Grace Care Center of Nocona

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the acquiring and administering of all drugs and biologicals to meet the needs of 1 of 6 residents (Resident #9) whose records were reviewed for medication orders.<BR/>The facility failed to ensure Resident #9 Gentak ointment 0.3% (Gentamicin Sulfate) for conjunctivitis was available for administration as ordered by the physician. <BR/>This failure placed the resident at risk for eye discomfort and delayed healing and resolution of an eye infection.<BR/>The findings include:<BR/>Review of Resident #9's admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of heart failure. Additional diagnoses included: myocardial infarction; pneumonia; major depressive disorder, recurrent, severe with psychotic symptoms; chronic pain syndrome; chronic obstructive pulmonary disease; hypertensive heart disease with heart failure; other idiopathic scoliosis, thoracolumbar region; unspecified dementia with behavioral disturbance; nicotine dependence; essential (primary) hypertension; and unspecified convulsions.<BR/>Review of the Physician Visit Communication Record and Progress Note, dated 8/16/22, revealed documentation the facility notified Resident #9's physician's office regarding redness and edema of the left eye. The provider's response from the nurse practitioner documented a diagnosis of conjunctivitis and an order for Gentak every 12 hours for 7 days, with a strip applied to the lower lid.<BR/>Review of Resident #9's current Physician Orders revealed an order for Gentak 0.3% (Gentamicin Sulfate), instill 1 strip in left eye two times a day for conjunctivitis for 7 days, dated 8/16/2022. <BR/>Review of Resident #9's electronic medication administration records, dated 8/01/22-8/31/22, revealed the following:<BR/>- Moxifloxacin HCL Solution 0.5%, instill 2 drops in left eye three times a day for eye infection until 08/15/22; order date 8/08/2022.<BR/>The nurses documented the eye drops were instilled three times daily at 8 AM, 12 PM, and 8 PM 8/09/22-8/15/22. There was no documented evidence on the medication administration record that the Moxifloxacin eye drops were instilled after 8/15/22.<BR/>- Gentak 0.3% (Gentamicin Sulfate), instill 1 strip in left eye two times a day for conjunctivitis for 7 days; order dated 8/16/2022. <BR/>The nurses documented the eye ointment initial dose at 8 PM on 8/16/22, instillation two times daily at 8 AM and 8 PM on 8/17/22 - 8/22/22, and the final dose instillation dose at 8 AM on 8/23/22. <BR/>During an observation and interview on 8/22/22 at 12:36 PM, Resident #9 was sitting on the side of her bed; the room light was off. The resident's left eye was red, including the upper and lower lids. Resident #9 stated she had an infection in her eye, and she went to the doctor. She stated the nurse put eye drops in her eye. She stated her left eye hurt and light hurt her eye, so she kept the overbed light off.<BR/>In an interview on 8/22/22 at 12:38 PM, LPN G charge nurse stated Resident #9 did not receive eye ointment; she received eye drops. The LPN stated the eye ointment was not available and was not applied to the resident's left eye.<BR/>In an interview on 8/23/22 at 10:24 AM, Resident #9 stated she had received eye drops in her left eye She stated the eye ointment was not available and she had not received it. She stated the doctor was supposed to come today.<BR/>During an interview and record review on 8/24/22 at 2:22 PM, the ADON stated the charge nurses entered physician orders into the residents' electronic medication administration records. Review of Resident #9's medication orders with the ADON revealed the order for Gentak eye ointment was no longer on the resident's current orders. The ADON stated it was probably discontinued yesterday. She stated the resident received the Moxifloxacin eye drops. The ADON stated she would look for a policy and procedure for physician's orders.<BR/>Review of the facility's policy and procedure for Ordering and Receiving Non-controlled Medications, dated as revised August 2020, revealed the following [in part]:<BR/>Policy<BR/>Medications and related products are received from the pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt.<BR/>Procedures<BR/>Ordering Medications from the Pharmacy<BR/>1. Medications orders are written on a physician order form, telephone order sheet, or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR system and transmitted to the pharmacy

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 5 (Resident # 9 and Resident #5) reviewed for the physical environment. The facility failed to ensure Resident #9's window blind and chest of drawers were damaged and Resident #5's window blind was damaged. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.Findings included: Observation on 10/13/2025 at 10:00am revealed Resident's room had broken window blind (blades that when shut omit light from entering the room). The bottom drawer of the chest of drawers was missing. During an interview on 10/10/2025 at 10:03am, Resident #9 stated the window blinds were damaged when she moved into the room, and it was annoying when the sun shines in the morning. Resident #9 said the chest of drawers was missing a drawer. Resident #9 stated that it made the room appear junky and unkept. Resident #9 stated that she had not complained about the broken window blind and chest of drawers. During an interview on 10/10/2025 at 10:07am, the RP for Resident #9 was visiting and stated the broken window blind and missing drawer for the chest of drawers were damaged and missing when Resident #9 was admitted . The RP stated she mentioned to staff about repairing the items but could not remember who or when but stated it has been a while. The RP stated she believed that as much money it would cost to stay at the facility the place would be more concerned about making the resident's home more presentable. Observation on 10/10/2025 at 3:15pm revealed Resident's s window blind had missing and broken blades. During an interview on 10/10/25 at 3:16pm, Resident #5 stated the room looked cheap and sunlight came in all the time. Resident #5 stated the window blind had been broken for a long time and did not recall telling facility staff about it. Resident #5 stated if they wanted the residents' rooms to look nice, they would have fixed the window blind, but they do not care. Resident #5 stated the broken window blind made him feel like he was living in a cheap motel, not home-like. At an interview on 10/15/25 at 12:07pm, the Administrator stated she did not know about the damaged blinds in Resident #5's and Resident #9's room. The administrator stated she would order replacement blinds today (10/15/25). The Administrator stated the Maintenance man would repair the chest of drawers for Resident #9. The Administrator stated her expectation was that the equipment and furnishing in resident's room be in good repair and failing to do so could diminish quality of life and well-being of residents. Record review of facility policy titled, Maintenance Service, no date:1. The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain records on each resident that are accurately documented for 1 of 2 residents (Resident #1) reviewed for shower/bath records.<BR/>The facility failed to ensure records reflecting bathing was performed for Resident #1 according to her schedule.<BR/>This failure to maintain accurate records could affect Residents by receiving inadequate care and services they needed. <BR/>Findings include:<BR/>Record review of Resident #1's Face Sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's Disease (long term degenerative disorder of the central nervous system), Hypertensive heart disease without heart failure (heart damage that resulted from high blood pressure) and Alzheimer's (degenerative brain disease).<BR/>Record review of Resident #1's care record revealed that Resident #1 had secheduled showers on Monday, Wednesday and Friday. <BR/>Record review of Resident #1's care record titled bathing, from 02/06/2023 to 03/07/2023, documented the following missed bathing times: <BR/>Wednesday: 02/08/2023- record showed it was blank, indicating it was not completed. <BR/>Friday: 02/10/2023- record shows N/A (not applicable), failing to indicate shower was completed. <BR/>Monday: 02/13/2023- record shows N/A (not applicable), failing to indicate shower was completed <BR/>Wednesday: 02/15/2023- record showed it was blank, indicating it was not completed. <BR/>Friday: 02/17/2023- record showed it was blank, indicating it was not completed. <BR/>Monday: 02/20/2023- record showed it was blank, indicating it was not completed. <BR/>Wednesday: 02/22/2023- record showed it was blank, indicating it was not completed. <BR/>Friday: 02/24/2023- record shows N/A (not applicable), failing to indicate shower was completed.<BR/>Monday: 02/27/2023- record shows N/A (not applicable), failing to indicate shower was completed <BR/>Wednesday: 03/01/2023- record showed it was blank, indicating it was not completed. <BR/>Friday: 03/03/2023- record showed it was blank, indicating it was not completed. <BR/>During an observation and interview with Resident #1, on 03/08/2023 at 2:00 PM, he denied any concerns with the care provided and denied concerns with receiving showers regularly. Resident #1 was clean, groomed, and no concerns were identified with his appearance during this interview.<BR/>During an interview with LVN A on 03/08/2023 at 3:21 p.m. regarding Resident #1's bathing schedule, LVN A said Resident #1 was scheduled to be bathed on Monday, Wednesdays, and Fridays. She said Resident #1 had been receiving his scheduled baths, but it was not being documenting in the electronic record as she didn't know it was supposed to be documented in the electronic record. She stated this failure could place the residents at risk of not being bathed and hygiene issues. She said it was the LVN's responsibility to make sure the resident was given a bath or shower. <BR/>During an interview with the DON on 03/08/2023 at 3:30 p.m. regarding Resident #1's bathing schedule, the DON said when a resident is bathed, it was to be entered into the electronic records when it was completed, but this was not being documented correctly. The DON stated if the baths were entered into the electronic medical record, as a task, it would trigger the facility staff to document when the baths were complete. Because Resident #1's task was not entered, there was no trigger for the staff to document the completion of this task. She said the documentation error was an administration issue that occurred before she worked at the facility but she would correct it. She said Resident #1 was receiving baths but they just did not document them. She said the failure of inaccurate documentation could prevent the residents from receiving their scheduled showers which could lead to hygiene concerns. <BR/>Observations and interviews with other interviewable residents, throughout this visit, revealed residents appeared clean and groomed and denied concerns with the care provided.<BR/>Record review of the Facility's Policy and Procedure over accurate documentation was requested and not provided at the time of exit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. <BR/>The facility failed to date and label food stored in the freezer located in the dishwashing room. <BR/>The kitchen floors had food spilled throughout the food preparation area and dishwashing room. <BR/>The floors had black appearing spoiled food under the food preparation counter.<BR/>These failure placed the residents at risk for foodborne illness and compromised health status.<BR/>The findings included:<BR/>Observation on 08/22/2022 at 9:20 AM during the initial tour revealed the floors in the dishwasher room and kitchen food preparation room had several layers of yellow colored, dingy appearing sheen on the floor surface. Food crumbs were observed throughout the kitchen area and a heavy black appearing decaying of food was under the sink, oven and preparation areas. <BR/>Observation on 08/22/2022 at 9:30 AM revealed the freezer unit contained 1 zip top bag with approximately 35 frozen meat patties; one zip top bag of chicken strips, approximately 30 pieces; and 6 mini pizzas that were were not dated and were left unsealed.<BR/>Observation 08/22/2022 at 9:40 AM revealed in the kitchen preparation area there was 1 bag of pancake mix (5-pound bag) on a shelf sitting over the preparation table that was opened and was not dated when opened.<BR/>Observation on 08/23/22 at 10:00 AM revealed the floors appeared to be in the same condition and appeared to be remain unclean with food remaining from the previous day. <BR/>Observation on 8/23/2022 at 11:45 AM, during the lunch meal preparation, the Dietary Manager used a towel to remove a pan of hot rolls from the over. The towel was dropped onto the floor. The Dietary Manger picked up the towel from the floor and put it on the food preparation counter. <BR/>During an interview on 08/24/2022 at 10:00 AM, the Dietary Manager stated she had dropped the ball regarding the kitchen floor. She said she was expected to work in the kitchen, and was a Certified Nurse Assistant and was expected to work on the resident floors when the evening meal was completed. She said she just did not have the time to properly clean the kitchen. She said during the initial tour the food in the freezer should have been dated. She said she should not have put the towel she dropped on the floor back onto the counter. <BR/>Review of facility policy and procedure titled Nutrition Service, dated 06/2015, revealed the following<BR/>[in part]:<BR/>The nutrition service works as a steam to provide quality nutrition services in the identified aeras. These areas include, but are not limited to:<BR/>1. <BR/>Clinical nutrition evaluation and documentation<BR/>2. <BR/> .Sanitation.<BR/>Review of the U.S. Food and Drug Administration, 2017 Food Code, reflected:<BR/>Preventing Contamination from the Premises <BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 6 of 6 employee files (Physical Therapist A, Housekeeping Assistant B, Dietary [NAME] C, LPN D, Dietary Aide E, and Speech Therapist F) reviewed for abuse protocol. <BR/>The facility did not complete reference checks on Physical Therapist A, Housekeeping Assistant B, Dietary [NAME] C, LPN D, Dietary Aide E, and Speech Therapist F prior to employment at the facility.<BR/>This failure could place residents at risk for abuse, neglect, and exploitation. <BR/>Findings include:<BR/>Review of the facility's policy Employee Reference Checks, HR0004.4, dated 07/01/2015, revealed the following:<BR/>Policy: It is the policy of the company to conduct employment reference checks in accordance with state and federal guidelines.<BR/>Fundamental Information:<BR/>Purpose: To ensure that all applicants for employment and former employees re-applying for employment have the necessary verifiable skills and experience to perform in the position for which they are applying. <BR/>Scope: This policy applies to all applicants applying and former employees re-applying for employment.<BR/>Management Responsibility: The location manager or designee will conduct all employment references checks. <BR/>Procedure: <BR/>1. Complete a minimum of 2 reference checks from prior employers on each viable applicant for employment with the company.<BR/>A Record Review of the employee files revealed they did not include reference checks for the following employees prior to employment:<BR/>Physical Therapist A - date of hire 06/09/22<BR/>Housekeeping Assistant B - date of hire 08/04/22<BR/>Dietary [NAME] C - date of hire 06/09/22<BR/>LPN D - date of hire 08/02/22<BR/>Dietary Aide E - date of hire 07/18/22<BR/>Speech Therapist F - date of hire 06/01/22<BR/>In an interview with the Human Resource Coordinator, on 08/24/22 at 9:45 a.m., she said the employee reference checks were not completed. The Human Resource Coordinator said the corporate office handles the employee hiring process and she thought the reference checks were being completed as they were completing the criminal history and employee misconduct registry checks. <BR/>In an interview with the Administrator, on 08/24/22 at 11:00 a.m., she said the employee reference checks were not completed. The Administrator said the Human Resource Coordinator thought corporate office was completing the employee reference checks as they handle the employee hiring process.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for residents who received meals prepared and served from the facility's kitchen.<BR/>A test tray was sampled for the lunch meal on 8/23/22 and was determined to lack flavor and seasoning.<BR/>The sampled test tray for the lunch meal on 8/23/22 revealed the food items were served on a thin paper plate and were not palatably warm.<BR/>This failure placed residents at risk for diminished nutritional intake, weight loss, and decreased feelings of well-being and quality of life.<BR/>The findings included:<BR/>In the confidential Resident Council Meeting, on 08/23/2022 at 2:00 PM, 5 out of 5 residents complained that the temperature of the food served to them was cool to lukewarm and could be warmer. <BR/>Review of the Resident Council Minutes for the last 3 months revealed a resident right was reviewed every month. The minutes reflected the residents met the first Wednesday of every month. The meeting minutes, dated 8/03/22, documented one resident said she would like for the food to be warmer. <BR/>Observation of the lunch meal on 08/23/22 revealed the meal service started at 12:00 PM. Residents who ate in their rooms were served first, and the residents who ate in the dining room were served last. <BR/>There were three nursing staff members assisting with delivering meal trays to the residents.<BR/>Observation on 8/23/22 at 12:15 PM revealed the last resident meal tray was served in the dining room.<BR/>Observation of a test tray evaluation on 08/23/2022 at 12:20 PM, revealed the test tray consisted of 1/4 cup of turkey breast, 1/4 cup of puree turkey breast, 1/4 cup of steamed carrots, 1/4 cup of buttered rice which five surveyors evaluated the test tray. The turkey breast was cold, carrots and buttered rice was cold with butter rice having no taste. <BR/>During an interview and observation on 08/23/2022 at 12:25 PM the Administrator was invited to taste the food items on the test tray provided by the kitchen. She proceeded to taste the food sample and said the food tasted cool and the buttered rice did not have much flavor. She said the food provided being served on a paper plate could have been the reason for the food being cold. When the Surveyor relayed there were no more glass plates available and two residents had received their lunch on paper plates, the Administrator said they had ordered more plates.<BR/>In an interview on 08/24/2022 at 10:00 AM, the Dietary Manager said she had been working on trying to keep the food warm and had made suggestions to the Administration without success. The Dietary Manager said they had discarded the chipped and cracked plates and did not have enough plates to serve all the residents if the resident census was more than 36. She stated paper plates had been used for two residents and for the test tray for the lunch meal on 8/23/2022, which could have been the reason for the food not retaining heat. She said they needed to order more [washable/reusable] plates. A policy and procedure for meal service was requested.<BR/>[No dietary policy and procedure regarding meal delivery was available or provided.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to accurately assess each resident's status for 1 of 3 Residents (Resident #1) reviewed for assessment accuracy in that: <BR/>Resident #1's Annual MDS dated [DATE] did not have Section N (under Gradual Dose Reduction) coded correctly to reflect that the resident has received a Gradual Dose Reduction and that the medication is not contraindicated.<BR/>This failure could place residents at risk of not receiving the proper care and services due to inaccurate records.<BR/>Finding included:<BR/>Record review of Resident #1's Face Sheet, dated 05/05/2023, revealed a [AGE] year-old male, re-admitted to the facility on [DATE] with admitting diagnosis of bipolar disorder (mood swings that range form from depressive lows to manic highs) and major depressive disorder (persistent depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the Annual MDS assessment, dated 03/28/2023, revealed the following: <BR/>Section C- BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Section I- active diagnosis of anxiety (state of anxiousness), depression (feeling of sadness), bipolar disorder (mood swings that range from depressive lows to manic highs), major depressive disorder (persistent depressed mood or loss of interest in activities, causing significant impairment in daily life) and schizophrenia (relapsing episodes of psychosis). <BR/>Section N- Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent- Yes. Has a gradual dose had not been attempted- No. Has a physician documented gradual dose reduction as contraindicated- No. <BR/>Record review of Resident 1's Physician Orders dated 02/24/2023 revealed orders for Risperdal (antipsychotic) 2 mg tablet: twice daily. <BR/>Record review of Resident #1's Physician notes dated 02/24/2023 revealed that a GDR was not indicated (the medication was gradually reduced) at this time, as patient is stable on current dose. <BR/>Record review of Resident #1's Care Plan, last revised on 09/12/2023, revealed care plans for: uses psychotropic medications; antidepressant and antipsychotic related to bipolar disorder, schizoaffective disorder, depression, and anxiety. The resident will remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment.<BR/>During an interview with the MDS coordinator on 10/05/2023 at 2:28 PM, revealed that she was new in the position, and was completed prior to her entering the position. She revealed after reviewing the records with the DON, section N was completed inaccurately. <BR/>In an interview on 10/05/2023 at 3:00 PM with the DON revealed that the Annual MDS was completed inaccurately and should have been coded the gradual dose reduction as being contraindicated in Section N. She revealed this failure could place the residents at risk of receiving inaccurate assessments and inadequate plans of care. <BR/>Request for the facility policy covering MDS accuracy of Assessments was not provided at the time of exit and was told they use the RAI manual as a reference.

Based on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 1 of 2 residents (Resident #3) reviewed for a mental illness, intellectual disability, or developmental disability.<BR/>The facility failed to ensure Resident #3, with an initial admission date of 03/22/18, had a diagnosis of mental illness and a PASARR Level II (PE) screening was not completed.<BR/>This failure placed residents at risk of mental health needs not being met. <BR/>The findings included:<BR/>A record review of Resident #3's admission Record, dated 11/21/24, revealed Resident #3 had an initial admission date of 03/22/18 and the latest admission date of 04/25/24. Resident had a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff). The resident had secondary diagnosis including Unspecified Dementia, unspecified severity, with other behavioral disturbance (a group of symptoms that affects memory, thinking and interferes with daily life); Bipolar Disorder (a mental health condition that causes extreme mood swings); Schizophrenia (a serious mental health condition that affects how people think, feel and behave); Schizoaffective Disorder, Bipolar Type (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder). <BR/>A record review of a PASARR Level I (PL1) Screening, dated 04/25/24, indicated Resident #3 had no evidence of mental illness. No PASARR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. <BR/>A record review of the Resident # 3's Quarterly MDS assessment, dated 09/11/24, revealed Active Diagnosis of Anxiety Disorder, Bipolar Disorder, and Schizophrenia. <BR/>A record review of Resident # 3's Care Plan, with a completion date of 09/26/24, indicated Resident #3 uses psychotropic medications related to schizoaffective disorder, bipolar. <BR/>In an interview on 11/21/24 at 11:51 am, the MDS Coordinator stated she was responsible for the PASSAR evaluations. She said Resident #3 did not have a primary diagnosis of dementia. She said Resident #3 should have had a PASSAR Level II evaluation completed, or a 1012 form completed on record as he had the qualifying diagnosis. She said there was no evidence Resident #3 had a 1012 form in his record. She said a potential negative outcome of this failure would be a resident might not receive PASSAR services if they were eligible. <BR/>In an interview on 11/21/24 at 12:38 pm, the Chief Nursing Officer, stated she had just spoken with the MDS Coordinator and was aware of Resident #3 not having a PASSAR Level II evaluation. She said a potential negative outcome would be the resident would not receive specialized services . <BR/>Record review of the facility policy PASRR Clinical Policy, Level 1, not dated, revealed the following [in part]:<BR/>Purpose: If documentation entered on the PL1 indicates MI/ID/DD, a PE must be completed.<BR/>Section C Steps for Assessment: 7. If Alzheimer/Dementia is the primary diagnosis and there is a MI diagnosis no PE is needed.

Based on interview and record review, The facility must employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at S483.70(e), in that: The facility failed to designate a qualified person to serve as the director of food service when there is no full-time dietitian. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses.Findings included: Record review undated of the DM's employee file revealed there was no documented evidence of a Dietary Manager Certificate found in the file. In an interview on 10/13/2025 at 9:00am, the DM stated she did not have her dietary manager certification. The DM stated she worked for the facility in dietary for 3 years and was named Dietary Manager in January 2025. The DM stated she is not certified and had not registered for any classes, stating she has no financial funds for school. In an interview on 10/14/2025 at 12:30pm, the facility's Dietitian stated she was contracted by the facility to visit quarterly, the last time at the facility was September. The Dietitian said the facility had stable residents and that it was not necessary to visit once per month. The Dietitian stated she was aware the facility did not have a certified DM and nine months ago gave the Administrator and DM the information to start on-line courses to obtain D certification. The dietitian did not know why the classes were not starting. In an interview on 10/15/2025 at 12:00 PM, the administrator stated she was aware the DM was not certified and had not applied for certification. She stated the failure could result in the residents not having their nutritional needs met and place them at risk for foodborne illness. Review of the Job description of the Dietary Manager, dated effective 11/2022, revealed in part: Job summary - Manage the operations of the dietary department to include staffing, food ordering and preparation, food delivery and cleaning, in accordance with facility policies, physician orders, care plans, and appropriate regulations.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 (hot water heater for the laundry) of 1 reviewed for essential equipment. The facility failed to repair or replace the water heater that supplied hot water for laundry for 2 months. This failure could place residents at risk of diminishing quality of life and declining health.Findings included: Observation on 10/13/2025 at 9:00am revealed that the hot water heater in the laundry was not working. No hot water was running in washing machine, handwash sink and the hot water heater was cold to the touch. During an interview on 10/13/2025 at 9:05am, Laundry Staff stated the hot water was out for several months. Laundry stated that Maintenance man and Administrator knew and tried to repair but it did not work. Laundry using bleach for sanitizing while hot water was out. During an interview on 10/13/2025 at 9:55am, the Maintenance Director stated he had worked at the facility for four months. The Maintenance Director stated the hot water heater for laundry had been out as long as he worked at the facility. The Maintenance Director stated the ordered parts was the wrong part, and he was waiting for the right part to come in to repair the water heater.During an interview on 10/15/2025 at 12:10pm, the Administrator stated the hot water heater in laundry was out for a while but, could not recall how long. The Administrator made several attempts to repair it. The Maintenance Director ordered the right part, and the water heater should be repaired today (10/15/25).Record review of facility policy titled, Maintenance Service, no date:1. The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.2. D). Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 (Resident #6) of 6 residents reviewed for resident call system, in that: The facility failed to provide a working communication system on 10/10/25 that was easily accessible and that would allow Resident #6 the ability to safely call staff for assistance.This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.The findings included: Record review of Resident #6's face sheet, dated 10/13/25, revealed a [AGE] year-old-female admitted on [DATE], with the following diagnoses dementia (mental impairment), repeated falls, glaucoma right and left eyes (loss of vision due to optic damage), chronic obstruction pulmonary disease (lung damage limiting airflow). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed the following:*Section C- Cognitive Patterns revealed Resident #6's BIMS score of 3 indicated severe cognitive impairment.*Section GG- Functional Abilities and Goals revealed Resident #6 was dependent on staff for all ADLs.*Section J Health Conditions revealed Resident #6 had a history of falls. Record review of Resident #6's Care Plan, dated 08/7/2025, revealed Resident #6 had a history of falls-8/12/24, 4/12/25, and an intervention was for the call light to be in reach. During an observation on 10/13/25 at 9:30 AM, Resident #6 was lying in her bed in her room, no call light access in room, call light on wall did not have any means to activate call system. During an interview on 10/13/25 at 9:31 am Resident #6 stated she did not have any way to use the call light if she needed help. Resident #6 stated if she needed help, she would have to yell for help. During an interview on 10/13/25 at 9:40 am, the Administrator did not know why Resident #6's room did not have a way to activate the call light but would be fixed immediately. The Administrator stated her expectation was that call lights should have been placed within reach of residents and in working order. The Administrator stated the effect on residents could have prevented them calling for assistance. The Administrator stated that everyone that worked in the room was responsible for ensuring the call light was in reach of residents and operational. The Administrator could not provide a reason for what led to the failure of the call light not being operational. Record review of facility policy titled, Call Lights: Accessibility and Timely Response, dated 01/01/2024, revealed, Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed .Providing access to assistive devices . Installing longer cords or providing remote controlled overhead or task lighting so that they are easily accessible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services.<BR/>The facility did not have RN coverage for 17 days on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].<BR/>This failure could place the residents at risk of not receiving needed care and services.<BR/>The findings were:<BR/>Review of the facility RN timesheets revealed there were no RN hours for Saturdays on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].<BR/>Review of the facility RN timesheets revealed there were no RN hours for Sundays on [DATE], [DATE], 12/29/.24, [DATE], [DATE], [DATE], [DATE], and [DATE].<BR/>During interview with the DON on [DATE] at 2:26p.m, she said she had been employed in the facility since [DATE]. She stated to the best of her knowledge the facility doesn't have RN coverage especially on weekends. The DON explained the facility used to have a RN that came on weekend but not anymore. She stated she understood RN coverage as a person with broad responsibility that provides specialized nursing care that LVN cannot or not required or qualified to do. She came an example with a peripherally inserted central catheter (PICC line) which LVN are not qualified to do. The DON stated she was not aware of the specific days not covered in the facility. She explained the management was aware of the lack of RN coverage in the facility. This was because on one occasion, he asked if not having an RN coverage will affect her license as a RN/DON. She was assured by the management that her license will not be affected. The DON stated she is aware the facility does not have RN coverage in the required days including weekends. She indicated the facility has approved and placed an advertisement looking for weekend RN coverage and she will be interviewing candidates soon.<BR/>In an interview with ADM on [DATE] at 2:49p.m, she is the Administrator and started working for the facility since [DATE]. The ADM explained the policy of the facility is to have RN coverage 8 hours a day, seven days a week. She knows there was some days the facility did not meet this requirement. She stated the purpose of RN coverage was to cover for any incident which the LVN cannot handle or not trained to provide service. The ADM noted the DON has covered some weekends. She said there was no negative effect because the facility has telehealth and can contact them if RN was needed. She stated the facility has not had incident requiring a RN on weekend recently. She monitors the RN coverage on her calendar in her office wall with names on who was covering on different days. She said she cannot force people to come in to work. The ADM explained the management has approved hire for a permanent RN coverage for the weekend. She noted the facility has placed recent advertising for RN coverage. Her expectation was to have RN coverage in the facility moving forward.<BR/>During interview with MD D, on [DATE] at 11: 17a.m, he stated he was the medical director for the facility. He explained he was aware that the facility did not have RN coverage in some days especially on weekends. He stated the management was aware of the lack of RN coverage but decided to not have the coverage and bear the consequences. MD D stated he was not aware any significant incident where an RN coverage was needed. However, he was informed by his brother, a doctor with the facility that he came to pronounce a death on one of the weekends because RN was not available.<BR/>Record review of the facility policy on staffing undated reflected the following:<BR/>Policy Statement:<BR/>Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.<BR/>Policy Interpretation and Implementation<BR/>1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct<BR/>resident care services.<BR/>oAt a minimum, the facility must maintain a ratio (for every 24-hour period) of one<BR/>licensed nursing staff person for each 20 residents or a minimum of 4 licensed-care hours per resident day. A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .

Based on record review, observation and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for Administration.<BR/>The facility failed to have sufficient resources to satisfy (pay) debts timely and when they come due. The facility had a past due balance of 4 months with the water vendor with a disconnection notice given with a date that had already passed; and a past due balance of 3 months with the fire vendor for services provided in September 2024 and January 2024. <BR/>The failure to have sufficient financial resources to pay debts timely had the potential to adversely affect the delivery of essential care and services. This failure could affect the 31 residents who utilized services provided and paid for by the facility.<BR/>Findings included:<BR/>Record review of invoices provided by the Administrator on 6/3/25 indicated unpaid balances for the following:<BR/>1. [Fire Vendor] - Invoice dated 1/31/25. Past due balance of $1000 was a due date of 2/28/25.<BR/>2. [Water Vendor] - Invoice dated 5/22/25. Past due balance of $6907.95. A total balance of $8298.46 with a due date of 6/15/23.<BR/>3. [Water Vendor] - Disconnect Notice for Non-Payment or Delinquent Accounts with an amount due of $6907.95. Service will be disconnected if the past due amount is not paid before closing time on May 25, 2025.<BR/>In an interview on 6/3/25 at 11:46 am, the Administrator said when the facility receives a bill, it is forward to Accounts Payable for payment. She said she does not make payments for the facility and only passes the bills on when they come in. She said she was aware of a past due balance for the [Water Vendor] and a termination notice had been sent for disconnection. She was aware of 2 pervious charges by the [Fire Vendor] for a total of $1000. She said she last sent the water bill and the disconnection notice to Accounts Payable on 5/29/25. <BR/>In an interview on 6/3/25 at 12:32 pm, the [NAME] Administrator for the [Fire and Water Vendor] stated the facility owes 2 past due fines for a total of $1000 from services provided on 9/17/24 and 1/6/25 when the fire department responded to false fire alarms. The [Fire Vendor] reviewed the facility's account yesterday and was considering having the facility's fire alarm disconnected and putting them on a fire watch for a past due balance. The [NAME] Administrator said the facility had a water bill that was 4 months past due for $6907.95. The [Water Vendor] issued a disconnect notice for 6/15/25 if the past due balance was not paid. The facility did not pay; however, water services will not be disconnected due to it being a nursing home. The [NAME] Administrator has emailed, sent certified letters, and talked to the CEO on the phone but it has done no good. <BR/>In an interview on 6/3/25 at 2:22 pm, the COO stated the CEO was not available for interview. She said the process for bill payment was when the facility receives a bill, it is passed on to Accounts Payable which was an independent company. Every Monday, Accounts Payable and the CEO have a meeting and a decision was made on which bills to pay. She said she only has the ability to pay bills on an emergency basis. She said she just paid the 2 outstanding bills, today, for the [Fire Vendor] for $1000 and the past due balance for the [Water Vendor] for $6907.95.<BR/>In an interview on 6/4/25 at 12:35 pm, the CEO said the 2 bills were paid and caught up yesterday, 6/3/25. He said bills are sent to an independent company for review and payment. The CEO said he did not remember there being past due balances for the [Water Vendor or Fire Vendor] or talking to anyone about them; he said the [Water Vendor] bill should not have gotten that far behind. He said he was going to find out where the breakdown occurred. <BR/>In observations of the facility on 6/3/25 and 6/4/25 revealed the facility had water services. <BR/>A facility policy was requested regarding vendor payment but not provided prior to exit on 06/04/2025.

Based on record review, observation and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for Administration.<BR/>The facility failed to have sufficient resources to satisfy (pay) debts timely and when they come due. The facility had a past due balance of 4 months with the water vendor with a disconnection notice given with a date that had already passed; and a past due balance of 3 months with the fire vendor for services provided in September 2024 and January 2024. <BR/>The failure to have sufficient financial resources to pay debts timely had the potential to adversely affect the delivery of essential care and services. This failure could affect the 31 residents who utilized services provided and paid for by the facility.<BR/>Findings included:<BR/>Record review of invoices provided by the Administrator on 6/3/25 indicated unpaid balances for the following:<BR/>1. [Fire Vendor] - Invoice dated 1/31/25. Past due balance of $1000 was a due date of 2/28/25.<BR/>2. [Water Vendor] - Invoice dated 5/22/25. Past due balance of $6907.95. A total balance of $8298.46 with a due date of 6/15/23.<BR/>3. [Water Vendor] - Disconnect Notice for Non-Payment or Delinquent Accounts with an amount due of $6907.95. Service will be disconnected if the past due amount is not paid before closing time on May 25, 2025.<BR/>In an interview on 6/3/25 at 11:46 am, the Administrator said when the facility receives a bill, it is forward to Accounts Payable for payment. She said she does not make payments for the facility and only passes the bills on when they come in. She said she was aware of a past due balance for the [Water Vendor] and a termination notice had been sent for disconnection. She was aware of 2 pervious charges by the [Fire Vendor] for a total of $1000. She said she last sent the water bill and the disconnection notice to Accounts Payable on 5/29/25. <BR/>In an interview on 6/3/25 at 12:32 pm, the [NAME] Administrator for the [Fire and Water Vendor] stated the facility owes 2 past due fines for a total of $1000 from services provided on 9/17/24 and 1/6/25 when the fire department responded to false fire alarms. The [Fire Vendor] reviewed the facility's account yesterday and was considering having the facility's fire alarm disconnected and putting them on a fire watch for a past due balance. The [NAME] Administrator said the facility had a water bill that was 4 months past due for $6907.95. The [Water Vendor] issued a disconnect notice for 6/15/25 if the past due balance was not paid. The facility did not pay; however, water services will not be disconnected due to it being a nursing home. The [NAME] Administrator has emailed, sent certified letters, and talked to the CEO on the phone but it has done no good. <BR/>In an interview on 6/3/25 at 2:22 pm, the COO stated the CEO was not available for interview. She said the process for bill payment was when the facility receives a bill, it is passed on to Accounts Payable which was an independent company. Every Monday, Accounts Payable and the CEO have a meeting and a decision was made on which bills to pay. She said she only has the ability to pay bills on an emergency basis. She said she just paid the 2 outstanding bills, today, for the [Fire Vendor] for $1000 and the past due balance for the [Water Vendor] for $6907.95.<BR/>In an interview on 6/4/25 at 12:35 pm, the CEO said the 2 bills were paid and caught up yesterday, 6/3/25. He said bills are sent to an independent company for review and payment. The CEO said he did not remember there being past due balances for the [Water Vendor or Fire Vendor] or talking to anyone about them; he said the [Water Vendor] bill should not have gotten that far behind. He said he was going to find out where the breakdown occurred. <BR/>In observations of the facility on 6/3/25 and 6/4/25 revealed the facility had water services. <BR/>A facility policy was requested regarding vendor payment but not provided prior to exit on 06/04/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services.<BR/>The facility did not have RN coverage for 17 days on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].<BR/>This failure could place the residents at risk of not receiving needed care and services.<BR/>The findings were:<BR/>Review of the facility RN timesheets revealed there were no RN hours for Saturdays on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].<BR/>Review of the facility RN timesheets revealed there were no RN hours for Sundays on [DATE], [DATE], 12/29/.24, [DATE], [DATE], [DATE], [DATE], and [DATE].<BR/>During interview with the DON on [DATE] at 2:26p.m, she said she had been employed in the facility since [DATE]. She stated to the best of her knowledge the facility doesn't have RN coverage especially on weekends. The DON explained the facility used to have a RN that came on weekend but not anymore. She stated she understood RN coverage as a person with broad responsibility that provides specialized nursing care that LVN cannot or not required or qualified to do. She came an example with a peripherally inserted central catheter (PICC line) which LVN are not qualified to do. The DON stated she was not aware of the specific days not covered in the facility. She explained the management was aware of the lack of RN coverage in the facility. This was because on one occasion, he asked if not having an RN coverage will affect her license as a RN/DON. She was assured by the management that her license will not be affected. The DON stated she is aware the facility does not have RN coverage in the required days including weekends. She indicated the facility has approved and placed an advertisement looking for weekend RN coverage and she will be interviewing candidates soon.<BR/>In an interview with ADM on [DATE] at 2:49p.m, she is the Administrator and started working for the facility since [DATE]. The ADM explained the policy of the facility is to have RN coverage 8 hours a day, seven days a week. She knows there was some days the facility did not meet this requirement. She stated the purpose of RN coverage was to cover for any incident which the LVN cannot handle or not trained to provide service. The ADM noted the DON has covered some weekends. She said there was no negative effect because the facility has telehealth and can contact them if RN was needed. She stated the facility has not had incident requiring a RN on weekend recently. She monitors the RN coverage on her calendar in her office wall with names on who was covering on different days. She said she cannot force people to come in to work. The ADM explained the management has approved hire for a permanent RN coverage for the weekend. She noted the facility has placed recent advertising for RN coverage. Her expectation was to have RN coverage in the facility moving forward.<BR/>During interview with MD D, on [DATE] at 11: 17a.m, he stated he was the medical director for the facility. He explained he was aware that the facility did not have RN coverage in some days especially on weekends. He stated the management was aware of the lack of RN coverage but decided to not have the coverage and bear the consequences. MD D stated he was not aware any significant incident where an RN coverage was needed. However, he was informed by his brother, a doctor with the facility that he came to pronounce a death on one of the weekends because RN was not available.<BR/>Record review of the facility policy on staffing undated reflected the following:<BR/>Policy Statement:<BR/>Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.<BR/>Policy Interpretation and Implementation<BR/>1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct<BR/>resident care services.<BR/>oAt a minimum, the facility must maintain a ratio (for every 24-hour period) of one<BR/>licensed nursing staff person for each 20 residents or a minimum of 4 licensed-care hours per resident day. A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 of 7 residents (Resident #1) reviewed for resident care, in that: <BR/>The facility failed to ensure Resident #1 was provided an x-ray as ordered by the physician. <BR/>This failure could place residents at risk for a decline in health status. <BR/>Findings included:<BR/>Record review of Resident #1's admission Record, dated 01/15/2025 revealed an [AGE] year-old male, with an admission date of 09/09/2024 with a principal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (gradual buildup of plaque in the walls of your arteries, limiting or blocking the flow of blood), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and osteoarthritis (a condition that causes the breakdown of cartilage in the joints, leading to pain and stiffness). The resident was discharged from the facility on 12/24/2024. <BR/>Record review of Resident's #1 nursing progress note, dated 12/12/2025 at 10:30 am, revealed the resident had a fall, complained of right shoulder and collarbone pain. The facility contacted the Physician, and he ordered an x-ray. The progress note stated, attempted several times to contact facility mobile x-ray company, unable to schedule at this time. There was no further documentation in the progress notes regarding acquiring an x-ray for the resident. <BR/>Record review of Resident #1's Physician's Orders, dated 01/15/2025, revealed there was no order for an x-ray on 12/12/2024. <BR/>In an interview on 1/15/2025 at 2:48 pm, the Physician said the facility notified him on 12/12/2024 that Resident #1 had fallen and he ordered an x-ray. The physician said he did not remember the facility calling him back and informing him that they were unable to reach the mobile x-ray. The physician said it was his expectation for the facility to contact him if they were not able to get an x-ray. <BR/>In an interview on 1/15/2025 at 3:00 pm, the DON said she was aware the physician had ordered an x-ray and was not aware Resident #1 did not get an x-ray until the next morning. She said the nurse texted the Physician that she could not reach the mobile x-ray company, but never heard back from him. She said it was her expectation for the nurse to follow up with the physician and notify the DON when she did not hear back from him. The DON said the x-ray was never done and got missed. She said the nurse never passed it on in shift change or in morning report. Resident #1 did not receive an x-ray as ordered. She said Resident #1 was placed on neuro-checks at the time of the fall, he complained of right shoulder pain that night, but the next morning, he denied pain and was assessed with full range of motion. The DON said this failure had the potential of the resident not receiving appropriate care. <BR/>In an interview on 1/25/2025 at 12:44 pm, Nurse A said the Resident #1 had a fall on 12/12/2024, she contacted the Physician, and he ordered a mobile x-ray. She attempted to call the mobile x-ray 6 times, but could never get through. She said she texted the doctor around 2:00 pm, but never heard back from him. She said she did not attempt to follow up with the doctor when he did not respond to her texts before she left her shift. She said she did not notify the DON or pass it on to the next shift she was not able to contact the mobile x-ray company. <BR/>A facility policy was requested, but the provided undated policy titled Resident Rights, failed to address the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer 1 of 3 residents (Resident #13), for PASRR screening and evaluation, with a newly evident mental disorder or a related condition for a level II PASRR review, in that:<BR/>Resident #13 was not referred to the state-designated authority for a PASRR re-evaluation upon evidence of new diagnoses of major depressive disorder, dated 09/01/2023 and evidence of potential indicator of psychosis on MDS significant change dated 05/01/2024. <BR/>This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.<BR/>Findings included: <BR/>Record review of Resident #13's face sheet, dated 05/23/2023, revealed a [AGE] year-old female, who was admitted into the facility on [DATE] with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (confusion without behaviors), repeated falls, muscle weakness, unsteadiness on feet and lack of coordination. <BR/>Record review of Resident #13's diagnosis report revealed she was diagnosed with major depressive disorder on 09/01/2023 and anxiety disorder effective 11/21/2024.<BR/>Record review of Resident #13's PASRR level 1 screening, dated 05/23/2023, revealed the resident was coded for not having a diagnosis of mental illness. <BR/>Record review of Resident #13''s MDS, dated [DATE] revealed the residents Brief Interview for Mental Status (BIMS) was coded as a 0, resident is rarely/never understood; Behaviors - Potential indicators of psychosis including hallucinations and delusions worsening since last MDS assessment.<BR/>Record review of Resident #13's physician's orders, dated 11/21/2024, revealed the following: <BR/>1. <BR/>Referral to senior psych care psychiatry to evaluate and treat starting 09/01/2023. <BR/>2. <BR/>Monitor for signs of depression, suicidal ideation and insomnia. 09/01/2023<BR/>3. <BR/>Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every morning and at bedtime for Agitation/Aggression, order date 09/18/2024<BR/>4. <BR/>Depakote Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F03.90), order date 10/16/2024<BR/>5. <BR/>trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 25 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE (F33.1) give 1/2 a 50mg tab to = 25mg. GDR attempt order date 12/17/2023<BR/>Review of Resident #13's Care Plan revised on 11/11/2024 reflected the following:<BR/>Focus: Resident is on an antidepressant medication r/t Depression and insomnia. <BR/>Date Initiated: 09/01/2023.<BR/>Goal: Resident #13 will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date Initiated: 09/01/2023.<BR/>In an interview on 11/21/2024 on 11:51 a.m., MDS coordinator stated, The resident has a diagnosis of major depressive disorder. I will review the chart for a 1012 form (form used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis) and get back with you.<BR/>In an interview on 11/21/2024 on 12:26 p.m., MDS coordinator stated she was responsible for PASRR's, I looked in Resident #13's chart and could not find a 1012 form. There are some diagnoses in the chart that would warrant a 1012 form. She also stated A negative result in not having a current 1012 form is that the resident has not received PASRR services and may not be receiving psych services if needed . <BR/>Review of the facilities policy and procedures titled PASRR Clinical Policy, not dated, reflected the following [in part]:<BR/>Purpose: The PASRR level 1 (PL1) Screening Form is designed to identify persons who are suspected of having Mental Illness (MI), Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as Related Conditions. The PASRR Evaluation (PE) is designed to confirm the suspicion of MI, ID or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual's level of functioning. <BR/>Section C; PASRR Screen (Screener) <BR/>INTENT: This section to be completed for resident's suspected of having Mental Illness. <BR/>Identify diagnoses: Review the medical record, if available, for diagnoses. Medical record sources can include but are not limited to verbal interview with the resident, or LAR, observation, progress notes, Annual Physical Exam, the most recent History and Physical, hospital discharge summaries or diagnosis list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 of 18 residents (Residents # 36, and #38) reviewed for care plans as follows:<BR/>1. <BR/>Resident #36 did not have a comprehensive care plan completed within 14 days of admission. Resident #36 was admitted on [DATE] and his first comprehensive care plan was not completed until 10/6/24. <BR/>2. <BR/>Resident #38 was admitted on [DATE] and did not have a comprehensive care plan completed until the CNO was notified on 11/19/24. Her care plan was then completed on 11/20/24. <BR/>This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. <BR/>Findings include:<BR/>Resident # 36<BR/>Record review of Resident #36's face sheet dated 11/20/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: chronic pancreatitis (inflammation of the pancreas), essential hypertension (high blood pressure), gastro esophageal reflux disease without esophagitis (acid reflux), benign prostatic hyperplasia without lower urinary tract symptoms (frequent urination), generalized anxiety disorder (anxiety), major depressive disorder (depression), and schizophrenia (a disorder that affects a person's ability to think ).<BR/>Record review of Resident #36 revelaed his comprehensive care plan was not completed until 11/20/24. <BR/>Record review of Resident #36 admission MDS revealed it was completed on 8/13/24, Quarterly MDS was completed on 11/13/24.<BR/>Observation of Resident #36 on 11/19/24 at 2:54 PM, revealed that Resident #36 voiced concerns about his mood, choices, dental, nutrition, pain management, and genitourinary needs. <BR/>Record review of Resident #36's care plan dated 10/6/24 indicated that these needs were being met. However, it was noted that his initial comprehensive care plan was not competed until 10/6/24.<BR/>During an interview with the CNO on 11/21/24 at 12:38 PM, she indicated Resident #36 had a baseline care plan completed, but not a comprehensive care plan completed until 10/6/24.<BR/>Resident # 38<BR/>Record review of Resident #38's face sheet dated 11/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: chronic pain, glaucoma (an eye condition that can cause blindness), sensorineural hearing loss (hearing loss), hypertension (high blood pressure), gastro esophageal reflux disease without esophagitis (acid reflux), osteoarthritis (arthritis of the joints), repeated falls, amnesia (memory loss), dizziness and giddiness (dizziness and unsteadiness), and overactive bladder (sudden need to urinate).<BR/>Record review of Resident #38 dated 11/19/24 revealed there had been no comprehensive care plan completed for Resident #38 who was admitted on [DATE].<BR/>Record review of Resident #38 admission MDS revealed it was completed on 10/27/24.<BR/>During an interview with the CNO on 11/20/24 at 3:36 PM, she stated there is not a comprehensive care plan for Resident #38. She stated that it is her expectation for care plans to be completed in the allowed time frame. She further stated that she had spoken with the MDS coordinator and instructed her that a care plan needed to be completed. <BR/>Record review of the facility's policy, Care Plans- Comprehensive Person-Centered, revealed the following documentation [in-part]: <BR/>Policy Statement<BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.<BR/>Policy Interpretation and Implementation: <BR/>#12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services.<BR/>The facility did not have RN coverage for 17 days on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].<BR/>This failure could place the residents at risk of not receiving needed care and services.<BR/>The findings were:<BR/>Review of the facility RN timesheets revealed there were no RN hours for Saturdays on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].<BR/>Review of the facility RN timesheets revealed there were no RN hours for Sundays on [DATE], [DATE], 12/29/.24, [DATE], [DATE], [DATE], [DATE], and [DATE].<BR/>During interview with the DON on [DATE] at 2:26p.m, she said she had been employed in the facility since [DATE]. She stated to the best of her knowledge the facility doesn't have RN coverage especially on weekends. The DON explained the facility used to have a RN that came on weekend but not anymore. She stated she understood RN coverage as a person with broad responsibility that provides specialized nursing care that LVN cannot or not required or qualified to do. She came an example with a peripherally inserted central catheter (PICC line) which LVN are not qualified to do. The DON stated she was not aware of the specific days not covered in the facility. She explained the management was aware of the lack of RN coverage in the facility. This was because on one occasion, he asked if not having an RN coverage will affect her license as a RN/DON. She was assured by the management that her license will not be affected. The DON stated she is aware the facility does not have RN coverage in the required days including weekends. She indicated the facility has approved and placed an advertisement looking for weekend RN coverage and she will be interviewing candidates soon.<BR/>In an interview with ADM on [DATE] at 2:49p.m, she is the Administrator and started working for the facility since [DATE]. The ADM explained the policy of the facility is to have RN coverage 8 hours a day, seven days a week. She knows there was some days the facility did not meet this requirement. She stated the purpose of RN coverage was to cover for any incident which the LVN cannot handle or not trained to provide service. The ADM noted the DON has covered some weekends. She said there was no negative effect because the facility has telehealth and can contact them if RN was needed. She stated the facility has not had incident requiring a RN on weekend recently. She monitors the RN coverage on her calendar in her office wall with names on who was covering on different days. She said she cannot force people to come in to work. The ADM explained the management has approved hire for a permanent RN coverage for the weekend. She noted the facility has placed recent advertising for RN coverage. Her expectation was to have RN coverage in the facility moving forward.<BR/>During interview with MD D, on [DATE] at 11: 17a.m, he stated he was the medical director for the facility. He explained he was aware that the facility did not have RN coverage in some days especially on weekends. He stated the management was aware of the lack of RN coverage but decided to not have the coverage and bear the consequences. MD D stated he was not aware any significant incident where an RN coverage was needed. However, he was informed by his brother, a doctor with the facility that he came to pronounce a death on one of the weekends because RN was not available.<BR/>Record review of the facility policy on staffing undated reflected the following:<BR/>Policy Statement:<BR/>Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.<BR/>Policy Interpretation and Implementation<BR/>1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct<BR/>resident care services.<BR/>oAt a minimum, the facility must maintain a ratio (for every 24-hour period) of one<BR/>licensed nursing staff person for each 20 residents or a minimum of 4 licensed-care hours per resident day. A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon and notify the attending physician of the pharmacist consultant's recommendation for 1 of 6 residents (Resident #9) whose records were reviewed for pharmacist drug regimen review. <BR/>The facility did not follow up with the attending physician on the Pharmacy Consultant's recommendation to provide a stop date for Resident #9's Xanax 0.5 mg PRN order. <BR/>This failure placed residents at risk for receiving anti-anxiety medication for an extended duration without physician review and determination for continuation and necessity of the medication.<BR/>The findings include:<BR/>Review of Resident #9's admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of heart failure. Additional diagnoses included: myocardial infarction; pneumonia; major depressive disorder, recurrent, severe with psychotic symptoms; chronic pain syndrome; chronic obstructive pulmonary disease; hypertensive heart disease with heart failure; other idiopathic scoliosis, thoracolumbar region; unspecified dementia with behavioral disturbance; nicotine dependence; essential (primary) hypertension; and unspecified convulsions.<BR/>Review of Resident #9's Significant Change MDS Assessment, dated 6/07/22, revealed documentation that antianxiety and antidepressant medications were given daily during the past 7 days.<BR/>Review of Resident #9's comprehensive care plan, dated as revised on 6/08/22, revealed it addressed the use of psychotropic medications Trazodone and Xanax related to anxiety, depression, and insomnia. <BR/>Review of Resident #9's medication orders revealed an order for Xanax 0.5 mg by mouth every 8 hours (scheduled), dated 6/01/22. The initial dose was administered on 6/08/22. The order was discontinued on 7/03/22.<BR/>Review of Resident #9's medication administration record, dated 8/01/22-8/31/22, revealed an order for Xanax 0.5 mg by mouth every 8 hours PRN for anxiety, dated 7/03/22. The order did not have a medication stop date. The record reflected the medication had been administered one to two times daily 8/04/22 through 8/23/22. <BR/>Review of the Consultant Pharmacist's Medication Regimen Review report, dated 8/17/22, revealed documentation that Resident #9 needed a renewal order with a stop date for PRN Xanax.<BR/>In an interview on 8/23/22 at 10:47 AM, Resident #9 stated she had panic attacks and took Xanax every 8 hours. She stated she had to ask for it (PRN order). She stated she took Xanax when she was living at home.<BR/>In an interview on 8/24/22 at 2:22 PM, the ADON stated the charge nurses entered physician orders into the residents' electronic medication administration records. She stated the DON was responsible for the follow-up to the Pharmacist Consultant's medication review recommendations. The ADON stated since the DON resigned on 8/19/22 she had started doing the follow-ups to the Pharmacist Consultant's recommendations. The ADON stated she did not know how to do a renewal order and enter an end-date for PRN medication. She stated she had not faxed the Pharmacist Consultant letter to the physician. The ADON stated she would look for a policy and procedure for physician's orders and follow-up to pharmacist consultant recommendations.<BR/>Review of the facility's policy and procedure for Documentation and Communication of Consultant Pharmacist Recommendations, dated August2020, revealed the following [in part]:<BR/>Policy<BR/>The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist's observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion .<BR/>Procedures<BR/>1. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team. This should include:<BR/>a. Documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated manner .<BR/>c. Potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for prescriber and/or nursing review .<BR/>2. Comments and recommendations concerning medication therapy are communicated in a timely fashion .<BR/>3. Recommendations are acted upon and documented by the facility staff and/or the prescriber <BR/>

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. <BR/>The facility failed to date and label food stored in the freezer located in the dishwashing room. <BR/>The kitchen floors had food spilled throughout the food preparation area and dishwashing room. <BR/>The floors had black appearing spoiled food under the food preparation counter.<BR/>These failure placed the residents at risk for foodborne illness and compromised health status.<BR/>The findings included:<BR/>Observation on 08/22/2022 at 9:20 AM during the initial tour revealed the floors in the dishwasher room and kitchen food preparation room had several layers of yellow colored, dingy appearing sheen on the floor surface. Food crumbs were observed throughout the kitchen area and a heavy black appearing decaying of food was under the sink, oven and preparation areas. <BR/>Observation on 08/22/2022 at 9:30 AM revealed the freezer unit contained 1 zip top bag with approximately 35 frozen meat patties; one zip top bag of chicken strips, approximately 30 pieces; and 6 mini pizzas that were were not dated and were left unsealed.<BR/>Observation 08/22/2022 at 9:40 AM revealed in the kitchen preparation area there was 1 bag of pancake mix (5-pound bag) on a shelf sitting over the preparation table that was opened and was not dated when opened.<BR/>Observation on 08/23/22 at 10:00 AM revealed the floors appeared to be in the same condition and appeared to be remain unclean with food remaining from the previous day. <BR/>Observation on 8/23/2022 at 11:45 AM, during the lunch meal preparation, the Dietary Manager used a towel to remove a pan of hot rolls from the over. The towel was dropped onto the floor. The Dietary Manger picked up the towel from the floor and put it on the food preparation counter. <BR/>During an interview on 08/24/2022 at 10:00 AM, the Dietary Manager stated she had dropped the ball regarding the kitchen floor. She said she was expected to work in the kitchen, and was a Certified Nurse Assistant and was expected to work on the resident floors when the evening meal was completed. She said she just did not have the time to properly clean the kitchen. She said during the initial tour the food in the freezer should have been dated. She said she should not have put the towel she dropped on the floor back onto the counter. <BR/>Review of facility policy and procedure titled Nutrition Service, dated 06/2015, revealed the following<BR/>[in part]:<BR/>The nutrition service works as a steam to provide quality nutrition services in the identified aeras. These areas include, but are not limited to:<BR/>1. <BR/>Clinical nutrition evaluation and documentation<BR/>2. <BR/> .Sanitation.<BR/>Review of the U.S. Food and Drug Administration, 2017 Food Code, reflected:<BR/>Preventing Contamination from the Premises <BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of two residents reviewed for infection control practices<BR/>CNAA and CNAB failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #2.<BR/>This failure could place resident's risk for cross contamination and the spread of infection. <BR/>Finding included:<BR/>Review of Resident #2's face sheet, dated 01/30/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of constipation and dementia.<BR/>Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 required total assistance with most activities of daily living (ADLs) and always incontinent of bowel and bladder.<BR/>Review of Resident #2 care reflected a plan for functional bladder and bowel incontinence related confusion, disease process, impaired mobility, inability to communicate needs, and loss of peritoneal tone.<BR/>Observation on 01/27/23 at 1:05p.m of incontinence care for Resident #2 revealed CNAA and CNAB did not wash hands before the start of care. Both donned gloves and removed Resident #2 old brief. CNAA wiped from front to back. Resident #2's brief was soiled with urine and fecal matter. CNAA did not change gloves but continued to clean Resident #2. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #2's clean brief and placing it underneath the resident and fastening. Meanwhile, CNAB was assisting CNAA to provide care. CNAB repositioned the resident and touched Resident perineal area. She did change gloves, washed hands before helping to fastened Resident #2 clean brief. CNAA and CNAB removed their gloves, picked up the trash and washed hands before exiting Resident #2's room.<BR/>In an interview on 01/27/23 at 1:24 p.m. CNAA said she had been employed in the facility for about 1 year and received infection control a month ago. CNAA stated cross contamination was mixing clean with dirty. CNAA said she should have washed hands before retrieving Resident #2's clean brief and fastening it. She added Resident #2 could get infection for not following good infection control practice.<BR/>During interview on 01/27/22 at 1:27p.m. with CNAB, she said cross contamination was going from clean to dirty. She acknowleged not changing soiled gloves before fastening Resident #1 clean brief. CNAB stated she had been employed since April 2022 in the facility and received infection control training about 3 months ago.<BR/>In an interview on 01/30/23 at 12:21 p.m. the DON stated being aware of some of the concerns raised about infection control practice. She explained she was responsible for infection control in the facility. She trained and monitored staffs with return demonstration. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. She noted she was new and trying to put a system in place for staffs.<BR/>Review of the facility policy and procedure dated 03/2022 reflected the following:<BR/>Purpose: Hand hygiene is the number one way to prevent facility acquired infection by reducing the spread of harmful germs that can cause serious illness or death to residents. The facility requires healthcare providers to perform hand hygiene per CDC recommendation.<BR/>Healthcare providers must perform hand hygiene for the following:<BR/>1) <BR/>Immediately before touching a resident or the resident's immediate environment<BR/>2) <BR/>Before moving from work on a soiled body site to a clean body site on the same patient.<BR/>3) <BR/>Immediately after glove removal .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. <BR/>The facility failed to date and label food stored in the freezer located in the dishwashing room. <BR/>The kitchen floors had food spilled throughout the food preparation area and dishwashing room. <BR/>The floors had black appearing spoiled food under the food preparation counter.<BR/>These failure placed the residents at risk for foodborne illness and compromised health status.<BR/>The findings included:<BR/>Observation on 08/22/2022 at 9:20 AM during the initial tour revealed the floors in the dishwasher room and kitchen food preparation room had several layers of yellow colored, dingy appearing sheen on the floor surface. Food crumbs were observed throughout the kitchen area and a heavy black appearing decaying of food was under the sink, oven and preparation areas. <BR/>Observation on 08/22/2022 at 9:30 AM revealed the freezer unit contained 1 zip top bag with approximately 35 frozen meat patties; one zip top bag of chicken strips, approximately 30 pieces; and 6 mini pizzas that were were not dated and were left unsealed.<BR/>Observation 08/22/2022 at 9:40 AM revealed in the kitchen preparation area there was 1 bag of pancake mix (5-pound bag) on a shelf sitting over the preparation table that was opened and was not dated when opened.<BR/>Observation on 08/23/22 at 10:00 AM revealed the floors appeared to be in the same condition and appeared to be remain unclean with food remaining from the previous day. <BR/>Observation on 8/23/2022 at 11:45 AM, during the lunch meal preparation, the Dietary Manager used a towel to remove a pan of hot rolls from the over. The towel was dropped onto the floor. The Dietary Manger picked up the towel from the floor and put it on the food preparation counter. <BR/>During an interview on 08/24/2022 at 10:00 AM, the Dietary Manager stated she had dropped the ball regarding the kitchen floor. She said she was expected to work in the kitchen, and was a Certified Nurse Assistant and was expected to work on the resident floors when the evening meal was completed. She said she just did not have the time to properly clean the kitchen. She said during the initial tour the food in the freezer should have been dated. She said she should not have put the towel she dropped on the floor back onto the counter. <BR/>Review of facility policy and procedure titled Nutrition Service, dated 06/2015, revealed the following<BR/>[in part]:<BR/>The nutrition service works as a steam to provide quality nutrition services in the identified aeras. These areas include, but are not limited to:<BR/>1. <BR/>Clinical nutrition evaluation and documentation<BR/>2. <BR/> .Sanitation.<BR/>Review of the U.S. Food and Drug Administration, 2017 Food Code, reflected:<BR/>Preventing Contamination from the Premises <BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation or physician's orders for 1 (Resident #1) of 12 residents reviewed for bed rails in that:<BR/>The facility failed to assess Resident #1 for entrapment from bed rails or contact Resident #1's representative to obtain informed consent, assess risk for entrapment or physician's orders. Resident #1 lodged (entrapped) his left arm on 12/28/22 into the 1/2 sized bed rail, causing him to sustain bruising to his chest, and psychosocial harm.<BR/>An IJ (Immediate Jeopardy) was identified on (05/19/2023). The IJ template was provided to the facility on [DATE] at 5:10 PM. While the IJ was lowered on 05/20/2023 at 6:30 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>This failure could affect residents by putting them at an increased and unnecessary risk of harm, entrapment, and/or fatal injury. <BR/>Findings included:<BR/>Record review of Resident #1's undated Face Sheet on 05/18/2023 revealed he was a [AGE] year-old-male admitted to the facility on [DATE] and had the following diagnoses: difficulty walking, acute kidney disease failure, chronic obstructive pulmonary disease, and malignant neoplasm (malignant tumor, of the large intestine, which may affect the colon or rectum. The colon (also called the large intestine) is broken up into a few different anatomic segments and attached to your small intestine) of the colon.<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS (brief interview for mental status) was blank and unrated. It also indicated Resident #1 required extensive assistance with most ADLs and total assistance with transfers. Resident #1 required extensive assistance with 2 or more people for bed mobility and transfers. The MDS section that addressed the use of bed rails (Section P) was left blank and indicated the bed rails were not in use. <BR/>Review of Resident #1's Care Plan revealed the following:<BR/>Focus: Resident #1's initial care plan dated 09/23/2022 revealed Resident #1 was at risk for falls related to weakness and debility. <BR/>Goal: Restraints used to prevent falls will be minimized/eliminated by target date 9/21/2022<BR/>Interventions: Anticipate and meet the resident's needs<BR/>Be sure resident's call light is in reach. The resident requires prompt response to all requests. <BR/>Focus: The resident uses side rails for repositioning <BR/>Goal: The resident will remain free of complications related to side rails. <BR/>Intervention: Discuss with the residents/family the risk and benefits when using side rails should be applied. <BR/>Record review of Resident #1's initial assessment dated [DATE] or any other assessment until 05/18/2023 revealed there were no consents, no risk assessment or physician's orders for bed side rails.<BR/>Record review of facility provided list revealed 12 residents who had bed rails none included consents, risk assessment or physician orders. Observation on 05/18/23 at 11:30 a.m. of each resident's bed revealed bed side rails were in place attached to the beds.<BR/>Interview with the DON on 5/19/23 at 11:10 AM revealed if the facility had the physician's orders, consent, and risk assessments, they would be in the clinical record. She specified this was the responsibility of the DON<BR/>Record review of the facility's self-report investigation dated 05/18/23 revealed the following: Resident #1 was noted to be against the left side rail with his lower body off the bed on 12/28/2022. No injury was noted. A small indention on his chest was indicated. No adverse reaction was noted. Actions and notifications reflected the resident was assessed for injury. The physician and family were notified. The family was educated prior to incident and post incident of side rail safety.<BR/>Review of a 43 minute and 41-second-long video dated 12/28/22 beginning at time stamp 5:36 revealed: The door to Resident #1's room could not be view if his door was open or closed.<BR/>-1-3 minutes - Resident #1 was lying on his back in bed, with half side rails up on each side of the bed. Resident #1 was holding the left side rail with his left hand. There was a trapeze bar hooked up to the bar above the bed, out of reach. Resident #1 was appeared restless and was fidgeting and adjusting the covers. He turned himself from his back to his left side, called out for help, then rolled back to his back<BR/>- 4:00 - Video Timeline beginning: Resident #1 was rattling/shaking the side rail while yelling help<BR/>- 4:47- Resident #1 turned onto his left side, moved his right leg across his body and off the bed. Resident #1's lower right side of his body rolled toward the left side off the bed onto knees. His upper left side of his body from the waist up remained between the side rail and mattress, with his right arm holding the top of the side rail. <BR/>- 5:01- Resident #1 raised his head and looked around. His left arm was between the side rail and mattress. He attempted to push himself up with his leg and right arm.<BR/>- 5:30 - 7:00- Resident #1 yelled, Help six times and rested his head on the mattress. His left arm remained between the mattress and the side rail. Resident #1 yelled, I can't., Help. an additional four times. Resident #1 yelled, Help; laying on the floor. twice. <BR/>- 7:40- Resident #1 was getting lower in the side rail and his chin was below the top of the side rail. Resident #1 used his right arm to try to raise himself up; his left arm remained between the side rail and mattress.<BR/>- 7:53- Resident #1 yelled, Come help please, please come help. four times.<BR/>- 9:00- Resident #1 pulled his pillow from the head of his bed and rested his head on it, yelling, Help<BR/>- 12:41- Resident 31 yelled, Help, I'm in distress, and was making grunting noises, and said, Please come see. <BR/>- 13:09 - Resident #1 said, I'm hurtin' bad; was grunting, and said, Please come see .my back's killing me .I can't move .Ohhh .Come on. <BR/>- 14:01-15:30- Resident #1 continued to yell Help, and mad grunting noises. <BR/>- 16:00-19:00- Resident #1 yelled, Ya gotta come .help .oh the pain .help me Resident #1 was lower to the ground, with the side rail pressing against his chest, his left arm remained between the side rail and mattress, and the top of the side rail was up to his chin. <BR/>- 20:54- Resident #1 yelled repeatedly, Help me I'm gonna die here.<BR/>- 21:28-The top of the rail was at Resident #1's ear level. Resident #1 yelled, Help me I'm gonna die., while using his right hand to pull the side rail away from his neck. <BR/>- 28:00- Resident #1 yelled, Ah, ah .ah repeatedly and pulling the side rail away from his neck while grunting and groaning.<BR/>- 34:30- Resident #1 said, Help I'm gonna die here, please help.<BR/>- 38:41- Staff could be heard saying, We are right here .oh god go get the nurse <BR/>Record review of the incident report revealed LVN A documented on 12/28/2022 the following: Skilled Nurse was called to Resident #1 room and noted both legs out of the bed and on the floor mat. Upper body in bed with right side of chest pressed against the bed rail (left side of bed), resident states I rolled out of bed.<BR/>Immediate Action Taken: Assessment done range of motion performed resident helped off of the floor PCP, Administrator, DON, Hospice Nurse, and POA notified. <BR/>Type of Injury: Location-chest (no measurements of wound/bruise)<BR/>Predisposed situation factor: Bedside rail up.<BR/>During an interview on 05/18/2023 at 12:30 PM LVN A said she was <BR/>there (started dayshift on 12/28/22) when Resident #1 was found caught between the bed rail and the mattress. LVN A said Resident #1 was trapped, and she heard him crying out for help. She said he had a large (unmeasured an opinion of the size) indention in his chest and he was complaining of pain. In regard to the incident report LVN A said initially there was not a bruise but an intention to his chest a little later. LVN A said she lifted his arm out from between the mattress and the railing and Resident #1 said it was painful. LVN A said the railings were up on both sides of the bed. LVN A said she went out into the hall and got CNA B to help, and they both lifted him up onto the bed. LVN A said the incident was communicated to the DON and she was told to call the physician after her assessment. LVN A said that all the beds in the facility have always had bed rails, all different types and sizes, but she said Resident #1 always went around the rails and scooted himself off the bed onto the floor mat, and that she never saw him grab on to the bed rails for assistance, she said she never mentioned this event (scooting himself off the bed) to anyone. LVN A said that she understood there was a probability for entrapment and injury with the use of any size bed rail, and there was the need for a consent due to the risks, and that an order had to be given by a doctor before the bedrails were applied to any resident's bed. <BR/>Attempts to interview the PCP on 05/18/2023 at 1:00 PM and 05/19/2023 at 8:30 AM were unsuccessful due to no one answering the telephone and not returning calls after leaving a message.<BR/>During an Interview with CNA B on 05/18/2023 at 3:15 PM revealed she did not remember the incident it was long time (December 2022) and does not remember what happened. She said she was at the facility when the incident happened but does not remember what happened. CNA B was asked what she would do if a resident was trapped in a bed rail and she said she would call out for help from her partner and never leave the room and get the nurse or someone.<BR/>During a subsequent interview with CNA B on 05/18/2023 at 4:30 PM revealed on 12/28/22 she heard Resident #1 was yelling out and went to Resident #1's room and found him on the floor and holding the bed rail. She said she stayed with him and yelled for LVN A to help her get Resident #1 off the floor. LVN A arrived and helped CNA B get Resident #1 off the bed rail. She said he was holding the bed rail. <BR/>During an interview with LVN C on 05/18/2023 at 4:45 PM revealed she was working on 12/28/2023 and unable to recall the incident. She said she was working that shift, but LVN A started the shift and was notified that Resident #1 was on the floor. She said she just heard that Resident #1 was caught in the bed rail. She said she did not know if Resident #1 had a physician's orders or if he had a bed rail assessment. <BR/>During an observation on 05/18/2023 at 11:45 AM revealed a bed rail similar to Resident #1's bed had large bolts holding the rails in place, this potentially could have been pressing against Resident #1's chest. <BR/>During an interview on 05/19/2023 at 10:45 AM with the DON and Administrator revealed the video shown of Resident #1 being caught in the bed rail, the DON said it should not have taken staff 45 (actually 31 minutes per video) to assist the resident who (DON and Administer said it looked like he was holding the rail and not caught in the bed rail just holding it). The Administrator said he was holding the rail and did not think it needed to be reported to the state. <BR/>On 05/19/2023 at 5:10 PM an Immediate Jeopardy was identified, and the Administrator was informed. The IJ Template was provided at this time.<BR/>During an interview with DON on 05/20/2023 at 11:00 AM the DON said she was unable to locate documentation for physician's orders, a bed rail assessment, consent to use the bed rails, or alternatives to use of the bed rails. Physician orders, bed rail assessment, consents and alternatives for bed rails was created and signed by the family and representatives as part of the Plan of Removal was provided at this time. (05/20/2023 at 11:00 AM)<BR/>During an interview and observation on 05/20/23 from 4:00 PM until 5:00 PM) revealed the Certified Occupation Therapist assessed 12 residents on 05/20/2023 beginning at 4:00 PM using bed rails and assessed each resident for bed rail use. One resident's bed rail was discontinued and recommendation for overhead bed trapeze be included. <BR/>During an interview on 05/20/23 at 11:00 AM the Maintenance Director said Resident #1's bed was supplied by the hospice service and his bed rails were already placed on the bed. He said he was unaware of any alerts or recalls by the manufacturer regarding bed rails. <BR/>Review of the website: https://www.fda.gov/media/88765/download on 05/24/2023 at 4:00 PM revealed the recommendations for bed rail assessment.<BR/>Resident Assessment<BR/>After a facility has attempted alternatives to bed rails and determined that these alternatives do not meet the resident's needs, the facility must assess the resident for the risks of entrapment and possible benefits of bed rails. In determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but not limited to:<BR/>o medical diagnosis, conditions, symptoms, and/or behavioral symptoms.<BR/>o Size and weight <BR/>o Sleep habits<BR/>o Medication(s)<BR/>o Acute medical or surgical interventions<BR/>o Underlying medical conditions <BR/>o Existence of delirium <BR/>o Ability to toilet self safely<BR/>o Cognition<BR/>o Communication <BR/>o Mobility (in and out of bed) <BR/>o Risk of falling. <BR/>The following Plan of Removal was accepted on 5/20/23 at 11:45 AM. The Plan or Removal reflected the following: <BR/>1. Resident #1 was assisted by staff back to bed on 12/28/2022.Resident #1 was assessed by the licensed nurse on 12/28/22with a small red indention noted to his upper middle chest, no other marks or injuries noted. Resident #1 was discharged from the facility on 2/26/23.<BR/>2. Residents have been reassessed/re-evaluated for use of bed rails to meet resident needs by the DON and designee on 5/19/2023. Those residents that require bed rails as an enabler have received verbal orders from the Medical Director on 5/19/2023. Residents/Responsible Party have been notified of the use of bed rails as an enabler for consent by the DON or designee on 5/19/2023. The DON or designee will review care plans for residents with side rails on or before 5/20/2023 to ensure care plans reflect current interventions and needs related to side rail use. The Maintenance or designee removed bed rails on 05/20/2023 from residents' beds that do not require bed rails as an enabler device and verified by surveyor. Therapy will screen residents for bed rail use on or before 5/20/2023 on the recommendation of the Certified Occupation Therapy Assistant on 05/20/23 on 4:30 PM two bed rails were removed and/or modified and verified by surveyor. <BR/>3. Education provided to licensed staff by the Administrator and designee on 5/18/2023 - 5/19/2023 regarding the requirement of providing alternatives to bed rails, and assessments for risk of entrapment. Education provided to staff by the Administrator and designee on 5/19/2023 regarding observations of residents' safety and timely assistance of residents, including resident calling out for assistance. Beginning on 5/20/2023 staff will be educated prior to the beginning of their next shift by the Administrator, DON, or designee regarding the 7 zones of bed entrapment, residents' physical conditions that increase risk of entrapment and the requirement of obtaining consents prior to implementing side rails. Staff will complete a posttest to confirm staffs understanding of education provided and verified by the surveyor. <BR/>4. The Director of Nursing or designee (DON was not available for interview but the Administrator) said audits will be will complete audits weekly for 4 weeks, then monthly for 2 months to ensure residents continue to be assessed for entrapment risk, alternatives continue to be provided for enable devices and consents continue to be obtained prior to implementing side rails. The Administrator or designee will complete audits weekly for 4 weeks and monthly for 2 months to ensure staff continue to be educated regarding bed entrapment and factors that increase risk for entrapment prior to providing resident care Findings of these audits will be presented at QAPI Committee meeting monthly for 3 months for review and recommendations as needed. The Director of Nursing is responsible for monitoring and follow-up as needed. The Assistant Director of Nursing and MDS nurse will be responsible for monitoring in the absence of the Director of Nursing. <BR/>Date of compliance: 05/20//2023 <BR/>The surveyor verified the implementation of the Plan of Removal as follows.<BR/>During interviews with 14 (5 LVNs, 6 CNA, 2 maintenance personnel and 1 housekeeper) staff members revealed they were in-serviced on 05/20/23 from 12:00 PM until 4:30 PM and revealed the following: received a pre and posttest on the use of bed rails; they explained the test had questions on the size and type of bedrails, the need for a physician's order, and that a resident had to be assessed for the use of bedrails before the rails could be adjusted to the bed. The staff said there were serious risks for the resident when their bed had side rails and gave examples of choking hazard, and their limbs getting caught up in the rails and causing injuries. <BR/>Observations on 5/20/23 from 4:00 PM until 5:00 PM revealed 12 resident beds with side rails were assessed by the Certified Occupation Therapy Assistant, 2 were removed. Reviews of the remaining residents with bed rails revealed they had physician's orders, care plans, assessments, and consents for the side rails. <BR/>Review of the facility's policy titled, Clinical Program Manual Side Rails dated 04/2013, revealed the following: <BR/>The use of side rails by a patient resident may be a restraint and ordinary depending on functional status and whether or not the side rails restricts freedom of movement. Prior to implementation side rails utilizes is evaluated by the interdisciplinary team to determine the reason for side rails and any alternative device that may be used to achieve the same goal<BR/>Procedure:<BR/> .2. Complete the side rail screen <BR/>3. Review the information with the interdisciplinary team, include not limited to reason for side rail consideration, ability to move self in bed with a or without a device, ability to transfer or without a device, ability to constantly request for assistance preventing falls and/or entrapment. Review alternatives to side rails but that will meet the identified needs alternatives may include but are not limited to trapeze concave mattress grab bars placing the bed lower to the floor and surrounding the bed with a soft mat bed alarms restorative nursing care to enhance ability to safely safety stand walk or improve bed mobility physical therapy occupational therapy to increase strength and mobility schedule toileting programs increasing visual and our verbal reminders to use call lights for a resident patient able to comprehend the information overview obtain A physician order to for side rails use if identified as a restraint order to include but not limited to reason for use type length of time to be used planned for side rails reduction and or elimination review the risk and benefits of side rails use with the resident patient or family legal representatives complete and provide a copy of the restraint information and consent review the risk and benefits of side rail use with the resident patient and or family legal representative document the plan for site rail reduction on the care plan or if side rails is determined to be a restraint communicate to staff that plan for side rails use and reduction educate staff on side rail use and reduction strategies as needed observe residents patients for the following risk factors of side rails use risk factor may include but not limited to protecting skin over areas of pressure decrease nutrition hydration intake increase difficulty behaviors increase withdrawal symptoms of depression incontinence increase fall risk document ongoing observation and the progress notes documentation to include but not limited to type of side rails length of time used frequency side rails are down resident patient participation and activities and interaction with others residents.<BR/>On 5/20/23 at 6:30 pm the IJ was lowered The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of 2 residents reviewed for pressure ulcers in that:<BR/>1. The facility failed to notify the physician and/or obtain wound care orders when Resident #1 was noted with a wound to the sacrum. <BR/>2. LVN D failed to assess and document a detailed description of Resident #1's wound.<BR/>These failures placed residents at risk for unidentified pressure ulcers and deterioration of existing pressure ulcers.<BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 01/27/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of urinary tract infection, Malignant neoplasm of colon (cancer), pneumonia, severe sepsis, acute kidney failure, asthma, and muscle weakness.<BR/>Review of Resident #1's admission assessment dated [DATE], reflected Resident #1 was admitted to the facility with intact skin and normal skin color.<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was at risk of developing pressure ulcers but no pressure ulcers were present. The MDS further indicated Brief Interview Mental Status (BIMS) was blank and unrated. It also indicated Resident #1 required extensive assistance with most ADL and total assistance with transfer<BR/>Review of Weekly skin assessment on 12/24/22, 12/31/2022, 01/07/23, 01/14/223 and 01/21/23 revealed Resident #1 skin was intact, warm, normal with no open areas <BR/>Review of Resident #1 care plan dated 09/27/22 reflected he has potential for pressure ulcer development related to immobility and end stage CA (cancer). The interventions included inform resident/family of any new area of skin breakdown and educate them as to the cause.<BR/>During interview with CNAC on 01/30/2023 at 10:55a.m, she revealed she was responsible for Resident #1 on 01/26/23 a day after surveyor made an entrance to the facility. CNAC explained she put resident on bed pan. She cleaned the resident after he was finished with toileting. She noticed a redden area like an abrasion on his sacrum. CNAC said the abrasion was not open. She followed the facility protocol and notified LVND. LVND informed her to let her know when she was done with the resident so she can provide the necessary treatment. CNAC stated LVND came and assessed Resident #1's abrasion and treated it. <BR/>During an interview with LVND on 01/30/23 at 11:08a.m, she said she has been employed by the facility since 2014. She explained she was the charge nurse responsible for Resident #1 on 01/26/23. LVND said she was informed by CNAC of a developing pressure ulcer on Resident #1 sacrum. She assessed the wound and provided treatment. She said it was a reddened area on sacrum and not open at the time. LVND explained it was the facility policy to measure the wound, document and notify the physician. LVND said she forgot to document the wound or call the doctor. She explained she stated she should have assessed, documented a description of the redden area, notified the physician, the family, obtained wound care orders and provided the treatment noted. She said she did not. LVND stated she got busy including admitting a new resident on that day.<BR/>Review of physician orders and MARS/TARS dated 01/01/23 through 01/26/23 indicated there were no orders for wound care and no evidence wound care was provided to the coccyx until 01/27/23.<BR/>Observation of Resident #1 pressure ulcers on 01/27/23 at 1:46p.m revealed three separate stage 2 pressure ulcers areas on the coccyx. The pressure ulcers were thin reddish clear dry wounds. The measurements completed by LVNE were as follows:<BR/>1) <BR/>Pressure Ulcers #1-A thin reddish open stage 2 (open break of top layer of skin and below) wound on left side sacrum 1.6x0.6x0.1<BR/>2) <BR/>Pressure Ulcers #2-A thin reddish open stage 2 wound on the lateral right sacrum 1.2x0.4x0.1<BR/>3) <BR/>Pressure Ulcers #3-A thin reddish open dry stage 2 wound on sacrum directly below wound #2-0.5x0.5x0.1.<BR/>In an interview with LVNE on 01/27/23 at 1:58p.m, she said she was not aware Resident #1 had stage 2 pressure ulcers until surveyor notified her. LVN E explained she had been off for the past 3 days and came back today. She said the facility protocol was to assess and treat wound with standing orders. The next step was to document and notify the doctor who will order the treatment. LVNE was asked if received information from the outgoing nurse about Resident #1's pressure ulcer. She said she did not.<BR/>During interview on 01/30/23 at 12: 21 p.m. with the DON, she said she had not been made aware of Resident #1's wound/pressure ulcer until LVNE informed her after talking to the surveyor. The DON stated it was her expectation that nurses document a full description of all skin impairments to include size, color, and the presence of drainage. DON explained she was not aware there was no documented assessment or physician notification for Resident #1's open skin area discovered on 01/26/23 until concerns were voiced by the Surveyor. Additionally, the DON stated he had provided in-service training to nurses related to steps to take when a resident was discovered with impaired skin. When the DON was asked why Resident #1's open area to the skin was not followed-up from the 24-hour report. She said she has been in the facility for few weeks and trying to set up a good system to monitor nursing care including pressure ulcers notification and communication between shifts. <BR/>In an interview with PHF on 01/30/23 at 1:12 p.m., he said he was the physician for Resident #1. He stated he was notified Resident #1 developed a stage 2 pressure ulcers on 01/27/23. PHF explained it was expected because of the resident's poor intake of protein. He said the facility was usually good at notifying him of changes in residents' conditions.<BR/>Review of Facility's pressure ulcers policy and procedures dated September 2011 reflected the following:<BR/>Skin Care and Wound Management<BR/>Treatment Protocol: Stage 2 Pressure ulcer<BR/>A stage 2 pressure ulcer is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with red, pink wound bed, without slough. May also as an intact or open/ruptured serum filled blister .<BR/>Procedure:<BR/>1) <BR/>Read the treatment protocol and select option most appropriate to the resident/patient need. Consider drainage and amount of moisture when selecting the treatment option.<BR/>2) <BR/>Obtain a physician order for treatment. Verify resident/patient has an order for pain management .<BR/>3) <BR/>Implement treatment protocol as ordered.<BR/>4) <BR/>Document wound measurements and characteristic on skin grid-pressure no less than weekly. More frequent documentation may be indicated based on changes in condition of wound .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Residents #1) reviewed for indwelling catheters. <BR/>1) <BR/>The facility failed to ensure Resident #1 indwelling catheter was secured to prevent pulling or tugging. <BR/>2) <BR/>The drainage urine bag was placed on resident's waist area instead of below bladder to prevent urine from flowing back into the bladder.<BR/>3) <BR/>The drainage bag was about 75% full, pulling on the catheter tube. <BR/>These failures could place residents at risk for discomfort, urethral trauma, and urinary tract infections.<BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 01/27/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of urinary tract infection, severe sepsis, and acute kidney failure.<BR/>Review of Resident #1's MDS dated [DATE] indicated Brief Interview Mental Status was blank and unrated. It also indicated Resident #1 required extensive assistance with most ADL and total assistance with transfer. Resident #1 was always of incontinent of bowel and bladder. There was no indication Resident #1 had a Foley Catheter. <BR/>Review of Resident #1 physician orders dated 01/01/23-01/31/23 revealed an order for Foley catheter with order date of 01/15/23. <BR/>Review of Resident #1's care plan initiated 09/12/22 revealed no plan for presence or care for Foley catheter on Resident #1.<BR/>Observation of Resident #1 on 01/27/23 at 1:46p.m revealed he was sitting on a reclining wheelchair. Resident #1 had a Foley catheter. The tubing from the catheter was visibly loose and touching the floor. It was not secured to the resident's leg. The drainage bag was around Resident #1 waist area slightly above the bladder. The bag was about 75% full of urine and the weight was pulling the tubing that appeared to be pulling on the resident penis. Resident #1 was grimacing while LVN A was repositioning the resident.<BR/>In an interview with LVN E on 01/27/23 at 1:58p.m, she said she was responsible for Resident #1 during the morning shift. She saw the loose Foley tubing, and the drainage bag around the resident waist. LVN E explained she has been off for the past 3 days and came back today. She was not aware that Resident #1's Foley catheter was not secured to his leg. She stated it was the facility protocol that the Foley catheter be strapped to the resident's leg. LVN E said the loose Foley tubing can cause physical trauma to Resident #1.<BR/>During interview with DON on 01/30/23 at 12:21p.m, she said she was aware of the issues regarding Resident #1 Foley catheter. The DON explained it was the facility policy and protocol to strap the Foley catheter. She said she did know why the staffs did not put it on the resident. <BR/>Review of Lippincott Manual of Nursing Practice 9th Edition 2009, page 783 indicated the following regarding securing a urinary catheter: <BR/>General Considerations:<BR/> .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device. <BR/>Where should the urinary drainage bag Foley bag be kept?<BR/>Always keep your urine bag below your bladder, which is at the level of your waist. This will prevent urine from flowing back into your bladder from the tubing and urine bag, which could cause an infection. <BR/>Review of the facility's policy on Foley catheter dated 05/2014 reflected the following:<BR/>Indwelling catheter evaluation and management<BR/>Procedure:<BR/>1) <BR/>Review the completed following: Most current MDS and CAA: Urinary incontinence and indwelling catheter<BR/>Bladder incontinence data collection/evaluation .<BR/>2) <BR/>Document care plans goals and interventions<BR/>3) <BR/>Anchor the catheter to prevent excessive tension and facilitate flow of urine .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of two residents reviewed for infection control practices<BR/>CNAA and CNAB failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #2.<BR/>This failure could place resident's risk for cross contamination and the spread of infection. <BR/>Finding included:<BR/>Review of Resident #2's face sheet, dated 01/30/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of constipation and dementia.<BR/>Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 required total assistance with most activities of daily living (ADLs) and always incontinent of bowel and bladder.<BR/>Review of Resident #2 care reflected a plan for functional bladder and bowel incontinence related confusion, disease process, impaired mobility, inability to communicate needs, and loss of peritoneal tone.<BR/>Observation on 01/27/23 at 1:05p.m of incontinence care for Resident #2 revealed CNAA and CNAB did not wash hands before the start of care. Both donned gloves and removed Resident #2 old brief. CNAA wiped from front to back. Resident #2's brief was soiled with urine and fecal matter. CNAA did not change gloves but continued to clean Resident #2. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #2's clean brief and placing it underneath the resident and fastening. Meanwhile, CNAB was assisting CNAA to provide care. CNAB repositioned the resident and touched Resident perineal area. She did change gloves, washed hands before helping to fastened Resident #2 clean brief. CNAA and CNAB removed their gloves, picked up the trash and washed hands before exiting Resident #2's room.<BR/>In an interview on 01/27/23 at 1:24 p.m. CNAA said she had been employed in the facility for about 1 year and received infection control a month ago. CNAA stated cross contamination was mixing clean with dirty. CNAA said she should have washed hands before retrieving Resident #2's clean brief and fastening it. She added Resident #2 could get infection for not following good infection control practice.<BR/>During interview on 01/27/22 at 1:27p.m. with CNAB, she said cross contamination was going from clean to dirty. She acknowleged not changing soiled gloves before fastening Resident #1 clean brief. CNAB stated she had been employed since April 2022 in the facility and received infection control training about 3 months ago.<BR/>In an interview on 01/30/23 at 12:21 p.m. the DON stated being aware of some of the concerns raised about infection control practice. She explained she was responsible for infection control in the facility. She trained and monitored staffs with return demonstration. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. She noted she was new and trying to put a system in place for staffs.<BR/>Review of the facility policy and procedure dated 03/2022 reflected the following:<BR/>Purpose: Hand hygiene is the number one way to prevent facility acquired infection by reducing the spread of harmful germs that can cause serious illness or death to residents. The facility requires healthcare providers to perform hand hygiene per CDC recommendation.<BR/>Healthcare providers must perform hand hygiene for the following:<BR/>1) <BR/>Immediately before touching a resident or the resident's immediate environment<BR/>2) <BR/>Before moving from work on a soiled body site to a clean body site on the same patient.<BR/>3) <BR/>Immediately after glove removal .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 2 of 3 residents (Residents #24 and #36) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining.<BR/>1. The facility failed to ensure Resident #24 was given a SNF ABN (Form CMS-10055) in addition to the NOMNC (Form CMS-10123 general notice) when she was discharged from skilled services.<BR/>2. The facility failed to ensure Resident #36 was given a NOMNC in addition to the SNF ABN when she was discharged from skilled services.<BR/>These failures could place residents at risk of not being fully informed about services covered by Medicare.<BR/>The findings include:<BR/>Resident #24<BR/>Review of Resident #24's admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] with a primary diagnosis of hypertensive heart disease without heart failure. Additional diagnoses included unspecified dementia with behavioral disturbance, insomnia, unspecified psychosis, and generalized anxiety disorder. The record reflected the resident had Medicare coverage Part A and B.<BR/>Review of Resident #24's Nursing Notes, dated 4/06/22, revealed documentation that Resident #24 was transferred and admitted to a behavioral health hospital for evaluation of behavior and medication adjustment.<BR/>Review of Resident #24's Nursing Notes, dated 4/06/22, revealed documentation that Resident #24 returned to the facility and was admitted with skilled nursing services. The notes reflected the admitting diagnoses for skilled therapy were hypertension without heart failure and Bradycardia.<BR/>Review of Resident #24's progress note, dated 6/13/22, revealed the MDS Coordinator documented she had contacted Resident #24's family member with NOMNC information. The note reflected the family member verbalized understanding of skilled care, the need for discharge when goals were met or maximum function was met, and of the appeal process; she did not wish to appeal at this time.<BR/>Review of the SNF Beneficiary Protection Notification Review (Form CMS-20052) completed for Resident #24 revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The form reflected a SNF ABN, Form CMS-10055, was not provided, due to the resident meeting maximum potential and discharged from skilled services with days left. The form reflected a NOMNC, Form CMS-10123) was provided and acknowledged by the beneficiary or the beneficiary's representative.<BR/>Review of the NOMNC form (Form CMS-10123) revealed notification was made to Resident #24's representative via telephone on 6/13/22, with a copy of the form mailed on 6/15/22, that skilled nursing services would end on 6/17/22. A SNF ABN form (Form CMS-10055) had not been completed and provided to the resident's representative.<BR/>Resident #36<BR/>Review of Resident #36's admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified fracture of lower end of right femur. Additional diagnoses included other fracture of shaft of right femur, hypertensive heart disease without heart failure, anxiety disorder, hypothyroidism, hyperlipidemia, generalized muscle weakness, unsteadiness on feet, history of falling, depression, and pain in right knee. The record reflected the resident had Medicare coverage Part A, B and D.<BR/>In an interview on 8/22/22 at 2:31 PM, Resident #36 stated she had gone to therapy every day and had built up strength in her arms and left leg. She stated she worked on transfers and weight bearing on her right leg.<BR/>Review of the SNF Beneficiary Protection Notification Review (Form CMS-20052) completed for Resident #36 revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The form reflected a SNF ABN, Form CMS-10055, was provided and acknowledged by the beneficiary or the beneficiary's representative. The form reflected a NOMNC, (Form CMS-10123) was not provided, the resident had been at a previous facility and unsure of the Medicare days used, and the resident had two days left after records for discharge were received.<BR/>Review of the SNF ABN (Form CMS-10055) revealed notification was made to Resident #36 on 8/02/22 that skilled nursing services would end on 8/05/22. The NOMNC form was not provided.<BR/>In an interview on 8/24/22 at 9:35 AM, the MDS Coordinator stated she started employment in the facility 6 months ago as the MDS Coordinator. She stated completing the beneficiary notice forms was part of her job duties. She stated she had not had any training for completing them. The MDS Coordinator stated there was a corporate zoom (video conference) meeting 6 weeks ago for the corporate MDS Coordinators/staff and it was determined that no one had been completing the SNF-ABN form (Form CMS-10055). She stated she had only been using the NOMNC form (Form CMS-10123) prior to that meeting. The MDS Coordinator stated she did not have a policy/procedure for completing the notification forms or guidance for which form to use for different discharge situations. She stated she would contact the corporate Senior Director of Clinical Reimbursement and ask for a policy and procedure. <BR/>In an interview on 8/24/22 at 10:00 AM, the MDS Coordinator provided a copy of the corporate policy/procedure for CMS guidelines on notification of non-coverage (NOMNC, SNF ABN), dated as revised 6/10/21. She stated it made sense to provide both the NOMNC and SNF ABN forms when a resident remained in the facility with MCR Part A days remaining. She stated that was how it was done when she had worked in home health.<BR/>Review of the facility's policy and procedure for CMS Guidelines on Notification of Non-coverage (NOMNC, SNF ABN .), dated as revised 6/10/21, revealed the following [in part]:<BR/>Purpose: To comply with CMS regulations on proper notification of coverage termination to Medicare beneficiaries and to release facility from financial responsibility.<BR/>Standard: Timely and proper completion of CMS forms by facility as it relates to CMS guidelines.<BR/>Important: This policy is strictly on the process of how/when to deliver the proper CMS forms .<BR/>NOMNC: Applies to Medicare A, B, C<BR/>1. Upon decision by clinical staff that resident is no longer meeting skilled criteria, a NOMNC (CMS-10123) will be delivered by facility appointed individual two days prior to coverage termination .<BR/>2. Facility will obtain signature and date from Resident/RP [resident's representative]. If the Resident cannot sign and date the form, facility should reach out to the RP via telephone and notate date/time/RP name. Facility should confirm contact by written notice mailed on the same date .<BR/>SNF ABN: Applies to Medicare A<BR/>1. Facility appointed individual will issue the SNF ABN (CMS-10055) when clinical/rehab staff believe Medicare will not pay or no longer pay when it is determined that a beneficiary does not require daily skilled nursing services .<BR/>- Upon termination of coverage due to no longer meeting skilled needs, if beneficiary has days remaining, the SNF ABN should be given to the resident for completion if Medicare A coverage is being terminated and to remain in facility .<BR/>4. The beneficiary or RP must sign the signature box to acknowledge that he/she has read and understands. If beneficiary cannot sign, facility may contact the RP by phone. If the RP is the person signing the form, the word rep must be noted

**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 a safe, clean, comfortable, and homelike environment, for 9 of 37 residents and 4 of 11 vacant rooms, observed for environment as evidence by:<BR/>A. The facility failed to repair and maintain 7 nightstands and 1 armoire for Residents #6, #23, #24, #32, #237, and 3 vacant rooms. <BR/>B. The facility failed to repair and maintain 4 toilet paper holders for Residents #2, #9, #26, and 1 vacant bathroom.<BR/>C. The facility failed to provide a toilet lid cover that fit the water tank in room Resident #9.<BR/>D. The facility failed to repair and maintain the lavatory sink for Residents #6 and #36, and to provide an adequate alternative for residents to maintain hygiene.<BR/>This failure could place residents at risk for a diminished quality of life and a diminished safe, clean, comfortable, homelike environment.<BR/>The findings include:<BR/>A.<BR/>A record review of Resident #237's Face Sheet, dated August 24, 2022, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis was senile degeneration of the brain. <BR/>In an observation, on 08/22/22 at 3:07 PM, Resident #237's nightstand was missing a handle to pull the drawer open on 1 of 3 drawers. The resident was not interviewable. <BR/>In an observation, 08/24/22 at 10:42 AM revealed room [ROOM NUMBER] was vacant. The handle to pull open a drawer on the nightstand was broken on 1 of 3 drawers. The drawer was not able to be opened. <BR/>A record review of Resident #6's Face Sheet, dated August 24, 2022, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her primary diagnosis was chronic ischemic (coronary) heart disease. <BR/>In an observation and interview, on 08/24/22 at 12:00 PM, revealed Resident #6's nightstand was missing a handle to pull a drawer open on 1 of 3 drawers. One of the pull handles on another drawer was halfway attached. Resident #6 said the nightstand had been broken since she had been at the facility. She did the best that she could and was only able to use one drawer. <BR/>A record review of Resident #23's Face Sheet, dated August 24, 2022, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis was Urinary Tract Infection. <BR/>In an observation and interview on 08/24/22 at 12:54 PM, revealed Resident #23's armoire was missing a pull handle on 1 of 1 drawer. Resident #23's family member said they had not been able to use it since the resident moved in. <BR/>A record review of Resident #32's Face Sheet, dated August 24, 2022, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE]. His primary diagnosis was schizoaffective disorder. <BR/>In an observation on 08/24/22 at 4:05 PM revealed Resident #32's nightstand was missing a pull handle on 1 of 3 drawers. The resident was not interviewable. <BR/>A record review of Resident #24's Face Sheet, dated August 24, 2022, revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE]. Her primary diagnosis was hypertensive heart disease. <BR/>In an observation on 08/24/22 at 4:06 PM revealed Resident #24's nightstand was missing a pull handle on 1 of 3 drawers. The resident was not interviewable. <BR/>In an observation, 08/24/22 at 4:08 PM revealed room [ROOM NUMBER] was vacant. The handle to pull open a drawer on the nightstand was broken on 1 of 3 drawers. The drawer was not able to be opened. <BR/>In an observation, 08/24/22 at 4:12 PM revealed room [ROOM NUMBER] was vacant. The handle to pull open a drawer on the nightstand was broken on 1 of 3 drawers. The drawer was not able to be opened. <BR/>B.<BR/>A record review of Resident #9's Face Sheet, dated August 24, 2022, revealed the resident was admitted to the facility on [DATE]. Her primary diagnosis was heart failure. <BR/>In an observation on 8/23/22 at 10:42 AM, Resident #9's bathroom toilet paper roll holder was missing from the wall and the roll of toilet paper was positioned on top of the horizontal grab bar on the wall across from the toilet. Resident #9 did not want to talk; she said her eyes were hurting. <BR/>A record review of Resident #2's Face Sheet, dated August 24, 2022, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her primary diagnosis was type 2 diabetes mellitus. <BR/>In an observation and interview, on 08/24/22 at 10:42 AM, Resident #2's bathroom toilet paper holder was broken, and the roll of toilet paper was positioned on top of the horizontal grab bar on the wall across from the toilet. Resident #2 said the toilet paper holder had been broken since she moved into this room. <BR/>In an observation on 08/24/22 at 4:13 PM revealed room [ROOM NUMBER] was vacant. room [ROOM NUMBER]'s bathroom revealed only one side of the toilet paper holder was attached to the wall. <BR/>A record review of Resident #26's Face Sheet, dated August 24, 2022, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. <BR/>In an observation on 08/24/22 at 4:14 PM, Resident #26's bathroom toilet paper holder was broken. The roll of toilet paper was positioned on top of the horizontal grab bar on the wall across from the toilet. Resident #26 was not available for interview. <BR/>C.<BR/>A record review of Resident #9's Face Sheet, dated August 24, 2022, revealed the resident was admitted to the facility on [DATE]. Her primary diagnosis was heart failure. <BR/>In an observation, on 8/23/22 at 10:42 AM, Resident #9's bathroom toilet tank lid did not fit the tank. A long rectangular tank lid had been placed on top of the toilet tank and was the wrong shape and size. The toilet tank was curved in the front and was not entirely covered by the straight rectangular tank lid. Resident #9 did not want to talk; she said her eyes were hurting. <BR/>D.<BR/>A record review of Resident #6's Face Sheet, dated August 24, 2022, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her primary diagnosis was chronic ischemic heart disease. <BR/>A record review of Resident #36's Face Sheet, dated August 24, 2022, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her primary diagnosis was unspecified fracture of lower end of right femur. <BR/>In an observation and interview on 08/23/22 at 9:15 AM, Resident #36 said her sink was not working in her room. She said there was an issue with the plumbing and was told not to use it until they get it fixed. There was a trash can observed located underneath the sink and piping. When asked how she brushes her teeth and washes her hands, she said she turns it on anyway for a second. The trash can under the sink catches the water. She said it has been broken for about 2 weeks. <BR/>In an interview on 08/23/22 at 9:50 AM, CNA H said she works on Hallway B and was familiar with the residents. She said she didn't know the sink wasn't working in Residents #6 and #36 bedroom. <BR/>In an interview with the ADON, on 08/23/22 at 9:53 AM, she said staff would bring Residents #6 and #36 to the shower room on the evening shift to complete hygiene. <BR/>A record review on 08/23/22 at 2:46 PM of the Maintenance Log located at the nurse's station revealed the sink was reported as having a leak on 08/13/22 for Residents #6 and #36. There was no documentation relating to pull handles missing from the resident's nightstand or broken toilet paper holders. <BR/>In an interview on 08/24/22 at 12:00 PM, Resident #6 said her sink doesn't work. When asked how she brushes her teeth, she said staff will bring her a cup of water. When asked how she washes her hands, she said she couldn't She said it had been broken for a while. <BR/>In an interview on 08/24/22 at 1:47 PM, the Maintenance Director said the sink for Residents #6 and #36 is old and the reason it has not be fixed is due to the size and shape of the P-trap (a p-shaped bend pipe used in drainpipes to connect your sink's drain directly to the sewer system). The Maintenance Director said the local store did not have the correct size of plumbing to fix the sink and so it had to be ordered. He said it would take 1 to 2 weeks for the part to arrive. The Maintenance Director was unaware of residents' nightstands missing pull handles to open the drawers and unaware residents' toilet paper holders were broken. He said staff should document issues in the Maintenance Log and that is what he goes by to know if things need to be fixed. <BR/>In an interview on 08/24/22 at 2:26 PM, the Administrator said she was aware of the sink not working for Residents #6 and #36. She said a part has been ordered and they are waiting for it to come in. When asked how the residents complete personal hygiene, she said Resident #36 turns it on anyway. She said Resident #6 requires assistance to complete her ADLs and cannot complete them on her own. When asked how Resident #6 washes her hands, she said staff provides the resident disposable wipes. The Administrator was unaware of residents' nightstands missing pull knobs and said staff are assigned room rounds and checks are conducted daily. She said she would make staff aware to look for that specifically when conducting room rounds. A facility policy was requested but was not provided by time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #8) whose records were reviewed for comprehensive care plans.<BR/>Resident #8 had physician's orders for antianxiety and antidepressant medications which were not addressed in the comprehensive care plan.<BR/>Resident #8 received psychological/behavioral health services which included medication regimen review and medication adjustments, which were not addressed in the comprehensive care plan.<BR/>This failure placed the resident at risk for not being monitored for potential side effects and/or adverse reactions to psychotropic medications and changes in mood state and behavioral symptoms.<BR/>The findings include:<BR/>Review of Resident #8's admission Record/Face Sheet, dated 8/08/22, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Additional diagnoses included: thyrotoxicosis, unspecified without thyrotoxic crisis or storm; unspecified dementia without behavioral disturbance; other recurrent depressive disorders; anxiety; unspecified psychosis; lack of coordination; difficulty in walking; unsteadiness on feet; generalized muscle weakness; major depressive disorder, recurrent severe without psychotic features; and insomnia.<BR/>Review of the quarterly MDS assessment, dated 6/03/22, revealed Resident #8 was assessed as having a BIMS score of 1 out 15 (cognitively impaired), was able to transfer and walk independently with supervision, had hallucinations and delusions, and received antianxiety and antidepressant medication daily during the past 7 days. The assessment reflected no mood state symptoms and no behavioral symptoms.<BR/>Review of the medication orders for Resident #8 revealed the following were included:<BR/>- Trazodone 100 mg by mouth at bedtime, order dated 6/20/20 (antidepressant medication);<BR/>- Trileptal 300 mg by mouth two times a day for behaviors, order dated 7/18/22 (anticonvulsant medication used for mood stabilization);<BR/>- Paxil 20 mg by mouth at bedtime, order dated 8/17/22 (antidepressant medication); and<BR/>- Vistaril 25 mg by mouth every 8 hours PRN for anxiety, with a stop date on 8/18/22.<BR/>Review of the psychological care/behavioral health service notes revealed documentation for medication regimen adjustments:<BR/>7/18/22 Discontinue Depakote; start Trileptal 300 mg two times a day for behavior management;<BR/>8/17/22 - Discontinue Buspar; start Paxil 20 mg at bedtime.<BR/>Review of Resident #8's comprehensive care plan, dated as initiated 4/15/22, revealed it did not address risk factors associated with the administration of psychotropic medications. The care plan addressed the resident's wandering behavior, potential to demonstrate verbally abusive behaviors related to dementia, and mood problem related to disease process, with approaches for behavioral health consults as needed, to administer medications as ordered and monitor/document for side effects and effectiveness. The medications to be administered and monitored for side effects and effectiveness were not specified. <BR/>In an interview on 8/24/22 at 3:05 PM, the MDS Coordinator stated when she started working in the facility 6 months ago, none of the residents had care plans. She stated when the residents electronic records were transferred from the prior electronic health record system to the new/current system, no resident care plans transferred over. She stated she was responsible for data entry of the residents' care plans and had developed care plans for all the residents in their electronic health records.<BR/>During a record review with the MDS Coordinator on 8/24/22 at 4:52 PM, Resident #8's comprehensive care plan was reviewed. The resident's care plan did not address the risk factors associated with the administration of psychotropic medications and did not address the mental health services the resident received for ongoing evaluation of mood and behavior, medication regimen review, and medication adjustments. <BR/>Review of the facility's policy and procedure for Care Plan Development, dated August 2015, revealed the following [in part]:<BR/>Care Plan Development<BR/>An individualized, comprehensive care plan using the results of the RAI/MDS assessment, resident/family/legal representative and interdisciplinary input will be developed for each resident in the facility within 21 days of admission or 7 days after the completion date of a comprehensive MDS assessment, and describe services that are to be furnished to attain or maintain the resident' highest practicable physical, mental and psychosocial well-being. The care plan will include measurable objectives, goals, and timetables. The care plan will be reviewed and revised on an as needed basis and at least every 92 days.<BR/>Procedure<BR/>3. Comprehensive care plans are designed to:<BR/>Include identified resident needs and strengths.<BR/>Include risk factors associated with needs.<BR/>Build upon resident strengths and abilities.<BR/>Indicate goals and objectives that are measurable and obtainable and are derived from information supplied by resident/family/legal guardian and MDS data.<BR/>The care plan will be reviewed and revised as needed, when a significant change in condition is noted, when outcomes were not achieved or when outcomes were completed, and at least every 92 days

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon and notify the attending physician of the pharmacist consultant's recommendation for 1 of 6 residents (Resident #9) whose records were reviewed for pharmacist drug regimen review. <BR/>The facility did not follow up with the attending physician on the Pharmacy Consultant's recommendation to provide a stop date for Resident #9's Xanax 0.5 mg PRN order. <BR/>This failure placed residents at risk for receiving anti-anxiety medication for an extended duration without physician review and determination for continuation and necessity of the medication.<BR/>The findings include:<BR/>Review of Resident #9's admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of heart failure. Additional diagnoses included: myocardial infarction; pneumonia; major depressive disorder, recurrent, severe with psychotic symptoms; chronic pain syndrome; chronic obstructive pulmonary disease; hypertensive heart disease with heart failure; other idiopathic scoliosis, thoracolumbar region; unspecified dementia with behavioral disturbance; nicotine dependence; essential (primary) hypertension; and unspecified convulsions.<BR/>Review of Resident #9's Significant Change MDS Assessment, dated 6/07/22, revealed documentation that antianxiety and antidepressant medications were given daily during the past 7 days.<BR/>Review of Resident #9's comprehensive care plan, dated as revised on 6/08/22, revealed it addressed the use of psychotropic medications Trazodone and Xanax related to anxiety, depression, and insomnia. <BR/>Review of Resident #9's medication orders revealed an order for Xanax 0.5 mg by mouth every 8 hours (scheduled), dated 6/01/22. The initial dose was administered on 6/08/22. The order was discontinued on 7/03/22.<BR/>Review of Resident #9's medication administration record, dated 8/01/22-8/31/22, revealed an order for Xanax 0.5 mg by mouth every 8 hours PRN for anxiety, dated 7/03/22. The order did not have a medication stop date. The record reflected the medication had been administered one to two times daily 8/04/22 through 8/23/22. <BR/>Review of the Consultant Pharmacist's Medication Regimen Review report, dated 8/17/22, revealed documentation that Resident #9 needed a renewal order with a stop date for PRN Xanax.<BR/>In an interview on 8/23/22 at 10:47 AM, Resident #9 stated she had panic attacks and took Xanax every 8 hours. She stated she had to ask for it (PRN order). She stated she took Xanax when she was living at home.<BR/>In an interview on 8/24/22 at 2:22 PM, the ADON stated the charge nurses entered physician orders into the residents' electronic medication administration records. She stated the DON was responsible for the follow-up to the Pharmacist Consultant's medication review recommendations. The ADON stated since the DON resigned on 8/19/22 she had started doing the follow-ups to the Pharmacist Consultant's recommendations. The ADON stated she did not know how to do a renewal order and enter an end-date for PRN medication. She stated she had not faxed the Pharmacist Consultant letter to the physician. The ADON stated she would look for a policy and procedure for physician's orders and follow-up to pharmacist consultant recommendations.<BR/>Review of the facility's policy and procedure for Documentation and Communication of Consultant Pharmacist Recommendations, dated August2020, revealed the following [in part]:<BR/>Policy<BR/>The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist's observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion .<BR/>Procedures<BR/>1. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team. This should include:<BR/>a. Documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated manner .<BR/>c. Potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for prescriber and/or nursing review .<BR/>2. Comments and recommendations concerning medication therapy are communicated in a timely fashion .<BR/>3. Recommendations are acted upon and documented by the facility staff and/or the prescriber <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure freedom from a significant medication error for 1 of 6 residents (Resident #9) whose records were reviewed for medication orders.<BR/>The facility failed to ensure Resident #9's Gentak ointment 0.3% (Gentamicin Sulfate) for conjunctivitis was administered as ordered by the physician. <BR/>This failure placed the resident at risk for eye discomfort and delayed healing and resolution of an eye infection.<BR/>The findings include:<BR/>Review of Resident #9's admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of heart failure. Additional diagnoses included: myocardial infarction; pneumonia; major depressive disorder, recurrent, severe with psychotic symptoms; chronic pain syndrome; chronic obstructive pulmonary disease; hypertensive heart disease with heart failure; other idiopathic scoliosis, thoracolumbar region; unspecified dementia with behavioral disturbance; nicotine dependence; essential (primary) hypertension; and unspecified convulsions.<BR/>Review of the Physician Visit Communication Record and Progress Note, dated 8/16/22, revealed documentation the facility notified Resident #9's physician's office regarding redness and edema of the left eye. The provider's response from the nurse practitioner documented a diagnosis of conjunctivitis and an order for Gentak every 12 hours for 7 days, with a strip applied to the lower lid.<BR/>Review of Resident #9's current Physician Orders revealed an order for Gentak 0.3% (Gentamicin Sulfate), instill 1 strip in left eye two times a day for conjunctivitis for 7 days, dated 8/16/2022. <BR/>Review of Resident #9's electronic medication administration records, dated 8/01/22-8/31/22, revealed the following:<BR/>- Moxifloxacin HCL Solution 0.5%, instill 2 drops in left eye three times a day for eye infection until 08/15/22; order date 8/08/2022.<BR/>The nurses documented the eye drops were instilled three times daily at 8 AM, 12 PM, and 8 PM 8/09/22-8/15/22. There was no documented evidence on the medication administration record that the Moxifloxacin eye drops were instilled after 8/15/22.<BR/>- Gentak 0.3% (Gentamicin Sulfate), instill 1 strip in left eye two times a day for conjunctivitis for 7 days; order dated 8/16/2022. <BR/>The nurses documented the eye ointment initial dose at 8 PM on 8/16/22, instillation two times daily at 8 AM and 8 PM on 8/17/22 - 8/22/22, and the final dose instillation dose at 8 AM on 8/23/22. <BR/>During an observation and interview on 8/22/22 at 12:36 PM, Resident #9 was sitting on the side of her bed; the room light was off. The resident's left eye was red, including the upper and lower lids. Resident #9 stated she had an infection in her eye, and she went to the doctor. She stated the nurse put eye drops in her eye. She stated her left eye hurt and light hurt her eye, so she kept the overbed light off.<BR/>In an interview on 8/22/22 at 12:38 PM, LPN G charge nurse stated Resident #9 did not receive eye ointment; she received eye drops. The LPN stated the eye ointment was not available and was not applied to the resident's left eye.<BR/>In an interview on 8/23/22 at 10:24 AM, Resident #9 stated she had received eye drops in her left eye She stated the eye ointment was not available and she had not received it. She stated the doctor was supposed to come today.<BR/>During an interview and record review on 8/24/22 at 2:22 PM, the ADON stated the charge nurses entered physician orders into the residents' electronic medication administration records. Review of Resident #9's medication orders with the ADON revealed the order for Gentak eye ointment was no longer on the resident's current orders. The ADON stated it was probably discontinued yesterday. She stated the resident received the Moxifloxacin eye drops. The ADON stated she would look for a policy and procedure for physician's orders.<BR/>Review of the facility's policy and procedure for Ordering and Receiving Non-controlled Medications, dated as revised August 2020, revealed the following [in part]:<BR/>Policy<BR/>Medications and related products are received from the pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt.<BR/>Procedures<BR/>Ordering Medications from the Pharmacy<BR/>1. Medications orders are written on a physician order form, telephone order sheet, or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR system and transmitted to the pharmacy

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 in one of one kitchen observed for evidence of pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of a lizard in the kitchen. The facility's failure placed the residents at risk for foodborne illness and/or disease spread by pests.The findings included: During an observation on 10/10/25 at 3:45pm, a live lizard was observed running across a shelf above the dishwashing machine and 3 -compartment sink area. During an interview on 10/10/2025 at 3:48pm, the [NAME] stated she had seen lizards in the kitchen before. The [NAME] stated she had not seen any other pest like roaches or any other bug. During an interview on 10/10/2025 at 4:00pm, the Maintenance Director stated the facility did not have a pest control contract with pest control vendor. The Maintenance Director stated he had not seen any pest control company come to the facility in the four months he worked at facility. The Maintenance Director supplied a business card for a local pest control and stated he thought it was the pest control that facility used at one time. During an interview on 10/10/2025 at 4:40pm, the owner of the local pest control stated the last time they provided service was 02/02/2025. Services stopped due to failure to pay. Stated has no contact with facility. During an interview on 10/13/2025 at 9:07am, the DM stated she saw lizards in the kitchen but did not know where they come from. The DM stated she reported that pest was found in kitchen but could not recall who she reported to. During an interview on 10/15/25 at 12:10pm, the Administrator stated she knew the facility lost their pest control vendor due to failure to pay the bill. The Administrator stated she was not aware of any pest problems in dietary with lizards. Record review of the facility's policy, Insect and Rodent Control, dated 2012, reflected, The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department . 2. Facility will maintain appropriate screens, close fitting doors, proper sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents .