Crestview Healthcare Residence

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 1 resident (Resident #1) reviewed for quality of care.Resident #1 had an appointment on or around 4/28/2025, for an MRI (a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in your body) for his prostate, and the facility failed to schedule the appointment and failed to place the necessary preop instructions needed for the procedure in PCC; subsequently Resident #1 missed his appointment twice. There were no adverse reactions from him not attending his appointment. These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Record review of Resident #1's admission record, dated 8/14/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included major depressive disorder, recurrent severe without psychotic feature (s characterized by multiple episodes of major depressive disorder that are severe in nature but do not include psychotic symptoms), chronic embolism and thrombosis of unspecified vein (a blood clot in a deep vein that has lasted for at least a month. It can be difficult to treat and can lead to scarring and vein damage), overactive bladder (causes sudden urges to urinate that may be hard to control), and benign prostatic hyperplasia with lower urinary tract symptoms (is a noncancerous enlargement of the prostate gland that can lead to lower urinary tract symptoms, affecting urination and overall quality of life). Record review of Resident #1's quarterly MDS, dated [DATE] reflected a BIMs of 10, which indicated mild cognitive impairment. Record review of Resident #1's physicians order dated 10/31/2024 reflected Resident #1 had a referral to see the urologist upon admission. Original orders from the hospital dated 3/31/2025 revealed the resident had a cystoscopy on 3/26/2024 which identified large bladder capacity. The resident has an overflow incontinence. TRUS not performed. It was recommended a Urolift but the patient canceled. 12/3/24: the resident wen in there of complaints included severe urge incontinence. Overall, he is frustrated with his status. Patient report delayed ejaculation. During an interview on 8/14/2025 at 1:50 PM with Resident #1 revealed he had an MRI that was scheduled that he did not attend. Resident #1 stated he waited a month to get the appointment scheduled, he was advised the facility never received he prep instructions. He stated he gave the instructions to the ADON. He stated he has waited 3 months for the appointment, and it is finally scheduled for 8/15/2025. He stated the DON apologized and assured him it was rescheduled, and he will be prepped the night before and he will be transported to his appointment. He stated he was upset that once he saw the ADON, she did not apologize to hm for the mistake she made. During an interview on 8/14/2025 at 4:20 PM with ADM revealed there was a transportation driver that brings the residents to their appointments if she was informed. He stated if residents had appointments scheduled at the same time, they utilized a ride share company. He stated there was a mix up with the appointment with Resident #1. He stated it was missed once and it was rescheduled. He stated it was an MRI appointment for urology. He stated it was not an appointment that was life threatening. During an interview on 8/14/2025 at 5:08 PM with ADON revealed Resident #1 came from another town hospital and he scheduled his own MRI and set up his own transportation where he attended his appointment in the other town. She stated he came back with no follow-up paperwork. She stated she received a call from the surgical confirming his appointment on or about 3/30/2025. She advised the surgical representative that there will not have anyone medically equipped on the van to handle Resident #1 after the procedure. The next day they called from the same surgical center and stated he cannot get on the van after the procedure. The ADON stated that was why the first appointment was cancelled. She stated Resident #1 then received a referral from the doctor to a local urologist. The ADON stated the appointment was scheduled but never questioned anything regarding preop instructions because she figured he did not need anything for the MRI. Once he arrived at the appointment, he could not be seen because he had not been prepped. The ADON stated they received the orders from the doctors' office, but the orders were not put into PCC so Resident #1 missed that appointment. The ADON stated the orders was now placed into the system and Resident #1 appointment was scheduled and he has started his preop for the procedure that will take place on tomorrow. The ADON stated the was not a life-threatening procedural appointment he missed. During an interview on 8/14/2025 at 5:38 PM with DON revealed it was the ADON or the charge nurse job to make sure appointments and orders are placed in PCC but ultimately it was her responsibility. The DON stated the first time, the surgical center in [NAME] did not communicate the instruction. The second time, it was not entered into PCC. When she learned about it, she scheduled it. She stated the ADON went on vacation, and she did not see the instruction. It was revealed, the instructions were not placed in PCC. She found the instructions and she went over them with Resident #1. She advised him it was scheduled for 8/15/2025 and he was alright with that. A record review of the facility's Abuse Prohibition undated policy revealed, each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. It may include failure to assist in personal hygiene, or in provision of food, clothing, shelter; failure to provide medical care for physical and mental health needs or failure to protect from health and safety hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #67, #33, #1) 3 residents reviewed for rights.<BR/>1. <BR/>The facility failed to prevent CNA K from calling Resident #67 a feeder on 2 occasions.<BR/>2. <BR/>The facility failed to empty Resident #33's urinal in a timely manner.<BR/>3 <BR/>The facility failed to respect Resident #1's personal property and care wishes.<BR/>The findings include:<BR/>Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease.<BR/>Record review of Resident #1's 03/03/23 MDS revealed a BIMs of 15 which indicated that she was cognitively intact.<BR/>Record Review of Resident #67's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy, rheumatoid arthritis, and reflux.<BR/>Record review of Resident #67's 04/13/23 MDS revealed a blank for the section that provided a BIMs score.<BR/>Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction <BR/>Record review of Resident #33's 02/10/23 MDS revealed a BIMS of 13, which indicated he was cognitively intact.<BR/>In an observation on 05/17/23 at 2:12 pm CNA K entered the room and called Resident #67 a feeder while speaking to a new staff member. <BR/>In an interview on 05/17/23 at 2:12 pm with Resident #1 she stated she has heard staff use the term feeder often when referring to her roommate because her roommate, Resident #67 requires assistance with her meals. <BR/>In an interview and observation on 05/17/23 at 2:13 pm with Resident #67 she was lying in the bed with her eyes closed and she was not interviewable, and not able to verbalize her feelings or thoughts <BR/>In an observation on 05/17/23 at 2:23 pm in the hall next to the nurses station CNA K was speaking to a new staff member and again used the term feeder while going through a list of residents with the new staff member.<BR/>In an interview and observation on 05/17/23 at 2:24 pm with CNA K she did not realize the term feeder was disrespectful and should not be used; she was going over required tasks for each resident with a new staff member. <BR/>In an observation on 05/20/23 at 4:00 pm with Resident #33 in his room the urinal with urine in it was sitting on the table in full view.<BR/>In an observation on 05/22/23 at 10:20 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table.<BR/>In an observation on 05/22/23 at 11:00 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table. <BR/>In an interview with Resident #1 on 05/17/23 at 2:12 pm she stated that CNA M had worked for the facility before and Resident #1 had problems with her because she was rude and not polite. CNA M has returned to the facility and and she came into the room and Resident #1 asked her not to use Resident #1's red hairbrush on her roommate (who has a blue brush) and CNA M told her Don't you think I know that, which upset Resident #1. Then CNA M proceeded to use Resident #1's hairbrush on her roommate (Resident #67). The resident ws upset that this staff member was alloweed back at the facility and felt she was disrespectful by using her brush on her roommmate and ignored becuase she had just asked her not to do that.<BR/>Record review of the undated facility policy titles Statement of Resident Rights revealed .1. All care necessary for you to have the highest possible level of health . 2. Safe, descent and clean conditions . 4. Be treated with courtesy, consideration, and respect

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to protect the residents' right to be free from neglect for 1 (Resident #3) of 6 residents reviewed for neglect. <BR/>The facility failed to ensure Resident #3's safety and well-being when RN D and CNA E left her in the Shower Room in soiled undergarments unattended for approximately 30 minutes. <BR/>This failure could result in residents receiving injuries and possible skin breakdown.<BR/>Noncompliance existed from 02/13/2025 to 02/18/2025, but the facility corrected the noncompliance through inservicing, one on one inservicing and the QAPI process. Therefore, the findings are of past noncompliance.<BR/>Findings included:<BR/>Record review of Resident #3's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of Generalized Atherosclerosis (a widespread buildup of plaque in the arteries throughout the body, which can lead to narrowing and blockage of blood vessels), Unspecified Dementia (a decline in cognitive function that cannot be attributed to a specific underlying cause), and Unspecified Abnormalities of Gait and Mobility (difficulty walking or moving without a specific cause). <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 3, indicating she had a significant level of cognitive impairment. Her Functional Status reflected she required partial/moderate assistance with mobility, Supervision or touching assistance with toileting hygiene, and Substantial/maximal assistance with showering. <BR/>Record review of Resident #3's care plan, initiated on 06/27/2019 and most recently update 02/04/2025, reflected she had an ADL Self Care Performance Deficit related to diagnosis of Dementia/schizoaffective Disorder, and Major Depressive Disorder. Care Planned Interventions include the following:<BR/>Resident requires staff x 1 for participation with bathing.<BR/>Resident requires staff x 1 to use toilet. Resident participates in toileting process.<BR/>Resident requires assist of staff x 1 for transfers. Resident participates in transfer process.<BR/>Resident requires staff x 1 to choose simple comfortable clothing and for ability to dress self.<BR/>Resident requires staff xx1 for a sponge bath when a full bath or shower cannot be tolerated.<BR/>Resident requires staff x 1 for reminding, prompting, cueing, for assistance with eating.<BR/>Resident requires setup help with meals but can feed self independently.<BR/>Resident requires staff x 1 to set up or assist with oral care.<BR/>Check nail length and trim and clean on bath day. Report any changes to the nurse.<BR/>Praise all efforts at self-care.<BR/>Record review of the facility's investigation report on 02/26/2025 at 12:21 PM reflected the facility was notified of this event by the outside representative on 02/13/2025 at 11:00 AM. According to the Facility's Investigation Report, RN D walked thru the Dining Room on 02/07/2025 after lunch and the outside representative notified him that Resident #3 needed to be changed as she had urinated on the floor. RN D notified CNA E that the resident needed to be changed. RN D placed Resident #3 in the Shower Room per CNA E's request. CNA E reported to RN D she would finish her round and attend to Resident #3. The outside representative later called Social Worker to report Resident #3 was alone in the shower for approximately 30 minutes unattended.<BR/>Record review of the Facility follow up included the following:<BR/>02/13/2025 RND and CNA E are suspended pending further investigation.<BR/>02/13/2025 Ad Hoc QAPI <BR/>02/13/2025 and 02/14/2025 Notification of Medical Director<BR/>02/13/2025-02/14/2025 All staff inservicing to include Abuse and Neglect, Resident rights/Dignity-Bowel and Bladder, Communication-Clarification of Task Assignment, and Shower Room Monitoring.<BR/>02/14/2025 Attempted notification of responsible party.<BR/>02/17/2025 Education sent to outside providers regarding reporting of Abuse and Neglect.<BR/>02/18/2025 One on One communications with RN D and CNA E to include Communication and Clarification and Shower supervision.<BR/>Record review of Resident #3's medical record on 02/26/2025 at 11:00 AM ,reflected the Social Worker completed an assessment for injury on 02/13/2026 at 4:45 PM. According to the note, Resident #3 did not demonstrate any signs of a negative outcome from this event. Skin Assessment completed on 02/14/2025 at 1:09 PM is negative for any physical injury.<BR/>Interview with Resident #3 was conducted on 02/26/2025 at 11:33 AM. Resident #3 stated the staff are good to her and always help her. She has no recollection of being left in the Shower Room unattended. <BR/>Interview with DON on 02/26/2025 was conducted at 10:26 AM. The DON stated it was her expectation that residents are not to be left alone in the Shower Room even if they can shower themselves. The DON stated the following interventions were implemented. RN D and CNA E were suspended on 02/12/2025 pending investigation. One on one communication with RN D and CNA E for training on staff-to-staff communication was completed on 02/18/2025. One on one training on Shower Supervision was completed with RN D and CNA E on 02/18/2025. The following in-service training was also implemented with direct care staff on 2/13/25 and 2/14/2025:<BR/>Abuse and Neglect<BR/>Resident Rights/Dignity related to Bowel and Bladder needs.<BR/>Communication-Clarification of Task Assignment<BR/>Shower Room Monitoring<BR/>Interview conducted with CNA F was conducted on 02/26/2025 at 2:23 PM. She confirmed receiving training as listed above and described that a resident is never to left alone in the shower room. She also stated staff should always communicate clearly with coworkers and nurse to make sure everyone understands what is going on. <BR/>Interview conducted with Activity Therapy staff G on 2/26/2025 at 2:35 PM. AT staff G confirms having received training as list above. She stated the main theme of the training was regarding monitoring residents in the shower and residents should never be left alone in the shower. Confirms receiving training on clear communication with coworker. Also reported having received training on reporting abuse and/or neglect the facility Administrator.<BR/>Interview conducted with CNA H on 02/26/2025. CNA H confirms receipt of training as listed above. CNA stated she was trained on the types of abuse and neglect and to whom to report. CNA H verbalized receipt of training on rights and dignity. CNA H stated staff are to be in the shower room with any resident regardless of their mobility status.<BR/>Interview with LVN I was conducted on 02/26/2025 at 2:51 PM. LVN, I confirmed receipt of training on abuse/neglect/exploitation and Resident Rights. LVN I stated residents are never to left unattended in the shower room for any reason.<BR/>Interview with the Social Worker on 02/26/2025 at 1:27 PM revealed, he had received information about this event from the outside representative on 02/13/2025 at 11:00 AM. The outside representative reported she thought Resident #3 was in the shower room unattended for approximately 30 minutes. <BR/>Interview with the outside representative by phone on 02/26/2025 at 2:07 PM was conducted. The outside representative stated she heard CNA E tell RN D to take Resident #3 to the shower and CNA E would be there in a little bit. The outside representative stated she did not know exactly how long Resident #3 was in the Shower Room, but she guessed it was about 30 minutes. The outside representative stated she did not realize Resident #3 was in the Shower Room alone until she heard her yell out.<BR/>Interview with RN D on 02/26/2025 at 1:55 PM stated Resident #3 was taken to the Shower Room to await CNA E. He stated, I should have just done the hygiene care myself. RN D also reported he will change his practice by not ever leaving anyone in the Shower Room but, rather outside in the hallway. RN D also stated he should have communicated better with CNA E. <BR/>Interview with CNA E was conducted at 02/26/2025 at 2:01 PM. CNA E stated she and RN D did not communicate regarding how long it was going to take CNA E to get to Resident #3. CNA E stated she should have let RN D know how long it was going to take her to get to Resident #3. <BR/>Interview with the Administrator was conducted 02/26/2025 at 4:54 PM. The Administrator stated every resident must be supervised while in the Shower Room. If the resident can shower independently, the CNA was to stand outside the door, knock and check on the resident frequently. Additionally, the Administrator was asked about the existence of documentation of notification of the physician and the resident representative regarding the event. The Administrator responded the physician was not notified because there was no injury, and the Resident Representative was not notified because Resident #3 was legally her own representative.<BR/>A telephone interview was conducted with Resident #3's family member at 5:42 PM. He stated he was pleased with the care and treatment Resident #3 received from the facility and was thankful for the assistance. He stated: they're doing a great job and I'm thankful for that.<BR/> Review of the facility's Abuse Prohibition policy, dated 12/2019, reflected:<BR/>Each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriate of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in the facility in that:<BR/>1. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description.<BR/>2. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly sealed. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description.<BR/>3. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not discarded by use by/expiration date.<BR/>4. <BR/>One 1-gallon bottle of Reduced Fat Milk past the Best By date was being used by [NAME] A<BR/>5. <BR/>3 boxes of food inside walk in cooler that were labeled by manufacturer to keep frozen.<BR/>6. <BR/>Food inside of freezer had freezer burn present.<BR/>7. <BR/>1 tray of baked chicken with internal temp of 100 degrees Fahrenheit was cooled improperly, prepared for dinner meal, and placed inside of refrigerator. <BR/>8. <BR/>1 box of meat was defrosting over a bowl of cut potatoes.<BR/>9. <BR/>Temperatures of cold lunch were held and served at a temperature above 41 degrees Fahrenheit. <BR/>This failure could place residents becoming ill from food contamination or bacterial growth.<BR/>Findings included:<BR/>In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator containing grated cheese with date 2/21 use by date 3/2, [NAME] with date 2/27/23, burritos dated 2/24, butter dated 2/24, without product description or use by date labeled.<BR/>In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator labeled sausage dated 2/28/23 and use by date 2/29 was not properly sealed.<BR/>In observation on 2/28/23 at 9:50AM, located in the refrigerator was an open container of labeled Hormel Thick and Easy clear thickened orange juice 46fl oz dated 2/6, ready care thickened apple juice dated 2/4, and thick and easy clear dated 12/6.<BR/>In observation on 2/28/23 at 9:50AM, there was 6 individual serving sized covered containers with unknown substance inside that was located in refrigerator without a date or product label.<BR/>In observation on 2/28/23 at 9:50AM, a metal container with plastic wrap cover was in the refrigerator labeled cherry salad and dated 1/19/23.<BR/>In observation on 2/28/23 at 9:50AM, a 5-gallon bucket was located under the prep area labeled sugar dated 1/6/23, chicken base dated 1/15/23, rice dated 4/23, beef base dated 1/15/23, and flour dated 1/15, with lid sitting loosely on top and was not secured.<BR/>In observation on 2/28/23 at 9:50AM, [NAME] A was pouring reduced fat milk from a gallon bottle with best by date of 2/25/23 into a puree cake recipe.<BR/>In observation on 2/28/23 at 9:50AM, a baking pan with cooked chicken was seen sitting on top of oven with a temperature of 100 degrees Fahrenheit.<BR/>In an interview on 2/28/23 at 10:02 AM the Dietary manager stated chicken sitting out on top of oven with temperature of 100 degrees Fahrenheit was not ok and needed to be thrown out.<BR/>In an observation on 2/28/23 at 10:05AM, a box of frozen deli meat was seen on the top shelf of a rolling cart above a bowl with cut potatoes on the bottom shelf.<BR/>In observation on 2/28/23 at 10:10AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05<BR/>In observation on 2/28/23 at 10:12AM, there was sour cream packets with use by date of 2/27/23 located in walk in cooler.<BR/>In observation on 2/28/23 at 10:15AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05<BR/>In an observation on 2/28/23 at 10:15AM, there was an open bag of corn tortillas inside walk in cooler that was not properly sealed.<BR/>In an observation on 2/28/23 at 10:15AM, there was 2 boxes of garlic Texas toast and 1 box of hoagie wheat rolls inside walk in cooler that were labeled by manufacturer to keep frozen.<BR/>In an observation on 2/28/23 at 10:16AM, inside of the freezer, there was a box of popcorn shrimp filled with ice and inside the bag was shrimp covered with freezer burn.<BR/>In an observation on 2/28/23 at 10:16AM, there was a box of deli sliced ham and turkey covered with freezer burn. <BR/>In an observation on 2/28/23 at 10:17AM, there was a box of corn dogs with freezer burn not sealed inside of freezer. <BR/>In an observation on 2/28/23 at 10:17AM, there was 1 banana cream pie inside freezer not sealed with freezer burn and open date written 1/15/23.<BR/>In an observation on 2/28/23 at 10:17AM, there was abag of unknown food that was not in manufacturer package unlabeled and covered with freezer burn. <BR/>In an observation on 2/28/23 at 10:20AM, there was a box of cookie dough not sealed inside of freezer.<BR/>In an observation on 2/28/23 at 10:25AM, there was 1 box of cocktail sauce package with manufacturer expiration date of 1/26/23.<BR/>In an observation on 2/28/23 at 10:25AM, there was 1 box of steak sauce package with manufacturer expiration date of 2/22/23.<BR/>In an observation on 2/28/23 at 10:27AM, there was 1 bag of an unknown food without food description label with date: 10/28 and use by: 3/28.<BR/>In an observation on 2/28/23 at 10:27AM, there were 3 bags of dry cereal without food description label.<BR/>In an observation on 2/28/23 at 10:46AM, the chicken that Dietary Manager said needed to be thrown out was seen in a bowl inside of the refrigerator.<BR/>In an interview on 2/28/23 at 10:46AM, theDietary Manager said I know the chicken needed to be thrown out and it will be thrown out later. <BR/>In an observation on 2/28/23 at 10:47AM, the ice machine located outside of dining room area had buildup inside of white, brown, pink, and black substance in area where ice trays were located and black substance present on water source that felt ice trays.<BR/>In an interview on 2/28/23 at 10:48AM, the Dietary Manager said she was responsible for making sure the outside of the machine was clean, but the inside of the ice machine was cleaned yearly by maintenance. She said the white, brown, pink, and black substance could contaminate ice and potentially make residents sick.<BR/>In an observation on 2/28/23 at 12:05PM, the chicken that was 100 degrees Fahrenheit from 9:50AM and Dietary Manager said would be discarded at 10:46AM was untouched in the refrigerator.<BR/>In an observation on 2/28/23 at 12:06PM, the cold lunch temperatures were all greater than 40 degrees Fahrenheit. The temperatures were: mustard potato salad 89 degrees Fahrenheit, mechanical soft subway sandwich meat and cheese was 41 degrees Fahrenheit, puree subway sandwich meat and cheese was 55 degrees Fahrenheit and without smooth texture, puree mustard potato salad was 81 degrees Fahrenheit, and pea salad that was not on the menu was 41 degrees Fahrenheit.<BR/>In an interview on 2/28/23 at 12:06PM, the Dietary Manager said the cold lunch being served should be held and served at less than 41 degrees Fahrenheit. She said she saw what the temperature was on each item when she took the temperatures, and she didn't need it pointed out that all of the cold food was too hot to be served for safety reasons to residents. She said it was her responsibility to oversee everything that went on in the kitchen. She said she had a checklist of tasks for her to complete but could not produce this or kitchen policies.<BR/>In an observation on 2/28/23 at 12:06PM, the Dietary Manager pulled the puree meat and cheese to reconstitute with reduced fat milk to make a smooth texture. <BR/>In an observation on 2/28/23 at 12:07PM-12:43PM [NAME] A was seen serving puree subway sandwich meat and cheese with a blue #12 serving spoon (2oz.) until Dietary Manager switched spoon with a white #10 serving spoon (3.2oz) after 3 of 4 puree plates had been served. All plates were served without cooling the food down to less than 41 degrees Fahrenheit. Puree meals consisted of puree meat and cheese, puree mustard potato salad, puree peanut butter crumble cake, and without puree bread or puree replacement for lettuce, tomato, and pickles. Mechanical soft meals consisted of mechanical soft meat and cheese, a whole hoagie roll, mustard potato salad, pea salad, and peanut butter crumble cake. The regular diet plates consisted of a whole hoagie roll, 4 pieces of deli sliced ham, 1 piece of sliced cheese, a scoop of potato salad, a small unmeasured amount of chopped lettuce, 1 thin slice of a small tomato, crumble cake, and no pickles. <BR/>In an interview on 3/1/23 at 1:08PM with Dietician, she said any item that was labeled with best by date meant it was best to be consumed by the date listed for better quality. She said there was no time frame for when that item should be thrown away but could become problematic for consumer if it were a milk-based product used after best by date. She said juice should be discarded after being open for 3 days and all cooked food should be discarded after 72 hours. She said all items should be properly sealed to prevent contaminants and bacteria growth. She said chicken should be cooled in the refrigerator and not at room temperature. She said any food cooled at room temperature could reach the danger zone of 45-135 degrees Fahrenheit, which could lead to bacteria growth and could cause consumer to become ill. She said food that was meant to be served cool should be maintained below 41 degrees Fahrenheit to prevent bacteria growth that could cause consumer to become ill. She said she provided an in-service to kitchen staff in November 2022, December 2022, and February 2023 regarding following the provided recipes and using a dense liquid for puree food. She said puree food should be smooth and without lumps. She said if puree food was not the correct consistency it could cause the consumer to choke. She said meat should not be stored over potatoes because drippings could cause bacteria growth and contamination could cause consumer to become ill.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 29 of 29 ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) residents by 5 ( DON,ADON,LVN C, CNA D and CNA E) of 5 staff passing lunch trays that were reviewed for infection control and transmission-based precautions policies and practice, in that:<BR/>The facility failed to ensure DON, ADON, LVN C, CNA D and CNA E did not grab resident's cups by the rim with bare hands, contaminating the tops of the rims, during the lunch meal serving process. <BR/>This failure could place residents at risk for infection through cross contaminations of pathogens. <BR/>Findings include:<BR/>During the lunch observation on 4/29/2024 at 12:15pm DON, ADON, LVN C, CNA D and CNA E were observed touching the rims of the Resident's cups ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) covered with plastic lids that did not fit properly with bare hands during the meal service. Hand hygeine was preformed between residents, however the lids of the cups were touch once to place on the tray , the tray deliver to the resident then removed from the tray to place in front of the resident. <BR/>Interview with CNA D on 4/29/2024 at 1:00 pm he stated he did not even realize he was grabbing the cups by the rims and will start grabbing by the sides. He was not sure what harm could come to the resident, but he would not want to drink from a cup someone had grabbed from the rim.<BR/>Interview with CNA E on 4/29/2024 at 1:05 pm she stated that she was not aware she was supposed to grab the cup from the side, and the way they have them on a tray it is hard to always grab from the side when you are trying to get the residents served their meals. <BR/>Interview with ADON on 4/29/2024 at 1:15 pm she stated that the cups should be grabbed by the side, but lunch was a little late today and they were in a hurry to get the residents their meal. She stated that grabbing the cups by the rim could potentially cause cross contamination. She also stated employees are encouraged to use hand sanitizer between delivery of resident trays and there is some available in the dining room. <BR/>Interview with LVN C on 4/29/2024 at 1:25 pm she stated that it is hard to grab the cups by the side for the first several residents as the drinks are pre poured and are on a tray . She stated that after she thought about it, grabbing by the side makes sense to help with cross contamination.<BR/>Interview with DON on 4/29/2024 at 1:30 pm she stated that she did not realize the lids did not cover the entire drinking area of the cup. She stated that cups should be grabbed by the side of the cups to prevent cross contamination.<BR/>Interview with ADM on 4/29/2024 at 2:00 pm he stated that his expectation is that the infection control and hand hygiene policies be followed. He stated anytime it is not followed it puts the resident at risk for infection from cross contamination. <BR/>Record review of the facility's infection prevention and control program policy, undated, stated:<BR/>This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of transmission of communicable disease and infection as per accepted national standards and guidelines. <BR/>Record review of the facility's Hand Hygiene policy, undated, stated:<BR/> Hand washing with either soap and water or hand sanitizer is the best way to stop the spread of infection,<BR/> Before and after Assisting a resident with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services within the facility with reasonable accommodation of the residents' needs and preferences for 4 of 12 residents (Resident #23, Resident # 57, Resident #83, and Resident #45) reviewed, in that:<BR/>The facility failed to: <BR/>1) <BR/>Ensure a call light was within reach for Resident #23<BR/>2) <BR/>Ensure a call light was within reach for Resident #57<BR/>3) <BR/>Ensure a call light was within reach for Resident #83<BR/>4) <BR/>Ensure a call light was within reach for Resident #45<BR/>This deficient practice placed residents at risk for delayed care and a decreased quality of life. <BR/>Findings Include:<BR/>1) <BR/>Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected he was dependent on staff for personal hygiene, bathing and toileting. Section I (Active Diagnoses) reflects medically complex conditions, Other Hereditary and Idiopathic Neuropathies (a condition that causes gradual muscle weakness), Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Unspecified Lack of Coordination (a condition that affects balance), Schizophreniform Disorder (a mental health condition that causes hallucinations, delusions and disorganized speech), Spinal Stenosis Spinal Region (where the space inside the backbone is too small placing pressure on the spinal cord), Low Back Pain, Kissing Spine (a condition that causes pain, inflammation and nerve damage), Generalized Muscle Weakness, Abnormalities of Gait and Mobility (problems with walking or standing) and Aphasia (a condition that affects how you communicate with speech).<BR/>Review of Resident #23's care plan initiated 11/11/22 reflected a focus, Resident is bed bound due to his own decision and refuses to be transferred with a mechanical lift and is unable to move and sit in a wheelchair /geriatric chair. Interventions include, keep call light within reach of resident and keep resident belongings accessible and within reach.<BR/>An observation and interview on 04/29/2024 at 01:15pm with Resident # 23, resident stated he can't reach call light and will usually ask his roommate for help to call for staff. Resident call light was not visible to surveyor nor to the resident. <BR/>2) <BR/>Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section I (Active Diagnoses) Hypothyroidism (a condition that causes decreased thyroid hormones), Parkinson's Disease (a movement disorder that causes tremors or stiffness), Other Idiopathic Peripheral Autonomic Neuropathy (a condition that causes numbness, pain, and balance issues) and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior).<BR/>Review of Resident #57's care plan initiated 11/11/22 reflected a focus, Potential for falls related to Decreased mobility and noncompliance with using walker for ambulation. Resident has had falls due to not using walker. Interventions include, encourage resident to keep belongings within reach, provide a safe environment with floors free from spills, assist with removing room clutter, glare free lighting, reachable call bell etc.<BR/>An observation and interview on 04/29/2024 at 10:05am with Resident #57, residents call light was not within reach. The call light was between the wall and the bed near the floor.<BR/>3) <BR/>Review of Resident # 83's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE] 3. Section C (Cognitive Patterns) Reflected a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) reflected resident is independent with activities of daily living. <BR/>Section I (Active Diagnoses) reflected, Hyperlipidemia (a condition that causes high lipids or fat in the blood), Major Depressive Disorder (a condition that affects mood), Insomnia (a condition that causes trouble falling or staying asleep), Constipation (a condition that causes bowel movements less than three times per week), Hypothyroidism (a condition that causes decreased thyroid hormones), Bipolar II Disorder (also known as manic depression), Schizoaffective Disorder Bipolar Type (a condition causing hallucinations, delusions, confused thoughts and behavior) , Diabetes Mellitus without Complications (a condition that affects the way the body processes blood sugar), Disorder of Muscle and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior).<BR/>Review of Resident #83's care plan initiated 12/05/2023 reflected a focus, The resident has an ADL Self Care<BR/>Performance Deficit. Interventions include, Encourage Resident to use bell to call for assistance before attempting any ADL's that resident cannot do independently.<BR/>An observation and interview on 04/29/2024 at 10:12am with Resident # 83, the resident stated he can't reach his call light and asks his roommate to press the button for him. Resident call light was not visible to surveyor. When the surveyor asked resident to locate the call light, he could not see nor find the light. <BR/>4) <BR/>Review of Resident #45's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 03/06/20. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she was dependent on staff for personal hygiene, bathing and toileting. She required substantial/maximal assistance with upper body dressing. She was dependent on staff and a mechanical lift for transfers to and from bed. Section I (Active Diagnoses) reflected, hemiplegia following cerebral infarct affecting left dominant side (paralysis of the left side of the body due to a stroke), diabetes mellitus (a condition that affects the way the body processes blood sugar), generalized muscle weakness, contracture of hand (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), and morbid (severe) obesity.<BR/>Review of Resident #45's care plan initiated 11/11/22 reflected a focus, Alteration in musculoskeletal status related to contractures to left hand. Interventions included, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. A focus initiated on 03/06/20 reflected, Resident has the potential for falls related to CVA . An intervention reflected, Place the resident's call light within reach and encourage the resident to use it for assistance as needed.<BR/>An observation on 04/29/24 at 2:14 PM revealed Resident #45 sitting up in a bariatric wheelchair next to her bed. Her left side, with hemiparesis (a condition that causes weakness or the inability to move on one side of the body) and a hand contracture was closest to the bed. The string for the resident's call light was hanging down from the ceiling. A stuffed animal was tied to the end of the string. The Stuffed animal was hanging several inches above the bed.<BR/>During an interview on 04/29/24 at 2:15 PM with Resident #45, she stated she wanted to get into bed, but she could not reach her call light, so she had to wait for staff. She stated she sometimes got her roommate to push her call light to get staff to the room.<BR/>During an interview on 05/01/24 at 2:00 PM, LVN L stated call lights should be in reach, accessible to the residents. She stated if the call light was not within reach, the residents may not be able to get medications, toileted, or have any other needs met. She stated she was not working with Resident #45 today but she would check the call light placement.<BR/>During an interview on 05/01/2024 at 2:15PM CNA F stated she checks on residents every thirty minutes during her shift, and she thought everyone had a call light string. She said there should not have been anyone that didn't have a string attached to their call light. She said she would notify her charge nurse if a resident didn't have a call light string, or she would go find a longer string herself. <BR/>During an interview on 05/01/2024 at 2:45PM with DON, she stated nursing staff checked each resident every 2 hours and should have ensured they could reach the call light with a string attached. She said it was unacceptable for any resident to not have independent access to the call light. <BR/>During an interview on 05/01/2024 at 3:00PM with ADM, he stated that all residents should have a working call light and the CNAs are responsible to ensure the resident can access the call light. He said residents should not have had to ask their roommates for assistance.<BR/>Review of facilities undated policy titled Answering Call Light, which states:<BR/>Purpose<BR/>The purpose of this procedure is to ensure timely responses to the resident's requests and needs.<BR/>General Guidelines<BR/>4. Be sure the call light is plugged in and functioning at all times.<BR/>5. Ensure that the call light is accessible to the resident when in bed, from the toilet, the shower and bathing facility and from the floor. <BR/>6. Report all defective call lights to the nurse supervisor promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #300 and Resident #301), reviewed for changes made to charges or other items and services.<BR/>The facility failed to ensure that Resident #300 and Resident #301 were provided a SNF ABN (SNF ABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. <BR/>This failure could place residents at risk for not being aware of changes to provided services not covered by Medicare and their financial responsibilities.<BR/>Findings included:<BR/>Review of Resident #300's admission MDS assessment dated [DATE], Section A (Identification Information) revealed an [AGE] year-old female admitted to the facility 09/06/23. Section C (Cognitive Patterns) revealed a BIMS score of 8 indicating moderately impaired cognition. Section I (Active Diagnoses) reflected diagnoses including coronary artery disease (disease of the blood vessels of the heart), septicemia (infection in the blood), and cerebrovascular accident (stroke).<BR/>Review of Resident #300's electronic medical record revealed no SNF ABN form.<BR/>Review of Resident #301's admission MDS assessment dated [DATE], Section A (Identification Information) revealed a [AGE] year-old female admitted to the facility 11/10/23. Section C (Cognitive Patterns) revealed a BIMS score of 14 indicating intact cognition. Section I (Active Diagnoses) reflected diagnoses including cerebrovascular accident (stroke), encephalopathy unspecified (damage or disease that affects the brain), and urinary tract infection.<BR/>Review of Resident #301's electronic medical record revealed no SNF ABN form.<BR/>Review of the Medicare discharge list reflected Resident #300's Medicare benefit days started on 09/06/23 and ended on 11/16/23. Resident #301's Medicare benefit days started on 11/10/23 and ended on 11/25/23.<BR/>During an interview on 04/30/24 at 2:56 PM, the ADM stated neither Resident #300 nor Resident #301 were provided with an ABN document. The ADM stated they did not have a policy regarding ABN notifications. He stated the facility had recently found the notices were not being provided and the staff were not sure of the process or who was responsible for providing the form to residents. He stated they recently started reviewing and monitoring Medicare days and potential changes in service during their daily meetings. The ADM stated he would be contacting the corporate office regarding a policy.<BR/>Review of the Medicare Claims Processing Manual accessed at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf, Chapter 30, section 70 reflected in part, If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in &sect;70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a Safe/Clean/Comfortable/Homelike Environment for three of six residents (Resident #57, Resident #23, and Resident #66). <BR/>The facility failed to ensure a safe/clean/comfortable/ homelike environment for Resident #57, Resident #23 and Resident #66.<BR/>This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and placing residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings Include:<BR/>1) <BR/>Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Hypothyroidism (a condition that causes decreased thyroid hormones), Parkinson's Disease (a movement disorder that causes tremors or stiffness), Other Idiopathic Peripheral Autonomic Neuropathy (a condition that causes numbness, pain, and balance issues) and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior).<BR/>During observation and interview on 04/29/2024 at 10:05AM with Resident #57, the room appeared cluttered with items stacked haphazardly against the wall. Multiple items on the floor which could have been dropped. The residents room appeared messy; bed disheveled and trash can was full. Resident stated housekeeping does not sweep and mop like they should. <BR/>2) <BR/>Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected he was dependent on staff for personal hygiene, bathing, and toileting. Section I (Active Diagnoses) reflects medically complex conditions, Other Hereditary and Idiopathic Neuropathies (a condition that causes gradual muscle weakness), Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Unspecified Lack of Coordination (a condition that affects balance), Schizophreniform Disorder (a mental health condition that causes hallucinations, delusions and disorganized speech), Spinal Stenosis Spinal Region (where the space inside the backbone is too small placing pressure on the spinal cord), Low Back Pain, Kissing Spine (a condition that causes pain, inflammation and nerve damage), Generalized Muscle Weakness, Abnormalities of Gait and Mobility (problems with walking or standing) and Aphasia (a condition that affects how you communicate with speech).<BR/>During observation on 04/29/2024 at 10:12AM with Resident #23, the room appeared cluttered with multiple items stacked high on counters and bedside table. There were personal items and debris on the floor. The bathroom had a walker lying on the shower floor with soiled underwear and socks.<BR/>3) <BR/>Review of Resident #66's MDS assessment dated [DATE] reflected a [AGE] year-old female originally admitted to the facility 09/23/22 with a readmission on [DATE]. Her diagnoses included septicemia (infection in the blood), diabetes mellitus (a condition that affects the way the body processes blood sugar) and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs). Her BIMS score was fifteen, indicating intact cognition.<BR/>During observation on 04/30/2024 at 8:50AM with Resident #66, her room appeared cluttered with multiple boxes stacked and a piece of wood furniture sitting directly in front of the sink. The boxes in front of the sink protruded outward approximately 3-4 feet. There were dirty containers that appeared to have had food in them. On the privacy curtain near the resident's bed, there were different colored marks on the curtain, which appeared to have been drawn with a marker, by the resident.<BR/>During an interview on 05/01/2024 at 1:52PM with HS , he stated the housekeepers swept and mopped the residents' rooms daily. He said that it was everyone's responsibility to pick up items off the floor when they observed it. He said resident rooms have clutter and that the facility had a deep cleaning scheduled soon. He said the clutter presented challenges for the housekeeping staff, making it difficult to sweep and mop around the items. <BR/>During an interview on 05/01/2024 at 2:45PM with DON, she stated her expectation was that the resident rooms were swept and mopped daily, by housekeeping. She said excess personal items and boxes piled up in residents' rooms create clutter, a potential fire hazard, and issues with cleanliness.<BR/>During an interview on 05/01/2024 at 3:00PM with ADM, he stated that he was aware of clutter is resident rooms. He said he had called some of the resident's family members in the past, to come pick up the extra items. He said the clutter caused issues with bugs, mildew, and mold when the boxes became wet, tripping hazards, and a fire hazard. He said the facility had another deep clean/declutter on the upcoming schedule. He acknowledged clutter was an ongoing issue within the resident's rooms. <BR/>The surveyor requested a policy regarding personal items for residents and the facility did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 1 (medication room [ROOM NUMBER]) of 2 medication storage rooms and 1 (medication cart #1) of 4 medication carts reviewed for medication storage that. <BR/>Medication cart # 1 was left unattended and unlocked.<BR/>An undated, opened and accessed, vial was stored in the medication room [ROOM NUMBER] refrigerator.<BR/>The medication room [ROOM NUMBER] refrigerator temperature was not monitored daily.<BR/>This failure could allow residents unsupervised access to prescription and over the counter medication and can result in the resident receiving ineffective medication due to lack of temperature management or proper labeling. <BR/>Findings included:<BR/>Observation on 4/29/2024 at 11:53 am revealed Medication cart # 1 was unlocked and unattended at the nurse's station not visible from the nurses sitting at the desk. Inspections of the contents revealed insulin pens and needles, prescription and over-the-counter medications. No nurses approached during the inspection. After approximately 4 minutes LVN A, who was sitting at the nurse's station, was asked about the cart. LVN A came around the desk and locked the cart. <BR/>An observation on 05/01/24 at 8:12 AM revealed a multi-dose vial of Influenza Vaccine in the medication room [ROOM NUMBER] refrigerator. The vial which had been opened and accessed, was not labeled with the date the vial was opened. <BR/>An observation on 05/01/24 at 8:15 AM revealed the medication refrigerator temperature log taped to the front of the refrigerator. The log was dated April 2024. The log did not have any entries for 4/2/24, 4/5/24, 4/6/24, 4/7/24, 4/15/24, 4/16/24, 4/19/24, 4/20/24, and 4/30/24.<BR/>Interview of LVN A on 4/29/2024 at 12:00 pm stated that she was unaware the cart was unlocked and that it may have been unlocked for about 5 minutes. She stated she did see the surveyor going through the drawers and did not see an issue with it. She stated that if a resident had been opening the drawers she would have intervened. She stated that most of the resident would not be at risk for the cart being unlocked because they were oriented and did not go thru things.<BR/>Interview with DON on 4/29/2024 at 12:30 pm she stated her expectation was the medication carts be locked when not attended. She stated that residents and visitors could have access to prescription and over-the counter medications and that could put them at risk for possible overdose and medication side effects. <BR/>During an interview on 05/01/24 at 8:16 AM, the DON stated, anything opened, including multi-dose vials, were dated when opened. She stated the nurse who opened the vial or bottle was responsible for dating the medication. She stated vials were good for 30 days once opened. She stated expired medications may not have been effective and then residents may not receive the desired effect. She stated the medication room refrigerator temperature was supposed to be monitored daily. She stated some medications were stored in the refrigerator to maintain their effectiveness. She stated it did not meet her expectations that 9 of 30 days were not monitored.<BR/>Record Review of the policy titled Storage of Medications, undated, states 6. Compartments (including, but not limited to, drawers, Cabinets, rooms, refrigerator, carts, and boxes) containing drugs and biological are locked when not in use. Unlocked medications are not left unattended. and 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication is stored separately from food and are labeled accordingly.<BR/>Record Review of the policy titled Medication, vaccine refrigerator temperature monitoring, updated January 2024, states Daily logs: The temperature will be checked and recorded by designated staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in the facility in that:<BR/>1. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description.<BR/>2. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly sealed. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description.<BR/>3. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not discarded by use by/expiration date.<BR/>4. <BR/>One 1-gallon bottle of Reduced Fat Milk past the Best By date was being used by [NAME] A<BR/>5. <BR/>3 boxes of food inside walk in cooler that were labeled by manufacturer to keep frozen.<BR/>6. <BR/>Food inside of freezer had freezer burn present.<BR/>7. <BR/>1 tray of baked chicken with internal temp of 100 degrees Fahrenheit was cooled improperly, prepared for dinner meal, and placed inside of refrigerator. <BR/>8. <BR/>1 box of meat was defrosting over a bowl of cut potatoes.<BR/>9. <BR/>Temperatures of cold lunch were held and served at a temperature above 41 degrees Fahrenheit. <BR/>This failure could place residents becoming ill from food contamination or bacterial growth.<BR/>Findings included:<BR/>In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator containing grated cheese with date 2/21 use by date 3/2, [NAME] with date 2/27/23, burritos dated 2/24, butter dated 2/24, without product description or use by date labeled.<BR/>In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator labeled sausage dated 2/28/23 and use by date 2/29 was not properly sealed.<BR/>In observation on 2/28/23 at 9:50AM, located in the refrigerator was an open container of labeled Hormel Thick and Easy clear thickened orange juice 46fl oz dated 2/6, ready care thickened apple juice dated 2/4, and thick and easy clear dated 12/6.<BR/>In observation on 2/28/23 at 9:50AM, there was 6 individual serving sized covered containers with unknown substance inside that was located in refrigerator without a date or product label.<BR/>In observation on 2/28/23 at 9:50AM, a metal container with plastic wrap cover was in the refrigerator labeled cherry salad and dated 1/19/23.<BR/>In observation on 2/28/23 at 9:50AM, a 5-gallon bucket was located under the prep area labeled sugar dated 1/6/23, chicken base dated 1/15/23, rice dated 4/23, beef base dated 1/15/23, and flour dated 1/15, with lid sitting loosely on top and was not secured.<BR/>In observation on 2/28/23 at 9:50AM, [NAME] A was pouring reduced fat milk from a gallon bottle with best by date of 2/25/23 into a puree cake recipe.<BR/>In observation on 2/28/23 at 9:50AM, a baking pan with cooked chicken was seen sitting on top of oven with a temperature of 100 degrees Fahrenheit.<BR/>In an interview on 2/28/23 at 10:02 AM the Dietary manager stated chicken sitting out on top of oven with temperature of 100 degrees Fahrenheit was not ok and needed to be thrown out.<BR/>In an observation on 2/28/23 at 10:05AM, a box of frozen deli meat was seen on the top shelf of a rolling cart above a bowl with cut potatoes on the bottom shelf.<BR/>In observation on 2/28/23 at 10:10AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05<BR/>In observation on 2/28/23 at 10:12AM, there was sour cream packets with use by date of 2/27/23 located in walk in cooler.<BR/>In observation on 2/28/23 at 10:15AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05<BR/>In an observation on 2/28/23 at 10:15AM, there was an open bag of corn tortillas inside walk in cooler that was not properly sealed.<BR/>In an observation on 2/28/23 at 10:15AM, there was 2 boxes of garlic Texas toast and 1 box of hoagie wheat rolls inside walk in cooler that were labeled by manufacturer to keep frozen.<BR/>In an observation on 2/28/23 at 10:16AM, inside of the freezer, there was a box of popcorn shrimp filled with ice and inside the bag was shrimp covered with freezer burn.<BR/>In an observation on 2/28/23 at 10:16AM, there was a box of deli sliced ham and turkey covered with freezer burn. <BR/>In an observation on 2/28/23 at 10:17AM, there was a box of corn dogs with freezer burn not sealed inside of freezer. <BR/>In an observation on 2/28/23 at 10:17AM, there was 1 banana cream pie inside freezer not sealed with freezer burn and open date written 1/15/23.<BR/>In an observation on 2/28/23 at 10:17AM, there was abag of unknown food that was not in manufacturer package unlabeled and covered with freezer burn. <BR/>In an observation on 2/28/23 at 10:20AM, there was a box of cookie dough not sealed inside of freezer.<BR/>In an observation on 2/28/23 at 10:25AM, there was 1 box of cocktail sauce package with manufacturer expiration date of 1/26/23.<BR/>In an observation on 2/28/23 at 10:25AM, there was 1 box of steak sauce package with manufacturer expiration date of 2/22/23.<BR/>In an observation on 2/28/23 at 10:27AM, there was 1 bag of an unknown food without food description label with date: 10/28 and use by: 3/28.<BR/>In an observation on 2/28/23 at 10:27AM, there were 3 bags of dry cereal without food description label.<BR/>In an observation on 2/28/23 at 10:46AM, the chicken that Dietary Manager said needed to be thrown out was seen in a bowl inside of the refrigerator.<BR/>In an interview on 2/28/23 at 10:46AM, theDietary Manager said I know the chicken needed to be thrown out and it will be thrown out later. <BR/>In an observation on 2/28/23 at 10:47AM, the ice machine located outside of dining room area had buildup inside of white, brown, pink, and black substance in area where ice trays were located and black substance present on water source that felt ice trays.<BR/>In an interview on 2/28/23 at 10:48AM, the Dietary Manager said she was responsible for making sure the outside of the machine was clean, but the inside of the ice machine was cleaned yearly by maintenance. She said the white, brown, pink, and black substance could contaminate ice and potentially make residents sick.<BR/>In an observation on 2/28/23 at 12:05PM, the chicken that was 100 degrees Fahrenheit from 9:50AM and Dietary Manager said would be discarded at 10:46AM was untouched in the refrigerator.<BR/>In an observation on 2/28/23 at 12:06PM, the cold lunch temperatures were all greater than 40 degrees Fahrenheit. The temperatures were: mustard potato salad 89 degrees Fahrenheit, mechanical soft subway sandwich meat and cheese was 41 degrees Fahrenheit, puree subway sandwich meat and cheese was 55 degrees Fahrenheit and without smooth texture, puree mustard potato salad was 81 degrees Fahrenheit, and pea salad that was not on the menu was 41 degrees Fahrenheit.<BR/>In an interview on 2/28/23 at 12:06PM, the Dietary Manager said the cold lunch being served should be held and served at less than 41 degrees Fahrenheit. She said she saw what the temperature was on each item when she took the temperatures, and she didn't need it pointed out that all of the cold food was too hot to be served for safety reasons to residents. She said it was her responsibility to oversee everything that went on in the kitchen. She said she had a checklist of tasks for her to complete but could not produce this or kitchen policies.<BR/>In an observation on 2/28/23 at 12:06PM, the Dietary Manager pulled the puree meat and cheese to reconstitute with reduced fat milk to make a smooth texture. <BR/>In an observation on 2/28/23 at 12:07PM-12:43PM [NAME] A was seen serving puree subway sandwich meat and cheese with a blue #12 serving spoon (2oz.) until Dietary Manager switched spoon with a white #10 serving spoon (3.2oz) after 3 of 4 puree plates had been served. All plates were served without cooling the food down to less than 41 degrees Fahrenheit. Puree meals consisted of puree meat and cheese, puree mustard potato salad, puree peanut butter crumble cake, and without puree bread or puree replacement for lettuce, tomato, and pickles. Mechanical soft meals consisted of mechanical soft meat and cheese, a whole hoagie roll, mustard potato salad, pea salad, and peanut butter crumble cake. The regular diet plates consisted of a whole hoagie roll, 4 pieces of deli sliced ham, 1 piece of sliced cheese, a scoop of potato salad, a small unmeasured amount of chopped lettuce, 1 thin slice of a small tomato, crumble cake, and no pickles. <BR/>In an interview on 3/1/23 at 1:08PM with Dietician, she said any item that was labeled with best by date meant it was best to be consumed by the date listed for better quality. She said there was no time frame for when that item should be thrown away but could become problematic for consumer if it were a milk-based product used after best by date. She said juice should be discarded after being open for 3 days and all cooked food should be discarded after 72 hours. She said all items should be properly sealed to prevent contaminants and bacteria growth. She said chicken should be cooled in the refrigerator and not at room temperature. She said any food cooled at room temperature could reach the danger zone of 45-135 degrees Fahrenheit, which could lead to bacteria growth and could cause consumer to become ill. She said food that was meant to be served cool should be maintained below 41 degrees Fahrenheit to prevent bacteria growth that could cause consumer to become ill. She said she provided an in-service to kitchen staff in November 2022, December 2022, and February 2023 regarding following the provided recipes and using a dense liquid for puree food. She said puree food should be smooth and without lumps. She said if puree food was not the correct consistency it could cause the consumer to choke. She said meat should not be stored over potatoes because drippings could cause bacteria growth and contamination could cause consumer to become ill.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 29 of 29 ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) residents by 5 ( DON,ADON,LVN C, CNA D and CNA E) of 5 staff passing lunch trays that were reviewed for infection control and transmission-based precautions policies and practice, in that:<BR/>The facility failed to ensure DON, ADON, LVN C, CNA D and CNA E did not grab resident's cups by the rim with bare hands, contaminating the tops of the rims, during the lunch meal serving process. <BR/>This failure could place residents at risk for infection through cross contaminations of pathogens. <BR/>Findings include:<BR/>During the lunch observation on 4/29/2024 at 12:15pm DON, ADON, LVN C, CNA D and CNA E were observed touching the rims of the Resident's cups ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) covered with plastic lids that did not fit properly with bare hands during the meal service. Hand hygeine was preformed between residents, however the lids of the cups were touch once to place on the tray , the tray deliver to the resident then removed from the tray to place in front of the resident. <BR/>Interview with CNA D on 4/29/2024 at 1:00 pm he stated he did not even realize he was grabbing the cups by the rims and will start grabbing by the sides. He was not sure what harm could come to the resident, but he would not want to drink from a cup someone had grabbed from the rim.<BR/>Interview with CNA E on 4/29/2024 at 1:05 pm she stated that she was not aware she was supposed to grab the cup from the side, and the way they have them on a tray it is hard to always grab from the side when you are trying to get the residents served their meals. <BR/>Interview with ADON on 4/29/2024 at 1:15 pm she stated that the cups should be grabbed by the side, but lunch was a little late today and they were in a hurry to get the residents their meal. She stated that grabbing the cups by the rim could potentially cause cross contamination. She also stated employees are encouraged to use hand sanitizer between delivery of resident trays and there is some available in the dining room. <BR/>Interview with LVN C on 4/29/2024 at 1:25 pm she stated that it is hard to grab the cups by the side for the first several residents as the drinks are pre poured and are on a tray . She stated that after she thought about it, grabbing by the side makes sense to help with cross contamination.<BR/>Interview with DON on 4/29/2024 at 1:30 pm she stated that she did not realize the lids did not cover the entire drinking area of the cup. She stated that cups should be grabbed by the side of the cups to prevent cross contamination.<BR/>Interview with ADM on 4/29/2024 at 2:00 pm he stated that his expectation is that the infection control and hand hygiene policies be followed. He stated anytime it is not followed it puts the resident at risk for infection from cross contamination. <BR/>Record review of the facility's infection prevention and control program policy, undated, stated:<BR/>This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of transmission of communicable disease and infection as per accepted national standards and guidelines. <BR/>Record review of the facility's Hand Hygiene policy, undated, stated:<BR/> Hand washing with either soap and water or hand sanitizer is the best way to stop the spread of infection,<BR/> Before and after Assisting a resident with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #67, #33, #1) 3 residents reviewed for rights.<BR/>1. <BR/>The facility failed to prevent CNA K from calling Resident #67 a feeder on 2 occasions.<BR/>2. <BR/>The facility failed to empty Resident #33's urinal in a timely manner.<BR/>3 <BR/>The facility failed to respect Resident #1's personal property and care wishes.<BR/>The findings include:<BR/>Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease.<BR/>Record review of Resident #1's 03/03/23 MDS revealed a BIMs of 15 which indicated that she was cognitively intact.<BR/>Record Review of Resident #67's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy, rheumatoid arthritis, and reflux.<BR/>Record review of Resident #67's 04/13/23 MDS revealed a blank for the section that provided a BIMs score.<BR/>Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction <BR/>Record review of Resident #33's 02/10/23 MDS revealed a BIMS of 13, which indicated he was cognitively intact.<BR/>In an observation on 05/17/23 at 2:12 pm CNA K entered the room and called Resident #67 a feeder while speaking to a new staff member. <BR/>In an interview on 05/17/23 at 2:12 pm with Resident #1 she stated she has heard staff use the term feeder often when referring to her roommate because her roommate, Resident #67 requires assistance with her meals. <BR/>In an interview and observation on 05/17/23 at 2:13 pm with Resident #67 she was lying in the bed with her eyes closed and she was not interviewable, and not able to verbalize her feelings or thoughts <BR/>In an observation on 05/17/23 at 2:23 pm in the hall next to the nurses station CNA K was speaking to a new staff member and again used the term feeder while going through a list of residents with the new staff member.<BR/>In an interview and observation on 05/17/23 at 2:24 pm with CNA K she did not realize the term feeder was disrespectful and should not be used; she was going over required tasks for each resident with a new staff member. <BR/>In an observation on 05/20/23 at 4:00 pm with Resident #33 in his room the urinal with urine in it was sitting on the table in full view.<BR/>In an observation on 05/22/23 at 10:20 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table.<BR/>In an observation on 05/22/23 at 11:00 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table. <BR/>In an interview with Resident #1 on 05/17/23 at 2:12 pm she stated that CNA M had worked for the facility before and Resident #1 had problems with her because she was rude and not polite. CNA M has returned to the facility and and she came into the room and Resident #1 asked her not to use Resident #1's red hairbrush on her roommate (who has a blue brush) and CNA M told her Don't you think I know that, which upset Resident #1. Then CNA M proceeded to use Resident #1's hairbrush on her roommate (Resident #67). The resident ws upset that this staff member was alloweed back at the facility and felt she was disrespectful by using her brush on her roommmate and ignored becuase she had just asked her not to do that.<BR/>Record review of the undated facility policy titles Statement of Resident Rights revealed .1. All care necessary for you to have the highest possible level of health . 2. Safe, descent and clean conditions . 4. Be treated with courtesy, consideration, and respect

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a Safe/Clean/Comfortable/Homelike Environment for three of six residents (Resident #57, Resident #23, and Resident #66). <BR/>The facility failed to ensure a safe/clean/comfortable/ homelike environment for Resident #57, Resident #23 and Resident #66.<BR/>This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and placing residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings Include:<BR/>1) <BR/>Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Hypothyroidism (a condition that causes decreased thyroid hormones), Parkinson's Disease (a movement disorder that causes tremors or stiffness), Other Idiopathic Peripheral Autonomic Neuropathy (a condition that causes numbness, pain, and balance issues) and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior).<BR/>During observation and interview on 04/29/2024 at 10:05AM with Resident #57, the room appeared cluttered with items stacked haphazardly against the wall. Multiple items on the floor which could have been dropped. The residents room appeared messy; bed disheveled and trash can was full. Resident stated housekeeping does not sweep and mop like they should. <BR/>2) <BR/>Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected he was dependent on staff for personal hygiene, bathing, and toileting. Section I (Active Diagnoses) reflects medically complex conditions, Other Hereditary and Idiopathic Neuropathies (a condition that causes gradual muscle weakness), Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Unspecified Lack of Coordination (a condition that affects balance), Schizophreniform Disorder (a mental health condition that causes hallucinations, delusions and disorganized speech), Spinal Stenosis Spinal Region (where the space inside the backbone is too small placing pressure on the spinal cord), Low Back Pain, Kissing Spine (a condition that causes pain, inflammation and nerve damage), Generalized Muscle Weakness, Abnormalities of Gait and Mobility (problems with walking or standing) and Aphasia (a condition that affects how you communicate with speech).<BR/>During observation on 04/29/2024 at 10:12AM with Resident #23, the room appeared cluttered with multiple items stacked high on counters and bedside table. There were personal items and debris on the floor. The bathroom had a walker lying on the shower floor with soiled underwear and socks.<BR/>3) <BR/>Review of Resident #66's MDS assessment dated [DATE] reflected a [AGE] year-old female originally admitted to the facility 09/23/22 with a readmission on [DATE]. Her diagnoses included septicemia (infection in the blood), diabetes mellitus (a condition that affects the way the body processes blood sugar) and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs). Her BIMS score was fifteen, indicating intact cognition.<BR/>During observation on 04/30/2024 at 8:50AM with Resident #66, her room appeared cluttered with multiple boxes stacked and a piece of wood furniture sitting directly in front of the sink. The boxes in front of the sink protruded outward approximately 3-4 feet. There were dirty containers that appeared to have had food in them. On the privacy curtain near the resident's bed, there were different colored marks on the curtain, which appeared to have been drawn with a marker, by the resident.<BR/>During an interview on 05/01/2024 at 1:52PM with HS , he stated the housekeepers swept and mopped the residents' rooms daily. He said that it was everyone's responsibility to pick up items off the floor when they observed it. He said resident rooms have clutter and that the facility had a deep cleaning scheduled soon. He said the clutter presented challenges for the housekeeping staff, making it difficult to sweep and mop around the items. <BR/>During an interview on 05/01/2024 at 2:45PM with DON, she stated her expectation was that the resident rooms were swept and mopped daily, by housekeeping. She said excess personal items and boxes piled up in residents' rooms create clutter, a potential fire hazard, and issues with cleanliness.<BR/>During an interview on 05/01/2024 at 3:00PM with ADM, he stated that he was aware of clutter is resident rooms. He said he had called some of the resident's family members in the past, to come pick up the extra items. He said the clutter caused issues with bugs, mildew, and mold when the boxes became wet, tripping hazards, and a fire hazard. He said the facility had another deep clean/declutter on the upcoming schedule. He acknowledged clutter was an ongoing issue within the resident's rooms. <BR/>The surveyor requested a policy regarding personal items for residents and the facility did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for four (Resident #46, #63, #28, and #33) of 4 residents reviewed for ADLs.<BR/>The facility failed to ensure residents were provided with ADL care when needed for Resident #46, #63, #28 and #33.<BR/>These failures could place residents at risk of worsening health conditions due to not having their personal hygiene needs addressed.<BR/>Findings include:<BR/>In a confidential staff interview, staff member stated that they were understaffed and residents did not always get checked every 2 hours, which led to the smells.<BR/>In an interview with a confidential visitor to the facility, the visitor stated several residents the visitor noted dirty and soiled clothing.<BR/>Record Review of Resident #46's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including dementia, depression, anxiety.<BR/>Record review of Resident #46's 03/17/23 MDS revealed her BIMS was left blank. It further revealed she required extensive assistance for bed mobility, transfer, walking in room, dressing, toilet use, and personal hygiene.<BR/>In an observation on 05/21/23 at 10:50 am Resident #46 was laying on the left side and observed wearing grey jogging pants that were wet from the top of the pants on down. A brief was be seen at the top. The room smelled of urine.<BR/>In an interview with a confidential visitor to the facility, the visitor stated several residents the visitor noted dirty and soiled clothing. <BR/>Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction (stroke).<BR/>Record review of Resident #33's 02/10/23 MDS revealed a BIMS of 13, which indicated cognitively intact answers. It further revealed he required extensive assistance with bed mobility, transfers and assistance with toileting and hygiene.<BR/>In an interview on 05/19/23 at 1:00 pm Resident #33 stated that the normal time it takes for his call light to be answered is 30 minutes, but it can be a lot longer. He stated he often had his urinal left for hours without being emptied. He stated that he was uncomfortable with his full urinal being left unemptied and it was embarassing.<BR/>Record Review of Resident #63's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including spinal stenosis, pulmonary disease, schizophreniform disorder.<BR/>Record review of Resident #63's 03/08/23 MDS revealed his BIMS was left blank; it further revealed he was an extensive assist for hygiene, eating, and dressing and for toilet use it was marked as activity did not occur.<BR/>A record review of a photo dated 04/10/23 at 6:32 pm revealed Resident #63 in a soiled brief with a soiled pad underneath him. <BR/>Record Review of Resident #28's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including intracerebral hemorrhage (stroke), and schizoaffective disorder (distorted reality).<BR/>Record review of Resident #28's 04/14/23 MDS revealed a BIMS of 10, which indicated he had moderately impaired cognition. It further revealed that he was an extensive assist with toileting, personal hygiene, and dressing.<BR/>A record review of a photo dated 04/24/23 at 10:18 am revealed Resident #28 with 2 soiled briefs on and 2 pads under him and all were soaked with urine .<BR/>Record Review of Resident #35's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction, schizoaffective disorder (distorted reality), and anxiety.<BR/>Record review of Resident #35's 04/15/23 MDS revealed a BIMS of 08, which indicated moderatley impaired cognition. Further review revealed he required extensive assistance with toileting, hygiene, dressing, bed mobility, and transfers.<BR/>A record review of a photo dated 04/24/23 at 4:46 pm revealed Resident #35 in his wheelchair with no socks on, just slip-on shoes and his trousers are covered in yellow stains on both legs, starting in the hip and pelvic area and continuing down his gray sweat pant legs [lunch was served at 12:00 pm]. <BR/>A record review of the undated facility dining times revealed that breakfast was at 8:00 am, lunch was at 12:00 pm, and dinner was at 5:00 pm. <BR/>In an interview on 05/19/23 at 10:15 am the DON stated that CNAs are expected to check on residents every 2 hours and as needed and that she had not noticed strong odors. She said residents left soiled could cause infections and skin breakdown. She denied any complaints about urine odors to the best of her knowledge.<BR/>Record review of an undated facility policy on Resident Rights stated that residents have a right to safe, decent and clean conditions. <BR/>Record review of the abuse prohibition policy, revised [DATE], revealed each resident has a right to be free from neglect; it further defined neglect as .failure to assist in personal hygiene . failure to provide medical care for physical and mental health needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of one residents (Resident #1) reviewed for pain.<BR/>1. <BR/>The facility failed to assess, reassess, and/or take steps to manage Resident #1's pain when she informed them of the pain to her left stump.<BR/>2. <BR/>The facility failed to administer Resident #1's PRN Tylenol #4 to adequately control her pain.<BR/>This failure caused the resident to experience avoidable pain that was severe, and more than transient lasting for weeks and put all could place residents at the facility at risk of suffering pain which could prevent them from achieving their highest practicable physical, mental, and psychosocial outcome.<BR/>Findings include:<BR/>Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, lung disease, and cerebrovascular disease (brain).<BR/>Record review of Resident #1's 03/03/23 MDS dated [DATE] revealed a BIMSs of 15, which indicated the resident was cognitively intact.<BR/>Record review of Resident #1's undated care plan revealed she will be free from pain related to amputations of both legs above the knee and peripheral vascular disease and stated she was also on Pain medication therapy because of Chronic Pain, peripheral vascular disease (poor blood flow in arms and legs), Gout, and migraines with the following initiation date: 03/03/15. The interventions were: Review (FREQ) for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. The care plan Later stated she has, Hemiplegia/Hemiparesis (paralysis) from Stroke; interventions were: Give medications as ordered. Monitor/document for side effects and effectiveness and the Date Initiated: 03/03/15. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 03/03/2015. And another section stated she has chronic/acute pain because of chronic physical disability, fracture, depression and disease process. Interventions listed were: Monitor/record pain characteristics PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors and the date Initiated: 03/03/15. Monitor/record/report to Nurse any signs of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) and the date Initiated: 03/03/15. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Therapeutic regimen followed, but pain control not adequate, changes required.<BR/>Record review of Resident #1's physician active orders printed 05/18/23 revealed the following orders for pain:<BR/>Cyclobenzaprine HCl Tablet 5 MG, Give 2 tablet by mouth every 12 hours as needed for muscle spasms 2 tabs = 10mg with a start date of 12/15/22.<BR/>Tylenol with Codeine #4 Tablet 300-60 MG (Acetaminophen-Codeine) Give 2 tablet by mouth every 6 hours as needed for Pain related to OTHER CHRONIC PAIN and a Start Date of 08/30/22.<BR/>In an interview and observation on 05/17/23 at 2:12 pm Resident #1 she did not get her night medicine on 05/12/23, which included medicine for sleep and for pain. She stated that her pain on 05/12/23 was a 10 out of 10 and she couldn't sleep either. She said her pain was relieved sometime after 7:00 am on 05/13/23 when the morning shift arrived. Resident #1 cringed multiple times and grabbed her left leg stump while she spoke. She also grimaced 3 times and then gasped while grabbing her left leg. She became tearful and stated that she has told all of the nurses she was in pain, and it has been for a few weeks; she said she has not been re-evaluated by a doctor after she informed the nurses she was in pain. Resident #1 did not feel the Tylenol #4 PRN was helping. She stated her current pain level was a 10 out of 10.<BR/>In an interview on 05/17/23 at 2:24 pm with the DON, this Surveyor informed her of Resident #1 complaining of 10 out of 10 pain.<BR/>Record review on 05/17/23 revealed that Resident #1's May 2023 MAR was blank on 05/11/23 and 05/12/23 for her 8:00 pm medications which were Melatonin 10 mg, Glucophage 500 mg, Tizanidine 4 mg, gabapentin 800 mg, Aggrenox 25-200, dilantin 200 mg, coreg 50 mg, Cymbalta 60 mg, and trazadone 250 mg. In addition, her 4:00 pm ziprasidone 40 mg was not administered on either date.<BR/>Interview on 05/17/23 at 2:30 pm with LVN O stated Resident #1 likes meds and got people fired; sShe had never seen the resident grimace. She stated she had a med at 6:45 am and she goes to pain management in Waco and [NAME]. Resident #1 was a drug addict. <BR/>In an interview on 05/17/23 at 2:35 pm with ADON 2 she said Resident #1 goes to [NAME] for pain management because they have a lift and she gets injections in Waco.<BR/>In an interview and observation on 05/17/23 at 4:40 pm with ADON 2 and DON, DON walked to medication cart and pulled out medication baggies that had a resident name at the top and a date and time for administration. She stated if the medications were not administered they would be in the cart and no medications were in the cart. <BR/>In an interview on 05/17/23 at 4:48 pm, while observing a med cart with the DON, unprompted CMA A stated that on 05/11/23 before she left for the evening she noted that a few residents, including Resident #1, did not have baggies for their night medications. She stated the new pharmacy company had a rep on site and the rep was informed that residents were missing meds and the rep stated she would send an email but it could take a day to get it straightened out . She stated that 05/10/23 was the first day of the new pharmaceutical system using the medications and baggies, so the rep was present.<BR/>In an observation on 05/17/23 at 4:52 pm with the DON she came out of a room carrying 2 baggies of medications with Resident #1's name and 05/12/23 8:00 pm on the top. <BR/>In an interview on 05/17/23 at 5:19 pm with the DON she stated she spoke to CMA B on phone and CMA B stated that Resident #1 refused her medications on 05/12/23. The DON asked if she should enter a progress note at this time reflecting the resident refused her medications. The DON stated that the expectation was that CMA B should have informed the nurse working that night of the refusal, the nurse should have spoken to the resident and offered the medications again. She said medications not being administered was a risk to the resident and the expectation was that medications be administered or reason be documented in the MAR .<BR/>In an interview on 05/17/23 at 5:19 pm with the ADON she stated Resident #1 can't be in pain, she was outside smoking and smiling just before she claimed to be in pain.<BR/>In an interview on 05/18/23 at 8:23 am with PHAR P she stated the rep would not call me back, she is her supervisor. She stated the deliveries arriving around midnight tonight would be for the day after tomorrow. The medication carts should have today's medications to be distributed and tomorrow's. She said it was not possible that the medications were not present in the building and that there was a central computer called a cubex that had the common medications so they could be pulled if needed.<BR/>In an interview on 05/18/23 at 9:55 am with MD, stated he took over for other medical director 3 days ago (05/15/23), and that he has not seen all of the residents yet. He stated his expectation was that he be notified if a resident was in pain and the medication was not resolving the pain, if the resident complained of uncontrolled pain. He stated he would then evaluate the resident to determine the best course of action.<BR/>In an interview on 05/18/23 at 1:27 pm with CMA A she stated she was pretty sure Resident #1, Resident #38 and Resident #50 were all missing night medications on 05/11/23 and she informed the pharmacy rep of these items being missing. She stated that she did not inform the DON because she told the pharmacy rep.<BR/>In an interview and observation on 05/18/23 at 4:50 pm with Resident #1 she said she saw the pain doctor today but doesn't think the medications are working. She said she did not get any medications last Thursday (05/11/23) or Friday (05/12/23) which included medications for pain and sleep. She said she did not get sleep on Thursday or Friday, she was in pain and couldn't calm down and she was crying on and off through the night. She stated that hell no I did not refuse my medications, and said she refused a patch that did not help her but other than that she did not refuse her medications ever. She said her left stump pain started around an 8 of 10 and went up to a 10 of 10 on both nights. She told ADON 2 on Tuesday 05/16/23 that she was in pain and she said they would try to fix it, but she told her a few times over the last few weeks and nothing was done about her pain. She was clearly uncomfortable, shifting multiple times, grabbing her left leg stump, and cringing and gasping a few times. In addition, she got emotional several times as we spoke. She said that it was a horrible anxiety and pain that got worse and worse through the night on Thursday and Friday when she did not get her medicine and her roommate was snoring and added to her frustration; she said it was overwhelming to deal with the pain and lack of sleep. <BR/>In an interview on 05/18/23 at 5:05 pm with the DON and ADON 2, ADON 2 she said the resident was a drug addict , and she had failed the screening for a pain pump. The DON and ADON 2 said Resident #1 should have hit her call light and she could have called or texted them to get her medicine .<BR/>In an interview on 05/18/23 at 7:15 pm with LVN C she stated that if the CMA had told her a resident refused medications she would have spoken to the resident, if the resident still refused she would document it in the MAR. She said CMA B left at 10:00 pm and the medication delivery came around midnight. She said there were a handful of medication in the corner of the drawer when CMA B left if she recalled correctly. She said she had not seen the pharmacy system that was used, and so she was going slowly to be thorough and not make mistakes. She did not recall the fate of the medications left in the drawer and nor did she recall any names on the baggies.<BR/>In an interview on 05/19/23 at 10:13 am the DON stated that the expectation was that the CMA notify the nurse if a medication was refused and the nurse would offer or document. She said without the correct documentation that residents could end up not getting the correct amount of medicine which would harm them. She said she and ADON 1 and ADON 2 run a report to look for blanks in the MAR and address these blanks. She stated the report was supposed to be run daily, but she had not run it this week. She said she did not know why it did not get done. <BR/>In an interview on 05/19/23 at 11:00 am with Resident #1 she stated she was in about a 3 of 10 pain level and that was comfortable for her.<BR/>In an interview on 05/19/23 at 11:52 am with CMA B she stated she couldn't find Resident #1 on 05/12/23 to give her the medicine she was supposed to administer and when she finally saw the resident around 9:30 pm the resident refused her medication. She said she did not inform anyone working that night. She stated she had the phone number for the DON but did not inform her of the refusal either. She confirmed she should have informed the nurse but forgot and forgot to chart the refusal. <BR/>Record review of Resident #1's pain assessment printed 05/17/23 revealed on 05/14/23 a pain assessment was done at 8:13 am, but no pain assessment was done on the following shift. On 05/05/23 at 2:14 am her pain was assessed, but it was not assessed again until 05/06/23 at 6:32 pm. On 05/02/23 no pain assessment was done on the morning shift, the only assessment was 8:10 pm and 9:15 pm. On 05/01/23 a pain assessment was done at 1:35 am, but no other pain assessment was done on 05/01/23.<BR/>Record review of Resident #1's progress notes printed 05/17/23 revealed her pain medication was marked as ineffective on 05/11/23 at 11:26 am with a follow-up pain of 8.<BR/>Record review of the progress notes for Resident #1 printed on 05/22/23 r evealed the following dates and mentions of pain and medications: 5/17 6:45 am c/o muscle discomfort; c/o gen discomfort, 5/16 7:27 am requested; 7:24 am pain in stump, 5/15 10:16 PM pending rx delivery for 10 medications, 5/15 7:50 pm Tylenol 4, 5/15 8:01 am requested for muscle spasms; pain in stump, 5/13 7:30 am requested prn pain medicine for pain in stump & requested PRN pain medication for level 9 pain in stump, 5/13 1:04 am pain 10/10, 5/12 7:55 am per resident request; c/o generalized pain; 5/11 11:26 am PRN administration was effective and a separate note 5/11 11:26 am PRN administration was ineffective with a follow up pain scale was 8; 5/11 7:24 am requested for pain; 5/10 9:26 am back; 5/9 9:28 am requested, back; 5/8 7:08 pm requested for stump pain noted; 5/8 8:39 am AD voiced her stump hurt; 5/8 7:44 am requested; back; 5/7 7:42 pm requested for stump pain noted; 5/7 2:33 am requested for back/stump pain noted 5/10; 5/6 6:32 pm stump/back pain noted; 5/4 6:42 pm requested for back pain noted; 5/4 7:45 am requested (effective documented at 2:18 pm); 5/3 6:47 pm requested for stump pain noted (effective documented at 11:35 pm); 5/3 7:31 am requested; back pain; 5/2 8:10 pm , assume administered just copied order but f/u 9:15 pm marked effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days for 2 (Resident #68 and #8) of 4 residents reviewed for psychotropic medication errors.<BR/>The facility failed to ensure psychotropic medications were prescribed for appropriate medical diagnoses for Resident #68 and Resident #8.<BR/>This failure put all residents at risk of decreased quality of life due to improper use of psychotropic medications.<BR/>Finding included:<BR/>Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, bipolar disorder, and depression.<BR/>Record review of Resident #68's May MAR revealed an order for aripiprazole 10 mg, give 1 tablet 1 time per day for behavior. Further record review revealed no diagnosis associated with the medication order.<BR/>Record Review of Resident #8's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including kidney disease, dementia, depression, anxiety, and adjustment disorder with mixed anxiety and depression.<BR/>Record review of Resident #8's 04/13/23 MDS revealed her BIMSs was blank.<BR/>Record review of the progress notes for Resident #8 printed on 05/22/23 at 4:11 pm revealed a progress note dated 05/16/23 at 4:21 pm written by ADON that stated stated spoke with family (RP) about AM and afternoon trazadone being discontinued and he was upset to why that would be the case; notified NP E and resident was placed back on trazadone 100 once in am and in afternoon and 150 mg 2 tab at night before bedtime. RP happy with change.<BR/>Record review of Progress note dated 05/15/23 at 3:16 pm stated Resident #8 was yelling down the hall and was entered by AD; 5/12/23 at 3:22 pm yells at other residents per LVN N, 5/12/23 3:08 pm combative today hitting other residents and cursing able to redirect by AD <BR/>Record review of the progress notes for May, printed 05/22/23 at 4:11 pm revealed 05/05/23 at 12:02 pm physician progress note mdd stable but does cry at times per staff; Cymbalta 30 mg hs and trazadone 100 mg po hs vit d3 25 mcg po daily signed by NP E.<BR/>Record review of Resident #8's May MAR revealed from 05/01/23 - 05/08/23 8:00 pm 100 mg Trazadone, and 12:00 pm 100 mg trazadone; from 05/08/23 - 05/16/23 150 mg trazadone at 8:00 pm; then starting 05/17/23 100 mg trazadone at 8:00 am, 100 mg trazadone at 12:00 pm, and 300 mg trazadone at 8:00 pm. Record review revealed no existing order for trazadone scheduled at 8:00 am prior to 05/17/23.<BR/>Record review of the manufacturer prescribing information for trazadone, in section 2.1 dosage selection, the dose may be increased by 50 mg/day every 3 to 4 days . The maximum dose for outpatients usually should not exceed 400 mg/day in divided doses. Inpatients (i.e., more severely depressed patients) may be given up to but not in excess of 600 mg/day in divided doses.<BR/>In an interview on 05/23/23 at 1:28 pm with DON she stated she would review all psychotropic medications and limit PRN orders to 14 days and add diagnoses for medications that were lacking an associated diagnosis. She stated that the consultant pharmacist had recommended a 30 day maximum on PRN psychotropic medications. She stated she was not aware that hospice was required to follow the 14 day PRN guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 26 (Resident #1, #7, #9, #12, #14, #15, #20, #22, #23, #25, #28, #30, #31, #33, #38, #45, #46, #47, #50, #54, #56, #62, #64, #65, #68, and #70) of 72 residents reviewed for medication errors.<BR/>1. <BR/>The facility failed to administer medications prescribed by provider(s) for Resident #1, #7, #14, #20, #22, #23, #25, #28, #31, #33, #38, #46, #47, #62, #64, #65, and #70.<BR/>2. <BR/>The facility failed to adhere to the parameters of medication administration as written by the provider(s) for Resident #1, #15, #12, #9 #25, #56, #47, #54, and #45.<BR/>3. <BR/>The facility failed to administer medications in a timely manner, within an hour of the scheduled administration time, and before meals as prescribed for Resident #33.<BR/>4. <BR/>The facility failed to ensure the administration of levothyroxine on 05/21/23 at 5:00 am for 3 of 3 (Resident #1, Resident #50, and Resident #68) residents reviewed for missing levothyroxine complaints on 05/21/23.<BR/>5. The facility failed to ensure the administration of medications that have a narrow therapeutic index for Resident #1, #25, and #30.<BR/>These failures could place resident at the facility and placed each resident at risk of continued serious medication errors that were likely to cause injury, harm, impairment or death, in addition to impairing psychosocial wellbeing.<BR/>Findings included:<BR/>#1 The facility failed to administer medications prescribed by provider(s).<BR/>Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease.<BR/>In an interview and observation on 05/17/23 at 2:12 pm Resident #1 she did not get her night medicine on 05/12/23, which included medicine for sleep and for pain. She stated that her pain on 05/12/23 was a 10 out of 10 and she couldn't sleep either. She said her pain was relieved sometime after 7:00 am on 05/13/23 when the morning shift arrived. Resident #1 cringed multiple times and grabbed her left leg stump while she spoke. She also grimaced 3 times and then gasped while grabbing her left leg. She became tearful and stated that she has told all of the nurses she was in pain, and it has been for a few weeks; she said she has not been re-evaluated by a doctor after she informed the nurses she was in pain. Resident #1 did not feel the Tylenol #4 PRN was helping. She stated her current pain level was a 10 out of 10.<BR/>In an interview on 05/17/23 at 2:24 pm with DON this Surveyor informed her of Resident #1 complaining of 10 out of 10 pain.<BR/>Record review on 05/17/23 revealed that Resident #1's May 2023 MAR was blank on 05/11/23 and 05/12/23 for her 8:00 pm medications which were Melatonin 10 mg, Glucophage 500 mg, Tizanidine 4 mg, gabapentin 800 mg, Aggrenox 25-200, dilantin 200 mg, coreg 50 mg, Cymbalta 60 mg, and trazadone 250 mg. In addition, her 4:00 pm ziprasidone 40 mg was not administered on either date. <BR/>Interview on 05/17/23 at 2:30 pm with LVN O stated Resident #1 likes meds [enjoys narcotics] and got people fired [complained often about care]; she had never seen the resident grimace. She stated she had a med at 6:45 am and she goes to pain management in Waco and [NAME]. Resident #1 was a drug addict, she knew from back in the day [before the resident admitted to the facility in 2015]. <BR/>In an interview and observation on 05/17/23 at 4:40 pm with ADON 2 and DON, the DON walked to the medication cart and pulled out medication baggies that had a resident name at the top and a date and time for administration. She stated if the medications were not administered they would be in the cart and no medications were in the cart . <BR/>In an interview on 05/17/23 at 4:48 pm, while observing a med cart with DON, unprompted CMA A stated that on 05/11/23 before she left for the evening she noted that a few residents, including Resident #1, did not have baggies for their night medications. She stated the new pharmacy company had a rep on site and the rep was informed that residents were missing meds and rep stated she would send an email but it could take a day to get it straightened out. She stated that 05/10/23 was the first day of the new pharmaceutical system using the medications and baggies, so the rep was present.<BR/>In an observation on 05/17/23 at 4:52 pm with DON she came out of a room behind the nurses station carrying 2 baggies of medications with Resident #1's name and 05/12/23 8:00 pm on the top [the medications that should have been administered to Resident #1 on Friday 05/12/23 at 8:00 pm]. <BR/>In an interview on 05/17/23 at 5:19 pm with DON she stated she spoke to CMA B on the phone and CMA B stated that Resident #1 refused her medications on 05/12/23. The DON asked if she should enter a progress note at this time reflecting the resident refused her medications. The DON stated that the expectation was that CMA B should have informed the nurse working that night of the refusal, the nurse should have spoken to the resident and offered the medications again. She said medications not being administered was a risk to the resident and the expectation was that medications be administered or the reason be documented in the MAR .<BR/>In an interview on 05/17/23 at 5:19 pm with the ADON she stated Resident #1 can't be in pain she was outside smoking and smiling just before she claimed to be in pain.<BR/>In an interview on 05/18/23 at 8:23 am with PHAR P she stated the rep would not call me back, she is her supervisor. She stated the deliveries arriving around midnight tonight would be for the day after tomorrow. The medication carts should have today's medications to be distributed and tomorrow's. She said it was not possible that the medications were not present in the building and that there was a central computer called a cubex that had the common medications so they could be pulled if needed. <BR/>In an interview on 05/18/23 at 1:27 pm with CMA A she stated she was pretty sure Resident #1, Resident #38 and Resident #50 were was all missing night medications on 05/11/23 and she informed the pharmacy rep of this<BR/>In an interview and observation on 05/18/23 at 4:50 pm with Resident # 1 she said she saw the pain doctor today, but doesn't think the medications are working. She said she did not get any medications last Thursday (05/11/23) or Friday (05/12/23) which included medications for pain and sleep. She said she did not get sleep on Thursday or Friday, she was in pain and couldn't calm down and she was crying on and off through the night. She stated that hell no I did not refuse my medications, and said she refused a patch that did not help her but other than that she did not refuse her medications ever. She said her left stump pain started around an 8 of 10 and went up to a 10 of 10 on both nights. She told ADON 2 on Tuesday 05/16/23 that she was in pain and she said they would try to fix it, but she told her a few times over the last few weeks and nothing was done about her pain. She was clearly uncomfortable, shifting multiple times, grabbing her left leg stump, and cringing and gasping a few times. In addition, she got emotional several times as we spoke. She said that it was a horrible anxiety and pain that got worse and worse through the night on Thursday and Friday when she did not get her medicine and her roommate was snoring and added to her frustration; she said it was overwhelming to deal with the pain and lack of sleep. <BR/>In an interview on 05/18/23 at 5:05 pm with DON and ADON 2, ADON 2 she said Resident #1 was a drug addict, and she had failed the screening for a pain pump. The DON and ADON 2 said Resident #1 should have hit her call light and Resident #1 could have called or texted them to get her medicine. <BR/>In an interview on 05/18/23 at 7:15 pm with LVN C she stated that if the CMA had told her a resident refused medications she would have spoken to the resident, if the resident still refused she would document it in the MAR. She said on 05/12/23 CMA B left at 10:00 pm and the medication delivery came around midnight. She said there were a handful of medication in the corner of the drawer when CMA B left if she recalled correctly . She did not now if the left over meds belonged to Resident #1 and they were in the cart when she signed off the cart in the morning.<BR/>In an interview on 05/19/23 at 10:13 am the DON stated that the expectation was that the CMA notify the nurse if a medication was refused and the nurse would offer or document. She said without the correct documentation that residents could end up not getting the correct amount of medicine which would harm them. She said she and ADON 1 and ADON 2 run a report to look for blanks in the MAR and address these blanks. She stated the report was supposed to be run daily, but she had not run it this week. She said she did not know why it did not get done. She stated missing medication could harm residents. She was not sure how these were missed and she was not sure why parameters were missing from several orders for blood pressure. She said she would get back to me and left the room.<BR/>In an interview on 05/19/23 at 11:00 am with Resident #1 she stated she was in about a 3 of 10 pain level and that was comfortable for her [her pain was under control].<BR/>In an interview on 05/19/23 at 11:52 am with CMA B she stated she couldn't find Resident #1 on 05/12/23 to give her the medicine she was supposed to administer and when she finally saw the resident around 9:30 pm the resident refused her medication. She said she did not inform anyone working that night;. sShe stated she had the phone number for the DON but did not inform her of the refusal either. She confirmed she should have informed the nurse but forgot and forgot to chart the refusal.<BR/>Record review of the Medication Admin Audit Report run on 05/17/23 at 4:52 pm for residents who had a blank for medication administration between 05/11/23 - 05/13/23 revealed the following medications were missed in addition to Resident #1 listed above:<BR/>Resident #7, Center 3 unit, 05/11/23 8:00 pm, melatonin 5 mg<BR/>Resident #14, Secure unit, 05/13/23 1:00 pm, Depakote sprinkles 125 mg<BR/>Resident #20, Secure unit, 05/13/23 8:00 am, metoprolol 12.5 mg<BR/>Resident #22, Center 3 unit, 05/11/23 8:00 pm, Aricept 10 mg, melatonin 5 mg, Xanax .5 mg, trazadone 50 mg, dicyclomine 10 mg<BR/>Resident #23, Center 3 unit, 05/11/23 8:00 pm, Humalog sliding scale (no blood sugar done)<BR/>Resident #25, Center 3 unit, 05/11/23 8:00 pm, Novalog sliding scale (no blood sugar done), lantus 30 units<BR/> 05/12/23 8:00 pm, Novalog sliding scale (no blood sugar done), lantus 30 units<BR/>Resident #28, Center 3 unit, 05/11/23 8:00 pm, melatonin 5 mg, risperidone 1 mg<BR/>Resident #29, Center 1 unit, 05/12/23 4:00 pm, combigan ophthalmic solution 1 drop in both eyes, methocarbamol 500 mg<BR/> 05/12/23 8:00 pm, senna 8.6 mg, latanoprost ophthalmic solution 1 drop in both eyes<BR/>Resident #31, Center 1 unit, 05/12/23 6:30 am, pantoprazole 40 mg<BR/> 05/12/23 8:00 am, benztropine .5 mg, baclofen 10 mg, coreg 25 mg, sertraline 100 mg, amlodipine <BR/> 10 mg, Depakote Sprinkles 500 mg, Vistaril 25 mg<BR/> 05/12/23 1:00 pm, Vistaril 25 mg<BR/>Resident #33, Center 1 unit, 05/11/23 8:00 pm, atorvastatin 80 mg, hydromorphone 2 mg, Flomax .4 mg, trazadone 150 mg,<BR/> novolog sliding scale, Gabapentin 600 mg, lantus 15 units, docusate 100 mg<BR/>Resident #38, Center 3 unit, 05/13/23 8:00 am, Zyprexa 10 mg<BR/>Resident #46, Secure unit, 05/13/23 1:00 pm, Depakote sprinkles 125 mg, med pass 2.0<BR/>Resident #47, Secure unit, 05/13/23 1:00 pm, lorazepam 1 mg, sodium chloride 1 g<BR/>Resident #62, Center 1 unit, 05/12/23 7:00 pm, metaxalone 400 mg<BR/> 05/12/23 8:00 pm, trazadone 50 mg, Aricept 5 mg<BR/>Resident #64, Center 1 unit, 05/12/23 5:00 am, levothyroxine<BR/> 05/11/23 4:00 pm, gabapentin 100 mg, risperidone 1 mg, benztropine .5 mg<BR/>Resident #65, Center 3 unit, 05/11/23 8:00 pm, Advair diskus 1 puff<BR/>Resident #70, Center 3 unit, 05/11/23 8:00 pm, lantus 15 units, Humalog sliding scale<BR/> 05/13/23 8:00 am, amlodipine 5 mg <BR/>Record review of all active orders printed 05/22/23 at 3:58 pm revealed the following orders:<BR/>Resident #7 had an order Melatonin Tablet 5 MG Give 1 tablet by mouth at bedtime related to INSOMNIA<BR/>Resident #14 had an order for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1<BR/>capsule by mouth three times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE<BR/>Resident #20 had an order for Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 0.5 tablet by mouth one time a day<BR/>related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR &lt;60 or bp &lt;120/60.<BR/>Resident #22 had the following orders: Aricept Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime<BR/>for DEMENTIA; Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth at bedtime for anxiety; Melatonin Oral Tablet 5 MG (Melatonin) Give 5 mg by mouth at bedtime for insomnia; traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER; and Dicyclomine HCl Capsule 10 MG Give 1 capsule by<BR/>mouth at bedtime for IBS;<BR/>Resident #23 had an order for tor HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals and at bedtime related to TYPE 2 DIABETES<BR/>Resident #25 had an order for NovoLOG Injection Solution (Insulin Aspart) Inject as per sliding scale, subcutaneously at bedtime<BR/>related to TYPE 2 DIABETES MELLITUS; and an order for Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS<BR/>Resident #28 had an order for Melatonin Tablet 5 MG Give 1 tablet by mouth at bedtime for insomnia; and RisperiDONE Tablet 1 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER<BR/>Resident #29 had an order for Combigan Ophthalmic Solution 0.2-0.5 %<BR/>(Brimonidine Tartrate-Timolol Maleate) Instill 1 drop in both eyes two times a day related to UNSPECIFIED GLAUCOMA; Methocarbamol Oral Tablet 500 MG (Methocarbamol) Give 1 tablet by mouth two times a day related to UNSPECIFIED OSTEOARTHRITIS; Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth at bedtime for constipation; and Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime for GLACOMA.<BR/>Resident #31 had an order for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 40 mg by<BR/>mouth in the morning related to GASTROESOPHAGEAL REFLUX DISEASE; Benztropine Mesylate Oral Tablet 1 MG<BR/>(Benztropine Mesylate) Give 0.5 tablet by mouth two times a day for EPS; Baclofen Oral Tablet 10 MG (Baclofen) Give 10 mg<BR/>by mouth two times a day for muscle spasms; Coreg Oral Tablet 25 MG (Carvedilol) Give 25 mg by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for BP under 100/60 or HR under 60; Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 100 mg by mouth one time a day for Depression; amLODIPine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 10 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for BP less than<BR/>100/60, HR less than 60; Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule by mouth two times a day related to GENERALIZED ANXIETY DISORDER; and Vistaril Oral Capsule 25 MG (Hydroxyzine<BR/>Pamoate) Give 1 capsule by mouth three times a day related to GENERALIZED ANXIETY DISORDER.<BR/>Resident #33 had an order for Atorvastatin Calcium Tablet 80 MG Give 1 tablet by mouth at bedtime for HLD; HYDROmorphone HCl Tablet 2 MG Give 1 tablet by mouth every 4 hours related to ACQUIRED ABSENCE OF RIGHT LEG BELOW KNEE; Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia; traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED (G47.00) administer<BR/>with 100mg tablet = 150mg; traZODone HCl Tablet 100 MG Give 1 tablet by mouth at bedtime for Insomnia related to INSOMNIA, UNSPECIFIED (G47.00) administer with 50mg tablet = 150mg; NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale, subcutaneously before meals and at bedtime related to TYPE 1 DIABETES; Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 capsule by mouth every 4 hours for diabetic nerve pain; Lantus SoloStar Solution Pen-injector 100 UNIT/ML<BR/>(Insulin Glargine) Inject 15 unit subcutaneously at bedtime for diabetes; and Docusate Sodium Capsule 100 MG Give 1 capsule<BR/>by mouth at bedtime for constipation<BR/>Resident #38 had an order for ZyPREXA Tablet 10 MG (OLANZapine) Give 1 tablet by mouth two times a day for Agitation related<BR/>to SCHIZOPHRENIA<BR/>Resident #46 had an order for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1<BR/>capsule by mouth three times a day related to ANXIETY DISORDER; and Med Pass 2.0 three times a day for 80cc offer<BR/>snacks with med pass<BR/>Resident #47 had an order for LORazepam Tablet 1 MG Give 1 mg by mouth three times a day for ANXIETY DISORDER; and Sodium Chloride Tablet 1 GM Give 1 tablet by mouth three times a day for HYPONATREMIA.<BR/>Resident #62 had an order for Metaxalone Tablet 400 MG Give 1 tablet by mouth at bedtime for muscle spasm; TraZODone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime for Inability to Sleep related to INSOMNIA; and Aricept Tablet 5 MG (Donepezil HCl) Give 1 tablet by mouth at bedtime for dementia.<BR/>Resident #64 had an order for Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth in the morning for low thyroid<BR/>hormone related to HYPOTHYROIDISM, UNSPECIFIED (E03.9) pt requests med be given at 0730; Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for pain; RisperDAL Oral Tablet 2 MG (Risperidone) Give 1<BR/>tablet by mouth two times a day related to PARANOID SCHIZOPHRENIA; and Benztropine Mesylate Oral Tablet 0.5 MG<BR/>(Benztropine Mesylate) Give 1 tablet by mouth two times a day for .<BR/>Resident #65 had an order for Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone-Salmeterol) 1 puff<BR/>inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE.<BR/>Resident #70 had an order for Lantus 100 UNIT/ML Solution Inject 15 unit subcutaneously at bedtime related to DIABETES; HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale, subcutaneously before meals and at bedtime related to DIABETES MELLITUS, and amLODIPine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR less than 60 or SBP less than 100.<BR/>Record review of the MAR for the month of April 2023 revealed every resident in the facility had medications that were not administered, with a total of 1239 omissions on the secured unit (Residents #8, #44, #27, #54, #4, #72, #42, #47, #45, #16, #60, #14, #61, #59, #46, and #30) and 255 omissions (Residents #56, #37, #12, #15, #25, #22, #70, #41, #50, #1, #22, #11, and #6) for the center unit. These counts reflected only medication administrations and did not include other orders that were not completed.<BR/>Record review of the MAR for the month of May (05/01/23 - 05/19/23) revealed 55 omitted medication administrations on the secure unit and 419 omitted medication administration on the center unit.<BR/>#2 The facility failed to adhere to the parameters of medication administration as written by the provider(s).<BR/>Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease (lung disease), and cerebrovascular (blood flow in brain) disease. <BR/>Record review of Resident #1's 03/03/23 MDS dated revealed a BIMSs of 15, which indicated the resident was cognitively intact.<BR/>Record review of Resident #1's May 23 MAR revealed on 05/04/23 8:00 pm her Coreg 50 mg (hold for BP less than 100/60 or heart rate less than 60) was held when her blood pressure was 124/60 and heart rate was 76. On 05/03/23 7:00 am her blood pressure was 177/77 and her Cozar 100 mg (hold if blood pressure is under 100 and call MD if over 170) but there was no documentation that the physician was not notified of her 177 systolic blood pressure. <BR/>In an interview on 05/18/23 at 5:08 pm with ADON 2 she stated that if a physician was notified of anything there should be a progress note on the date and time the notification was made. In addition, she said it should be on the 24-hour report. She denied any notifications of blood pressure out of range being on the 24-hour report in May.<BR/>Record Review of Resident #15's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, depression, anxiety, and schizoaffective disorder. <BR/>Record review of Resident #15's 05/08/23 MDS revealed a BIMSs of 13, which indicated the resident was cognitively intact.<BR/>Record review of Resident #15's May 23 MAR revealed on 05/07/23 at 8:00 am her BP was 174/96 and her metoprolol 50 mg ER (hold for BP under 100 and notify MD if over 170) was administered and MD was not notified;. oOn 05/17/23 at 8:00 am her BP was 175/89 and her metoprolol was administered, and the MD was not notified.<BR/>Record Review of Resident #12's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, lung disease, and low thyroid.<BR/>Record review of Resident #12's 03/24/23 MDS revealed a BIMSs of 15, which indicated the resident was cognitively intact.<BR/>Record review of Resident #12's May 23 MAR revealed on 05/01/23 at 8:00 am her BP was 107/42 and heart rate was 79, and her metoprolol 50 mg was administered. On 05/02/23 at 8:00 am her BP was 110/53 and heart rate was 80 and her metoprolol was administered. The medication required measuring BP and heart rate but had no hold parameters. On 05/02/23 at 8:00 am her BP was 110/53 and HR was 80 and her lisinopril 20 mg (hold if BP less than 100/60) was administered by CMA B.<BR/>Record Review of Resident #9's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, cerebral infarction (stroke), and hyperlipidemia (high cholesterol).<BR/>Record review of Resident #9's 03/15/23 MDS revealed a BIMSs of 6, which indicated severely impaired cognition.<BR/>Record review of Resident #9's May 23 MAR revealed on 05/05/23 at 8:00 am his BP was 106/68 and his lisinopril 20 mg (hold if BP is less than 100/60) was marked as held by CMA B per parameters but the parameters were safe to administer his medication. <BR/>Record Review of Resident #25's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, pulmonary disease, Alzheimer's, and bipolar disorder.<BR/>Record review of Resident #25's 05/08/23 MDS revealed a BIMSs of 2, which indicated a severely impaired cognitive function.<BR/>Record review of Resident #25's May 23 MAR revealed the following orders:<BR/>Humalog sliding scale before meals and bedtime<BR/>Humalog inject 8 units before meals (no parameters)<BR/>Lantus inject 32 units one time per day (7:00 am, no parameters)<BR/>Lantus inject 30 units at bedtime (no parameters)<BR/>On 05/13/23 at 8:00 pm her Lantus 30 units at bedtime was held with a note BS=199 by LVN J.<BR/>On 05/03/23 at 7:00 am her lantus 32 units was held with a note glucose 111 held by LVN G.<BR/>On 05/03/23 at 7:00 am her Humalog 8 units was held with a note 111 by LVN G.<BR/>On 05/04/23 at 7:00 am her Lantus 32 units was held with a note 107 by LVN G.<BR/>On 05/04/23 at 7:00 am her Humalog 8 units was held with a note 107 by LVN G .<BR/>Record Review of Resident #56's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy (mental confusion), and hypertension (high BP) .<BR/>Record review of Resident #56's 05/10/23 MDS revealed a BIMSs of 0, indicating the resident was not able to complete the test.<BR/>Resident review of Resident #56's May 23 MAR revealed an order for metoprolol 25 mg give 1 tablet via PEG-tube two times a day related to essential (primary) hypertension, hold if SBP under 100, DBP under 60 or HR under 55; there are no blood pressures or heartrates associated with administration and no boxes to enter the information.<BR/>Record Review of Resident #47's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including atherosclerosis (blocked vessels), depression, and anxiety.<BR/>Record review of Resident #47's 03/01/23 MDS dated [DATE] revealed it had a blank for the BIMSs score.<BR/>Record review of Resident #47's May 23 MAR revealed an order for lisinopril 5 mg (hold if BP less than 100/60), and on 05/04/23 at 8:00 am her BP was 96/50 and her lisinopril was administered by LVN N. <BR/>Record Review of Resident #54's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, Alzheimer's disease, and hypertension.<BR/>Record review of Resident #54's 04/21/23 MDS dated revealed a blank for the BIMSs score.<BR/>Record review of Resident #54's May 23 MAR revealed an order for a Lidoderm 5% patch, apply to neck topically; apply for 12 hours in a 24 hour period; the record showed the patch was applied at 8:00 am daily and removed the following day at 7:59 am, then a new patch was applied at 8:00 am . The patch was documented as applied on the following dates: 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18 and 5/19 at 8:00 am. The patch was documented as removed at 7:59 am on the following dates: 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18 and 5/19.<BR/>In an interview on 05/23/23 at 1:30 pm with DON and NP E, NP E stated that the order said the patch should be applied for 12 hours out of 24 hours. DON stated that is not what was being done, the patch was applied in the morning and left in place until the next morning. She stated the instructions for the removal of the patch would be updated.<BR/>Record Review of Resident #45's face sheet dated 05/22/23 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, depression, and anxiety.<BR/>Record review of Resident #45's 05/03/23 MDS dated revealed a BIMSs of 15, which indicated the resident was cognitively intact.<BR/>Record review of Resident #45's May 23 MAR revealed an order for amlodipine 5 mg with no parameters, on 05/09/23 at 8:00 am her BP was 116/59 and it was marked as held per parameters; on 05/10/23 at 8:00 am her BP was 116/59 and her medicine was administered.<BR/>In an interview on 05/18/23 at 9:55 am with the Medical Director, he stated that administering BP medications when the resident's blood pressure is below the threshold could cause serious injuries such as heart attack and stroke and could also lead to death.<BR/>#3 The facility failed to administer medications in a timely manner, within an hour of the scheduled administration time, and before meals as prescribed <BR/>Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction.<BR/>In an observation on 05/18/23 at 1:27 pm CMA A administered the following to Resident #33 creon, pancrealipase, 1 capsule, scheduled at 1:00 pm; hydromorphone, 2 mg, pulled from secure drawer, documented in log, scheduled at 12:00 pm, so administered an hour and a half late, and gabapentin, 600 mg, it was in a baggie, then a blister pack by itself, it was scheduled for 12:00 pm, so it was an hour and a half late, and the order was written as administer every 4 hours. <BR/>Record review of the Medication Admin Audit Report run on 05/17/23 for Resident #33 revealed on 05/13/23 his novolog sliding scale insulin (ordered before meals and bedtime) scheduled at 7:30 am was administered at 8:39 am; his 11:30 am dose pre-lunch dose on the same day was administered at 2:50 pm. On 05/14/23 his 7:30 am pre-breakfast does was administered at 8:40 am. On 05/01/23 his 8:00 am medications (Plavix 75 mg, pancrelipase 6000 units, rivaroxaban 20 mg) were all administered at 1:10 pm . <BR/>His 05/02/23 4:30 pm pre-dinner dose was scheduled at 4:30 pm and administered at 5:43 pm; his bedtime dose on 05/07/23 was scheduled for 8:00 pm and was administered at 11:02 pm and the next night (05/08/23) it was administered at 11:06 pm. <BR/>A record review of the undated facility dining times revealed that breakfast was at 8:00 am, lunch was at 12:00 pm, and dinner was at 5:00 pm.<BR/>Record review of Resident #33's hospital records obtained 05/22/23 revealed he was admitted to the emergency room [DATE] at 6:53 am. It further revealed that paramedics administered glucose prior to his arrival at the hospital because his blood sugar was 36.<BR/>#4 The facility failed to ensure the administration of levothyroxine on 05/21/23 at 5:00 am for 3 of 3 (Resident #1, Resident #50, and Resident #68) <BR/>Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease.<BR/>Record review of the progress notes for Resident #1 printed 05/22/23 written by ADON 1 revealed a note dated 05/21/23 at 1:35 pm indicated Resident stated she did not receive her 0500 Levothyroxine. Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated<BR/>Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, hypothyroidism, bipolar disorder, and depression.<BR/>Record review of Resident #68's progress notes, printed on 05/22/23 revealed a note dated 05/21/23 1:44 pm by ADON 1 indicated the Resident stated that he did not receive his Levothyroxine this AM at 0500. Remedi Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated by LVN D.<BR/>Record Review of Resident #50's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, renal disease, and pulmonary disease.<BR/>Record review of Resident #50's MDS dated [DATE] revealed a BIMS of 14 which indicated she was cognitively intact.<BR/>Record review of the progress notes printed on 05/22/23 for Resident #50 revealed a note dated 05/21/23 at 4:59 pm by ADON 2 indicated the Resident reported that she did not get her am synthroid this morning., She was informed her that a an investigation would be made and cameras pulled to verify if medication was administered. About 10 minutes later resident returned with synthroid in her hand and stated, LVN D never misses my medication she must have given it to me and I was still asleep. Provided resident with water and resident took synthroid at this time. <BR/>Record review of the progress notes printed on 05/22/23 for Resident # 50 revealed a progress note dated 05/21/23 at 1:43 pm by ADON 1 indicated Resident stated that she did not receive her Levothyroxine this AM at 0500. Remedi Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been administrated by LVN D.<BR/>#5 The facility failed[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in the facility in that:<BR/>1. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description.<BR/>2. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly sealed. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description.<BR/>3. <BR/>Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not discarded by use by/expiration date.<BR/>4. <BR/>One 1-gallon bottle of Reduced Fat Milk past the Best By date was being used by [NAME] A<BR/>5. <BR/>3 boxes of food inside walk in cooler that were labeled by manufacturer to keep frozen.<BR/>6. <BR/>Food inside of freezer had freezer burn present.<BR/>7. <BR/>1 tray of baked chicken with internal temp of 100 degrees Fahrenheit was cooled improperly, prepared for dinner meal, and placed inside of refrigerator. <BR/>8. <BR/>1 box of meat was defrosting over a bowl of cut potatoes.<BR/>9. <BR/>Temperatures of cold lunch were held and served at a temperature above 41 degrees Fahrenheit. <BR/>This failure could place residents becoming ill from food contamination or bacterial growth.<BR/>Findings included:<BR/>In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator containing grated cheese with date 2/21 use by date 3/2, [NAME] with date 2/27/23, burritos dated 2/24, butter dated 2/24, without product description or use by date labeled.<BR/>In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator labeled sausage dated 2/28/23 and use by date 2/29 was not properly sealed.<BR/>In observation on 2/28/23 at 9:50AM, located in the refrigerator was an open container of labeled Hormel Thick and Easy clear thickened orange juice 46fl oz dated 2/6, ready care thickened apple juice dated 2/4, and thick and easy clear dated 12/6.<BR/>In observation on 2/28/23 at 9:50AM, there was 6 individual serving sized covered containers with unknown substance inside that was located in refrigerator without a date or product label.<BR/>In observation on 2/28/23 at 9:50AM, a metal container with plastic wrap cover was in the refrigerator labeled cherry salad and dated 1/19/23.<BR/>In observation on 2/28/23 at 9:50AM, a 5-gallon bucket was located under the prep area labeled sugar dated 1/6/23, chicken base dated 1/15/23, rice dated 4/23, beef base dated 1/15/23, and flour dated 1/15, with lid sitting loosely on top and was not secured.<BR/>In observation on 2/28/23 at 9:50AM, [NAME] A was pouring reduced fat milk from a gallon bottle with best by date of 2/25/23 into a puree cake recipe.<BR/>In observation on 2/28/23 at 9:50AM, a baking pan with cooked chicken was seen sitting on top of oven with a temperature of 100 degrees Fahrenheit.<BR/>In an interview on 2/28/23 at 10:02 AM the Dietary manager stated chicken sitting out on top of oven with temperature of 100 degrees Fahrenheit was not ok and needed to be thrown out.<BR/>In an observation on 2/28/23 at 10:05AM, a box of frozen deli meat was seen on the top shelf of a rolling cart above a bowl with cut potatoes on the bottom shelf.<BR/>In observation on 2/28/23 at 10:10AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05<BR/>In observation on 2/28/23 at 10:12AM, there was sour cream packets with use by date of 2/27/23 located in walk in cooler.<BR/>In observation on 2/28/23 at 10:15AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05<BR/>In an observation on 2/28/23 at 10:15AM, there was an open bag of corn tortillas inside walk in cooler that was not properly sealed.<BR/>In an observation on 2/28/23 at 10:15AM, there was 2 boxes of garlic Texas toast and 1 box of hoagie wheat rolls inside walk in cooler that were labeled by manufacturer to keep frozen.<BR/>In an observation on 2/28/23 at 10:16AM, inside of the freezer, there was a box of popcorn shrimp filled with ice and inside the bag was shrimp covered with freezer burn.<BR/>In an observation on 2/28/23 at 10:16AM, there was a box of deli sliced ham and turkey covered with freezer burn. <BR/>In an observation on 2/28/23 at 10:17AM, there was a box of corn dogs with freezer burn not sealed inside of freezer. <BR/>In an observation on 2/28/23 at 10:17AM, there was 1 banana cream pie inside freezer not sealed with freezer burn and open date written 1/15/23.<BR/>In an observation on 2/28/23 at 10:17AM, there was abag of unknown food that was not in manufacturer package unlabeled and covered with freezer burn. <BR/>In an observation on 2/28/23 at 10:20AM, there was a box of cookie dough not sealed inside of freezer.<BR/>In an observation on 2/28/23 at 10:25AM, there was 1 box of cocktail sauce package with manufacturer expiration date of 1/26/23.<BR/>In an observation on 2/28/23 at 10:25AM, there was 1 box of steak sauce package with manufacturer expiration date of 2/22/23.<BR/>In an observation on 2/28/23 at 10:27AM, there was 1 bag of an unknown food without food description label with date: 10/28 and use by: 3/28.<BR/>In an observation on 2/28/23 at 10:27AM, there were 3 bags of dry cereal without food description label.<BR/>In an observation on 2/28/23 at 10:46AM, the chicken that Dietary Manager said needed to be thrown out was seen in a bowl inside of the refrigerator.<BR/>In an interview on 2/28/23 at 10:46AM, theDietary Manager said I know the chicken needed to be thrown out and it will be thrown out later. <BR/>In an observation on 2/28/23 at 10:47AM, the ice machine located outside of dining room area had buildup inside of white, brown, pink, and black substance in area where ice trays were located and black substance present on water source that felt ice trays.<BR/>In an interview on 2/28/23 at 10:48AM, the Dietary Manager said she was responsible for making sure the outside of the machine was clean, but the inside of the ice machine was cleaned yearly by maintenance. She said the white, brown, pink, and black substance could contaminate ice and potentially make residents sick.<BR/>In an observation on 2/28/23 at 12:05PM, the chicken that was 100 degrees Fahrenheit from 9:50AM and Dietary Manager said would be discarded at 10:46AM was untouched in the refrigerator.<BR/>In an observation on 2/28/23 at 12:06PM, the cold lunch temperatures were all greater than 40 degrees Fahrenheit. The temperatures were: mustard potato salad 89 degrees Fahrenheit, mechanical soft subway sandwich meat and cheese was 41 degrees Fahrenheit, puree subway sandwich meat and cheese was 55 degrees Fahrenheit and without smooth texture, puree mustard potato salad was 81 degrees Fahrenheit, and pea salad that was not on the menu was 41 degrees Fahrenheit.<BR/>In an interview on 2/28/23 at 12:06PM, the Dietary Manager said the cold lunch being served should be held and served at less than 41 degrees Fahrenheit. She said she saw what the temperature was on each item when she took the temperatures, and she didn't need it pointed out that all of the cold food was too hot to be served for safety reasons to residents. She said it was her responsibility to oversee everything that went on in the kitchen. She said she had a checklist of tasks for her to complete but could not produce this or kitchen policies.<BR/>In an observation on 2/28/23 at 12:06PM, the Dietary Manager pulled the puree meat and cheese to reconstitute with reduced fat milk to make a smooth texture. <BR/>In an observation on 2/28/23 at 12:07PM-12:43PM [NAME] A was seen serving puree subway sandwich meat and cheese with a blue #12 serving spoon (2oz.) until Dietary Manager switched spoon with a white #10 serving spoon (3.2oz) after 3 of 4 puree plates had been served. All plates were served without cooling the food down to less than 41 degrees Fahrenheit. Puree meals consisted of puree meat and cheese, puree mustard potato salad, puree peanut butter crumble cake, and without puree bread or puree replacement for lettuce, tomato, and pickles. Mechanical soft meals consisted of mechanical soft meat and cheese, a whole hoagie roll, mustard potato salad, pea salad, and peanut butter crumble cake. The regular diet plates consisted of a whole hoagie roll, 4 pieces of deli sliced ham, 1 piece of sliced cheese, a scoop of potato salad, a small unmeasured amount of chopped lettuce, 1 thin slice of a small tomato, crumble cake, and no pickles. <BR/>In an interview on 3/1/23 at 1:08PM with Dietician, she said any item that was labeled with best by date meant it was best to be consumed by the date listed for better quality. She said there was no time frame for when that item should be thrown away but could become problematic for consumer if it were a milk-based product used after best by date. She said juice should be discarded after being open for 3 days and all cooked food should be discarded after 72 hours. She said all items should be properly sealed to prevent contaminants and bacteria growth. She said chicken should be cooled in the refrigerator and not at room temperature. She said any food cooled at room temperature could reach the danger zone of 45-135 degrees Fahrenheit, which could lead to bacteria growth and could cause consumer to become ill. She said food that was meant to be served cool should be maintained below 41 degrees Fahrenheit to prevent bacteria growth that could cause consumer to become ill. She said she provided an in-service to kitchen staff in November 2022, December 2022, and February 2023 regarding following the provided recipes and using a dense liquid for puree food. She said puree food should be smooth and without lumps. She said if puree food was not the correct consistency it could cause the consumer to choke. She said meat should not be stored over potatoes because drippings could cause bacteria growth and contamination could cause consumer to become ill.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #13) reviewed for accidents hazards and supervision, in that:<BR/>On 01/23/2025 Resident #13 was transferred by CNA C using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #13 pivoted into the chair, her leg did not pivot well, and the knee twisted and popped which later caused swelling and pain to the left knee.<BR/>This failure could lead to injury or death to residents.<BR/>Findings include:<BR/>Record review of Resident #13's face sheet dated 02/11/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis (a chronic, autoimmune disease that affects the central nervous system-brain and spinal cord, Muscle Weakness (a lack of muscle strength or the inability to control voluntary muscle force), and Unspecified Abnormalities of Gait and Mobility. <BR/>Record review of Resident #13's Quarterly MDS assessment, dated 01/30/2025, reflected a BIMS of 15 which suggested the resident's cognition was intact. Section G revealed Resident #13 required extensive assistance with 2 persons for transfers. The prior Quarterly MDS assessment, dated 12/28/2024, in effect at the time of the event, revealed the resident was classified as requiring substantial/maximal assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. There was no designation for 2 person assist with a mechanical lift.<BR/>Record review of Resident #1's Care Plan dated 03/27/2015 and revised on 02/03/2025, revealed Resident #13 required a mechanical lift X 2 staff assist for all transfers. The previous Care Plan dated 12/6/24 did not specifically address the resident's transfer needs. <BR/>Record review of the Provider Investigation Report, dated 02/05/2025, related to the facility's self-report of Resident #13's injury on 01/23/2025, revealed on 01/23/2025 at 5:15 PM, [CNA C] performed a one person standing assist, as the resident pivoted into the chair the leg did not pivot well and the knee twisted and popped. At the time the resident denied any pain. X-ray results received on 01/24/2025 were negative with no acute fractures. On 01/24/2025 the resident did not communicate any pain. On 01/25/2025 the knee was found to be visibly swollen. The resident declined pain medications. An order for prednisone for inflammation was given and referral for an Orthopedic Physician appointment was given. The Orthopedic appointment is scheduled for 2/11/2025. Upon medical record review it was discovered that there was no order for transfer with a lift. At that time an order was placed for two-person mechanical lift device for transfer. The Administrator was informed of the event by Resident #13 on 01/29/2025 and the event was reported to HHSC on 01/29/2025 at 5:44 PM. Record review of the statement from the Director of Therapy reflected he stated he verbally communicated a transfer status change sometime during the dates of 1/20/2025 to 1/24/2025 from one person assist to two person Hoyer lift to another CNA but had not appropriately communicated the transfer status change to clinical leadership. As a result, an appropriate order was not received to officially change the status to a 2 person assist with a mechanical lift. This failure to communicate the resident's transfer status created confusion amongst the front-line staff and led to the injury. On 01/23/2025 when CNA C performed the transfer, Resident #13's order still reflected the need for a one person standing assist. Further record review revealed in-services on Safe Lifting and Movement of Resident and Use of Mechanical Device, Transfer List Communication, and Accessing [NAME] were implemented with the staff.<BR/>Interview with the Administrator was conducted on 02/11/2025 at 3:00 PM. The Administrator described the facts as disclosed in the Facility Investigation Report. The administrator stated after the investigation was completed, an Ad Hoc QAPI Committee was convened, a Root Cause Analysis was completed, and the Director of Therapy received a corrective action for his failure to communicate. A Performance Improvement Plan was initiated. The Administrator described the current process of monitoring of resident transfer needs. The Administrator stated the transfer needs of each resident is discussed in the facility's morning meeting. <BR/>On 02/11/2025 Record Review of the Interview with CNA C was conducted. CNA C stated she was not aware Resident #13's transfer status had changed prior to the implementation of the transfer. <BR/>Record Review of the facility policy titled, Safe Lifting & Movement of Residents policy statement reads, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and moved residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #37) reviewed for PASARR Level 1 screenings.<BR/>The facility did not send the correct PASARR Level 1 screening to the local authority for Residents #37. <BR/>This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.<BR/>Findings included:<BR/>Resident #37<BR/>Record review of a Face Sheet dated 03/01/23 for Resident #37 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included alcohol abuse with alcohol induced psychotic disorder with hallucinations (a set of psychiatric symptoms that may include hallucinations, delusions, alcoholic paranoia, and generally losing touch with reality), chronic kidney disease stage 3 (gradual loss of kidney function), atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart), and major depressive disorder (a mental disorder characterized by at least 2 weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).<BR/>Record review of Resident #37's diagnosis report revealed that she was diagnosed with alcohol abuse with alcohol induced psychotic disorder hallucinations on 04/07/22. <BR/>Record review of Resident #37's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated a cognition level that was intact in section C. <BR/>Record review of Resident 37's care plan dated 03/01/2023 revealed a focus that Resident #37 required psychotropic drugs r/t to: Depression., psychiatric diagnoses of: (Schizophrenia, Bi-Polar Disorder, Psychosis, etc.) with a goal to have the smallest, most effective dose without side effects through review date. Interventions in place to administer medications as ordered, monitor side effects and report, dose reduction as needed, and psych consult as needed. <BR/>Record review of Resident #37's PASARR Level 1 Screening dated 08/04/22 indicated resident did not have a Mental Illness, Intellectual Disability, or Developmental Disability in section C. <BR/>In an interview on 03/02/2023 at 2:43 PM with the ADM, he stated PASARR screenings were usually done prior to a resident admitting to the facility. He stated the MDS Coordinator and Social Worker were responsible for completing PASARR screenings if the PASARR was not done prior to admission, and he believed they should had been formerly trained on PASARR completion. He stated the MDS Coordinator, and the Social Worker were responsible for ensuring the PASARR was completed accurately. He stated if a resident had a diagnosis of a psychological disorder, it should be noted on the PASARR. He stated the PASARR completed on 08/04/22 for Resident # 37 was completed inaccurately. He stated an inaccurate PASARR could result in a resident not receiving services they may need or improper placement of a resident. <BR/>In an interview on 03/02/2023 at 2:48 PM with MDS coordinator, she stated residents usually come to the facility with a PASARR already complete. She stated if a resident comes from home she usually gets with the resident and family and completes the PASARR herself. She stated the only way a resident would not have had a psychological diagnosis notated on their PASARR would be if the resident had a main diagnosis of Dementia. She stated Resident # 37's PASARR was completed inaccurately, and she felt like the diagnosis of alcohol abuse with alcohol induced psychotic disorder hallucinations was put in Resident # 37's chart inaccurately. She stated if a PASARR was completed inaccurately it could cause a resident to go without desired services that could be offered, or they could not receive the care they needed. She stated she was not sure who entered Resident #37's Diagnoses into the electronic records. <BR/>In an interview on 03/02/2023 at 2:56 PM with the DON, she stated PASARR screenings should be done prior to admission of a resident. She stated the Social Worker or MDS Coordinator were responsible for completing PASARR screenings if the resident admits without one. She stated she believed the MDS Coordinator was responsible for ensuring the accuracy of PASARR screenings. She stated she thought the diagnosis of alcohol abuse with alcohol induced psychotic disorder hallucinations should have been notated on Resident # 37's PASARR screening. She stated the PASARR screening for Resident # 37 was completed inaccurately. She stated when a PASARR screening was not completed accurately a resident may not receive services that could be offered to them. <BR/>In an interview on 03/02/2023 at 3:16 PM with the ADON, she stated she does not know much about PASARR screening and how they were done or who does them. She stated she input residents diagnoses in the electronic records when a resident admitted , and she put the diagnosis for alcohol abuse with alcohol induced psychotic disorder hallucinations in Resident #37's electronic record when Resident #37 admitted . She stated she had gotten the diagnoses off of resident #37's admission paperwork the day of admission. She stated she does not know where the diagnosis of alcohol abuse with alcohol induced psychotic disorder hallucinations came from, but that it was possibly added by error.<BR/>Record review of the policy entitled admission Criteria, dated March 2019 read in part, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. <BR/>a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source to determine if the individual meets the criteria for a MD, ID or RD. <BR/>b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. <BR/>(1) the admitting nurse notifies the social services department when a resident I identified as having a possible (or evident) MD, ID, o RD. <BR/>(2) the social worker is responsible for making referrals to the appropriate state-designated authority.)<BR/>c. Upon completion of the level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. <BR/>d. the state PASARR representative provides a copy of the report to the facility.

FACILITY<BR/>Medication Storage and Labeling<BR/>Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. <BR/>The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 of 2 medication carts that were reviewed for pharmacy services. <BR/>This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift. <BR/>The findings included:<BR/>During an observation and record review on 3/1/23 at 12:00 p.m., an inspection of the medication cart #1 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/7/23 - 2/12/23, 2/16/23, 2/19/23-2/21/23, 2/25/23-2/26/23, and 2/29/23-2/28/23. <BR/>During an observation and record review on 3/1/23 at 12:30 p.m., an inspection of the medication cart #2 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/2/23, 2/5/23, 2/7/23, 2/12/23, 2/18/23-2/20/23, and 2/24/23-2/26/23. <BR/>During an interview on 3/1/23 at 12:30 p.m., MA A for cart #2 stated she has been aware of the missing signatures and stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift. <BR/>During an interview on 3/1/23 at 12:40 p.m., LVN A stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift.<BR/>During an interview on 3/1/23 12:35 p.m., the ADON stated she has acknowledged the noncompliance and stated that it is not in compliance can be a detriment to the residents. <BR/>During an interview on 3/1/23 9:00 a.m., the Director of Nursing DON stated she has acknowledged the possible noncompliance and stated that if not in compliance that it can be a detriment to the residents. She has also stated, This is an issue and all the nurses have been consulted about signing the narcotic count sheet at the time of the count. <BR/>Record review of the facility's policy titled, Controlled Substances, no date, revealed, .12. At the end of Each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.

Based on interview, observation, and record review the facility failed to assure that menus were developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines for 4 of 8 residents reviewed for specialty diets.<BR/>- [NAME] A was not following menu and recipes for specialty diets.<BR/>This failure could prevent 70 residents from receiving their recommended daily nutritional intake.<BR/>Findings included:<BR/>In observation on 2/28/23 at 9:50AM, CookA was pouring reduced fat milk from a gallon bottle with best by date of 2/25/23 into a puree cake recipe. <BR/>In an observation on 2/28/23 from 12:07pm-12:43pm [NAME] A was seen serving puree submarinesandwich meat and cheese with a blue #12 serving spoon (2oz.) until Dietary Manager switched spoon with a white #10 serving spoon (3.2oz).<BR/>In an interview on 2/28/23 at 12:06PM, the Dietary Manager said the serving spoons were color coded to ensure the residents were receiving the correct amount of food to meet their nutritional needs.<BR/>In an interview on 3/2/23 at1:53PM, the Dietician said using a smaller serving spoon could cause weight loss and not using the whole milk could prevent weight gain. The Dietician said not following the menu by leaving something out could reduce caloric intake and lead to weight loss. <BR/>In an interview on 3/2/23 at 1:34PM, the ADON said Dietary Manager was aware of changes such as whole milk being ordered as she was in these meetings and was responsible for updating her dietary system with these changes.<BR/>Record review of Pureed Sandwich Submarine dated 4/13/22 revealed for Portion: a #10 scoop of puree sandwich filling and 2 #20 scoops of puree bread.<BR/>Record review of Pureed Peanut butter crumble cake did not indicate which type of milk to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 (secure hall and 200 hall) of 2 halls observed for insects.<BR/>The facility failed to ensure the facility was free from deceased and living insects on the 200 hall and the secure hall.<BR/>This failure placed all residents at risk of not living in a safe, clean and home-like environment. <BR/>The findings included:<BR/>In an observation on 05/17/23 beginning at 3:52 pm on the secure unit revealed in the hall by the exit door was noted to have a deceased insect body on the wall.<BR/>In an observation on 05/22/23 at 10:20 am on the secure unit the same issues observed on 05/17/23 at 3:52 pm were still present; the secure unit the wall in the hall by the exit door was noted to have a deceased insect body on the wall.<BR/>In an interview on 05/18/23 at 1:25 pm with CMA A she stated she was aware of roaches in Resident #33's room.<BR/>Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction (stroke).<BR/>Record review of Resident #33's 02/10/23 MDS revealed a BIMs of 13, which indicated he is cognitively intact.<BR/>In an observation and interview on 05/20/23 at 4:00 pm with Resident #33 he stated that he saw roaches all of the time on the walls and they are all over the place. A small dead roach was observed by Resident #33's bed and another small dead roach was observed on the roommate's side of the room. In addition, several small gnats were observed.<BR/>In an interview on 05/20/23 at 12:30 pm MAINT I stated if water bugs are found they are usually dead, but sometimes new residents move in and report seeing roaches. When reports are made, the rooms are inspected to find trash or food that may be the cause of the issues. Pest control was an ongoing monthly service contract to resolve issues .<BR/>In an interview on 05/20/23 at 12:30 pm MAINT I stated if water bugs are found they are usually dead, but sometimes new residents move in and report seeing roaches. When reports are made, the rooms are inspected to find trash or food that may be the cause of the issues. Pest control was an ongoing monthly service contract to resolve issues <BR/>In an interview with a confidential visitor to the facility, the visitor stated living insects were present, roaches and gnats and that staff were informed and aware (unknown name of staff).<BR/>In an observation on 05/22/23 at 6:00 pm a small living cockroach was seen running across the floor in Resident #33's room and under his chest of drawers.<BR/>Record review of the pest control monthly receipt dated 04/26/23 revealed the provider treated room and hallway for scorpions and roaches and bathroom. This was in addition to the monthly visit dated 04/02/23.<BR/>Record review of the undated facility policy titled Pest Control Policy stated .ensure that the building is kept free of insects .<BR/>Record review of an undated facility policy on Resident Rights stated that residents have a right to safe, decent, and clean conditions.

FACILITY<BR/>Medication Storage and Labeling<BR/>Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. <BR/>The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 of 2 medication carts that were reviewed for pharmacy services. <BR/>This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift. <BR/>The findings included:<BR/>During an observation and record review on 3/1/23 at 12:00 p.m., an inspection of the medication cart #1 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/7/23 - 2/12/23, 2/16/23, 2/19/23-2/21/23, 2/25/23-2/26/23, and 2/29/23-2/28/23. <BR/>During an observation and record review on 3/1/23 at 12:30 p.m., an inspection of the medication cart #2 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/2/23, 2/5/23, 2/7/23, 2/12/23, 2/18/23-2/20/23, and 2/24/23-2/26/23. <BR/>During an interview on 3/1/23 at 12:30 p.m., MA A for cart #2 stated she has been aware of the missing signatures and stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift. <BR/>During an interview on 3/1/23 at 12:40 p.m., LVN A stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift.<BR/>During an interview on 3/1/23 12:35 p.m., the ADON stated she has acknowledged the noncompliance and stated that it is not in compliance can be a detriment to the residents. <BR/>During an interview on 3/1/23 9:00 a.m., the Director of Nursing DON stated she has acknowledged the possible noncompliance and stated that if not in compliance that it can be a detriment to the residents. She has also stated, This is an issue and all the nurses have been consulted about signing the narcotic count sheet at the time of the count. <BR/>Record review of the facility's policy titled, Controlled Substances, no date, revealed, .12. At the end of Each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.

FACILITY<BR/>Medication Storage and Labeling<BR/>Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. <BR/>The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 of 2 medication carts that were reviewed for pharmacy services. <BR/>This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift. <BR/>The findings included:<BR/>During an observation and record review on 3/1/23 at 12:00 p.m., an inspection of the medication cart #1 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/7/23 - 2/12/23, 2/16/23, 2/19/23-2/21/23, 2/25/23-2/26/23, and 2/29/23-2/28/23. <BR/>During an observation and record review on 3/1/23 at 12:30 p.m., an inspection of the medication cart #2 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/2/23, 2/5/23, 2/7/23, 2/12/23, 2/18/23-2/20/23, and 2/24/23-2/26/23. <BR/>During an interview on 3/1/23 at 12:30 p.m., MA A for cart #2 stated she has been aware of the missing signatures and stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift. <BR/>During an interview on 3/1/23 at 12:40 p.m., LVN A stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift.<BR/>During an interview on 3/1/23 12:35 p.m., the ADON stated she has acknowledged the noncompliance and stated that it is not in compliance can be a detriment to the residents. <BR/>During an interview on 3/1/23 9:00 a.m., the Director of Nursing DON stated she has acknowledged the possible noncompliance and stated that if not in compliance that it can be a detriment to the residents. She has also stated, This is an issue and all the nurses have been consulted about signing the narcotic count sheet at the time of the count. <BR/>Record review of the facility's policy titled, Controlled Substances, no date, revealed, .12. At the end of Each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.