on the clean drain board. When he placed them on the clean side drain board, he did not invert the pot or the lid so that the water could drain off.<BR/>Dietary staff A then placed chicken fingers in the wet processor pot, which was wet on the interior, the lid and the blade. He then pur&eacute;ed the chicken with milk and then placed it in a pan and placed it on the steam table.<BR/>Observation on 2/6/24 at 12:02 PM revealed Dietary staff A, then took the processor and dipped each part in the wash, rinse and quat sanitizer sinks for approximately two seconds, and then took them out and placed and assembled on the processor base at 12:03 PM. He then placed chicken in the wet processor and ground the chicken. After grinding, he placed it in a pan and then put it on the steam table at 12:04 PM.<BR/>Observation and record review of the quaternary sanitizer label Solution QA Ultra revealed the following documentation. Apply 200 to 400 ppm active quaternary. To clean public eating establishment surfaces. Wet for at least 60 seconds and let air dry. Do not rinse. This product is an effective sanitizer for use on food contact services in 60 seconds at 200 ppm active quaternary. Sanitization. Effective sanitizer at an active quaternary concentration of 200 to 400 ppm. <BR/>There was a personal drink in a foam cup stored on top of the chest freezer.<BR/>Observation at 1:12 PM revealed the shakes were still out without any ice or refrigeration on the service line. There was one carton left on the cart that was part of the thawed 20 shakes that were at the service line. The last cart went out and meal service was over at 1:14 PM. At 1:15 PM a temperature was taken of the last carton of shake that was left and it was 56&deg;F. <BR/>On 2/6/24 at 1:18 PM an interview was conducted with Dietary staff A regarding dietary sanitation issues. He stated he had not been told anything about the length of time to submerge the equipment in the sanitizing solution. He stated residents could get sick if food contact surfaces were not sanitized correctly. He stated usually the bottom half of the shakes were frozen. He added that the shakes had been in the refrigerator since yesterday (2/05/24). He further stated that he had been working in the facility since November 2023. He stated his training orientation consisted of showing him dietary procedures at one lunch and was let go on his own at supper that same day . <BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 4:33 PM and concluded at 5:18 PM:<BR/>There was a personal drink on the cart next to an open box of shakes. The personal drink was later moved to the table next to the microwave and coffee machine.<BR/> Dietary staff B was observed carrying empty soup bowls to the steamtable up against her chest/shirt.<BR/>On 2/6/24 at 5:02 PM an interview was conducted with Dietary staff B regarding her dietary training. She stated, an employee showed her dietary procedures for two days and then the employee left. She added she followed other staff like a puppy to learn. <BR/>- The following interviews and observations were made during a kitchen tour on 2/7/24 that began at 10:51 AM and concluded at 12:04 PM:<BR/>There was a personal half bottle of water and a can of energy drink on a lower shelf on the steam table line. <BR/>There was an uncovered, unlabeled cup of white crystalline substance stored on top of the toaster. During an interview with the Dietary Manager on 2/7/24 at 12:03 PM, he stated the substance in the cup was sugar.<BR/>On 2/8/24 at 9:30 AM kitchen observation and interview was conducted with the Dietary Manager regarding issues observed in the kitchen. Regarding when the shakes expired, he stated staff go by the date on the carton. Observation revealed that there was no date on the box that the shakes were in and there was also no date on the carton itself. Documentation on the carton revealed the manufacturer recommended disposing of the thawed shakes after 14 days . The underside of the upper shelf of the stove had an accumulation of dried splatter. He also stated regarding not washing hands between soiled and clean operations, clean food equipment could still get contaminated. When the soiled ceiling vents were mentioned, he stated the filter above the dishwasher was changed every month and the last time was last week. Regarding personal drink storage, he stated personal drinks were supposed to be stored in his office. Observation of the chest freezer revealed that the interior of the lid was detaching and the magnetic trim was detached in an area. He stated the fluorescent light in the pantry had been unshielded ever since he had been here. He stated he was told that the lights did not need shields. Regarding the shakes he stated the shakes were normally in an ice bath to keep them below 40 F&deg;. He further stated that foods on the steam table should be 165&deg;F when reheated . He stated staff were instructed to let equipment dry. He added that the quat level should have been 200 ppm at least and staff should have let the processor dry. He further stated that the food contact items should be in the sanitizer at least 45 seconds in the three-compartment sink. He stated staff forgot to bring their drinks in the office. He stated he reminded staff daily on handwashing and sanitizer and glove use. He stated he expected them to do the right thing. He stated he conducted direct monitoring of staff, corrected the staff, and assisted the staff. He stated he and the staff were responsible to ensure dietary sanitation procedures were conducted correctly. He stated residents could get sick as a result of the dietary sanitation issues observed. He stated that dietary orientation training was at least a week and then staff were shadowed. <BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated dietary staff had been in-serviced and needed to be re-in-serviced. He stated that he monitored the sanitation by making rounds. He also stated he expected the staff to clean and let equipment dry and date foods correctly. He stated that all staff were responsible including the Dietary Manager and Administrator. The result of issues with dietary sanitation could result in making the residents sick.<BR/>Record review of the dietary department in-services held between 10/3/23 and 2/6/24 revealed that there were four in-services held that contained multiple subjects. It was also noted that the documentation for the in-service did not include any specific information of what was covered. There were only the topic and signatures from the staff. <BR/>The in-services topics were as follows for 10/3/23: Handwashing, cleaning, hairnets. Dietary staff, B and D attended these in-services.<BR/>The services were as follows for 10/19/23: stocking, and temperature logs. Dietary staff B and D attended these in-services.<BR/>The in-services were as follows for 12/11/23: Handwashing, cleaning, temperatures, job duties. Dietary staff A, B and D attended these in-services.<BR/>The in-service was as follows for 1/2/24: Serving times, job duties, dates, cleaning, tickets. Dietary staff, A, B, C and D attended these in-services. <BR/>Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures. Manual, 2018, Section 4-5, revealed the following documentation, Policy: General Kitchen Sanitation. Policy Number: 04.003. Policy: the facility recognizes that foodborne illness has a potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary, kitchen, facilities, in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure: <BR/>1.Clean and sanitize all food preparation areas, food contact surfaces, dining facilities, and equipment. After each use, clean and sanitize, all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. <BR/>4.Clean and sanitize all multiuse utensils, and food contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation. Based on food temperature, type of food and amount of food particle accumulation. <BR/>5. After cleaning and use, storage and handling of all food contact surfaces of equipment and multiuse utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants. <BR/>6. Clean non-food contact surfaces of equipment at intervals, as necessary to keep them free of dust, dirt, and food particles, and otherwise in a clean and sanitary condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #66 an #73) and 2 of 2 (ADON B AND LVN C) staff reviewed for infection control. <BR/>1. ADON B failed to perform hand hygiene between glove changes when providing wound care for Resident #66 <BR/>2. LVN C failed to perform hand hygiene between glove changes when providing wound care for Resident #73. <BR/>3. LVN C failed to keep dirty and clean supplies separated when providing wound care for Resident # 73.<BR/>These failures could place residents at risk for spread of infection and cross contamination. <BR/>Findings include:<BR/>Resident #66<BR/>Record review of face sheet for Resident #66 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: symptomatic epilepsy (seizure disorder), hyperlipidemia (high levels of fat particles in the blood), alcohol abuse, hypertension (high blood pressure) and diabetes (high blood sugar). <BR/>Review of Resident #66's MDS, dated [DATE] revealed Resident #66 had a BIMS of 09 which indicated the resident's cognition was moderately impaired. The MDS revealed Resident #66 was at risk of developing pressure ulcers and a pressure reducing device was used for the bed.<BR/>Record review of Resident #66's Comprehensive Care Plan, dated 02/01/24 revealed the resident was at risk for skin breakdown with approaches to follow skin care protocol and to immediately report any skin breakdown to charge nurse.<BR/>On 02/07/24 04:08 PM observed wound care of the coccyx, right lower buttock and both lower extremities on Resident # 66 with ADON B. Observed ADON B changing gloves several times during wound care but did not sanitize hands between glove changes. ADON B finished cleansing the wound with 4x4 gauze and changed gloves, then proceeded to apply a clean dressing to the wound without sanitizing his hands. No hand sanitizer was available on the table of supplies during wound care. ADON B moved to a wound on the resident's right lower buttock and washed his hands with soap and water prior to beginning wound care. Again, ADON B changed gloves several times during wound care for the buttock wound, cleansing with a 4x4 gauze. ADON B did not sanitize his hands at any point during the wound care when gloves were changed, including prior to applying the clean dressing to the wound. ADON B then moved to perform the lower extremity wound care. Observed ADON B cleanse the wounds to the lower legs with a 4x4 gauze, apply Vaseline gauze, padding and wrapped lower legs with a gauze then secured with tape. ADON B changed gloves multiple times during wound care of the lower legs, but did not sanitize his hands between glove changes, including between dirty and clean parts of the wound care and when applying a clean dressing to the legs. Observed ADON B wash his hands with soap and water after completing the wound care procedure. <BR/>On 02/08/24 12:50 PM in an interview with ADON B, he stated the policy for hand sanitizing with glove changes was to wash hands with soap and water prior to gloving and again after the procedure is complete, then use hand sanitizer each time in between, with every glove change. He stated he has been trained on hand sanitizing and infection control every couple of months by the facility nurse educator or the DON. ADON B stated a potential negative outcome for failing to sanitize hands and cross contaminating is the resident could get an infection or worse.<BR/>Resident #73<BR/>Record review of face sheet for Resident #73, dated 10/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: osteomyelitis (bone infection), infection of skin, generalized muscle weakness, major depressive disorder, and anxiety disorder (feeling of fear or worry). <BR/>Review of Resident #73's MDS, dated [DATE] revealed Resident #73 had a BIMS of 14 which indicated the resident's cognition was intact. The MDS revealed Resident #73 had pressure ulcer care, application of ointments/medications, application of non-surgical dressings and a pressure reducing device for the bed.<BR/>Record review of Resident #73's Comprehensive Care Plan, dated 11/28/23 revealed Resident #73 had a pressure ulcer to the right buttock and left hip related to immobility. Approaches include cleansing wounds and applying dressings according to MD orders.<BR/>On 02/07/24 11:10 AM observed wound care for Resident #73 with LVN C. A wound was observed to the resident's right chest. Observed LVN C wash her hands prior to wound care. Supplies were set up on the bedside table with a plastic covering and 4x4's in plastic cup. LVN C donned gloves and began to cleanse the wound with a moistened 4x4 gauze. Observed LVN put dirty 4x4's on the sanitized table with clean supplies after cleansing the wound each time. LVN C continued to put dirty 4x4's on the clean table four additional times during the wound care. LVN C did not sanitize her hands or change gloves at any time during the wound care. LVN C then picked up a clean dressing and applied it to the wound without changing gloves or washing her hands. Observed LVN C wash her hands with soap and water following the procedure.<BR/>On 02/08/24 12:35 PM in an interview with LVN C, she stated the policy for hand sanitizing between glove changes is to sanitize hands with hand sanitizer up to three times after glove changes, then use soap and water. She stated hands should be sanitized every time gloves are changed. She stated the policy to avoid cross contamination of clean supplies and dirty areas is to not put dirty supplies on a clean table near clean supplies. She stated it would be preferable to have a trash bag or trashcan available for dirty supplies. LVN C stated she has been trained on handwashing and infection prevention by the facility nurse educator and nursing administration. She stated training is usually monthly. She stated a potential negative outcome of failing to sanitize hands and cross-contaminating would be infection and sepsis.<BR/>On 02/08/24 01:15 PM in an interview with the ADM he stated hand sanitizing should be done before and after a procedure and every time when changing gloves. He stated the policy during procedures to avoid cross-contamination of clean and dirty areas is to keep clean and dirty items apart and avoid them coming into contact with each other. The ADM said his expectation of staff is to follow hand hygiene policy for all procedures, especially during wound care and perineal care. He stated nursing administration and the corporate nurse educator were responsible for training staff and training is ongoing. He stated a potential negative outcome of failing to practice hand hygiene and infection control is the spread of illness, such as bacteria and viruses, cause people to get sick and possibly cause an outbreak of infection.<BR/>On 02/08/24 01:25 PM in an interview with the DON, she stated hand washing should occur prior to and following a procedure. She stated hand sanitizing using ABHR should occur every time gloves are changed during a procedure. She stated the policy, during a procedure, to avoid cross-contamination of clean and dirty areas and supplies is to separate them and have a bag or trash can to dispose of dirty supplies so the clean supplies don't risk contamination. The DON stated staff are trained quarterly and sometimes monthly on hand hygiene and infection control measures. She stated she is responsible for training staff as well as the facility nurse educator. She stated her expectation from staff for hand hygiene and infection control practices is that they do it properly during procedures and between residents. DON stated a potential negative outcome of failure to sanitize hands and cross-contaminating is a risk of infection.<BR/>Record review of the facility's policy titled Standard Precautions, dated 10/18 (revised) revealed: <BR/>Policy Statement - Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents .<BR/>Standard precautions include the following practices:<BR/>1. Hand hygiene<BR/>a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of<BR/>alcohol-based hand rub (ABHR), which does not require access to water.<BR/>b. Hand hygiene is performed with ABHR or soap and water:<BR/>(I) before and after contact with the resident;<BR/>(2) before performing an aseptic task;<BR/>(3) after contact with items in the resident's room; and<BR/>(4) after removing PPE.<BR/>c. Hands are washed with soap and water whenever:<BR/>(1) visibly soiled with dirt, blood, or body fluids;<BR/>(2) after direct or indirect contact with dirt, blood or body fluids;<BR/>(3) after removing gloves; .<BR/>2. Gloves<BR/>a. Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous<BR/>membranes, non-intact skin, and other potentially infected material.<BR/>one body site to another (when moving from a dirty site to a clean'' one).<BR/>f. Gloves are not to be reused.<BR/>g. Gloves are removed promptly after use, before touching non-contaminated items and environmental<BR/>surfaces, and before going to another resident.<BR/>h. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other<BR/>residents or environments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from neglect for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that:<BR/>1) The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. <BR/>This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated.<BR/>The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration.<BR/>These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. <BR/>The findings include:<BR/>Resident #1<BR/>Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder).<BR/>Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; <BR/>If Blood Sugar is less than 60, call MD. <BR/>If Blood Sugar is 61 to 150, give 0 Units. <BR/>If Blood Sugar is 151 to 250, give 3 Units. <BR/>If Blood Sugar is 251 to 350, give 5 Units. <BR/>If Blood Sugar is 351 to 450, give 7 Units. <BR/>If Blood Sugar is 451 to 500, give 10 Units. <BR/>If Blood Sugar is greater than 500, call NP/PA. <BR/>Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A.<BR/>Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . <BR/>Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. <BR/>Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON.<BR/>Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin:<BR/>Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank.<BR/>Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested, and it was 203 and 3 units of insulin was administered prior to dinner - admission Observation by LVN C.<BR/>Further record review of the MAR revealed the following:<BR/>On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B.<BR/>On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. <BR/>On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B.<BR/>Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following:<BR/>04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B.<BR/>04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B<BR/>Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . <BR/>Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization <BR/>Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. <BR/>Labs. <BR/>Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. <BR/>Specimen: blood. <BR/>Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L .<BR/>carbon dioxide 8 on a normal scale of 21-32 mmol/L. <BR/>Glucose 1,030 on a normal scale of 74-106 mg/dL. <BR/>Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. <BR/>Blood, urine moderate. <BR/>Glucose, urine 100 mg/dL. <BR/>Ketones, urine 40 mg/dL. <BR/>Disposition. <BR/>Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. <BR/>Comment. <BR/>Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety.<BR/>Expected patient class: in patient.<BR/>Level of service: ICU. <BR/>Discharge summary note. <BR/>Discharge summary. <BR/>Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM)<BR/>Cause of death: renal failure, metabolic acidosis, lactic acidosis.<BR/>Other contributing factors: <BR/>Principal problem: acute metabolic encephalopathy.<BR/>Active problems: . diabetes myelitis. DKA (diabetic keto acidosis) . <BR/>Hospital Course:<BR/>(Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . <BR/>Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows:<BR/>Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: [DATE]. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. <BR/>Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. <BR/>Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused.<BR/>Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility.<BR/>On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to the ER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500.<BR/>On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. <BR/>On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter.<BR/>On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care.<BR/>On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B.<BR/>On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23.<BR/>On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. <BR/>On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. <BR/>On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022.<BR/>On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in.<BR/>On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. <BR/>On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high.<BR/>On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own.<BR/>On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin.<BR/>On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. <BR/>Resident #2<BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD.<BR/>If blood sugar is 150 to 200 give two units.<BR/>If blood sugar is 201 to 250 give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, give 12 units.<BR/>If blood sugar is greater than 450, give zero units.<BR/>If blood sugar is greater than 450, call MD. Subcutaneous. <BR/>[DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] <BR/>Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM <BR/>Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days.<BR/>Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 .<BR/>Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. <BR/>Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #3 <BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD. <BR/>If blood sugar is 150 to 200, give two units.<BR/>If blood sugar is 201 to 250, get four units.<BR/>If blood sugar is 251 to 300, gives six units. <BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is greater than 400, call NP/PA. Subcutaneous <BR/>[DX: type two diabetes mellitus without complications] <BR/>Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM.<BR/>Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: <BR/>Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank.<BR/>Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days.<BR/>Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 .<BR/>Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #4 <BR/>Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. <BR/>Further record review of the Physician Order Report revealed the following orders:<BR/>Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro <BR/>Insulin pen; 100 unit/ML; AMT: per sliding scale; <BR/>If blood sugar is less than 70, call NP/PA.<BR/>If blood sugar is 70 to 150, give 0 units.<BR/>If blood sugar is 151 to 200, give two units.<BR/>If blood sugar is 201 to 250, give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 300 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, gives 12 units.<BR/>If blood sugar is 450 to 500, give 14 units. <BR/>If blood sugar is greater than 501, called NP/PA. Subcutaneous.<BR/>[DX: type two diabetes myelitis without complications]<BR/>Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM <BR/>Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications]<BR/>Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM<BR/>Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. <BR/>Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes.<BR/>Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM.<BR/>Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime.<BR/>Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals and missing documentation for the residents listed on the MAR chart audit until the facility conducted a chart [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 5 residents (Resident #1) of five residents whose records were reviewed for abuse.<BR/>Facility staff did not implement facility policy and immediately notify administration when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. <BR/>This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. <BR/>Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition. <BR/>Record review of Resident #1's care plan dated 5/2/24 indicated Resident #1 had a history of pain with a start date of 4/29/24. Staff are instructed to handle gently and try to eliminate any environmental stimuli. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. FM #1 stated that when Resident #1 returned from the hospital on 6/23/24 after she had been hospitalized for fractured ribs. FM#1 stated she observed that CNA B was rough with Resident #1 when she jerked her up to change her. FM#1 stated she told CNA B that she (FM#1) would change Resident #1 herself. FM #1 stated she reported to LVN A that CNA B was rough with Resident #1. FM#1 stated she was concerned about Resident #1's safety and wellbeing.<BR/>During an interview on 6/25/24 at 2:50 p.m. LVN A stated that when Resident #1 returned from the hospital and was in her room with FM #1. LVN A stated that FM #1 reported to him that CNA B was real rough with Resident #1. LVN A stated that FM #1 told him that [CNA B] was rough with her and made her get out of bed. LVN A stated that he was not in the room when CNA B assisted Resident #1 and did not think CNA B was the type of person to be abusive. LVN A stated that he had been trained on Abuse and Neglect and trained to report allegations of abuse immediately to the Administrator. LVN A stated that the facility had routine in-services on Abuse and Neglect and to report allegations to the ADM. LVN A stated he did not think CNA B had abused Resident #1 and had FM #1 stated that CNA B hit or punched Resident #1 he then would have reported it.<BR/>During an interview on 6/25/24 at 3:15 p.m. with the ADM; he stated that when the FM told LVN A that CNA B was rough with the resident, it should had been reported to him. The ADM stated that if the family member had not used the word abused that LVN A may not have thought it was reportable. The ADM stated that had LVN A reported it to him, the facility would have investigated the reported incident. The ADM stated that I just gave in services on ANE and reporting two weeks ago. It is posted all over the building to report to me and my phone number is listed. The ADM confirmed that nothing had been reported to him by LVN A. <BR/>During an interview on 6/25/24 at 3:24 p.m. with the DON, she stated that if a FM told LVN A that CNA B was rough with Resident #1, LVN A should have reported it to her or the ADM so it could be investigated. The DON stated that rough is not gentle and if someone reported that a staff was rough with a resident, she would have investigated it as the staff was being not gentle and either grabbing or pulling, rushing. The DON stated had it been reported to her, she would report it to the ADM and then report to the state. The DON stated that LVN A had been trained to report suspected abuse or neglect. The DON stated that the person making the complaint would not have to use the word abused and the word rough would be a reportable incident. The DON stated she had not been informed of this incident until now. <BR/>During an interview on 6/25/24 at 3:53 p.m. with CNA C, stated that if a family member or staff member stated that a staff member was rough with a resident, she would immediately report to the charge nurse and to the Administrator. CNA C stated that she believed the term rough could mean tearing skin, pulling an arm out of socket and if a family member thinks a staff is being rough, they are rough, and it had to be reported. <BR/>During a phone interview on 6/27/24 at 3:45 p.m. with CNA B; stated that when Resident #1 returned from the hospital her FM (#1) notified her that Resident #1 was sitting on the edge of the bed and the floor was wet. CNA B stated she entered Resident #1's room and found Resident #1 sitting on the edge of her bed with pants around her ankles. CNA B stated the floor was wet under Resident #1's feet and the pants were the roommates' pants as they were too small for Resident #1. CNA B stated that Resident #1 had been in the hospital and had fractured ribs. CNA B stated she stepped out of the room to get a pull-up for Resident #1. CNA B stated she removed the pants from Resident #1; s ankles, put a pull-up and pants on Resident #1 and then assisted Resident #1 to stand up to pull up the pull up and pants. CNA B stated she put her arms under Resident #1's arms to assist her to stand up and did not use any force nor was rough. CNA B stated after she dressed Resident #1, she assisted Resident #1 back onto her bed and realized that Resident #1's socks were wet. CNA B stated she attempted to remove the socks and the FM told her she would do it herself because she did not want Resident #1 to stand up again. CNA B stated that she had been trained on abuse/neglect and to report any allegations of abuse/neglect immediately to the abuse coordinator, the Administrator. CNA B stated that if someone told her that a staff member had been rough with a resident, she would immediately notify her charge nurse and then immediately would notify the Administrator that an allegation had been made. <BR/>Record review of the facility's Abuse Prevention policy revised on 10/2023 revealed in part, the facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect: <BR/>- Include training for new and existing staff on activities that constitute abuse, neglect, reporting procedures. <BR/>- Indicators of abuse include, but are not limited to: Resident, staff, or family report of abuse. <BR/>-Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately but not later than 2 hours of after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. <BR/>Record review of the facility's In-service on Abuse and Neglect for LVN A dated and signed 11/4/22 revealed in part: The facility during its orientation program and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 5 residents (Resident #1) reviewed for reporting.<BR/>The facility failed to ensure staff immediately reported an allegation of when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. <BR/>This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. <BR/>Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition. <BR/>Record review of Resident #1's care plan dated 5/2/24 indicated Resident #1 had a history of pain with a start date of 4/29/24. Staff are instructed to handle gently and try to eliminate any environmental stimuli. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. FM #1 stated that when Resident #1 returned from the hospital on 6/23/24 after she had been hospitalized for fractured ribs. FM#1 stated she observed that CNA B was rough with Resident #1 when she jerked her up to change her. FM#1 stated she told CNA B that she (FM#1) would change Resident #1 herself. FM #1 stated she reported to LVN A that CNA B was rough with Resident #1. FM#1 stated she was concerned about Resident #1's safety and wellbeing. <BR/>During an interview on 6/25/24 at 2:50 p.m. LVN A stated that when Resident #1 returned from the hospital and was in her room with FM #1. LVN A stated that FM #1 reported to him that CNA B was real rough with Resident #1. LVN A stated that FM #1 told him that [CNA B] was rough with her and made her get out of bed. LVN A stated that he was not in the room when CNA B assisted Resident #1 and did not think CNA B was the type of person to be abusive. LVN A stated that he had been trained on Abuse and Neglect and trained to report allegations of abuse immediately to the Administrator. LVN A stated that the facility had routine in-services on Abuse and Neglect and to report allegations to the ADM. LVN A stated he did not think CNA B had abused Resident #1 and had FM #1 stated that CNA B hit or punched Resident #1 he then would have reported it.<BR/>During an interview on 6/25/24 at 3:15 p.m. the ADM stated that when the FM told LVN A that CNA B was rough with the resident, it should had been reported to him. The ADM stated that if the family member had not used the word abused that LVN A may not have thought it was reportable. The ADM stated that had LVN A reported it to him, the facility would have investigated the reported incident. The ADM stated that I just gave in services on ANE and reporting two weeks ago. It is posted all over the building to report to me and my phone number is listed. The ADM confirmed that nothing had been reported to him by LVN A. <BR/>During an interview on 6/25/24 at 3:24 p.m. with the DON, she stated that if a FM told LVN A that CNA B was rough with Resident #1, LVN A should have reported it to her or the ADM so it could be investigated. The DON stated that rough is not gentle and if someone reported that a staff was rough with a resident, she would have investigated it as the staff was being not gentle and either grabbing or pulling, rushing. The DON stated had it been reported to her, she would report it to the ADM and then report to the state. The DON stated that LVN A had been trained to report suspected abuse or neglect. The DON stated that the person making the complaint would not have to use the word abused and the word rough would be a reportable incident. The DON stated she had not been informed of this incident until now. <BR/>During an interview on 6/25/24 at 3:53 p.m. CNA C stated that if a family member or staff member stated that a staff member was rough with a resident, she would immediately report to the charge nurse and to the Administrator. CNA C stated that she believed the term rough could mean tearing skin, pulling an arm out of socket and if a family member thinks a staff is being rough, they are rough, and it had to be reported. <BR/>During an interview on 6/26/24 at 9:35 a.m. with the ADM and DON; ADM stated that the facility completed a self-report of abuse to the state on 6/25/24 and has conducted interviews with LVN A and CNA B to determine who was involved in the allegation of abuse made by a family member. The ADM stated that during their investigation they were able to identify Resident #1 and FM #1 and have interviewed FM #1, LVN A and CNA B regarding the allegation of abuse that CNA B was rough with Resident #1. The ADM stated that CNA B is currently suspended and is not at the facility. The ADM stated that Resident #1 has not returned from the hospital at this time. <BR/>During a phone interview on 6/27/24 at 3:45 p.m. CNA B stated that when Resident #1 returned from the hospital her FM (#1) notified her that Resident #1 was sitting on the edge of the bed and the floor was wet. CNA B stated she entered Resident #1's room and found Resident #1 sitting on the edge of her bed with pants around her ankles. CNA B stated the floor was wet under Resident #1's feet and the pants were the roommates' pants as they were too small for Resident #1. CNA B stated that Resident #1 had been in the hospital and had fractured ribs. CNA B stated she stepped out of the room to get a pull-up for Resident #1. CNA B stated she removed the pants from Resident #1; s ankles, put a pull-up and pants on Resident #1 and then assisted Resident #1 to stand up to pull up the pull up and pants. CNA B stated she put her arms under Resident #1's arms to assist her to stand up and did not use any force nor was rough. CNA B stated after she dressed Resident #1, she assisted Resident #1 back onto her bed and realized that Resident #1's socks were wet. CNA B stated she attempted to remove the socks and the FM told her she would do it herself because she did not want Resident #1 to stand up again. CNA B stated that she had been trained on abuse/neglect and to report any allegations of abuse/neglect immediately to the abuse coordinator, the Administrator. CNA B stated that if someone told her that a staff member had been rough with a resident, she would immediately notify her charge nurse and then immediately would notify the Administrator that an allegation had been made. <BR/>Record review of Resident #1's progress notes dated from 6/19/24-6/25/24 revealed no progress notes entered by LVN A regarding FM#1 allegation that CNA B was rough with Resident #1. <BR/>Record review of the facility provided Incident/Accident and Grievance records dated from 6/19/24-6/25/24 revealed no documentation that LVN A reported the allegation made by FM#1 that CNA B was rough with Resident #1. <BR/>Record review of the facility's Abuse Prevention policy revised on 10/2023 revealed in part, the facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. <BR/>- Include training for new and existing staff on activities that constitute abuse, neglect .reporting procedures. <BR/>- Indicators of abuse include, but are not limited to: Resident, staff, or family report of abuse. <BR/>- Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately but not later than 2 hours of after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. <BR/>Record review of the facility's In-service on Abuse and Neglect for LVN A dated and signed 11/4/22 revealed in part: The facility during its orientation program and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. <BR/>A. <BR/>The ADM failed to investigate Resident #1's allegation of abuse made against an unknown nighttime staff on 11/23/24.<BR/>B. <BR/>The ADM failed to investigate a resident to resident altercation (Resident #1 attempting to pull Resident #2 out of bed) that occurred on 11/14/24.<BR/>C. <BR/>The ADM failed to investigate a resident-to-resident altercation (Resident #1 grabbed Resident #3 in the face) that occurred on 11/14/24.<BR/>These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment.<BR/>Findings included:<BR/>Resident #1 <BR/>Record Review of Resident #1's face sheet, dated 11/22/24, revealed an [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). <BR/>Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 exhibited physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing). The identified symptoms placed the resident at significant risk for physical illness or injury. The identified symptoms placed others at risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or living environment. <BR/>Record review of Resident #1's care plan, dated 11/22/24, revealed a focused area, initiated on 11/22/24, Resident #1 had a history of aggressive behavior towards others. The goal initiated on 11/22/24, was Resident #1 would have fewer than 3 episodes of aggressive behavior before the next review date. The interventions initiated 11/22/24 included keeping the environment calm, relaxed, convey acceptance of the resident during periods of inappropriate behavior, remove from public area when behavior was unacceptable, and to ask for help when his behavior becomes unacceptable.<BR/>Record review of the facility event summary report, dated 08/26/24-11/26/24, revealed the following:<BR/>Resident #1 had an aggressive/combative resident to resident aggression on 11/23/24.<BR/>Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercations that occurred on 11/14/24 with Resident # 2 and Resident #3. <BR/>Record review of Resident #1's progress notes, dated 09/22/24-11/22/24, did not reveal any progress notes that involved him pulling a resident (Resident #2) out bed or grabbing another resident (Resident #3) in the face on 11/14/24.<BR/>Record review of the admission/discharge report dated 08/25/24-11/27/24, revealed Resident # 1 was discharged and return was not anticipated on 11/25/24.<BR/>During an interview on 11/26/24 at 10:00 AM, Family Member M stated she had concerns about Resident #1's stay at the facility. She said she was told by facility staff that Resident #1 had told them a nighttime staff had hit him on the weekend (11/23/24) and that she was notified that Resident #1 had a fall. She said she did not know the full name of the staff who reported this information to her nor did she know the name of the staff that allegedly hit Resident #1. She said Resident #1 told her that a woman had hit him. She said the same staff reported that another female resident had hit Resident #1. She said she did not tell anyone specifically about what the facility staff and Resident #1 told her, but that staff knew because she (Family Member M) was vocal about it. She could not name the staff that were present when she was in the memory unit. <BR/>A confidential interview revealed that Resident #1 had a fall the weekend of 11/23/24. They said they could not remember if it was a Friday or a Saturday. They said when they came to work, Resident #1 was quiet and not as active as he once was. They said that Resident #1 gestured with his hand that staff had hit him on top of the head. They asked Resident #1 if it was an overnight staff that had hit him, and Resident #1 stopped answering questions when they started asking for details. They stated Family Member M had expressed in the past that she did not feel that the overnight staff were taking care of Resident #1. They said the weekend that they came in for their shift, and Resident #3 allegedly fell he (Resident #1) did have a cut on his eye and his lip. They said they had been trained to call the ADM, who was the abuse coordinator if they witnessed or suspected ANE. They said they had been taught to contact the abuse coordinator immediately. They said that they did not contact the ADM because it was the weekend. They said no one had asked them anything about the nature of the fall. <BR/>During an interview on 11/26/24 at 3:06 PM, CNA A stated that she did not know much about the fall that occurred on 11/23/24 involving Resident #1. They said CNA O told her that Resident #1 had an unwitnessed fall when she came on shift. She said CNA O told her that LVN N was helping her do rounds and change residents. She said CNA O said that she and LVN N had come out of Resident #1's room, and he had fallen. CNA A said she did not remember a staff member telling her that Family Member M had concerns about the injuries, but that Family Member M did express to her that she had concerns about the injuries that Resident #1 sustained. CNA A said that when Family Member M said that she did not think the injuries were consistent with a fall, she encouraged Family Member M to talk to LVN B because as a certified nurse aide she had been trained to refer family member concerns to her nurse. CNA A said Resident #1's face was beat up. She said Resident #1 had steri-strips (reinforces skin closure) all over his face. She said he had a busted lip and a cut by his eye. She said no one had interviewed her regarding Resident #1's behaviors or Family Member M's allegations. CNA said that she had been trained to report ANE as soon as possible to the ADM.<BR/>During an interview on 11/26/24 at 3:55 PM, the Assistant Activity Director stated on Saturday, 11/23/24, she went into the memory unit and noticed Resident #1 was at the dining room table with his head down. She thought this was odd because Resident #1 was usually up and pacing around. She said CNA P told her that Resident #1 had fallen. The Assistant Activity Director said that later on in the day (11/23/24), Family Member M came to the facility and said to her that Resident #1 reported to her (Family Member M) that someone came into his room at night and hit him. She said it was around lunchtime when she (Family Member M) told her that Resident # made the allegation. The Assistant Activity Director stated she told the aides (she did not disclose who) that were working the memory unit and that the aides said that it looked like someone hit Resident #1. She said she told the aides to get a nurse to explain Resident #1's injuries to Family Member M. The Assistant Activity Director told LVN B that Family Member M thought someone had beaten Resident #1 up. She said no one had interviewed her to ask her about her knowledge of the incident regarding allegations of abuse. She said she was unaware of any physical altercations that involved Resident #1. <BR/>During an interview on 11/26/24 at 8:20 PM, LVN B stated on the day (11/23/24), Resident #1 fell on the overnight shift. She said Resident #1 had also fallen on her shift (day shift) . She said CNA A said that she had found Resident #1 on the floor. She said she assessed Resident #1 and called Hospice out for assistance. She said she notified Family Member M. Family Member M was upset because Resident #1 had fallen on the overnight shift. LVN B said it was around 1:00 PM when Resident #1 had fallen on her shift. LVN B said she did not have details about Resident #1's first fall. She said that she could tell by her body language but that she was speaking in Spanish to CNA A. LVN B said it was relayed to her from CNA A that Family Member M did not believe the lacerations, cuts, and gashes had come from a fall but that he looked like he had been punched. LVN B said she was unaware that Resident #1 had any physical altercations with female residents in the locked unit. She said she had never been interviewed regarding Resident #1's behaviors or the allegations of ANE. <BR/>During an interview on 11/27/24 at 9:30 AM, CNA C stated she heard that Resident #1 had a broken nose and that someone had been hitting him on top of the head. She said she heard it was a nighttime staff that was hitting him. She said she did not know which nighttime staff. She said she was told this on 11/26/24 by CNA A. <BR/> During an interview on 11/27/24 at 9:23 AM, the ADM stated that regarding resident-to-resident altercations, he expected staff to separate them and ensure the residents were calm and safe. He said they should immediately notify the abuse coordinator. He said the potential negative outcome was that if steps were missed or done out of order, something could happen to the residents or escalate the incidents. He said not reporting resident-to-resident altercations or handling them appropriately could cause an inability for barriers and interventions to be put in place to protect residents. He said if an incident occurs on the weekend, the staff should respond the same. He said the failure to conduct investigations of ANE could prevent them from knowing how something occurred and what occurred and hurt the ability to prevent abuse from happening again. He said prevention measures should be in place. He said that the aggressor should be monitored depending on the situation and that no additional aggressive behavior should be allowed. He said he, as the abuse coordinator, was responsible for investigating and resident protection measures. He said he was unaware of Family Member M's allegations of abuse. He said none of the incidents were investigated because he was unaware of the incidents. Preventive measures were not put in place to protect Resident #1 after the allegations of abuse because he was unaware of the incident. <BR/>Resident #2 <BR/>Record Review of Resident #2's face sheet, dated 11/27/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), anxiety (increased worry) and cognitive communication (difficulty communicating). <BR/>Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score was blank. Section E did not reveal any documented behaviors for Resident #2.<BR/>Record Review of Resident #2's Brief Interview for Mental Status (BIMS) dated 11/27/24 revealed the summary score was 99, indicating the resident was severely cognitively impaired.<BR/>Record review of Resident #2's care plan, dated 08/22/24, revealed a focused area, initiated on 10/01/24, that indicated Resident #2 had socially inappropriate/disruptive behaviors as evidenced by abusing the staff. The goal initiated on 10/31/24 Resident #2 will not harm self or others. The interventions initiated 10/01/24 included assessing the resident for placement, assess whether the behavior endangers the resident and others, avoid over stimulation, praise for acceptable behavior and maintain a calm environment. <BR/>Record review of Resident #2's progress notes dated from 08/27/24- 11/27/24 did not reveal any information regarding her resident-to-resident altercation on 11/14/24 with Resident #1.<BR/>Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident #2 and Resident #1. <BR/>During an interview on 11/26/24 at 3:06 PM, CNA A stated on the same day he punched her in the face, Resident #1 had increased behaviors. She said she heard Resident #2 yelling. When she walked into Resident #2's room, she observed Resident #1 attempting to pull Resident #2 out of bed. She said Resident #2's bed was lowered to the floor with a bedside mat next to it. She said she observed Resident #1 standing on the mat next to Resident #2's bed, and he had her by her (Resident #2) legs. CNA said that Resident #2 was screaming, and Resident #1 was accusing them (staff) of restraining Resident #2 and that he would call the police. CNA A said she attempted to redirect Resident #1, but he tried to hit her. She said she blocked the first hit from Resident #1. She said he then tried to grab the fire extinguisher and said he would hit her. She said Resident #1 grabbed a chair, and because other residents were close, she went to grab the chair from him. She said that when she got the chair from him, and she was putting it down, Resident #1 hit her hard in the face, and she started crying. She said that on the same date that Resident #1 hit her he also tried to pull Resident #2 out of bed. She said the Former DON wanted to send Resident #1 to a behavior center but was told by the ADM that they wanted to try other things. She said she told the ADM that Resident #1 and the other residents in the locked unit were not safe. She said she did tell the ADM about Resident #1 hitting her and pulling Resident #2 out of bed. She said no one had interviewed her regarding Resident #1's behaviors or his interactions with Resident #2.<BR/>During an interview on 11/27/24 at 9:23 AM, the ADM stated he was unaware of an incident where Resident #1 tried to pull Resident #2 out of bed. He said none of the incidents were investigated because he was unaware of the incidents. <BR/>During an interview on 11/27/24 at 1:05 PM, Resident #2 was unable to answer any questions about the alleged incident between her and Resident #1. She turned her head and refused to speak. <BR/>Resident #3 <BR/>Record Review of Resident #3's face sheet, dated 11/27/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dementia (memory loss), anxiety (increased worry) and cognitive communication deficit (difficulty communicating).<BR/>Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section E did not reveal any documented behaviors for Resident #3.<BR/>Record review of Resident #3's progress notes dated from 08/27/24- 11/27/24 did not reveal any information regarding her resident-to-resident altercation on 11/14/24 with Resident #1.<BR/>Record review of Resident #3's care plan, dated 06/12/24, revealed a focused area, initiated on 10/01/24, Resident #3 had physically abusive behavior symptoms. The goal initiated on 11/06/24, was Resident #3 would not physically abuse other residents, visitors, and staff. The interventions initiated 10/01/24 included assess whether the resident's behavior endangers the resident or others, convey an attitude of acceptance towards the resident, maintain a calm environment, and allow extra time to process information. <BR/>Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-resident altercation that occurred on 11/14/24 with Resident #1. <BR/>During an interview on 11/26/24 at 3:06 PM, CNA A stated on the same day (12/05/24) he punched her in the face, Resident #1 had increased behaviors. She said that on the same date that Resident #1 hit her in the face, he also grabbed Resident #3 in the face. She said the ADM and bthe SW were present when Resident #1 grabbed Resident #3 in the face. She said Resident #1 did it so fast that she could not intervene. She said Resident #3 exclaimed, Why did he do that?. She said the Former DON wanted to send Resident #1 to a behavior center but was told by the ADM that they wanted to try other things. She said she told the ADM that Resident #1 and the other residents in the locked unit were not safe. She said she did not tell the ADM about Resident #1 grabbing Resident #3 in the face because he was present when Resident #1 grabbed Resident #3 in the face. She said no one had interviewed her regarding Resident #1's behaviors or his interaction with Resident #3. <BR/>During an interview on 11/27/24 at 9:23 AM, the ADM stated he said he was unaware of an incident where Resident #1 grabbed Resident #3 in the face. He said none of the incidents were investigated because he was unaware of the incidents. <BR/>During an interview on 11/27/24 at 1:17 PM, Resident #3 stated she could not remember the date or the name of the male resident who grabbed her in the face. She said it hurt. She said that the male resident was no longer in the facility, and she was glad because him grabbing her scared her. She said she did not know why he grabbed her, but he was mean. <BR/>Record review of the facility policy, Abuse Investigation and Reporting, revised October 2023 revealed:<BR/> Policy Statement <BR/>The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property.<BR/> Policy Interpretation and Implementation <BR/>The facility will develop and implement written policies and procedures that: <BR/>o <BR/>Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; and <BR/>o <BR/>Establish policies and procedures to investigate any such allegations.<BR/>IV. Investigation of Alleged Abuse, Neglect and Exploitation <BR/>An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. <BR/>Written procedures for investigations include: <BR/>o <BR/>Identifying staff responsible for the investigation; <BR/>o <BR/>Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); <BR/>o <BR/>Investigating different types of alleged violations; <BR/>o <BR/>Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; <BR/>o <BR/>Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and <BR/>o <BR/>Providing complete and thorough documentation of the investigation. <BR/>Record review of the facility policy, Resident-to Resident Altercations, revised October 2023 revealed:<BR/>Policy Statement <BR/>All altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. <BR/>Policy Interpretation and Implementation <BR/>Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. <BR/>If two residents are involved in an altercation, the nursing staff will: a. Separate the residents, and institute measures to calm the situation up to and/or including 1:1 supervision of the offending resident; <BR/> Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for two of 22 residents (Residents #18 and #69) reviewed for care plans.<BR/>1. <BR/>The facility failed to develop a care plan for Resident #18 regarding dialysis.<BR/>2. <BR/>The facility failed to develop a care plan for Resident #69 regarding insulin for treatment of the diagnosis of diabetes. <BR/>These failures could place residents at risk of not receiving the care required to meet their individualized needs. <BR/>Finding included:<BR/>Resident #18<BR/>Record review of the undated face sheet for Resident #18 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of cerebral infarction, unspecified (stroke), unspecified inflammation of eyelid (history of), other specified glaucoma (vision disorder), palpitations (irregular heart beat), essential hypertension (high blood pressure), personal history of transient ischemic attack (blockage of blood flow to the brain), dependence on renal dialysis (procedure to remove waste from blood when kidney function has declined), type two diabetes mellitus, without complications (blood sugar disorder), and end stage renal disease (kidney disease). <BR/>Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #18 had a BIMS score of 15 indicating that the resident was cognitively intact. Further record review of the MDS revealed active diagnoses of hypertension, renal insufficiency, renal failure, or end stage renal disease, diabetes mellitus, cerebral vascular accident, transient ischemic, attack, or stroke. Additional review of the MDS revealed that the resident was on dialysis while a resident.<BR/>Record review of the current care plan for Resident #18, last reviewed/revised: 1/22/24, revealed there was no specific care plan regarding dialysis. <BR/>Record review of the current physician orders for Resident #18, dated 2/6/24 revealed the following order, Hemodialysis performed on Tuesday, Thursday, Saturday at 5:45 AM dialysis center . Special instructions: send blanket, mustard, and lunch. Once a day on Tuesday, Thursday, Saturday, 6 AM - 6 PM. Start date 7/17/23. Open ended . <BR/>During an interview on 2/06/24 at 10:50 AM, LVN A Resident #18 was out of the room at dialysis on Tuesday, Thursday, and Saturday and would leave at 8:30 AM and come back before supper. <BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON regarding Resident #18's omitted care plan for dialysis. She stated she was not sure why there was not one. She said there should have been a care plan for dialysis. She stated if residents had no care plan, staff would not know how to care for the resident. She stated, she and nursing staff develop the baseline care plan. She added she and the Clinical Case Manager worked together to develop the care plans. She stated we review the orders and have started to conduct care conferences. <BR/>On 2/8/24 at 5:10 PM an interview was conducted with the Administrator regarding a missed dialysis care plan for Resident #18. He stated he was unsure why the issue occurred. He stated that he expected that staff should have developed a care plan when the resident was started on dialysis. He stated that the DON and the ADON were responsible for care plans being developed. He stated there could be miscommunication if a care plan was not developed for dialysis. <BR/>Resident #69<BR/>Record review of Resident #69's face sheet, dated 02/07/2024, revealed [AGE] year-old female admitted [DATE] with diagnoses that included, but were not limited to, diabetes (body doesn't make enough insulin or can use it as well as it should), diabetic nephropathy (uncontrolled diabetes can cause damage to blood vessels in the kidney that filter waste from the blood, which can cause kidney failure), aphasia (loss of ability to understand or express speech), acute myocardial infarction (heart attack), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (chronic brain disorder and when active symptoms can include delusions-false belief about external reality; hallucinations-hear, see, smell, taste or feel things that appear to be real but only exist in the mind; disorganized speech-any interruption that makes communication difficult and sometimes impossible to understand; trouble thinking and lack of motivation), epilepsy (a disorder of the brain characterized by repeated seizures- a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain), congestive heart failure (the heart can't pump blood well enough to meet the body's needs), intracardiac thrombosis (a blood clot in the heart), and cerebral infarction (occurs as result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) . <BR/>Record review of Resident #69's physician orders (no date) revealed Novolin 70-30 Flex Pen U-100 8 units; subcutaneous twice a day morning 07:00 AM-10:00 AM; Bedtime 7:00 PM - 10:00 PM start date of 08/29/2023 open ended end date. <BR/>Record review of Resident #69's admission comprehensive MDS assessment dated [DATE] revealed Resident #69 had a BIMS of 06 which suggested severe cognitive impairment; active diagnosis reveals diabetes mellitus; medications revealed the resident received insulin injections seven days a week.<BR/>Record review of Resident #69's quarterly comprehensive MDS assessment dated [DATE], the medication section revealed the resident received insulin injections seven days a week. <BR/>Record reviewed Resident #69's care plan dated 01/22/2024 revealed no approach for diabetes or the use of insulin. <BR/>In an interview on 02/08/2024 at 10:30 AM, Resident #69 stated she received an injection for her diabetes. <BR/>In an interview on 02/08/2024 at 4:14 PM, the DON stated there was no care plan for insulin. DON stated, that is on me, there should be a care plan showing insulin is a method to treat the diabetes. She stated that without a care plan, a staff member would not know how to care for the resident. <BR/>Record review of the facility policy titled Comprehensive Care Plans, 1/26/24 V.1 revealed the following documentation, 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 time frames to meet a resident medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines:<BR/>1. The care planning process will include an assessment of the resident's strengths, and needs, and will incorporate the residents 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. <BR/>2. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDS assessment, and by day 21 of the patients stay. All care assessment areas . triggered by the MDS will be considered in developing the care plan. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the care plan. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. <BR/>3. The comprehensive care plan will describe, at a minimum the following: <BR/>a. The services that are to be furnished to attain and maintain the residents highest practicable physical, mental, and psychosocial well-being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that 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' goals and preferences for 1 of 3 residents (Resident #1) reviewed for pain management.<BR/>The facility failed to ensure Resident #1 received Hydrocodone-Acetaminophen-Schedule III 300-30 mg tablet every 6 hours-as needed (PRN) for pain on 10/30/24 from 6 A.M. to 1:50 P.M. <BR/>This failure placed the resident at risk of increased pain and decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet dated 10/31/24 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. This report included Resident #1's diagnoses as unspecified pain, atherosclerosis of native arteries of extremities with rest pain to right leg (severe burning pain in your legs and feet that continues even when you're resting.), fracture of unspecified parts of lumbosacral spine and pelvis (a medical condition that can be cause by trauma or disease), and subsequent encounter for a fracture with routine healing (a type of care that occurs during the healing or recovery phase of a fracture). <BR/>Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status score of 13, indicating her cognition was intact. MDS's Section I - Active Diagnoses reflected Resident #1 had venous insufficiency, chronic, peripheral (improper functioning of the vein valves in the les, causing swelling and skin changes), and atherosclerosis of native arteries of extremities with right pain to the right leg (a condition that occurs when arteries in the legs and feet narrow and harden due to plaque buildup, which can cause pain, numbness, and cold extremities.). The MDS Section GG Functional Abilities indicated Resident #1 was dependent on staff for rolling left and right, lying to sitting on the side of her bed, transferring from chair/bed-to-chair, and was unable to walk 10 feet due to medical condition or safety concerns. <BR/>Review of Resident #1's Care Plan dated 09/05/2024 included pain, which was added on 10/22/24, due to acute pain, chronic pain, and neuropathic pain. The goal was that these pains would be resolved or be within a tolerable range within one hour of intervention over the next 90 days. The approach, which would be administered by nursing, included administering pain medications as ordered, establish causative factors and way to alleviate them, monitor pain, and position for comfort. This plan included Resident #1's activities of daily living with start date of 10/22/24 and the goal was to anticipate and meet her needs with 1-2 person assist for ambulation and transfers. <BR/>Review of Resident #1's Physician Order Report dated 09/30/2024 to 10/31/24 reflected: Hydrocodone-Acetaminophen - Schedule II table; 5-325 mg; amount: one tablet; oral every 4 hours - PRN; PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, and PRN 6.<BR/>Review of an e-mail dated 10/30/24 at 9:17 A.M. indicated Assistant Director of Nursing (ADON C) sent an e-mail on 10/30/24 at 10:09 A.M. to Pharmacy Technician (PT D) indicating the lock box with the residents' narcotics was not opening with the key, and this box was in the medication cart on Station 1.<BR/>Review of e-mail attachment dated 11/01/24 and written by P H indicated a medication dose for Resident #1 was not requested from the facility's Stat Safe (EKit) on 10/30/24 between 5 A.M. and 2 P.M. <BR/>Review of Resident #1's Medication Administration Record dated 10/01/24 - 10/31/24 PRN 1 for Hydrocodone - Acetaminophen - Schedule II table; 5-325; amount to administer: one tablet oral, indicated on 10/30/24 at 5:35 A.M. her pain level was a 6 and at 2:04 P.M. her pain level was a 4. This report reflected these medications were not given to Resident #1.<BR/>During an interview on 10/30/24 at 12:05 P.M. with Resident #1 she asked Licensed Vocational Nurse (LVN A) for her Hydrocodone pill on 10/30/24 at approximately 4:30 A.M. LVN A returned and said she could not open the lock box with the narcotics. Resident #1 said she did not ask her for a different pain pill. Resident #1 said at approximately 7:30 A.M. Certified Medication Aide (CMA B) administered her medications, and that was when she asked her for her Hydrocodone; however, CMA B said she could not give it to her. Resident #1 said she did not ask for a different pain pill. Resident #1 said CMA B administered her medications at approximately 12 P.M., and that's when she asked her for her Hydrocodone. CMA B said she could not administer her pill because the box was locked, and Resident #1 did not ask her for a different pain pill. Resident #1 said she thought it was about 6 P.M. when she received her Hydrocodone. <BR/>During an interview on 10/31/24 at 12:47 P.M. with LVN A indicated on 10/30/24 at approximately 6 A.M., Resident #1 asked her for her Hydrocodone for pain, which was PRN, and she can take every 4 hours as needed. LVN A said she could not open the locked box with Resident #1's Hydrocodone, and informed LVN F that she could not administer Resident #1 her Hydrocodone. LVN F said she would take care of it (locked box). LVN A said the facility has an EKit; however, it does not include Hydrocodone because it required a triplicate order. LVN A said Resident #1 had Tylenol; however, she did not give it to her because she asked for Hydrocodone. LVN A said she should have notified the nurse practitioner or used the EKit to administer Resident #1's Hydrocodone. <BR/>During an interview on 10/30/24 at 2:20 P.M. with DON E indicated the physician would have to call in an order for one narcotic pill; however, she was not sure if the physician was notified. <BR/>During an interview on 10/30/24 at 2:59 P.M. with Certified Medication Aide (CMA B) indicated at approximately 7 A.M. she was informed the box with the narcotics could not be unlocked because the key was not working. CMA B said at approximately 7:30 P.M. Resident #1 asked for her Hydrocodone, and she informed her that she could not give her this pill because the box could not be unlocked. CMA B said she did not report to LVN F that Resident #1 requested her Hydrocodone. CMA B said after this medication pass, she informed the Director of Nurses (DON E) that she could not give Resident #1 her Hydrocodone. DON E informed her that they were sending someone to repair the box. CMA B said she did not inform LVN B that resident was in pain and wanted her Hydrocodone. <BR/>During an interview on 10/30/24 at 3:27 P.M. with LVN G indicated she was informed by LVN A that she had not been able to open the narcotics box since 5:30 A.M. LVN G said LVN A tried to administer Resident #1 her Hydrocodone but could not unlock the box with the narcotics. LVN G said Resident #1 had a history of asking for her Hydrocodone as if they were scheduled. LVN G said she was not informed by CMA B that Resident #1 had asked for her Hydrocodone on 10/30/24 at 7:30 A.M. and at 12 P.M. LVN G said the process would have been to notify the charge nurse, assess her pain level, administer the pill ordered, if out of this pill give the resident a substitute, like Tylenol, and call the physician. LVN G said she did not attempt to obtain this pill from the Stat Safe (EKit with medications to use in an emergency), because when she checked on Resident #1, she was asleep. LVN G said to use the EKit you must call the pharmacy for a code to obtain the Hydrocodone. <BR/>During an interview on 10/01/24 at 8:30 A.M. with P H indicated Resident #1 had Hydrocodone in the Stat Safe (EKit) that was in the facility's medication room. When Resident #1's Hydrocodone was delivered to the facility she was sent 29 of 30 days, and the 30th day was her backup for when she runs out or there was an emergency requiring access to her Hydrocodone. The nurse needed to input the resident's information and the medication needed into the EKit, and the EKit would indicate if the medication was available. If it was, the facility's nurse should call the pharmacy to obtain a code that they input into the EKit, which dispensed the pill. <BR/>Observation on 11/01/24 at approximately 3 P.M., DON E demonstrated how the EKit worked by inputting Resident #1's information and the medication needed. The EKit's digital response indicated Resident #1 had Hydrocodone available in the E-Kit. Prior to this demonstration, DON E was not aware the EKit had Hydrocodone that could be dispensed by calling the pharmacist for the code. <BR/>Record review of the facility's policy and procedure Preparation and General Guidelines dated 06/01/22 indicated medications are administered as prescribed in accordance with good nursing principles and only by legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without interruptions. <BR/>Review of the facility's policy and procedure for Medication Ordering and Receiving from Pharmacy dated 06/01/22 indicated Emergency pharmacy services are available on a 24-hour basis. Emergency needs for medications are met by the facility's approved emergency medication supply or by special order from the provider pharmacy. The pharmacy supplies emergency medications including emergency drugs, antibiotics., (controlled substances, products for infusion) and routine medications where appropriate, in limited quantities (in portable, sealed containers, automated dispensing units ([NAME])) in compliance with applicable state regulations. To access medication from the emergency kit or ADS, secondary to a new order or when medication for which there is a current prescription is not readily available, the nurse should not take a medication from the e-box or ADS without checking allergies on the medical record and possible drug-drug interactions with pharmacist. The nurse confers with the prescriber to determine whether the order is a true emergency order and cannot be delayed until the scheduled pharmacy delivery. The nurse may alert, if the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to [NAME] that it meets the criteria of an emergency situation. Only after verifying the above has occurred, the pharmacy has received a complete prescription, the nurse unlocks the container/cabinet/breaks the container's seal or accesses the ADU via assigned security codes and removes the required medication. If the medication is not available in the emergency kit, the nurse contacts the pharmacy, using the after-hours emergency number if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 5 residents (Resident #1) of five residents whose records were reviewed for abuse.<BR/>Facility staff did not implement facility policy and immediately notify administration when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. <BR/>This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. <BR/>Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition. <BR/>Record review of Resident #1's care plan dated 5/2/24 indicated Resident #1 had a history of pain with a start date of 4/29/24. Staff are instructed to handle gently and try to eliminate any environmental stimuli. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. FM #1 stated that when Resident #1 returned from the hospital on 6/23/24 after she had been hospitalized for fractured ribs. FM#1 stated she observed that CNA B was rough with Resident #1 when she jerked her up to change her. FM#1 stated she told CNA B that she (FM#1) would change Resident #1 herself. FM #1 stated she reported to LVN A that CNA B was rough with Resident #1. FM#1 stated she was concerned about Resident #1's safety and wellbeing.<BR/>During an interview on 6/25/24 at 2:50 p.m. LVN A stated that when Resident #1 returned from the hospital and was in her room with FM #1. LVN A stated that FM #1 reported to him that CNA B was real rough with Resident #1. LVN A stated that FM #1 told him that [CNA B] was rough with her and made her get out of bed. LVN A stated that he was not in the room when CNA B assisted Resident #1 and did not think CNA B was the type of person to be abusive. LVN A stated that he had been trained on Abuse and Neglect and trained to report allegations of abuse immediately to the Administrator. LVN A stated that the facility had routine in-services on Abuse and Neglect and to report allegations to the ADM. LVN A stated he did not think CNA B had abused Resident #1 and had FM #1 stated that CNA B hit or punched Resident #1 he then would have reported it.<BR/>During an interview on 6/25/24 at 3:15 p.m. with the ADM; he stated that when the FM told LVN A that CNA B was rough with the resident, it should had been reported to him. The ADM stated that if the family member had not used the word abused that LVN A may not have thought it was reportable. The ADM stated that had LVN A reported it to him, the facility would have investigated the reported incident. The ADM stated that I just gave in services on ANE and reporting two weeks ago. It is posted all over the building to report to me and my phone number is listed. The ADM confirmed that nothing had been reported to him by LVN A. <BR/>During an interview on 6/25/24 at 3:24 p.m. with the DON, she stated that if a FM told LVN A that CNA B was rough with Resident #1, LVN A should have reported it to her or the ADM so it could be investigated. The DON stated that rough is not gentle and if someone reported that a staff was rough with a resident, she would have investigated it as the staff was being not gentle and either grabbing or pulling, rushing. The DON stated had it been reported to her, she would report it to the ADM and then report to the state. The DON stated that LVN A had been trained to report suspected abuse or neglect. The DON stated that the person making the complaint would not have to use the word abused and the word rough would be a reportable incident. The DON stated she had not been informed of this incident until now. <BR/>During an interview on 6/25/24 at 3:53 p.m. with CNA C, stated that if a family member or staff member stated that a staff member was rough with a resident, she would immediately report to the charge nurse and to the Administrator. CNA C stated that she believed the term rough could mean tearing skin, pulling an arm out of socket and if a family member thinks a staff is being rough, they are rough, and it had to be reported. <BR/>During a phone interview on 6/27/24 at 3:45 p.m. with CNA B; stated that when Resident #1 returned from the hospital her FM (#1) notified her that Resident #1 was sitting on the edge of the bed and the floor was wet. CNA B stated she entered Resident #1's room and found Resident #1 sitting on the edge of her bed with pants around her ankles. CNA B stated the floor was wet under Resident #1's feet and the pants were the roommates' pants as they were too small for Resident #1. CNA B stated that Resident #1 had been in the hospital and had fractured ribs. CNA B stated she stepped out of the room to get a pull-up for Resident #1. CNA B stated she removed the pants from Resident #1; s ankles, put a pull-up and pants on Resident #1 and then assisted Resident #1 to stand up to pull up the pull up and pants. CNA B stated she put her arms under Resident #1's arms to assist her to stand up and did not use any force nor was rough. CNA B stated after she dressed Resident #1, she assisted Resident #1 back onto her bed and realized that Resident #1's socks were wet. CNA B stated she attempted to remove the socks and the FM told her she would do it herself because she did not want Resident #1 to stand up again. CNA B stated that she had been trained on abuse/neglect and to report any allegations of abuse/neglect immediately to the abuse coordinator, the Administrator. CNA B stated that if someone told her that a staff member had been rough with a resident, she would immediately notify her charge nurse and then immediately would notify the Administrator that an allegation had been made. <BR/>Record review of the facility's Abuse Prevention policy revised on 10/2023 revealed in part, the facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect: <BR/>- Include training for new and existing staff on activities that constitute abuse, neglect, reporting procedures. <BR/>- Indicators of abuse include, but are not limited to: Resident, staff, or family report of abuse. <BR/>-Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately but not later than 2 hours of after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. <BR/>Record review of the facility's In-service on Abuse and Neglect for LVN A dated and signed 11/4/22 revealed in part: The facility during its orientation program and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 5 residents (Resident #1) reviewed for reporting.<BR/>The facility failed to ensure staff immediately reported an allegation of when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. <BR/>This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. <BR/>Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition. <BR/>Record review of Resident #1's care plan dated 5/2/24 indicated Resident #1 had a history of pain with a start date of 4/29/24. Staff are instructed to handle gently and try to eliminate any environmental stimuli. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. FM #1 stated that when Resident #1 returned from the hospital on 6/23/24 after she had been hospitalized for fractured ribs. FM#1 stated she observed that CNA B was rough with Resident #1 when she jerked her up to change her. FM#1 stated she told CNA B that she (FM#1) would change Resident #1 herself. FM #1 stated she reported to LVN A that CNA B was rough with Resident #1. FM#1 stated she was concerned about Resident #1's safety and wellbeing. <BR/>During an interview on 6/25/24 at 2:50 p.m. LVN A stated that when Resident #1 returned from the hospital and was in her room with FM #1. LVN A stated that FM #1 reported to him that CNA B was real rough with Resident #1. LVN A stated that FM #1 told him that [CNA B] was rough with her and made her get out of bed. LVN A stated that he was not in the room when CNA B assisted Resident #1 and did not think CNA B was the type of person to be abusive. LVN A stated that he had been trained on Abuse and Neglect and trained to report allegations of abuse immediately to the Administrator. LVN A stated that the facility had routine in-services on Abuse and Neglect and to report allegations to the ADM. LVN A stated he did not think CNA B had abused Resident #1 and had FM #1 stated that CNA B hit or punched Resident #1 he then would have reported it.<BR/>During an interview on 6/25/24 at 3:15 p.m. the ADM stated that when the FM told LVN A that CNA B was rough with the resident, it should had been reported to him. The ADM stated that if the family member had not used the word abused that LVN A may not have thought it was reportable. The ADM stated that had LVN A reported it to him, the facility would have investigated the reported incident. The ADM stated that I just gave in services on ANE and reporting two weeks ago. It is posted all over the building to report to me and my phone number is listed. The ADM confirmed that nothing had been reported to him by LVN A. <BR/>During an interview on 6/25/24 at 3:24 p.m. with the DON, she stated that if a FM told LVN A that CNA B was rough with Resident #1, LVN A should have reported it to her or the ADM so it could be investigated. The DON stated that rough is not gentle and if someone reported that a staff was rough with a resident, she would have investigated it as the staff was being not gentle and either grabbing or pulling, rushing. The DON stated had it been reported to her, she would report it to the ADM and then report to the state. The DON stated that LVN A had been trained to report suspected abuse or neglect. The DON stated that the person making the complaint would not have to use the word abused and the word rough would be a reportable incident. The DON stated she had not been informed of this incident until now. <BR/>During an interview on 6/25/24 at 3:53 p.m. CNA C stated that if a family member or staff member stated that a staff member was rough with a resident, she would immediately report to the charge nurse and to the Administrator. CNA C stated that she believed the term rough could mean tearing skin, pulling an arm out of socket and if a family member thinks a staff is being rough, they are rough, and it had to be reported. <BR/>During an interview on 6/26/24 at 9:35 a.m. with the ADM and DON; ADM stated that the facility completed a self-report of abuse to the state on 6/25/24 and has conducted interviews with LVN A and CNA B to determine who was involved in the allegation of abuse made by a family member. The ADM stated that during their investigation they were able to identify Resident #1 and FM #1 and have interviewed FM #1, LVN A and CNA B regarding the allegation of abuse that CNA B was rough with Resident #1. The ADM stated that CNA B is currently suspended and is not at the facility. The ADM stated that Resident #1 has not returned from the hospital at this time. <BR/>During a phone interview on 6/27/24 at 3:45 p.m. CNA B stated that when Resident #1 returned from the hospital her FM (#1) notified her that Resident #1 was sitting on the edge of the bed and the floor was wet. CNA B stated she entered Resident #1's room and found Resident #1 sitting on the edge of her bed with pants around her ankles. CNA B stated the floor was wet under Resident #1's feet and the pants were the roommates' pants as they were too small for Resident #1. CNA B stated that Resident #1 had been in the hospital and had fractured ribs. CNA B stated she stepped out of the room to get a pull-up for Resident #1. CNA B stated she removed the pants from Resident #1; s ankles, put a pull-up and pants on Resident #1 and then assisted Resident #1 to stand up to pull up the pull up and pants. CNA B stated she put her arms under Resident #1's arms to assist her to stand up and did not use any force nor was rough. CNA B stated after she dressed Resident #1, she assisted Resident #1 back onto her bed and realized that Resident #1's socks were wet. CNA B stated she attempted to remove the socks and the FM told her she would do it herself because she did not want Resident #1 to stand up again. CNA B stated that she had been trained on abuse/neglect and to report any allegations of abuse/neglect immediately to the abuse coordinator, the Administrator. CNA B stated that if someone told her that a staff member had been rough with a resident, she would immediately notify her charge nurse and then immediately would notify the Administrator that an allegation had been made. <BR/>Record review of Resident #1's progress notes dated from 6/19/24-6/25/24 revealed no progress notes entered by LVN A regarding FM#1 allegation that CNA B was rough with Resident #1. <BR/>Record review of the facility provided Incident/Accident and Grievance records dated from 6/19/24-6/25/24 revealed no documentation that LVN A reported the allegation made by FM#1 that CNA B was rough with Resident #1. <BR/>Record review of the facility's Abuse Prevention policy revised on 10/2023 revealed in part, the facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. <BR/>- Include training for new and existing staff on activities that constitute abuse, neglect .reporting procedures. <BR/>- Indicators of abuse include, but are not limited to: Resident, staff, or family report of abuse. <BR/>- Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately but not later than 2 hours of after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. <BR/>Record review of the facility's In-service on Abuse and Neglect for LVN A dated and signed 11/4/22 revealed in part: The facility during its orientation program and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 5 residents (Resident #1) of five residents whose records were reviewed for abuse.<BR/>Facility staff did not implement facility policy and immediately notify administration when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. <BR/>This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. <BR/>Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition. <BR/>Record review of Resident #1's care plan dated 5/2/24 indicated Resident #1 had a history of pain with a start date of 4/29/24. Staff are instructed to handle gently and try to eliminate any environmental stimuli. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. FM #1 stated that when Resident #1 returned from the hospital on 6/23/24 after she had been hospitalized for fractured ribs. FM#1 stated she observed that CNA B was rough with Resident #1 when she jerked her up to change her. FM#1 stated she told CNA B that she (FM#1) would change Resident #1 herself. FM #1 stated she reported to LVN A that CNA B was rough with Resident #1. FM#1 stated she was concerned about Resident #1's safety and wellbeing.<BR/>During an interview on 6/25/24 at 2:50 p.m. LVN A stated that when Resident #1 returned from the hospital and was in her room with FM #1. LVN A stated that FM #1 reported to him that CNA B was real rough with Resident #1. LVN A stated that FM #1 told him that [CNA B] was rough with her and made her get out of bed. LVN A stated that he was not in the room when CNA B assisted Resident #1 and did not think CNA B was the type of person to be abusive. LVN A stated that he had been trained on Abuse and Neglect and trained to report allegations of abuse immediately to the Administrator. LVN A stated that the facility had routine in-services on Abuse and Neglect and to report allegations to the ADM. LVN A stated he did not think CNA B had abused Resident #1 and had FM #1 stated that CNA B hit or punched Resident #1 he then would have reported it.<BR/>During an interview on 6/25/24 at 3:15 p.m. with the ADM; he stated that when the FM told LVN A that CNA B was rough with the resident, it should had been reported to him. The ADM stated that if the family member had not used the word abused that LVN A may not have thought it was reportable. The ADM stated that had LVN A reported it to him, the facility would have investigated the reported incident. The ADM stated that I just gave in services on ANE and reporting two weeks ago. It is posted all over the building to report to me and my phone number is listed. The ADM confirmed that nothing had been reported to him by LVN A. <BR/>During an interview on 6/25/24 at 3:24 p.m. with the DON, she stated that if a FM told LVN A that CNA B was rough with Resident #1, LVN A should have reported it to her or the ADM so it could be investigated. The DON stated that rough is not gentle and if someone reported that a staff was rough with a resident, she would have investigated it as the staff was being not gentle and either grabbing or pulling, rushing. The DON stated had it been reported to her, she would report it to the ADM and then report to the state. The DON stated that LVN A had been trained to report suspected abuse or neglect. The DON stated that the person making the complaint would not have to use the word abused and the word rough would be a reportable incident. The DON stated she had not been informed of this incident until now. <BR/>During an interview on 6/25/24 at 3:53 p.m. with CNA C, stated that if a family member or staff member stated that a staff member was rough with a resident, she would immediately report to the charge nurse and to the Administrator. CNA C stated that she believed the term rough could mean tearing skin, pulling an arm out of socket and if a family member thinks a staff is being rough, they are rough, and it had to be reported. <BR/>During a phone interview on 6/27/24 at 3:45 p.m. with CNA B; stated that when Resident #1 returned from the hospital her FM (#1) notified her that Resident #1 was sitting on the edge of the bed and the floor was wet. CNA B stated she entered Resident #1's room and found Resident #1 sitting on the edge of her bed with pants around her ankles. CNA B stated the floor was wet under Resident #1's feet and the pants were the roommates' pants as they were too small for Resident #1. CNA B stated that Resident #1 had been in the hospital and had fractured ribs. CNA B stated she stepped out of the room to get a pull-up for Resident #1. CNA B stated she removed the pants from Resident #1; s ankles, put a pull-up and pants on Resident #1 and then assisted Resident #1 to stand up to pull up the pull up and pants. CNA B stated she put her arms under Resident #1's arms to assist her to stand up and did not use any force nor was rough. CNA B stated after she dressed Resident #1, she assisted Resident #1 back onto her bed and realized that Resident #1's socks were wet. CNA B stated she attempted to remove the socks and the FM told her she would do it herself because she did not want Resident #1 to stand up again. CNA B stated that she had been trained on abuse/neglect and to report any allegations of abuse/neglect immediately to the abuse coordinator, the Administrator. CNA B stated that if someone told her that a staff member had been rough with a resident, she would immediately notify her charge nurse and then immediately would notify the Administrator that an allegation had been made. <BR/>Record review of the facility's Abuse Prevention policy revised on 10/2023 revealed in part, the facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect: <BR/>- Include training for new and existing staff on activities that constitute abuse, neglect, reporting procedures. <BR/>- Indicators of abuse include, but are not limited to: Resident, staff, or family report of abuse. <BR/>-Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately but not later than 2 hours of after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. <BR/>Record review of the facility's In-service on Abuse and Neglect for LVN A dated and signed 11/4/22 revealed in part: The facility during its orientation program and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 5 residents (Resident #1) reviewed for reporting.<BR/>The facility failed to ensure staff immediately reported an allegation of when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. <BR/>This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. <BR/>Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition. <BR/>Record review of Resident #1's care plan dated 5/2/24 indicated Resident #1 had a history of pain with a start date of 4/29/24. Staff are instructed to handle gently and try to eliminate any environmental stimuli. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. FM #1 stated that when Resident #1 returned from the hospital on 6/23/24 after she had been hospitalized for fractured ribs. FM#1 stated she observed that CNA B was rough with Resident #1 when she jerked her up to change her. FM#1 stated she told CNA B that she (FM#1) would change Resident #1 herself. FM #1 stated she reported to LVN A that CNA B was rough with Resident #1. FM#1 stated she was concerned about Resident #1's safety and wellbeing. <BR/>During an interview on 6/25/24 at 2:50 p.m. LVN A stated that when Resident #1 returned from the hospital and was in her room with FM #1. LVN A stated that FM #1 reported to him that CNA B was real rough with Resident #1. LVN A stated that FM #1 told him that [CNA B] was rough with her and made her get out of bed. LVN A stated that he was not in the room when CNA B assisted Resident #1 and did not think CNA B was the type of person to be abusive. LVN A stated that he had been trained on Abuse and Neglect and trained to report allegations of abuse immediately to the Administrator. LVN A stated that the facility had routine in-services on Abuse and Neglect and to report allegations to the ADM. LVN A stated he did not think CNA B had abused Resident #1 and had FM #1 stated that CNA B hit or punched Resident #1 he then would have reported it.<BR/>During an interview on 6/25/24 at 3:15 p.m. the ADM stated that when the FM told LVN A that CNA B was rough with the resident, it should had been reported to him. The ADM stated that if the family member had not used the word abused that LVN A may not have thought it was reportable. The ADM stated that had LVN A reported it to him, the facility would have investigated the reported incident. The ADM stated that I just gave in services on ANE and reporting two weeks ago. It is posted all over the building to report to me and my phone number is listed. The ADM confirmed that nothing had been reported to him by LVN A. <BR/>During an interview on 6/25/24 at 3:24 p.m. with the DON, she stated that if a FM told LVN A that CNA B was rough with Resident #1, LVN A should have reported it to her or the ADM so it could be investigated. The DON stated that rough is not gentle and if someone reported that a staff was rough with a resident, she would have investigated it as the staff was being not gentle and either grabbing or pulling, rushing. The DON stated had it been reported to her, she would report it to the ADM and then report to the state. The DON stated that LVN A had been trained to report suspected abuse or neglect. The DON stated that the person making the complaint would not have to use the word abused and the word rough would be a reportable incident. The DON stated she had not been informed of this incident until now. <BR/>During an interview on 6/25/24 at 3:53 p.m. CNA C stated that if a family member or staff member stated that a staff member was rough with a resident, she would immediately report to the charge nurse and to the Administrator. CNA C stated that she believed the term rough could mean tearing skin, pulling an arm out of socket and if a family member thinks a staff is being rough, they are rough, and it had to be reported. <BR/>During an interview on 6/26/24 at 9:35 a.m. with the ADM and DON; ADM stated that the facility completed a self-report of abuse to the state on 6/25/24 and has conducted interviews with LVN A and CNA B to determine who was involved in the allegation of abuse made by a family member. The ADM stated that during their investigation they were able to identify Resident #1 and FM #1 and have interviewed FM #1, LVN A and CNA B regarding the allegation of abuse that CNA B was rough with Resident #1. The ADM stated that CNA B is currently suspended and is not at the facility. The ADM stated that Resident #1 has not returned from the hospital at this time. <BR/>During a phone interview on 6/27/24 at 3:45 p.m. CNA B stated that when Resident #1 returned from the hospital her FM (#1) notified her that Resident #1 was sitting on the edge of the bed and the floor was wet. CNA B stated she entered Resident #1's room and found Resident #1 sitting on the edge of her bed with pants around her ankles. CNA B stated the floor was wet under Resident #1's feet and the pants were the roommates' pants as they were too small for Resident #1. CNA B stated that Resident #1 had been in the hospital and had fractured ribs. CNA B stated she stepped out of the room to get a pull-up for Resident #1. CNA B stated she removed the pants from Resident #1; s ankles, put a pull-up and pants on Resident #1 and then assisted Resident #1 to stand up to pull up the pull up and pants. CNA B stated she put her arms under Resident #1's arms to assist her to stand up and did not use any force nor was rough. CNA B stated after she dressed Resident #1, she assisted Resident #1 back onto her bed and realized that Resident #1's socks were wet. CNA B stated she attempted to remove the socks and the FM told her she would do it herself because she did not want Resident #1 to stand up again. CNA B stated that she had been trained on abuse/neglect and to report any allegations of abuse/neglect immediately to the abuse coordinator, the Administrator. CNA B stated that if someone told her that a staff member had been rough with a resident, she would immediately notify her charge nurse and then immediately would notify the Administrator that an allegation had been made. <BR/>Record review of Resident #1's progress notes dated from 6/19/24-6/25/24 revealed no progress notes entered by LVN A regarding FM#1 allegation that CNA B was rough with Resident #1. <BR/>Record review of the facility provided Incident/Accident and Grievance records dated from 6/19/24-6/25/24 revealed no documentation that LVN A reported the allegation made by FM#1 that CNA B was rough with Resident #1. <BR/>Record review of the facility's Abuse Prevention policy revised on 10/2023 revealed in part, the facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. <BR/>- Include training for new and existing staff on activities that constitute abuse, neglect .reporting procedures. <BR/>- Indicators of abuse include, but are not limited to: Resident, staff, or family report of abuse. <BR/>- Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately but not later than 2 hours of after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. <BR/>Record review of the facility's In-service on Abuse and Neglect for LVN A dated and signed 11/4/22 revealed in part: The facility during its orientation program and through ongoing training provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for two of 22 residents (Residents #18 and #69) reviewed for care plans.<BR/>1. <BR/>The facility failed to develop a care plan for Resident #18 regarding dialysis.<BR/>2. <BR/>The facility failed to develop a care plan for Resident #69 regarding insulin for treatment of the diagnosis of diabetes. <BR/>These failures could place residents at risk of not receiving the care required to meet their individualized needs. <BR/>Finding included:<BR/>Resident #18<BR/>Record review of the undated face sheet for Resident #18 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of cerebral infarction, unspecified (stroke), unspecified inflammation of eyelid (history of), other specified glaucoma (vision disorder), palpitations (irregular heart beat), essential hypertension (high blood pressure), personal history of transient ischemic attack (blockage of blood flow to the brain), dependence on renal dialysis (procedure to remove waste from blood when kidney function has declined), type two diabetes mellitus, without complications (blood sugar disorder), and end stage renal disease (kidney disease). <BR/>Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #18 had a BIMS score of 15 indicating that the resident was cognitively intact. Further record review of the MDS revealed active diagnoses of hypertension, renal insufficiency, renal failure, or end stage renal disease, diabetes mellitus, cerebral vascular accident, transient ischemic, attack, or stroke. Additional review of the MDS revealed that the resident was on dialysis while a resident.<BR/>Record review of the current care plan for Resident #18, last reviewed/revised: 1/22/24, revealed there was no specific care plan regarding dialysis. <BR/>Record review of the current physician orders for Resident #18, dated 2/6/24 revealed the following order, Hemodialysis performed on Tuesday, Thursday, Saturday at 5:45 AM dialysis center . Special instructions: send blanket, mustard, and lunch. Once a day on Tuesday, Thursday, Saturday, 6 AM - 6 PM. Start date 7/17/23. Open ended . <BR/>During an interview on 2/06/24 at 10:50 AM, LVN A Resident #18 was out of the room at dialysis on Tuesday, Thursday, and Saturday and would leave at 8:30 AM and come back before supper. <BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON regarding Resident #18's omitted care plan for dialysis. She stated she was not sure why there was not one. She said there should have been a care plan for dialysis. She stated if residents had no care plan, staff would not know how to care for the resident. She stated, she and nursing staff develop the baseline care plan. She added she and the Clinical Case Manager worked together to develop the care plans. She stated we review the orders and have started to conduct care conferences. <BR/>On 2/8/24 at 5:10 PM an interview was conducted with the Administrator regarding a missed dialysis care plan for Resident #18. He stated he was unsure why the issue occurred. He stated that he expected that staff should have developed a care plan when the resident was started on dialysis. He stated that the DON and the ADON were responsible for care plans being developed. He stated there could be miscommunication if a care plan was not developed for dialysis. <BR/>Resident #69<BR/>Record review of Resident #69's face sheet, dated 02/07/2024, revealed [AGE] year-old female admitted [DATE] with diagnoses that included, but were not limited to, diabetes (body doesn't make enough insulin or can use it as well as it should), diabetic nephropathy (uncontrolled diabetes can cause damage to blood vessels in the kidney that filter waste from the blood, which can cause kidney failure), aphasia (loss of ability to understand or express speech), acute myocardial infarction (heart attack), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (chronic brain disorder and when active symptoms can include delusions-false belief about external reality; hallucinations-hear, see, smell, taste or feel things that appear to be real but only exist in the mind; disorganized speech-any interruption that makes communication difficult and sometimes impossible to understand; trouble thinking and lack of motivation), epilepsy (a disorder of the brain characterized by repeated seizures- a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain), congestive heart failure (the heart can't pump blood well enough to meet the body's needs), intracardiac thrombosis (a blood clot in the heart), and cerebral infarction (occurs as result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) . <BR/>Record review of Resident #69's physician orders (no date) revealed Novolin 70-30 Flex Pen U-100 8 units; subcutaneous twice a day morning 07:00 AM-10:00 AM; Bedtime 7:00 PM - 10:00 PM start date of 08/29/2023 open ended end date. <BR/>Record review of Resident #69's admission comprehensive MDS assessment dated [DATE] revealed Resident #69 had a BIMS of 06 which suggested severe cognitive impairment; active diagnosis reveals diabetes mellitus; medications revealed the resident received insulin injections seven days a week.<BR/>Record review of Resident #69's quarterly comprehensive MDS assessment dated [DATE], the medication section revealed the resident received insulin injections seven days a week. <BR/>Record reviewed Resident #69's care plan dated 01/22/2024 revealed no approach for diabetes or the use of insulin. <BR/>In an interview on 02/08/2024 at 10:30 AM, Resident #69 stated she received an injection for her diabetes. <BR/>In an interview on 02/08/2024 at 4:14 PM, the DON stated there was no care plan for insulin. DON stated, that is on me, there should be a care plan showing insulin is a method to treat the diabetes. She stated that without a care plan, a staff member would not know how to care for the resident. <BR/>Record review of the facility policy titled Comprehensive Care Plans, 1/26/24 V.1 revealed the following documentation, 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 time frames to meet a resident medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines:<BR/>1. The care planning process will include an assessment of the resident's strengths, and needs, and will incorporate the residents 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. <BR/>2. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDS assessment, and by day 21 of the patients stay. All care assessment areas . triggered by the MDS will be considered in developing the care plan. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the care plan. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. <BR/>3. The comprehensive care plan will describe, at a minimum the following: <BR/>a. The services that are to be furnished to attain and maintain the residents highest practicable physical, mental, and psychosocial well-being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 2 of 8 residents (Resident #2, Resident #3) reviewed for staffing. <BR/>The facility failed to have sufficient nursing staff in the memory care unit to provide supervision to assure resident safety. <BR/>This failure could place residents at risk for not having their physical, mental, and psychosocial well-being met.<BR/>Findings include:<BR/>Record review of a face sheet dated 6/25/24 indicated Resident #2 is an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease with early onset, Major depressive disorder, Dementia-mild with agitation, Generalized anxiety disorder, Impulse disorder, Cognitive communication deficit.<BR/>Record review of a Resident #2's quarterly MDS assessment dated [DATE] indicated a BIMS of 2 which indicated severely impaired cognition and documented frequent urinary incontinence.<BR/>Record review of Resident #2's care plan dated 4/11/24 indicated Resident #2 revealed documented problem, goal, or approach to address Resident #2's behavior and history of exposing his penis and urinating on floors in the unit. <BR/>Record review of a face sheet dated 6/25/24 indicated Resident #3 is a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Dementia with anxiety and agitation, Mood disorder, Cognitive communication disorder, Depression, Alzheimer's disease, Generalized anxiety disorder. <BR/>Record review of a Resident #3's quarterly MDS assessment dated [DATE] indicated a BIMS of 2 which indicated severely impaired cognition. <BR/>Record review of Resident #3's care plan dated 4/11/24 indicated Resident #3 revealed documented problem, goal, or approach to address Cognitive loss/Dementia: Anticipate needs and observe for non-verbal cues, approach in a calm manner. Psychosocial Well-being-Resident has behaviors such as wandering and can be combative at times, also wanders into other residents; Resident has physically abused behavioral symptoms gets aggressive at times with staff: Assess whether the behavior endangers the resident and/or others, intervene as necessary; avoid power struggles, avoid power struggles with resident; divert resident's behavior by redirecting. Keep distance between residents and others when resident becomes physically abusive, move resident to a quiet, calm environment. <BR/>Record review of Resident #3's psychological assessment dated [DATE] revealed the following: On examination, patient exhibited loosening of associations and preservation. Thought content was significant for auditory hallucinations, visual hallucinations, paranoia, delusions. Patient's insight was poor. Judgment was poor. Patient risk of aggression is at risk for verbal aggression. <BR/>Record Review of Resident #3's psychological assessment dated [DATE] revealed the following: Attention span and concentration was poor. Patient was oriented to person and no spheres. Patient was disoriented. Recent memory was severely impaired. Remote memory was severely impaired. Fund of knowledge was severely impaired on examination, patient exhibited loosening of associations, perseveration, and bizarre thoughts. Thought content was significant for auditory hallucinations, visual hallucinations, paranoia, delusions. Patient's insight was poor. Judgment was poor. Patient is at little to no risk of aggression. <BR/>During a phone interview on 6/25/24 at 9:55 a.m. with FM #1; stated that a male resident (Resident #2) had exposed his penis and urinated in several areas in the secure unit. FM #1 stated that on several occasions there had only been one staff in the secure unit and residents had been left unsupervised in the common areas of the secure unit. <BR/>During an interview on 6/25/24 at 2:50 p.m. with LVN A; stated that Resident #2 had a history of urinating on the floors in the unit. LVN A stated Resident #2 he does that, he will whip it out and pee wherever or by the residents on the floor, he just does that. LVN A stated that there should be always 2 staff in the secure unit and at times there are not 2 staff available if someone calls in or goes on break. <BR/>During an interview and observation on 6/25/24 at 3:53 p.m. with CNA C; Stated that Resident #2 had a history of pulling his pants down below his penis and peeing in various areas of the unit that included in closets, behind curtains, resident rooms, or hallways. CNA C stated that there was not a precursor to the behavior and staff had often find urine on the floor. CNA C stated that she had worked at the facility for several years and was unaware if Resident #2's care plan addressed these behaviors. CNA C stated that she had notified the nurses in the past and that it was not a new behavior. CNA C stepped away and assisted a female resident behind closed doors for approximately five minutes. Residents were observed sitting in the dining room, a male resident was observed pacing the hallway and Resident #3 was observed pacing the hallway, entering resident rooms and the dining room while yelling and cursing. Resident #3 approached several residents as she cussed I'll beat your ass. CNA C exited the resident room and stated that she was the only staff in the secure unit because the other staff was on lunch. CNA C stated that Resident #3 would walk the hallways and cuss and yell throughout the day. CNA C stated that some residents have complained about Resident #3 and Resident #2 in the past. <BR/>During an observation and attempted interview on 6/25/24 at 4:07 p.m. with Resident #2, observed Resident #2 on his bed covered with blankets. Resident #2 had his eyes open and did not respond to verbal prompts. <BR/>During an interview on 6/25/24 at 4:19 p.m. with the DON; stated that the secure unit should always have 2 staff, and she had not been aware that CNA C was the only one in the unit when the other staff member was on lunch. The DON stated that there had to be always two staff due to resident behaviors and resident needs. The DON stated that Resident #3 had a history of being aggressive towards other residents and staff had been made aware that there had to be two staff in the secure unit. The DON stated that either there would be 2 CNAs or 1 CNA and a nurse but there was no exception to the two staff rule. The DON stated that if staff had been assisting other residents behind closed doors than the other residents were not supervised. The DON stated that CNA C should have notified her that she was the only one in the unit and waited for another staff to monitor the other residents when she performed care behind a closed door. <BR/>During an observation on 6/26/24 at 11:22 a.m. in the secured unit, Resident #3 was observed walking the secure hallway with two female staff within a few feet of Resident #3. Resident #3 paced back and forth while yelling out, I'll whoop your ass right now. Resident #3 entered an unknown resident room and stated, I'll beat your ass today. The female staff followed behind Resident #3 but did not enter the unknown resident room before Resident #3 exited back into the hallway. <BR/>During an interview and observation on 6/26/24 at 11:25 a.m. with Resident #4, Resident was sitting at a table in the dining room participating in a coloring activity. Resident #4 pointed at Resident #3 who had walked in the dining room and was cussing I'll whoop your ass right now in the direction of other residents. Resident #4 stated, I hate that lady, she cusses too much. She takes stuff from the other residents. Resident #4 stated that sometimes there was not staff around to stop Resident #3 from getting into other residents' stuff or rooms. Resident #4 stated that Resident #2 pees everywhere and will come into resident rooms and lay in their beds or pee on their floors. Resident #4 stated that there are not enough staff back here. <BR/>During an and interview and observation on 6/26/24 beginning at 11:27 a.m. in the secured unit, CNA D was observed in the hallway with another staff member following Resident #3. CNA D stated that there were always two staff in the secure unit unless a staff went to lunch. CNA D stated that they try to have two staff if possible. Resident #3 walked from the hallway into the dining room where several residents were participating in activities. Resident #3 walked up to several residents and touched the wheelchair of a resident. The Activity assistant was observed in the dining room assisting residents with activities. Resident #3 walked up to a table and grabbed several crayons and put them in her mouth and began to chew. Two female staff approached Resident #3 with a napkin and attempted to request Resident #3 to spit out the crayons. Resident #3 shoved CNA D and Resident #3 walked out of the dining room back into the hallway and entered another resident room as staff followed. Resident #3 walked out of the resident room back down the hallway where staff again attempted to have Resident #3 spit out the crayons. Resident #3-bit CNA D's finger and Resident #3 walked into the dining room and a male nurse entered to assist staff. The activity assistant brought a cookie to Resident #3 and staff persuaded Resident #3 to spit out the crayons and proceeded to eat the cookie. <BR/>During an interview on 6/26/24 at 11:39 a.m. with the Activity assistant; stated that Resident #2 will just go into a doorway and urinate. The Activity assistant stated that this occurred daily, and the female residents get upset. The Activity assistant stated that staff will find puddles of urine on the floor and staff do not always observe Resident #2 urinating on the floor. The Activity assistant stated that Resident #3 goes into rooms and grabs stuff and residents get aggressive with her 'because she grabs stuff. The Activity assistant stated that she worked in the secure unit daily to perform activities and there had been several times that she found herself alone in the unit with no other staff. The Activity assistant stated that I'll turn around and no other staff are back here with me. The Activity assistant stated that due to residents' behaviors, dementia and roaming it was difficult to be the only staff in the secure unit. The Activity assistant stated her duties were to conduct resident activities and not to perform resident care. <BR/>During an observation and attempted interview on 6/26/24 at 11:42 a.m., Resident #2 was observed exiting another resident's room. The Activity Assistant stated that Resident #2 had a history of sleeping in other resident rooms and should have been redirected to his own room. <BR/>Record review of the facility provided policy and in-service dated 7/12/23 revealed: There should always be two staff members in the secured unit at all times. <BR/>Record review of the facility provided policy, Staffing dated 9/28/23 revealed: Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care and considering the number, acuity and diagnoses of the facility's resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 6 of 22 resident rooms (2, 7, 8 ,9, 47, and 49) and 2 of 4 baths (Station 1 - Bath #1 and #2) , reviewed for environment.<BR/>1)The facility failed to ensure resident use equipment were safe and in good repair (Rooms 2, 7, 8, 9 and Station 1 - Bath #1 and #2).<BR/>2)The failed to ensure rooms #47 and #49 had running water available in the sinks in their rooms<BR/>3)The facility failed to ensure room [ROOM NUMBER] had an operating air conditioner/heater unit in the room. <BR/>These failures could place residents at risk for living in an unsafe, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. <BR/>The findings included:<BR/>Observation on 2/6/24 at 5:58 PM in Bath #2, on station one, the shower bed pad had a torn bottom vinyl surface, 10 of 13 drain holes with splits. The headrest had an approximately 5 x 7 area with multiple splits, exposing the interior foam. <BR/>Observation on 2/6/24 at 6:03 PM in Bath #1 on station 1, two of the three shower chairs had a stretched-out mesh back that had thin areas. <BR/>Observation on 2/7/24 at 8:32 AM in room [ROOM NUMBER], the window curtains were off the track in areas and missing hooks. The window curtains could not be fully pulled closed. One of the two bedside cabinets had worn missing and scarred finish. The sink drained slow. <BR/>Observation on 2/7/24 at 9:03 AM in room [ROOM NUMBER], the center privacy curtain was off the hooks in areas. The central privacy curtain jammed on the track which left in approximately 4-foot gap on the A bed side. <BR/>Observation on 2/7/24 at 9:25 AM in room [ROOM NUMBER], there was an approximately 2-foot section of window curtain that was detached from the track. Further observation revealed that two of the two bedside tables had badly scarred finish. <BR/>Observation on 2/7/24 at 9:36 AM in room [ROOM NUMBER], two of the two bedside tables had badly scarred surfaces.<BR/>On 2/7/24 at 1:57 PM an interview was conducted with CNA A regarding residents using the shower bed. She stated it was used for Residents #3, 8, 19, 25, 27, 41, 44, 65, and 78. <BR/>During an interview on 2/7/24 at 2:16 PM LVN B stated the shower bed was used for Residents #3, 8, 19, and 65. <BR/>On 2/7/24 at 4:29 PM an observation was made of Bath #2. The shower bed still had splits at the drain holes. On the underside, 7 of the 13 drain holes had splits in the vinyl which ranged from approximately 1 inch to 4 inches. The top side had 12 of 13 drain holes with splits in the vinyl which range from approximately 1 inch to 2 inches. These splits exposed the absorbent foam interior of the shower bed pad. The headrest portion of the pad had approximately nine splits in the vinyl exposing foam which range from approximately 1 inch to 3 inches. There was an approximately 6 x 6 ceramic tile missing on the shower stall wall. There was approximately a 1' x 2' missing area of floor tile along the back base of the toilet.<BR/>Observation on 2/7/24 at 4:34 PM in Bath #1, the base of the cabinet had exposed, wet, swollen, and buckled particleboard. Two of two doors were missing on the lower cabinet.<BR/>On 2/7/24 at 4:46 PM an interview was conducted with the Maintenance Supervisor regarding maintenance processes in the facility. Regarding monthly scheduled maintenance he stated, he received a list of duties daily from the facility's TELS system (electronic online Maintenance scheduling system). He added, the corporate office goes through the list, requests displayed in green means completed, and orange means it was being worked on now. He stated once everything was completed, corporate wipes the list out of the system. Regarding regular maintenance daily requests, he stated, staff would leave a note attached to his door. He added that staff conduct Angel Rounds on Thursday, and staff observe things that need repair. All managers conduct Angel Rounds. The Managers split the building in half, make observations, and staff then talk about their observations in meetings. The issues were written down and once the issues were completed, they were filed in the Administrator's office.<BR/>On 2/7/24 at 5:02 PM an interview was conducted with the Administrator regarding Angel Rounds documentation. He stated, he had not been keeping them. He added that the rounds were conducted on Tuesdays and Thursdays.<BR/> On 2/7/24 at 5:03 PM an interview and observation were conducted with the Maintenance Supervisor regarding repair needs observed in the facility. Regarding the detached window curtains, he stated, he ordered some clips in December 2023. He stated the order for the privacy curtain clips got kicked back and were re-ordered in January 2024. He stated, he wanted to buy more bedside tables, but the budget would not allow it. He added the facility only equipped room [ROOM NUMBER] with all brands new items. Regarding Bath #2's missing tiles he stated, I know, the budget does not allow it. Regarding the stretched mesh on the shower chairs in Bath #1, he stated, I looked in the book they're about $300. At that time, it was observed that the mesh was stretched/thinned on two of two pink shower chair backs. He stated he was unsure how long it had been that way. He stated wear and tear was the reason for these issues occurring. He stated Angel Rounds was their system of monitoring for needed repairs. He stated Maintenance was responsible to ensure that maintenance issues were taken care of in the facility. He stated, the facility tries to get things done. He added the observed maintenance and repair issues could affect the safety of residents.<BR/>On 2/7/24 at 5:16 PM an interview was conducted with LVN B regarding the shower bed mat that was damaged. She stated that she did not know how long it had been in this condition in the bath. She stated she was not aware of the tears in the mat. She stated, overuse caused the situation, and it needed to be replaced. She added, It is stretched and cracked and has weak spots. She stated, staff let maintenance know if they notice something that needed repair. She stated staff and maintenance were responsible for ensuring the mat was in good condition. She stated, frail skin could get caught in the cracks and residents with open wounds could spread infections.<BR/>On 2/8/24 at 8:54 AM, an interview was conducted with LVN C. She stated on her section of Station 1, residents #3, 25, 41, 44 and 78 used the shower bed. <BR/>On 2/8/24 at 9:01 AM an observation was made of Bath #2 and the shower bed foam mat was in the same condition with splits and cracks on the bottom and top surfaces exposing the interior foam. The shower stall was still missing an approximately 6 x 6 ceramic wall tile and there was approximately a 2' x 1' area of floor tile missing at the rear base of the toilet.<BR/>Observation on 2/8/24 at 9:03 AM in Bath #1 revealed the doors were missing on the lower cabinet, and it had a buckled base and exposed particleboard. Two of the two shower chairs had the mesh back threads stretched out at the seams.<BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated that the shower bed pad was ordered yesterday. He was not sure how long it had been in that condition. He added there was neglect of the building prior to his employment, and they had gotten it cleaned up. He stated there was wear and tear on the building. He stated during morning meetings staff let maintenance know if there were issues and then follow up with maintenance. He added the facility was starting a QR code system to report repairs; that was instituted on 1/25/24. He stated it would be fully implemented in the future. He was asked what he expected staff to have done. He stated he expected staff to report maintenance issues to the Administrator and Maintenance Supervisor. He stated the shower bed foam could harbor bacteria and cause infections. He stated the residents could pull on the curtains and fall. He added, the bedside cabinets would have to be bought slowly, monthly. He added that the Maintenance Supervisor was responsible for maintenance duties.<BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON. Regarding the damaged shower bed foam mat, she stated it can mess up a resident's skin and the residents could be exposed to urine, feces, and infections.<BR/>Memory Unit<BR/>Observation on 02/06/24 at 1:05 PM in the memory unit, the sink in room [ROOM NUMBER] did not have running water on the left side faucet of the sink, which was the hot water side. When the left knob for the hot water was turned on, no water appeared. The right-side faucet did have water coming out of the faucet. <BR/>In an interview on 02/06/24 at 1:10 PM, a family member stated there was a reason the water was turned off; the resident in room [ROOM NUMBER] would come through the joining bathroom into room [ROOM NUMBER] and turn on the water and spill it all over the floor. <BR/>Observation on 02/06/24 at 1:15 PM in the memory unit, the sink in room [ROOM NUMBER] did not have running water out of either faucet in sink. <BR/>Observation in the memory unit on 02/07/24 at 2:00 PM, rooms #47 and #49 did not have either cold or hot water coming from the faucets.<BR/>In an interview on 02/07/2024 at 4:00 PM, Maintenance Supervisor (MS) stated he had the water turned off in both rooms #47 and #49. He stated the tall resident next door is horrible, and I have had to get on to him. He was ruining my floors for all the water he has spilled on them not to mention the PTAC (air conditioner/heater unit); he has poured water and pisses in the unit. The unit that is in the room now is the third unit. I have turned the breaker off the PTAC, so he doesn't tear up another one. <BR/>In an interview on 02/07/2024 at 5:30 PM, family member stated the resident totally relies on staff assistance with all the ADLs. They turn on the water underneath the sink when they need to wash the resident's hands, the roommates, or their hands. <BR/>In an observation on 02/08/2024 at 2:45 AM, there was water available to the sinks in rooms #49 and #47 (both hot and cold). <BR/>In an interview on 02/08/2024 at 2:34 PM, MS stated the night shift are the ones who turn off the water at night so Resident #61 will not spill water everywhere. <BR/>Record review of the facility policy, titled Maintenance Services, Revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. <BR/>1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. <BR/>2. Functions of the maintenance personnel include but are not limited to: <BR/>a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. <BR/>b. Maintaining the building in good repair and free from hazards. <BR/>f. Establishing priorities and providing repair service.<BR/>j. Others that may become necessary or appropriate. <BR/>3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner <BR/>8. The Maintenance Director is responsible for maintaining the following records/reports. <BR/>k. Inspection of building; <BR/>l. Work order requests <BR/>9. Records shall be maintained in the Maintenance Directors office. <BR/>10. Maintenance personnel shall follow establish safety regulations to ensure the safety and well-being of all concerned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for two of 22 residents (Residents #18 and #69) reviewed for care plans.<BR/>1. <BR/>The facility failed to develop a care plan for Resident #18 regarding dialysis.<BR/>2. <BR/>The facility failed to develop a care plan for Resident #69 regarding insulin for treatment of the diagnosis of diabetes. <BR/>These failures could place residents at risk of not receiving the care required to meet their individualized needs. <BR/>Finding included:<BR/>Resident #18<BR/>Record review of the undated face sheet for Resident #18 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of cerebral infarction, unspecified (stroke), unspecified inflammation of eyelid (history of), other specified glaucoma (vision disorder), palpitations (irregular heart beat), essential hypertension (high blood pressure), personal history of transient ischemic attack (blockage of blood flow to the brain), dependence on renal dialysis (procedure to remove waste from blood when kidney function has declined), type two diabetes mellitus, without complications (blood sugar disorder), and end stage renal disease (kidney disease). <BR/>Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #18 had a BIMS score of 15 indicating that the resident was cognitively intact. Further record review of the MDS revealed active diagnoses of hypertension, renal insufficiency, renal failure, or end stage renal disease, diabetes mellitus, cerebral vascular accident, transient ischemic, attack, or stroke. Additional review of the MDS revealed that the resident was on dialysis while a resident.<BR/>Record review of the current care plan for Resident #18, last reviewed/revised: 1/22/24, revealed there was no specific care plan regarding dialysis. <BR/>Record review of the current physician orders for Resident #18, dated 2/6/24 revealed the following order, Hemodialysis performed on Tuesday, Thursday, Saturday at 5:45 AM dialysis center . Special instructions: send blanket, mustard, and lunch. Once a day on Tuesday, Thursday, Saturday, 6 AM - 6 PM. Start date 7/17/23. Open ended . <BR/>During an interview on 2/06/24 at 10:50 AM, LVN A Resident #18 was out of the room at dialysis on Tuesday, Thursday, and Saturday and would leave at 8:30 AM and come back before supper. <BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON regarding Resident #18's omitted care plan for dialysis. She stated she was not sure why there was not one. She said there should have been a care plan for dialysis. She stated if residents had no care plan, staff would not know how to care for the resident. She stated, she and nursing staff develop the baseline care plan. She added she and the Clinical Case Manager worked together to develop the care plans. She stated we review the orders and have started to conduct care conferences. <BR/>On 2/8/24 at 5:10 PM an interview was conducted with the Administrator regarding a missed dialysis care plan for Resident #18. He stated he was unsure why the issue occurred. He stated that he expected that staff should have developed a care plan when the resident was started on dialysis. He stated that the DON and the ADON were responsible for care plans being developed. He stated there could be miscommunication if a care plan was not developed for dialysis. <BR/>Resident #69<BR/>Record review of Resident #69's face sheet, dated 02/07/2024, revealed [AGE] year-old female admitted [DATE] with diagnoses that included, but were not limited to, diabetes (body doesn't make enough insulin or can use it as well as it should), diabetic nephropathy (uncontrolled diabetes can cause damage to blood vessels in the kidney that filter waste from the blood, which can cause kidney failure), aphasia (loss of ability to understand or express speech), acute myocardial infarction (heart attack), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (chronic brain disorder and when active symptoms can include delusions-false belief about external reality; hallucinations-hear, see, smell, taste or feel things that appear to be real but only exist in the mind; disorganized speech-any interruption that makes communication difficult and sometimes impossible to understand; trouble thinking and lack of motivation), epilepsy (a disorder of the brain characterized by repeated seizures- a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain), congestive heart failure (the heart can't pump blood well enough to meet the body's needs), intracardiac thrombosis (a blood clot in the heart), and cerebral infarction (occurs as result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) . <BR/>Record review of Resident #69's physician orders (no date) revealed Novolin 70-30 Flex Pen U-100 8 units; subcutaneous twice a day morning 07:00 AM-10:00 AM; Bedtime 7:00 PM - 10:00 PM start date of 08/29/2023 open ended end date. <BR/>Record review of Resident #69's admission comprehensive MDS assessment dated [DATE] revealed Resident #69 had a BIMS of 06 which suggested severe cognitive impairment; active diagnosis reveals diabetes mellitus; medications revealed the resident received insulin injections seven days a week.<BR/>Record review of Resident #69's quarterly comprehensive MDS assessment dated [DATE], the medication section revealed the resident received insulin injections seven days a week. <BR/>Record reviewed Resident #69's care plan dated 01/22/2024 revealed no approach for diabetes or the use of insulin. <BR/>In an interview on 02/08/2024 at 10:30 AM, Resident #69 stated she received an injection for her diabetes. <BR/>In an interview on 02/08/2024 at 4:14 PM, the DON stated there was no care plan for insulin. DON stated, that is on me, there should be a care plan showing insulin is a method to treat the diabetes. She stated that without a care plan, a staff member would not know how to care for the resident. <BR/>Record review of the facility policy titled Comprehensive Care Plans, 1/26/24 V.1 revealed the following documentation, 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 time frames to meet a resident medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines:<BR/>1. The care planning process will include an assessment of the resident's strengths, and needs, and will incorporate the residents 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. <BR/>2. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDS assessment, and by day 21 of the patients stay. All care assessment areas . triggered by the MDS will be considered in developing the care plan. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the care plan. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. <BR/>3. The comprehensive care plan will describe, at a minimum the following: <BR/>a. The services that are to be furnished to attain and maintain the residents highest practicable physical, mental, and psychosocial well-being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive plan must be prepared by an interdisciplinary team to the extent practicable, the participation of the resident and the resident's representative(s)of the care plan conference for 2 of 22 residents (Resident #33 and Resident #43) reviewed for comprehensive resident centered care plans.<BR/>The facility failed to invite Resident #33 and Resident #43 or the representatives to attend their care plan conferences.<BR/>These failures placed the residents at risk for unmet care needs and a decreased quality of life. <BR/>Findings included:<BR/>Resident #33<BR/>Record review of Resident #33's face sheet, dated 02/07/24, revealed a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Benign neoplasm of pineal gland (central nervous system tumors, which begin in the brain), Reduced mobility (unsteadiness while walking, difficulty getting in and out of a chair, or falls), Symptomatic epilepsy (a type of seizure) (repeated seizures-defined as a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain) & epileptic syndromes with complex partial seizures (most common type of epilepsy in adults -can last as long as 30 seconds to 2 minutes), anxiety disorder (persistent excessive worry that interfere with daily activities), conversion disorder with seizures or convulsions (a condition where a mental health issue disrupts how the brain works, physical symptoms that a person cannot control), hypotension (low blood pressure), cognitive communication deficit (difficulty with thinking and how someone uses language), pain (physical suffering or discomfort caused by illness or injury), oropharyngeal phase dysphagia (difficulty swallowing food & liquids), and lack of coordination (muscle control problem that causes an inability to coordinate movements; leads to jerky, unsteady, to-and-fro motion). <BR/>Record review of quarterly MDS assessment dated [DATE] revealed Resident #33 had a staff assessment for mental status revealed short-term and long-term memory problems, memory/recall ability was none, and cognitive skills for daily decision making was 03 (severely impaired-never/rarely made decisions). The MDS further revealed Resident #33 required substantial/maximal assistance with eating; oral, toilet, personal hygiene; bathing; upper and lower dressing; putting on/off footwear; partial/moderate assistance with rolling right & left, sit to lying, lying to sitting on side of bed; sit to stand; chair/bed-to-chair transfer; always incontinent of bladder and bowel; receives 51% or more nutrition by tube feeding seven days a week. <BR/>In an interview on 02/07/2024 at 5:54 PM, Resident #33's family member stated the only care plan meetings that had been attended were with the local authority for PASRR.<BR/>Record review of care conference report for Resident #33 revealed a quarterly care planning meeting dated 12/05/2023 with the social worker, the activity director and the MDS coordinator. <BR/>Record review of care conference report for Resident #33 revealed a quarterly care planning meeting dated 01/24/2024 with ADON A, the DON, the social worker, the activity director, the administrator, the MDS coordinator, and ADON B. <BR/>Record review of Resident #33's progress notes dated 04/23/2023 - 02/07/2024 revealed no documentation that Resident #33 or Resident #33's representative was invited to the care plan meeting. <BR/>Resident #43<BR/>Record review of Resident #43's face sheet, dated 02/06/24, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia (mental disorder), rhabdomyolysis (rare muscle injury) and pain. <BR/>Record review of Resident #43's comprehensive MDS assessment, dated 09/18/23, revealed Resident #43 was understood and had a BIMS score of 04 which indicated his cognition was severely impaired.<BR/>During a phone interview on 02/07/24 at 11:28 AM, Resident #43's RP stated she had not been invited to a care plan meeting since the beginning of last year (2023). <BR/>Record review of Resident #43's care conference report revealed a quarterly meeting was held on 02/14/23 and Resident #43's RP was listed as one of the attendees. <BR/>Record review of Resident #43's care conference report revealed a quarterly meeting was held on 10/26/23 and Resident #43's RP was not listed as one of the attendees.<BR/>Record review of Resident #43's progress notes dated 08/01/2023 - 02/07/2024 revealed no documentation that Resident #43 or Resident #43's RP was invited to the care plan meeting. <BR/>During an interview on 02/08/24 at 2:16 PM, the SW stated she was responsible for inviting residents and their RP to care plan meetings. The SW stated Resident #43 had a care plan meeting on 10/26/23 and she confirmed Resident #43's RP was not at the meeting. The SW stated she remembered calling Resident #43's RP to invite her to the care plan meeting and stated she usually did a progress note about it. The SW stated she was not able to locate the progress report and she did not document it anywhere else. The SW stated she understands if something was not documented, there was no way to prove it was done. The SW stated the potential negative outcome to the resident and their RP was they would not know what was current in the residents' care and they would not know about any new orders. <BR/>During an interview on 02/08/24 at 2:53 PM, the ADM stated the SW was responsible for inviting residents' and their RP to care plan meetings. The ADM stated he did not know why Resident #33 and Resident #43's RPs were not invited to their care plan meetings. The ADM stated he expected the SW to document all invitations to care plan meetings. The ADM stated the potential negative outcome to the residents' and their RP was families may not know what was going on with the resident and families would not have a chance to address all members of the team. <BR/>In an interview on 02/08/2024 at 5:15 PM, the social worker stated Resident #33 has had care plan meetings with the local authority for PASRR and she was documenting on her side of the quarterly meetings when PASRR met. She agreed there were no notes in the care conference reports prior to 12/05/2023 of care plan meetings and no documentation of invitations to the resident representative. She stated if it was not documented, it did not happen. She stated the negative outcome of not having care plan meetings were that the resident's care could not have continuity for all departments: nursing, dietary, activities, and psychosocial.<BR/>Record review of the facility policy titled, Comprehensive Care Plans with a revised date of 01/26/24, reflected the following:<BR/>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, mental and psychosocial needs that are identified in the resident's comprehensive assessment.<BR/>Policy Explanation and Compliance Guidelines:<BR/> .4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to:<BR/>a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan.<BR/>b. A registered nurse with responsibility for the resident.<BR/>c. A nurse aide with responsibility for the resident.<BR/>2 d. A member of the food and nutrition services staff.<BR/>e. The resident and the resident's representative, to the extent practicable.<BR/>f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure, at the time of discharge, the communication of necessary information for a safe transition of care home for 1 of 1 (Resident #81) records reviewed for discharge planning.<BR/>The facility failed to provide an accurate and complete plan of care for 1 of 3 closed records (Resident #43) with plans of services for home, a list of medications in laymen's terms submitted, or a sign receipt of plan of care. <BR/>This failure has the potential to affect all residents and places them at risk of not receiving appropriate resources once discharged home. <BR/>Findings included: <BR/>Resident # 81 <BR/>Record reviewed Resident # 81's face sheet revealed that the resident was[AGE] years old and admitted [DATE] with the following diagnoses: acid reflux dysphagia (difficulty swallowing), muscle wasting and atrophy (the decrease in size and wasting of muscle), type 2 diabetes with low blood sugar, nasal congestion, allergic rhinitis (allergic response causing itch, watery eyes, sneezing, and other similar symptoms), muscle spasm, constipation, dysuria (discomfort when urinating), depression, thrombocytopenia (low number of platelets in the blood), high blood pressure, stroke, hyperlipidemia (an elevated level of lipids), dehydration, and partial intestinal obstruction. <BR/>Record Review of Resident #81 progress note, dated 11/08/2023, stated: Resident discharged to a named facility, per family request, stable when transported by transport service, all medications and some belongings already transported. No other discharge documents found in system. <BR/>Interview with Social Worker on 02/08/2023 at 3:34 PM, the Social Worker stated that she did not know that she was responsible for putting the discharge summary in the system. The Social Worker looked in the computer system and stated, I do not see a discharge summary for Resident #81. The Social Worker stated that she only sets up needed services for the residents when they are being discharged and then she will write a progress note. The Social Worker stated that the normal process was that nursing would do the actual discharge summary and then someone would then put it in the system. The Social Worker stated that she did not even know what a discharge summary looked like. Observed the Social Worker pulling up discharge summary on the internet to see what they looked like. The Social Worker stated that she was not aware that she needed to give the family a discharge summary. The Social Worker stated that once she puts in a progress note then she will notify the family and tell them the services were being done. The Social Worker stated that she had been a social worker in the facility since April 2022 and had never done a discharge summary. The Social Worker stated that the negative potential outcome for a resident/family not having a discharge summary was that a resident or family would not have the information needed about the services that were completed and/or if services were even set up. <BR/>In an interview with DON on 02/08/2023 at 4:01 PM, the DON stated that the discharge for Resident #81 was planned per family member request and that the Social Worker should have made sure to get services set up and the discharge summary in the system. The DON stated that if the discharge summary was not in the system, then How do you know if anything has been taken care of or what services were set in place. The DON stated that the Social Worker should have known better and knew she was responsible. The DON stated that if the Social Worker did not know how to do things, then she should have asked someone. The DON stated that the Social Worker had been a social worker in other places as well and should have known that it was her responsibility. <BR/>Interview with the Administrator on 02/08/2024 at 4:52 PM, the Administrator stated that he was not aware of the discharge summary not being completed or not being put into the system. The Administrator stated that the Social Worker was responsible for putting discharge summaries in the system. The Administrator stated that nursing was responsible for completing the discharge summary, then they will give it to the Social Worker, she would be responsible for putting into system and completing any additional services to set up for the resident. The Administrator stated that he looked for the discharge summary for Resident #81 and was unable to find the discharge summary. The Administrator stated that he could not be positive if the discharge summary was completed or not because it was not in the system. The Administrator stated that the policy for discharges was that the discharge summaries should be completed upon discharge. The Administrator stated that it makes him question the whole discharge planning process and if they were even getting them done or not. The Administrator stated that the negative potential outcome for discharge summary not being completed was that the resident would not get the services set up for them that are needed. <BR/>Record Review of facility provided policy, labeled, Discharge Summary and Plan, date revised in December 2016, stated: <BR/>Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. <BR/>Policy Interpretation and Implementation: <BR/>1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. <BR/>2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 3). As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. 4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 5. The post-discharge plan will be developed by the care planning interdisciplinary team with the assistance of the residents and his or her family and will include: a). where the individual plans to reside, b). arrangements that have been made for follow up care and services. C). a description of the resident's stated discharge goals. D). the degree of caregiver/support person availability, capacity, and capability to perform required care. E). how the IDT will support the resident or representative in the transition to post-discharge care. F). what factors may make the resident vulnerable to preventable readmission g). how those factors will be addressed. 6). The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. 7). The resident/representative will be involved in the post-discharge plan. 8). Residents will be asked about how their interest is returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge. 9). If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. Data used in helping the resident select an appropriate facility includes the receiving facility's: a). standardized patient assessment date, b). quality measure data, c) data on resource use. 11). 12). A member of the IDT will review the final post discharge plan with the resident and family at least twenty-four hours before the discharge is to take place. 13). A copy of the following will be provided to the resident and receiving facility and a copy will be filled in the resident's medical records: a). An evaluation of the resident's discharge needs, b). The post-discharge plan, c). The discharge summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for 1 of 1 resident (Resident #63) reviewed for mental health services, in that:<BR/>The facility failed to administer a dose of Resident #63's Risperidone (antipsychotic used for bipolar and schizophrenic disorder) for a week. There were behavior changes as consequences to the medication being discontinued. <BR/>This failure affected one resident and placed resident at risk of emotional distress, negative behavior changes, and diminished quality of life. <BR/>Findings include:<BR/>Resident #63 <BR/>Record reviewed Resident #63's face sheet revealed that the resident was a [AGE] year-old female and admitted [DATE] with the following diagnoses: Alzheimer's disease, depression, schizoaffective disorder, bipolar disease, insomnia, hypothyroidism, anxiety, muscle weakness, high blood pressure. <BR/>Record Review of Resident 63's MDS dated revealed that Resident #63 had a BIMS of 9 meaning Resident #63 is mildly impaired. Section C for Cognitive patterns was left blank and incomplete. Section D for Mood was left incomplete. Section E for Behavior stated that Resident #63 did not display behaviors of delusions or hallucinations and the remainder was left blank and incomplete. <BR/>Record Review of Resident #63's Medication Administration Record dated 12/10/2023-1/09/2024, revealed no documented evidence Resident #63 was given Risperidone 1 mg for day or night on the dates of 12/28/2023-1/09/2024. <BR/>During an interview with the Family Member of Resident #63 on 02/06/2024 at 10:10 am. The Family Member stated that a couple of weeks ago the facility discontinued Resident #63's Risperidone and it had caused her to have negative behavior changes such as agitation, shaking, mood swings, etc. The Family member stated that when he had called and spoke with the Clinical Resource Nurse, he was told that because Medicaid did not pay as much for the residents that were taking antipsychotics, the facility took Resident #63 off the medication. The Family Member stated that Resident #63 started to see things and hear voices. Family Member stated that it made him angry to see Resident #63 suffer the way she did. Family Member stated that he had to go to Resident #63's doctor and get him to contact the facility to get the facility to put Resident #63 back on the medication and it took Resident #63 about a week to get balanced back on the medication again. The medication was restarted a week later after 1/09/2024 after Resident #63 began to display delusions. Family Member stated that Resident #63 had been taking the medication since 1986 due to a diagnosis of bipolar with schizophrenia. <BR/>During an interview with the DON on 02/08/2024 at 2:02 pm. The DON stated that the reason that Resident #63 was removed from the medication was due to a failed GDR. The DON stated that the pharmacy recommended that she come off the medication. The DON stated that the facility spoke to the PCP, and he was in agreement with the pharmacy. The DON stated that once Resident #63 started to show negative behavior changes, she was put back on the medication by the doctor. The DON stated that Resident #63 was admitted to the facility with the Risperidone and had been taking the medication since 1986. The DON stated that pharmacy did not want Resident #63 on the medication due to improper diagnosis. The DON stated that she had gotten with the family member and got paperwork that he had received for psych services to put Resident #63 back on the medication due to the diagnosis of bipolar and schizophrenia disorder. The DON stated that the repercussions of abruptly stopping the medication was negative behaviors and withdrawals. The DON stated that proper tapering of the medication was needed. The DON stated that proper tapering would mean to dose the medication down before stopping it all together. The DON stated that Resident #63 was not tapered down and should have been. The DON stated that Resident #63 was doing fine until all the medication came out of her system and then she started to show negative behaviors. <BR/>During an interview with the Clinical Resource Nurse on 02/08/2024 at 2:16 pm. The Clinical Resource Nurse stated that Resident #63 had been taken off the medication due to pharmacy recommendations to do a GDR. The Clinical Resource Nurse stated he was not sure if it was the PCP or the psych doctor who approved Resident #63 to come off the Risperidone. The Clinical Resource Nurse stated that usually with that medication the resident would need to be tapered off the medication but because it was such a low dose, then the resident should have been fine have been taken off the medication all at once. The Clinical Resource Nurse stated that to taper a medication off that the dosage is slowly dropped over a course of time. The Clinical Resource Nurse stated that Resident #63 was not tapered down because she was on a low dosage. The Clinical Resource Nurse stated that the doctor wanted to see how Resident #63 would do without the medication. The Clinical Resource Nurse stated that Resident #63 started to show negative behaviors. The Clinical Resource Nurse stated that the family member was saying that Resident #63 was calling all hours of the night, and that is what she would do before she was put on the medication many years ago. The Clinical Resource Nurse stated that the family member stated that he did not want Resident #63 off the medication. The Clinical Resource Nurse stated that he told family member that the facility would contact him next time if they ever decided to take Resident #63 off any medications. The Clinical Resource Nurse stated that Resident #63 came into the facility with the medication when she was admitted to the facility. The Clinical Resource Nurse stated the family member did go to the original psych doctor to get the paperwork to show Resident #63 was schizophrenic and bipolar. <BR/>During an interview with the Administrator on 02/08/2024 at 2:30 pm. The Administrator stated that he was made aware of the Resident #63 had been taken off her medication because the family member contacted corporate and then corporate sent him an email. The Administrator stated that Resident #63 diagnoses is Alzheimer's, bipolar, and schizophrenic. The Administrator stated that Resident #63 was admitted into the facility on Risperidone and had been taking the medication since 1987. The Administrator stated that by coming off the medication without tapering could cause the resident to bring on depression and all symptoms of schizophrenia. The Administrator stated that if they were going to take Resident #63 off the medication, she should have been tapered off. The Administrator stated that he is not sure who told them to take Resident #63 off the medication and that he only learned of the situation after the fact. The Administrator stated that the family member should have been contacted about taking Resident #63 off the medication. <BR/>Record review of the facility policy, titled Pharmacy Services, Overview, Revised April 2007, revealed the following documentation, Policy Statement. The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication, and biologicals, and the services of a licensed pharmacist. Policy Interpretation and Implementation. <BR/>3. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support resident's needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but it's not limited to, collaborating with the facility and Medical Director to . <BR/>f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers. <BR/>h. Collaborate with the staff and practitioners to address and resolve medication related needs or problems. <BR/>l. Help the facility develop a process for receiving, transcribing, and recapitulating medication orders. <BR/>Record review of the facility policy, titled Adverse Consequences and Medication Error, Overview, Revised April 2014, revealed: <BR/>Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist. <BR/>2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychological status. An adverse consequence may include a). adverse drug/medication reaction. <BR/>5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professionals' providing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 22 residents reviewed for medications (#11 and #18 ).<BR/>1)The facility failed to accurately acquire and administer medications as ordered for two residents (Residents #11 and #18). Resident #11 missed doses of ordered Plavix (antiplatelet medication) and Resident #18 missed doses of hydralazine (blood pressure medication) and hydrocortisone eye ointment (anti-inflammatory medication).<BR/>These failures could place residents at risk of experiencing missed medications which could result in the exacerbation of their medical conditions and a decline in health status. <BR/>The findings included:<BR/>Resident #18<BR/>Record review of the undated face sheet for Resident #18 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of cerebral infarction, unspecified (stroke), unspecified inflammation of eyelid (history of), other specified glaucoma (vision disorder), palpitations (irregular heart beat), essential hypertension (high blood pressure), personal history of transient ischemic attack (TIA - mini stroke), dependence on renal dialysis (procedure to remove waste from blood when kidney function has declined), type two diabetes mellitus, without complications (blood sugar disorder), and end stage renal disease (kidney disease). <BR/>Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #18 had a BIMS score of 15 indicating that the resident was cognitively intact. Further record review of the MDS revealed active diagnoses of hypertension, renal insufficiency, renal failure, or end stage renal disease, diabetes mellitus, cerebral vascular accident, transient ischemic, attack, or stroke. Additional review of the MDS revealed that the resident was on dialysis while a resident.<BR/>Record review of the significant change MDS assessment dated [DATE] revealed that Resident #18 also had an active diagnosis of glaucoma, cataracts, or macular degeneration.<BR/>Record review of the current care plan for Resident #18 last reviewed/revised: 1/22/24 revealed that there was a problem documented as follows, Problem start date: 1/9/24. Problem end date 3/9/24. Category: visual function. Resident has impaired vision related to aging process. Edited: 1/22/24. The documented goal was as follows, long-term goal target date: 4/24/24. Resident will not experience negative consequences of vision loss as evidence by remaining physically safe and participating in social and self-care activities. Edited: 1/22/24. Approaches included, Approach start date: 1/9/24. Administer eye medication as ordered. Evaluate/record/report effectiveness, and any adverse side effects. Edited: 1/9/24. Approach start date: 1/9/24. Arrange ophthalmologist/optometrist consult. Implement recommendations. Edited: 1/9/24 . <BR/>Record review of the current care plan for Resident #18, last reviewed/revise: 1/22/24, revealed there was no specific care plan regarding hypertension or administration of medications related to hypertension. <BR/>During an interview on 2/6/24 at 5:50 PM Resident #18 stated the facility wase waiting on a blood pressure pill to come in for her. She further stated they were having problems with getting her medications in. <BR/>During an interview on 2/7/24 at 9:36 AM Resident #18 stated she had two blood pressure medicines. One was nifedipine which she got, but hydralazine was not in and it had been over a week . <BR/>Record review of the current physician orders for Resident #18, dated 2/6/24 revealed the following orders, Hydralazine tablet; 50 mg; amount: 50 mg; oral. Three times a day. Morning 6 AM - 10 AM, midday 11 AM - 2 PM, bedtime 7 PM - 10 PM. Start date 12/31/22. Open ended . [blood pressure medication]<BR/>Record review of the MAR for January 2024 for Resident #18, from 1/15/24 through 1/31/24 revealed that the resident was administered hydralazine on 40 of 51 opportunities. Between that time, the resident was not available on a Tuesday, Thursday, or Saturday for the midday dose on seven of seven occasions. This was the resident's dialysis days. On those seven days, the resident only received the medication two of the three ordered times daily .<BR/>Record review of the February 2024 MAR for Resident #18 from 2/1/24 through 2/7/24 revealed that the resident received the medication on eight of 21 opportunities. it was documented that the medication was unavailable/not in stock on nine opportunities from 2/4/24 midday dose through 2/7/24 morning dose. It was also noted that on Thursday (dialysis day), 2/1/24, the resident was documented as unavailable and did not receive a midday dose. The resident only received two of the three ordered doses . <BR/>Record review of the current physician orders for Resident #18 dated 2/6/24 revealed the following order, Hydrocortisone, ophthalmic ointment; 1%; amount: one; both eyes. Twice a day. Morning 7 AM - 10 AM, bedtime 7 PM - 10 PM. Start date 10/16/23. Open ended . [anti-inflammatory medication]<BR/>Record review of the MAR for Resident #18 for December 2023 revealed that the hydrocortisone 1% ophthalmic ointment was given 24 times of the 62 opportunities. It was also documented that the resident was unavailable eight times and the medication was unavailable 30 times . <BR/>Record review of the January 2024 MAR for Resident #18 revealed that the resident was given the hydrocortisone ophthalmic ointment 16 times of the 62 opportunities. It was further documented that the resident was unavailable two times and the medication was unavailable 45 times .<BR/>Record review of the MAR for Resident #18 for February 2024 revealed that from 2/1/24 through 2/7/24. The resident was given the hydrocortisone ophthalmic ointment medication five or 14 opportunities. It was further documented that the resident was unavailable two times, and the medication was unavailable on seven times .<BR/>Record review of the pharmacy consultant reports for Resident #18 for December 2023, and January 2024 revealed a recommendation on 12/18/23 to indicate diagnoses for the residents' drugs. On 1/25/24, the consultant pharmacist recommendation to physician was regarding the timing of the administration of the resident's Carafate, which was ordered four times a day since 6/2023. There was no documentation regarding the residents missed hydrocortisone ophthalmic ointment or missed dosages of hydralazine. <BR/>Resident #11 <BR/>Record review of the current undated face sheet for female Resident #11 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), essential hypertension (high blood pressure), unspecified systolic (congestive) heart failure (heart failure), cerebral infarction, unspecified (stroke), and other persistent atrial fibrillation (irregular heart rhythm). <BR/>Record review of the quarterly MDS assessment for Resident #11 dated 12/2/23 revealed that the resident had a BIMS score of 14 indicating that she was cognitively intact. Further record review of the MDS revealed active diagnoses of coronary artery disease, heart failure, hypertension, cerebral vascular accident, transient ischemic attack, or stroke . <BR/>Record review of the progress notes for a Resident #11 dated 2/22/23 at 5:45 PM revealed the following documentation, resident will be going to the dentist Tuesday (2/28/23). Her Plavix will be (discontinued) until then awaiting the dentist orders. Plavix 75 mg. [Plavix - antiplatelet medication]<BR/>Record review of the progress notes for Resident #11 revealed the following progress note dated 12/19/2023, 4:38 PM, resident back from urology doctor appointment and requesting information regarding the Plavix prescription she was previously taking. Resident came back from doctor appointment and wanted to know why she wasn't taking Plavix. After researching Plavix was to be held for a dental appointment on 2/22/23 but never restarted. Order reactivated. Reviewed with DON and provider <BR/>Record review of the current physician orders for Resident #11 dated 2/6/24 revealed the following order, Clopidogrel tablet: 75 mg; amount; 75; oral. Once a morning. Morning 7 AM - 10 AM. Start date 1/24/24. Open ended. <BR/>Record review of the December 2023 MAR for Resident #11 revealed the following order, clopidogrel tablet; 75 mg; amount to administer: one tablet; oral, once a morning, start date, 12/19/23 - end date 1/3/24, (DC date). Diagnosis: Atherosclerotic heart disease of native coronary artery without angina pectoris. <BR/>Record review of the January 2024 MAR for Resident #11 revealed her order for Plavix was restarted with a start date of 1/3/24 through 1/5/24. There was an additional order for the Plavix that had a start date 1/10/24 through 1/19/24 as an end date. There was also an additional current order for the resident's Plavix that had a start date of 1/24/24, which was open ended.? <BR/>Record review of the care plan for Resident #11 last reviewed/revised 1/25/24 revealed no care plan related to the administration of Plavix (clopidogrel). <BR/>During an interview with Resident #11 on 2/7/24 at 9:03 AM she stated she had missed medications in the past, but the facility had straightened it out. She stated at the time of the incident she had a procedure and was taken off Plavix. She stated she was off the medication for several months, but the facility had gotten her back on it. She added it was restarted approximately 3 months ago. <BR/>On 2/8/24 at 11:36 AM an interview was conducted with Resident #11. She stated she had not experienced any adverse effects from being off the Plavix. She added she had stents and her physician told her she would need Plavix the rest of her life. [Note: Stent - metal mesh used to keep an artery open.] <BR/>On 2/8/24 at 3:15 PM an interview was conducted with Nurse Practitioner A for residents, #11 and #18. Regarding Resident #11's missed Plavix she stated, generally it should be resumed after a procedure. She stated, I guess it was slipped. She further stated regarding Resident #11, She needs it (Plavix). She should be back on it. Regarding Resident #18's missed hydralazine and hydrocortisone ophthalmic ointment, she stated she saw that both medications were ordered. She stated Resident #18 had an ophthalmologist and she (Nurse Practitioner) lets the ophthalmologist order what was needed for her. She added, The hydralazine is given to keep blood pressure under control. The hydralazine should have been given. I don't understand why it was not. She further stated regarding Resident #18's missed doses of hydralazine that the facility should administer the medication to her when she comes back from dialysis. She stated this situation could be an oversight problem. I'm not sure . <BR/>On 2/8/ 24 at 3:23 PM an interview and observation were conducted with CMA B regarding the missed medications for Resident #18. She stated, the hydralazine, she thought, ran out and the pharmacy did not send it. She stated that staff tell the nurse or re-order the medication on the computer. She stated, the pharmacy says they will send medications and then they do not send them. She stated she had reported to the nurses that the medications were not available. She stated a resident's blood pressure could go up and down and have a stroke if she did not receive her blood pressure medication. She stated that she was not present when the medication error occurred for Resident #11. She stated that she had worked in the facility only three months as medication aid. She stated Resident #18's hydralazine order had just come in Tuesday or Wednesday. Observation of the pill card at this time from the medication cart revealed that two pills were missing of the 30-pill pack. CMA B stated the hydrocortisone ophthalmic ointment for Resident #18 was not present.<BR/>On 2/8/24 at 3:30 PM an interview was conducted with LVN B regarding the missed Plavix for Resident #11. She stated, she was not present when it stopped. She stated she understood she went to the doctor and had a procedure, and the Plavix was stopped. Regarding Resident #18's hydrocortisone eye ointment, she stated at one time the resident kept the medications in her room. Family would bring medications also. She stated that she was unsure why the resident did not have her eye ointment. Regarding the missed doses of hydralazine, she stated sometimes the resident was at dialysis and not present for a dose. She thought the resident received a dose when she was at dialysis. She added that staff did not have any instructions related to medications missed when residents were gone to dialysis. She stated the facility does not send medications with her to dialysis. She stated It depended on when she returned from dialysis as to if she received the medication. She stated the resident would usually receive a bedtime dose, but the missed doses were not replaced. Regarding delays in receiving medications, she stated sometimes staff wait on medications and then pass the information on to the next shift. She stated staff were waiting on the eye ointment for Resident #18 and that medication delays were an ongoing issue. She added if it has been a long time, and the medication was not here, the staff would call the pharmacy and let the DON know. She stated she could not remember if she informed the DON about the eye ointment for Resident #18. She stated the resident's blood pressure could go up if the resident did not receive her medication as ordered. She further stated she had not considered this situation as not following the physician orders.<BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON regarding Resident #11's missed Plavix. She stated, she was not employed in the facility then. She stated at an appointment, medical staff at the appointment reviewed the resident's medications and found the error. She stated she was not sure why Plavix was taken off her physician orders. She stated, We fixed the error. She stated the facility's medication system could not place a medication on hold like other systems. She added that she could see how someone in a hurry, stopped the medication, and did not start it up again. She stated that she expected staff to have started the order and to give the medication. She stated nurses and the medication aids were responsible for ensuring that medications were given accurately to residents. She stated, staff monitored medication orders by pulling up the MAR and pulling up a medication report. She stated with Plavix, the resident could develop a blood clot and have a stroke if the medication was missed. Regarding Resident #18's medication situation, she stated, she was not sure about the hydralazine. She added, staff had access to the stock safe and did not give the medication. She stated she had conducted in-services on the stock safe. She stated at times if the medication was not on the cart, staff did not give it. She stated the nurses were not aware of missed medications for Residents #11 and #18. She added that the CMAs said they did not tell the nurse about the hydralazine. She stated that she was still investigating the issue on the eye ointment for Resident #18 and stated, I'm not sure what happened there. She stated staff should be informing if they were out of medications. She stated medications could have been purchased locally. She stated she felt the situation occurred due to poor communication and not letting the nurses and the DON know. She stated she expected staff to have provided the medication and notified the nurses. She stated the CMA should report medication issues to the nurse, and if the medication was not in the safe to then contact the DON. She stated that the DON and nurse were responsible for ensuring that residents received their medication's. She stated the resident's eye situation could have worsen and her blood pressure could have led to a stroke as a result of the missed medications.<BR/>On 2/8/24 at 5:10 PM an interview was conducted with the Administrator regarding missed medications for Resident #11 and Resident #18. He stated he felt there was a break in communication that caused the situation to occur. He stated his staff should communicate. He added, the first day the medication was not there, they should have told the nurse. He stated that the nurses, the DON and the ADON were responsible for residents receiving their medications. He stated without Plavix, the stent could have clotted. The resident (that missed hydralazine) could have experienced an increase in blood pressure and the missed eye ointment, it would not help her vision.<BR/>Record review of the in-service, titled E Kit, instructor DON, dated 11/15/23 revealed the following documentation, Topic: if out of medication or meds not received, we need to be sure to check the E kit for every med before charting Drug Unavailable. This in-service was given to staff in the nursing department. <BR/>Record review of the facility policy, titled Pharmacy Services, Overview, Revised April 2007, revealed the following documentation, Policy Statement. The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication, and biologicals, and the services of a licensed pharmacist. Policy Interpretation and Implementation. <BR/>3. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support resident's needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but it's not limited to, collaborating with the facility and Medical Director to . <BR/>f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers. <BR/>h. Collaborate with the staff and practitioners to address and resolve medication related needs or problems. <BR/>l. Help the facility develop a process for receiving, transcribing, and recapitulating medication orders. <BR/>Based on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications for 1/2 medication carts and 1/2 medication storage rooms reviewed for pharmaceutical services in that: <BR/>MA B had expired aspirin 325 mg on cart of 02/23. <BR/> Seven bottles of Geri-Care Geri-Lanta 355 ml (12 fl oz.) was found to be expired on 12/23 <BR/>These failures could place residents at risk of taking medications that are expired causing medication to be ineffective or having adverse reactions. <BR/>Findings include: <BR/>Observation made of medication storage room on south hall (wing 1) on 02/07/2024 at 2:33 pm with LVN C revealed seven bottles of Geri-Care Geri-Lanta 355 ml (12 fl oz.) expired on 12/23. Observed LVN C dispose of the expired medication by taking it to the DON to discard. <BR/>Observation made of medication storage room on south hall (wing 1) on 02/07/2024 at 2:33 pm with LVN C revealed seven bottles of Geri-Care Geri-Lanta 355 ml (12 fl oz.) expired on 12/23. Observed LVN C dispose of the expired medication by taking it to the DON to discard. <BR/>Interview with the DON on 02/07/2024 at 1:53 pm. revealed the DON stated that she expects the staff to keep the carts and storage clean. The DON stated that the medication aides are responsible for checking the carts prior to the beginning of their shift. The DON stated that the ADON will do random cart checks to make sure that the cart is cleaned, and expiration dates are checked approximately weekly. The DON stated that for an expired medication is that the resident could metabolize the medication differently cause ineffective medication. The DON stated that an in-service will be completed. The DON stated that staff have been trained on expired medications through in-services and in-services occur approximately bi-weekly. <BR/>Interview with the Administrator on 02/07/2024 at 2:01 pm., the Administrator stated that he expects medication aides to check the carts and to make sure there are no expired medications in the carts or in the medication storage rooms. The Administrator stated that the negative potential outcome for expired medications is that it could cause the resident to not get the correct dosage of medications or it being ineffective. The Administrator stated that the negative potential outcome for loose medications on the cart could cause a resident to have a missed medication because not enough medication left. The Administrator stated that the staff will get in-serviced on loose medications and expired medications. <BR/>Interview with LVN C about the expired medications on 02/07/2024 at 2:37 pm revealed LVN C stated that it is the responsibility of all staff to check the medication storage for expired medications. LVN C stated that the room is just randomly checked when the staff have time. LVN C stated that the negative potential outcome for expired medications or supplements is it not working, medication error, and adverse reactions. LVN C stated that they have had in-services and it is just randomly, not a set time. <BR/>Interview with LVN B (charge nurse) on 02/07/2024 at 2:48 pm, LVN B stated that it is the responsibility of the staff member that is assigned to that cart to make sure cart is cleaned. LVN B stated that all staff are responsible to check the medication room. LVN B stated that the negative potential outcome for expired medications is ineffective medication or overdose, resident could get sick, adverse reactions, or not the desired effect. LVN B stated that the negative potential outcome for loose medications is if the cart is left unlocked then a resident could get the wrong medication or with the loose medication a resident could have a missed medication. LVN B stated that in-services are completed and are held approximately monthly. LVN B stated that the DON, ADON, and Pharmacist will check the medication room randomly but is not sure how often. <BR/>Record Review of facility provided policy, labeled, Storage of Medications, provided on 02/08/2024 date Revised November 2020, revealed: <BR/>Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. <BR/>Policy Interpretation and Implementation: <BR/>2. Drugs and Biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. <BR/>4. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 1 resident reviewed for medication errors ( Resident #11). <BR/> The facility failed to restart Resident #11's physician's ordered Plavix after a dental appointment. The resident was without her Plavix (blood thinner to treat stroke, heart attack, and other heart related disorders), for approximately 10 months (2/22/23 thru 12/19/23). <BR/>This failure could result in residents having risk of heart attacks, strokes, blood clots, and risk of hospitalizations. <BR/>Findings include: <BR/>Resident #11 <BR/>Record review of the current undated face sheet for female Resident #11 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), essential hypertension (high blood pressure), unspecified systolic (congestive) heart failure (heart failure), cerebral infarction, unspecified (stroke), and other persistent atrial fibrillation (irregular heart rhythm). <BR/>Record review of the quarterly MDS assessment for Resident #11 dated 12/2/23 revealed that the resident had a BIMS score of 14 indicating that she was cognitively intact. Further record review of the MDS revealed active diagnoses of coronary artery disease, heart failure, hypertension, cerebral vascular accident, transient ischemic attack, or stroke. <BR/>Record review of the progress notes for a Resident #11 dated 2/22/23 at 5:45 PM revealed the following documentation, resident will be going to the dentist Tuesday (2/28/23). Her Plavix will be (discontinued) until then awaiting the dentist orders. Plavix 75 mg. [Plavix - antiplatelet medication]<BR/>Record review of the progress notes for Resident #11 revealed the following progress note dated 12/19/2023, 4:38 PM, resident back from urology doctor appointment and requesting information regarding the Plavix prescription she was previously taking. Resident came back from doctor appointment and wanted to know why she wasn't taking Plavix. After researching Plavix was to be held for a dental appointment on 2/22/23 but never restarted. Order reactivated. Reviewed with DON and provider <BR/>Record review of the current physician orders for Resident #11 dated 2/6/24 revealed the following order, Clopidogrel tablet: 75 mg; amount; 75; oral. Once a morning. Morning 7 AM - 10 AM. Start date 1/24/24. Open ended. <BR/>Record review of the December 2023 MAR for Resident #11 revealed the following order, clopidogrel tablet; 75 mg; amount to administer: one tablet; oral, once a morning, start date, 12/19/23 - end date 1/3/24, (DC date). Diagnosis: Atherosclerotic heart disease of native coronary artery without angina pectoris. <BR/>Record review of the January 2024 MAR for Resident #11 revealed her order for Plavix was restarted with a start date of 1/3/24 through 1/5/24. There was an additional order for the Plavix that had a start date 1/10/24 through 1/19/24 as an end date. There was also an additional current order for the resident's Plavix that had a start date of 1/24/24, which was open ended.? <BR/>Record review of the care plan for Resident #11 last reviewed/revised 1/25/24 revealed no care plan related to the administration of Plavix (clopidogrel). <BR/>During an interview with Resident #11 on 2/7/24 at 9:03 AM she stated she had missed medications in the past, but the facility had straightened it out. She stated at the time of the incident she had a procedure and was taken off Plavix. She stated she was off the medication for several months, but the facility had gotten her back on it. She added it was restarted approximately 3 months ago. <BR/>On 2/8/24 at 11:36 AM an interview was conducted with Resident #11. She stated she had not experienced any adverse effects from being off the Plavix. She added she had stents and her physician told her she would need Plavix the rest of her life. [Note: Stent - metal mesh used to keep an artery open.] <BR/>On 2/8/24 at 3:15 PM an interview was conducted with Nurse Practitioner A for Resident #11. ?Regarding Resident #11 missed Plavix she stated generally it should be resumed after a procedure. She stated, I guess it was slipped. She further stated regarding Resident #11, She needs it (Plavix). She should be back on it. <BR/>On 2/8/24 at 3:30 PM an interview was conducted with LVN B regarding the missed Plavix for Resident #11. She stated she was not employed in the facility when it stopped. ?She stated she had been told the resident went to the doctor and had a procedure and the Plavix was stopped. <BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON regarding Resident #11's missed Plavix. She stated she was not employed in the facility then. She stated that at an appointment medical staff at the appointment reviewed the resident's medications and found the error. She stated she was not sure why Plavix was taken off her physician orders. She stated, We fixed the error. She stated the facility's medication system could not place a medication on hold like other systems. She added that she could see how someone in a hurry stopped the medication and did not start it up again. She stated that she expected staff to have started the order and to give the medication. She stated nurses and the medication aides were responsible for ensuring that medications were given accurately to residents. ?She stated staff monitored medication orders by pulling up the MARS and pulling up a medication report. She stated with Plavix the resident could have developed a blood clot and had a stroke if the medication was missed. <BR/>On 2/8/24 at 5:10 PM an interview was conducted with the Administrator regarding missed medications for Resident #11. He stated he felt there was a break in communication that caused the situation to occur. He stated his staff should communicate. He stated that the nurses, DON and ADON were responsible for residents receiving their medications. He stated without Plavix, the stent could have clotted. <BR/> Record review of the facility policy, titled Pharmacy Services, Overview, Revised April 2007, revealed the following documentation, Policy Statement. The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication, and biologicals, and the services of a licensed pharmacist. Policy Interpretation and Implementation. <BR/>3. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support resident's needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but it's not limited to, collaborating with the facility and Medical Director to . <BR/>f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers. <BR/>h. Collaborate with the staff and practitioners to address and resolve medication related needs or problems. <BR/>l. Help the facility develop a process for receiving, transcribing, and recapitulating medication orders. <BR/>Record review of the facility policy, titled Adverse Consequences and Medication Error, Overview, Revised April 2014, revealed: <BR/>Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist. <BR/>2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychological status. An adverse consequence may include a). adverse drug/medication reaction. <BR/>5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professionals' providing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure menus were followed for 8 of 24 residents (Residents #4, 32, 35, 51, 67, 69, 70 and 75) reviewed during mealtimes.<BR/>The facility failed to ensure Residents #4, 32, 35, 51, 67, 69, 70 and 75 received their meals according to the menu for 2 of 3 food forms (mechanical soft and puree)<BR/>This failure could place residents at risk for unwanted weight loss and hunger.<BR/>The findings included :<BR/>Resident #4<BR/>Record review of the current undated face sheet for male Resident #4 revealed that the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was [AGE] years old and had diagnoses of unspecified, focal traumatic brain injury with loss of consciousness, status, unknown, subsequent and encounter (brain injury), dysphasia, oral phase (swallowing disorder), sleep disorder, unspecified, and diabetes mellitus due to underlying condition without complications (blood sugar disorder).<BR/>Record review of the current physician's orders for Resident #4 dated 2/7/24 revealed a diet order of Diet: regular diet with fortified foods. Texture: pur&eacute;e diet. Start date 12/6/23.<BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed that Resident #4 had a diet order of diet: regular diet with fortified foods, texture: pur&eacute;ed. Start date 12/6/23.<BR/>Resident #32<BR/>Record review of the current undated face sheet for male Resident #32 revealed that the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was [AGE] years old and had diagnoses of displaced, intertrochanteric fracture of left femur (femur fracture) , subsequent encounter for close fracture with routine healing, cognitive communication deficit, unspecified, hearing loss, unspecified, ear and unspecified dementia, unspecified severity, with anxiety.<BR/>Record review of the physician' orders dated 2/7/24 for Resident #32 revealed a documented order of Diet: regular diet texture: mechanical soft. Start date, 12/20/23. <BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed that Resident #32 had a diet order that reflected diet: regular diet, texture: mechanical soft. Start date 12/20/23.<BR/>Resident #35<BR/>Record review of the current undated face sheet for female Resident #35 revealed that she was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of hypertensive chronic kidney disease with stage one through stage four chronic kidney disease, or unspecified, chronic kidney disease, unspecified, lack of coordination and dysphasia unspecified (swallowing disorder).<BR/>Record review of the physician orders dated 2/7/24 revealed that Resident #35 had a diet order documented as Diet: regular. Texture: mechanical, soft . Start date 1/17/24 . Start date 1/17/24. <BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed that Resident #35 had a diet order of, diet: regular diet, texture: mechanical soft. Start date 1/17/24.<BR/>Resident #51<BR/>Record review of the current updated face sheet for female Resident #51 that the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was [AGE] years old and had diagnoses of Alzheimer's disease (cognitive disorder), dysphasia, oral pharyngeal phase (swallowing disorder), chronic obstructive pulmonary disease (lung disorder) and unspecified lack of coordination.<BR/>Record review of the current physician orders dated 2/7/24 revealed that Resident #51 had a diet order documented as Diet: regular diet. Texture: mechanical soft. Fluid consistency: nectar. Start date 1/19/24.<BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed that Resident #51 had a diet order of diet: regular diet, texture: mechanical soft. Start date, 1/19/24.<BR/>Resident #67<BR/>Record review of the current undated face sheet for female Resident #67 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had a diagnoses of alcohol abuse, uncomplicated, insomnia, unspecified (sleep disorder), and chest pain unspecified.<BR/>Record review of the current physician orders for Resident #67 dated 2/7/24 revealed the resident had a diet order documented as Diet: regular diet. Texture: mechanical, soft . Start date 1/12/24.<BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed that Resident #67 had a diet order which reflected diet: regular diet, texture: mechanical soft. Start date 1/12/24.<BR/>Resident #69<BR/>Record review of the current undated face sheet for female Resident #69 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had a diagnoses of diabetes mellitus due to underlying condition with diabetic nephropathy (blood sugar disorder), aphasia (cognitive disorder), and cerebral infarction, unspecified (stroke).<BR/>Record review of the physician's orders dated 2/7/24 for Resident #69 revealed a diet order documented as Diet: regular diet. Texture: mechanical . Start date 6/30/23.<BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed Resident #69 had order of diet: regular diet, texture: mechanical soft. Start date 6/30/23.<BR/> Resident #70<BR/>Record review of the current undated face sheet for male Resident #70 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke), insomnia, due to other mental disorder (sleep disorder), and dysphasia (swallowing disorder).<BR/>Record review of the current physician orders dated 2/7/24 for Resident #70 revealed that the resident had an order documented as, Diet: regular diet. Texture: pur&eacute;ed .Start date 7/24/23.<BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed that Resident #70 had a diet order which reflected diet: regular diet, texture: pur&eacute;ed. Start date 7/24/23.<BR/>Resident #75<BR/>Record review of the current undated face sheet for female Resident #75 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke with right weakness), aphasia (cognitive disorder), pain, unspecified, and Type II diabetes mellitus with diabetic polyneuropathy (blood sugar disorder).<BR/>Record review of the physician's orders dated 2/7/24 for Resident #75 reflected a diet order of Diet: regular diet. Texture: pur&eacute;e. Start date 10/31/23.<BR/>Record review of the Order Report By Category: 1/6/24-2/6/24 revealed that Resident #75 had a diet order which reflected diet: regular diet, texture: pur&eacute;ed. Start date 10/31/23. <BR/>-Record review of the Tuesday (2/06/24) Hospitality . 2023 5 Week - Week - 3 lunch menu revealed:<BR/>Residents on a regular/mechanical soft diet should have received:<BR/>3 ounces of ground herb baked chicken with gravy, A skinless baked potato, 1/2 cup broccoli florets, and a dinner roll.<BR/>-Record review of the Tuesday (2/06/24) Hospitality . 2023 5 Week - Week - 3 lunch menu revealed that residents on a regular/pur&eacute;ed diet should have received: <BR/>1/3 cup pur&eacute;ed herb baked chicken, 1 cup pur&eacute;ed baked potato, 1/3 cup pur&eacute;ed broccoli florets and 1/4 cup pur&eacute;ed Dinner roll. <BR/>The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 11:21 AM and concluded at 1:16 PM:<BR/>Observation of the steam table revealed the following with temperatures taken by Dietary staff A:<BR/>Broccoli served with a 4 ounce ladle<BR/>White gravy served with a 4 ounce ladle.<BR/>Fortified potatoes served with a #8 scoop (1/2 cup).<BR/>Baked potatoes <BR/>Rolls <BR/>Chicken fingers served three with each serving<BR/>Pur&eacute;ed chicken served with a #16 scoop (1/4 cup)<BR/>Pur&eacute;ed broccoli served with the #12 scoop (1/3 cup)<BR/>Mechanical altered chicken served with a #16 scoop (1/4 cup).<BR/>Pur&eacute;ed bread served with a #16 scoop (1/4 cup) <BR/>Meal service started at approximately 12:10 PM and was served by Dietary staff A.<BR/>Observation on 2/6/24 at 12:28 PM revealed Resident #4 was served by Dietary staff A a pur&eacute;ed diet with a #16 scoop of pur&eacute;ed chicken, #16 scoop of pur&eacute;ed bread, #12 scoop pur&eacute;ed broccoli, a shake, and a dessert. The resident should have received 1/3 cup of pureed chicken. There was no pur&eacute;ed baked potato served.<BR/>Observation on 2/6/24 at 12:33 PM revealed Resident #35 was served a mechanical altered tray with a baked potato with skin, 4 ounces of broccoli, #16 scoop of chicken with gravy, a roll, and a shake. The resident should have received 3 ounces of ground chicken and a skinless baked potato.<BR/>Observation on 2/6/24 at 12:34 PM Resident #67 was served a mechanical altered diet that included a baked potato with skin, #16 scoop of mechanical altered chicken with gravy, roll, and 4 ounces broccoli. The resident should have received 3 ounces of ground chicken and a skinless baked potato.<BR/>Observation on 2/6/24 at 12:56 PM Resident #32 received a pur&eacute;ed diet tray that was a # 16 scoop of pur&eacute;ed chicken with gravy, #12 scoop of broccoli, #16 scoop of pur&eacute;e bread, tea, water, pudding. The resident should have received a mechanical soft diet which would have included 3 oz ground herb baked chicken with gravy, a skinless baked potato, a &frac12; cup broccoli florets, and a dinner roll. <BR/>Observation on 2/6/24 at 12:59 PM Resident #70 received a mechanical altered meal tray that included a mechanical altered chicken with gravy #16 scoop, 4 ounces of broccoli, a baked potato with skin and a roll. The resident should have received 3 ounces of ground chicken and a skinless baked potato.<BR/>Observation on 2/6/24 at 1:07 PM Resident #75 was served a pur&eacute;e diet tray and she received a #16 scoop of pur&eacute;e chicken with gravy, # 12 scoop of broccoli, # 16 scoop of bread. There was no pur&eacute;ed baked potato to be served. The resident should have received 1/3 cup of pureed chicken. There was no pur&eacute;ed baked potato served.<BR/>On 2/6/24 at 1:18 PM an interview was conducted with Dietary staff A regarding why he had not served any pur&eacute;ed baked potatoes. He stated, It just blanked my mind (forgot). He then added, he should have prepared regular mashed potatoes for the pureed diet. He further stated he did not realize that those on a mechanical altered diet should have received a skinless baked potato. He stated, Scoop sizes is new to me. Working in a restaurant is different. I was not trained on scoop sizes. He further stated that he had been working in the facility since November 2023. He stated that his orientation consisted of being shown lunch procedures one day and he was on his own at supper that same day. He stated by not following the menu residents may ask for more food. He added he was unsure of what could be caused as a result of the lost calories from reduced portion size and omitted foods.<BR/>-Record review of the Tuesday (2/06/24) Hospitality . 2023 5 Week - Week - 3 supper menu revealed residents on a regular/pureed should have received:<BR/>6 ounces pur&eacute;ed minestrone soup, 3/4 cup pur&eacute;ed tuna salad sandwich, 1/2 cup pur&eacute;ed macaroni salad, and 1/3 cup pur&eacute;ed canned fruit. <BR/>-The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 4:33 PM and concluded at 5:18 PM:<BR/>Tuna salad <BR/>Bread<BR/>Minestrone Soup served with a 6 ounce ladle.<BR/>Beef patty<BR/>Corn served with a 4 ounce ladle.<BR/>Mashed potatoes served with a #12 scoop (1/3 cup).<BR/>Pur&eacute;ed corn served with a #12 scoop <BR/>Pur&eacute;ed rice served with the #12 scoop <BR/>Pur&eacute;e chicken serve with a #12 scoop. <BR/>Meal trays were served by Dietary staff B.<BR/>Observation 2/6/24 at 4:39 PM Resident #32 was served a pur&eacute;e tray. The resident received pur&eacute;ed chicken, pur&eacute;ed rice and pur&eacute;ed corn, shake, applesauce. The resident should have received a mechanical soft diet which would have included 6 ounces of minestrone soup, a tuna salad sandwich, 1/2 cup macaroni salad and 1/2 cup soft canned fruit.<BR/>Observation 2/6/24 at 4:42 PM the puree meal tray for Resident #75 was served and she received applesauce, a shake, tea, water, pur&eacute;ed chicken, pur&eacute;ed corn, and pur&eacute;ed rice. The resident should have received 6 oz pureed minestrone soup, 3/4 cup pureed tuna salad sandwich, and 1/2 cup pureed macaroni salad. None of those foods were present on the service line.<BR/>On 2/6/24 at 4:56 an interview and observation were conducted with Dietary staff B. She was asked why the residents on pur&eacute;ed diets did not receive the pur&eacute;ed tuna salad sandwich, pureed minestrone soup and pureed macaroni salad as called for on the menu. She stated the tuna salad sandwich was a cold food and that pureed foods must be hot . Dietary staff B was then shown the therapeutic spreadsheets for the meal. She stated, I've never seen those. We use this. and she pointed at the week-at-a-glance menu, which only indicated regular diets.<BR/>During an interview on 2/6/24 at 4:58 PM the Dietary Manager stated he did not know staff were supposed to use the therapeutic spreadsheets and added, I learned something new. He further stated, he was hired off and on for three years at the facility and took over as Dietary Manager in July 2023. He stated the Dietitian visited twice a month.<BR/>On 2/6/24 at 5:02 PM an interview was conducted with Dietary staff B regarding her dietary training. She stated a girl showed her dietary procedures for two days and the employee left. She added, I followed others like a puppy to learn. <BR/>-Record review of the Wednesday (2/07/24) Hospitality . 2023 5 Week - Week 3 lunch menu revealed residents on a regular pur&eacute;ed diets should have received:<BR/>1/2 cup pur&eacute;ed country pork tips with gravy, 1/2 cup pur&eacute;ed parsley noodles, 1/3 cup pur&eacute;ed Capri vegetables and 1/4 cup pur&eacute;ed herb butter roll. <BR/>Residents on regular/mechanical soft diets should have received:<BR/>4 ounces ground country pork tips with gravy, 1/2 cup parsley noodles, 1/2 cup Capri vegetables, one herb butter roll.<BR/>-The following interviews and observations were made during a kitchen tour on 2/7/24 that began at 10:51 AM and concluded at 12:04 PM:<BR/>On 2/7/24 at 11:26 AM an observation was made of the steam table. The cook was Dietary staff C. On the steam table was the following:<BR/>Capri/mixed vegetables served with the 4 ounce ladle.<BR/>Noodles served with a #8 scoop (1/2 cup).<BR/>Pork tips served with a #8 scoop (1/2 cup).<BR/>Ground pork tips served with a #12 scoop (1/3 cup).<BR/>Pur&eacute;ed Capri/mixed vegetables Served with a # 12 scoop (1/3 cup).<BR/>Pur&eacute;ed pork served with a #8 scoop (1/2 cup).<BR/>Pur&eacute;ed bread served with the #16 scoop (1/24cup).<BR/>Pur&eacute;ed parslied noodles served with the # 12 scoop (1/3 cup).<BR/>Fortified mashed potatoes served with a #8 scoop (1/2 cup).<BR/>Hamburger patties <BR/>Rolls<BR/>Observation on 2/7/24 at 11:43 AM revealed Resident #69 was on a regular mechanical soft diet and was served a #12 scoop of mechanical altered meat with gravy, #8 scoop of noodles, 4 ounces of mixed vegetables and one roll. The resident should have received 4 ounces of the mechanically altered pork with gravy (1/2 cup).<BR/>Observation on 2/7/24 at 11:49 AM revealed the meal tray for Resident #51 was prepared which was a mechanical soft diet. The resident received #8 scoop noodles, 4 ounces mix vegetables, and mechanical altered pork and gravy serve with a #12 scoop and a roll. The resident should have received 4 ounces of the mechanically altered pork with gravy (1/2 cup).<BR/>Observation on 2/7/24 at 11:51 AM revealed the meal tray was prepared for Resident #4, which was a pur&eacute;ed tray and the resident received pur&eacute;e noodles #12 scoop, pur&eacute;ed mixed vegetables #12 scoop, pur&eacute;ed meat and gravy #8 scoop and pur&eacute;e bread with a # 16 scoop. The resident should have received a 1/2 cup of pureed parslied noodles.<BR/>During an interview on 2/7/24 at 12:35 PM Dietary staff C stated, for the noon meal she told the Dietary Manager to get the service line scoops and he (Dietary Manager) stated he would make sure it was right.<BR/>On 2/8/24 at 9:09 AM an interview was conducted with LVN D as to why Resident #32 was on a pur&eacute;e diet. She stated he just moved to hospice and did not know why he was on that diet since she had seen him eat solid foods from the family. She added that Resident #75 was on a mechanical soft diet. She stated there had been problems with the kitchen with a lack of attention to dietary needs and the department had experienced a high turnover. She stated the situation had improved. She stated, residents may choke or aspirate if they did not receive the correct pureed diet as ordered. <BR/>On 2/8/24 at 9:30 AM an interview was conducted with the Dietary Manager regarding tray card updates. He stated they were updated as soon as diets were changed, or the resident let him know. He stated therapy came and informed him about those changes. He added sometimes he did not get the diet changes from nursing, but it had improved some. He stated he told the staff to read the ticket (tray card). He also stated that he was not aware that Resident #32 was currently on a mechanical soft diet.<BR/>The Dietary Manager stated staff were not paying attention, and it was a lack of knowledge that caused the issues with following the menu. He also stated that he expected staff to ask questions. To ensure that the menu was followed, he stated that he checked the steam table and asked questions. He stated that he as the Dietary Manager was responsible for ensuring that the menu was followed. He further stated that residents could have allergic reactions, death, and lose weight, if the menu was not followed. He also stated that dietary orientation training was at least a week and then staff are shadowed.<BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated sometimes the food delivery trucks did not bring the correct foods and that the dietary department had a high turnover. He stated that the facility monitored following the menu by communicating with the Dietary Manager, ensured that all foods were present and that substitutes were documented. He stated he expected staff to follow the menu and document substitutions. He stated that the Dietary Manager, Administrator and all dietary staff were responsible for ensuring that the menu was followed. He stated residents would not eat the food, lose weight or experience malnutrition as a result of not following the menu.<BR/>Record review of the facility's one page Weekly Menu for Hospitality . 2023 5 Week - Week 3 Diet: Regular/Regular week at a glance revealed the following foods should have been served on the following days:<BR/>Tuesday (2/06/24) lunch: herb, baked chicken, baked potato, broccoli florets, dinner roll, pudding with whip topping <BR/>Tuesday (2/06/24) supper: minestrone soup, tuna salad sandwich, potato chips, pineapple tidbits. <BR/>Wednesday (2/07/24) lunch: country pork tips with gravy, parsley noodles, Capri vegetable, herb butter roll <BR/>This was the week-at-a-glance menu used by the facility staff during the survey. These menus were only regular diets and had no specific measurements/amounts of the food indicated.<BR/>Record review of the facility policy, titled Food and Nutrition Services, Revised September 2021, revealed the following documentation, Policy Statement. Each resident is provided with a nourishing, palatable, well-balanced, diet that meets his or her daily nutritional and special dietary needs, taking in consideration the preferences of each resident. Policy Interpretation, and Implementation. <BR/>2. A resident centered diet and nutrition plan will be based on this assessment. <BR/>6. Food and nutrition services Staff will inspect food trays to ensure that the correct meal is provided to each resident, the meal appears palatable and attractive, and it is served at a safe and appetizing temperature. <BR/>a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the dietary staff, so that a new food tray can be issued <BR/>Record review of the facility policy titled Nutrition and Food Service Policy and Procedure Manual, 2018, Section 1-3, revealed the following documentation, Policy: Menu Planning. Policy Number: 01.002. Policy: the facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well balanced, nutritious, and meets the preferences of the resident population. A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences will be used. Modification for resident population and preferences may be made as appropriate. Procedure: <BR/>1. Menus will be prepared by each facility by (Vendor) using the menu matrix program. Menus are updated twice each year with the spring - summer and fall - winter cycles and are updated intermittently based on the resident preferences. The menu will be for a five-week cycle and will include a week-at-a glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide, and an order guide. Menus are available in paper form and web-based. <BR/>2. Alternates may include a comparable entr&eacute;e, vegetable and starch. An always available menu may also be offered. The alternate menu should be individualized by each facility based on their resident population and preferences. The alternate menu must also include diet extensions for each diet offered. <BR/>

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability.<BR/>1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/8/24 lunch). <BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. <BR/>The findings included:<BR/>During confidential individual interviews 6 of 16 residents voiced concerns related to food palatability.<BR/>One resident stated The food is always cold. It's all meals. Another resident stated, The foods are hard. One other resident stated, It sucks. It's not good. The hamburger buns are hard occasionally, and it has poor flavor. A resident stated that the food was so bad that she had to buy her food somewhere else. The resident added that the food was so bad that it made her throw up. Another resident stated, The food is cold and Does not taste good. <BR/>Record review of the Resident Council Minutes dated 11/10/23 revealed resident comments related to the food served in the facility. It was documented, They would like for dietary to put bread in Ziploc bags so bread would not get soggy.<BR/>Record review of the Resident Council Minutes dated 1/5/24 revealed residents had concerns regarding the food served. It was documented, . residents mentioned that the potatoes are rotten. The bread has mold on it. <BR/>- The following interviews and observations were made during a kitchen tour on 2/7/24 that began at 10:51 AM and concluded at 12:04 PM:<BR/>On 2/7/24 at 10:51 AM the Dietary Manager was informed of a request for a test tray for the noon meal.<BR/>On 2/7/24 at 11:26 AM an observation was made of the steam table. Dietary Staff C took temperatures of the foods on the steamtable with the following results:<BR/>Mixed vegetables at 156&deg;F<BR/>Noodles 176&deg;F <BR/> Pork tips 191&deg;F <BR/>Ground pork tips 171&deg;F<BR/>Pur&eacute;ed mixed vegetables and 170&deg;F. <BR/>Pur&eacute;ed pork 177&deg;F <BR/>Pur&eacute;ed bread 108.3&deg;F <BR/>Pur&eacute;e noodles 163.2&deg;F<BR/>Fortified mashed potatoes 155.7&deg;F.<BR/>Hamburger patty 168&deg;F<BR/>Rolls room temperature<BR/>Meal service started at 11:37 AM with the memory unit cart.<BR/>The memory unit cart service ended at 11:45 AM and left the kitchen.<BR/>The Station 1 cart tray prep began at 11:45 AM.<BR/>At 12:01 PM the last tray for Station 1 was prepared and at 12:01 PM they started preparing the sample tray. The preparation for the sample tray was completed at 12:03 PM and at 12:04 PM the cart for Station 1 left the kitchen. At 12:06 PM the cart arrived on Station 1 and staff began serving from the cart at 12:06 PM with the assistance of five staff and serving the Station 1 dining room first. At 12:10 PM the staff started serving residents on Station 1 hall and there were three staff serving the hallway. At 12:15 PM the last tray was served to Resident #35. The resident started eating at 12:16 PM.<BR/>At 12:17 PM the test trays arrived at the conference room and sampling began at 12:19 PM with the following results:<BR/>Beef patty 98.6&deg;F, cold<BR/>Mashed potatoes, 106&deg;F and tasted like instant potatoes and cold.<BR/>Ground pork, 108&deg;F and lukewarm<BR/>Pork tips 109&deg;F, lukewarm<BR/>Noodles 94.5&deg;F, cold and gummy<BR/>Mix vegetables 100&deg;F, cold<BR/>Pur&eacute;ed meat 113.2&deg;F, cold<BR/>Pur&eacute;ed vegetables 109&deg;F, cold and had poor flavor unlike vegetables <BR/>Pur&eacute;ed noodles 106.9&deg;F cold, gummy and had poor flavor unlike noodles <BR/>On 2/7/24 at 12:40 PM an observation and interview were conducted in the kitchen with Dietary Staff C. She stated one of two in use plate warmer bins was not operable. She further stated the bottom plates were hot but not the top ones. Observation of the third plate warmer bin revealed that it was not operable. Only one of three plate warmer bins were operable.<BR/>On 2/8/24 at 9:30 AM an interview was conducted with the Dietary Manager. He stated the speed on the line and the plate warmers was why the palatability issues occurred. He stated that the last time that the plate warmers worked on was two years ago in August (2022). He stated staff should have transferred plates over to the hot plates and picked up the speed on the service line. He also expected staff to pass the trays faster on the halls. He stated he tasted the foods in order to monitor the palatability of foods. He stated that all staff were responsible for ensuring that the foods were palatable. He further stated that residents could become sick, angry, and call the state if their foods were not palatable. He stated that residents had not stated to him that the foods were cold. He stated he attended menu reviews every Friday with residents and activities staff.<BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated most days he ate the facility food and it was fine. He stated their monitoring method was test trays. He stated the food had improved and he gave feedback. He stated that he expected residents to inform staff if the seasoning was not acceptable. He stated that the kitchen staff, Dietary Manager, and everyone were responsible for food palatability. He stated that as a result of unpalatable food residents may not eat, lose weight, or experience malnutrition. <BR/>Record review of the facility policy, titled Food and Nutrition Services, Revised September 2021, revealed the following documentation, Policy Statement. Each resident is provided with a nourishing, palatable, well-balanced, diet that meets his or her daily nutritional and special dietary needs, taking in consideration the preferences of each resident. Policy Interpretation, and Implementation. <BR/>2. A resident centered diet and nutrition plan will be based on this assessment. <BR/>6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the meal appears palatable and attractive, and it is served at a safe and appetizing temperature. <BR/>a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the dietary staff, so that a new food tray can be issued

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 meals (2/06/24 - Supper) observed for 2 of 2 residents with orders for pur&eacute;ed and mechanical soft diets (Residents #32 and #75).<BR/>The facility failed to provide food that was in a form to meet resident needs, 1 of 3 meals observed (2/06/24 - Supper) for 2 of 2 residents with orders for pur&eacute;ed diets (Resident #75) and mechanical soft diets (Resident #32).<BR/>This failure could place residents at risk of decreased food intake and choking.<BR/>The findings included:<BR/> Resident #75<BR/>Record review of the current undated face sheet for female Resident #75 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke with right weakness), aphasia (cognitive disorder), pain, unspecified, and Type II diabetes mellitus with diabetic polyneuropathy (blood sugar disorder).<BR/>Record review of the admission MDS assessment for Resident #75 dated 11/12/23 revealed that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed the resident was on a mechanically altered diet.<BR/>Record review of the current care plan for Resident #75 revealed a Problem with a start date of 2/5/24, Category: nutritional status. I have experienced a significant weight loss within the past 30 - 60 days. I am at risk for a significant weight loss, the following conditions, contribute to my weight, loss and risk CVA, failure to thrive. Created: 2/5/24. The Goal listed documented the following, Long-term goal target date: 5/5/24. I will not sustain a significant weight loss through the next review. 2/5/24. An additional care plan Problem was noted with a problem start date: 11/12/23 that documented, Category: nutritional status. Nutritional status/diet: regular pur&eacute;ed, diet/thin liquids. Edited: 1/3/24. Approaches included, Approach start date: 11/12/23. Diet as ordered. Created: 1/3/24. Approach start date: 11/12/23. Report problems to charge nurse, i.e.: Choking, Difficulty chewing. Created: 1/3/24. <BR/>Record review of the dietary progress note for Resident #75 dated 12/7/23 revealed the following, December weights obtained. Up 10 pounds in one month but down 7 pounds in about one and 1/2 months. Continue with plan of care, pur&eacute;ed and ready care supplement in place. <BR/>Record review of the physician's orders for Resident #75 dated 2/7/24 reflected a diet order of Diet: regular diet. Texture: pur&eacute;e. Start date 10/31/23.<BR/> Resident #32<BR/>Record review of the current undated face sheet for male Resident #32 revealed that the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was [AGE] years old and had diagnoses of displaced, intertrochanteric fracture of left femur (femur fracture), subsequent encounter for close fracture with routine healing, cognitive communication deficit, unspecified, hearing loss, unspecified, ear and unspecified dementia, unspecified severity, with anxiety (cognitive and mental disorder).<BR/>Record review of the significant change MDS assessment for Resident #32 dated 1/18/24 revealed that the resident did not have a BIMS score and was documented as having short term and long-term memory problems. The resident was also documented as being cognitively severely impaired. Further record review of the MDS revealed the resident was documented as being on a mechanically altered diet.<BR/>Record review of the care plan for Resident #32 revealed a Problem with a problem start date of 12/19/23. Category: nutritional status. Nutritional status diet: mechanical soft diet/thin liquids. Edited: 1/16/24. Approaches listed included, Approach start date: 12/19/23. Diet as ordered: regular. Created: 12/19/23.<BR/>Record review of the dietary progress note for Resident #32 dated 1/16/24 revealed the following documentation, Nutrition wound note . Classification: underweight. Noted resident on hospice care. Diet: Regular, mechanical soft, thin . Labs: 12/27/23 . Albumin 3.3 low. Skin: Unstaged pressure injury - coccyx (buttocks area) . Goal: receive adequate nutrition as condition allows. Will continue to follow.<BR/>Record review of the physician's orders for Resident #32 dated 2/7/24 revealed a documented order of Diet: regular diet texture: mechanical soft. Start date, 12/20/23. <BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 11:21 AM and concluded at 1:16 PM:<BR/>Observation of the steam table revealed the following with temperatures taken by Dietary staff A:<BR/>Broccoli <BR/>White gravy.<BR/>Fortified potatoes <BR/>Baked potatoes <BR/>Rolls <BR/>Chicken fingers <BR/>Pur&eacute;e chicken <BR/>Pur&eacute;e broccoli <BR/>Mechanical altered chicken <BR/>Pur&eacute;ed bread <BR/>Meal service started at approximately 12:10 PM and was served by Dietary staff A.<BR/>Record review of the tray card for Resident #32 for lunch: Tuesday, February 6, 2024 revealed that the resident was on a regular/pur&eacute;e diet and should have received 1/3 cup pur&eacute;ed herb baked chicken, 1 cup pur&eacute;ed baked potato, 1/3 cup pur&eacute;ed broccoli florets, 1/4 cup pur&eacute;e Dinner roll.<BR/>Observation on 2/6/24 at 12:56 PM revealed Resident #32 received a pur&eacute;ed diet tray that was a #16 scoop of pur&eacute;ed chicken with gravy, #12 scoop of broccoli, #16 scoop of pur&eacute;ed bread, tea, water, and pudding. The resident should have received a mechanical soft diet which would have included 3 oz ground herb baked chicken with gravy, a skinless baked potato, a half cup of broccoli florets, and a dinner roll. The resident received the incorrect form of food.<BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 4:33 PM and concluded at 5:18 PM:<BR/>On the steamtable were the following foods served by Dietary staff B:<BR/>Tuna salad bread<BR/>Minestrone Soup <BR/>Beef patty<BR/>Corn <BR/>Mashed potatoes were very flat and thin in texture.<BR/>Pur&eacute;ed corn had a heavy accumulation of hulls.<BR/>Pur&eacute;ed rice was very watery and thin.<BR/>Pur&eacute;ed chicken <BR/>Record review of the tray card for Resident #32 for supper: Tuesday, February 6, 2024, revealed that the resident was on a regular/pur&eacute;e diet and should have received 6 ounces of pur&eacute;ed minestrone soup, 3/4 cup pur&eacute;ed tuna salad sandwich, a 1/2 cup pur&eacute;ed macaroni salad, and a 1/3 cup pur&eacute;ed canned fruit. <BR/>Observation on 2/6/24 at 4:39 PM revealed Resident #32 was served a pur&eacute;ed tray where all the foods were flat on the plate. The pur&eacute;ed corn had a heavy accumulation of hulls. The resident received pur&eacute;ed chicken, pur&eacute;ed rice, pur&eacute;ed corn, a shake, and applesauce. The resident should have received a mechanical soft diet which would have included 6 ounces minestrone soup, a tuna salad sandwich, a half cup of macaroni salad and a half cup of soft canned fruit.<BR/>Record review view of the tray card for Resident #75 for supper: Tuesday, February 6, 2024, revealed that the resident was on a regular/pur&eacute;e diet and should have received 6 ounces of pur&eacute;ed minestrone soup, 3/4 cup pur&eacute;ed, tuna salad sandwich, a 1/2 cup pur&eacute;ed macaroni salad, and a 1/3 cup pur&eacute;ed canned vegetables. <BR/>Observation on 2/6/24 at 4:42 PM revealed the pureed meal tray for Resident #75 was included r applesauce, a shake, tea, water, pur&eacute;ed chicken, pur&eacute;ed corn, pur&eacute;ed rice and all were flat on the plate. The pureed corn had a heavy accumulation of hulls.<BR/>Observation on 2/6/24 at 4:59 PM, revealed the pureed foods were tasted with the following results:<BR/>Pur&eacute;ed chicken was grainy and flat on the plate.<BR/>Pur&eacute;ed corn was full of hulls, and flat on the plate.<BR/>Pur&eacute;ed rice was flat on the plate and very thin.<BR/>On 2/6/24 at 5:02 PM an interview was conducted with Dietary Staff B regarding her dietary orientation and training. She stated an employee showed her dietary procedures for two days and then the employee left. She stated she followed other staff like a puppy trying to learn. She then stated she did not know the what the correct consistency should be for pureed foods. She added, I was not really trained on pur&eacute;e. She stated residents could choke if they did receive pureed food in an incorrect form. <BR/>On 2/6/24 at 5:08 PM, the Dietary Manager was interviewed. He stated he had trained the other two cooks on pur&eacute;es (excluding Dietary staff B). He added that pureed foods should not be flat and should be pudding consistency. He stated residents could choke, or aspirate from foods not being pur&eacute;ed correctly. He then stated he had conducted in-services, but sometimes it falls on deaf ears.<BR/>On 2/8/24 at 9:30 AM an interview was conducted with the Dietary Manager regarding why the food form issues occurred. He stated staff let the corn go too long and staff had been told that pureed foods should be in a pudding consistency. He stated he expected staff to ask questions about the pur&eacute;e. He added that he told staff to use chicken and beef stock, and not water for pur&eacute;es . He stated all staff were responsible to ensure that foods were in the correct form. He added that residents could experience choking and aspiration if foods were not in the correct form. He added that he had conducted training on pur&eacute;es approximately a month ago. Regarding dietary orientation and training staff, he stated that orientation was at least a week and then staff were shadowed.<BR/>On 2/8/24 at 9:09 AM an interview was conducted with LVN D as to why Resident #32 was on a pur&eacute;e diet. She stated he just moved to hospice but had seen him eat whole foods from family without issue. She added she did not know why dietary had the resident on a pureed diet. Regarding Resident #75 being served a pur&eacute;e diet, she stated the resident was on a mechanical altered diet. She added that there had been problems with the kitchen's lack of attention regarding dietary requests. She added that dietary had a high turnover, but it had improved. She stated they may choke or aspirate as a result of residents not receiving the pur&eacute;e diet as ordered.<BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding food form. He stated that staff needed more training. He added the staff should look at the food to ensure that it was the correct consistency. He stated he expected staff to produce the pur&eacute;e the way it was supposed to be. He stated that Dietary staff, dietary manager and nursing staff were responsible for ensuring that the foods were in the correct form. He stated that residents could aspirate or not be able to swallow the food if it was not in the correct form.<BR/>Record review of the vendors Diet Manual dated 2016 revealed the following documentation. <BR/>3. Mechanically Altered Textures. Mechanically altered textures are available for persons having difficulty with chewing or swallowing as prescribed by their physician, speech therapist, or registered dietitian. Dysphasia Diets. Use for residents with swallowing difficulties due to medical conditions, such as a stroke, degenerative diseases, like Huntington's, or Parkinson's, cancer, and/or radiation therapy. <BR/> . Pureed. This level is for people with moderate to severe swallowing difficulties and have a poor ability to protect their airway.<BR/>This allows pur&eacute;ed food (pudding like consistency) that is smooth and easily stays together.<BR/>Food should be avoided if they require chewing. Coarse and dry textures, raw fruits and vegetables, breads, and nuts should also be avoided.<BR/>Beverages should be thin (regular), nectar like, honey like or pudding like . <BR/> . MechSoft<BR/>This is a step up from the pureed diet. Some chewing ability is required. The level 2 diet is for people with mild to moderate swallowing difficulty. <BR/>This diet consists of foods that are moist, soft and easy formed into bolus . Avoid food that are difficult to chew, dry and coarse<BR/>Meat should be ground or minced and should be kept moist with sauces and gravies <BR/>Bread should be soft <BR/>Beverages should be thin, , nectar like, honey like or pudding like .<BR/>Texture Guidelines. Item - Avoid .Pureed - corn (whole or creamed) .<BR/>3.1. Pureed Texture. <BR/>Description. The pureed texture is a mechanical modification of the regular diet or any therapeutic diet designed for people with moderate to severe swallowing difficulty and a poor ability to protect their airway. This texture allows pur&eacute;ed food, (pudding like consistency) that is smooth and easily stays together. Food should be avoided if they require chewing. Coarse and dry textures, raw fruits and vegetables, breads, and nuts should also be avoided. Beverages should be thin (regular), nectar like, honey like or pudding like. It is critical that standardized recipes be followed when preparing pur&eacute;ed foods to ensure nutritional quality is maintained. Food Group - Vegetable. Food Allowed - Vegetables should be soft, well cooked and pur&eacute;ed without lumps, hulls or seeds.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services.<BR/>1) The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions.<BR/>2) The facility failed to ensure food and non-food contact surfaces were clean. <BR/>3) The facility failed to ensure staff stored personal items in a manner that prevented contamination. <BR/>4) The facility failed to ensure food was accurately dated and labeled. <BR/>5) The facility failed to protect foods from potential contamination. <BR/>6) The facility failed to ensure staff wore hair restraints in food areas.<BR/>7) The facility failed to ensure sanitizer were at recommended concentrations and used according to manufacturer recommendations, <BR/>8) The facility failed to rapidly reheat potentially hazardous hot food to 165 degrees F prior to placing on the steam table. <BR/>9) The facility failed to ensure that potentially hazardous cold foods were maintained at 41 degrees F or below.<BR/>10) The facility failed to ensure staff used good hygienic practices.<BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings included :<BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 8:54 AM and concluded at 9:45 AM:<BR/>Dietary staff D was observed washing his hands. He turned off the water with his bare hand and then dried them with paper towels. He then donned a pair of gloves and then handled soiled dish trays in the dishwasher area. He then move to the clean dishes and put away trays from the clean side of the dishwasher. <BR/>Observation on 2/6/24 at 9:05 AM, revealed as the Dietary staff D was observed wearing gloves, he was going back-and-forth from soiled dishes to putting away clean lids at the dishwasher and not washing his hands and changing gloves between the soiled and clean operations.<BR/>There was a plastic headband stored on top of the toaster next to a covered thermometer. <BR/>Observation on 2/6/24 at 9:13 AM, revealed the Dietary staff D was wearing gloves and went from handling soiled to clean equipment at the dishwasher area without washing his hands between the soiled and clean operation. He handled soiled dishes and then put away pitchers and cups that were clean.<BR/>Observation on 2/6/24 at 9:18 AM revealed the three compartment sink quaternary sanitizer level was tested at 100 ppm by Dietary staff A. At that time Dietary staff A stated It needs to be a little stronger .<BR/>The front area produce refrigerator had three thawed cartons of vanilla Ready Care shakes on a tray. The cartons reflected Use within 14 days of thawing. There was no label or date to determine if the 14 days had passed. <BR/>The magnetic lid trim was pulling away from the lid on the chest freezer. <BR/>Observation on 2/6/24 at 9:26 AM, revealed Dietary staff A was observed taking food equipment out of the quaternary sink, three compartment sink sanitizer basin where he had just cleaned food equipment. He tested the level of sanitizer in the sanitizing sink, and it was 100 ppm quat. He stated at this time, Maybe I need to drain it and refill it. <BR/>Observation on 2/6/24 at 9:30 AM revealed Dietary staff A stated, he did not add any fresh quaternary sanitizer to the basin after he had initially tested it at 9:18 AM.<BR/>Two of two sets of fluorescent lights in the pantry had no shield. <BR/>Observation on 2/6/24 at 9:40 AM revealed Dietary staff A refilled the sanitizing sink for the three compartment sink and the level of quaternary sanitizer was tested at 200 ppm.<BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 11:21 AM and concluded at 1:16 PM:<BR/>A large ice scoop was hanging in a metal holder on the wall but the handle and top area of the ice scoop had a buildup of dirt/brown substance in the creased areas.<BR/>Observation of the steam table revealed the following with temperatures were taken by Dietary staff A:<BR/>Broccoli 192.4&deg;F <BR/>White gravy 186.4&deg;F. <BR/>Fortified potatoes 178.9&deg; <BR/>Rolls no temperature taken and served room temperature. <BR/>Chicken fingers 205&deg; out of the oven.<BR/>Pur&eacute;e chicken was 153.5&deg;F. Not reheated to 165 degrees F. after cooling during the pureeing process.<BR/>Pur&eacute;e broccoli 154&deg;F <BR/>Mechanical altered chicken 152&deg;F. Not reheated to 165 degrees F. after cooling during the pureeing process.<BR/>Pur&eacute;ed bread no temperature taken. <BR/>There was a plastic headband stored on top of the toaster next to an uncovered cup of white crystal substance that had no label.<BR/>The ceiling vent above the dishwasher was thick with a buildup of fluffy dust and dirt.<BR/>There was a portable fan placed on the clean side of the dishwasher and was turned on and the intake vent of the fan had a buildup of dirt. The fan was blowing across a rack of clean glasses.<BR/>Dietary staff D was observed washing his hands at the hand sink, then turning off the water using a paper towel. He then dried his hands and arms with the same paper towel. He donned, a pair gloves, and then re-gloved and continued with dietary duties.<BR/>MA A entered the kitchen and did not have on a hair restraint. Her hair was pulled up into a loose top knot type bun with loose hair .<BR/>At the service line, there was a box of 20 thawed vanilla Ready Shakes, and there was no date on the boxed indicating when the vanilla shakes were thawed. The shakes were not on any source of refrigeration.<BR/>Interview on 2/6/24 at 11:46 AM, Dietary staff D stated the shakes had been stored in the produce refrigerator.<BR/>Observation on 2/6/24 at 10:50 AM, revealed the pur&eacute;e processing was conducted by Dietary staff A. He was about to pur&eacute;ed broccoli. Observation of the blade and processor pot interior revealed they were wet and soiled with debris. Also, the lid shoot had debris. The surveyor intervened and he washed the processor parts in the three compartments sink. After washing them, he took his wet hands and handled the blade and assemble the processor parts that were dripping wet. He then pur&eacute;ed the broccoli in the processor. Dietary staff A then placed the pur&eacute;e in a pan and placed it on the steam table. He then washed the parts in the three-compartment sink, the lid, the blade and processor pot. He only dipped the parts in the sanitizer basin for approximately two seconds, and then placed the parts on the clean drain board. When he placed them on the clean side drain board, he did not invert the pot or the lid so that the water could drain off.<BR/>Dietary staff A then placed chicken fingers in the wet processor pot, which was wet on the interior, the lid and the blade. He then pur&eacute;ed the chicken with milk and then placed it in a pan and placed it on the steam table.<BR/>Observation on 2/6/24 at 12:02 PM revealed Dietary staff A, then took the processor and dipped each part in the wash, rinse and quat sanitizer sinks for approximately two seconds, and then took them out and placed and assembled on the processor base at 12:03 PM. He then placed chicken in the wet processor and ground the chicken. After grinding, he placed it in a pan and then put it on the steam table at 12:04 PM.<BR/>Observation and record review of the quaternary sanitizer label Solution QA Ultra revealed the following documentation. Apply 200 to 400 ppm active quaternary. To clean public eating establishment surfaces. Wet for at least 60 seconds and let air dry. Do not rinse. This product is an effective sanitizer for use on food contact services in 60 seconds at 200 ppm active quaternary. Sanitization. Effective sanitizer at an active quaternary concentration of 200 to 400 ppm. <BR/>There was a personal drink in a foam cup stored on top of the chest freezer.<BR/>Observation at 1:12 PM revealed the shakes were still out without any ice or refrigeration on the service line. There was one carton left on the cart that was part of the thawed 20 shakes that were at the service line. The last cart went out and meal service was over at 1:14 PM. At 1:15 PM a temperature was taken of the last carton of shake that was left and it was 56&deg;F. <BR/>On 2/6/24 at 1:18 PM an interview was conducted with Dietary staff A regarding dietary sanitation issues. He stated he had not been told anything about the length of time to submerge the equipment in the sanitizing solution. He stated residents could get sick if food contact surfaces were not sanitized correctly. He stated usually the bottom half of the shakes were frozen. He added that the shakes had been in the refrigerator since yesterday (2/05/24). He further stated that he had been working in the facility since November 2023. He stated his training orientation consisted of showing him dietary procedures at one lunch and was let go on his own at supper that same day . <BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 4:33 PM and concluded at 5:18 PM:<BR/>There was a personal drink on the cart next to an open box of shakes. The personal drink was later moved to the table next to the microwave and coffee machine.<BR/> Dietary staff B was observed carrying empty soup bowls to the steamtable up against her chest/shirt.<BR/>On 2/6/24 at 5:02 PM an interview was conducted with Dietary staff B regarding her dietary training. She stated, an employee showed her dietary procedures for two days and then the employee left. She added she followed other staff like a puppy to learn. <BR/>- The following interviews and observations were made during a kitchen tour on 2/7/24 that began at 10:51 AM and concluded at 12:04 PM:<BR/>There was a personal half bottle of water and a can of energy drink on a lower shelf on the steam table line. <BR/>There was an uncovered, unlabeled cup of white crystalline substance stored on top of the toaster. During an interview with the Dietary Manager on 2/7/24 at 12:03 PM, he stated the substance in the cup was sugar.<BR/>On 2/8/24 at 9:30 AM kitchen observation and interview was conducted with the Dietary Manager regarding issues observed in the kitchen. Regarding when the shakes expired, he stated staff go by the date on the carton. Observation revealed that there was no date on the box that the shakes were in and there was also no date on the carton itself. Documentation on the carton revealed the manufacturer recommended disposing of the thawed shakes after 14 days . The underside of the upper shelf of the stove had an accumulation of dried splatter. He also stated regarding not washing hands between soiled and clean operations, clean food equipment could still get contaminated. When the soiled ceiling vents were mentioned, he stated the filter above the dishwasher was changed every month and the last time was last week. Regarding personal drink storage, he stated personal drinks were supposed to be stored in his office. Observation of the chest freezer revealed that the interior of the lid was detaching and the magnetic trim was detached in an area. He stated the fluorescent light in the pantry had been unshielded ever since he had been here. He stated he was told that the lights did not need shields. Regarding the shakes he stated the shakes were normally in an ice bath to keep them below 40 F&deg;. He further stated that foods on the steam table should be 165&deg;F when reheated . He stated staff were instructed to let equipment dry. He added that the quat level should have been 200 ppm at least and staff should have let the processor dry. He further stated that the food contact items should be in the sanitizer at least 45 seconds in the three-compartment sink. He stated staff forgot to bring their drinks in the office. He stated he reminded staff daily on handwashing and sanitizer and glove use. He stated he expected them to do the right thing. He stated he conducted direct monitoring of staff, corrected the staff, and assisted the staff. He stated he and the staff were responsible to ensure dietary sanitation procedures were conducted correctly. He stated residents could get sick as a result of the dietary sanitation issues observed. He stated that dietary orientation training was at least a week and then staff were shadowed. <BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated dietary staff had been in-serviced and needed to be re-in-serviced. He stated that he monitored the sanitation by making rounds. He also stated he expected the staff to clean and let equipment dry and date foods correctly. He stated that all staff were responsible including the Dietary Manager and Administrator. The result of issues with dietary sanitation could result in making the residents sick.<BR/>Record review of the dietary department in-services held between 10/3/23 and 2/6/24 revealed that there were four in-services held that contained multiple subjects. It was also noted that the documentation for the in-service did not include any specific information of what was covered. There were only the topic and signatures from the staff. <BR/>The in-services topics were as follows for 10/3/23: Handwashing, cleaning, hairnets. Dietary staff, B and D attended these in-services.<BR/>The services were as follows for 10/19/23: stocking, and temperature logs. Dietary staff B and D attended these in-services.<BR/>The in-services were as follows for 12/11/23: Handwashing, cleaning, temperatures, job duties. Dietary staff A, B and D attended these in-services.<BR/>The in-service was as follows for 1/2/24: Serving times, job duties, dates, cleaning, tickets. Dietary staff, A, B, C and D attended these in-services. <BR/>Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures. Manual, 2018, Section 4-5, revealed the following documentation, Policy: General Kitchen Sanitation. Policy Number: 04.003. Policy: the facility recognizes that foodborne illness has a potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary, kitchen, facilities, in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure: <BR/>1.Clean and sanitize all food preparation areas, food contact surfaces, dining facilities, and equipment. After each use, clean and sanitize, all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. <BR/>4.Clean and sanitize all multiuse utensils, and food contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation. Based on food temperature, type of food and amount of food particle accumulation. <BR/>5. After cleaning and use, storage and handling of all food contact surfaces of equipment and multiuse utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants. <BR/>6. Clean non-food contact surfaces of equipment at intervals, as necessary to keep them free of dust, dirt, and food particles, and otherwise in a clean and sanitary condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #66 an #73) and 2 of 2 (ADON B AND LVN C) staff reviewed for infection control. <BR/>1. ADON B failed to perform hand hygiene between glove changes when providing wound care for Resident #66 <BR/>2. LVN C failed to perform hand hygiene between glove changes when providing wound care for Resident #73. <BR/>3. LVN C failed to keep dirty and clean supplies separated when providing wound care for Resident # 73.<BR/>These failures could place residents at risk for spread of infection and cross contamination. <BR/>Findings include:<BR/>Resident #66<BR/>Record review of face sheet for Resident #66 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: symptomatic epilepsy (seizure disorder), hyperlipidemia (high levels of fat particles in the blood), alcohol abuse, hypertension (high blood pressure) and diabetes (high blood sugar). <BR/>Review of Resident #66's MDS, dated [DATE] revealed Resident #66 had a BIMS of 09 which indicated the resident's cognition was moderately impaired. The MDS revealed Resident #66 was at risk of developing pressure ulcers and a pressure reducing device was used for the bed.<BR/>Record review of Resident #66's Comprehensive Care Plan, dated 02/01/24 revealed the resident was at risk for skin breakdown with approaches to follow skin care protocol and to immediately report any skin breakdown to charge nurse.<BR/>On 02/07/24 04:08 PM observed wound care of the coccyx, right lower buttock and both lower extremities on Resident # 66 with ADON B. Observed ADON B changing gloves several times during wound care but did not sanitize hands between glove changes. ADON B finished cleansing the wound with 4x4 gauze and changed gloves, then proceeded to apply a clean dressing to the wound without sanitizing his hands. No hand sanitizer was available on the table of supplies during wound care. ADON B moved to a wound on the resident's right lower buttock and washed his hands with soap and water prior to beginning wound care. Again, ADON B changed gloves several times during wound care for the buttock wound, cleansing with a 4x4 gauze. ADON B did not sanitize his hands at any point during the wound care when gloves were changed, including prior to applying the clean dressing to the wound. ADON B then moved to perform the lower extremity wound care. Observed ADON B cleanse the wounds to the lower legs with a 4x4 gauze, apply Vaseline gauze, padding and wrapped lower legs with a gauze then secured with tape. ADON B changed gloves multiple times during wound care of the lower legs, but did not sanitize his hands between glove changes, including between dirty and clean parts of the wound care and when applying a clean dressing to the legs. Observed ADON B wash his hands with soap and water after completing the wound care procedure. <BR/>On 02/08/24 12:50 PM in an interview with ADON B, he stated the policy for hand sanitizing with glove changes was to wash hands with soap and water prior to gloving and again after the procedure is complete, then use hand sanitizer each time in between, with every glove change. He stated he has been trained on hand sanitizing and infection control every couple of months by the facility nurse educator or the DON. ADON B stated a potential negative outcome for failing to sanitize hands and cross contaminating is the resident could get an infection or worse.<BR/>Resident #73<BR/>Record review of face sheet for Resident #73, dated 10/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: osteomyelitis (bone infection), infection of skin, generalized muscle weakness, major depressive disorder, and anxiety disorder (feeling of fear or worry). <BR/>Review of Resident #73's MDS, dated [DATE] revealed Resident #73 had a BIMS of 14 which indicated the resident's cognition was intact. The MDS revealed Resident #73 had pressure ulcer care, application of ointments/medications, application of non-surgical dressings and a pressure reducing device for the bed.<BR/>Record review of Resident #73's Comprehensive Care Plan, dated 11/28/23 revealed Resident #73 had a pressure ulcer to the right buttock and left hip related to immobility. Approaches include cleansing wounds and applying dressings according to MD orders.<BR/>On 02/07/24 11:10 AM observed wound care for Resident #73 with LVN C. A wound was observed to the resident's right chest. Observed LVN C wash her hands prior to wound care. Supplies were set up on the bedside table with a plastic covering and 4x4's in plastic cup. LVN C donned gloves and began to cleanse the wound with a moistened 4x4 gauze. Observed LVN put dirty 4x4's on the sanitized table with clean supplies after cleansing the wound each time. LVN C continued to put dirty 4x4's on the clean table four additional times during the wound care. LVN C did not sanitize her hands or change gloves at any time during the wound care. LVN C then picked up a clean dressing and applied it to the wound without changing gloves or washing her hands. Observed LVN C wash her hands with soap and water following the procedure.<BR/>On 02/08/24 12:35 PM in an interview with LVN C, she stated the policy for hand sanitizing between glove changes is to sanitize hands with hand sanitizer up to three times after glove changes, then use soap and water. She stated hands should be sanitized every time gloves are changed. She stated the policy to avoid cross contamination of clean supplies and dirty areas is to not put dirty supplies on a clean table near clean supplies. She stated it would be preferable to have a trash bag or trashcan available for dirty supplies. LVN C stated she has been trained on handwashing and infection prevention by the facility nurse educator and nursing administration. She stated training is usually monthly. She stated a potential negative outcome of failing to sanitize hands and cross-contaminating would be infection and sepsis.<BR/>On 02/08/24 01:15 PM in an interview with the ADM he stated hand sanitizing should be done before and after a procedure and every time when changing gloves. He stated the policy during procedures to avoid cross-contamination of clean and dirty areas is to keep clean and dirty items apart and avoid them coming into contact with each other. The ADM said his expectation of staff is to follow hand hygiene policy for all procedures, especially during wound care and perineal care. He stated nursing administration and the corporate nurse educator were responsible for training staff and training is ongoing. He stated a potential negative outcome of failing to practice hand hygiene and infection control is the spread of illness, such as bacteria and viruses, cause people to get sick and possibly cause an outbreak of infection.<BR/>On 02/08/24 01:25 PM in an interview with the DON, she stated hand washing should occur prior to and following a procedure. She stated hand sanitizing using ABHR should occur every time gloves are changed during a procedure. She stated the policy, during a procedure, to avoid cross-contamination of clean and dirty areas and supplies is to separate them and have a bag or trash can to dispose of dirty supplies so the clean supplies don't risk contamination. The DON stated staff are trained quarterly and sometimes monthly on hand hygiene and infection control measures. She stated she is responsible for training staff as well as the facility nurse educator. She stated her expectation from staff for hand hygiene and infection control practices is that they do it properly during procedures and between residents. DON stated a potential negative outcome of failure to sanitize hands and cross-contaminating is a risk of infection.<BR/>Record review of the facility's policy titled Standard Precautions, dated 10/18 (revised) revealed: <BR/>Policy Statement - Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents .<BR/>Standard precautions include the following practices:<BR/>1. Hand hygiene<BR/>a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of<BR/>alcohol-based hand rub (ABHR), which does not require access to water.<BR/>b. Hand hygiene is performed with ABHR or soap and water:<BR/>(I) before and after contact with the resident;<BR/>(2) before performing an aseptic task;<BR/>(3) after contact with items in the resident's room; and<BR/>(4) after removing PPE.<BR/>c. Hands are washed with soap and water whenever:<BR/>(1) visibly soiled with dirt, blood, or body fluids;<BR/>(2) after direct or indirect contact with dirt, blood or body fluids;<BR/>(3) after removing gloves; .<BR/>2. Gloves<BR/>a. Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous<BR/>membranes, non-intact skin, and other potentially infected material.<BR/>one body site to another (when moving from a dirty site to a clean'' one).<BR/>f. Gloves are not to be reused.<BR/>g. Gloves are removed promptly after use, before touching non-contaminated items and environmental<BR/>surfaces, and before going to another resident.<BR/>h. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other<BR/>residents or environments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation and record review, the facility failed to ensure all residents were treated with respect and dignity for 2 of 5 residents (Resident # 4 and Resident # 5) reviewed for dignity.<BR/>CNA N made a video of Resident #5 yelling and cussing and posted it on a social media platform on 11/16/2023.<BR/>Facility sent Resident # 4 to secondary provider day center on 11/21/2023 without a coat, shoes or wearing a bra.<BR/>CNA B and LVN A failed to cover residents during wound care or incontinent care or provide privacy on 11/29/2023. <BR/>This failure placed all residents at risk of psychosocial harm due to a diminished quality of life.<BR/>Finding included:<BR/>During an interview on 11/30/2023 at 5:05 PM, Resident #5's family member stated that family had noticed a video on snapchat that was title Resident #5's first name Chronicles and the video showed a table and in the background, they could hear Resident #5's voice. The family member stated they were not able to see Resident #5 only hear her yelling and cussing. The family member stated they reported the incident to the Administrator and sent the video clip that was posted. The family member stated that in the video they could hear a person laughing. The family member stated someone had posted on the social media pages is that Resident #5's first and last names and CNA N replied yes. The family member stated Resident #5 if she were able to speak and understand, would be upset to have had that video made of her and posted for people to see. The family member stated that Resident #5 was a very private person before her illness and would be upset knowing someone had videoed her demonstrating behaviors out of her control. The family member stated it hurt their feelings knowing CNA N made fun of Resident #5. <BR/>Record review of Resident #5's undated face sheet documented an admit date of 06/23/2023 to the facility secure memory unit, was 56 years with the following diagnoses: Dementia - memory loss, anxiety - worry and fear about everyday situation, Restlessness and agitation - shouting twitching or jerking of the body, Pain - signal that something hurts, Depression -lowering of a person's mood, psychotic disturbance - disconnection from reality, mood disturbance - feeling of distress, Alzheimer's disease with early onset - destroys memory and important mental function, Insomnia - trouble falling or staying asleep. <BR/>Record review of Resident #5's MDS resident quarterly assessment dated [DATE] documented the resident was usually understood, usually understands others, BIMS score of 1 indicating sever impairment, assessment for short term and long-term memory not completed due to Resident #5 was not able to complete BIMS interview, signs of delirium yes for difficulty focusing attention, yes for disorganized thinking rambling or irrelevant conversation. <BR/>During an interview on 11/29/2023 at 4:50 PM, the Administrator stated he received a call from Resident #5's family member who told him about the video, that it was posted on snap chat and someone commented was that Resident #5's first and last named used and CNA N replied yes. The Administrator stated CNA N was terminated same day. The Administrator stated CNA N did admit to making the video and posting the video on social media but did not say why she made the video. The Administrator stated CNA N did not understand the severity of the video posted at that time, however, did understand after she was spoken to. The Administrator stated CNA N did seem somewhat remorseful after the incident. The Administrator was asked if it was appropriate for staff to post a video of the resident, he replied, not at all it is like CNA N was making fun of Resident #5. The Administrator stated CNA N violated the company policy. The Administrator stated this type of conduct was a HIPAA violation, a violation of resident rights. <BR/>During an interview on 11/29/2023 at 5:47 PM, the DON stated during the hiring process for employment staff signed a paper related to HIPAA, to not video or take pictures of residents. The DON stated that HR determined CNA N would be terminated for violation of facility policy and procedures. <BR/>During an interview on 11/29/2023 at 10:44 PM, Resident #5 only answered questions with ok, yes baby, come here little baby, and that man. <BR/>During an interview on 11/30/2023 at 2:41 PM, CNA N stated the following about the video of Resident #5. CNA N was walking down the hall of memory care and Resident #5 was sitting in the dining room cussing. CNA N stated she recorded the table in the dining room and Resident #5 was in the background, but her face was not in the video. CNA N stated she labeled the video as Resident #5 first name Chronicles. CNA N stated a person commented and asked, is that Resident #5 and CNA N replied yes. CNA N stated once again it wasn't Resident #5's face or anything just the table and her cussing in the background. CNA N stated she received a text form the ADON during her lunch break, that she would need to speak with him when she returned from break. CNA N stated, the DON and ADON informed her a family member for Resident #5 had reported her to corporate for the video she had posted on snapchat. CNA N stated the DON informed her corporate determined that was grounds for immediate termination. CNA N stated the DON told her you are not to have your phone out around residents, and it was considered a HIPAA violation. CNA N stated she decided to not make a comment to the facility about the video because she knew she had posted the video and she just left. CNA N stated she knew she signed a paper about code of conduct when hired. <BR/>Record review of Policy and Procedure acknowledgment dated March 2018 documented CNA N signed this form on 07/13/2023, acknowledging employee handbook was available electronically. <BR/>Record Review of employee file for CNA N documented her hire date as 07/12/2023.<BR/>During an interview on 11/30/2023 at 12:40 PM Care Provider for Resident #4 stated when Resident #4 arrived at the day center not wearing a coat, shoes, or a bra. The Care Provider stated the temperature was cold that day, and that was not normal for Resident #4 to be dressed like that. The Care Provider stated that Resident #4 had previously been a client at the day center and was ambulatory however they had an incident at the facility and had not been at the day center for a while. Resident #4 was no longer ambulatory and was using a wheelchair when she returned to the day center for services. <BR/>Record review of Resident #4 undated face sheet documented she was admitted to the facility on [DATE] with the following diagnoses: Intellectual disabilities - below average intelligence, Unsteadiness on feet - balance problems, Pain - signal that something hurts, Depression -lowering of a person's mood, glaucoma - eye pressure, lack of coordination- walking unsteady.<BR/>Record review of Resident #4's MDS quarterly assessment dated [DATE] documented her BIMS score of 3 indicating sever impairment, functional abilities for dressing upper body dressing as 03 indicating partial/moderate assistance, helper dose less than half, lower body dressing as 02 indicating substantial/maximal assistance, helper does more than half, putting on/taking off footwear as 02 indicating substantial/maximal assistance, helper does more than half.<BR/>Record review of Resident #4's care plan dated 11/15/2023 documented: ADL's - Dressing/Grooming amount of assist: limited x 1 assist. <BR/>Behavioral Symptoms Resident has a diagnosis of Intellectual disabilities and resides in the secured unit due to his/her wandering and poor safety awareness. Approaches as - Assure that I have proper fitting and appropriate foot attire.<BR/>During an interview on 11/29/2023 at 4:50 PM, the Administrator stated the CNA's assist Resident #4 with getting dressed to go to the day center. <BR/>During an interview on 11/29/2023 at 5:00 PM, the DON stated the day center called and reported Resident #4 arrived without a coat, shoes, or a bra. The DON stated therapy had assisted the resident to the therapy room that morning for services. That therapy staff assisted Resident #4 to the lobby, and she left on the bus for the day center. The DON stated Resident #4 was not dressed for the day center, she was not wearing a jacket, shoes, or a bra. The DON stated she did an in-service with all staff to ensure residents are dress appropriately when they leave the facility. <BR/>During an observation made on 11/29/2023 at 11:15 AM. Observed Resident #2 lying in bed on back with head of bed elevated. Resident #2 in brief only no shirt or pants. Resident #2 had top sheet lying on left side of body. Resident #2 was nonverbal but able to answer yes and no questions by nodding head. Resident hands are contracted, and resident cannot use hands.<BR/>During an observation made on 11/29/2023 at 11:25 AM. CNA B completed incontinent care and gathered all dirty linen and then left Resident #2 lying flat in bed with only brief on. Resident #2 was uncovered with curtain at end of bed. CNA B left the room with the sack of dirty linen. CNA B pushed door to room all the way open on her way out of the room. CNA B returned to room and pulled curtain &frac12; way on left side of bed. CNA B repositioned Resident #2 and raised head of bed and then covered Resident #2 with a sheet. CNA B went to roommate (Resident #1) side of the room to change Resident #1. Resident #1 was lying on back in bed with only a sheet covering his lower body and curtain was end of bed. CNA B and LVN A performed incontinent care for Resident #1. Resident #1 was repositioned and covered with a sheet. <BR/>During an observation made on 11/29/2023 at 11:57 AM. Observed CNA B and LVN A completing incontinent care for Resident #1. Observed Resident #1's door open and curtains at foot of bed. Residents and staff are visible from the hallway.<BR/>During an observation made on 11/29 at 1:37 PM of Resident #1 with curtain open and door open while Resident #1 was wearing a brief with no shirt or pants on. <BR/>During an interview with DON on 11/29/2023 at 5:00 PM. DON stated that she would expect staff to provide care to all residents in a respectful manner. DON stated that staff should be treating all residents as if it were their own grandmother. DON stated, I am pretty sure that staff have been in-serviced for dignity. DON stated that the negative potential outcome for exposing residents and not being respectful is that it may make them feel bad, unwanted, unworthy, and not good at all. DON stated that for the residents that cannot verbalize how they feel, it may make them feel worse because they are not able to express how it is making them feel and are not able to change the outcome. DON stated that staff should treat all residents just as they would treat all the other residents, the same, with respect and provide proper care.<BR/>During an interview with Family Member of Resident #1 on 11/30/2023 at 12:30 PM. Family Member stated that Resident #1 has no ability to answer questions. Family Member stated Resident #1 would be upset and feel violated if he knew he was being exposed to other during incontinent care or wound care. Family Member stated Resident #1 would want privacy. Family Member stated Resident #1 has no ability to use the call light. Family Member stated he depends on staff for all his care.<BR/>During an interview with CNA B on 11/30/2023 at 12:32 PM. CNA B stated that the policy for providing privacy for residents is to pull the curtain and close the door. CNA B stated that by not providing privacy to a resident that it could embarrass them, It would embarrass me, personally. CNA B stated, It is a dignity issue. CNA B stated that the facility has provided in-services for providing privacy such as pulling the curtains and shutting the door and stuff like that. CNA B stated that she does not remember when she had been in-serviced last on dignity. CNA B stated that the negative potential outcome for not providing privacy is that it is a violation of the resident's privacy and their right to have privacy. CNA B stated it may make the resident feel like they do not want to be seen in that way by others or what exactly is going on with their care. CNA B stated, It is a violation of their rights and privacy.<BR/>During an interview with LVN A on 11/30/2023 at 1:11 PM. LVN A stated that the negative potential outcome for not providing privacy to a resident is it could cause emotional distress and negative effects mentally to the resident. LVN A stated that she has been trained in dignity by the means of in-services. LVN A stated that the in-services are usually provided monthly. LVN A stated that she thought that she had provided privacy but was nervous and was not positive but stated that she will do better next time. <BR/>During an interview with Family Member of Resident #2 on 11/30/2023 at 3:22PM. Family Member stated Resident #2 is non-verbal and can answer simple yes and no questions by nodding his head. Family Member stated was not sure if Resident #2 would understand questioning about being exposed during care. Family Member stated if Resident #2 knew he was exposed during incontinent care or wound care Resident #2 would feel bad and violated if he was in his right mind. Family Member stated Resident #2 was a very private person. Family Member stated is not sure if Resident #2 would be able to use the call light. Family Member stated there has never been a call light in Resident #2'a room. Family Member stated Resident #2 depends on staff for all his care. <BR/>Record review of the facility in-service dated 11/09/2023 titled resident personal care, 30 staff members signed. <BR/>Record review of the facility Dignity policy dated revised February 2021:<BR/>Policy Statement:<BR/>Each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, and feeling of self-worth and self-esteem.<BR/>Policy Interpretation and Implementation<BR/>1. Residents are treated with dignity and respect at all times. <BR/>Record review of facility in-service dated 11/16/2023, Titled social media documented: Employees will not record residents without permission, or post on any social media sites. Policy to be reviewed and staff to sign, this is grounds for immediate termination. Signatures of 41 staff members were documented on the in-service. <BR/>Record review of facility policy Cell Phones dated revision date December 2019:<BR/>Policy Statement<BR/>Unless approved for facility business, the possession and use of cellular phones, pagers and other portable communication devices is strictly prohibited while on duty, except during an employee's scheduled break period.<BR/>Policy Interpretation and Implementation<BR/>1. Use of these devices will be restricted to the employee break room or outside of the facility.<BR/>2. Photographing, videoing and/or recording of any resident, visitor, employee and/or the facility is strictly prohibited under all circumstances. Should any such activity be necessary, it must first be approved and cleared by Senior Living Properties, LLC legal counsel.<BR/>3. Violations of this policy will be considered a Resident Rights Violation and a HIPAA Violation. The Facility Abuse Prohibition Coordinator will notify the appropriate state and/or local agencies should a violation occur.<BR/>4. While on duty, these devices will be stored in the employee's locker, purse/backpack, or vehicle. If purses/backpacks are stored in a work area, these devices must be turned off.<BR/>5. Failure to adhere to this policy will result in disciplinary action, up to and including termination of employment.<BR/>Record Review of facility provided policy labeled, Confidentiality of Information and Personal Privacy, date revised in October 2017, revealed.<BR/>Policy Statement:<BR/>Our facility will protect and safeguard resident confidentiality and personal privacy. <BR/>Policy Interpretation and Implementation:<BR/>2. The facility will strive t protect the resident's privacy regarding his or her: a). accommodations, b). medical treatments, d). personal care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and/or record review the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of new pressure ulcers/injuries for 2 of 3 residents (Resident #1 and Resident #2) reviewed for pressure injuries, in that:<BR/>1. <BR/> LVN A failed to implement proper wound care techniques and implement adequate infection control practices to promote wound healing during observation of wound care on 11/29/2023.<BR/>2. <BR/>LVN A failed to follow orders for wounds for providing wound care for Resident #1 and Resident #2, leaving wounds open to air and exposed to bacteria and possible infection. <BR/>3. <BR/>Facility staff failed to treat and cover wounds for Resident #1 and Resident #2<BR/>4. <BR/>Facility failed to follow doctors' orders of providing a wound culture (is a test to find germs such as bacteria, a virus, or a fungus that can cause an infection) for Resident #1<BR/>This failure could cause resident wounds to worsen, spread of infection, loss of limb, and possible sepsis leading to death.<BR/>This failure was determined to be an Immediate Jeopardy situation that was identified on 12/01//2023 at 12:00 p.m. While the IJ was removed on 12/01/2023 at 8:15 pm, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>The findings included:<BR/>Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: acute respiratory failure - difficult to breath on your own, quadriplegia - paralysis of all four limbs, tracheostomy - an opening in the windpipe from outside of the neck to help oxygen reach the lungs, contracture to left ankle - inability to move foot to a neutral position, contracture to right knee - can no longer move is stiff, contracture to right ankle - inability to move foot to a neutral position, abnormalities of gait and mobility -unable to walk in typical way, obstructive and reflux uropathy - urine cannot drain through the urinary tract, rash and other nonspecific skin eruption - skin reaction to an irritant, urinary calculus - solid particles in the urinary system, pain - mild to severe discomfort, pressure ulcer of other site (unstageable) - sore on a specific area of skin from pressure resulting in the lack of blood flow and oxygen to tissue, muscle weakness - lack of muscle strength, unspecified disorder of eye and adnexa - eye and surrounding structure disorder, acid reflux - stomach acid or bile irritating the stomach lining , muscle spasms - involuntary movement, cardiac arrhythmias - improper beating of the heart, vitamin Deficiency - too little of one or more vitamin, hypokalemia - low blood level, dysphagia - difficulty speaking, hypoxemia - low level of oxygen in the blood, persistent vegetative state - a person shows no sign of awareness, cognitive communication deficit - difficulty with thinking, chronic respiratory failure shortness of breath, diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving - brain dysfunction trauma to the brain. <BR/>Record review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was left blank and incomplete. <BR/>Record Review of Resident #1 Annual MDS dated [DATE] revealed: On the section for risk of pressure ulcers/injuries indicated Resident #1 is at risk for pressure ulcers. On the section under skin conditions: Current number of unhealed pressure ulcers/ Injuries at each stage was left blank and not complete. <BR/>Record Review of Resident #1 Care Plan dated 11/22/2018 revealed Resident #1 had a pressure ulcer and states Resident #1 was not as mobile as he used to be, his skin is fragile and he is at risk for skin tears, bruising, pressure wounds with interventions of monitor for signs and symptoms of skin breakdown or bruising, notify doctor of any skin breakdown or bruising, may wear boots for preventions per family request, Resident #1 has contractures and was unable to float heels, wound care as ordered. Resident #1 needs assist bars for psychological comfort and to establish bed boundaries. Resident #1 needs help from staff with turning and uses his assist bars for some repositioning with interventions of: assist bar will be reviewed at least quarterly to ensure they are still needed, check on and reposition when giving care and prn, staff to ensure that assist bars are up X 2/4 and secured when in bed, treat with respect and dignity. Resident #1 had urinary incontinence with interventions of: motor and report red areas noted, provide cheerful dialogue while cleansing to encourage and maintain self-esteem, provide incontinent care every 2 hours and as toileting pattern indicates. Resident #1 had ADLs functional status/rehabilitation potential with the interventions of: consistent approach amongst caregivers, monitor for presence of pain/intolerance during self-care, provide adequate rest periods between activities, report a further deterioration in status to physician. Resident #1 had a self-care deficit with traumatic brain injury. Resident #1 requires total assistance with ADLs with interventions of may utilize Geri chair (a large padded chair that is designed to help seniors with limited mobility) to get out of bed, provide assistance x2 with bathing/showering three times a week, incontinent of bowel and requires x 2 assist with peri-care, requires x1 assist with dressing, requires x1 assist with eating, Resident #1 has enteral feedings, requires x2 assist with bathing. Requires x2 toileting, requires x2 assist with transfers, requires x2 assist with transfers with lift, requires x2 assist with bed mobility, turn, and reposition x2 assist every 2 hours. Resident #1 had interventions in place for weekly head to toe skin check. Resident #1 had a pressure ulcer to right buttocks with immobilization with interventions of; apply dressings as doctor ordered: clean, apply Santyl and calcium alginate and foam dressing, assess pressure ulcer for staged, size, (length, width, and depth), presence/absence of granulation tissue and epithelialization,(development of new epidermis and granulation tissue. Granulation tissue is new connective tissue with new, fragile, thin-walled capillaries) and condition of surrounding skin daily, conduct a systematic skin inspection weekly, report any signs of any further skin breakdown, keep clean and dry as possible, minimize skin exposure to moisture. Resident #1 had a pressure ulcer on left upper back with immobilization with interventions of: apply dressing per doctor orders, clean, apply Santyl and calcium alginate and foam dressing daily to left upper back, assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin every day. Keep clean and dry as possible, minimize skin exposure to moisture, keep linens clean, dry as possible, minimize skin exposure to moisture, keep linens clean, dry, and wrinkle free, keep resident off left upper back. <BR/>Record Review of Resident #2's face sheet documented he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 was admitted with a diagnosis which includes: post-traumatic seizures - occurs after head trauma, quadriplegia - paralysis of all four limbs, unspecified injury of right foot - injury or damage to body part, tachycardia - rapid or irregular heartbeat, elevation of liver transaminase levels - abdominal pain or swelling , hyperosmolality and hypernatremia - electrolyte problems, granulomatous disorder of the skin and subcutaneous tissue - raised bumps under skin, non-pressure chronic ulcer of skin of other sites with fat layer exposed - open area of skin, seborrheic dermatitis - scaly red patches of skin, muscle spasms - involuntary movement, pain - mild to severe discomfort, hypokalemia - low blood level, contracture right hip - shortening or hardening of muscles, contracture left hip - shortening or hardening of muscles, contracture right knee - shortening or hardening of muscles, contracture left knee - shortening or hardening of muscles, contracture right and left ankle - shortening or hardening of muscles, muscle wasting and atrophy - wasting of muscle, generalized muscle weakness - decreased in strength, acid reflux - stomach acid or bile irritating the stomach lining, contracture of right wrist - shortening or hardening of muscles, concussion with loss of consciousness - injury caused by head trauma, persistent vegetative state - no sign of awareness, personal history of traumatic brain injury - brain trauma , tracheostomy - an opening in the windpipe from outside of the neck to help oxygen reach the lungs, gastrostomy - an opening into the stomach from the abdominal wall, made surgically for the introduction of food. <BR/>Record review of Resident #2's Annual Minimum Data Set (MDS) dated [DATE] documented that Resident #2's BIMS (Brief Interview for Mental Status) was left blank and incomplete. <BR/>Record Review of Resident #2 Annual MDS (Minimum Data Set) dated 11/06/2023 revealed that Resident #2 was listed as a risk of pressure ulcers. On the section under unhealed pressure ulcer/injuries is listed as Resident #2 does not have any pressure ulcers when he does have pressure injuries. <BR/>Record Review of Resident #2 Care Plan dated 11/15/2023 revealed Resident #2 had a risk for pressure ulcers due to impaired sensory perception. Resident #2 is at risk for skin breakdown as evidenced by contractures, moisture/excessive perspiration, nutritional concerns, limited mobility, incontinence with interventions of; consider specialty mattress or bed, elevate heels, and use protectors as able, skin assessment and inspection every shift with close attention to heels, use pillows between knees and bony prominences to avoid direct contact. Resident #2 had a risk for pressure ulcer due to moisture, has MASD to left groin with interventions of assess for other moisture problem areas such as in skin folds, avoid hot water, use mild soap and soft cloths or packaged cleanser wipes, check incontinence pads frequently (every 2-3 hours) and change as needed, moisture dry unbroken skin, skin assessment and inspection every shift with close attention to heels, use moisture barrier ointments (protective skin barriers), wound care as ordered. Resident #2 had a risk for pressure ulcer due to bedfast/mobility with interventions of Braden scale as needed and quarterly, consider specialty bed, elevate heels off bed or use heel protectors, notify doctor and resident representatives of any skin issues, position prone if appropriate or elevate head of bed no more than 30 degrees, position with pillows to elevate pressure points off the bed, pressure reducing mattress, skin assessment weekly, skin inspection each incontinent episode and during bath, report changes to charge nurse, turn and reposition every 2 to 3 hours and as needed. Resident #2 had a risk for pressure ulcer due to friction and shear with interventions of: minimum of 2 people plus draw sheet to lift resident while in bed, skin assessment and inspection every shift with close attention to heels. Resident #2 needed assistance for psychological comfort and to establish bed boundaries. Resident #2 required assistance from staff for repositioning with interventions of: assist bar will be reviewed at least quarterly, to ensure they are still needed, check on and reposition when giving care and as needed, staff to ensure that assist bars are up X1/4 and secured when in bed, treat with respect and dignity. Resident #2 had urinary incontinence with interventions of: monitor and report red areas noted, provide cheerful dialogue while cleansing to encourage maintained self-esteem, provide incontinent care every two hours and as voiding pattern indicates. Resident #2 required assistance with ADLs and is unable to perform any on his own with interventions of: may use Geri chair (a large padded chair that is designed to help seniors with limited mobility) to enable getting out of bed, provide assistance x2 with bathing/showering three times a week, incontinent of bowel and bladder and requires x 2 assist with peri-care, requires x1 assist with dressing, requires x 1 with eating and has enteral feedings, requires x 2 assist with bathing, requires x 2 assist with toileting, requires x 2 assist with transfers, requires x 2 assist with bed mobility, turn and reposition x 2 every 2 hours. Resident #2 had interventions in place for weekly head to toe skin check (Licensed Nurse). Resident #2 had non-healing surgical wound with previous gastrostomy with interventions of: assess condition of surrounding skin, report emergencies of skin excoriation, dressing changes per physician order, observe and report signs of localized infection, pain, redness, swelling, tenderness, loss of function, heat at the infected area. Observe and report signs of sepsis (fever, lassitude, or malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting, diarrhea, headache, lymph node), record the amount, type, consistency, color, and odor of drainage from the wound. Record the location (size, length, width, and depth), color, and presence/absence of granulation tissue and epithelization of surgical wound. Use principles of infection control and universal/standard precautions.<BR/> Resident #2 had chronic wound to left groin with interventions of need protectors/float heels, pain medication as needed for comfort, re-evaluation for improvement in 14 days, supplements as ordered, treatments and medication as ordered. Resident #2 had pressure ulcer left four toes with interventions of apply dressing per doctor order: clean, calcium alginate, cover with foam dressing. Assess resident for pain related to pressure ulcer or its treatment. Prevent or treat pain by keeping foot in boot. Conduct a systematic skin inspection daily, report any signs of any further skin worsening. Keep clean and dry as possible. Minimize skin exposure to moisture, keep resident off toes. Reduce friction injuries by using protective boots. Use protective boot to relieve pressure on the heels. Resident #2 had infection of the foot with interventions of assess and record if resident's feet are desensitized to pain and/or pressure. <BR/>During an Observation of Resident #2 on 11/29/2023 at 11:15 AM. Observed Resident #2 lying in bed on back with head of bed elevated. Resident #2 was in a brief only, no shirt or pants. Resident #2 has top sheet lying on left side of body. Resident #2 is nonverbal but able to answer yes and no questions by nodding head or blinking eyes. Resident #2's left foot moving up and down on bed. Observed Resident #2 with four toes bloody with no skin on ends of toes. Observed Resident #2's pinkie toe with dime size scab to top and side of toe. Resident #2 had the sheet under foot had blood. There was blood on right lower leg and heel. Observed Resident #2's call light on the floor at head of bed. Resident #2's hands are contracted, and resident cannot use hands.<BR/>During an observation and interview with CNA B on 11/29/2023 beginning at 11:25 AM. CNA B stated she went in room to change Resident #2, the roommate to Resident #1. CNA B went to check on Resident #2 and noticed blood on sheet and Resident #2's' toes. CNA B stated she last worked on Sunday and Resident #2's toes were not like that. CNA B stated she had never seen his toes like that. CNA B stated she does not know what happened or when it happened. CNA B stated she came on shift at 06:30 AM and took a break at 10:00 AM and does not remember seeing his foot like that. CNA B stated the wound nurse made rounds that morning (12/01/2023). CNA B stated Resident #2 was not able to use a regular call light. CNA B stated Resident #2 might be able to use a pressure pad call light, but he probably would not use that either. CNA B stated Resident #2 has wound to his Left groin. During incontinent care surveyor attempted to observe wound to left groin but Resident #2 refused to relax his leg. Left groin with thick bloody drainage. Surveyors were unable to see wound. CNA B stated she was told it was from the use of briefs rubbing leg due to Resident #2 constantly moving leg. CNA B stated there was an ABD pad in groin and she removed ABD pad. Observed minimal bloody drainage on ABD pad. Resident #2 had old pressure wound to buttocks that had been healed. Resident #2's crack to buttocks was red no open areas noted. Resident #2 had open area to right hip the size and shape of a black-eyed pea. Resident #2 wound not covered, no drainage wound bed pink. Resident #2 had a dried gauze to lower abdomen with an unknown substance on it. The gauze was tinted yellow and pink. CNA B stated she was not sure where that came from. Resident #2 had strong body odor smell. CNA B gathered all dirty linen and left resident lying flat in bed with only brief on. Resident was uncovered with curtain at end of bed. CNA B left the room with the sack of dirty linen. CNA B pushed door to room all the way open on her way out of the room. CNA B returned to room and pulled curtain &frac12; way on left side of bed. CNA B repositioned Resident #2 and raised head of bed and covered resident with a sheet. CNA B went to Resident #1 to change resident. Observed Resident #1 lying on back in bed with only a sheet covering his lower body and curtain was end of bed. Resident #1 right foot was hanging off the left side of the bed. CNA B and LVN A performed incontinent care for Resident #1. Resident #1 had pressure ulcer to right buttock open to air, bloody drainage noted to bed pad. Resident had wound to coccyx covered with foam dressing with date 11-28-23. LVN A stated she had not done wound care for resident today. She stated his wound care was daily. Resident #1 turned to right side. Observed Resident #1 had large area to left bottom shoulder blade. LVN A stated 2 weeks ago resident had a scratch there from his lift and now he had that. LVN A stated, I just don't see how a scratch turned to this. LVN A stated Resident #1 had been on an air mattress since she went to work there. Resident #1 with a wound to left lower shoulder blade upper circle covered in black eschar, yellowish green below the black and large red beefy area below that. Bloody drainage noted on bed pad, left open and not covered. When resident was turned to right there was a strong foul odor coming from the wound. The wound was open to air. CNA B placed gloved hand on open wound several times during incontinent care. Resident #1 has small black eyed pea size wound to left hip. Open to air. No drainage noted. Wound bed is pink. CNA B and LVN A repositioned Resident #1 and covered with a sheet. <BR/>During an interview with LVN A on 11/29/2023 at 12:24 PM. LVN A stated she did not have any orders for dressing for Resident #2. LVN A stated she text (wound nurse) again to check on orders. <BR/>During an observation of Resident #2. Observed Resident #2 on 11/29/2023 at 1:40 PM left foot wrapped with foam gauze and secured with tegaderm due to resident constant movement of foot. <BR/>During an observation for wound care for Resident #1 on 11/29/2023 at 1:55 PM provided by LVN A assisted by CNA B. LVN A stated she did do the wound care for Resident #1. LVN A stated she placed alginate to wound bed, covered with foam dressing and covered with tegaderm due to Resident #1's constant foot movement. LVN A stated she did not measure wounds. LVN A gathered wound supplies and placed on bedside table. No observation of BST being sanitized and no barrier. LVN A changed gloves. No observation of hand washing or ABHR. LVN A donned gloves and placed saline in 3 cups. LVN A then placed gauze in all 3 cups. LVN A placed Santyl in medicine cup. LVN A placed all supplies on foot of resident's bed on used bed pad. LVN A removed old dressing to coccyx using a q-tip. LVN A placed old dressing on bed pad behind resident she cleaned wound with normal saline and gauze. LVN A cleaned out to inner wound. LVN A then opened calcium alginate packed and placed on bed pad beside dirty gauze and old dressing. LVN A tore off small piece and placed inside of wound. She covered wound with foam dressing. Resident #1 wounds were measured as listed: right buttocks: 3.5 width x 3.5 and superficial. Wound shows to have grown from what is documented. Resident #1 back shoulder is measuring: 5 x 5.5 from length to width and the depth is 1.25. As per documentation it shows that the wound on the shoulder has also grown in a week. Resident #1's coccyx wound is measuring to be: 1.5 cm in length, 2.5 cm in width, and 1.0 in depth, which indicate the wound has grown since last week. LVN A cleaned bottom cheek wound from [NAME] to enter. LVN A placed used gauze on bed pad behind Resident #1. LVN A applied Santyl to wound bed with q-tip. LVN A used calcium alginate from package laying in pile of used gauze and covered wound. LVN A covered with foams dressing. LVN A dated and initialed dressing and removed gloves. LVN A removed gloves. LVN A turned Resident #1 on right side. Observed Resident #1 left shoulder wound uncovered with brownish discharge on bed pad and foul odor from wound. Resident #1 shoulder wound measured 5cmX5 &frac12; cm X 1 &frac14; cm. LVN A cleaned wound from outer to inner wound. LVN A applied Santyl to wound bed and covered with calcium alginate and foam dressing. LVN A gathered trash and removed gloves and repositioned Resident #1. LVN A grabbed suction and dropped it on the floor and then picked up the tubing and placed it in the trash. Observed no additional tubing in the drawer. LVN A removed gloves and exited the room to go get more supplies. No observation of hand washing. LVN A returned to the room. LVN A donned gloves and suctioned Resident #1's trach and change residents inner canula. LVN A repositioned Resident #1 and doffed gloves. LVN A cleaned BST placing unused supplies in box on BST. LVN A washed hands. LVN A stated Resident #1 was not able to rub dressing off his shoulder. LVN A stated the only movement Resident #1 does was when he coughs, and he moves his legs. LVN A stated the only way it could be rubbed off was when staff turn Resident #1. LVN A stated the pressure ulcer to left hip had no orders. LVN A was told to leave it open to air and monitor it. Observed pressure ulcer to left hip was black eyed pea size and shape and the wound bed was superficial and pink. No observation of hand washing or ABHR during glove changes during wound care. No observation of glove changed when going from dirty to clean.<BR/>During an Interview with CNA B on 11/29/2023 at 2:10 PM. CNA B stated if the dressing comes off a wound, she would notify the nurse. CNA B stated when Resident #1's family visited the other day, CNA B had showered Resident #1 and his family member had noticed the wounds on Resident #1's shoulder and bottom. CNA B stated she covered wound with a dressing and notified the charge nurse. CNA B stated the family member went to DON to complain about the wounds. CNA B stated the DON told her she was not allowed to cover any wounds.<BR/>During an interview with the DON on 11/29/2023 at 4:19 PM. DON stated she did a skin sweep last Friday and passed out shower sheets for staff to use. DON stated the staff have not been completing the shower sheets. DON stated she does not have any shower sheets to provide for evidence of shower sheets being completed. <BR/>During an Interview with LVN A for infection control practices on 11/30/2023 at12:50 PM. LVN A stated that she had been trained in infection control practices. LVN A stated that she has had in-services for infection control practices. LVN A stated that the facility will do verbal refreshers with the staff randomly by just walking up to them and asking random infection control questions. LVN A stated that the facility does provide in-services and they are approximately monthly. LVN A stated that they will also go over infection control in the monthly meeting and that was covered by the Administrator and the DON. LVN A stated that they just had skills check for hand washing at the beginning of the month. LVN A stated that the Nurse Educator was the one who oversaw the skills check. LVN A stated that she did not learn to use a dirty paper towel to turn off the faucet at this particular facility, but she did learn to do that when she worked at another facility. LVN A stated that it was a mistake that she should not have made. LVN A stated that the negative potential outcome for not using proper infection control practices is cross contamination, potential infection, exposure to bacteria. LVN A stated that when she was cleaning the wound for Resident #1, she did not drag, she used a half-moon one swipe method and she started from furthest away from the wound working her way to the wound so that she would not bring anything from outside of the wound to the inside of the wound. LVN A stated that her thought process is to get everything outside of the wound cleaned so that she did not contaminate the wound itself. LVN A stated that she has never been trained in wound care by the facility, she just tried to use her best judgement. LVN A stated that the Nurse Educator will train in wound care if needed but just has not gotten to it yet. LVN A stated that the negative potential outcome for improperly cleaning a wound could be cross contamination, sepsis, further wound damage, or worse infection. <BR/>During an interview on 11/30/2023 at 1:36 PM, NP M stated she saw Resident #2 on 11/29/2023, around 7:15 AM and saw the wounds on his toes. She stated the wounds on his toes looked fresh and she notified LVN A. She stated, LVN A had walked off when she was doing the assessment on Resident #2. She stated she can do the wound care but cannot cover the wounds. She stated she told LVN A that it would be okay until she could get it covered with a bandage, because she did not have a bandage available at the time, she was doing the assessment. NP M stated she would have expected the wounds to be covered before 12:26 PM. <BR/>During an interview on 11/30/2023 at 1:36 PM, NP M stated this is her second week for seeing Resident #1. She stated Resident #1's wounds developed over a period of a few days is how she understood it. She stated some of them were significant wounds, she debrided his shoulder wound and stated, that was the worst one. She stated, I ordered a culture of Resident #1's shoulder, and it came back positive, and Resident #1 was started on Levaquin (an antibiotic that is used to treat bacterial infections), this medication was used to treat a respiratory infection and wound. NP M stated the wound did have an odor when she saw it on 11/29/23. She stated she has taken care of Resident #1 one time before with his heel and that was the only pressure injury he had had. NP M stated those are true pressure injuries on bony points. She states she does not know if they could have been prevented.<BR/>During an interview with DON on 11/30/2023 at 3:56 PM. DON stated there was no wound culture done for left shoulder wound on Resident #1. DON stated the only culture done was a sputum culture (test to detect and identify bacteria or fungi that infects the lungs or breathing passages) from Resident #1 trach on 11/22/2023.<BR/>During an Interview with NP M on 11/30/2023 at 4:24 PM. FNP stated she spoke with LVN A, and she stated the culture did come back and Resident #1 was started on Levaquin(an antibiotic that is used to treat bacterial infections). NP M stated it was good that Levaquin covered both cultures.<BR/>Record Review of facility provided policy labeled, Wound Care, date revised in June 2022, revealed.<BR/>Purpose:<BR/>The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. <BR/>Preparation:<BR/>1. Verify that there is a physician's order for the procedure. <BR/>2. Review the resident's care plan to assess for any special needs for the resident. A). For example, the resident may have PRN orders for pain medication to be administered prior to wound care. <BR/>3. Assemble the equipment and supplies as needed. Date and initialed all bottles and jars upon opening. <BR/>Equipment and Supplies:<BR/>The following equipment and supplies will be necessary when performing this procedure.<BR/>1. Dressing material, as indicated.<BR/>2. Disposable cloths, as indicated. <BR/>3. Antiseptic (as ordered).<BR/>4. Personal Protective Equipment<BR/>Steps in the Procedure:<BR/>1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached.<BR/>2. Perform hand hygiene. <BR/>3. Position Resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. <BR/>4. Put on clean gloves. Loosens tape and remove dressing. <BR/>5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. <BR/>6. Put on clean gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. <BR/>7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. <BR/>8. Pour liquid solutions directly or gauze sponges on their papers. <BR/>9. Wash wound in a circular motion from the inside out with ordered wound cleanse. Use additional gauze and repeat as needed with fresh gauze each time. <BR/>10. Apply treatments and dress wound as ordered by physician. <BR/>11. [NAME] tape with initials, time, and date and apply to dressing. <BR/>12. Remove the disposable cloth next to the resident and discard into the designated container. <BR/>13. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Perform hand hygiene. <BR/>14. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed. <BR/>15. Place the call light within easy reach of the resident. <BR/>16. Sanitize overbed table. <BR/>17. Return the overbed table to its proper position. <BR/>18. Sanitize scissors. <BR/>19. Perform hand hyge3eine. <BR/>20. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room.<BR/>Documentation:<BR/>The following information should be recorded in the resident's medical record. <BR/>1. The type of wound care given. <BR/>2. The date and time the wound care was given. <BR/>3. The name and title of the individual performing the wound care.<BR/>4. Any change in the resident's condition. <BR/>5. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. <BR/>6. Assess the resident for pain and medicate as ordered. <BR/>7. Any problems or complaints made by the resident related to the procedure. <BR/>8. If the resident refused the treatment and the reasons why. <BR/>9. The signature and site of the person recording the data. <BR/>Reporting:<BR/>1. Notify the supervisor if the resident refuses the wound care. <BR/>2. Report other information in accordance with center policy and professional standards of practice. <BR/>Record Review of facility provided wound log for Resident #1, labeled, Facility Wound Summary Report, dated 11/22/2023, revealed:<BR/>It [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #66 an #73) and 2 of 2 (ADON B AND LVN C) staff reviewed for infection control. <BR/>1. ADON B failed to perform hand hygiene between glove changes when providing wound care for Resident #66 <BR/>2. LVN C failed to perform hand hygiene between glove changes when providing wound care for Resident #73. <BR/>3. LVN C failed to keep dirty and clean supplies separated when providing wound care for Resident # 73.<BR/>These failures could place residents at risk for spread of infection and cross contamination. <BR/>Findings include:<BR/>Resident #66<BR/>Record review of face sheet for Resident #66 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: symptomatic epilepsy (seizure disorder), hyperlipidemia (high levels of fat particles in the blood), alcohol abuse, hypertension (high blood pressure) and diabetes (high blood sugar). <BR/>Review of Resident #66's MDS, dated [DATE] revealed Resident #66 had a BIMS of 09 which indicated the resident's cognition was moderately impaired. The MDS revealed Resident #66 was at risk of developing pressure ulcers and a pressure reducing device was used for the bed.<BR/>Record review of Resident #66's Comprehensive Care Plan, dated 02/01/24 revealed the resident was at risk for skin breakdown with approaches to follow skin care protocol and to immediately report any skin breakdown to charge nurse.<BR/>On 02/07/24 04:08 PM observed wound care of the coccyx, right lower buttock and both lower extremities on Resident # 66 with ADON B. Observed ADON B changing gloves several times during wound care but did not sanitize hands between glove changes. ADON B finished cleansing the wound with 4x4 gauze and changed gloves, then proceeded to apply a clean dressing to the wound without sanitizing his hands. No hand sanitizer was available on the table of supplies during wound care. ADON B moved to a wound on the resident's right lower buttock and washed his hands with soap and water prior to beginning wound care. Again, ADON B changed gloves several times during wound care for the buttock wound, cleansing with a 4x4 gauze. ADON B did not sanitize his hands at any point during the wound care when gloves were changed, including prior to applying the clean dressing to the wound. ADON B then moved to perform the lower extremity wound care. Observed ADON B cleanse the wounds to the lower legs with a 4x4 gauze, apply Vaseline gauze, padding and wrapped lower legs with a gauze then secured with tape. ADON B changed gloves multiple times during wound care of the lower legs, but did not sanitize his hands between glove changes, including between dirty and clean parts of the wound care and when applying a clean dressing to the legs. Observed ADON B wash his hands with soap and water after completing the wound care procedure. <BR/>On 02/08/24 12:50 PM in an interview with ADON B, he stated the policy for hand sanitizing with glove changes was to wash hands with soap and water prior to gloving and again after the procedure is complete, then use hand sanitizer each time in between, with every glove change. He stated he has been trained on hand sanitizing and infection control every couple of months by the facility nurse educator or the DON. ADON B stated a potential negative outcome for failing to sanitize hands and cross contaminating is the resident could get an infection or worse.<BR/>Resident #73<BR/>Record review of face sheet for Resident #73, dated 10/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: osteomyelitis (bone infection), infection of skin, generalized muscle weakness, major depressive disorder, and anxiety disorder (feeling of fear or worry). <BR/>Review of Resident #73's MDS, dated [DATE] revealed Resident #73 had a BIMS of 14 which indicated the resident's cognition was intact. The MDS revealed Resident #73 had pressure ulcer care, application of ointments/medications, application of non-surgical dressings and a pressure reducing device for the bed.<BR/>Record review of Resident #73's Comprehensive Care Plan, dated 11/28/23 revealed Resident #73 had a pressure ulcer to the right buttock and left hip related to immobility. Approaches include cleansing wounds and applying dressings according to MD orders.<BR/>On 02/07/24 11:10 AM observed wound care for Resident #73 with LVN C. A wound was observed to the resident's right chest. Observed LVN C wash her hands prior to wound care. Supplies were set up on the bedside table with a plastic covering and 4x4's in plastic cup. LVN C donned gloves and began to cleanse the wound with a moistened 4x4 gauze. Observed LVN put dirty 4x4's on the sanitized table with clean supplies after cleansing the wound each time. LVN C continued to put dirty 4x4's on the clean table four additional times during the wound care. LVN C did not sanitize her hands or change gloves at any time during the wound care. LVN C then picked up a clean dressing and applied it to the wound without changing gloves or washing her hands. Observed LVN C wash her hands with soap and water following the procedure.<BR/>On 02/08/24 12:35 PM in an interview with LVN C, she stated the policy for hand sanitizing between glove changes is to sanitize hands with hand sanitizer up to three times after glove changes, then use soap and water. She stated hands should be sanitized every time gloves are changed. She stated the policy to avoid cross contamination of clean supplies and dirty areas is to not put dirty supplies on a clean table near clean supplies. She stated it would be preferable to have a trash bag or trashcan available for dirty supplies. LVN C stated she has been trained on handwashing and infection prevention by the facility nurse educator and nursing administration. She stated training is usually monthly. She stated a potential negative outcome of failing to sanitize hands and cross-contaminating would be infection and sepsis.<BR/>On 02/08/24 01:15 PM in an interview with the ADM he stated hand sanitizing should be done before and after a procedure and every time when changing gloves. He stated the policy during procedures to avoid cross-contamination of clean and dirty areas is to keep clean and dirty items apart and avoid them coming into contact with each other. The ADM said his expectation of staff is to follow hand hygiene policy for all procedures, especially during wound care and perineal care. He stated nursing administration and the corporate nurse educator were responsible for training staff and training is ongoing. He stated a potential negative outcome of failing to practice hand hygiene and infection control is the spread of illness, such as bacteria and viruses, cause people to get sick and possibly cause an outbreak of infection.<BR/>On 02/08/24 01:25 PM in an interview with the DON, she stated hand washing should occur prior to and following a procedure. She stated hand sanitizing using ABHR should occur every time gloves are changed during a procedure. She stated the policy, during a procedure, to avoid cross-contamination of clean and dirty areas and supplies is to separate them and have a bag or trash can to dispose of dirty supplies so the clean supplies don't risk contamination. The DON stated staff are trained quarterly and sometimes monthly on hand hygiene and infection control measures. She stated she is responsible for training staff as well as the facility nurse educator. She stated her expectation from staff for hand hygiene and infection control practices is that they do it properly during procedures and between residents. DON stated a potential negative outcome of failure to sanitize hands and cross-contaminating is a risk of infection.<BR/>Record review of the facility's policy titled Standard Precautions, dated 10/18 (revised) revealed: <BR/>Policy Statement - Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents .<BR/>Standard precautions include the following practices:<BR/>1. Hand hygiene<BR/>a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of<BR/>alcohol-based hand rub (ABHR), which does not require access to water.<BR/>b. Hand hygiene is performed with ABHR or soap and water:<BR/>(I) before and after contact with the resident;<BR/>(2) before performing an aseptic task;<BR/>(3) after contact with items in the resident's room; and<BR/>(4) after removing PPE.<BR/>c. Hands are washed with soap and water whenever:<BR/>(1) visibly soiled with dirt, blood, or body fluids;<BR/>(2) after direct or indirect contact with dirt, blood or body fluids;<BR/>(3) after removing gloves; .<BR/>2. Gloves<BR/>a. Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous<BR/>membranes, non-intact skin, and other potentially infected material.<BR/>one body site to another (when moving from a dirty site to a clean'' one).<BR/>f. Gloves are not to be reused.<BR/>g. Gloves are removed promptly after use, before touching non-contaminated items and environmental<BR/>surfaces, and before going to another resident.<BR/>h. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other<BR/>residents or environments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #1 and #3) of 6 residents reviewed. <BR/>The facility failed to implement a baseline care plan that included the minimum healthcare information necessary to properly care for Resident #1 and Resident #3.<BR/>This failure could place newly admitted residents at risk for insufficient immediate care needs for the resident being met and maintained.<BR/>Findings Included:<BR/>Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Cerebral vascular accident (interruption in the flow of blood to cells in the brain), xerosis cutis (rough dry skin that may have scales or small cracks), hypo-osmolality (a condition were the levels of electrolytes, proteins, and nutrients in the blood are lower than normal), constipation (less than three bowel movements a week), type 2 diabetes mellitus (the body does not produce enough insulin, or it resists insulin) without complications, and hypertension (high blood pressure). <BR/>Record review of Resident #1's admission assessment dated [DATE] at 2:20 PM revealed, Resident #1 arrived by transport service in wheelchair, one person assistance for ADL's, responds to commands, oriented to person, place, time, and situation, speech clear, and left side weaker for hand grasp and foot press strength.<BR/>Record review of Resident #1's hospital record dated 08/24/2023 revealed active problems of acute cerebrovascular accident, type 2 diabetes mellitus without complication, without long-term current insulin use, hypertension, skin tear to left lower leg without complication, and skin burn. No resolved hospital problems.<BR/>Record review of Resident #1's baseline care plan with start date of 08/28/2023 did not address CVA, type 2 diabetes mellitus, skin tear, skin burn, and specify what assistance Resident #1 requires with activities of daily living. <BR/>Record review of Resident #3's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: sepsis (body's extreme reaction to an infection), viral hepatitis C (viral infection that causes liver swelling) without hepatic coma, hypertension, esophageal varices (abnormal veins in the lower part of the tube running from the throat to the stomach) without bleeding, gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the esophagus), constipation, cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), acute kidney failure (the kidneys suddenly cannot filter waste from the blood), and depression (serious mood disorder). <BR/>Record review of Resident #3's admission assessment dated [DATE] revealed resident arrived via ambulance, manual lift from stretcher with two person assist, oriented to person, place, time, and situation. <BR/>Record review of Resident #3's hospital record dated 08/25/2023 revealed Resident #3 will need to complete a six week course of IV antibiotics (Oxacillin 12g IV Q24 through 09/22/2023) for endocarditis. <BR/>Record review of Resident #3's baseline care plan with start date of 08/28/2023 did not to address diagnoses of endocarditis and continuous IV therapy, cirrhosis, hypertension, gastro-esophageal reflux disease, or depression. <BR/>During an interview on 09/05/2023 at 9:23 AM the DON said that she was responsible for developing and implementing the care plans. The DON stated that when she gets a referral for a new admission, she will review the diagnoses and medications and completes the baseline care plan within 24 hours. The DON stated she will update the comprehensive care plans after she talks with the residents and learns more about them. The DON revealed she was still learning everyone's role for updating the care plans. The baseline care plans were reviewed with DON. The DON stated that the care plans were not complete and needed to be more specific to each resident's care. <BR/>During an interview on 09/05/2023 at 11:37 AM, LVN A stated that care plans were important in knowing how to take care of the resident. <BR/>During a phone interview on 09/05/2023 at 12:55 PM, the ADM stated that care plans should address each residents need and treatments to direct the care of the resident. The ADM stated they would be having a staff meeting to address the issues identified. <BR/>During an interview on 09/05/2023 at 1:15 PM, LVN B stated that care plans were like the brains of the operation. LVN B stated that the care plan needs to be thorough, so you know how to take care of that resident. <BR/>During an interview on 09/05/2023 at 2:05 PM, RN stated that care plans were imperative for care, and that it needed to be specific to each resident, because each resident is different. <BR/>Record review of the facility policy Care Planning and Care Plan Meeting Workflow (undated), revealed the following documentation:<BR/>Baseline/admission Care Plan (SLP Template): The Baseline care plan is added on all new admission or readmissions discharged greater than 30 day. The Baseline care plan is to be completed within 24 hours of admission. The Initial Plan of care Review is conducted with the resident and/or their responsible representative 48 hours after admission .<BR/>Record review of the Facility Assessment Tool (12/13/2022) revealed the following documentation:<BR/>3.4 Consider the following competencies: Person-centered care. This should include but not be limited to person-centered care planning .<BR/>Policy Interpretation and Implementation<BR/>(1) <BR/>To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident admission.<BR/>(2) <BR/>The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to:<BR/>a. <BR/>Initial goals based on admission orders,<BR/>b. <BR/>Physician orders,<BR/>c. <BR/>Dietary orders,<BR/>d. <BR/>Therapy services,<BR/>e. <BR/>Social Services; and<BR/>f. <BR/>PASARR recommendation; if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 1 resident reviewed for medication errors ( Resident #11). <BR/> The facility failed to restart Resident #11's physician's ordered Plavix after a dental appointment. The resident was without her Plavix (blood thinner to treat stroke, heart attack, and other heart related disorders), for approximately 10 months (2/22/23 thru 12/19/23). <BR/>This failure could result in residents having risk of heart attacks, strokes, blood clots, and risk of hospitalizations. <BR/>Findings include: <BR/>Resident #11 <BR/>Record review of the current undated face sheet for female Resident #11 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), essential hypertension (high blood pressure), unspecified systolic (congestive) heart failure (heart failure), cerebral infarction, unspecified (stroke), and other persistent atrial fibrillation (irregular heart rhythm). <BR/>Record review of the quarterly MDS assessment for Resident #11 dated 12/2/23 revealed that the resident had a BIMS score of 14 indicating that she was cognitively intact. Further record review of the MDS revealed active diagnoses of coronary artery disease, heart failure, hypertension, cerebral vascular accident, transient ischemic attack, or stroke. <BR/>Record review of the progress notes for a Resident #11 dated 2/22/23 at 5:45 PM revealed the following documentation, resident will be going to the dentist Tuesday (2/28/23). Her Plavix will be (discontinued) until then awaiting the dentist orders. Plavix 75 mg. [Plavix - antiplatelet medication]<BR/>Record review of the progress notes for Resident #11 revealed the following progress note dated 12/19/2023, 4:38 PM, resident back from urology doctor appointment and requesting information regarding the Plavix prescription she was previously taking. Resident came back from doctor appointment and wanted to know why she wasn't taking Plavix. After researching Plavix was to be held for a dental appointment on 2/22/23 but never restarted. Order reactivated. Reviewed with DON and provider <BR/>Record review of the current physician orders for Resident #11 dated 2/6/24 revealed the following order, Clopidogrel tablet: 75 mg; amount; 75; oral. Once a morning. Morning 7 AM - 10 AM. Start date 1/24/24. Open ended. <BR/>Record review of the December 2023 MAR for Resident #11 revealed the following order, clopidogrel tablet; 75 mg; amount to administer: one tablet; oral, once a morning, start date, 12/19/23 - end date 1/3/24, (DC date). Diagnosis: Atherosclerotic heart disease of native coronary artery without angina pectoris. <BR/>Record review of the January 2024 MAR for Resident #11 revealed her order for Plavix was restarted with a start date of 1/3/24 through 1/5/24. There was an additional order for the Plavix that had a start date 1/10/24 through 1/19/24 as an end date. There was also an additional current order for the resident's Plavix that had a start date of 1/24/24, which was open ended.? <BR/>Record review of the care plan for Resident #11 last reviewed/revised 1/25/24 revealed no care plan related to the administration of Plavix (clopidogrel). <BR/>During an interview with Resident #11 on 2/7/24 at 9:03 AM she stated she had missed medications in the past, but the facility had straightened it out. She stated at the time of the incident she had a procedure and was taken off Plavix. She stated she was off the medication for several months, but the facility had gotten her back on it. She added it was restarted approximately 3 months ago. <BR/>On 2/8/24 at 11:36 AM an interview was conducted with Resident #11. She stated she had not experienced any adverse effects from being off the Plavix. She added she had stents and her physician told her she would need Plavix the rest of her life. [Note: Stent - metal mesh used to keep an artery open.] <BR/>On 2/8/24 at 3:15 PM an interview was conducted with Nurse Practitioner A for Resident #11. ?Regarding Resident #11 missed Plavix she stated generally it should be resumed after a procedure. She stated, I guess it was slipped. She further stated regarding Resident #11, She needs it (Plavix). She should be back on it. <BR/>On 2/8/24 at 3:30 PM an interview was conducted with LVN B regarding the missed Plavix for Resident #11. She stated she was not employed in the facility when it stopped. ?She stated she had been told the resident went to the doctor and had a procedure and the Plavix was stopped. <BR/>On 2/8/24 at 4:45 PM an interview was conducted with the DON regarding Resident #11's missed Plavix. She stated she was not employed in the facility then. She stated that at an appointment medical staff at the appointment reviewed the resident's medications and found the error. She stated she was not sure why Plavix was taken off her physician orders. She stated, We fixed the error. She stated the facility's medication system could not place a medication on hold like other systems. She added that she could see how someone in a hurry stopped the medication and did not start it up again. She stated that she expected staff to have started the order and to give the medication. She stated nurses and the medication aides were responsible for ensuring that medications were given accurately to residents. ?She stated staff monitored medication orders by pulling up the MARS and pulling up a medication report. She stated with Plavix the resident could have developed a blood clot and had a stroke if the medication was missed. <BR/>On 2/8/24 at 5:10 PM an interview was conducted with the Administrator regarding missed medications for Resident #11. He stated he felt there was a break in communication that caused the situation to occur. He stated his staff should communicate. He stated that the nurses, DON and ADON were responsible for residents receiving their medications. He stated without Plavix, the stent could have clotted. <BR/> Record review of the facility policy, titled Pharmacy Services, Overview, Revised April 2007, revealed the following documentation, Policy Statement. The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication, and biologicals, and the services of a licensed pharmacist. Policy Interpretation and Implementation. <BR/>3. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support resident's needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but it's not limited to, collaborating with the facility and Medical Director to . <BR/>f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers. <BR/>h. Collaborate with the staff and practitioners to address and resolve medication related needs or problems. <BR/>l. Help the facility develop a process for receiving, transcribing, and recapitulating medication orders. <BR/>Record review of the facility policy, titled Adverse Consequences and Medication Error, Overview, Revised April 2014, revealed: <BR/>Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist. <BR/>2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychological status. An adverse consequence may include a). adverse drug/medication reaction. <BR/>5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professionals' providing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 2 medication carts (med cart on South Hall). <BR/>MA B had loose pills in the medication cart assigned to her on South Hall. <BR/>This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. <BR/>The findings include: <BR/>Record Review of Resident #42's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, depression, anxiety, urgency of urination, allergic rhinitis, type 2 diabetes with high blood sugar, congestive heart failure, irritable bowel syndrome with constipation, cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver, muscle wasting and atrophy, high blood pressure, reduced mobility. <BR/>Record Review of Resident #50's face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, anxiety, aphasia (loss or difficulty to understand or express speech), muscle weakness, depression, muscle spasm, constipation, high blood pressure, type 2 diabetes, hyperlipidemia, hyperthyroidism, pulmonary hypertension. <BR/>Record Review of Resident #56's face sheet reflected he was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of: end stage renal disease, fluid overload, gastrointestinal hemorrhage (a sign of a disorder in the digestive tract), hypotension, allergic rhinitis, thrombocytopenia (low platelets), depression, difficulty swallowing, bipolar disorder, type 2 diabetes, muscle weakness, renal dialysis (is a treatment for people whose kidneys are failing), muscle wasting and atrophy, acid reflux, hyperlipidemia, hypothyroidism, chronic kidney disease. <BR/> Observation and interview on 02/07/2024 at 1:28 pm during a medication cart check with MA B, revealed 6 loose medications in the medication cart in which MA B was responsible for. The medications that were found were as listed: glyburide 5 mg (1 pill) belonging to Resident #50, atorvastatin 20 mg (2 pills) belonging to Resident #50, hydroxyzine hydrochloride 25 mg (2) pill belonging to Resident #42, and carvedilol 6.25 mg belonging to Resident #56. The medications were identified by MA B by locating the medication cards and locating the missing medications. MA B observed the loose medications in her cart. MA B stated that it had been her responsibility to check her cart upon taking responsibility of the cart for the day. MA B stated that the charge nurse is also responsible for checking the carts and carts are usually checked before every shift. MA B stated that she had been trained in medication storage through in-services and the facility will hold in-services approximately monthly. MA B stated that the negative potential outcome for having loose medications in the cart is that the resident could not have enough medication and the pharmacy may not refill their medications causing a missed medication. <BR/>Interview with the Clinical Resource Nurse on 02/07/2023 at 1:42 pm revealed the Clinical Resource Nurse was informed of the loose medications found on the cart during the medication cart check. The Clinical Resource Nurse stated that he expects all staff that is responsible for the cart to check the cart prior to shift. The Clinical Resource Nurse stated that the negative potential outcome for loose medications on the cart is that it could cause a resident to miss a dose of medication because they have to dispose of that medication. The Clinical Resource Nurse stated that he will be in-serviced on loose medications. <BR/>Interview with the DON on 02/07/2024 at 1:53 pm. revealed the DON stated that she expects the staff to keep the carts and storage clean. The DON stated that the medication aides are responsible for checking the carts prior to the beginning of their shift. The DON stated that the ADON will do random cart checks to make sure that the cart is cleaned and are checked approximately weekly. The DON stated that the negative potential outcome for loose medications is that the wrong resident could get the medication, or it could cause a missed medication. The DON stated that an in-service will be completed. The DON stated that staff have been trained on expired medications and loose pills through in-services and in-services occur approximately bi-weekly. <BR/>Interview with the Administrator on 02/07/2024 at 2:01 pm., The Administrator stated that the negative potential outcome for loose medications on the cart could cause a resident to have a missed medication because not enough medication left. The Administrator stated that the staff will get in-serviced on loose medications and expired medications. <BR/>Record Review of facility provided policy, labeled, Storage of Medications, provided on 02/08/2024 date Revised November 2020, revealed: <BR/>Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. <BR/>Policy Interpretation and Implementation: <BR/>2. Drugs and Biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from neglect for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that:<BR/>1) The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. <BR/>This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated.<BR/>The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration.<BR/>These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. <BR/>The findings include:<BR/>Resident #1<BR/>Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder).<BR/>Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; <BR/>If Blood Sugar is less than 60, call MD. <BR/>If Blood Sugar is 61 to 150, give 0 Units. <BR/>If Blood Sugar is 151 to 250, give 3 Units. <BR/>If Blood Sugar is 251 to 350, give 5 Units. <BR/>If Blood Sugar is 351 to 450, give 7 Units. <BR/>If Blood Sugar is 451 to 500, give 10 Units. <BR/>If Blood Sugar is greater than 500, call NP/PA. <BR/>Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A.<BR/>Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . <BR/>Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. <BR/>Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON.<BR/>Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin:<BR/>Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank.<BR/>Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested, and it was 203 and 3 units of insulin was administered prior to dinner - admission Observation by LVN C.<BR/>Further record review of the MAR revealed the following:<BR/>On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B.<BR/>On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. <BR/>On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B.<BR/>Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following:<BR/>04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B.<BR/>04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B<BR/>Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . <BR/>Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization <BR/>Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. <BR/>Labs. <BR/>Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. <BR/>Specimen: blood. <BR/>Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L .<BR/>carbon dioxide 8 on a normal scale of 21-32 mmol/L. <BR/>Glucose 1,030 on a normal scale of 74-106 mg/dL. <BR/>Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. <BR/>Blood, urine moderate. <BR/>Glucose, urine 100 mg/dL. <BR/>Ketones, urine 40 mg/dL. <BR/>Disposition. <BR/>Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. <BR/>Comment. <BR/>Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety.<BR/>Expected patient class: in patient.<BR/>Level of service: ICU. <BR/>Discharge summary note. <BR/>Discharge summary. <BR/>Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM)<BR/>Cause of death: renal failure, metabolic acidosis, lactic acidosis.<BR/>Other contributing factors: <BR/>Principal problem: acute metabolic encephalopathy.<BR/>Active problems: . diabetes myelitis. DKA (diabetic keto acidosis) . <BR/>Hospital Course:<BR/>(Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . <BR/>Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows:<BR/>Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: [DATE]. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. <BR/>Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. <BR/>Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused.<BR/>Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility.<BR/>On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to the ER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500.<BR/>On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. <BR/>On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter.<BR/>On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care.<BR/>On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B.<BR/>On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23.<BR/>On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. <BR/>On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. <BR/>On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022.<BR/>On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in.<BR/>On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. <BR/>On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high.<BR/>On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own.<BR/>On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin.<BR/>On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. <BR/>Resident #2<BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD.<BR/>If blood sugar is 150 to 200 give two units.<BR/>If blood sugar is 201 to 250 give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, give 12 units.<BR/>If blood sugar is greater than 450, give zero units.<BR/>If blood sugar is greater than 450, call MD. Subcutaneous. <BR/>[DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] <BR/>Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM <BR/>Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days.<BR/>Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 .<BR/>Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. <BR/>Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #3 <BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD. <BR/>If blood sugar is 150 to 200, give two units.<BR/>If blood sugar is 201 to 250, get four units.<BR/>If blood sugar is 251 to 300, gives six units. <BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is greater than 400, call NP/PA. Subcutaneous <BR/>[DX: type two diabetes mellitus without complications] <BR/>Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM.<BR/>Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: <BR/>Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank.<BR/>Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days.<BR/>Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 .<BR/>Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #4 <BR/>Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. <BR/>Further record review of the Physician Order Report revealed the following orders:<BR/>Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro <BR/>Insulin pen; 100 unit/ML; AMT: per sliding scale; <BR/>If blood sugar is less than 70, call NP/PA.<BR/>If blood sugar is 70 to 150, give 0 units.<BR/>If blood sugar is 151 to 200, give two units.<BR/>If blood sugar is 201 to 250, give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 300 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, gives 12 units.<BR/>If blood sugar is 450 to 500, give 14 units. <BR/>If blood sugar is greater than 501, called NP/PA. Subcutaneous.<BR/>[DX: type two diabetes myelitis without complications]<BR/>Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM <BR/>Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications]<BR/>Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM<BR/>Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. <BR/>Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes.<BR/>Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM.<BR/>Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime.<BR/>Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals and missing documentation for the residents listed on the MAR chart audit until the facility conducted a chart [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that:<BR/> The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. <BR/>This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated.<BR/>The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration.<BR/>These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. <BR/>The findings include:<BR/>Resident #1<BR/>Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder).<BR/>Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; <BR/>If Blood Sugar is less than 60, call MD. <BR/>If Blood Sugar is 61 to 150, give 0 Units. <BR/>If Blood Sugar is 151 to 250, give 3 Units. <BR/>If Blood Sugar is 251 to 350, give 5 Units. <BR/>If Blood Sugar is 351 to 450, give 7 Units. <BR/>If Blood Sugar is 451 to 500, give 10 Units. <BR/>If Blood Sugar is greater than 500, call NP/PA. <BR/>Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A.<BR/>Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . <BR/>Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. <BR/>Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON.<BR/>Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin:<BR/>Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank.<BR/>Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested, and it was 203 and 3 units of insulin was administered prior to dinner - admission Observation by LVN C.<BR/>Further record review of the MAR revealed the following:<BR/>On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B.<BR/>On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. <BR/>On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B.<BR/>Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following:<BR/>04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B.<BR/>04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B<BR/>Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . <BR/>Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization <BR/>Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. <BR/>Labs. <BR/>Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. <BR/>Specimen: blood. <BR/>Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L .<BR/>carbon dioxide 8 on a normal scale of 21-32 mmol/L. <BR/>Glucose 1,030 on a normal scale of 74-106 mg/dL. <BR/>Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. <BR/>Blood, urine moderate. <BR/>Glucose, urine 100 mg/dL. <BR/>Ketones, urine 40 mg/dL. <BR/>Disposition. <BR/>Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. <BR/>Comment. <BR/>Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus.<BR/>Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety.<BR/>Expected patient class: in patient.<BR/>Level of service: ICU. <BR/>Discharge summary note. <BR/>Discharge summary. <BR/>Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM)<BR/>Cause of death: renal failure, metabolic acidosis, lactic acidosis.<BR/>Other contributing factors: <BR/>Principal problem: acute metabolic encephalopathy.<BR/>Active problems: . diabetes myelitis. DKA (diabetic keto acidosis) . <BR/>Hospital Course:<BR/>(Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . <BR/>Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows:<BR/>Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: [DATE]. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. <BR/>Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. <BR/>Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused.<BR/>Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility.<BR/>On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to the ER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500.<BR/>On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. <BR/>On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter.<BR/>On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care.<BR/>On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B.<BR/>On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23.<BR/>On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. <BR/>On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. <BR/>On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022.<BR/>On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in.<BR/>On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. <BR/>On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high.<BR/>On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own.<BR/>On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin.<BR/>On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. <BR/>Resident #2<BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD.<BR/>If blood sugar is 150 to 200 give two units.<BR/>If blood sugar is 201 to 250 give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, give 12 units.<BR/>If blood sugar is greater than 450, give zero units.<BR/>If blood sugar is greater than 450, call MD. Subcutaneous. <BR/>[DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] <BR/>Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM <BR/>Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days.<BR/>Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 .<BR/>Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. <BR/>Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #3 <BR/>Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale;<BR/>If blood sugar is less than 60, call MD. <BR/>If blood sugar is 150 to 200, give two units.<BR/>If blood sugar is 201 to 250, get four units.<BR/>If blood sugar is 251 to 300, gives six units. <BR/>If blood sugar is 301 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is greater than 400, call NP/PA. Subcutaneous <BR/>[DX: type two diabetes mellitus without complications] <BR/>Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM.<BR/>Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: <BR/>Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank.<BR/>Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days.<BR/>Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 .<BR/>Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>Resident #4 <BR/>Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. <BR/>Further record review of the Physician Order Report revealed the following orders:<BR/>Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro <BR/>Insulin pen; 100 unit/ML; AMT: per sliding scale; <BR/>If blood sugar is less than 70, call NP/PA.<BR/>If blood sugar is 70 to 150, give 0 units.<BR/>If blood sugar is 151 to 200, give two units.<BR/>If blood sugar is 201 to 250, give four units.<BR/>If blood sugar is 251 to 300, give six units.<BR/>If blood sugar is 300 to 350, give eight units.<BR/>If blood sugar is 351 to 400, give 10 units.<BR/>If blood sugar is 401 to 450, gives 12 units.<BR/>If blood sugar is 450 to 500, give 14 units. <BR/>If blood sugar is greater than 501, called NP/PA. Subcutaneous.<BR/>[DX: type two diabetes myelitis without complications]<BR/>Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM <BR/>Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications]<BR/>Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM<BR/>Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. <BR/>Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes.<BR/>Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM.<BR/>Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime.<BR/>Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR.<BR/>On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation; which included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 17 of 24 residents (Resident #1, 8, 13, 25, 29, 31, 32, 38, 40, 41, 43, 51, 52, 56, 68, 180); in that:<BR/>Seventeen residents were residing in the secure memory unit without physician orders. <BR/>This failure effected 17 residents by not allowing them to have an environment that promoted individuality and allowed them as much independence as possible. <BR/>The findings include:<BR/>Review of Resident #1's face sheet dated 12/07/22 documented an [AGE] year-old, female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: psychotic disorder with delusions (disorder characterized by an impaired relationship with reality often including confusion and hallucinations), dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), chronic lung disease, pain, high cholesterol, falls, high blood pressure, depression, and anxiety. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident # 8's face sheet dated 12/07/22 documented a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: chronic breathing problems, weakness, dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), high blood pressure, anxiety, mood disturbances (mental health condition affecting emotions), and falls. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #13's face sheet dated 12/07/22 documented an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), anxiety, impulse disorder (mental and behavioral disorder that involve a lack of self/control), muscle weakness, difficulty, sleeping, high cholesterol, and depression. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #25's face sheet dated 12/07/22 documented and [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: delusions (fixed and false personal beliefs that are resistant to change even with conflicting evidence), muscle weakness, pain, high blood pressure, dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), depression, and anxiety. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #29's face sheet dated 12/07/22 documented a [AGE] year-old male admitted to the facility on one 01/04/21 with the following diagnosis: high blood sugar, brain injury with lack of oxygen, dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), anxiety, delusions (fixed and false personal beliefs that are resistant to change even with conflicting evidence), high cholesterol, falls, high blood pressure, and chronic difficulty breathing. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #31's face sheet dated 12/07/22 documented a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: mood disorder (mental health condition affecting emotions), depression, high blood pressure, chronic difficulty breathing, pain dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), and high cholesterol. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #38's face sheet dated 12/07/22 documented an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), muscle weakness, unsteadiness on feet, non-traumatic brain bleed, chronic difficulty breathing, high cholesterol, depression, difficulty sleeping, and high blood pressure. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #40's face sheet dated 12/07/22 documented a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: chronic difficulty breathing, high blood sugar, muscle weakness, dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), kidney disease, anxiety, pain, high blood pressure, seizures, and high cholesterol. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #41's face sheet dated 12/07/22 documented a [AGE] year-old male admitted to the facility on one 10/05/22 with the following diagnosis: mental disorder with disturbances in thoughts, perception and behavior, dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), anxiety, disease of the liver, high blood pressure, pain, and alcohol abuse. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #43's face sheet dated 12/07/22 documented a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), anxiety, mood disorder (condition affecting emotions), anxiety, pain, and agitation. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #51's face sheet dated 12/07/22 documented [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis: alcohol dependence, alcohol induced, dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), pain, high blood pressure, high cholesterol, high blood sugar, and mood disorder (condition affecting emotions). Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #52's face sheet dated 12/07/22 documented and [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: high blood pressure, dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), high cholesterol, depression, heart failure, chronic breathing issues, and muscle weakness. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #56's face sheet documented a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: hypo-osmolarity (condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia (condition in which the sodium level in the blood is lower than normal), traumatic brain bleed, Syndrome of inappropriate antidiuretic hormone secretion (condition in which the body makes too much antidiuretic hormone), panic disorder (brief episode of intense anxiety, which causes the physical sensations of fear), difficulty swallowing, Bipolar disorder (mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and depression. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit. <BR/>Review of Resident #68's face sheet dated 12/07/22 documented [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis: dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), high blood pressure, high blood sugars, psychotic disorder (set of symptoms characterized by a loss of touch with reality due to a disruption in the way that the brain processes information) with hallucinations (false perceptions, such as hearing, seeing, or feeling something that is not there). Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Review of Resident #180's face sheet dated 12/07/22 documented a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: dementia (loss of cognitive functioning/ thinking, remembering, and reasoning), high blood sugars, psychotic disorder (set of symptoms characterized by a loss of touch with reality due to a disruption in the way that the brain processes information), and high blood pressure. Review of resident's physician orders dated 12/07/22 revealed there were no orders for the secured unit.<BR/>Observation on 12/07/22 at 11:22 AM Resident #56 was on the secure unit walking around. In an interview with Resident #56, she said she did not know why she was up on the secure unit. She said the facility did not explain it to her, just told her she was going somewhere else. She said apparently, I got into it with someone, I don't remember, that's what they'll tell you anyway. When asked if she had any other altercations at the facility, she said no. Record review of Resident #56's most recent comprehensive MDS (minimum data settings) dated 11/17/22 showed her BIMS (brief interview for mental status) as a 12 which is considered cognitively intact.<BR/>Interview on 12/07/22 at 1:00 PM, DON was asked why Resident #56 was on the secure unit, she said the resident had a history of elopement. The DON said an elopement assessment was done for Resident #56 but later checked resident's record saying the elopement assessment was never done. When asked if there were any signed consents, she said she wasn't sure that she would have to check with the social worker and later said she did not have any. The Administrator said initially Resident #56 was put on the regular side of facility on quarantine then moved to the memory unit on 11/28/22. The Social Worker was asked if she had any legal papers for Resident #56 for guardianship, she said she had no legal papers, just that the resident came from a memory unit at a different facility. <BR/>In an interview on 12/07/22 at 1:33 PM Resident #56 with the DON, Corporate RN, and Surveyor. The DON asked the resident if she wanted to be moved outside of the secure unit, the resident said, yes, I want to be back upfront away from these people, and her (speaking of her roommate) who yells. She was asked to describe what a stop sign, red light, green light, and yellow light looks like and what they were for, the resident was able to answer the questions correctly. She was asked about crossing the road, where to cross the road, Resident #56 said at the end of the block. When asked what she would do before crossing the street, the resident said look both ways to make sure a car wasn't coming. The resident said she wanted to go back to her apartment but that she didn't have it anymore because her cousin let it go and didn't pay on it anymore. <BR/>Telephone conference call on 12/07/22 at 1:50 PM with Resident #56's Emergency Contact #1, the Administrator, Corporate RN, DON, and Surveyor about Resident #56 being on the secure unit and/or moving to the regular unit. Emergency contact #1 said she was all for her being in a regular room but felt resident would be able to talk a visitor in to letting her out of the door which required a code to get out. She thought the resident would be in serious danger if she got out of facility, that the resident has been homeless before trying to sell her belongings to live on. Emergency contact #1 said people can't believe what Resident #56 says, she's mentally ill doesn't foresee leaving the secure unit being a good idea. She said she did not have guardianship papers.<BR/>In an interview on 12/08/22 at 9:05 AM Administrator said she could not find the SLP (Senior Living Properties) pre-placement evaluation form the facility policy required to be done before placing residents on the secure unit. The Administrator said the facility was going to slow down the admission process for the secure unit way down.<BR/>Interview on 12/08/22 at 10:35 AM Administrator was shown the facility policy titled admission Criteria to Secure Unit where it stated a physician order was required along with justifying diagnosis for admission to secured unit. Then the DON was asked if the 17 residents had physician orders for the secure unit. The DON said most of the residents were at the facility prior to when she started work, she did not realize it needed to be corrected. The Administrator said there should've been orders for residents in the secure unit.<BR/>Telephone interview on 12/08/22 at 2:08 PM the Medical Director said he was not aware the residents on the secure unit not having orders, he said that is something that would have to be fixed. The Medical Director was asked about Resident #56 being on the secure unit with no legal documentation (Guardianship) and her BIMS score being a 12, cognitively intact. He said Resident #56 had a history of head trauma and had problems keeping her sodium levels within normal limits. He said when her sodium levels were normal, she was of sound mind and body. He said the facility would have to be diligent on checking her labs and keeping her sodium levels where they should be, the resident was not psychotic when her sodium levels were normal. When the Medical Director was told of the only documentation the facility had was the resident observed one time of wandering and previous hospital records, he said she couldn't be punished based on things that we're done in the past, the decision needed to be made on her current level of condition.<BR/>Review of facility policy dated 04/2020 and titled admission Criteria to Secure Unit where it stated a physician order was required along with justifying diagnosis for admission to secured unit reflected the following:<BR/>2. Documented evidence justifying placement on Secured Unit:<BR/>The potential resident exhibits, wandering or exit, seeking or other behaviors that place of residence in danger, or potential danger.<BR/>3. And in all cases: less restrictive alternatives have been unsuccessful.<BR/>Documentation requirements upon admission to secure unit: <BR/>1. <BR/>Physician order including justifying diagnosis for admission to secured unit.

Based on interview and record review the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen.<BR/>The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The designated Dietary Manager had not completed the required dietary manager's course.<BR/>This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met.<BR/>The findings include:<BR/>Record review of the personnel file for the designated Dietary Manager revealed there was no documentation of completion of the required dietary manager's course. <BR/>On 12/6/22 at 12:44 PM, an interview was conducted with the Dietary Manager regarding her qualifications. She stated her required (University of Florida) Certified Dietary Manager course will not be completed until May 2023. She stated she provided the course invoice as proof she was enrolled. At that time the Dietary Manager provided a copy of only her Texas Food Safety Manager Certification Examination certificate.<BR/>Record review of the Texas Food Safety Manager Certification Examination certificate for the Dietary Manager revealed that she completed the Learn to Serve Texas Food Safety Manager Certification Examination, effective date 11/01/2021. The certificate expired five years from the effective date.<BR/>Record review of the document titled University of Florida Division of Continuing Education - Professional Development, Receipt: E 00011209, date: 10/28/2021 revealed that the Dietary Manager had enrolled in a course titled Nutrition and Food Service Professional Training Pathway, Online. <BR/>Record review of the University of Florida website, https://pwd.aa.ufl.edu/foodservice/, revealed that this course prepared individuals for the Certified Dietary Manager (CDM) credentialing exam.<BR/>On 12/7/22 at 9:50 AM an interview was conducted with the Dietary Manager, and she stated she could miss special dietary requests for residents if she failed to complete the required Dietary Manager course. She added, she was hired in August 2022 and the Administrator hired her. <BR/>On 12/7/22 at 5:59 PM an interview was conducted with the Administrator regarding the Dietary Manager's qualifications. She stated, she had hired the current Dietary Manager and other dietary employees when the dietary employee contracts were not renewed from another company. She stated she expected that the Dietary Manager to have all requirements met. She also stated that she was responsible to ensure that the Dietary Manager met all qualifications. She added that residents could have a negative outcome related to their dietary needs if the Dietary Manager was not qualified. <BR/>On 12/8/22 at 11:46 AM an interview was conducted with the Administrator, and she stated the facility did not have a full-time Dietitian. <BR/>Record review of the facility document titled Job Description, Review Date: 5/20/21, Revised Date 5/20/21 revealed the following documentation, Position Title: Dietary Services Manager . Department: Dietary . Required Job Qualifications . Experience. Required. Must hold or be capable of acquiring certificates required by the state .<BR/>Record review of the facility policy titled Food and Nutrition Services Staff, Revised October 2017, revealed the following documentation, Policy Statement. The food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department. Policy Interpretation and Implementation. <BR/>1. The food and nutrition services staff, under the supervision of the Dietitian and/or the food and nutrition services manager, will safely and effectively carry out the functions of the food and nutrition services department .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services.<BR/>1) The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions.<BR/>2) The facility failed to ensure food and non-food contact surfaces were clean. <BR/>3) The facility failed to ensure staff stored personal items in a manner that prevented contamination. <BR/>4) The facility failed to ensure food was accurately dated and labeled. <BR/>5) The facility failed to protect foods from potential contamination. <BR/>6) The facility failed to ensure staff wore hair restraints in food areas.<BR/>7) The facility failed to ensure sanitizer were at recommended concentrations and used according to manufacturer recommendations, <BR/>8) The facility failed to rapidly reheat potentially hazardous hot food to 165 degrees F prior to placing on the steam table. <BR/>9) The facility failed to ensure that potentially hazardous cold foods were maintained at 41 degrees F or below.<BR/>10) The facility failed to ensure staff used good hygienic practices.<BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings included :<BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 8:54 AM and concluded at 9:45 AM:<BR/>Dietary staff D was observed washing his hands. He turned off the water with his bare hand and then dried them with paper towels. He then donned a pair of gloves and then handled soiled dish trays in the dishwasher area. He then move to the clean dishes and put away trays from the clean side of the dishwasher. <BR/>Observation on 2/6/24 at 9:05 AM, revealed as the Dietary staff D was observed wearing gloves, he was going back-and-forth from soiled dishes to putting away clean lids at the dishwasher and not washing his hands and changing gloves between the soiled and clean operations.<BR/>There was a plastic headband stored on top of the toaster next to a covered thermometer. <BR/>Observation on 2/6/24 at 9:13 AM, revealed the Dietary staff D was wearing gloves and went from handling soiled to clean equipment at the dishwasher area without washing his hands between the soiled and clean operation. He handled soiled dishes and then put away pitchers and cups that were clean.<BR/>Observation on 2/6/24 at 9:18 AM revealed the three compartment sink quaternary sanitizer level was tested at 100 ppm by Dietary staff A. At that time Dietary staff A stated It needs to be a little stronger .<BR/>The front area produce refrigerator had three thawed cartons of vanilla Ready Care shakes on a tray. The cartons reflected Use within 14 days of thawing. There was no label or date to determine if the 14 days had passed. <BR/>The magnetic lid trim was pulling away from the lid on the chest freezer. <BR/>Observation on 2/6/24 at 9:26 AM, revealed Dietary staff A was observed taking food equipment out of the quaternary sink, three compartment sink sanitizer basin where he had just cleaned food equipment. He tested the level of sanitizer in the sanitizing sink, and it was 100 ppm quat. He stated at this time, Maybe I need to drain it and refill it. <BR/>Observation on 2/6/24 at 9:30 AM revealed Dietary staff A stated, he did not add any fresh quaternary sanitizer to the basin after he had initially tested it at 9:18 AM.<BR/>Two of two sets of fluorescent lights in the pantry had no shield. <BR/>Observation on 2/6/24 at 9:40 AM revealed Dietary staff A refilled the sanitizing sink for the three compartment sink and the level of quaternary sanitizer was tested at 200 ppm.<BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 11:21 AM and concluded at 1:16 PM:<BR/>A large ice scoop was hanging in a metal holder on the wall but the handle and top area of the ice scoop had a buildup of dirt/brown substance in the creased areas.<BR/>Observation of the steam table revealed the following with temperatures were taken by Dietary staff A:<BR/>Broccoli 192.4&deg;F <BR/>White gravy 186.4&deg;F. <BR/>Fortified potatoes 178.9&deg; <BR/>Rolls no temperature taken and served room temperature. <BR/>Chicken fingers 205&deg; out of the oven.<BR/>Pur&eacute;e chicken was 153.5&deg;F. Not reheated to 165 degrees F. after cooling during the pureeing process.<BR/>Pur&eacute;e broccoli 154&deg;F <BR/>Mechanical altered chicken 152&deg;F. Not reheated to 165 degrees F. after cooling during the pureeing process.<BR/>Pur&eacute;ed bread no temperature taken. <BR/>There was a plastic headband stored on top of the toaster next to an uncovered cup of white crystal substance that had no label.<BR/>The ceiling vent above the dishwasher was thick with a buildup of fluffy dust and dirt.<BR/>There was a portable fan placed on the clean side of the dishwasher and was turned on and the intake vent of the fan had a buildup of dirt. The fan was blowing across a rack of clean glasses.<BR/>Dietary staff D was observed washing his hands at the hand sink, then turning off the water using a paper towel. He then dried his hands and arms with the same paper towel. He donned, a pair gloves, and then re-gloved and continued with dietary duties.<BR/>MA A entered the kitchen and did not have on a hair restraint. Her hair was pulled up into a loose top knot type bun with loose hair .<BR/>At the service line, there was a box of 20 thawed vanilla Ready Shakes, and there was no date on the boxed indicating when the vanilla shakes were thawed. The shakes were not on any source of refrigeration.<BR/>Interview on 2/6/24 at 11:46 AM, Dietary staff D stated the shakes had been stored in the produce refrigerator.<BR/>Observation on 2/6/24 at 10:50 AM, revealed the pur&eacute;e processing was conducted by Dietary staff A. He was about to pur&eacute;ed broccoli. Observation of the blade and processor pot interior revealed they were wet and soiled with debris. Also, the lid shoot had debris. The surveyor intervened and he washed the processor parts in the three compartments sink. After washing them, he took his wet hands and handled the blade and assemble the processor parts that were dripping wet. He then pur&eacute;ed the broccoli in the processor. Dietary staff A then placed the pur&eacute;e in a pan and placed it on the steam table. He then washed the parts in the three-compartment sink, the lid, the blade and processor pot. He only dipped the parts in the sanitizer basin for approximately two seconds, and then placed the parts on the clean drain board. When he placed them on the clean side drain board, he did not invert the pot or the lid so that the water could drain off.<BR/>Dietary staff A then placed chicken fingers in the wet processor pot, which was wet on the interior, the lid and the blade. He then pur&eacute;ed the chicken with milk and then placed it in a pan and placed it on the steam table.<BR/>Observation on 2/6/24 at 12:02 PM revealed Dietary staff A, then took the processor and dipped each part in the wash, rinse and quat sanitizer sinks for approximately two seconds, and then took them out and placed and assembled on the processor base at 12:03 PM. He then placed chicken in the wet processor and ground the chicken. After grinding, he placed it in a pan and then put it on the steam table at 12:04 PM.<BR/>Observation and record review of the quaternary sanitizer label Solution QA Ultra revealed the following documentation. Apply 200 to 400 ppm active quaternary. To clean public eating establishment surfaces. Wet for at least 60 seconds and let air dry. Do not rinse. This product is an effective sanitizer for use on food contact services in 60 seconds at 200 ppm active quaternary. Sanitization. Effective sanitizer at an active quaternary concentration of 200 to 400 ppm. <BR/>There was a personal drink in a foam cup stored on top of the chest freezer.<BR/>Observation at 1:12 PM revealed the shakes were still out without any ice or refrigeration on the service line. There was one carton left on the cart that was part of the thawed 20 shakes that were at the service line. The last cart went out and meal service was over at 1:14 PM. At 1:15 PM a temperature was taken of the last carton of shake that was left and it was 56&deg;F. <BR/>On 2/6/24 at 1:18 PM an interview was conducted with Dietary staff A regarding dietary sanitation issues. He stated he had not been told anything about the length of time to submerge the equipment in the sanitizing solution. He stated residents could get sick if food contact surfaces were not sanitized correctly. He stated usually the bottom half of the shakes were frozen. He added that the shakes had been in the refrigerator since yesterday (2/05/24). He further stated that he had been working in the facility since November 2023. He stated his training orientation consisted of showing him dietary procedures at one lunch and was let go on his own at supper that same day . <BR/>- The following interviews and observations were made during a kitchen tour on 2/6/24 that began at 4:33 PM and concluded at 5:18 PM:<BR/>There was a personal drink on the cart next to an open box of shakes. The personal drink was later moved to the table next to the microwave and coffee machine.<BR/> Dietary staff B was observed carrying empty soup bowls to the steamtable up against her chest/shirt.<BR/>On 2/6/24 at 5:02 PM an interview was conducted with Dietary staff B regarding her dietary training. She stated, an employee showed her dietary procedures for two days and then the employee left. She added she followed other staff like a puppy to learn. <BR/>- The following interviews and observations were made during a kitchen tour on 2/7/24 that began at 10:51 AM and concluded at 12:04 PM:<BR/>There was a personal half bottle of water and a can of energy drink on a lower shelf on the steam table line. <BR/>There was an uncovered, unlabeled cup of white crystalline substance stored on top of the toaster. During an interview with the Dietary Manager on 2/7/24 at 12:03 PM, he stated the substance in the cup was sugar.<BR/>On 2/8/24 at 9:30 AM kitchen observation and interview was conducted with the Dietary Manager regarding issues observed in the kitchen. Regarding when the shakes expired, he stated staff go by the date on the carton. Observation revealed that there was no date on the box that the shakes were in and there was also no date on the carton itself. Documentation on the carton revealed the manufacturer recommended disposing of the thawed shakes after 14 days . The underside of the upper shelf of the stove had an accumulation of dried splatter. He also stated regarding not washing hands between soiled and clean operations, clean food equipment could still get contaminated. When the soiled ceiling vents were mentioned, he stated the filter above the dishwasher was changed every month and the last time was last week. Regarding personal drink storage, he stated personal drinks were supposed to be stored in his office. Observation of the chest freezer revealed that the interior of the lid was detaching and the magnetic trim was detached in an area. He stated the fluorescent light in the pantry had been unshielded ever since he had been here. He stated he was told that the lights did not need shields. Regarding the shakes he stated the shakes were normally in an ice bath to keep them below 40 F&deg;. He further stated that foods on the steam table should be 165&deg;F when reheated . He stated staff were instructed to let equipment dry. He added that the quat level should have been 200 ppm at least and staff should have let the processor dry. He further stated that the food contact items should be in the sanitizer at least 45 seconds in the three-compartment sink. He stated staff forgot to bring their drinks in the office. He stated he reminded staff daily on handwashing and sanitizer and glove use. He stated he expected them to do the right thing. He stated he conducted direct monitoring of staff, corrected the staff, and assisted the staff. He stated he and the staff were responsible to ensure dietary sanitation procedures were conducted correctly. He stated residents could get sick as a result of the dietary sanitation issues observed. He stated that dietary orientation training was at least a week and then staff were shadowed. <BR/>On 2/8/24 at 11:55 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated dietary staff had been in-serviced and needed to be re-in-serviced. He stated that he monitored the sanitation by making rounds. He also stated he expected the staff to clean and let equipment dry and date foods correctly. He stated that all staff were responsible including the Dietary Manager and Administrator. The result of issues with dietary sanitation could result in making the residents sick.<BR/>Record review of the dietary department in-services held between 10/3/23 and 2/6/24 revealed that there were four in-services held that contained multiple subjects. It was also noted that the documentation for the in-service did not include any specific information of what was covered. There were only the topic and signatures from the staff. <BR/>The in-services topics were as follows for 10/3/23: Handwashing, cleaning, hairnets. Dietary staff, B and D attended these in-services.<BR/>The services were as follows for 10/19/23: stocking, and temperature logs. Dietary staff B and D attended these in-services.<BR/>The in-services were as follows for 12/11/23: Handwashing, cleaning, temperatures, job duties. Dietary staff A, B and D attended these in-services.<BR/>The in-service was as follows for 1/2/24: Serving times, job duties, dates, cleaning, tickets. Dietary staff, A, B, C and D attended these in-services. <BR/>Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures. Manual, 2018, Section 4-5, revealed the following documentation, Policy: General Kitchen Sanitation. Policy Number: 04.003. Policy: the facility recognizes that foodborne illness has a potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary, kitchen, facilities, in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure: <BR/>1.Clean and sanitize all food preparation areas, food contact surfaces, dining facilities, and equipment. After each use, clean and sanitize, all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. <BR/>4.Clean and sanitize all multiuse utensils, and food contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation. Based on food temperature, type of food and amount of food particle accumulation. <BR/>5. After cleaning and use, storage and handling of all food contact surfaces of equipment and multiuse utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants. <BR/>6. Clean non-food contact surfaces of equipment at intervals, as necessary to keep them free of dust, dirt, and food particles, and otherwise in a clean and sanitary condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for two of five resident rooms (5 and 21) reviewed on 1 of 2 facility units (Station one), in that:<BR/>The facility failed to ensure two of five resident rooms (5 and 21) occupied by 4 residents (Residents #21, 27, 65 and 126), had privacy curtains and tracks that were not missing, inappropriately placed, and/or damaged and would provide full visual privacy.<BR/>This failure could place residents at risk of being exposed while receiving personal care. <BR/>The findings include:<BR/>On 12/6/22 at 2:38 PM an observation was made of Residents #126 and #27, who were roommates in room [ROOM NUMBER]. Resident #126 was in bed and non-verbal with upper and lower contractures, g-tube, and tracheostomy. Resident #126 had no privacy curtain around the bed.<BR/>Resident #27 was nonverbal, had a catheter, upper and lower contractures, and his right foot had a dressing. He had a tracheostomy and skull scars. A g-tube pump was bedside. CNAs A and B transferred the resident from the shower bed/gurney to his bed by mechanical lift and exposed his buttocks to Resident #126 in the process due to no privacy curtains at Resident #126's bed. <BR/>Resident #27's bed was located outside of the privacy curtains that were installed, and no curtain was attempted to be pulled or his bed moved when staff provided incontinent care to Resident #126 also at this time.<BR/>On 12/6/22 at 3:24 PM an interview was conducted with CNAs A and B regarding the privacy curtains in the room. CNA A stated she started working in October 2022 and there were no privacy curtains at Resident #126's bed. CNA B stated, that at one time there were privacy curtains there, but the track would break. CNA B further stated it had been approximately a year since the privacy curtains had been installed around Resident #126's bed. CNAs A and B further stated, the residents should be provided privacy. Adding that these two residents could not speak, so staff needed to be their voices regarding issues that affect them. Neither CNA A or B knew specifically why the privacy curtains in the room were missing and inappropriately placed.<BR/>Observation on 12/6/22 at 3:24 PM, of the privacy curtain track at Resident #126's bed revealed that one end of the track was pulling away from the ceiling. <BR/>On 12/7/22 at 7:53 AM an observation of room [ROOM NUMBER] revealed that the privacy curtain track at the A bed was missing approximately a 2-foot section. The resident in A bed (Resident #21) could be viewed during care, if the resident from the B bed (Resident #65) exited the room.<BR/>On 12/7/22 at 8:40 AM Resident #126 was observed in bed in room [ROOM NUMBER] with no privacy curtain installed around the bed. <BR/>On 12/7/22 at 8:46 AM Resident #27 was observed in bed in room [ROOM NUMBER] and his bed was still not centered within the privacy curtain track. <BR/>On 12/8/22 at 7:38 AM resident #126 was observed in bed in room [ROOM NUMBER], the door to the room was open and there were no privacy curtains installed around his bed. The resident's disposable brief was exposed, and he was partially off the bed. Only his hip was on the bed, and his knees were off the bed. At the time staff were passing the room in the public hallway (Housekeeping staff A and B).<BR/>On 12/8/22 at 8:19 AM an interview was conducted with the Maintenance Supervisor. Regarding privacy curtains, he stated he checks a group of rooms weekly for water temperatures and he visually checks the privacy curtains during this time. He added that his primary focus was the water temperatures, and he tries to check what he can at this time. He stated the room is not private and the integrity of the room is affected when privacy curtains were not installed or placed appropriately. He stated he was not aware that a section of privacy curtain track was missing in room five. He further stated he had not conducted any privacy curtain work in room [ROOM NUMBER]. He stated he first learned of the privacy curtain problems in room [ROOM NUMBER] was on 12/07/22. He also stated he found there was a toggle bolt torn from the ceiling privacy curtain track in room [ROOM NUMBER]. The Maintenance Supervisor stated the facility tracked and reported maintenance requests/repairs through the TELS online maintenance system and verbally by staff. He added he makes a list each morning of what staff reported to him. He also stated that staff can enter reports/requests in TELS. He stated staff have not used the TELS system to the best of its ability and repair requests were mostly verbal reports. He further stated that staff had not asked for Resident #27's bed to be moved in the area where the privacy curtains could be used. He stated he and the staff were responsible for ensuring that the privacy curtains were in good repair and in place. He stated the damaged and missing privacy curtains could be frustrating to the residents and added that if he were a resident in this situation, he would want the privacy curtains installed correctly. <BR/>On 12/8/22 at 8:37 AM an interview was conducted with ADON B regarding privacy. Regarding resident #27 bed being outside of the privacy curtain. She stated, she did not know why #27's bed was moved. She stated the lack of appropriately placed privacy curtains and subsequent exposure of residents was a lack of respect for the resident. She added that she would not want this situation to happen to her. <BR/>On 12/8/22 at 8:45 AM an interview was conducted with DON regarding privacy and privacy curtains. She stated, she told staff about the missing privacy curtain (in room [ROOM NUMBER]) about 3 weeks ago but failed to check to see if the privacy curtains were in place. She stated she was not sure who was responsible for monitoring the privacy curtains to ensure they were appropriately placed. She stated this absence and incorrect placement of privacy curtains and resident exposure could affect the privacy and dignity of residents. <BR/>On 12/8/22 at 11:46 AM an interview was conducted with the Administrator regarding issues in the facility. She stated, she expected staff to report the need for privacy curtains and protect the resident privacy. She stated the absence and incorrect placement of privacy curtains and exposure of residents was a resident dignity issue. <BR/>Record review of the facility policy title Dignity, Revised February 2021, revealed the following documentation, Policy Statement. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation . <BR/>11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .<BR/>Record review of the facility policy titled Maintenance Service, revised November 2021 revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. <BR/>1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. <BR/>2. Functions of maintenance personnel include, but not limited to: <BR/>a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. <BR/>b. Maintaining the building in good repair and free from hazards .<BR/>f. Establish priorities in providing repair service . <BR/>i. Providing routinely scheduled maintenance service to all areas. <BR/>j. Others that may become necessary or appropriate. <BR/>3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in safe and operable manner .

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 1 of 1 facility observed for pest control.<BR/>1. <BR/>The facility failed to follow the instructions from the pest control company to have multiple holes fixed in the facility that rodents potentially used for access into the building between 1/10/2025 and 2/25/2025. <BR/>The noncompliance was identified as PNC . The noncompliance began on 1/10/2025and ended on 3/3/2025. The facility had corrected the non-compliance before the survey began. <BR/>These failures could place residents at risk for the spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings included:<BR/>Record review of facility's document titled Service inspection Report dated 1/10/2025 revealed:<BR/>After speaking with [Maintenance Man A] and [ADM ], there is a good plan for getting all the holes fixed which ultimately will fix the mouse issue. Spoke with ADM and taking a day to focus on getting the holes fixed and also mentioned hiring a contractor that can come out and just knock it out. I walked with Maintenance Man A and was able to show him the holes and even found a couple new ones. <BR/>Record review of facility's document titled Service inspection Report dated 2/25/2025 revealed:<BR/>Inspected and found the same holes that were listed previously still have not been fixed. These need to be fixed along with several other holes listed previously. The [administrator and DON] are going to try and have these fixed, but they do not have a maintenance person. As a tech I can fix these holes along with a helper it will not be professional, but the holes will be fixed a proposal has been sent out in the past but have not gotten a response for this. <BR/>During an interview with Resident #2 on 3/4/2025 at 12:07pm, she stated she had not had any more mice concerns since they patched up the holes in her room. Resident #2 was unable to recall when they patched the holes up in her room. Resident #2 stated before the holes had been fixed, she had some papers that had been chewed up. <BR/>During an interview with Resident #3 family member on 3/4/2025 at 5:30pm, she stated she had brought Resident #3 some candy bars. Resident #3's family member stated on 2/21/2025, she went to open the candy bar and she noticed the candy had been bitten into and there were mouse dropping in the drawer where the candy bars had been kept in. Resident #3's family member stated, when she notified a staff member their response to her was that the facility had a rat problem. Resident #3's family member was unable to name the staff member and Resident #3 was discharged on 2/26/2025. <BR/>During an interview with RMM on 3/05/2025 at 10:16AM, he stated the building had been without a maintenance man for a while and the last one wasn't doing his job correctly, so they had let him go. He stated they had hired a new maintenance man and he had started working at the facility two days ago [3/3/2025]. He stated he has been working with the new maintenance man and they had made some good progress and most, if not all, of the holes had been fixed. He currently stated the pest control program consisted of the Pest Control company coming out once a week until the problem is resolved and then it would go back to a monthly schedule. He stated he had also been working with housekeeping in making sure the rooms are being kept clean. He stated any mouse droppings that have been found in the past week appear old and not fresh. RMM stated he had contacted the city code enforcement in regard to the restaurant they shared an alley with. He stated the field had been unkept and there was trash pilling up which was contributing to their rodent problems. <BR/>During observations made on 3/05/2025 between 10:20AM and 11:21 AM, Rooms 8, 9,12,14, 17, 30, 45, 46, entrance lobby and halls 1 and 2 were inspected with RMM for holes. Multiple holes below the sinks had been repaired. The entrance lobby of the facility had two large holes where drywall had been replaced and sealed. Exterior campus of the facility had multiple rodent traps placed along the edges of the building. No open holes were observed. <BR/>During an interview with the DON on 3/06/2025 at 3:29pm, he stated the plan for the pest control had been to set out traps and to fix the holes. He stated the maintenance man they had, reported he had fixed all the holes, but they later learned he had not. He stated when they did a walk through about two weeks ago, they had noticed there were still holes that needed to be repaired. He stated they did find two mouse nests, one between room eight and one by the front lobby, and they were disposed of. He stated at this point all the holes should be fixed. He stated the facility did not hire an external entity for facility repairs. He stated he felt the steps the facility had taken had been adequate. He stated the potential negative outcome of rodents being in the facility could be infection control or people getting sick. <BR/>During an interview with the ADM on 3/06/2025 at 3:52pm, he stated he believed the lack of a maintenance man was the reason they were unable to address the issues with the rodents. He stated now that they had repaired most of the holes and they had a new maintenance man , they would be monitoring for new holes and any signs of continued rodent issues. He stated they have at this time increase the visits from the Pest control Company to weekly visits. He stated they would continue to remove any unnecessary clutter from the facility because that can also draw them in. He stated the potential negative outcome of not having an adequate pest control program was an infestation and infection control issues. <BR/>Record review of facility document titled Plan of Action- Rodents undated revealed: <BR/> .Proposal<BR/>Observations/Reports: rodent activity has been reported in resident rooms. Recommend service escalation to mitigate theses issues. <BR/>Temporary escalation Recommended- until issues subside- weekly.<BR/>Record review of facility document titled Pest Management Service Agreement dated 2/2/22 revealed:<BR/>Services to be performed.<BR/>a. <BR/>Perform monthly pest control services .<BR/>b. <BR/>Inspecting and treating exterior pest issues .<BR/>c. <BR/>Inspecting and treating interior pest issues .<BR/>d. <BR/>Monitoring and maintain any equipment use to bait and or eliminate pest inside and outside the building <BR/>e. <BR/>When requested, treat specific areas that are experiencing a particular problem .<BR/>f. <BR/>Providing suggestions and advice to the staff that would help alleviate any existing pest issues and prevent future issues.<BR/>Record review of facility document titled Pest Control last revised May 2008 revealed:<BR/>Our facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents <BR/>6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 1 of 1 resident was reviewed for privacy (Resident #8). <BR/>1. LVN B left Resident #8's information up on the screen while her computer cart was on the other side of the nurse's station, and she was at the nurse's station. The computer screen was left up with Resident #8's information up and residents were walking by, putting Resident #8's information at risk.<BR/>This failure could place residents at risk of having medical information exposed to others and misuse of personal information. <BR/>Findings Included: <BR/>Resident #8:<BR/>Record review of an admission Record review for Resident #8 showed a [AGE] year-old male with an original admission date of 7/21/2022 and a readmission date of 11/23/2024 with diagnoses of end stage renal disease, fluid overload, atrial fibrillation, insomnia, lesions of oral mucosa, muscle spasm, edema, nausea, difficulty in walking, lack of coordination, abnormal posture, pain, muscle weakness, encephalopathy, pleural effusion, pneumonia, severe sepsis with septic shock, dependence on renal dialysis, depressive disorders, acute kidney failure, respiratory failure with hypoxia, essential (primary) hypertension, type 2 diabetes mellitus without complications, unspecified with intoxication with perceptual disturbance, metabolic encephalopathy, chronic obstructive pulmonary disease, and right heart failure.<BR/>Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #8 indicated a BIMS (Brief Interview for Mental Status) score of 10 meaning Resident #8 was moderately cognitively impaired. <BR/>An observation was made of an exposed medical record for Resident #8 on 1/17/2025 at 4:18 PM. While making observations for call lights, it was observed that LVN B was sitting at the nurse's station behind the desk while her computer was on the medication cart on the opposite side of the nurse's station. The computer was left open and exposed while residents were walking by the exposed chart. <BR/>During an interview on 1/17/2025 at 4:27 PM, LVN B stated that she should have minimized the screen, but she had thought that if she were at the nurse's station it would be good. LVN B stated that she was not by the open medical record. LVN B stated that she had been trained in privacy. LVN B stated that she had not had any recent training in privacy due to new management. LVN B stated that the negative potential outcome of not providing privacy for resident's medical records was that the wrong person could get ahold of the resident information and misuse their information. LVN B stated that she should have locked the screen. <BR/>During an interview on 1/17/2025 at 5:53 PM, the DON stated that he expected all staff to abide by HIPAA. The DON stated that he expected the staff to minimize the screen or lock the screen to provide privacy to all residents. The DON stated that it was the responsibility of all staff to provide privacy to all residents and to protect their personal and medical information. The DON stated that the negative potential outcome could be that it could cause extortion and stealing resident information. <BR/>During an interview on 1/17/2025 at 6:01 PM, the Administrator stated that he expected that anytime the staff walked away from the kiosk, then the screen was to be locked or minimized. The Administrator stated that he was getting an in-service together. The Administrator stated that it could cause a resident's information to get stolen and cause identity theft and sometimes it takes years for someone to be able to correct that situation. <BR/>Record Review of facility provided policy, Labeled, Electronic Medical Records, date Revised in June 2019, stated: <BR/>Policy Statement: Electronic medical records may be used in lieu of paper records when approved by the Administrator.<BR/>Policy Interpretation: <BR/>3. <BR/>Only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system.<BR/>4. <BR/>The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure.<BR/>8. <BR/>Our electronic medical records system has safeguards to prevent unauthorized access of electronic protected health information (e-PHI). These safeguards include administrative, technical, and physical safeguards that are appropriate for:<BR/>a. <BR/>The probability and criticality of risks to e-PHI based on a thorough risk analysis conducted by this facility.<BR/>b. <BR/>The size, complexity, and capabilities of this organization; and<BR/>c. <BR/>The technical infrastructure, hardware, software, and security capabilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 2 medication carts (med cart on South Hall). <BR/>MA B had loose pills in the medication cart assigned to her on South Hall. <BR/>This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. <BR/>The findings include: <BR/>Record Review of Resident #42's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, depression, anxiety, urgency of urination, allergic rhinitis, type 2 diabetes with high blood sugar, congestive heart failure, irritable bowel syndrome with constipation, cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver, muscle wasting and atrophy, high blood pressure, reduced mobility. <BR/>Record Review of Resident #50's face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, anxiety, aphasia (loss or difficulty to understand or express speech), muscle weakness, depression, muscle spasm, constipation, high blood pressure, type 2 diabetes, hyperlipidemia, hyperthyroidism, pulmonary hypertension. <BR/>Record Review of Resident #56's face sheet reflected he was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of: end stage renal disease, fluid overload, gastrointestinal hemorrhage (a sign of a disorder in the digestive tract), hypotension, allergic rhinitis, thrombocytopenia (low platelets), depression, difficulty swallowing, bipolar disorder, type 2 diabetes, muscle weakness, renal dialysis (is a treatment for people whose kidneys are failing), muscle wasting and atrophy, acid reflux, hyperlipidemia, hypothyroidism, chronic kidney disease. <BR/> Observation and interview on 02/07/2024 at 1:28 pm during a medication cart check with MA B, revealed 6 loose medications in the medication cart in which MA B was responsible for. The medications that were found were as listed: glyburide 5 mg (1 pill) belonging to Resident #50, atorvastatin 20 mg (2 pills) belonging to Resident #50, hydroxyzine hydrochloride 25 mg (2) pill belonging to Resident #42, and carvedilol 6.25 mg belonging to Resident #56. The medications were identified by MA B by locating the medication cards and locating the missing medications. MA B observed the loose medications in her cart. MA B stated that it had been her responsibility to check her cart upon taking responsibility of the cart for the day. MA B stated that the charge nurse is also responsible for checking the carts and carts are usually checked before every shift. MA B stated that she had been trained in medication storage through in-services and the facility will hold in-services approximately monthly. MA B stated that the negative potential outcome for having loose medications in the cart is that the resident could not have enough medication and the pharmacy may not refill their medications causing a missed medication. <BR/>Interview with the Clinical Resource Nurse on 02/07/2023 at 1:42 pm revealed the Clinical Resource Nurse was informed of the loose medications found on the cart during the medication cart check. The Clinical Resource Nurse stated that he expects all staff that is responsible for the cart to check the cart prior to shift. The Clinical Resource Nurse stated that the negative potential outcome for loose medications on the cart is that it could cause a resident to miss a dose of medication because they have to dispose of that medication. The Clinical Resource Nurse stated that he will be in-serviced on loose medications. <BR/>Interview with the DON on 02/07/2024 at 1:53 pm. revealed the DON stated that she expects the staff to keep the carts and storage clean. The DON stated that the medication aides are responsible for checking the carts prior to the beginning of their shift. The DON stated that the ADON will do random cart checks to make sure that the cart is cleaned and are checked approximately weekly. The DON stated that the negative potential outcome for loose medications is that the wrong resident could get the medication, or it could cause a missed medication. The DON stated that an in-service will be completed. The DON stated that staff have been trained on expired medications and loose pills through in-services and in-services occur approximately bi-weekly. <BR/>Interview with the Administrator on 02/07/2024 at 2:01 pm., The Administrator stated that the negative potential outcome for loose medications on the cart could cause a resident to have a missed medication because not enough medication left. The Administrator stated that the staff will get in-serviced on loose medications and expired medications. <BR/>Record Review of facility provided policy, labeled, Storage of Medications, provided on 02/08/2024 date Revised November 2020, revealed: <BR/>Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. <BR/>Policy Interpretation and Implementation: <BR/>2. Drugs and Biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 2 of 5 residents (Resident #1, Resident #2) reviewed for supervision. The facility failed to ensure Resident #1, and Resident #2 received supervision to prevent Resident #2, who had a history of sexual behaviors, from sexually abusing Resident #1, when she put her hand in her panties. Resident #1 was on one to one (1:1) supervision due to a previous incident of aggression with a different resident; however, she was allowed to alone in her room with Resident #2. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm, due to lack of supervision.Findings include: <BR/>Resident #2<BR/>Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression).<BR/>*Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: <BR/>Section C Brief Interview for Mental Status (BIMS) score revealed a score of 1 which indicated the resident's cognition was severely impaired.<BR/>Section E-Behavior:<BR/>Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days.<BR/>Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days.<BR/>Functional Abilities-Mobility: Walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. <BR/>*Record review of Resident #2's Care Plan, dated 08/24/25 revealed her inappropriate sexual activity was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25.<BR/>Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary.<BR/>Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection.<BR/>*Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma.<BR/>On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. <BR/>On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzheimer's late onset to Resident #2's diagnosis. <BR/>Resident #1:<BR/>Record review of Resident #1's Face Sheet current as 0f 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), insomnia (trouble sleeping).<BR/>*Record review of Resident #1's admission Comprehensive Minimum Data Set, dated [DATE] revealed: <BR/>Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired.<BR/>Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. <BR/>Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited.<BR/>Functional Abilities-Mobility, walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper.<BR/>*Record review of Resident #1's Care Plan dated 08/12/25 included:<BR/>Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety.<BR/>Problem, on 08/12/25 the plan included that she had been physically aggressive towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others.<BR/>*Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1 was assessed and she had no signs of trauma. <BR/>*Record review of Resident #1's Progress Notes indicated the following:<BR/>On 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. 08/23/35 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma.<BR/>During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. <BR/>During an interview on 09/03/25 at 10:46 am, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the living/dining area and saw Resident #2 go into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. <BR/> During an interview on 9/04/25 at 1:34 PM CNA P stated that prior to 08/23/25, she had never done 1:1 observation. She stated she was working on 08/23/25. She stated she did not recall anyone specifically telling her that they were leaving, and they were the 1:1 staff for Resident # 1. She stated on 08/23/25 she was the person to get Resident #1 dressed and she sat her at the dining room table.<BR/>During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody had hurt her and she could not recall being touched on her body by Resident #2.<BR/>During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #1 had a history of inappropriate sexual behavior.<BR/>During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and CNP replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall a night CNA informing her that she was leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table.<BR/>During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. The admission Coordinator said she did not review Resident #2's notes in the admission packet; and then confirmed Resident #2's admission transfer notes did include 3 incidents of inappropriate sexual behavior 08/03/25 - two incidents, and one incident on 07/16/25.<BR/>During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation.<BR/>During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission.<BR/>During an interview on 09/04/25 at 1:19 PM, the FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. <BR/>During an interview on 09/04/21 at 1:41 PM, the DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggressor on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle, and he had to move her hand away. The DON said he asked LVN F to supervise his assessment of Resident #2's and nothing else happened. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #1's pants, and that Resident #1 did not have a 1:1 observation at the time of this incident.<BR/>During an interview on 9/04/25 at 1:40 PM CNA E stated that she has never been any resident's 1:1 staff. She stated they are typically informed by the DON or the previous shift staff may tell them if a resident is on 1:1 supervision. She stated the DON would tell them if a resident was off 1:1 supervision. She stated she had been trained by the facility staff that they stay until relief comes. She stated she did not know when, but the training had occurred since she had been at the facility.<BR/>During an interview on 09/04/25 at 2:18 PM, the Administrator indicated that the facility's investigation included that LVN F witnessed said she witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff.<BR/>During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 AM on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left.<BR/>During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2.<BR/>During an interview on 09/05/25 at 10:35 PM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days, and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because you don't know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties.<BR/>During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25, Resident #2 was not assigned special observation; however, Resident #1 was on 1:1 observation due to an incident of aggression on 08/21/25. On 08/23/25 LVN F said she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs &ldquo;come get them&rdquo; and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she was not informed CNA O was not starting her shift at 6 AM, had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON.<BR/>The facility's policy and procedure, Observation Levels, dated 04/2024 indicated &ldquo;It is the policy of the facility that staff monitoring is instituted to maintain the safety of each resident and provided by a system of progressive intensity of resident observation and oversight. The use of the level that provide each resident with optimal level of safety in the least restrictive manner will be utilized. Resident will be routinely observed in compliance with physician orders and/or clinical protocols.&rdquo; <BR/>The level of supervision included:<BR/>Standard observation (assess and document at no less than every two hours). Minimum level of observation for all residents.<BR/>Line of sight (assess and document at 15-minute intervals). A level of observation wherein the resident remains in staff view. A specific staff member may be assigned, and the line-of-sight observation is maintained by staff in person and not through video monitoring.<BR/>One to one (staff member constantly with the resident and documents at 15-minute intervals). Consist of One-to-one with a resident never farther away than 10 or less feet. The residents must remain within this parameter. A licensed nurse my place a resident ton line-of-sight or one-on-one and increase the level of observation at any time as clinically necessary. In all cases the least restrictive clinically appropriate intervention will be implemented. The license nurse my not decrease the level of observation until conferring with the director of nursing/designee and/or physician.<BR/>The procedure includes three levels of resident observation are used. The levels are designated to provide increasing intensity of observation, precaution, and oversight commensurate with physician and staff. The appropriate observation level is implemented:<BR/>After evaluation and assessment, a level of observation may be instituted by the attending physician or registered nurse.<BR/>If a registered nurse institutes an observation level, the attending physician is notified as soon as possible.<BR/>The physician's order shall include the Observation Level and the reason for the monitoring.<BR/>The charge nurse will assign staff to perform the standard observation level on a designated set of residents. Resident online of sight or one on one will be assigned specific staff.<BR/>The charge nurse will assign staff to perform the standard observation level on a specific designated set of residents. Resident online of sight or one on one will be assigned specific staff. The nurse will arrange for staff to be relieved for breaks and meals. <BR/>Assigned staff will complete the resident observations as rounds are made and document on the rounds from. Staff will observe the resident's location and note the residents' behavior. Rounds are not to be documented in advance.<BR/>In addition to recording the whereabouts of resident at ordered intervals, the purpose of observation is to provide a system of progressive intensity of resident observation, precaution and oversight based on resident acuity, severity and type of symptoms, and overall needs.<BR/>The order of observation level is communicated to all staff.<BR/>Staff must hand-off responsibility for maintaining observation of assigned resident of any break or potential interruption in completing assigned rounds.<BR/>The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided.<BR/>The following Plan of Removal was accepted on 09/05/2025 at 10:46AM:<BR/>&ldquo;Plan of Removal<BR/>09/05/2025<BR/>The facility failed to provide the &ldquo;planned&rdquo; or &ldquo;scheduled&rdquo; 1:1 supervision for resident #1 that resulted in exposing her to a hazard of being inappropriately / sexually touched by resident #2.<BR/>1. On 08/23/25 Resident #2, who was the aggressor that put her hand inside Resident #1's panties, was placed on 1:1 observation. Resident #1, who was supposed to be on 1:1 observation when Resident #2 put her hand in her panties, was returned to 1:1 observation. On 08/26/25, Resident #2 was taken off of 1:1 observation after IDT's review.Person(s) Responsible: Administrator, Director of Nursing, and/or DesigneeDate: 8/26/2025<BR/>2. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designeeDate: 8/23/2025<BR/>3. Education was provided to the Administrator and the Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and the Resident-to-Resident Policy.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse ConsultantDate: 9/4/2025<BR/>4. All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 9/4/2025<BR/>5. When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025<BR/>6. QAPI&mdash;<BR/>Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time.Person(s) Responsible: AdministratorDate: 9/4/2025<BR/>7. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. <BR/>On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Observation on 09/05/25 at 7:55 AM revealed CNAs B, C and DON were working on the memory unit. The DON, who was monitoring, said he was filling in because CNA M was not able to work her shift, and ADON, would also fill in as needed. The DON said there was not a resident in this unit, who was on 1:1 observation or a special level of observation. The staff were expected to monitor and prevent Resident #2 from entering a resident's room. The memory unit had a 3-foot-tall wall that is approximately 12 feet wide and separates the living/dining area from the hallway, which allowed staff to see the residents in the living/dining area and the hallway. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 8:05 AM, revealed Resident #2 was observed walking around the living/dining area and the CNAs were in the hallway and living/dining area observing approximately 9 Residents, including Residents #1 and #2. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 10:06 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 11:21 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 11:23 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was standing near the CNAs. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 2:10 PM, CNAs, B, C, and LVN F, who was monitoring, were on duty, and Resident #2 was walking in the living/dining area. Resident #2 did not enter a resident's room. <BR/>Observation on 09/05/25 at 4:55 PM, CNAs B and C, and MA G, who was monitoring, were in the memory care unit, and Resident #2 was walking in the hallway. Resident #2 did not enter a resident's room. <BR/>Interview on 09/05/25 at 12:57 PM, the DON indicated Resident #2 was the only one identified with sexual behaviors; however, since 08/23/25 she had not made any attempts to touch a resident or staff inappropriately. <BR/>*Record Review of Resident #2's Event Report dated 09/03/25 indicated:<BR/>On 08/24/25 at 10:54 AM. Resident #2 was being monitored on the memory unit on, and she was wandering among the common areas with 1:1 assigned staff member. She exhibits no signs of agitation or pain. She has minimal verbal exchanges and has been minimal in complete thoughts and sentences. <BR/>On 08/24 at 4:22 PM Resident #2 only makes visual contact nonverbal, in good spirit, affect appropriate, and can't assist with questions to complete any SW admission assessments. <BR/>On 08/26/25 at 10:56 AM revealed Resident #2's Interdisciplinary Team met and discontinued her 1:1 observation. <BR/>On 09/02/05 LVN F received orders from FNP T, who was in the facility, to complete Resident #2 a CBC, CMP, TSH, A1C, senior psych referral, and Aricept 5mg q hs. This report included that on <BR/>On 09/02/25 at 10:37 AM LVN F received orders from PNP to change Remeron to HS, change Paxil to AM, monitor for over sedation, and add history of Alzheimer's late onset. <BR/>*Review Resident #2's FNP T's Progress Note dated 09/02/25 indicated Resident #2 was taking Aricept 5 mg at bedtime orally once a day. This assessment indicated Resident #2 required memory care unit, Aricept, and psych consult. <BR/>During interview conducted with staff on duty on 09/05/25 from 10:06 PM until 5:01 PM that worked on the 6 AM to 6 PM shift (FNP T at 10:06 PM, LVN F at 10:35 AM , DON at 11:09 PM, ADON at 11:32 PM, CNA H at 1:06 pm, LVN I at 1:36 PM, CNA HH at 1:56 PM, LVN F at 1:49 PM, SW at 2:12 PM, CNA P at 2:32 PM, Activity Director at 2:50 PM, MA J at 2:58 PM, CNA II, at 3:23 PM, Admissions Coordinator at 3:29 PM, HK Supervisor at 4:45 PM, MA G at 5:42 PM), and 6 pm to 6 am shifts (RN Z at 5:51 PM, and CNA and CNA D at 1:28 PM). These staff were in-serviced on preventing Abuse, Neglect, and Exploitation, Levels of Observation, and Resident to Resident Altercat

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 2 of 4 common resident baths (Station 1 (right and left)) and 1 of 5 resident rooms on Station1 (room [ROOM NUMBER]) which affected 3 of 8 residents (#27, 46 and 126), in that:<BR/>1)The facility failed to ensure the shower gurney padded overlay was not damaged with splits and torn areas that exposed the foam interior (1 of 4 baths (Station 1 (right)), <BR/>2) The facility failed to ensure shower chair mesh was not torn and frayed (1 of 4 baths (Station 1 (left)), and <BR/>3) The facility failed to ensure one of 5 resident rooms on Station 1 did not have lingering, pervasive sewer type odors (room [ROOM NUMBER]).<BR/>These failures could lead to resident's injuries, spread of infections and cause the facility to have an unsightly appearance. <BR/>The findings include:<BR/>On 12/6/22 add 2:38 PM an observation was made of CNAs A and B transferring Resident #27 from the shower bed/gurney to his bed by Hoyer lift. It was also observed that there was an approximately 3-inch C-shaped split/tear on the gurney's foam overlay top surface. This split exposed the interior foam of the overlay.<BR/>On 12/7/22 at 8:40 AM Resident #126 was observed in bed and there was a strong lingering sewer type odor coming from the restroom. The restroom door was open and Resident #126's bed was next to the restroom. Resident #27 also resided in this room.<BR/>On 12/7/22 at 9:39 AM an interview was conducted with the Maintenance Supervisor, regarding odors in room [ROOM NUMBER]. He stated it was a possibility that water was not flushed in the drains in a long time which causes odors. He stated he typically did not check rooms for sewer odors with any regularity. He further stated he did not routinely flush the drains in rooms where showers and sinks were not regularly used such as in room [ROOM NUMBER].<BR/>On 12/7/22 at 6:26 PM an observation was made of the Station one right side bath. The shower bed/gurney foam overlay had an approximately 2-inch and a 3-inch slash/tear on the underside that exposed the foam interior. On the top side, there was an approximately 3-inch C-shaped deep slit/tear on the top surface of the foam overlay and the foam interior was exposed.<BR/>On 12/8/22 at 8:19 AM an interview was conducted with the Maintenance Supervisor, and he stated the facility tracked and reported maintenance requests/repairs through the TELS online maintenance system and verbally by staff. He added he makes a list each morning of what staff reported to him. He also stated that staff can enter reports/requests in TELS. He stated staff have not used the TELS system to the best of its ability and repair requests were mostly verbal reports. <BR/>On 12/8/22 at 11:01 AM an observation was made of the Station one left bath and two of two shower chairs had mesh backs that were stretched, torn and frayed. One of two of the shower chairs had one side of the mesh back torn and pulling partially from the frame; approximately an 8-inch tear.<BR/>On 12/8/22 at 11:32 AM an observation of the right bath on Station one revealed the shower bed/gurney overlay had splits on the top and bottom surface. <BR/>On 12/8/22 at 12:04 PM an interview was conducted with the DON. She stated she was not sure why the repairs for the shower chairs and the overlay on the gurney were not reported. The Administrator stated at that time that she felt that it was a staff consistency issue as to why the issues were not reported. The Administrator stated she expected staff to have reported the needed repairs in the TELS system and pulled the shower chairs and overlay from service. She stated these repair issues could result in a negative outcome for residents that included injuries and infections.<BR/>On 12/8/22 at 2:23 PM there was a strong pervasive sewer type odor observed in room [ROOM NUMBER]. Resident #126's bed was next to the restroom door where the sewer odor was emanating.<BR/>On 12/8/22 at 2:34 PM an interview was conducted with the Maintenance Supervisor about the odor in room [ROOM NUMBER]. He stated he typically did not flush the drains in room [ROOM NUMBER] to prevent the sewer odors. <BR/>On 12/8/22 at 5:14 PM, an interview was conducted with the Administrator. She stated the foul odors would cause the resident environment to be unpleasant. <BR/>Record review of the list of residents using the shower bed/gurney, dated 12/8/22, revealed that there were four residents in the facility who used the shower gurney/shower bed. The residents were Residents #2, 26, 47 and 126.<BR/>Record review of the facility policy titled Maintenance Service, revised November 2021 revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. <BR/>1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. <BR/>2. Functions of maintenance personnel include, but not limited to: <BR/>a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. <BR/>b. Maintaining the building in good repair and free from hazards . <BR/>f. Establish priorities in providing repair service . <BR/>i. Providing routinely scheduled maintenance service to all areas. <BR/>j. Others that may become necessary or appropriate. <BR/>3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in safe and operable manner .<BR/>Record review of the facility policy titled Home Like Environment, Revised February 2021, revealed the following documentation, Policy Statement. Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible. Policy Interpretation and Implementation. <BR/>1. Staff provides person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. <BR/>2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect their personal lives, homelike setting. These characteristics include: <BR/>a. Clean, sanitary and orderly environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 22 residents (Residents #43) reviewed for advance directives.<BR/>1. Resident #43's Out-of-Hospital Do Not Resuscitate (OOH-DNR) and physician orders were not consistent.<BR/>This failure could place residents at risk for not having their end of life wishes honored and incomplete records.<BR/>Findings included:<BR/>Record review of Resident #43's face sheet, dated 02/06/24, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia (mental disorder), rhabdomyolysis (rare muscle injury) and pain. The face sheet also revealed Resident #43's advance directives were: Do Not Resuscitate.<BR/>Record review of Resident #43's active physician order summary dated 02/06/24 revealed physician orders listed code status: full code with a start date of 09/27/23. <BR/>Record review of Resident #43's Out of Hospital Do Not Resuscitate form revealed a completed form dated 11/15/23.<BR/>Record review of Resident #43's comprehensive MDS, dated [DATE], revealed Resident #43 was understood and had a BIMS score of 04 which indicated his cognition was severely impaired.<BR/>During an interview on 02/08/24 at 12:45 PM, the SW stated she was responsible for updating the OOH-DNR and any other advance directives, but the DON was responsible for updating the physician orders. The SW stated she remembers telling the DON about the change in code status and was unsure why the physician orders were not updated. <BR/>During an interview on 02/08/24 at 12:50 PM, the DON stated she was responsible for updating the code status for the residents in their physician orders. The DON stated it is unknown why the physician orders were not updated for Resident #43. The DON stated the potential negative outcome to the resident would be their wishes would not be met. <BR/>During an interview on 02/08/24 at 2:53 PM, the ADM stated the DON and the SW were responsible for updating the residents' chart if their code status changed. The ADM stated he did not know why the physician orders were not updated when Resident #43's code status changed. The ADM stated the potential negative outcome to the residents was they would not have their wishes granted regarding end of life. <BR/>Record review of the facility policy titled, Do Not Resuscitate, with a reviewed date of 05/20, reflected the following:<BR/>Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 22 residents (Residents #43) reviewed for advance directives.<BR/>1. Resident #43's Out-of-Hospital Do Not Resuscitate (OOH-DNR) and physician orders were not consistent.<BR/>This failure could place residents at risk for not having their end of life wishes honored and incomplete records.<BR/>Findings included:<BR/>Record review of Resident #43's face sheet, dated 02/06/24, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia (mental disorder), rhabdomyolysis (rare muscle injury) and pain. The face sheet also revealed Resident #43's advance directives were: Do Not Resuscitate.<BR/>Record review of Resident #43's active physician order summary dated 02/06/24 revealed physician orders listed code status: full code with a start date of 09/27/23. <BR/>Record review of Resident #43's Out of Hospital Do Not Resuscitate form revealed a completed form dated 11/15/23.<BR/>Record review of Resident #43's comprehensive MDS, dated [DATE], revealed Resident #43 was understood and had a BIMS score of 04 which indicated his cognition was severely impaired.<BR/>During an interview on 02/08/24 at 12:45 PM, the SW stated she was responsible for updating the OOH-DNR and any other advance directives, but the DON was responsible for updating the physician orders. The SW stated she remembers telling the DON about the change in code status and was unsure why the physician orders were not updated. <BR/>During an interview on 02/08/24 at 12:50 PM, the DON stated she was responsible for updating the code status for the residents in their physician orders. The DON stated it is unknown why the physician orders were not updated for Resident #43. The DON stated the potential negative outcome to the resident would be their wishes would not be met. <BR/>During an interview on 02/08/24 at 2:53 PM, the ADM stated the DON and the SW were responsible for updating the residents' chart if their code status changed. The ADM stated he did not know why the physician orders were not updated when Resident #43's code status changed. The ADM stated the potential negative outcome to the residents was they would not have their wishes granted regarding end of life. <BR/>Record review of the facility policy titled, Do Not Resuscitate, with a reviewed date of 05/20, reflected the following:<BR/>Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive plan must be prepared by an interdisciplinary team to the extent practicable, the participation of the resident and the resident's representative(s)of the care plan conference for 2 of 22 residents (Resident #33 and Resident #43) reviewed for comprehensive resident centered care plans.<BR/>The facility failed to invite Resident #33 and Resident #43 or the representatives to attend their care plan conferences.<BR/>These failures placed the residents at risk for unmet care needs and a decreased quality of life. <BR/>Findings included:<BR/>Resident #33<BR/>Record review of Resident #33's face sheet, dated 02/07/24, revealed a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Benign neoplasm of pineal gland (central nervous system tumors, which begin in the brain), Reduced mobility (unsteadiness while walking, difficulty getting in and out of a chair, or falls), Symptomatic epilepsy (a type of seizure) (repeated seizures-defined as a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain) & epileptic syndromes with complex partial seizures (most common type of epilepsy in adults -can last as long as 30 seconds to 2 minutes), anxiety disorder (persistent excessive worry that interfere with daily activities), conversion disorder with seizures or convulsions (a condition where a mental health issue disrupts how the brain works, physical symptoms that a person cannot control), hypotension (low blood pressure), cognitive communication deficit (difficulty with thinking and how someone uses language), pain (physical suffering or discomfort caused by illness or injury), oropharyngeal phase dysphagia (difficulty swallowing food & liquids), and lack of coordination (muscle control problem that causes an inability to coordinate movements; leads to jerky, unsteady, to-and-fro motion). <BR/>Record review of quarterly MDS assessment dated [DATE] revealed Resident #33 had a staff assessment for mental status revealed short-term and long-term memory problems, memory/recall ability was none, and cognitive skills for daily decision making was 03 (severely impaired-never/rarely made decisions). The MDS further revealed Resident #33 required substantial/maximal assistance with eating; oral, toilet, personal hygiene; bathing; upper and lower dressing; putting on/off footwear; partial/moderate assistance with rolling right & left, sit to lying, lying to sitting on side of bed; sit to stand; chair/bed-to-chair transfer; always incontinent of bladder and bowel; receives 51% or more nutrition by tube feeding seven days a week. <BR/>In an interview on 02/07/2024 at 5:54 PM, Resident #33's family member stated the only care plan meetings that had been attended were with the local authority for PASRR.<BR/>Record review of care conference report for Resident #33 revealed a quarterly care planning meeting dated 12/05/2023 with the social worker, the activity director and the MDS coordinator. <BR/>Record review of care conference report for Resident #33 revealed a quarterly care planning meeting dated 01/24/2024 with ADON A, the DON, the social worker, the activity director, the administrator, the MDS coordinator, and ADON B. <BR/>Record review of Resident #33's progress notes dated 04/23/2023 - 02/07/2024 revealed no documentation that Resident #33 or Resident #33's representative was invited to the care plan meeting. <BR/>Resident #43<BR/>Record review of Resident #43's face sheet, dated 02/06/24, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia (mental disorder), rhabdomyolysis (rare muscle injury) and pain. <BR/>Record review of Resident #43's comprehensive MDS assessment, dated 09/18/23, revealed Resident #43 was understood and had a BIMS score of 04 which indicated his cognition was severely impaired.<BR/>During a phone interview on 02/07/24 at 11:28 AM, Resident #43's RP stated she had not been invited to a care plan meeting since the beginning of last year (2023). <BR/>Record review of Resident #43's care conference report revealed a quarterly meeting was held on 02/14/23 and Resident #43's RP was listed as one of the attendees. <BR/>Record review of Resident #43's care conference report revealed a quarterly meeting was held on 10/26/23 and Resident #43's RP was not listed as one of the attendees.<BR/>Record review of Resident #43's progress notes dated 08/01/2023 - 02/07/2024 revealed no documentation that Resident #43 or Resident #43's RP was invited to the care plan meeting. <BR/>During an interview on 02/08/24 at 2:16 PM, the SW stated she was responsible for inviting residents and their RP to care plan meetings. The SW stated Resident #43 had a care plan meeting on 10/26/23 and she confirmed Resident #43's RP was not at the meeting. The SW stated she remembered calling Resident #43's RP to invite her to the care plan meeting and stated she usually did a progress note about it. The SW stated she was not able to locate the progress report and she did not document it anywhere else. The SW stated she understands if something was not documented, there was no way to prove it was done. The SW stated the potential negative outcome to the resident and their RP was they would not know what was current in the residents' care and they would not know about any new orders. <BR/>During an interview on 02/08/24 at 2:53 PM, the ADM stated the SW was responsible for inviting residents' and their RP to care plan meetings. The ADM stated he did not know why Resident #33 and Resident #43's RPs were not invited to their care plan meetings. The ADM stated he expected the SW to document all invitations to care plan meetings. The ADM stated the potential negative outcome to the residents' and their RP was families may not know what was going on with the resident and families would not have a chance to address all members of the team. <BR/>In an interview on 02/08/2024 at 5:15 PM, the social worker stated Resident #33 has had care plan meetings with the local authority for PASRR and she was documenting on her side of the quarterly meetings when PASRR met. She agreed there were no notes in the care conference reports prior to 12/05/2023 of care plan meetings and no documentation of invitations to the resident representative. She stated if it was not documented, it did not happen. She stated the negative outcome of not having care plan meetings were that the resident's care could not have continuity for all departments: nursing, dietary, activities, and psychosocial.<BR/>Record review of the facility policy titled, Comprehensive Care Plans with a revised date of 01/26/24, reflected the following:<BR/>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, mental and psychosocial needs that are identified in the resident's comprehensive assessment.<BR/>Policy Explanation and Compliance Guidelines:<BR/> .4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to:<BR/>a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan.<BR/>b. A registered nurse with responsibility for the resident.<BR/>c. A nurse aide with responsibility for the resident.<BR/>2 d. A member of the food and nutrition services staff.<BR/>e. The resident and the resident's representative, to the extent practicable.<BR/>f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 2 of 24 residents reviewed for unnecessary medications (Resident #40 and #32).<BR/>1. The facility failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 11/28/2024 and Lorazepam (medication used to treat anxiety disorders) dated 12/18/2024 had a stop date to ensure the medication did not extend beyond 14 days for Resident #40.<BR/>2. The facility failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 12/16/2024 had a stop date to ensure the medication did not extend beyond 14 days for Resident #32.<BR/>This failure placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs and placed residents at risk for receiving unnecessary medications.<BR/>Findings include: <BR/>Record review of Resident #40's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #40 had a medical history of paranoid schizophrenia (a chronic mental illness characterized by disruptions in thought, perception, emotion, and behavior), rhabdomyolysis (serious condition where damaged skeletal muscle breaks down rapidly), and generalized anxiety disorder. Resident #40 had a legal responsible party listed in the face sheet.<BR/>Record review of Resident #40's quarterly MDS Section C- Cognitive Patterns dated 2/8/2025 revealed no BIMS score which indicates Resident #40 is rarely/never understood. <BR/>Record review of Resident #40's physician orders revealed an order for lorazepam - Schedule IV tablet: 0.5 mg . Every 6 Hours - PRN, start date 12/18/2024 with no end date. Physician orders revealed an order for Lorazepam Intensol (lorazepam) - Schedule IV concentrate; 2 mg/mL; amt:0.25mL; oral Every 2 Hours - PRN, start date 1/03/2025 with no end date. <BR/>Record review of Resident #40's care plan dated 2/13/2025 revealed resident had Problem start date: 10/28/2024, category psychotropic drug use, [Resident #40] is at risk for side effects related to taking an antianxiety medication (Lorazepam). Goal: I will exhibit no side effects related to taking an antianxiety medication. <BR/>Record review of Resident #32's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #32 had a medical history of unspecified dementia (a decline in cognitive function that cannot be attributed to a specific known cause), panic disorder (a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, eventually leading to the inability to perform simple daily tasks). Resident #32 had a legal responsible party listed in the face sheet.<BR/>Record review of Resident #32's admission MDS Section C- Cognitive Patterns dated 12/24/2024 revealed a BIMs score of 00 which indicates Resident #32 had severe cognitive impairment. <BR/>Record review of Resident #32's physician orders revealed an order for lorazepam - Schedule IV tablet; 0.5 mg; oral Every 6 Hours, start date 12/18/2024 with no end date. Physician orders revealed an order for Lorazepam Intensol (lorazepam) - Schedule IV concentrate; 2 mg/mL; amt:0.25mL; oral Every 2 Hours - PRN, start date 1/03/2025 with no end date. <BR/>Record review of Resident #32's care plan dated 12/19/2024 revealed resident had Problem start date: 12/11/2024, category psychotropic drug use, Problem: Psychotropic Drug Use: I take medication to control my mood and at risk for adverse reaction. Goal: GDR (gradual dose reduction) and wean off. <BR/>During an interview with the DON on 3/13/2025 at approximately 12:15pm, he stated the nurses are responsible for ensuring residents are free of unnecessary medications. He stated they monitor compliance with unnecessary medications by doing audits monthly and quarterly reviews. He stated the PRN orders are monitored at the same time consent forms are audited. He stated the potential negative outcome of unnecessary medications could be an increased risk of drowsiness, increase risk of falls and sedation. He stated he was not aware Resident #40 and Resident #32 had PRN psychotropic medications without a 14 day stop date. <BR/>During an interview with the ADM on 3/13/2025 at 12:55pm, he stated nursing is responsible for ensuring resident are free from unnecessary or PRN medications. He stated the potential negative outcome of unnecessary medications could be Residents having an adverse medical reaction to the drug. He stated compliance is monitored with the DON along with monthly pharmacy consults. <BR/>Record review of facility policy titled Psychoactive Medications dated July 2024 revealed: <BR/>Definition <BR/>A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics .<BR/>17. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e 14 days).<BR/>a. If the attending physician or prescribing practitioner believes that it is appropriate for the prn order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the pm order.

Based on observation and interview, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for residents reviewed for accommodation of needs. <BR/>The facility failed to provide a call light or call pad system to 2 resident rooms (19 and 21) observed during investigation process. <BR/>During an observation made on 11/29/2023 at 11:59 AM. Observed Resident #3's face pad call light on the floor between the bed and nightstand. Resident #3 was unable to reach and get the call light off the floor. <BR/>During an observation made on 11/29/2023 at 1:40 PM. Observed Resident #2's call light was on the floor on the right side of the head of the bed. <BR/>During an observation made on 11/29/2023 at 1:42 PM. Observed Resident #1's call light was wedged at the end of suction machine on the nightstand on left side of the bed. <BR/>During an observation made on 11/29/2023 at 1:45 PM. Observed Resident #3's face pad call light on the floor between the bed and nightstand. Resident #3 was unable to reach and get the call light off the floor.<BR/>During an observation made on 11/29/2023 at 2:43 PM. Observed call light for Resident #1 on the suction machine on the nightstand and the resident was unable to get access to the call light. Observed Resident #1 sleeping and free from distress. <BR/>During an observation made on 11/29/2023 at 2:46 PM. Observed call light for Resident #2 on the floor and Resident #2 unable to get to the call light. <BR/>During an observation made on 11/29/2023 at 2:55 PM of Resident #3 Observed the face pad call light on the floor in between Resident #3's bed and the nightstand. Resident #3 would not have been able to get to the face pad call light due to being quadriplegic and not able to get to the call light. <BR/>During an interview with Administrator on 11/29/2023 at 5:30 PM for call lights. Administrator stated that his expectations of answering call lights was that staff should answer call lights as quickly as they can but to not leave the resident for too long without checking on them. Administrator stated that all residents should have a call light or some way of being able to call for help. Administrator stated that if the resident was unable to call for assistance, then it could be bad, really bad. Administrator stated that if the call lights are not being answered then it could be dangerous, and the resident needs are not being met. Administrator stated that the residents that are not able to get out of bed and are incontinent could run the risk of wounds getting worse or new developing wounds. Administrator stated that it could be a situation in which could have been prevented. <BR/>During an observation made on night shift of Resident #1 on 11/30/2023 at 10:04 PM. Observed Resident #1 sleeping on back, free from distress. Observed Resident #1's call light on the suctioning machine on the nightstand. Observed call light out of reach. Resident #1 was not able to move and grab call light. <BR/>During an observation made on night shift of Resident #2 on 11/30/2023 at 10:07 PM. Observed Resident #2 laying on back, Resident #2 looked restless. Observed Resident #2 with no call light. Observed oximeter machine sounding alarm and oxygen listed on machine read 90. <BR/>Record Review of facility provided policy labeled, Answering Call Light, date revised in March 2021, revealed:<BR/>Purpose: The purpose of this procedure is to ensure timely responses to the resident's request and needs. <BR/>General Guidelines: 1). Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident.<BR/> 4). Be sure that the call light is plugged in and functioning at all times. <BR/>5). When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. <BR/>6). Some residents may not be able to use their call light. Be sure you check these residents frequently. <BR/>7). Report all defective call lights to the nurse supervisor promptly.<BR/>Steps in the procedure:<BR/>3. If assistance is needed when you enter the room, summons help by using the call signal.