MULLICAN CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II for 1 of 3 residents (Resident #17) whose records were reviewed for mental disorders.<BR/>The facility failed to refer Resident #17 for a PASARR evaluation based on mental disorder diagnoses of Psychosis.<BR/>This deficient practice could affect residents with mental illness and contribute to a delay in services needed.<BR/>The findings included:<BR/> Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident #17's quarterly MDS assessment, dated 02/05/24, indicated Resident #17 was usually understood and sometimes understood by others. Resident #17's BIMs score was 15, which indicated he was cognitively intact. Resident #17 required extensive assistance with toileting, personal hygiene, transfer, and bathing. The MDS indicated he had a diagnosis of Schizophrenia and bipolar. <BR/>Record review of Resident #17's physician's orders dated 07/03/23 indicated, Quetiapine Fumarate Tablet 250 MG Give 1 tablet by mouth two times a day related to schizoaffective disorder, bipolar.<BR/>Record review of Resident #17's comprehensive care plan, dated 03/09/24 indicated Resident #17 required anti-psychotic medications for schizoaffective disorder. The interventions were to give medication as ordered.<BR/>Record review of Resident #17's PASRR Level 1 screening completed on 5/22/23 did not reflect Resident #17 had a diagnosis of Psychosis or an indicator that Resident #17 had a mental illness.<BR/>During an interview on 04/10/24 at 4:12 p.m., the MDS nurse stated when she started at this facility as the MDS nurse she did not have a lot of knowledge on PASARRs. She said she would call her regional nurse and see what she needed to do for Resident #17s PASARR. <BR/>During an interview on 04/10/24 at 5:57 p.m., the MDS nurse said she had called her regional nurse and she explained the process. She looked at Resident #17 chart and said he had a diagnosis of Psychosis which should trigger a referral for PASARR evaluation. She said she had filled out the 1012 form (Mental Illness/Dementia Resident Review) and the physician had signed it. She said she would get the form submitted for review to the local authority. <BR/>During an interview on 04/10/24 at 6:00 p.m., The Administrator said the MDS nurse was responsible to complete the level 2 if needed. He said a level 2 was done to determine to see if they could benefit from any services offered. He said if the PASRR Level 1 had a discrepancy it should have been corrected. He said a resident could lose on receiving services if the PASRR was not completed correctly.<BR/>During an interview on 04/10/24 at 6:04 p.m., the DON said the MDS nurses were responsible for the PASRR and she was not sure when a 1012 form was needed. She said Resident #17 did have a diagnosis of schizophrenia and bipolar which was considered a mental illness.<BR/>Review of a facility policy, titled, PASRR Level 1 Screen Policy and Procedure, dated 03/06/19, indicated, Policy: It is the policy of Creative Solutions in Healthcare facilities to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via Simple LTC timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with, and the training and therapy they need to live as independently as possible.<BR/>PASRR Program has 3 Goals:<BR/>1. To identify individuals with MI, ID, or DD/RC (this includes adults and children).<BR/>2. To ensure appropriate placement, whether in a community or in a NF.<BR/>3. To ensure individuals receive the required services for their MI, ID, or DD.<BR/>Procedure:<BR/>1. The Facility Admissions process will ensure a PL1 Screening Form is obtained from the RE on day of<BR/>admission or prior to admission. A PL1 is obtained for every individual, regardless of payment.<BR/>type, seeking admission to a Medicaid-certified NF.<BR/>2. The PL1 Screening Form is completed by the RE (referring entity) using the paper copy of the PL1 Screening Form. 3. The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. The Type of admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers, and DOB is correct. The Date of the PL1 is correct (i.e., correct day, month, and year), and review each item on the PL1 to ensure accuracy and prevent a regulatory problem. 4. The Facility will enter the PL1 Form exactly as written except for corrections to identifying data. It is critical to submit timely PL1s due to the following: It is the policy of this facility to ensure that all residents are screened and appropriately addressed via the PASARR process as outlined by regulations. The results of this process will be used to develop, review, and revise the resident's care plan. Procedures: 1. The facility's designated staff will review all potential admissions for possible positive PASARR conditions and ensure that CMS Preadmission guidelines are followed Review the PL1 Form for completion and correctness before admission. <BR/>Record review of facility policy titled, PASRR Nursing Facility Specialized Services Policy and Procedure, revised 3-6-19 indicated, Policy: It is the policy of Creative Solutions in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately. 1.PL1 is completed. 2.If PL1 is coded as suspicion of Ml, ID, or DD, then a PE is required. 3.The LA completes the PE and if Positive, a PCSP Initial Meeting is scheduled. 4.NF PCSP meetings scheduled within 14 days of admission and annually. Note: The Annual PCSP NF meeting must be at least 334 days from previous NF PCSP.

**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 was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #39) reviewed for treatment and services related to indwelling catheters. <BR/>The facility failed to ensure Resident #39's foley catheter was secured on 05/27/2025. <BR/>This failure could place residents at risk for urinary tract infections and a decreased quality of life. <BR/>Findings included:<BR/>Record review of a face sheet dated 05/28/2025 indicated Resident #39 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the prostate (prostate cancer) and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate which results in difficulty urinating). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #39 understood others and was understood. The MDS assessment indicated Resident #39 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #39 required supervision or touching assistance with toileting, showering/bathing, dressing, and personal hygiene. The MDS assessment indicated Resident #39 had an indwelling catheter (tube inserted into the bladder).<BR/>Record review of Resident #39's Order Summary Report dated 05/28/2025 indicated an order to ensure catheter strap was in place and holding every shift change as needed with a start date of 03/05/2025. <BR/>Record review of Resident #39's care plan last reviewed 05/27/2025 indicated he had an indwelling foley catheter. Resident #39's goal was for him to show no signs and symptoms of a urinary infection and remain free from catheter related trauma through the next review date. Resident #39's interventions included to ensure the tubing was anchored to his leg or linens so that the tubing was not pulling on the urethra (tube connects the urinary bladder to the external opening of the body). <BR/>During an observation and interview on 05/27/2025 at 9:58 AM, Resident #39 was in his wheelchair in his room. Resident #39 showed surveyor his foley catheter was not secured to his leg. Resident #39 said it had been unsecured for days. Resident #39 said he had reported it to the staff, but they still had not fixed it. <BR/>During an interview on 05/28/2025 at 8:39 AM, LVN C said she did not know why Resident #39's foley catheter was not secured. LVN C said the catheters are checked daily by the nurses to ensure they were secured. LVN C said if the catheter was not secured it could cause trauma to the urethra, the catheter could dislodge causing trauma, and the catheter could cause sores from it rubbing the penis. <BR/>During an interview on 05/29/2025 at 10:08 AM, the DON said the nurses, CNAs, and anybody giving care to the residents should be checking to ensure the foley catheters were secured. The DON said she had not noticed any issues with the foley catheters not being secured, and the nurses should be doing rounds to ensure they had the catheters secured. The DON said it was important for the foley catheters to be secured because they did not want them to pull it out and hurt their urethra. <BR/>During an interview on 05/29/2025 at 10:40 AM, the Administrator said Resident #39 should have an order for his foley catheter to be secured to his leg, and the nurse was responsible for ensuring it was secured. The Administrator said it was important for the foley catheter to be secured to keep it flowing correctly and where it needed to be, so it was not tugging. <BR/>Record review of the facility's undated policy titled, Catheter Care, indicated, Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. The policy did not further address securement of the foley catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 6 residents (Resident #28) reviewed for pharmacy services.<BR/>The facility failed to ensure RN A accurately reconciled Resident #28's narcotic medication log when she disposed Resident #28's clonazepam (controlled medication used for anxiety) tablet on 05/27/25. <BR/>This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. <BR/>Findings included:<BR/>Record review of Resident #28's face sheet dated 05/28/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included anxiety and gastrostomy status (surgical opening into the stomach for nutritional support and medication administration). <BR/>Record review of Resident # 28's quarterly MDS assessment dated [DATE], indicated she was rarely/never understood and usually understood others. Resident #28 had short/long term memory problems and her cognition was severely impaired. Resident #28 was dependent on staff on all ADLs and had a feeding tube. The MDS assessment indicated Resident #28 had received an antianxiety medication during the 7-day look back period.<BR/>Record review of Resident #28's comprehensive care plan revised on 12/19/23, indicated she used antianxiety medications. The care plan interventions included to administer anti-anxiety medications as ordered by the physician.<BR/>Record review of Resident #28's order summary report dated 05/28/25, indicated she had an order for clonazepam 0.5mg give one tablet via g-tube two times a day related to anxiety with a start date of 10/20/24. <BR/>Record review of Resident #28's treatment administration record dated 05/01/25-05/31/25, indicated Resident #28 had received one tablet of clonazepam 0.5mg daily at 7:00 AM and 3:00 PM.<BR/>During an observation and interview on 05/27/25 at 3:23 PM, RN A opened the narcotic box located on the nurse's medication cart and removed one tablet of Clonazepam 0.5mg from the medication card. RN A crushed the tablet and poured it in a medicine cup. RN A proceeded to apply PPE and administer Resident #28's clonazepam via her gastrostomy tube. RN A obtained the narcotic book from under the nurse's station and signed off the clonazepam tablet she administered. There was only 1 tablet of clonazepam 0.5mg left in the medication card. The narcotic record indicated Resident #28 should have had 2 tablets of Clonazepam 0.5mg tablets remaining. When asked how come the narcotic record indicated there should have been 2 tablets remaining, RN A said she was fixing to administer the tablet when she remembered the state surveyor wanted to observe the medication being administered so she disposed the tablet. RN A said she did not get a witness to the disposal of the medication because she had already disposed the medication and she had panicked. RN A said she had just started at the facility 3 days ago and did not know the policy on narcotic medication disposal. RN A said at previous facilities she was responsible for obtaining a witness when she disposed the clonazepam tablet and failure to do so was a discrepancy. <BR/>During an interview on 05/29/25 at 09:13 AM, the DON said she expected a witness be obtained when narcotic medications were being disposed. She said the nurse was responsible to get a witness while they were wasting the medication and not after. She said failure to have a witness would lead to a drug diversion. <BR/>During an interview on 05/29/25 at 09:20 AM, the Administrator said when narcotic medications were disposed, there should be a witness. He said the nurse and nursing administration were responsible for ensuring a witness was obtained when disposing a narcotic medication. He said failure to obtain a witness could lead to a drug diversion. <BR/>Record review of the facility's undated policy Controlled Medications- Administration, indicated . Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. 6. When a controlled medication is administered, the license nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration, amount administered, signature of the nurses administering the dose, completed after the medication is actually administered. 7. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. If allowed by your state, they may be destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 16 residents reviewed for laboratory services (Residents #4). <BR/>The facility failed to obtain Resident #4's Keppra level (level obtained to ensure medication is in therapeutic range) as ordered.<BR/>This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.<BR/>Findings included:<BR/>Record review of Resident #4's face sheet dated 05/28/25 indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included dementia (memory loss) and epilepsy (seizures).<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated she was usually understood and usually understood others. The MDS assessment indicated she had a BIMs score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #4 had a seizure disorder or epilepsy and had taken anticonvulsant medication within the 7-days of the look back period. <BR/>Record review of Resident #4's comprehensive care plan revised on 04/27/21, indicated Resident #4 had a seizure disorder and was at risk for injury. The care plan interventions included to monitor labs and report any subtherapeutic or toxic results to the medical director. <BR/>Record review of the Resident #4's hospice admission orders dated 02/22/25, indicated . DC routine labs except Keppra level as ordered.<BR/>Record review of Resident #4's order summary report dated 05/28/25, indicated she had the following orders:<BR/>Keppra level every 3 months. **[Hospice] no further labs without prior approval** with an order date of 02/22/25.<BR/>Keppra 500mg give one tablet 2 times a day related to epilepsy with an order start date of 11/05/24.<BR/>Record review of Resident #4's progress notes dated 04/28/25-05/29/25, did not indicate Resident #4 had any seizures. <BR/>Record review of Resident #4's medication administration record dated 05/01/25-05/31/25, indicated she had received one tablet of Keppra 500mg tablet twice daily in the morning and at night.<BR/>Record review of Resident #4's lab results dated 02/13/25, indicated Resident #4's Keppra level was 35.1 and within therapeutic range. <BR/>Record review of Resident #4's lab requisition dated 02/23/25, indicated to discontinue standing orders of HGBA1C, CBC, CMP, and Lipid. The lab requisition did not indicate to discontinue the Keppra level. <BR/>Record review of Resident #4's lab order report dated 05/06/25 for the Keppra level indicated . cancelled order . draw later- third party with the cancellation reason d/c all labs due to hospice 04/18/25.<BR/>During an interview on 05/28/25 at 10:01 AM, the Regional Compliance Nurse said they did not have the Keppra level for the Month of May. She said they were redrawing today 05/28/25. She said the lab was cancelled by a third party as per the lab report printed from the lab site. She said she was unsure of how it was cancelled.<BR/>During an interview on 05/29/25 at 1:50 PM, the Phlebotomist/Processor of the lab company said the phlebotomist assigned to the facility was not available. She said when a lab was preordered, it was listed on the draw report sheet. She said the assigned technician for day would print the draw report sheet, obtain those labs listed and any new labs the facility had completed a requisition for. She said when a lab was cancelled, the requisition with the request to cancel the labs listed was completed. The lab processor said there was a miscommunication somewhere where they were told to discontinue all labs with no clarification the Keppra was to be continued. She said the facility and the lab company were responsible for ensuring the labs were obtained as orders. She said failure to obtain the lab as ordered placed the resident at risk for her levels not to be within range.<BR/>During an interview on 05/29/25 at 09:13 AM, the DON said she when the lab requisition was filled out to discontinue Resident #4's lab the Keppra level was not included. The DON said Resident #4 was on hospice and the Keppra level was the only lab the hospice continued. The DON said Resident #4 had not had any seizures. The DON said she was unsure as to how the lab delayed the lab draw that day. She said failure to obtain the Keppra level as ordered could cause Resident #4 to have a seizure or her level would not be within therapeutic range. The DON said the nurse was responsible for ensuring the labs were drawn as ordered. The DON said nursing administration should have gone behind the nurse to check the lab was obtained as well. <BR/>During an interview on 05/29/25 at 09:20 AM, the Administrator said he expected labs to be obtained as ordered. The Administrator said the nurse and nursing administration were responsible for ensuring labs were obtained and labs were not missed. He said the risks depended on lab being drawn. He said by not obtaining Resident #4's Keppra level could place Resident #4 at risk for her levels to be out of therapeutic range. <BR/>During an interview on 05/28/25 at 2:12 PM, the Regional Compliance Nurse said they did not have a policy on labs.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 17 residents (Residents #15, #3 and #23) reviewed for palatable food. <BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was served cold and did not taste good for Residents #15, #3, and #23. <BR/>This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>Findings include:<BR/>1. During an interview on 02/13/2023 at 10:54 a.m., Resident #15 stated the food was lousy and did not have enough flavor. Resident #15 stated she reported this to staff but could not recall their names. <BR/>2. During an interview on 02/13/2023 at 3:08 p.m., Resident #3 stated the meat was tough. Resident #3 stated sometimes the aides could not even cut the meat up for her. <BR/>3. During an interview on 02/13/2023 at 3:10 p.m., Resident #23 stated the food was nasty. Resident #23 stated, It looks like somebody chewed it up and spit it out. Resident #23 stated she reported this to staff but could not recall their names. <BR/>4. During an observation and interview on 02/14/2023 at 12:52 p.m., a lunch tray was sampled by the Dietary Manager and five surveyors. The sample tray consisted of barbecue chicken, baked beans, coleslaw, tangerine oranges, and a roll. The Dietary Manager stated the appearance could have been neater and a smaller piece of chicken. The Dietary Manager stated the barbecue chicken was cold, bland, and dry. The Dietary Manager stated the baked beans was cold, coleslaw tangy taste, and the tangerine oranges was bland. The Dietary Manager stated the roll was cold and cooked to long at the bottom. <BR/>During an interview on 02/16/2023 at 11:47 a.m., CNA N stated residents complained to her daily about the food being cold, not seasoned, and overcooked. CNA N stated she offered the residents an alternative when they complained to her. CNA N stated all food complaints were reported to the charge nurse. CNA N stated residents not eating their food could potentially cause weight loss. <BR/>During an interview on 02/16/2023 at 12:22 p.m., CNA O stated residents complained to her about the food being cold, not seasoned, and overcooked. CNA O stated Resident #23 had complained to her and stated the food was nasty. CNA O stated residents were offered an alternative. CNA O stated all complaints were reported to the dietary staff. CNA O was unable to recall names. CNA O stated the failure could potentially put residents at risk for weight loss. <BR/>During an interview on 02/16/2023 at 12:40 p.m., RN P stated residents had complained to her about the food. RN P stated staff also had reported to her that residents complained about the food. RN P stated when staff or residents reports to her about the food, she ensures the residents was offered an alternative. RN P stated she had never reported the issue to anyone. RN P stated she should have reported complaints to the Dietary Manager. RN P stated this failure could potentially put residents at risk for weight loss. <BR/>During an interview on 02/16/2023 at 2:47 p.m., the Dietary Manager stated residents and staff had complained to her about the food. The Dietary Manager stated some of the complaints where the food was cold or lack of flavor. The Dietary Manager stated most of the complaints are noted during resident council. The Dietary Manager stated she visits with residents randomly to see if there were any complaints with the food. The Dietary Manager stated she random goes behind the cooks to ensure the temperature was at the correct settings. The Dietary Manager stated if there were any issues, staff was verbally in-serviced immediately. The Dietary Manager stated test trays were done once a month with the dietician. The Dietary Manager stated she had not complained about the temperature or flavor. The Dietary Manager stated residents not eating their food could potentially cause weight loss or death. <BR/>During an interview on 02/16/2023 at 5:56 p.m., the Administrator stated she expected all food to be palatable and at the correct temperature. The Administrator stated she had received complaints about the meat being too tough. The Administrator stated an alternative was offered. The Administrator stated a test tray was done randomly to ensure the food was palatable and at the correct temperature. The Administrator stated there was no issues noted with the test tray. The Administrator stated residents not eating their food could potentially cause weight loss or decrease in their independence. <BR/>Record review of the Food and Nutrition Services policy, last revised on 10/2017, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal was provided to each resident, the food appears palatable and attractive, and it was served at a safe and appetizing temperature .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure:<BR/>1. Food items were dated and labeled. <BR/>2. Expired food item was discarded.<BR/>3. The ice machine was clean and free from debris <BR/>4. K-Quat (sanitation) test strips were not expired<BR/>5. The juice machine spigot was clean<BR/>6. The toaster was clean and free of food debris.<BR/>7. The cooking grease in the deep fryer was kept clean.<BR/>8. The deep fryer was free of grease build up.<BR/>These failures could place residents at risk for foodborne illness.<BR/>Findings include:<BR/>1. During an observation in the refrigerators and freezers on 02/13/2023 starting at 11:20 a.m. revealed a plastic storage bag labeled ham with an opened date 02/02/2023 and used by date 02/09/2023; plastic storage bag that was identified by the Dietary Manager as sliced ham undated; 5 lb. container labeled tuna salad undated; plastic bag identified by the Dietary Manager as hamburger patties. <BR/>2. During an observation in the dry storage room on 02/13/2023 starting at 11:38 a.m. revealed two packages of hamburger buns undated. <BR/>3. During an observation in the kitchen on 02/13/2023 at 11:42 a.m., revealed the toaster with food particles, grease buildup around the deep fryer, and dark brown grease noted inside the deep fryer, red gooey substance observed on the juice machine spigot, and K-Quat sanitation solution test strips with an expiration date of 11/01/2022. <BR/>4. During an observation on the A/B Hall on 02/13/2023 at 12:09 p.m., revealed an ice machine with a white liquid substance on the exterior part of the machine. The ice scoop container had a white substance noted inside. <BR/>During an observation and interview on 02/16/2023 at 10:53 a.m., the Housekeeping Supervisor stated her staff was responsible for cleaning the exterior of the ice machine. The Housekeeping Supervisor observed with the surveyor the exterior of the ice machine and the container that hold the scoop. The Housekeeping Supervisor agreed they both needed to be cleaned. The Housekeeping Supervisor stated it should be cleaned once a week. The Housekeeping Supervisor stated the last time it was cleaned was last week by her. The Housekeeping Supervisor stated she was unaware that her staff was responsible for cleaning the scoop container until surveyor intervention. The Housekeeping Supervisor stated this failure could put residents at risk for a food-borne illness. <BR/>During an interview on 02/16/2023 at 2:37 p.m., [NAME] S stated all kitchen staff were responsible for labeling, dating food products, discarding items prior to the expiration date, and cleaning the juice machine spigot, and toaster. [NAME] S stated the fryer grease should be changed weekly and the grease buildup should be cleaned daily. [NAME] S stated these failures could potentially cause a food-borne illness.<BR/>During an interview on 02/16/2023 at 2:47 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so her staff are not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager said all food should be labeled with date received and the date it was opened. The Dietary Manager stated when the food truck comes and delivers, whoever touched the item should label and date the item. The Dietary Manager stated all kitchen staff were responsible for ensuring the toaster, juice spigot and the fryer grease buildup was cleaned daily. The Dietary Manager stated all staff were responsible for ensuring expired items were discarded daily. The Dietary Manager stated the grease should be changed weekly. The Dietary Manager stated due to being short staff on 02/13/2023, these issues were not addressed. The Dietary Manager stated she was responsible for ensuring the test strips was not expired. The Dietary Manager stated she was unaware the test strips were expired until surveyor intervention. The Dietary Manager stated she did daily rounds during the day and address any issues. The Dietary Manager stated she has had issues in the past and tried to address them daily by verbal reminders. The Dietary Manager stated she did not have a cleaning schedule prior to surveyor intervention. The Dietary Manager stated the last in-service besides the verbal reminders was about three months ago. The Dietary Manager stated these failures could potentially cause a food borne illness or cross contamination. <BR/>During an interview on 02/13/2023 at 5:56 p.m., the Administrator stated she expected the kitchen to be clean and staff preventing cross contamination. The Administrator stated he expected all food to be labeled and dated. He said food items should be discarded prior to the expiration date. The Administrator stated the toaster should be cleaned after every use. The Administrator stated the juice machine spigot should be cleaned nightly and the grease should be changed weekly. The Administrator stated the exterior part of the ice machine, and the scoop container should be cleaned daily. The Administrator stated she did superficial rounds to ensure the logs was up to date, cleanliness, and overall appearance. The Administrator stated she inspected the refrigerator at least twice a week. The Administrator stated the last time she inspected was last week and did not notice any issues. The Administrator stated she inspected the ice machine at least once a week. The Administrator stated these failures could potentially cause a food borne illness.<BR/>Record review of the Refrigerators and Freezers policy, last revised on 12/2014, revealed this facility will ensure safety refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines 7. All food shall be appropriately dated to ensure proper rotation by expiration dates, Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food was opened. <BR/>Record review of the Food Receiving and Storage policy, last revised on 10/2017, revealed food shall be received and stored in a manner that complies with safe food handling practices . 1. Food services, or designated staff, will maintain clean food storage areas at all times. 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 staff (LVN T) reviewed for infection control.<BR/>The facility failed to ensure LVN T performed hand hygiene while checking blood sugars for Resident #2 and Resident #7 and when administering insulin to Resident #7. <BR/>This failure could place residents and staff at risk for cross-contamination and the spread of infection. <BR/>Findings included:<BR/>During an observation on 02/13/2023 at 3:56 PM, LVN T put on a pair of gloves and went into Resident #2's room to check her blood sugar. LVN T came out of Resident #2's room with the gloves still on and removed them at the medication cart and started charting on her tablet (used for documentation of medications). LVN T did not perform hand hygiene after glove removal. After this, LVN T put on gloves and went into Resident #7's and checked her blood sugar. LVN T came out of Resident #7's room and removed the gloves at the medication cart. LVN T did not perform hand hygiene after removing her gloves. LVN T prepared insulin and put on another pair of gloves and administered the insulin to Resident #7. LVN T came out of the room and removed her gloves at the medication cart and did not perform hand hygiene. <BR/>During an interview on 02/13/2023 4:03 PM, LVN T stated she should have performed hand hygiene before and after glove removal. LVN T stated she did not perform hand hygiene because there was no hand sanitizer. LVN T stated she did not have any hand sanitizer on her medication cart. LVN T stated she had looked and was not able to find any hand sanitizer in the facility. LVN T stated, I do not know who I have told about it, referring to not being able to find any hand sanitizer. LVN T stated performing hand hygiene was important for infection control and to prevent cross contamination. <BR/>During an interview on 02/16/2023 at 9:28 AM, Medical Records Staff Z stated she was responsible for ordering supplies. She stated she ordered the hand sanitizer a case a month, and that she was aware, the facility always had hand sanitizer available for the staff. <BR/>During an interview on 02/16/2023 at 11:48 AM, LVN B stated hand sanitizer was readily available for the staff and she had never struggled to get any hand sanitizer. LVN B stated it was important to perform hand hygiene to prevent the spread of infection.<BR/>During an interview on 02/16/2023 at 6:37 PM, the infection control preventionist stated staff should perform hand hygiene before and after providing care, before putting on gloves and after taking gloves off. The infection control preventionist stated the staff could do alcohol-based hand sanitizer up to 3 times when checking blood sugars and then they would have to perform hand hygiene with soap and water. The infection control preventionist stated she did check offs on random staff for hand hygiene every 6 weeks. The infection control preventionist stated it was important to perform hand hygiene to cut down on bloodborne pathogens, for the staff to protect themselves and the residents. The infection control preventionist stated not performing hand hygiene placed the residents at risk for COVID, germs and any bloodborne pathogen. The infection control preventionist stated no staff member had ever reported to her there was no hand sanitizer available that the facility always had hand sanitizer available. <BR/>During an interview on 02/16/2023 at 7:15 PM, the ADON stated hand hygiene should be performed before all care, before entering a room, when hands were soiled, before putting on gloves and after removing gloves. The ADON stated all staff were responsible for performing hand hygiene. The ADON stated anytime she walked on the floor she watched staff to see if they were performing hand hygiene. The ADON stated it had not been reported to her that there was no hand sanitizer available. The ADON stated that she knew of the facility always had hand sanitizer available for the staff. The ADON stated not performing hand hygiene placed the residents at risk for the spread of infection. <BR/>During an interview on 02/16/2023 at 8:07 PM, the DON stated hand hygiene should be performed prior to resident interaction, after providing care, and after removal of gloves. The DON stated LVN T should have performed hand hygiene after removing her gloves, while checking blood sugars and administering insulin. The DON stated all the staff knew they were supposed to perform hand hygiene. The DON stated she did spot checks to check for staff performing hand hygiene. The DON stated the facility had never not had hand sanitizer, if they were to get low, she would go to the store and buy some. The DON stated not performing hand hygiene placed the residents at risk for cross contamination. <BR/>During an interview on 02/16/2023 at 9:03 PM, the administrator stated she expected all the staff to perform hand hygiene. The administrator stated the DON was ultimately responsible for ensuring the staff were performing hand hygiene. The administrator stated not performing hand hygiene was an infection control issue. <BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, last revised on August 2019, revealed, The facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); F. Before donning sterile gloves . m. After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 3 of 17 residents (Residents #7, #47 and #45) reviewed for grievances. <BR/>1. The facility did not ensure a grievance was file for Resident #7 when three pair of shoes was not returned from the laundry. <BR/>2. The facility did not ensure a grievance was file for Resident #47 when a multicolored dress, a pair of socks, and a head band was not returned from the laundry. <BR/>3. The facility failed to file a grievance for Resident #45 when a jacket and green matching sweatshirt and pants was not returned from the laundry. <BR/>4. The facility failed to ensure the grievances for Residents #7, #47, and #45 were resolved until after surveyor interventions.<BR/>These failures could place residents at risk for grievances not being addressed or resolved promptly.<BR/>Findings include: <BR/>1.Record review of Resident #7's order summary report, dated 02/16/2023, indicated Resident #7 was a [AGE] year-old-female, originally admitted to the facility on [DATE] with a diagnosis which included congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and essential hypertension (high blood pressure). <BR/>Record review of Resident #7's annual MDS, dated [DATE], indicated Resident #7 usually understood others and usually made herself understood. The assessment indicated Resident #7 was cognitively intact with a BIMS score of 14. <BR/>Record review of Resident #7's undated care plan did not address Resident #7 missing personal property.<BR/>During an interview on 02/14/2023 at 3:15 p.m., Resident #7 stated she had three pairs of shoes missing. Resident #7 stated she had reported the missing items to the Housekeeping Supervisor last year, unable to recall exact date. Resident #7 stated she still had not received the shoes. <BR/>2. Record review of Resident #47's order summary report, dated 02/16/2023, indicated Resident #47 was a [AGE] year-old-female, admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (high blood pressure), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of Resident #47's annual MDS, dated [DATE], indicated Resident #47 understood others and made herself understood. The assessment indicated Resident #47 was cognitively intact with a BIMS score of 15. <BR/>Record review of Resident #47's undated care plan did not address Resident #47 missing personal property.<BR/>Record review of the facility's grievances dated October 2022-Febraury 2023 did not reveal a grievance for Residents #47 and #7 missing personal property. <BR/>During an interview on 02/13/2023 at 3:46 p.m., Resident #47 stated she had a multicolored dress, a pair of socks, and a head band missing. Resident #47 stated she had reported the missing items to the Housekeeping Supervisor. Resident #47 stated she still had not received the items. <BR/>During an interview on 02/16/2023 at 10:53 a.m., the Housekeeping Supervisor stated Resident #47 reported to her, she was missing a dress, a pair of socks and a head band. The Housekeeping Supervisor stated she went through all of the closets in the facility to see if the items were located in someone else closet. The Housekeeping Supervisor stated after she could not locate the shoes, she reported the missing items during the morning meeting the following day. The Housekeeping Supervisor could not recall the exact the date but believed it was three months ago. The Housekeeping Supervisor stated she assumed after reporting the missing items during morning meeting it was handled by the DON. The Housekeeping Supervisor stated Resident #7 reported to her, she was missing two pairs of shoes. The Housekeeper Supervisor stated she had just become the supervisor, so she went and asked the DON what the process on handling lost items was. The Housekeeper Supervisor stated the DON told her she will be replacing the shoes. The Housekeeper Supervisor stated after being told by the DON the items would be replaced, she assumed the issue was taken care of. The Housekeeping Supervisor stated this failure could make residents feel their rights were not taken into consideration.<BR/>During an interview on 02/16/2023 at 4:21 p.m., the DON stated prior to 02/13/2023 she had not received any information about Resident #47 having any missing property. The DON stated if a resident/staff reported to her, a grievance form would be completed, and she would assign a staff member to start looking for those items. The DON stated if the items were not located, they should have been replaced. The DON stated a staff member reported to her Resident #7 was missing three pair of shoes. The DON was unable to recall the staff name. When asked when the missing items was reported to her, she stated I don't know. The DON stated she did not remember specifically filling out a grievance form. The DON stated the social worker should have been assign but she could not remember. When asked why the shoes were not replaced, she stated I don't know why the shoes wasn't replaced. The DON stated this failure could make residents feel their rights were not taken into consideration.<BR/>During an interview on 02/16/2023 at 5:56 p.m., the Administrator stated she was the grievance officer. The Administrator stated the grievance would be investigated by the department head related to the specific compliant. The Administrator stated complaints and grievances were discussed during the morning management meetings. The Administrator stated Resident #7 complained about missing her shoes around October 2022. The Administrator stated it was bought to the morning meeting and the DON stated, I'm getting on amazon now to purchase them. The Administrator stated she did not follow up to see if the shoes were actually ordered. The Administrator stated she was not aware of Resident #47's missing items. The Administrator stated the person that Resident #47 reported to was responsible for reporting it to her. The Administrator stated after being educated by the corporate team a grievance form should be completed on anything that was brought to her attention. The Administrator stated she felt like there was a system in place, but it was not a successful one. The Administrator stated this failure could make residents feel their rights were not taken into consideration.<BR/>3. Record review of Resident #45's face sheet, dated 02/16/2023, revealed Resident #45 was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation (lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus with unspecified complications (high blood sugars), and schizoaffective disorder, bipolar type (mental disorder that causes abnormal thought processes and unstable mood). <BR/>Record review of the quarterly MDS assessment with an assessment reference date of 12/24/2022, revealed Resident #45 was understood and understood others. The MDS assessment revealed Resident #45 had a BIMS score of 15, indicating she was cognitively intact. <BR/>Record review of the facility's grievances did not reveal a grievance for Resident #45's missing jacket and green matching sweatshirt and pants. <BR/>During an interview on 02/14/2023 at 11:24 AM, Resident #45 stated she was missing a black jacket and a green matching sweatshirt and pants. Resident #45 stated the clothes had gone to the laundry and were not brought back. Resident #45 stated this happened last week and she had told Laundry Aide R and Laundry Aide Q, and they had not been able to find the missing items. <BR/>During an interview on 02/14/2023 at 3:53 PM, the Housekeeping/Laundry Supervisor stated she was not aware Resident #45 was missing a jacket and a green matching sweatshirt and pants. The Housekeeping/Laundry Supervisor stated if there were missing clothing items the laundry aides were supposed to notify her. The Housekeeping/Laundry Supervisor stated when she was notified of a missing clothing item that was not found she would report it in the morning meetings, and they decided what to do from there. The Housekeeping/Laundry Supervisor stated it was important for the residents' clothes to be returned to them because they should have their stuff and they paid for it. <BR/>During an interview on 02/14/2023 at 4:10 PM, Laundry Aide R stated Resident #45 had not reported to her that she was missing a black jacket and a green matching sweatshirt and pants. Laundry Aide R stated if residents were missing clothing items, she would report it to the Housekeeping/Laundry Supervisor. <BR/>During an interview on 02/14/2023 at 4:15 PM, Laundry Aide Q stated Resident #45 had reported to her last week that she was missing a jacket and a green matching sweatshirt and pants. Laundry Aide Q stated she had been looking for the missing items but had not been able to locate them. Laundry Aide Q stated she told the housekeeping/laundry supervisor she could not find the items. Laundry Aide Q stated if she could not find an item, she would report it to the Housekeeping/Laundry Supervisor, and the Housekeeping/Laundry Supervisor would handle it from there. Laundry Aide Q stated the residents' clothes not being returned to them could make them sad and unhappy, and it was their belongings and they deserved to have them. <BR/>During an interview on 02/14/2023 at 5:26 PM, the administrator stated usually social services was responsible for the grievances, but the facility currently did not have a social worker. The administrator stated she had taken over the grievances while the facility did not have a social worker The administrator stated, Grievances are only for misappropriation or something that I cannot fix then and there, if it is an abuse allegation I do a self-report, if it is laundry missing, I do not fill out a grievance form. The administrator stated she was not aware of Resident #45 missing a jacket and a green matching sweatshirt and pants.<BR/>During an interview on 02/15/2023 at 8:50 AM, the administrator stated she looked at the facility's policy for grievances, and when someone notified her of missing clothing items, she should fill out a grievance form. <BR/>During an interview on 2/16/23 at 6:49 PM, the ADON stated if a resident reported missing clothes staff should go to the laundry and ask them if it was there, and if it was not immediately found a grievance should be filed. The ADON stated, I think any of us can file a grievance and then the administrator does the investigation. The ADON stated no residents had reported to her that they were missing laundry. The ADON stated it was important to file grievances to ensure there was follow up and that the issue was addressed. <BR/>During an interview on 2/16/23 at 7:34 PM, the DON stated if a resident notified her, they were missing an item she would find out what the item was and start searching for it. The DON stated, Anybody could write up a grievance. The DON stated she was not aware Resident #45 was missing a jacket and a green matching sweatshirt and pants. The DON stated a grievance should have been written for Resident #45's missing clothing items. The DON stated it was important to fill out grievance forms so they could keep track of what was going on and get back with the residents and replace the items if necessary. The DON stated in their morning meetings daily they discussed if residents were missing items. <BR/>Record review of the facility's policy titled, Grievances/Complaints-Staff Responsibility, last revised May 2017, revealed, Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. Policy Interpretation and Implementation 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative (sponsor), or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents etc., the staff member is encouraged to guide the resident, or person acting on the resident's behalf as to how to file a written complaint with the facility. 2. Staff members will inform the resident or the person acting on the resident's behalf that he or she may file a grievance or complaint with the Administrator or other government agencies as noted on the resident's bulletin board, without fear of threat or any other form of reprisal. 3. Staff members will inform the resident or the person acting on the resident's behalf as to where to obtain a Resident Grievance/Complaint Form and where to locate the procedures for filing a grievance or complaint (e.g., posted on the residents' bulletin board) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit abuse and neglect for 1 of 15 residents reviewed for abuse. (Residents #1)<BR/>The facility failed to report\per policy to the state agency within 2 hours of Resident #1's allegations of abuse.<BR/>This failure could place residents at risk of unreported abuse, neglect, and exploitation. <BR/>Findings included:<BR/>Record review of facility's Policy for Abuse and Neglect with a revised date of 03/29/2018 indicated:<BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart <BR/>e. Reporting <BR/>Any person having reasonable cause to believe, and elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services .<BR/>Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type (feelings of euphoria, racing thoughts, increased risky behavior and symptoms of mania). The face sheet also indicated Resident #1 was his own responsible party. <BR/>Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 15 which indicated Resident #1 was cognitively intact. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing.<BR/>Record review of a witness statement dated 08/01/2023 signed by the ADON indicated Resident #1 made repeated allegations of abuse stating, she's abusing me, don't tell [the ADON] anything - she's abusing me and stop yelling at me [ADON].<BR/>During an interview on 03/27/2024 at 3:08 PM, Resident #1 said the DON and ADON were mean to him. Resident #1 said the DON and ADON would get mad at him when he felt weak from Parkinson's and needed extra help. <BR/>During an interview on 04/01/2024 at 10:35 AM, the ADON said the incident involving the witness statement dated 08/01/2023 was not reported to state because it was not abuse. The ADON said the Administrator at the time told her to document the incident. The ADON said she did not know why the Administrator wanted her to write the statement. The ADON stated all allegation of abuse should be reported to the Abuse Coordinator and the DON if the abuse coordinator is not available to prevent harm to residents.<BR/>During an interview on 04/02/2024 at 11:15 AM, the DON said she had not seen the written witness statement dated 08/01/2023 before. The DON said she was not present when the situation occurred but later had heard about it and did not feel it was reportable. The DON said the importance of reporting allegations is for proper investigations to be conducted to protect the residents. <BR/>During an interview on 04/02/2024 at 01:10 PM, LVN A said he was the Administrator for the facility from April - September 2023. LVN A said he could not recall if he asked the ADON to write the witness statement dated 08/01/2023. LVN A said Resident #1 had not reported any history of abuse in the past with the ADON. LVN A said he was not able to answer if the incident should have been reported as an allegation of abuse because to many variables and he could not remember what was happening at that exact time. LVN A stated any allegations of abuse should be reported to the Administrator (Abuse Coordinator). When the Abuse Coordinator is not available, the staff should report to the DON. LVN A stated all abuse allegation should be reported to the state no later than 24 hours. LVN A said investigation should be completed to protect the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, and neglect, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 17 residents (Resident #7) reviewed for abuse.<BR/>The facility failed to acknowledge, investigate, and report neglect to the state agency on behalf of Resident #7.<BR/>This failure could place residents at risk for neglect due to unreported and uninvestigated allegations of neglect.<BR/>Findings include:<BR/>Record review of Resident # 7's face sheet, dated 02/16/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include: cerebral infarction, ( a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off.) hemiplegia (paralysis) and hemiparesis one?sided weakness following cerebral infarction affecting unspecified side, muscle weakness, lack of coordination, muscle wasting atrophy ( thinning or loss of muscle tissue), need for assistance with personal care, incontinent (having no or insufficient voluntary control over urination or defecation).<BR/>Record review of Resident # 7's comprehensive MDS assessment, dated November 26, 2022, revealed Resident #7's BIMS score was 14, which indicated cognition intact. Resident #7 required extensive assistance with two persons physical assist for bed mobility, transfers, dressing, and toileting. Resident #7 could make her needs known and could be understood. Section H 0300, urinary continence, indicated Resident #7 was always incontinent. Section H 0400, bowel continence, indicated Resident #7 was always incontinent. Section E0800, rejection of care, indicated Resident #7 did not refuse care. <BR/>Record review of Resident #7's care plan, with a revision date of 12/16/2022, indicated Resident #7 had a potential impairment to skin integrity related to decreased mobility and incontinence. The care plan interventions included, keep skin clean/dry, identify/document potential causative factors and eliminate/resolve where possible. <BR/>Record review of Resident #7's progress note dated 02/13/2023, revealed Resident reported to this nurse upon entry to room at ac (before) breakfast blood sugar that CNA previous night shift was refusing this resident ADL care. Day shift arrived and provided care to resident. This nurse reported allegations to Administrator. Progress note was signed by LVN B on 02/13/2023 at 8:30 AM.<BR/>During an interview on 02/14/23 10:03 AM, Resident #7 stated she pressed her call light and the CNA for the night came to her room. Resident #7 said the CNA came into the room and asked Resident #7, what now. Resident #7 stated the CNA spoke to her rudely. Resident #7 stated she asked, Can I get changed please, and the CNA said No, I just changed you an hour ago and slammed the door and left and she did not come back. Resident #7 said she waited about 35 minutes and then turned the call light back on. Resident #7 stated the CNA worked 2-10 or 10-6 and she was afraid of her. Resident #7 stated she reported this to LVN B on the morning of 02/13/2023. Resident #7 was unable to provide the CNA's name.<BR/>During an interview on 02/16/23 at 11:46 AM, LVN B stated Monday (02/13/23) morning Resident #7 told her that the aide refused to change her. LVN B stated the CNA had gone into Resident #7's room and told her she would not change her. LVN B stated Resident #7 was unable to give her a name for the CNA just said it was the night CNA. LVN B said she immediately reported it to the administrator, who was the abuse coordinator. LVN B stated it was important to report abuse and neglect to protect the residents and their rights because the facility was their home. <BR/>During an interview on 02/16/23 at 8:33 PM, the DON stated she was not aware Resident #7 had reported to LVN B the CNA refused to provide ADL care on Sunday night (02/12/23). The DON stated she had done in-services in the past on reporting allegations of abuse and neglect to the administrator, and if the administrator was not available to report it to her. The DON stated if she received any allegations of abuse or neglect, she would first investigate it and then determine if it should be reported. The DON stated it sounds like it could have been reported regarding Resident #7's allegations, but she needed more information. The DON stated Resident #7's allegations not being reported could place her at risk for impaired skin integrity and it could cause Resident #7 emotional distress. <BR/>During an interview on 02/16/23 at 9:29 PM, the administrator stated she was not aware Resident #7 had reported to LVN B the CNA refused to provide ADL care on Sunday night (02/12/23). The administrator said LVN B did not report to her that Resident #7 had notified her a CNA refused to provide ADL care on Sunday night (02/12/23). The administrator said LVN B should have reported Resident #7's allegations to her immediately so that she could have investigated and reported the allegation. The administrator said she expected the staff to report all allegations of abuse or neglect to her immediately. The administrator said the allegations not being reported could harm the resident and her skin and was a dignity issue. <BR/>A record review of the facility's April 2021, Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating policy revealed, policy statement: all reports of resident abuse (including the injuries of unknown origin), neglect, exploitation, or theft misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. findings of all investigations are documented and reported. Policy interpretation and implementation: Reporting allegations to the Administrator and authorities: If a resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected; the suspicion must be reported immediately to the administrator and to other officials according to state law. the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing certification agency responsible for surveying licensing the facility; the local state ombudsman; the residents representative; the residents attending physician; the facility's medical director; adult Protective Services; law enforcement; immediately is defined as within two hours of an allegation involving abuse or results in serious bodily injury or within 24 hours of an allegation that does not involve abuse or results in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 3 residents (Residents #1) reviewed for transfer and discharge.<BR/>The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. <BR/>This failure could place residents at risk of improper discharge planning and diminished quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type (feelings of euphoria, racing thoughts, increased risky behavior and symptoms of mania). The face sheet also indicated Resident #1 was his own responsible party. <BR/>Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 15 which indicated Resident #1 was cognitively intact. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing. <BR/>Record review of Resident #1's Discharge summary dated [DATE] signed by the physician indicated Resident #1 was discharged from the facility and sent to behavioral psychological hospital with Resident #1 to return to facility after evaluation and treatment.<BR/>Record review of Resident #1's order summary report dated as of 08/04/2023 indicated:<BR/>May send to inpatient psychiatric hospital per physicians dated 08/04/2023. Further review revealed there was no discharge order noted. <BR/>Record review of Resident #1's Discharge summary dated [DATE] signed by the physician indicated Resident #1 was discharged from the facility and sent to behavioral psychiatric hospital with Resident #1 to return to facility after evaluation and treatment.<BR/>During an interview on 03/25/2024 at 2:59 PM the Social Worker said she was responsible for issuing 30-day notices and assisting with discharges when residents were discharged home. She said Resident #1 was sent out on 08/04/2023 at his request to a psychiatric unit and never returned to the facility and she could not recall anything more regarding Resident #1. The Social Worker said clinical nursing followed up when residents were sent out to another facility and the Administrator managed those types of discharges.<BR/>During an interview on 03/26/2024 at 1:30 PM LVN A (Administrator from April - September 2023. ) said Resident #1 was not allowed to return to the facility after the psychiatric hospital evaluation and treatment. LVN said the psychological hospital tried to send him back, but he told the hospital that the facility would not accept Resident #1 back because the facility could no longer meet Resident #1's needs. LVN A said Resident #1 should have received a 30-day discharge notice, but he was unsure of the policy and procedure. LVN A said the failure would make it difficult for Resident #1 to find placement elsewhere.<BR/>During an interview on 03/27/2024 at 2:30 PM the Ombudsman said the facility did not notify her of the discharge of Resident #1. <BR/>During an interview on 03/27/2024 at 4:45 PM, LVN A (Administrator from April - September 2023) said he could not recall the proper procedure or policy regarding a discharged resident. LVN A said all the paperwork was placed in a folder and he was no longer the administrator and does not know where the paperwork was located. LVN A said the failure to notify the Ombudsman placed Resident #1 at risk of not having other options, the Ombudsman would have been capable of assisting in placement. <BR/>Record review of facility's undated Policy for Discharge or Transfer to another Facility indicated:<BR/>It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances .<BR/>Policy Explanation and Compliance Guidelines:<BR/>The facility will evaluate and determine the level of care needed for the resident prior to admission to the facility's ability to meet resident's needs. <BR/>Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions:<BR/>The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .<BR/>Emergency Transfer/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).<BR/>Obtain a physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis .<BR/>The Social Services Director, or designee, will provide copies of emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as list meets all requirements for content if such notices.<BR/>The resident will be permitted to return to the facility upon discharge from the acute care setting .<BR/>Documentation - Notification of Discharges<BR/>For Facility-initiated transfer or discharge of a resident, the facility will notify the resident and the residents' representative(s) of the transfer or discharge and the reasons for of the move in writing and in a language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term (LTC) Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of 3 residents reviewed for transfer/discharge. <BR/>1. The facility failed to admit Resident #1 back to facility after he was sent to the psychiatric hospital on [DATE].<BR/>2.The facility failed to give Resident #1 a 30-day discharge notice.<BR/>This failure could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type (feelings of euphoria, racing thoughts, increased risky behavior and symptoms of mania). The face sheet also indicated Resident #1 was his own responsible party. <BR/>Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 15 which indicated Resident #1 had was cognitively intact. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing. <BR/>Record review of Resident #1's Discharge summary dated [DATE] signed by the physician indicated Resident #1 was discharged from the facility and sent to behavioral psychiatric hospital with Resident #1 to return to facility after evaluation and treatment. <BR/>Record review of Resident #1's order summary report dated as of 08/04/2023 indicated he had orders as followed:<BR/>1. <BR/>May send to inpatient psychiatric hospital per physicians dated 08/04/2023.<BR/>There was no discharge order noted.<BR/>During an interview on 03/25/2024 at 2:59 PM the Social Worker said she was responsible for issuing 30-day notices and assisting with discharges when residents were discharged home. She said Resident #1 was sent out on 08/04/2023 at his request to a psychiatric unit and never returned to the facility. The Social Worker said the Administrator and clinical nursing followed up when residents were sent out to another facility. <BR/>During an interview on 03/26/2024 at 1:30 PM LVN A said he was the Administrator for the facility from April - September 2023. LVN A said Resident #1 was not allowed to return to the facility after the psychological hospital evaluation and treatment. LVN said the psychiatric hospital tried to send him back, but he told the hospital that the facility would not accept Resident #1 back because the facility could no longer meet Resident #1's needs. LVN A said he could not recall the reasons the facility could no longer meet the resident's needs exactly. LVN A said Resident #1 should have received a 30-day discharge notice, but he was unsure of the policy and procedure. LVN A said the failure would make it difficult for Resident #1 to find placement elsewhere. <BR/>During an interview on 03/27/2024 at 3:08 PM, Resident #1 said he did not receive a discharge notice from the facility. Resident #1 said the LVN A had told him he could return to the facility after evaluation and treatment from the psychiatric hospital. Resident #1 said he felt emotionally drained during this time because he felt homeless.<BR/>Record review of facility's undated Policy for Discharge or Transfer to another Facility indicated:<BR/>It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances .<BR/>Policy Explanation and Compliance Guidelines:<BR/>The facility will evaluate and determine the level of care needed for the resident prior to admission to the facility's ability to meet resident's needs. <BR/>Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions:<BR/>The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .<BR/>Emergency Transfer/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).<BR/>Obtain a physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis .<BR/>The Social Services Director, or designee, will provide copies of emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as list meets all requirements for content if such notices.<BR/>The resident will be permitted to return to the facility upon discharge from the acute care setting .<BR/>Documentation - Notification of Discharges<BR/>For Facility-initiated transfer or discharge of a resident, the facility will notify the resident and the residents' representative(s) of the transfer or discharge and the reasons for of the move in writing and in a language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term (LTC) Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure an accurate MDS was completed for 4 of 17 residents (Resident's #12, #22, #28, and #47) reviewed for MDS assessment accuracy.<BR/>1. The facility failed to accurately document oral status for Resident #47 on the MDS assessment.<BR/>2. The facility failed to accurately document hospice status for Resident #22 on the MDS assessment.<BR/>3. The facility failed to accurately document a diagnosis of pneumonia on Resident #28's MDS assessment.<BR/>4. The facility failed to accurately reflect Resident #12's dental status on the MDS assessment.<BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>The findings included: <BR/>1. Record review of Resident #47's face sheet, dated 02/16/2023, revealed Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acquired absence of left leg below knee (left leg amputation below the knee). <BR/>Record review of Resident #47's order summary report, dated 02/16/2023, revealed an order which started on 09/19/2022, for dental care as needed. <BR/>Record review of the comprehensive MDS assessment, dated 10/02/2022, revealed Resident #47 had clear speech and was understood by staff. The MDS revealed Resident #47 was able to understand others. The MDS revealed Resident #47 had a BIMS score of 15 which indicated no cognitive impairment. The MDS revealed Resident #47 had no obvious or likely cavity or broken natural teeth. <BR/>Record review of the comprehensive care plan, last revised on 9/24/2022, revealed no plan of care for oral or dental status. <BR/>Record review of the admit or readmit screener assessment - section D, dated 09/20/2022 revealed Resident #47 had broken and carious teeth. <BR/>Record review of the oral or dental status assessment, dated 09/19/2022, revealed Resident #47 had missing teeth. <BR/>During an observation and interview on 02/15/2023 at 8:11 AM, Resident #47 stated she was having pain to her lower jaw in the back on the right side. Resident #47 stated the pain was 9 out of 10 on the pain scale during the last month. Resident #47 stated the pain was worse during meals when she was eating. Resident #47 was smiling with no facial grimacing observed. Resident #47 was working on her small gem puzzle during the interview. Resident #47 had missing teeth and inflamed gums. Resident #47's natural teeth were black with obvious cavities. Resident #47 had a split tooth to her lower jaw in the back on the right side that was rubbing on her tongue. Resident #47 stated she told the DON about her dental pain approximately 1 month ago. Resident #47 stated the DON told her she would see about the dentist. Resident #47 stated she had not been told anything else regarding a dental appointment.<BR/>2. Record review of Resident #22's face sheet, dated 02/16/2023, revealed Resident #22 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), hemiplegia and hemiparesis following a stroke affecting the right-dominant side (conditions that cause weakness on one side of the body), and chronic obstructive pulmonary disease - COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of the order summary report, dated 02/16/2023, revealed Resident #22 had an order that started on 11/09/2019 to admit to hospice care. <BR/>Record review of the MDS assessment, dated 11/15/2022, revealed Resident #22 had clear speech and was understood by staff. The MDS revealed Resident #22 was able to understand others. The MDS revealed Resident #22 had a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed Resident #22 had a life expectancy of less than 6 months. The MDS revealed Resident #22 had no hospice care while a resident during the look-back period. <BR/>Record review of the comprehensive care plan, initiated on 03/20/2019, revealed Resident #22 had a terminal prognosis and was receiving hospice services. <BR/>3. Record review of Resident #28's face sheet, dated 02/16/2023, revealed Resident #28 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of traumatic brain injury (head injury causing damage to the brain by external force or mechanism), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), and aphasia(comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). <BR/>Record review of the order summary report, dated 02/16/2023, revealed no antibiotics were ordered. <BR/>Record review of the MDS assessment, dated 01/17/2023, revealed Resident #28 had unclear speech and was rarely understood by staff. The MDS revealed Resident #28 sometimes understood others. The MDS revealed Resident #28 had poor short-term and long-term memory. The MDS revealed Resident #28 had no recall ability. The MDS revealed Resident #28 had severely impaired decision-making ability. The MDS revealed Resident #28 had an active diagnosis of pneumonia during the look-back period. The MDS revealed Resident #28 had no shortness of breath, fever, vomiting, or dehydration. The MDS revealed Resident #28 received no antibiotics during the look-back period. <BR/>Record review of the comprehensive care plan, last revised on 05/07/2022, revealed no care plan for pneumonia. <BR/>Record review of the medication administration record, dated January 2023, revealed no antibiotic were given during the look-back period. <BR/>During an interview on 02/16/2023 at 5:33 PM, the MDS Coordinator stated the MDS assessments were accurate to the best of her knowledge and according to the charting. The MDS Coordinator stated she looked at assessments, doctors' orders, and progress notes to complete the MDS assessment. The MDS Coordinator stated if there was a discrepancy in the charting, she would have assessed the resident herself. The MDS Coordinator stated she did not look at Resident #47's assessment that revealed her dental status. The MDS Coordinator stated she forgot to check the box for hospice care for Resident #22. The MDS Coordinator stated she forgot to uncheck the box for pneumonia for Resident #28. The MDS Coordinator stated it was important to ensure the MDS assessment was accurate to get an accurate representation of the resident. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated she was the RN responsible for ensuring the MDS assessment was complete and accurate. The DON stated oral or dental status should have been accurately reflected for Resident #47 so it would have been reflected on the plan of care. The DON stated hospice care should have been checked for Resident #22. The DON stated pneumonia should not have been checked as an active diagnosis for Resident #28. The DON stated the importance of ensuring the MDS assessment was accurate was for billing purposes. <BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she expected MDS assessments to be completed accurately and timely. The ADM stated the importance of completing MDS assessments accurately and timely was to ensure residents were not receiving delays in care and the facility was not receiving delays in billing. <BR/>4. Record review of the consolidated physician orders dated 02/16/23 indicated Resident #12 was a [AGE] year-old female that was admitted to the facility on [DATE] and had a diagnosis of Schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), Asthma (inflamed airways that make it difficult to breath) and HTN (force of blood against the artery walls is too high). <BR/>Record review of the Comprehensive MDS dated [DATE] indicated Resident #12 usually made herself understood and usually understands. Resident #12's BIMS score was a 7 indicating severe impairment. The MDS indicated Resident #12 was on a mechanically altered diet. The MDS indicated no issues with swallowing or dental status.<BR/>Record review of Resident #12's order summary dated 07/28/22 indicated a regular diet with soft and bite-size food (Level 6 texture). The order summary indicated dental care as needed. <BR/>Record review of Resident #12's care plan dated 07/03/22 indicated a potential nutritional problem related to new admit. Interventions included for the Dietary manager to discuss food preferences with resident and family upon admission to meet dietary needs.<BR/>Record review of Resident #12's oral and dental status assessment completed on 07/04/22 indicated Resident #12 did not have any upper teeth and broken teeth on the bottom. <BR/>During an observation and interview on 2/15/23 at 3:00 p.m., Resident #12's teeth were broken, missing and discolored. Resident #12 stated her teeth hurt when she chewed and she, almost choked on broccoli the other day because she was not able to chew properly. Resident #12 stated she had reported her teeth hurting to staff but was unable to verbalize which staff members or when.<BR/>During an interview on 02/14/23 at 10:01a.m., family member stated she reported to facility staff when Resident #12 was admitted on [DATE] that resident had issues with dental and she notified the Administrator again in January 2022 that Resident #12 needed a dental evaluation.<BR/>During an interview on 02/15/2023 at 8:38 a.m., the Customer Care Representative at Health drive denied having a dental referral for Resident #12.<BR/>During an interview on 02/15/23 at 4:20 p.m., CNA F stated Resident #12's family member makes weekly visits to the facility. CNA F stated she was aware that Resident #12 was complaining of tooth pain and needing a dental eval. CNA F stated she did not report it to the Administrator because the family member told her she had already reported the tooth pain to the Administrator and the facility should be taking care of it.<BR/>During an interview on 02/15/23 at 11:14 a.m., the MDS nurse stated she completed Resident #12's MDS and indicated on the MDS Resident #12 did not have any dental issues. The MDS nurse stated she was not aware of the oral and dental assessment found in Resident #12's chart. The MDS nurse stated she only looked at the nursing assessment that was completed upon admission to assist with filling out the MDS. The MDS nurse reported she completed her own assessment on Resident #12 for the MDS and, she might have marked no dental issues on the MDS because Resident #12 would not let her look at her teeth. The MDS nurse stated she was responsible for filling out the MDS correctly and not indicating dental issues or tooth pain could have resulted in distress to the patient. <BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she was not aware that Resident #12 needed a dental evaluation and her family had never notified her that Resident #12 needed dental care. The DON stated Resident #12 should have been assessed upon admission for dental issues and staff should have been working as a team to monitor Resident #12's need for dental services. The DON stated the MDS nurse was responsible for making sure the MDS was filled out correctly. The DON stated she was responsible for looking over the MDS and making sure it was correct. The DON stated not getting dental care could have made Resident #12 feel bad due to pain.<BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator reported she expected the MDS to be accurate and the MDS nurse was responsible for making sure the MDS was correct. The Administrator stated the Corporate MDS team was responsible for making sure the MDS nurse filled out the MDS correctly. <BR/>Record review of the Certifying Accuracy of the Resident Assessment policy, last revised in November 2019, revealed Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy further revealed information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II for 1 of 3 residents (Resident #17) whose records were reviewed for mental disorders.<BR/>The facility failed to refer Resident #17 for a PASARR evaluation based on mental disorder diagnoses of Psychosis.<BR/>This deficient practice could affect residents with mental illness and contribute to a delay in services needed.<BR/>The findings included:<BR/> Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident #17's quarterly MDS assessment, dated 02/05/24, indicated Resident #17 was usually understood and sometimes understood by others. Resident #17's BIMs score was 15, which indicated he was cognitively intact. Resident #17 required extensive assistance with toileting, personal hygiene, transfer, and bathing. The MDS indicated he had a diagnosis of Schizophrenia and bipolar. <BR/>Record review of Resident #17's physician's orders dated 07/03/23 indicated, Quetiapine Fumarate Tablet 250 MG Give 1 tablet by mouth two times a day related to schizoaffective disorder, bipolar.<BR/>Record review of Resident #17's comprehensive care plan, dated 03/09/24 indicated Resident #17 required anti-psychotic medications for schizoaffective disorder. The interventions were to give medication as ordered.<BR/>Record review of Resident #17's PASRR Level 1 screening completed on 5/22/23 did not reflect Resident #17 had a diagnosis of Psychosis or an indicator that Resident #17 had a mental illness.<BR/>During an interview on 04/10/24 at 4:12 p.m., the MDS nurse stated when she started at this facility as the MDS nurse she did not have a lot of knowledge on PASARRs. She said she would call her regional nurse and see what she needed to do for Resident #17s PASARR. <BR/>During an interview on 04/10/24 at 5:57 p.m., the MDS nurse said she had called her regional nurse and she explained the process. She looked at Resident #17 chart and said he had a diagnosis of Psychosis which should trigger a referral for PASARR evaluation. She said she had filled out the 1012 form (Mental Illness/Dementia Resident Review) and the physician had signed it. She said she would get the form submitted for review to the local authority. <BR/>During an interview on 04/10/24 at 6:00 p.m., The Administrator said the MDS nurse was responsible to complete the level 2 if needed. He said a level 2 was done to determine to see if they could benefit from any services offered. He said if the PASRR Level 1 had a discrepancy it should have been corrected. He said a resident could lose on receiving services if the PASRR was not completed correctly.<BR/>During an interview on 04/10/24 at 6:04 p.m., the DON said the MDS nurses were responsible for the PASRR and she was not sure when a 1012 form was needed. She said Resident #17 did have a diagnosis of schizophrenia and bipolar which was considered a mental illness.<BR/>Review of a facility policy, titled, PASRR Level 1 Screen Policy and Procedure, dated 03/06/19, indicated, Policy: It is the policy of Creative Solutions in Healthcare facilities to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via Simple LTC timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with, and the training and therapy they need to live as independently as possible.<BR/>PASRR Program has 3 Goals:<BR/>1. To identify individuals with MI, ID, or DD/RC (this includes adults and children).<BR/>2. To ensure appropriate placement, whether in a community or in a NF.<BR/>3. To ensure individuals receive the required services for their MI, ID, or DD.<BR/>Procedure:<BR/>1. The Facility Admissions process will ensure a PL1 Screening Form is obtained from the RE on day of<BR/>admission or prior to admission. A PL1 is obtained for every individual, regardless of payment.<BR/>type, seeking admission to a Medicaid-certified NF.<BR/>2. The PL1 Screening Form is completed by the RE (referring entity) using the paper copy of the PL1 Screening Form. 3. The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. The Type of admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers, and DOB is correct. The Date of the PL1 is correct (i.e., correct day, month, and year), and review each item on the PL1 to ensure accuracy and prevent a regulatory problem. 4. The Facility will enter the PL1 Form exactly as written except for corrections to identifying data. It is critical to submit timely PL1s due to the following: It is the policy of this facility to ensure that all residents are screened and appropriately addressed via the PASARR process as outlined by regulations. The results of this process will be used to develop, review, and revise the resident's care plan. Procedures: 1. The facility's designated staff will review all potential admissions for possible positive PASARR conditions and ensure that CMS Preadmission guidelines are followed Review the PL1 Form for completion and correctness before admission. <BR/>Record review of facility policy titled, PASRR Nursing Facility Specialized Services Policy and Procedure, revised 3-6-19 indicated, Policy: It is the policy of Creative Solutions in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately. 1.PL1 is completed. 2.If PL1 is coded as suspicion of Ml, ID, or DD, then a PE is required. 3.The LA completes the PE and if Positive, a PCSP Initial Meeting is scheduled. 4.NF PCSP meetings scheduled within 14 days of admission and annually. Note: The Annual PCSP NF meeting must be at least 334 days from previous NF PCSP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 17 residents (Resident #17, Resident #26, Resident #40, and Resident #67) reviewed for care plans. <BR/>The facility failed to develop and implement a care plan for Resident #17's need for assistance with ADLs. <BR/>The facility failed to develop and implement a care plan for Resident #26's dental problems.<BR/>The facility failed to develop and implement a care plan for Resident #40's contractures. <BR/>The facility failed to develop and implement a care plan for Resident #67's wandering/risk for elopement.<BR/>These failures could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #17's face sheet, dated 02/16/2023, indicated she was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified (lung disease that causes obstructed air flow in the lungs), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and dependence on supplemental oxygen. <BR/>Record review of the MDS comprehensive assessment with an assessment reference date of 04/25/2022, indicated Resident #17 was understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 13, indicating Resident #17's cognition was intact. The MDS assessment indicated Resident #17 did not reject evaluation or care. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing, toilet use and limited assistance with personal hygiene and supervision for eating. <BR/>Record review of Resident #17's care plan with target date of 04/09/2023 indicated no care plan for Resident #17's need for assistance with ADLs. <BR/>2. Record review of Resident #26's face sheet dated 02/16/2023 indicated, Resident #26 was re-admitted on [DATE] with diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), schizoaffective disorder, bipolar type (mood disorder characterized by abnormal thought processes and unstable mood), and type 2 diabetes mellitus with other diabetic neurological complication (high blood glucose levels with nerve damage). <BR/>Record review of Resident #26's comprehensive MDS assessment with an assessment reference date of 11/27/2022 indicated, Resident #26 was usually understood and usually understood others. The MDS assessment indicated Resident #26 had a BIMS score of 13, indicating her cognition was intact. The MDS assessment indicated Resident #26 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and supervision for eating. Resident #26's MDS assessment indicated she did not have broken or loosely fitting full or partial denture, no natural teeth or tooth fragments, abnormal mouth tissue obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort, or difficulty with chewing. <BR/>Record review of Resident #26's Order Summary Report dated 02/16/2023 indicated physician's orders for dental care PRN (as needed) with start date of 03/09/2020 and amoxicillin oral capsule 500 mg give 1 capsule by mouth every 8 hours for tooth abscess for 10 days until finished with start date of 02/11/2023. <BR/>Record review of Resident #26's care plan with target date of 12/17/2022 did not reveal Resident #26's dental problems.<BR/>During an observation and interview on 02/15/23 at 8:13 AM, Resident #26 stated in the past maybe the year before last she had her upper teeth in the back one on the right and one on the left side smoothed down because they were cavities. Resident #26 stated her other teeth were now being affected because she needs those 2 teeth pulled out and had not been able to see the dentist. Resident #26 stated her Medicaid did not pay for dental and she did not have money to pay the dentist. Resident #26 stated she had told the nurses her teeth were causing her pain and they needed to be taken out. Resident #26 stated one of the facility staff was supposed to refer her to a dentist that would take her Medicaid, but she had not heard back from them. Resident #26 was unable to recall who the staff member was. Resident #26 stated about a week ago she got an abscess on her left side related to her teeth and the facility physician order antibiotics for this. Observation of Resident #26's teeth indicated 2 upper teeth in the back one on the right and one on the left side were jagged and black with the left side having [NAME]/corrosion than the right. Resident #26 stated the pain was worse throughout the day and when she ate food. Resident #26 stated she had tramadol for chronic pain, and this helped with her teeth pain as well. Resident #26 stated sometimes she could not sleep related to the pain to her teeth, but that her pain had improved since starting the antibiotics. <BR/>3. Record review of a face sheet dated 02/16/2023 indicated Resident #67 was an [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors), essential (primary) hypertension (high blood pressure), and hypothyroidism (a condition resulting from decreased thyroid hormones). <BR/>Record review of the comprehensive MDS assessment with assessment reference date of 04/05/2022 indicated Resident #67 was usually understood and understands others. The MDS assessment indicated Resident #67 had a BIMS score of 06, indicating severe cognitive impairment. The MDS assessment indicated Resident #67 did not exhibit wandering. The MDS assessment indicated Resident #67 required limited assistance with bed mobility, transfer, walk in room and corridor, dressing toilet use, personal hygiene, and supervision for eating. <BR/>Record review of the care plan with target date of 02/19/2023 did not reveal Resident #67 had wandering/elopement care planned. <BR/>Record review of Resident #67's Quarterly Review for Secured Unit with effective date of 12/30/2022 indicated Resident #67 required placement on a secured unit due to habitually wanders or would wander out of building and is unable to find their way back.<BR/>During an interview on 2/13/2023 at 4:55 PM, CNA F stated she worked on the secured unit Monday-Friday 2 PM-10 PM and sometimes 10 PM-6 PM and provided care to Resident #67. CNA F stated Resident #67 wandered and at times would exit seek.<BR/>During an interview and observation on 02/16/2023 at 10:55 AM, Resident #67 was walking up and down the hall on the unit. Resident #67 stated she liked to walk, and she wished she could walk outside, but she had gotten in trouble for walking outside and she was trying to abide by the rules. <BR/>During an interview on 02/16/2023 at 5:59 PM the MDS coordinator stated the interdisciplinary team was responsible for completing the residents' care plans. The MDS coordinator stated the interdisciplinary team consisted of the administrator, the DON, nurses, the infection control preventionist, therapy, and the ADON. The MDS coordinator stated she tried to look over the care plans to ensure they were complete and accurate. The MDS coordinator stated Resident #17 should have been care planned for her needs for ADL assistance. The MDS coordinator stated the interdisciplinary team should have put it in and she did not know why it was not care planned. The MDS coordinator stated it was important for her ADL assistance to be care planned so staff would know how she transfers and how she ambulates. The MDS coordinator stated Resident #26 should have been care planned for her dental problems, and the interdisciplinary team should have done it. The MDS coordinator stated it was important for Resident #26's dental problems to be care planned so she could be referred to the dentist, make diet changes, if necessary, monitor for weight loss and pain. The MDS coordinator stated she did not know why Resident #26's dental problems were not care planned. The MDS coordinator stated Resident #67 used to have a care plan for wandering/risk of elopement and she did not know if maybe somebody discontinued it. The MDS coordinator stated Resident #67 should have been care planned for wandering/risk of elopement by the interdisciplinary team. <BR/>The MDS coordinator stated it was important for Resident #67 to be care planned for wandering/risk of elopement, so staff knew why she was on the secured unit, and not having this care planned placed her at risk for somebody letting her out of the unit. <BR/>During an interview on 02/16/2023 at 6:52 PM, the ADON stated she wrote acute care plans like for antibiotics or falls anything on the nurses 24-hour report. The ADON stated completing the care plans was a team effort. The ADON stated Resident #17's care plan should include her need for assistance with ADLs, and she believed this not being on the care plan was an oversight. The ADON stated it was important for Resident #17's care plan to include her need for assistance with ADLs so that the proper level of care was provided by the staff. The ADON stated she was aware that Resident #26 was having dental problems because she required antibiotics for an abscess. The ADON stated Resident #26's dental problems should have been care planned by the interdisciplinary team to make sure her dental problems did not progress and to try to fix the problem. The ADON stated she was aware Resident #67 wandered and was at risk for elopement. The ADON stated Resident #67 should have been care planned for wandering/elopement risk by the interdisciplinary team, and she was not able to say why it was not done. The ADON stated since Resident #67 was on the secured unit not having her wandering/elopement risk care planned placed her at risk of elopement. <BR/>During an interview on 02/16/2023 at 7:37 PM, the DON stated Resident #17 should have been care planned for her need for assistance with ADLs. The DON stated the interdisciplinary team should have care planned this and it must have been an oversight that it was not care planned. The DON stated Resident #17 not having her need for ADL assistance care planned placed her at risk for not receiving the help that she required. The DON stated she was not aware Resident #26 had dental issues, but that it should have been care planned. The DON stated the interdisciplinary team should have care planned this. The DON stated it was important for Resident #26's dental problems to be care planned to ensure proper follow up and that she is feeling better and receiving the help she needs. The DON stated she was aware Resident #67 wandered and was at risk for elopement. The DON stated this should have been care planned by the interdisciplinary team, and she did not know why it was not done. The DON stated sometimes they miss things and she tried to correct them. The DON stated Resident #67 not being care planned for wandering/risk of elopement caused no harm to her. <BR/>During an interview on 02/16/2023 at 8:47 PM, the administrator stated the MDS coordinator was responsible for completing the care plans, but the interdisciplinary team should let her know what should be included in the care plan. The administrator stated the care plan should be updated after any change in the residents' condition. The administrator stated she expected Resident #17 to be care planned for her need of assistance with ADLS, Resident #26's dental problems be care planned, and Resident #67 be care planned for wandering/elopement risk. The administrator stated these not being care planned did not accurately reflect their needs. <BR/>4. Record review of Resident #40's face sheet, dated 02/16/2023, revealed Resident #40 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and contractures (fixed tightening of muscle, tendons, ligaments, or skin) to bilateral ankles, feet, and right hand. <BR/>Record review of the order summary report, dated 02/16/2023, revealed no orders or monitoring for contractures. <BR/>Record review of the MDS assessment, dated 01/18/2023, revealed Resident #40 had clear speech and was usually understood by staff. The MDS revealed Resident #40 was usually able to understand others. The MDS revealed Resident #40 had a BIMS score of 11 which indicated moderate cognitive impairment. The MDS revealed Resident #40 required extensive assistance with bed mobility and total dependence with transfers, dressing, and toilet use. The MDS revealed Resident #40 had functional limitation in range of motion that interfered with daily functions to one side of her upper extremities and both sides of her lower extremities. <BR/>Record review of the comprehensive care plan, last revised on 08/21/2022, revealed no care plan for contractures. <BR/>Record review of the treatment encounter note, dated 02/15/2023, revealed active and passive range of motion was performed to Resident #40's right upper extremity, incorporating prolonged and sustained stretch, to improve range of motion and decrease risk for further contracture development. <BR/>During an observation and interview on 02/13/2023 at 11:02 AM, Resident #40's right hand was curled into a fist with no devices, braces, or splints observed. Resident #40 was non-interviewable as evidence by confused conversation. <BR/>During an observation on 02/14/2023 at 3:22 PM, Resident #40's right hand was curled into a fist with no devices, braces, or splints observed.<BR/>During an observation and interview on 02/16/2023 at 3:26 PM, Resident #40's right hand was curled into a fist with no devices, braces, or splints observed. CNA U was unaware Resident #40 had a contracture. CNA U attempted to uncurl Resident #40's hand and was unable because of joint stiffness and limited range of motion to right hand. CNA U stated she was unsure if Resident #40 required a hand carrot, splint, or brace. CNA U stated she was unsure if Resident #40 was receiving therapy services. CNA U stated she was notified of residents with contractures by the nurse. CNA U stated interventions for contractures were found on the [NAME] (simplified and pertinent information in the electronic charting system that is generated from care plan interventions). CNA U stated the importance of ensuring contractures were on the care plan was to prevent skin breakdown and worsening of the contractures. <BR/>During an interview on 02/16/2023 at 5:20 PM, LVN T stated interventions used for contracture management should have been on the nurse administration record and on the care plan. LVN T stated there were no interventions for Resident #40 on the care plan or on the nurse administration record. LVN T stated the importance of ensuring contractures were included on the care plan was to prevent further contractures and ensure consistency of care. <BR/>During an interview 02/16/2023 at 5:33 PM, the MDS Coordinator stated the IDT (interdisciplinary team) was responsible for ensuring care plans were completed and accurate. The MDS Coordinator stated Resident #40 should have a care plan for contractures. The MDS Coordinator was unsure why Resident #40's contractures were not care planned. The MDS Coordinator stated the importance of ensuring contractures were care planned for Resident #40 was to prevent further decline and ensure the correct interventions were in place. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated the IDT was responsible for ensuring care plans were completed and accurate. The DON stated she was unsure why Resident #40's contractures were not care planned. The DON stated the importance of ensuring contractures were care planned for Resident #40 was to prevent further decline and ensure the appropriate care was provided. <BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she expected the IDT to ensure contractures were included on the care plan. The ADM stated the importance of ensuring contractures were included on the care plan was to prevent further decline and ensure Resident #40 was at the highest level of functioning. <BR/>Record review of the Care Plans, Comprehensive Person-Centered policy, last revised in March of 2022, revealed 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy further revealed 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. Services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2. Any specialized services to be provided as a result of PASARR recommendations; and 3. which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident' strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 3 of 3 (Resident #17, Resident #15, and Resident #25) residents reviewed for care plan revisions. <BR/>1.The facility failed to revise Resident #17's care plan to include he removed his Foley catheter leg strap (a device used to reduce the risk of tension or pulling on the catheter, which could cause some very unpleasant trauma within the bladder or urethra) as ordered at times.<BR/>2. The facility failed to revise Resident #15 care plan to remove her wander guard.<BR/>3. The facility failed to revise Resident #25 care plan to remove he was a smoker. <BR/>These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.<BR/>Findings included:<BR/>1.Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness).<BR/>Record review of Resident #17's quarterly MDS assessment, dated 02/05/24, indicated Resident #17 was usually understood and sometimes understood by others. Resident #17's BIMs score was 15, which indicated he was cognitively intact. Resident #17 required extensive assistance with toileting, personal hygiene, transfer, and bathing. The MDS indicated he had an indwelling catheter during the 7-day look-back assessment period. <BR/>Record review of Resident #17's physician's orders dated 07/02/23 indicated, Urinary Catheter 16 FR, 30 CC. Diagnosis: retention of urine.<BR/>Record review of Resident #17's physician's orders dated 07/03/23 indicated, Secure catheter with a leg strap every shift.<BR/>Record review of Resident #17's comprehensive care plan, dated 07/06/23 indicated Resident #17 had a catheter. The interventions of the care plan were for staff to keep the drainage bag below bladder level, cover the bag for dignity; give catheter care as ordered, and report immediately if the catheter comes out, and if the resident was in pain. Resident #17's care plan did not address his care for the leg strap, his refusal, or the removal of the leg strap.<BR/>Record review of Resident #17's medication administration (MAR) record dated 04/01/24 through 04/09/24 revealed nurses were signing that Resident #17's was wearing his leg strap as ordered. <BR/>During an observation and interview on 04/09/24 at 4:09 p.m., MA F was providing Resident #17 with peri-care. She said Resident #17 did not have on his leg strap. She said it was important for Resident #17 to have on his leg strap to prevent pulling but he often removed his leg strap. She said she thought the nursing staff was aware of the removal of his leg strap.<BR/>During an interview on 04/09/24 at 4:30 p.m., Resident # 17 did not say he had removed his Foley leg strap today (04/09/24) but said he did not like them. <BR/>During an interview on 04/10/24 at 12:09 pm LVN C said Resident #17 should have a leg strap or some type of anchor in place to prevent dislodgement or pulling of his Foley catheter. She said she had applied his leg strap many times but he would take them off. She said she had told the ADON that he did not like to wear the leg strap about 2 months ago. She said she did not add the removal of his leg strap to his care plan because she did not do anything to any resident's care plan.<BR/>During an interview on 04/10/24 at 3:45 p.m., LVN B said Resident #17 should have a leg strap to prevent his Foley catheter from pulling or dislodgement. She said Resident #17 told her last week he did not want to wear a leg strap anymore. She said she could not remember if she had reported his removal or refusal of his leg strap to anyone or documented it. <BR/>During an interview on 04/10/24 at 4:12 p.m., the MDS nurse said she was responsible for updating care plans after each MDS assessment. She said she updated care plans based on the information she received during her quarterly, significant changes, and/or annual assessments. The MDS nurse said any acute care plan updates were done by the ADON/DON. The MDS nurse verified by looking at Resident #17's care plan and said he did not have anything related to his leg strap. She said it was important to update the care plan because it indicated how to take care of the residents. <BR/>During an interview on 04/10/24 at 4:31 p.m., the ADON said the MDS nurse was responsible for the care plans but the IDT worked on care plans. She said she updated acute care plans based on the information she received from morning or clinical meetings, 24-hour reports, and physician's orders. She said she was not aware Resident #17 was removing or refusing his leg strap until questioned by the surveyor. She said the care plan intended to show what needs to be done to meet the resident's needs and if care plans were not being updated some vital information could be missed. <BR/>During an interview on 04/10/24 at 5:20 p.m., the DON said all nurses could update a care plan. She said the IDT worked on care plans to ensure they were complete and accurate. She said she was not aware Resident #17 refused or removed his Foley catheter. She said it was important to place this on his care plan because it reflected the care he should be receiving. <BR/>During an interview on 04/10/24 at 6:00 p.m., The Administrator said care plans were updated by the IDT team. He said they had a morning meeting, clinical meetings, and standard of care meetings. He said they had plenty of time to identify and update Resident #17's care plan. He said he did not know why Resident #17's care plan was not updated but said his care plan should have been updated to reflect his removal or refusal of the leg strap. the care plan should reflect a picture of the resident's care needs. He said if a resident had a change of medication, then his/her care plan should reflect the change.<BR/>2.Record review of face sheet, dated 10/10/23 indicated Resident #15 was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( person was presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbance), Cognitive communication deficit ( difficulty with thinking and how someone uses language), other schizophrenia (category applies to presentations in which symptoms predominate that are characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important). <BR/>Record review of the order summary, dated 04/04/24, indicated Resident #15 had a wander guard with function check every night shift.<BR/>Record review of the care plan, revised 12/19/2023, indicated Resident #15 was at moderate risk for falls related to decreased safety awareness, wandering. Interventions included ensure resident was wearing proper footwear and provide a clear path for wandering to help avoid stumbling while wandering.<BR/>Record review of the quarterly MDS assessment, dated 03/07/2024, revealed Resident #15 was sometimes understood and sometimes understood by others. Resident #15's BIMs score was 03, which indicated she was cognitively severely impaired. Resident #15 MDS indicated no wandering. <BR/>Record review of Resident #15's medication administration record dated 04/10/2024, indicated wander guard check every day on night shift was checked off by the nurse. <BR/>3. Record review of the face sheet, dated 04/09/2024, revealed Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete paralysis, while hemiparesis refers to partial paralysis), vascular dementia, unspecified severity with agitation (major neurocognitive disorder due to vascular disease), other abnormalities of gait and mobility(injury or underlying medical condition can cause an abnormal gait).<BR/>Record review of the care plan, revised 02/26/2024, indicated Resident #25 was a smoker, with intervention for smoking risks and hazards, and smoking cessation aids available.<BR/>Record review of the quarterly MDS assessment, dated 03/07/2024, revealed Resident #25 has unclear speech and responds adequately to simple, direct communication. The MDS revealed Resident #25 had a BIMS of 5, which indicated severe cognitive impairment. The MDS assessment did not indicated Resident #25 was a smoker.<BR/>During an interview on 04/10/2024 at 4:21 p.m., LVN B stated the MDS coordinator and the ADON were responsible for updating the care plan. LVN B stated Resident # 15 no longer had a wander guard and Resident # 25 had not smoked in a long time. LVN B stated it was important for the care plan to be accurate so the residents would get the appropriate care. LVN B stated she didn't feel there was a risk to the residents with the care plan not being update for Resident # 15 no longer needing a wander guard or resident # 25' care plan not being updated to reflect he was no longer a smoker. <BR/>During an interview on 04/10/2024 at 4:21 p.m., the ADON stated all the interdisciplinary team was responsible for updating the care plans. The ADON stated Resident # 15's care plan for the wander guard and Resident #25's care plan for smoking should had been updated months ago. The ADON stated it was important for the care plans to be updated for resident care. The ADON stated she did not feel there was a harm to the residents. The ADON stated she would monitor during morning meetings. <BR/>During an interview on 04/10/2024 at 5:20 p.m., the DON stated the care plans are done during the interdisciplinary team meetings. The DON stated this was an oversight. The DON stated it was important for the care plan to updated to provide true and accurate care. The DON stated there was no harm to the residents. The DON stated she would monitor by doing order audits. <BR/>During an interview on 04/10/2024 at 5:54 p.m., the Administrator stated care done during the morning meetings. The Administrator stated it was important for each care plan to be person center care. The Administrator stated he believed this was an oversight. The Administrator stated he did believe there was any harm to the resident. The Administrator stated they would monitor by doing audits. <BR/>Record review of facility undated policy titled, Comprehensive Care Plans, indicated residents' preferences and goal may change throughout their stay, so facilities should have on going discussions with the residents and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 17 residents (Resident #17) reviewed for respiratory care and services. <BR/>The facility failed to administer oxygen at 3-4 liters per minute via nasal cannula as prescribed by the physician for Resident #17. <BR/>This failure could place residents who receive respiratory care at risk for developing respiratory complications.<BR/>The findings included:<BR/>Record review of Resident #17's face sheet, dated 02/16/2023, revealed she was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified (lung disease that causes obstructed air flow in the lungs), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and dependence on supplemental oxygen. <BR/>Record review of the MDS comprehensive assessment with an assessment reference date of 04/25/2022, indicated Resident #17 was understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 13, indicating Resident #17's cognition was intact. The MDS assessment indicated Resident #17 did not reject evaluation or care. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing, toilet use and limited assistance with personal hygiene and supervision for eating. The MDS assessment indicated Resident #17 received oxygen therapy while a resident in the facility. <BR/>Record review of Resident #17's care plan last revised 09/29/2022 revealed an intervention to give oxygen therapy as ordered 3 to 4 LPM (liters per minute) via NC (nasal cannula) as ordered by the physician.<BR/>Record review of Resident #17's order summary report dated 02/16/2023, revealed a physician's order for oxygen at 3-4 L via nasal cannula continuous every shift related to chronic obstructive pulmonary disease, unspecified with start date of 08/14/2022. <BR/>Record review of Resident #17's respiratory administration record for February 2023, revealed O2@ 3-4 L via NC continuous every shift related to chronic obstructive pulmonary disease, signed off completed for 02/14/2023 (day shift and evening shift). <BR/>During an observation on 02/14/2023 at 9:15 AM, Resident #17 was lying in bed with oxygen via nasal cannula and oxygen was set between 2-3 liters per minute. <BR/>During an observation on 02/14/2023 at 3:33 PM, Resident #17 was lying in bed with oxygen via nasal cannula and oxygen was set between 2-3 liters per minute.<BR/>During an observation on 02/14/2023 at 5:10 PM Resident #17 was lying in bed with oxygen via nasal cannula and oxygen was set between 2-3 liters per minute. <BR/>During an observation and interview on 02/14/2023 at 5:20 PM, LVN T stated she was Resident #17's nurse this shift 2PM-10PM. LVN T verified Resident #17's oxygen was set at 2.5 liters per minute. LVN T stated she was responsible for following the physician's orders and the oxygen for Resident #17 should be set at 3-4 liter per minute. LVN T stated earlier in her evening shift she had signed off that Resident #17's oxygen was set at 3-4 liters per minute, and there was not reason the oxygen was set at 2.5 liters per minute, but she had signed that it was set at 3-4 liters per minute. LVN T stated Resident #17's oxygen not being set at the correct liters per minute could cause her hypoxia (low oxygen) and result in her death. <BR/>During an interview on 2/15/2023 at 11:35 AM, RN P stated she was the charge nurse on the 6AM-2PM shift on Monday-Friday. RN P stated she worked on 2/14/2023 6AM-2PM and provided care for Resident #17. RN P stated Resident #17 usually had her oxygen set at 3 liters per minute, so she just signed it off completed on 2/14/23 for day shift. RN P stated she did not verify that the oxygen was set at 3-4 liters per minute, but she should have. RN P stated the oxygen not being set at the correct level could cause problems such as confusion. <BR/>During an interview on 02/16/2023 at 6:46 PM, the ADON stated the nurse working the floor was responsible for ensuring the residents' oxygen was set correctly. The ADON stated the nurse should have signed off the respiratory administration record at the same time the oxygen setting was verified. The ADON stated she walked around the halls and did random checks every couple hours to check on the nurses. The ADON stated the oxygen not being set correctly could affect the residents' oxygen saturations and result in falls and altered mental status. <BR/>During an interview on 02/16/2023 at 7:30 PM, the DON stated the nurse working the floor was responsible for ensuring the physicians orders were followed and the oxygen was set correctly. The DON stated she did random checks throughout the day to make sure things were being done correctly. The DON stated the oxygen should be set correctly to maintain the residents' oxygen saturation levels. The DON stated the oxygen not being set correctly could result in hypoxia (low oxygen) and could cause altered mental status. <BR/>During an interview on 02/16/2023 at 8:43 PM, the administrator stated she expected the nurses to follow the physician orders, including setting the oxygen correctly. The administrator stated nursing was responsible for ensuring the oxygen was set correctly for all the residents. The administrator stated it was important for the oxygen to be set correctly because oxygen was needed to breathe and live. <BR/>Record review of the facility's policy titled, Oxygen Administration, last revised October 2010, revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident . Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 1 of 17 residents (Resident #271) reviewed for accuracy of medical records.<BR/>The facility failed to ensure Resident #271's medication administration record was accurate and complete. <BR/>This failure could place residents at risk of not receiving care and services to meet their needs.<BR/>The findings included:<BR/>Record review of Resident #271's face sheet, dated 02/16/2023, revealed Resident #271 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and cerebrovascular disease (a group of conditions that affect the blood flow and the blood vessels in the brain). <BR/>Record review of the MDS assessment, dated 2/10/2023, revealed Resident #271 had clear speech and was understood by staff. The MDS revealed Resident #271 was usually able to understand others. The MDS revealed Resident #271 had a BIMS score of 5 which indicated severe cognitive impairment. The MDS revealed Resident #271 had no refusal of care. <BR/>Record review of the comprehensive care plan, last revised on 02/14/2023, revealed Resident #271 had a thyroid condition and took medications. The care plan revealed Resident #271 had diabetes and was at risk for high or low blood sugar. The interventions included: diabetes medication and accuchecks (blood glucose monitoring) as ordered by the physician.<BR/>Record review of the medication administration record (MAR), dated October 2022, revealed levothyroxine 100 mg by mouth every morning at 5:30 AM was not signed out as administered on 10/04/2022 or 10/14/2022. The MAR further revealed finger stick blood sugars twice daily was not signed out as administered on 10/23/2022, 10/27/2022, or 10/30/2022 at 5:00 PM. <BR/>During an interview on 02/16/2023 at 4:53 PM, CMA V stated a blank box on a MAR would mean a medication was not given or was not documented it was given. CMA V stated all medications should have been signed out on the MAR. CMA V was unsure why Resident #271 had several blanks on her MAR. CMA V stated it was important to document medication administration to prove that medications were given according to the doctor's orders. <BR/>During an interview on 02/16/2023 at 5:20 PM, LVN T stated a blank box on a MAR would indicate a medication was not given or was not documented it was given. LVN T stated all medication and blood sugar checks should have been signed out of the MAR. LVN T stated she was unsure why Resident #271 had several blanks on her MAR. LVN T stated it was important to ensure documentation was completed for continuity of care and follow up by staff. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated a blank box on a MAR would indicate a medication was not given or was not documented it was given. The DON stated the nurses and medication aides were responsible for ensuring no blanks were on the MAR. The DON stated accurate documentation of MAR were monitored by performing random checks. The DON was unsure why Resident #271 had blank boxes on her MAR. The DON stated accurate documentation was important to ensure residents were receiving their medications. <BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she expected nursing staff to ensure no blanks were on the MAR. The ADM stated the importance of accurately documenting medication administration was the health and safety of the residents and to prevent medication errors. <BR/>Record review of the Documentation of Medication Administration policy, last revised in April of 2007, revealed 1. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. name and strength of the drug; b. dosage; c. method of administration (e.g., oral, injection (and site), etc.); d. date and time of administration; e. reasons why a medication was withheld, not administered, or refused (as applicable); f. signature and title of the person administering the medication; and g. resident response to the medication, if applicable.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 staff (LVN T) reviewed for infection control.<BR/>The facility failed to ensure LVN T performed hand hygiene while checking blood sugars for Resident #2 and Resident #7 and when administering insulin to Resident #7. <BR/>This failure could place residents and staff at risk for cross-contamination and the spread of infection. <BR/>Findings included:<BR/>During an observation on 02/13/2023 at 3:56 PM, LVN T put on a pair of gloves and went into Resident #2's room to check her blood sugar. LVN T came out of Resident #2's room with the gloves still on and removed them at the medication cart and started charting on her tablet (used for documentation of medications). LVN T did not perform hand hygiene after glove removal. After this, LVN T put on gloves and went into Resident #7's and checked her blood sugar. LVN T came out of Resident #7's room and removed the gloves at the medication cart. LVN T did not perform hand hygiene after removing her gloves. LVN T prepared insulin and put on another pair of gloves and administered the insulin to Resident #7. LVN T came out of the room and removed her gloves at the medication cart and did not perform hand hygiene. <BR/>During an interview on 02/13/2023 4:03 PM, LVN T stated she should have performed hand hygiene before and after glove removal. LVN T stated she did not perform hand hygiene because there was no hand sanitizer. LVN T stated she did not have any hand sanitizer on her medication cart. LVN T stated she had looked and was not able to find any hand sanitizer in the facility. LVN T stated, I do not know who I have told about it, referring to not being able to find any hand sanitizer. LVN T stated performing hand hygiene was important for infection control and to prevent cross contamination. <BR/>During an interview on 02/16/2023 at 9:28 AM, Medical Records Staff Z stated she was responsible for ordering supplies. She stated she ordered the hand sanitizer a case a month, and that she was aware, the facility always had hand sanitizer available for the staff. <BR/>During an interview on 02/16/2023 at 11:48 AM, LVN B stated hand sanitizer was readily available for the staff and she had never struggled to get any hand sanitizer. LVN B stated it was important to perform hand hygiene to prevent the spread of infection.<BR/>During an interview on 02/16/2023 at 6:37 PM, the infection control preventionist stated staff should perform hand hygiene before and after providing care, before putting on gloves and after taking gloves off. The infection control preventionist stated the staff could do alcohol-based hand sanitizer up to 3 times when checking blood sugars and then they would have to perform hand hygiene with soap and water. The infection control preventionist stated she did check offs on random staff for hand hygiene every 6 weeks. The infection control preventionist stated it was important to perform hand hygiene to cut down on bloodborne pathogens, for the staff to protect themselves and the residents. The infection control preventionist stated not performing hand hygiene placed the residents at risk for COVID, germs and any bloodborne pathogen. The infection control preventionist stated no staff member had ever reported to her there was no hand sanitizer available that the facility always had hand sanitizer available. <BR/>During an interview on 02/16/2023 at 7:15 PM, the ADON stated hand hygiene should be performed before all care, before entering a room, when hands were soiled, before putting on gloves and after removing gloves. The ADON stated all staff were responsible for performing hand hygiene. The ADON stated anytime she walked on the floor she watched staff to see if they were performing hand hygiene. The ADON stated it had not been reported to her that there was no hand sanitizer available. The ADON stated that she knew of the facility always had hand sanitizer available for the staff. The ADON stated not performing hand hygiene placed the residents at risk for the spread of infection. <BR/>During an interview on 02/16/2023 at 8:07 PM, the DON stated hand hygiene should be performed prior to resident interaction, after providing care, and after removal of gloves. The DON stated LVN T should have performed hand hygiene after removing her gloves, while checking blood sugars and administering insulin. The DON stated all the staff knew they were supposed to perform hand hygiene. The DON stated she did spot checks to check for staff performing hand hygiene. The DON stated the facility had never not had hand sanitizer, if they were to get low, she would go to the store and buy some. The DON stated not performing hand hygiene placed the residents at risk for cross contamination. <BR/>During an interview on 02/16/2023 at 9:03 PM, the administrator stated she expected all the staff to perform hand hygiene. The administrator stated the DON was ultimately responsible for ensuring the staff were performing hand hygiene. The administrator stated not performing hand hygiene was an infection control issue. <BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, last revised on August 2019, revealed, The facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); F. Before donning sterile gloves . m. After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, clean, and comfortable environment for 2 of 17 residents in rooms (#205-B and room#104-B) reviewed for environment.<BR/>The facility did not repair the chipped paint on the walls in room [ROOM NUMBER]-B.<BR/>The facility did not repair the torn away baseboards in room#205-B.<BR/>The facility failed to ensure room#104-B was clean.<BR/>These failures could place the residents at risk for an unsafe environment.<BR/>Findings included:<BR/>1.During an observation and interview on 02/14/23 at 12:00 p.m., Resident in room [ROOM NUMBER]-B was sitting in her bed watching TV, observation made of baseboard trim tearing away from the walls in room. Resident in room [ROOM NUMBER]-B stated the shower next door leaked water in her closet and she thought that was why the trim was messed up. Observation made of paint chipped around the baseboards in room#205-B. Resident in room [ROOM NUMBER]-B stated she did not like the trim tearing away from the wall and would like for it to be fixed because bugs would run out from under the trim. Resident in room [ROOM NUMBER]-B stated she had notified staff but could not remember which ones.<BR/>During an interview on 02/14/23 at 10:01 a.m., Resident in room [ROOM NUMBER]-B's family member stated the resident's room was next to the shower room and when other residents took a shower it would leak in the closet next to the trim that was torn away. Family member stated maintenance had recently worked on the shower, but the baseboards remained torn away from the wall.<BR/>During an interview on 02/15/23 at 4:20 p.m., CNA F stated resident in room [ROOM NUMBER]-B's family member visited the facility weekly. CNA F stated the resident in room [ROOM NUMBER]-B's family member had never complained to her of the trim and she never noticed the trim. CNA F stated room repairs should have been logged in the maintenance book at the nursing station and it was everyone's responsibility to report needed repairs. <BR/>During an interview on 02/16/23 at 11:00 a.m., LVN B stated resident in room [ROOM NUMBER]-B had never complained of the chipped paint or the trim tearing away from the wall. LVN B stated all staff was responsible for reporting needed repairs and for filling out the form in the maintenance log at the nursing station. LVN B stated she did not know about the trim, or she would have reported it. LVN B stated the trim could have been a fall hazard. <BR/>During an interview on 02/15/23 at 11:35 a.m., the maintenance supervisor stated he had repaired the shower 2 weeks ago that was leaking in room [ROOM NUMBER]-B. The maintenance supervisor stated, he was not aware of the trim coming off the wall in room [ROOM NUMBER]-B, but he was having to repair all the trim in the facility. The maintenance supervisor stated he had started the repairs in the men's unit on 02/14/23 and was completing repairs one unit at a time. The maintenance supervisor stated he, does not walk into each room to look for repairs and he depended on staff to put needed repairs in the Maintenance logbook. The maintenance supervisor reported nurses were required to do quality rounds and log any maintenance issues. <BR/>Record review of the maintenance log dated 2/14/23-4/12/23 indicated no issues with room [ROOM NUMBER]-B.<BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she expected the trim to be reported and fixed in room [ROOM NUMBER]-B. The DON stated, All staff was responsible for reporting repairs when they see them. The DON reported trim coming off the wall could have been a potential for injury. <BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected the trim to be fixed and all staff was responsible for reporting. The Administrator stated the trim was a trip hazard and it could have led to building damage if not repaired. <BR/>Record review of the policy on Homelike Environment revised 2/2021 indicated staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as clean, sanitary, and orderly environment. <BR/>2.During an observation made on 2/14/23 at 12:24 p.m., Resident in room#104-B's closet had a dark brown substance dried on the trim of the closet door in his room. <BR/>During an observation and interview on 02/15/23 at 12:05 p.m., room#104-B had a dark brown substance dried on the wall above his bed, next to the window. The dark brown substance remained on the closet door frame of room#104-B. CNA E stated she did not know the dark brown substance was on the wall in the room and she was responsible for checking the rooms every 2 hours. CNA E stated housekeeping just left the room. <BR/>During an attempted interview on 02/15/23 at 12:15 p.m., resident in room#104-B was not interviewable. <BR/>During an interview on 02/16/23 at 4:36 p.m., CNA H stated she did not know about the dark brown substance on the wall or door trim in room#104-B or she would have notified housekeeping. CNA H stated the CNAs were responsible for making room checks every 2 hours and cleaning feces on the wall if they saw it.<BR/>During an interview on 02/16/23 at 9:27 a.m., the housekeeping supervisor stated she expected housekeeping staff to clean the dark brown substance on the walls and trim in resident rooms and housekeeping was responsible. Housekeeping supervisor stated she noticed the dark brown substance on the wall on 02/16/23 about 8:15 a.m. and she notified Housekeeper L that the dark brown substance needed to be cleaned. Housekeeping Supervisor stated she was responsible for making daily rounds in resident rooms, but she also worked on a hall and did not always have time to check every room. Housekeeper Supervisor stated she will start making daily rounds to make sure each room was clean. Housekeeping Supervisor stated housekeeping was responsible for cleaning rooms 3 times a day and housekeeping was expected to check every room. Housekeeper Supervisor stated she expected dark brown substance to be cleaned to prevent germs and make sure other residents did not get sick. <BR/>During an interview on 02/16/23 at 10:56 a.m., housekeeper L stated she worked on the men's unit on 02/15/23 and 02/16/23. Housekeeper L stated she was expected to check resident rooms once daily. Housekeeper L stated she did not see the dark brown substance dried on the door trim on 2/15/23 or 2/16/23. Housekeeper L stated she did not see the dark brown substance on the wall in room#104-B during her rounds on 2/16/23. Housekeeper L stated she did not know about the dark brown substance until CNA E had notified her on 2/16/23 and she cleaned it. Housekeeper L stated, she cannot see without glasses and was not wearing them on 02/15/23 or 02/16/23. Housekeeper L stated the Housekeeper Supervisor did not inform her on 02/16/23 that she needed to clean the dark brown substance. Housekeeper L stated she was expected to look for things such as dark brown substances and make sure they were cleaned. Housekeeper L stated, the feces had been on the wall a while because it was hard to scrub off and it was in a bunch of areas. Housekeeper L stated she did not know if anyone checked behind the housekeepers to make sure the rooms were clean. Housekeeper L stated it was important to make sure the rooms were clean because of infection control and the residents or employees could have got sick. <BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she expected the dark brown substances to be cleaned off the walls in resident rooms and housekeeping was responsible for making sure the rooms were clean. The DON stated housekeeping checked resident rooms daily. The DON stated staff will start having to do angel rounds (administrative staff assigned to make daily rounds to check rooms) to make sure resident rooms were clean and not in need of repairs.<BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected housekeeping to clean dark brown substances dried on the walls in resident rooms and housekeeping was responsible for making sure the rooms were clean. The Administrator stated housekeeping should have been constantly doing rounds and all staff were responsible for reporting feces on the walls. <BR/>Record review of the policy on Homelike Environment revised 2/2021 indicated staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as clean, sanitary, and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, clean, and comfortable environment for 2 of 17 residents in rooms (#205-B and room#104-B) reviewed for environment.<BR/>The facility did not repair the chipped paint on the walls in room [ROOM NUMBER]-B.<BR/>The facility did not repair the torn away baseboards in room#205-B.<BR/>The facility failed to ensure room#104-B was clean.<BR/>These failures could place the residents at risk for an unsafe environment.<BR/>Findings included:<BR/>1.During an observation and interview on 02/14/23 at 12:00 p.m., Resident in room [ROOM NUMBER]-B was sitting in her bed watching TV, observation made of baseboard trim tearing away from the walls in room. Resident in room [ROOM NUMBER]-B stated the shower next door leaked water in her closet and she thought that was why the trim was messed up. Observation made of paint chipped around the baseboards in room#205-B. Resident in room [ROOM NUMBER]-B stated she did not like the trim tearing away from the wall and would like for it to be fixed because bugs would run out from under the trim. Resident in room [ROOM NUMBER]-B stated she had notified staff but could not remember which ones.<BR/>During an interview on 02/14/23 at 10:01 a.m., Resident in room [ROOM NUMBER]-B's family member stated the resident's room was next to the shower room and when other residents took a shower it would leak in the closet next to the trim that was torn away. Family member stated maintenance had recently worked on the shower, but the baseboards remained torn away from the wall.<BR/>During an interview on 02/15/23 at 4:20 p.m., CNA F stated resident in room [ROOM NUMBER]-B's family member visited the facility weekly. CNA F stated the resident in room [ROOM NUMBER]-B's family member had never complained to her of the trim and she never noticed the trim. CNA F stated room repairs should have been logged in the maintenance book at the nursing station and it was everyone's responsibility to report needed repairs. <BR/>During an interview on 02/16/23 at 11:00 a.m., LVN B stated resident in room [ROOM NUMBER]-B had never complained of the chipped paint or the trim tearing away from the wall. LVN B stated all staff was responsible for reporting needed repairs and for filling out the form in the maintenance log at the nursing station. LVN B stated she did not know about the trim, or she would have reported it. LVN B stated the trim could have been a fall hazard. <BR/>During an interview on 02/15/23 at 11:35 a.m., the maintenance supervisor stated he had repaired the shower 2 weeks ago that was leaking in room [ROOM NUMBER]-B. The maintenance supervisor stated, he was not aware of the trim coming off the wall in room [ROOM NUMBER]-B, but he was having to repair all the trim in the facility. The maintenance supervisor stated he had started the repairs in the men's unit on 02/14/23 and was completing repairs one unit at a time. The maintenance supervisor stated he, does not walk into each room to look for repairs and he depended on staff to put needed repairs in the Maintenance logbook. The maintenance supervisor reported nurses were required to do quality rounds and log any maintenance issues. <BR/>Record review of the maintenance log dated 2/14/23-4/12/23 indicated no issues with room [ROOM NUMBER]-B.<BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she expected the trim to be reported and fixed in room [ROOM NUMBER]-B. The DON stated, All staff was responsible for reporting repairs when they see them. The DON reported trim coming off the wall could have been a potential for injury. <BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected the trim to be fixed and all staff was responsible for reporting. The Administrator stated the trim was a trip hazard and it could have led to building damage if not repaired. <BR/>Record review of the policy on Homelike Environment revised 2/2021 indicated staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as clean, sanitary, and orderly environment. <BR/>2.During an observation made on 2/14/23 at 12:24 p.m., Resident in room#104-B's closet had a dark brown substance dried on the trim of the closet door in his room. <BR/>During an observation and interview on 02/15/23 at 12:05 p.m., room#104-B had a dark brown substance dried on the wall above his bed, next to the window. The dark brown substance remained on the closet door frame of room#104-B. CNA E stated she did not know the dark brown substance was on the wall in the room and she was responsible for checking the rooms every 2 hours. CNA E stated housekeeping just left the room. <BR/>During an attempted interview on 02/15/23 at 12:15 p.m., resident in room#104-B was not interviewable. <BR/>During an interview on 02/16/23 at 4:36 p.m., CNA H stated she did not know about the dark brown substance on the wall or door trim in room#104-B or she would have notified housekeeping. CNA H stated the CNAs were responsible for making room checks every 2 hours and cleaning feces on the wall if they saw it.<BR/>During an interview on 02/16/23 at 9:27 a.m., the housekeeping supervisor stated she expected housekeeping staff to clean the dark brown substance on the walls and trim in resident rooms and housekeeping was responsible. Housekeeping supervisor stated she noticed the dark brown substance on the wall on 02/16/23 about 8:15 a.m. and she notified Housekeeper L that the dark brown substance needed to be cleaned. Housekeeping Supervisor stated she was responsible for making daily rounds in resident rooms, but she also worked on a hall and did not always have time to check every room. Housekeeper Supervisor stated she will start making daily rounds to make sure each room was clean. Housekeeping Supervisor stated housekeeping was responsible for cleaning rooms 3 times a day and housekeeping was expected to check every room. Housekeeper Supervisor stated she expected dark brown substance to be cleaned to prevent germs and make sure other residents did not get sick. <BR/>During an interview on 02/16/23 at 10:56 a.m., housekeeper L stated she worked on the men's unit on 02/15/23 and 02/16/23. Housekeeper L stated she was expected to check resident rooms once daily. Housekeeper L stated she did not see the dark brown substance dried on the door trim on 2/15/23 or 2/16/23. Housekeeper L stated she did not see the dark brown substance on the wall in room#104-B during her rounds on 2/16/23. Housekeeper L stated she did not know about the dark brown substance until CNA E had notified her on 2/16/23 and she cleaned it. Housekeeper L stated, she cannot see without glasses and was not wearing them on 02/15/23 or 02/16/23. Housekeeper L stated the Housekeeper Supervisor did not inform her on 02/16/23 that she needed to clean the dark brown substance. Housekeeper L stated she was expected to look for things such as dark brown substances and make sure they were cleaned. Housekeeper L stated, the feces had been on the wall a while because it was hard to scrub off and it was in a bunch of areas. Housekeeper L stated she did not know if anyone checked behind the housekeepers to make sure the rooms were clean. Housekeeper L stated it was important to make sure the rooms were clean because of infection control and the residents or employees could have got sick. <BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she expected the dark brown substances to be cleaned off the walls in resident rooms and housekeeping was responsible for making sure the rooms were clean. The DON stated housekeeping checked resident rooms daily. The DON stated staff will start having to do angel rounds (administrative staff assigned to make daily rounds to check rooms) to make sure resident rooms were clean and not in need of repairs.<BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected housekeeping to clean dark brown substances dried on the walls in resident rooms and housekeeping was responsible for making sure the rooms were clean. The Administrator stated housekeeping should have been constantly doing rounds and all staff were responsible for reporting feces on the walls. <BR/>Record review of the policy on Homelike Environment revised 2/2021 indicated staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as clean, sanitary, and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 3 of 17 residents (Residents #7, #47 and #45) reviewed for grievances. <BR/>1. The facility did not ensure a grievance was file for Resident #7 when three pair of shoes was not returned from the laundry. <BR/>2. The facility did not ensure a grievance was file for Resident #47 when a multicolored dress, a pair of socks, and a head band was not returned from the laundry. <BR/>3. The facility failed to file a grievance for Resident #45 when a jacket and green matching sweatshirt and pants was not returned from the laundry. <BR/>4. The facility failed to ensure the grievances for Residents #7, #47, and #45 were resolved until after surveyor interventions.<BR/>These failures could place residents at risk for grievances not being addressed or resolved promptly.<BR/>Findings include: <BR/>1.Record review of Resident #7's order summary report, dated 02/16/2023, indicated Resident #7 was a [AGE] year-old-female, originally admitted to the facility on [DATE] with a diagnosis which included congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and essential hypertension (high blood pressure). <BR/>Record review of Resident #7's annual MDS, dated [DATE], indicated Resident #7 usually understood others and usually made herself understood. The assessment indicated Resident #7 was cognitively intact with a BIMS score of 14. <BR/>Record review of Resident #7's undated care plan did not address Resident #7 missing personal property.<BR/>During an interview on 02/14/2023 at 3:15 p.m., Resident #7 stated she had three pairs of shoes missing. Resident #7 stated she had reported the missing items to the Housekeeping Supervisor last year, unable to recall exact date. Resident #7 stated she still had not received the shoes. <BR/>2. Record review of Resident #47's order summary report, dated 02/16/2023, indicated Resident #47 was a [AGE] year-old-female, admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (high blood pressure), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of Resident #47's annual MDS, dated [DATE], indicated Resident #47 understood others and made herself understood. The assessment indicated Resident #47 was cognitively intact with a BIMS score of 15. <BR/>Record review of Resident #47's undated care plan did not address Resident #47 missing personal property.<BR/>Record review of the facility's grievances dated October 2022-Febraury 2023 did not reveal a grievance for Residents #47 and #7 missing personal property. <BR/>During an interview on 02/13/2023 at 3:46 p.m., Resident #47 stated she had a multicolored dress, a pair of socks, and a head band missing. Resident #47 stated she had reported the missing items to the Housekeeping Supervisor. Resident #47 stated she still had not received the items. <BR/>During an interview on 02/16/2023 at 10:53 a.m., the Housekeeping Supervisor stated Resident #47 reported to her, she was missing a dress, a pair of socks and a head band. The Housekeeping Supervisor stated she went through all of the closets in the facility to see if the items were located in someone else closet. The Housekeeping Supervisor stated after she could not locate the shoes, she reported the missing items during the morning meeting the following day. The Housekeeping Supervisor could not recall the exact the date but believed it was three months ago. The Housekeeping Supervisor stated she assumed after reporting the missing items during morning meeting it was handled by the DON. The Housekeeping Supervisor stated Resident #7 reported to her, she was missing two pairs of shoes. The Housekeeper Supervisor stated she had just become the supervisor, so she went and asked the DON what the process on handling lost items was. The Housekeeper Supervisor stated the DON told her she will be replacing the shoes. The Housekeeper Supervisor stated after being told by the DON the items would be replaced, she assumed the issue was taken care of. The Housekeeping Supervisor stated this failure could make residents feel their rights were not taken into consideration.<BR/>During an interview on 02/16/2023 at 4:21 p.m., the DON stated prior to 02/13/2023 she had not received any information about Resident #47 having any missing property. The DON stated if a resident/staff reported to her, a grievance form would be completed, and she would assign a staff member to start looking for those items. The DON stated if the items were not located, they should have been replaced. The DON stated a staff member reported to her Resident #7 was missing three pair of shoes. The DON was unable to recall the staff name. When asked when the missing items was reported to her, she stated I don't know. The DON stated she did not remember specifically filling out a grievance form. The DON stated the social worker should have been assign but she could not remember. When asked why the shoes were not replaced, she stated I don't know why the shoes wasn't replaced. The DON stated this failure could make residents feel their rights were not taken into consideration.<BR/>During an interview on 02/16/2023 at 5:56 p.m., the Administrator stated she was the grievance officer. The Administrator stated the grievance would be investigated by the department head related to the specific compliant. The Administrator stated complaints and grievances were discussed during the morning management meetings. The Administrator stated Resident #7 complained about missing her shoes around October 2022. The Administrator stated it was bought to the morning meeting and the DON stated, I'm getting on amazon now to purchase them. The Administrator stated she did not follow up to see if the shoes were actually ordered. The Administrator stated she was not aware of Resident #47's missing items. The Administrator stated the person that Resident #47 reported to was responsible for reporting it to her. The Administrator stated after being educated by the corporate team a grievance form should be completed on anything that was brought to her attention. The Administrator stated she felt like there was a system in place, but it was not a successful one. The Administrator stated this failure could make residents feel their rights were not taken into consideration.<BR/>3. Record review of Resident #45's face sheet, dated 02/16/2023, revealed Resident #45 was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation (lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus with unspecified complications (high blood sugars), and schizoaffective disorder, bipolar type (mental disorder that causes abnormal thought processes and unstable mood). <BR/>Record review of the quarterly MDS assessment with an assessment reference date of 12/24/2022, revealed Resident #45 was understood and understood others. The MDS assessment revealed Resident #45 had a BIMS score of 15, indicating she was cognitively intact. <BR/>Record review of the facility's grievances did not reveal a grievance for Resident #45's missing jacket and green matching sweatshirt and pants. <BR/>During an interview on 02/14/2023 at 11:24 AM, Resident #45 stated she was missing a black jacket and a green matching sweatshirt and pants. Resident #45 stated the clothes had gone to the laundry and were not brought back. Resident #45 stated this happened last week and she had told Laundry Aide R and Laundry Aide Q, and they had not been able to find the missing items. <BR/>During an interview on 02/14/2023 at 3:53 PM, the Housekeeping/Laundry Supervisor stated she was not aware Resident #45 was missing a jacket and a green matching sweatshirt and pants. The Housekeeping/Laundry Supervisor stated if there were missing clothing items the laundry aides were supposed to notify her. The Housekeeping/Laundry Supervisor stated when she was notified of a missing clothing item that was not found she would report it in the morning meetings, and they decided what to do from there. The Housekeeping/Laundry Supervisor stated it was important for the residents' clothes to be returned to them because they should have their stuff and they paid for it. <BR/>During an interview on 02/14/2023 at 4:10 PM, Laundry Aide R stated Resident #45 had not reported to her that she was missing a black jacket and a green matching sweatshirt and pants. Laundry Aide R stated if residents were missing clothing items, she would report it to the Housekeeping/Laundry Supervisor. <BR/>During an interview on 02/14/2023 at 4:15 PM, Laundry Aide Q stated Resident #45 had reported to her last week that she was missing a jacket and a green matching sweatshirt and pants. Laundry Aide Q stated she had been looking for the missing items but had not been able to locate them. Laundry Aide Q stated she told the housekeeping/laundry supervisor she could not find the items. Laundry Aide Q stated if she could not find an item, she would report it to the Housekeeping/Laundry Supervisor, and the Housekeeping/Laundry Supervisor would handle it from there. Laundry Aide Q stated the residents' clothes not being returned to them could make them sad and unhappy, and it was their belongings and they deserved to have them. <BR/>During an interview on 02/14/2023 at 5:26 PM, the administrator stated usually social services was responsible for the grievances, but the facility currently did not have a social worker. The administrator stated she had taken over the grievances while the facility did not have a social worker The administrator stated, Grievances are only for misappropriation or something that I cannot fix then and there, if it is an abuse allegation I do a self-report, if it is laundry missing, I do not fill out a grievance form. The administrator stated she was not aware of Resident #45 missing a jacket and a green matching sweatshirt and pants.<BR/>During an interview on 02/15/2023 at 8:50 AM, the administrator stated she looked at the facility's policy for grievances, and when someone notified her of missing clothing items, she should fill out a grievance form. <BR/>During an interview on 2/16/23 at 6:49 PM, the ADON stated if a resident reported missing clothes staff should go to the laundry and ask them if it was there, and if it was not immediately found a grievance should be filed. The ADON stated, I think any of us can file a grievance and then the administrator does the investigation. The ADON stated no residents had reported to her that they were missing laundry. The ADON stated it was important to file grievances to ensure there was follow up and that the issue was addressed. <BR/>During an interview on 2/16/23 at 7:34 PM, the DON stated if a resident notified her, they were missing an item she would find out what the item was and start searching for it. The DON stated, Anybody could write up a grievance. The DON stated she was not aware Resident #45 was missing a jacket and a green matching sweatshirt and pants. The DON stated a grievance should have been written for Resident #45's missing clothing items. The DON stated it was important to fill out grievance forms so they could keep track of what was going on and get back with the residents and replace the items if necessary. The DON stated in their morning meetings daily they discussed if residents were missing items. <BR/>Record review of the facility's policy titled, Grievances/Complaints-Staff Responsibility, last revised May 2017, revealed, Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. Policy Interpretation and Implementation 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative (sponsor), or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents etc., the staff member is encouraged to guide the resident, or person acting on the resident's behalf as to how to file a written complaint with the facility. 2. Staff members will inform the resident or the person acting on the resident's behalf that he or she may file a grievance or complaint with the Administrator or other government agencies as noted on the resident's bulletin board, without fear of threat or any other form of reprisal. 3. Staff members will inform the resident or the person acting on the resident's behalf as to where to obtain a Resident Grievance/Complaint Form and where to locate the procedures for filing a grievance or complaint (e.g., posted on the residents' bulletin board) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, and neglect, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 17 residents (Resident #7) reviewed for abuse.<BR/>The facility failed to acknowledge, investigate, and report neglect to the state agency on behalf of Resident #7.<BR/>This failure could place residents at risk for neglect due to unreported and uninvestigated allegations of neglect.<BR/>Findings include:<BR/>Record review of Resident # 7's face sheet, dated 02/16/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include: cerebral infarction, ( a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off.) hemiplegia (paralysis) and hemiparesis one?sided weakness following cerebral infarction affecting unspecified side, muscle weakness, lack of coordination, muscle wasting atrophy ( thinning or loss of muscle tissue), need for assistance with personal care, incontinent (having no or insufficient voluntary control over urination or defecation).<BR/>Record review of Resident # 7's comprehensive MDS assessment, dated November 26, 2022, revealed Resident #7's BIMS score was 14, which indicated cognition intact. Resident #7 required extensive assistance with two persons physical assist for bed mobility, transfers, dressing, and toileting. Resident #7 could make her needs known and could be understood. Section H 0300, urinary continence, indicated Resident #7 was always incontinent. Section H 0400, bowel continence, indicated Resident #7 was always incontinent. Section E0800, rejection of care, indicated Resident #7 did not refuse care. <BR/>Record review of Resident #7's care plan, with a revision date of 12/16/2022, indicated Resident #7 had a potential impairment to skin integrity related to decreased mobility and incontinence. The care plan interventions included, keep skin clean/dry, identify/document potential causative factors and eliminate/resolve where possible. <BR/>Record review of Resident #7's progress note dated 02/13/2023, revealed Resident reported to this nurse upon entry to room at ac (before) breakfast blood sugar that CNA previous night shift was refusing this resident ADL care. Day shift arrived and provided care to resident. This nurse reported allegations to Administrator. Progress note was signed by LVN B on 02/13/2023 at 8:30 AM.<BR/>During an interview on 02/14/23 10:03 AM, Resident #7 stated she pressed her call light and the CNA for the night came to her room. Resident #7 said the CNA came into the room and asked Resident #7, what now. Resident #7 stated the CNA spoke to her rudely. Resident #7 stated she asked, Can I get changed please, and the CNA said No, I just changed you an hour ago and slammed the door and left and she did not come back. Resident #7 said she waited about 35 minutes and then turned the call light back on. Resident #7 stated the CNA worked 2-10 or 10-6 and she was afraid of her. Resident #7 stated she reported this to LVN B on the morning of 02/13/2023. Resident #7 was unable to provide the CNA's name.<BR/>During an interview on 02/16/23 at 11:46 AM, LVN B stated Monday (02/13/23) morning Resident #7 told her that the aide refused to change her. LVN B stated the CNA had gone into Resident #7's room and told her she would not change her. LVN B stated Resident #7 was unable to give her a name for the CNA just said it was the night CNA. LVN B said she immediately reported it to the administrator, who was the abuse coordinator. LVN B stated it was important to report abuse and neglect to protect the residents and their rights because the facility was their home. <BR/>During an interview on 02/16/23 at 8:33 PM, the DON stated she was not aware Resident #7 had reported to LVN B the CNA refused to provide ADL care on Sunday night (02/12/23). The DON stated she had done in-services in the past on reporting allegations of abuse and neglect to the administrator, and if the administrator was not available to report it to her. The DON stated if she received any allegations of abuse or neglect, she would first investigate it and then determine if it should be reported. The DON stated it sounds like it could have been reported regarding Resident #7's allegations, but she needed more information. The DON stated Resident #7's allegations not being reported could place her at risk for impaired skin integrity and it could cause Resident #7 emotional distress. <BR/>During an interview on 02/16/23 at 9:29 PM, the administrator stated she was not aware Resident #7 had reported to LVN B the CNA refused to provide ADL care on Sunday night (02/12/23). The administrator said LVN B did not report to her that Resident #7 had notified her a CNA refused to provide ADL care on Sunday night (02/12/23). The administrator said LVN B should have reported Resident #7's allegations to her immediately so that she could have investigated and reported the allegation. The administrator said she expected the staff to report all allegations of abuse or neglect to her immediately. The administrator said the allegations not being reported could harm the resident and her skin and was a dignity issue. <BR/>A record review of the facility's April 2021, Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating policy revealed, policy statement: all reports of resident abuse (including the injuries of unknown origin), neglect, exploitation, or theft misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. findings of all investigations are documented and reported. Policy interpretation and implementation: Reporting allegations to the Administrator and authorities: If a resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected; the suspicion must be reported immediately to the administrator and to other officials according to state law. the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing certification agency responsible for surveying licensing the facility; the local state ombudsman; the residents representative; the residents attending physician; the facility's medical director; adult Protective Services; law enforcement; immediately is defined as within two hours of an allegation involving abuse or results in serious bodily injury or within 24 hours of an allegation that does not involve abuse or results in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the Minimum Date Set (MDS) specified by the state and approved by CMS for 1 of 17 residents (Resident #45) reviewed for quarterly assessments. <BR/>The facility failed to ensure Resident #45's MDS assessments were done quarterly. <BR/>This failure could place residents at risk for not having their assessments completed timely and not having their individually assessed needs met. <BR/>Findings include:<BR/>Record review of Resident #45's face sheet, dated 02/16/2023, revealed Resident #45 was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation (lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus with unspecified complications (high blood sugars), and schizoaffective disorder, bipolar type (mental disorder that causes abnormal thought processes and unstable mood). <BR/>Record review of Resident #45's electronic medical record revealed an admission assessment with an assessment reference date (ARD) of 04/14/2022 and was completed on 04/18/2022. The quarterly MDS assessment following the admission assessment had an assessment reference date (ARD) of 08/27/2022 and was completed on 08/27/2022. This was more than 3 months between MDS assessments. <BR/>During an interview on 02/16/2023 at 6:12 PM, the MDS coordinator stated she was responsible for completing the MDS assessments. The MDS coordinator stated the MDS assessments should be completed quarterly. The MDS coordinator stated she used the facility's system to calculate when the next MDS assessment was due, therefore she was not sure if Resident #45's quarterly MDS assessment was completed late. The MDS coordinator stated her regional MDS person monitored her completion of MDS assessments weekly. The MDS coordinator stated it was important to complete the MDS assessments timely for the state and to monitor the residents' progress. <BR/>During an interview on 02/16/2023 at 7:58 PM, the DON stated she was the RN signing the MDS assessments. The DON stated the MDS assessments should be done quarterly. The DON stated Resident #45's MDS assessment was completed late, due to an oversight. The DON stated corporate usually monitored the MDS assessments and she looked over them when she signed them. The DON stated it was important to complete the MDS assessments timely to keep the residents' charts up to date and accurate. <BR/>During an interview on 02/16/2023 at 8:54 PM, the administrator stated ultimately the DON was responsible for ensuring the MDS assessments were completed timely. The administrator stated she expected for the MDS assessments to be completed timely. The administrator stated corporate did audits of the MDS assessments maybe once a month. The administrator stated not completing the MDS assessments timely could delay care. The administrator stated it was important to complete the MDS assessments timely in case something with the residents had changed, it could be addressed. <BR/>Record review of the facility's policy titled, MDS Completion and Submission Timeframes, last revised July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . <BR/>Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 updated October 2019 indicated, The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCPA, SCQA, or Annual assessment + 92 calendar days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure an accurate MDS was completed for 4 of 17 residents (Resident's #12, #22, #28, and #47) reviewed for MDS assessment accuracy.<BR/>1. The facility failed to accurately document oral status for Resident #47 on the MDS assessment.<BR/>2. The facility failed to accurately document hospice status for Resident #22 on the MDS assessment.<BR/>3. The facility failed to accurately document a diagnosis of pneumonia on Resident #28's MDS assessment.<BR/>4. The facility failed to accurately reflect Resident #12's dental status on the MDS assessment.<BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>The findings included: <BR/>1. Record review of Resident #47's face sheet, dated 02/16/2023, revealed Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acquired absence of left leg below knee (left leg amputation below the knee). <BR/>Record review of Resident #47's order summary report, dated 02/16/2023, revealed an order which started on 09/19/2022, for dental care as needed. <BR/>Record review of the comprehensive MDS assessment, dated 10/02/2022, revealed Resident #47 had clear speech and was understood by staff. The MDS revealed Resident #47 was able to understand others. The MDS revealed Resident #47 had a BIMS score of 15 which indicated no cognitive impairment. The MDS revealed Resident #47 had no obvious or likely cavity or broken natural teeth. <BR/>Record review of the comprehensive care plan, last revised on 9/24/2022, revealed no plan of care for oral or dental status. <BR/>Record review of the admit or readmit screener assessment - section D, dated 09/20/2022 revealed Resident #47 had broken and carious teeth. <BR/>Record review of the oral or dental status assessment, dated 09/19/2022, revealed Resident #47 had missing teeth. <BR/>During an observation and interview on 02/15/2023 at 8:11 AM, Resident #47 stated she was having pain to her lower jaw in the back on the right side. Resident #47 stated the pain was 9 out of 10 on the pain scale during the last month. Resident #47 stated the pain was worse during meals when she was eating. Resident #47 was smiling with no facial grimacing observed. Resident #47 was working on her small gem puzzle during the interview. Resident #47 had missing teeth and inflamed gums. Resident #47's natural teeth were black with obvious cavities. Resident #47 had a split tooth to her lower jaw in the back on the right side that was rubbing on her tongue. Resident #47 stated she told the DON about her dental pain approximately 1 month ago. Resident #47 stated the DON told her she would see about the dentist. Resident #47 stated she had not been told anything else regarding a dental appointment.<BR/>2. Record review of Resident #22's face sheet, dated 02/16/2023, revealed Resident #22 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), hemiplegia and hemiparesis following a stroke affecting the right-dominant side (conditions that cause weakness on one side of the body), and chronic obstructive pulmonary disease - COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of the order summary report, dated 02/16/2023, revealed Resident #22 had an order that started on 11/09/2019 to admit to hospice care. <BR/>Record review of the MDS assessment, dated 11/15/2022, revealed Resident #22 had clear speech and was understood by staff. The MDS revealed Resident #22 was able to understand others. The MDS revealed Resident #22 had a BIMS score of 8 which indicated moderately impaired cognition. The MDS revealed Resident #22 had a life expectancy of less than 6 months. The MDS revealed Resident #22 had no hospice care while a resident during the look-back period. <BR/>Record review of the comprehensive care plan, initiated on 03/20/2019, revealed Resident #22 had a terminal prognosis and was receiving hospice services. <BR/>3. Record review of Resident #28's face sheet, dated 02/16/2023, revealed Resident #28 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of traumatic brain injury (head injury causing damage to the brain by external force or mechanism), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), and aphasia(comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). <BR/>Record review of the order summary report, dated 02/16/2023, revealed no antibiotics were ordered. <BR/>Record review of the MDS assessment, dated 01/17/2023, revealed Resident #28 had unclear speech and was rarely understood by staff. The MDS revealed Resident #28 sometimes understood others. The MDS revealed Resident #28 had poor short-term and long-term memory. The MDS revealed Resident #28 had no recall ability. The MDS revealed Resident #28 had severely impaired decision-making ability. The MDS revealed Resident #28 had an active diagnosis of pneumonia during the look-back period. The MDS revealed Resident #28 had no shortness of breath, fever, vomiting, or dehydration. The MDS revealed Resident #28 received no antibiotics during the look-back period. <BR/>Record review of the comprehensive care plan, last revised on 05/07/2022, revealed no care plan for pneumonia. <BR/>Record review of the medication administration record, dated January 2023, revealed no antibiotic were given during the look-back period. <BR/>During an interview on 02/16/2023 at 5:33 PM, the MDS Coordinator stated the MDS assessments were accurate to the best of her knowledge and according to the charting. The MDS Coordinator stated she looked at assessments, doctors' orders, and progress notes to complete the MDS assessment. The MDS Coordinator stated if there was a discrepancy in the charting, she would have assessed the resident herself. The MDS Coordinator stated she did not look at Resident #47's assessment that revealed her dental status. The MDS Coordinator stated she forgot to check the box for hospice care for Resident #22. The MDS Coordinator stated she forgot to uncheck the box for pneumonia for Resident #28. The MDS Coordinator stated it was important to ensure the MDS assessment was accurate to get an accurate representation of the resident. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated she was the RN responsible for ensuring the MDS assessment was complete and accurate. The DON stated oral or dental status should have been accurately reflected for Resident #47 so it would have been reflected on the plan of care. The DON stated hospice care should have been checked for Resident #22. The DON stated pneumonia should not have been checked as an active diagnosis for Resident #28. The DON stated the importance of ensuring the MDS assessment was accurate was for billing purposes. <BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she expected MDS assessments to be completed accurately and timely. The ADM stated the importance of completing MDS assessments accurately and timely was to ensure residents were not receiving delays in care and the facility was not receiving delays in billing. <BR/>4. Record review of the consolidated physician orders dated 02/16/23 indicated Resident #12 was a [AGE] year-old female that was admitted to the facility on [DATE] and had a diagnosis of Schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), Asthma (inflamed airways that make it difficult to breath) and HTN (force of blood against the artery walls is too high). <BR/>Record review of the Comprehensive MDS dated [DATE] indicated Resident #12 usually made herself understood and usually understands. Resident #12's BIMS score was a 7 indicating severe impairment. The MDS indicated Resident #12 was on a mechanically altered diet. The MDS indicated no issues with swallowing or dental status.<BR/>Record review of Resident #12's order summary dated 07/28/22 indicated a regular diet with soft and bite-size food (Level 6 texture). The order summary indicated dental care as needed. <BR/>Record review of Resident #12's care plan dated 07/03/22 indicated a potential nutritional problem related to new admit. Interventions included for the Dietary manager to discuss food preferences with resident and family upon admission to meet dietary needs.<BR/>Record review of Resident #12's oral and dental status assessment completed on 07/04/22 indicated Resident #12 did not have any upper teeth and broken teeth on the bottom. <BR/>During an observation and interview on 2/15/23 at 3:00 p.m., Resident #12's teeth were broken, missing and discolored. Resident #12 stated her teeth hurt when she chewed and she, almost choked on broccoli the other day because she was not able to chew properly. Resident #12 stated she had reported her teeth hurting to staff but was unable to verbalize which staff members or when.<BR/>During an interview on 02/14/23 at 10:01a.m., family member stated she reported to facility staff when Resident #12 was admitted on [DATE] that resident had issues with dental and she notified the Administrator again in January 2022 that Resident #12 needed a dental evaluation.<BR/>During an interview on 02/15/2023 at 8:38 a.m., the Customer Care Representative at Health drive denied having a dental referral for Resident #12.<BR/>During an interview on 02/15/23 at 4:20 p.m., CNA F stated Resident #12's family member makes weekly visits to the facility. CNA F stated she was aware that Resident #12 was complaining of tooth pain and needing a dental eval. CNA F stated she did not report it to the Administrator because the family member told her she had already reported the tooth pain to the Administrator and the facility should be taking care of it.<BR/>During an interview on 02/15/23 at 11:14 a.m., the MDS nurse stated she completed Resident #12's MDS and indicated on the MDS Resident #12 did not have any dental issues. The MDS nurse stated she was not aware of the oral and dental assessment found in Resident #12's chart. The MDS nurse stated she only looked at the nursing assessment that was completed upon admission to assist with filling out the MDS. The MDS nurse reported she completed her own assessment on Resident #12 for the MDS and, she might have marked no dental issues on the MDS because Resident #12 would not let her look at her teeth. The MDS nurse stated she was responsible for filling out the MDS correctly and not indicating dental issues or tooth pain could have resulted in distress to the patient. <BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she was not aware that Resident #12 needed a dental evaluation and her family had never notified her that Resident #12 needed dental care. The DON stated Resident #12 should have been assessed upon admission for dental issues and staff should have been working as a team to monitor Resident #12's need for dental services. The DON stated the MDS nurse was responsible for making sure the MDS was filled out correctly. The DON stated she was responsible for looking over the MDS and making sure it was correct. The DON stated not getting dental care could have made Resident #12 feel bad due to pain.<BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator reported she expected the MDS to be accurate and the MDS nurse was responsible for making sure the MDS was correct. The Administrator stated the Corporate MDS team was responsible for making sure the MDS nurse filled out the MDS correctly. <BR/>Record review of the Certifying Accuracy of the Resident Assessment policy, last revised in November 2019, revealed Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy further revealed information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 17 residents (Resident #17, Resident #26, Resident #40, and Resident #67) reviewed for care plans. <BR/>The facility failed to develop and implement a care plan for Resident #17's need for assistance with ADLs. <BR/>The facility failed to develop and implement a care plan for Resident #26's dental problems.<BR/>The facility failed to develop and implement a care plan for Resident #40's contractures. <BR/>The facility failed to develop and implement a care plan for Resident #67's wandering/risk for elopement.<BR/>These failures could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #17's face sheet, dated 02/16/2023, indicated she was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified (lung disease that causes obstructed air flow in the lungs), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and dependence on supplemental oxygen. <BR/>Record review of the MDS comprehensive assessment with an assessment reference date of 04/25/2022, indicated Resident #17 was understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 13, indicating Resident #17's cognition was intact. The MDS assessment indicated Resident #17 did not reject evaluation or care. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing, toilet use and limited assistance with personal hygiene and supervision for eating. <BR/>Record review of Resident #17's care plan with target date of 04/09/2023 indicated no care plan for Resident #17's need for assistance with ADLs. <BR/>2. Record review of Resident #26's face sheet dated 02/16/2023 indicated, Resident #26 was re-admitted on [DATE] with diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), schizoaffective disorder, bipolar type (mood disorder characterized by abnormal thought processes and unstable mood), and type 2 diabetes mellitus with other diabetic neurological complication (high blood glucose levels with nerve damage). <BR/>Record review of Resident #26's comprehensive MDS assessment with an assessment reference date of 11/27/2022 indicated, Resident #26 was usually understood and usually understood others. The MDS assessment indicated Resident #26 had a BIMS score of 13, indicating her cognition was intact. The MDS assessment indicated Resident #26 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and supervision for eating. Resident #26's MDS assessment indicated she did not have broken or loosely fitting full or partial denture, no natural teeth or tooth fragments, abnormal mouth tissue obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort, or difficulty with chewing. <BR/>Record review of Resident #26's Order Summary Report dated 02/16/2023 indicated physician's orders for dental care PRN (as needed) with start date of 03/09/2020 and amoxicillin oral capsule 500 mg give 1 capsule by mouth every 8 hours for tooth abscess for 10 days until finished with start date of 02/11/2023. <BR/>Record review of Resident #26's care plan with target date of 12/17/2022 did not reveal Resident #26's dental problems.<BR/>During an observation and interview on 02/15/23 at 8:13 AM, Resident #26 stated in the past maybe the year before last she had her upper teeth in the back one on the right and one on the left side smoothed down because they were cavities. Resident #26 stated her other teeth were now being affected because she needs those 2 teeth pulled out and had not been able to see the dentist. Resident #26 stated her Medicaid did not pay for dental and she did not have money to pay the dentist. Resident #26 stated she had told the nurses her teeth were causing her pain and they needed to be taken out. Resident #26 stated one of the facility staff was supposed to refer her to a dentist that would take her Medicaid, but she had not heard back from them. Resident #26 was unable to recall who the staff member was. Resident #26 stated about a week ago she got an abscess on her left side related to her teeth and the facility physician order antibiotics for this. Observation of Resident #26's teeth indicated 2 upper teeth in the back one on the right and one on the left side were jagged and black with the left side having [NAME]/corrosion than the right. Resident #26 stated the pain was worse throughout the day and when she ate food. Resident #26 stated she had tramadol for chronic pain, and this helped with her teeth pain as well. Resident #26 stated sometimes she could not sleep related to the pain to her teeth, but that her pain had improved since starting the antibiotics. <BR/>3. Record review of a face sheet dated 02/16/2023 indicated Resident #67 was an [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with no behaviors), essential (primary) hypertension (high blood pressure), and hypothyroidism (a condition resulting from decreased thyroid hormones). <BR/>Record review of the comprehensive MDS assessment with assessment reference date of 04/05/2022 indicated Resident #67 was usually understood and understands others. The MDS assessment indicated Resident #67 had a BIMS score of 06, indicating severe cognitive impairment. The MDS assessment indicated Resident #67 did not exhibit wandering. The MDS assessment indicated Resident #67 required limited assistance with bed mobility, transfer, walk in room and corridor, dressing toilet use, personal hygiene, and supervision for eating. <BR/>Record review of the care plan with target date of 02/19/2023 did not reveal Resident #67 had wandering/elopement care planned. <BR/>Record review of Resident #67's Quarterly Review for Secured Unit with effective date of 12/30/2022 indicated Resident #67 required placement on a secured unit due to habitually wanders or would wander out of building and is unable to find their way back.<BR/>During an interview on 2/13/2023 at 4:55 PM, CNA F stated she worked on the secured unit Monday-Friday 2 PM-10 PM and sometimes 10 PM-6 PM and provided care to Resident #67. CNA F stated Resident #67 wandered and at times would exit seek.<BR/>During an interview and observation on 02/16/2023 at 10:55 AM, Resident #67 was walking up and down the hall on the unit. Resident #67 stated she liked to walk, and she wished she could walk outside, but she had gotten in trouble for walking outside and she was trying to abide by the rules. <BR/>During an interview on 02/16/2023 at 5:59 PM the MDS coordinator stated the interdisciplinary team was responsible for completing the residents' care plans. The MDS coordinator stated the interdisciplinary team consisted of the administrator, the DON, nurses, the infection control preventionist, therapy, and the ADON. The MDS coordinator stated she tried to look over the care plans to ensure they were complete and accurate. The MDS coordinator stated Resident #17 should have been care planned for her needs for ADL assistance. The MDS coordinator stated the interdisciplinary team should have put it in and she did not know why it was not care planned. The MDS coordinator stated it was important for her ADL assistance to be care planned so staff would know how she transfers and how she ambulates. The MDS coordinator stated Resident #26 should have been care planned for her dental problems, and the interdisciplinary team should have done it. The MDS coordinator stated it was important for Resident #26's dental problems to be care planned so she could be referred to the dentist, make diet changes, if necessary, monitor for weight loss and pain. The MDS coordinator stated she did not know why Resident #26's dental problems were not care planned. The MDS coordinator stated Resident #67 used to have a care plan for wandering/risk of elopement and she did not know if maybe somebody discontinued it. The MDS coordinator stated Resident #67 should have been care planned for wandering/risk of elopement by the interdisciplinary team. <BR/>The MDS coordinator stated it was important for Resident #67 to be care planned for wandering/risk of elopement, so staff knew why she was on the secured unit, and not having this care planned placed her at risk for somebody letting her out of the unit. <BR/>During an interview on 02/16/2023 at 6:52 PM, the ADON stated she wrote acute care plans like for antibiotics or falls anything on the nurses 24-hour report. The ADON stated completing the care plans was a team effort. The ADON stated Resident #17's care plan should include her need for assistance with ADLs, and she believed this not being on the care plan was an oversight. The ADON stated it was important for Resident #17's care plan to include her need for assistance with ADLs so that the proper level of care was provided by the staff. The ADON stated she was aware that Resident #26 was having dental problems because she required antibiotics for an abscess. The ADON stated Resident #26's dental problems should have been care planned by the interdisciplinary team to make sure her dental problems did not progress and to try to fix the problem. The ADON stated she was aware Resident #67 wandered and was at risk for elopement. The ADON stated Resident #67 should have been care planned for wandering/elopement risk by the interdisciplinary team, and she was not able to say why it was not done. The ADON stated since Resident #67 was on the secured unit not having her wandering/elopement risk care planned placed her at risk of elopement. <BR/>During an interview on 02/16/2023 at 7:37 PM, the DON stated Resident #17 should have been care planned for her need for assistance with ADLs. The DON stated the interdisciplinary team should have care planned this and it must have been an oversight that it was not care planned. The DON stated Resident #17 not having her need for ADL assistance care planned placed her at risk for not receiving the help that she required. The DON stated she was not aware Resident #26 had dental issues, but that it should have been care planned. The DON stated the interdisciplinary team should have care planned this. The DON stated it was important for Resident #26's dental problems to be care planned to ensure proper follow up and that she is feeling better and receiving the help she needs. The DON stated she was aware Resident #67 wandered and was at risk for elopement. The DON stated this should have been care planned by the interdisciplinary team, and she did not know why it was not done. The DON stated sometimes they miss things and she tried to correct them. The DON stated Resident #67 not being care planned for wandering/risk of elopement caused no harm to her. <BR/>During an interview on 02/16/2023 at 8:47 PM, the administrator stated the MDS coordinator was responsible for completing the care plans, but the interdisciplinary team should let her know what should be included in the care plan. The administrator stated the care plan should be updated after any change in the residents' condition. The administrator stated she expected Resident #17 to be care planned for her need of assistance with ADLS, Resident #26's dental problems be care planned, and Resident #67 be care planned for wandering/elopement risk. The administrator stated these not being care planned did not accurately reflect their needs. <BR/>4. Record review of Resident #40's face sheet, dated 02/16/2023, revealed Resident #40 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and contractures (fixed tightening of muscle, tendons, ligaments, or skin) to bilateral ankles, feet, and right hand. <BR/>Record review of the order summary report, dated 02/16/2023, revealed no orders or monitoring for contractures. <BR/>Record review of the MDS assessment, dated 01/18/2023, revealed Resident #40 had clear speech and was usually understood by staff. The MDS revealed Resident #40 was usually able to understand others. The MDS revealed Resident #40 had a BIMS score of 11 which indicated moderate cognitive impairment. The MDS revealed Resident #40 required extensive assistance with bed mobility and total dependence with transfers, dressing, and toilet use. The MDS revealed Resident #40 had functional limitation in range of motion that interfered with daily functions to one side of her upper extremities and both sides of her lower extremities. <BR/>Record review of the comprehensive care plan, last revised on 08/21/2022, revealed no care plan for contractures. <BR/>Record review of the treatment encounter note, dated 02/15/2023, revealed active and passive range of motion was performed to Resident #40's right upper extremity, incorporating prolonged and sustained stretch, to improve range of motion and decrease risk for further contracture development. <BR/>During an observation and interview on 02/13/2023 at 11:02 AM, Resident #40's right hand was curled into a fist with no devices, braces, or splints observed. Resident #40 was non-interviewable as evidence by confused conversation. <BR/>During an observation on 02/14/2023 at 3:22 PM, Resident #40's right hand was curled into a fist with no devices, braces, or splints observed.<BR/>During an observation and interview on 02/16/2023 at 3:26 PM, Resident #40's right hand was curled into a fist with no devices, braces, or splints observed. CNA U was unaware Resident #40 had a contracture. CNA U attempted to uncurl Resident #40's hand and was unable because of joint stiffness and limited range of motion to right hand. CNA U stated she was unsure if Resident #40 required a hand carrot, splint, or brace. CNA U stated she was unsure if Resident #40 was receiving therapy services. CNA U stated she was notified of residents with contractures by the nurse. CNA U stated interventions for contractures were found on the [NAME] (simplified and pertinent information in the electronic charting system that is generated from care plan interventions). CNA U stated the importance of ensuring contractures were on the care plan was to prevent skin breakdown and worsening of the contractures. <BR/>During an interview on 02/16/2023 at 5:20 PM, LVN T stated interventions used for contracture management should have been on the nurse administration record and on the care plan. LVN T stated there were no interventions for Resident #40 on the care plan or on the nurse administration record. LVN T stated the importance of ensuring contractures were included on the care plan was to prevent further contractures and ensure consistency of care. <BR/>During an interview 02/16/2023 at 5:33 PM, the MDS Coordinator stated the IDT (interdisciplinary team) was responsible for ensuring care plans were completed and accurate. The MDS Coordinator stated Resident #40 should have a care plan for contractures. The MDS Coordinator was unsure why Resident #40's contractures were not care planned. The MDS Coordinator stated the importance of ensuring contractures were care planned for Resident #40 was to prevent further decline and ensure the correct interventions were in place. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated the IDT was responsible for ensuring care plans were completed and accurate. The DON stated she was unsure why Resident #40's contractures were not care planned. The DON stated the importance of ensuring contractures were care planned for Resident #40 was to prevent further decline and ensure the appropriate care was provided. <BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she expected the IDT to ensure contractures were included on the care plan. The ADM stated the importance of ensuring contractures were included on the care plan was to prevent further decline and ensure Resident #40 was at the highest level of functioning. <BR/>Record review of the Care Plans, Comprehensive Person-Centered policy, last revised in March of 2022, revealed 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy further revealed 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. Services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2. Any specialized services to be provided as a result of PASARR recommendations; and 3. which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident' strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure residents received proper treatment and assistive devices to maintain or enhance vision abilities for 1 out of 1 resident (Resident #12) reviewed for vision services.<BR/>The facility failed to assist resident #12 in locating and utilizing any available resources for the provision of the services the resident needs. The facility did not make an appointment for Resident #12 to have a vision evaluation. <BR/>This failure could affect residents in need of referrals for vision evaluations and place them at risk of not receiving necessary treatment and services. <BR/>Findings included: <BR/>Record review of the consolidated physician orders dated 02/16/23 indicated Resident #12 was a [AGE] year-old female that was admitted to the facility on [DATE] and had a diagnosis of Schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), Asthma (inflamed airways that make it difficult to breath) and HTN (force of blood against the artery walls is too high).<BR/>Record review of the Comprehensive MDS dated [DATE] indicated Resident #12 usually made herself understood and usually understood others. The MDS indicated Resident #12 had impaired vision and required corrective lenses. Resident #12's BIMS score was a 7 indicating severe impairment. The MDS indicated it was somewhat important to Resident #12 to of had books, newspapers, and magazines to read. <BR/>Record review of the care plan revised on 11/11/22 indication no issues with vision.<BR/>Record review of Resident #12's order summary report dated 6/30/22 indicated to have an ophthalmology/optometry consult PRN.<BR/>During an observation and interview on 02/15/23 at 3:00 p.m., Resident #12 was in bed wearing pink (non-prescription) glasses. Resident #12 stated she could not watch tv or read without bifocals and she had reported it to staff on several occasions. Resident #12 did not know what staff members she had notified or when. <BR/>During an interview on 02/14/23 at 10:01 a.m., Resident #12's family member stated she had notified the facility during Resident #12's admission on [DATE] that Resident #12 was needing glasses because she did not have any. Family member stated she had notified the Administrator again in January 2022 that Resident #12 needed glasses.<BR/>During an interview on 02/15/23 at 8:00 a.m., the Administrator stated she was not aware of Resident #12 having any vision issues or needing glasses. The Administrator stated she did not remember Resident #12's family member reporting a vision issue to her. The Administrator stated all vision request were referred to Health drive and she was responsible for completing the referrals because the facility did not have a social worker. <BR/>During an interview on 02/15/2023 at 8:38 a.m., the Customer Care Representative at Health drive denied having a vision referral for Resident #12.<BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated all referrals for podiatry, dental and vision were sent to Health drive. The DON stated the Administrator was responsible for making Resident #12's appointment and notifying the family. The DON stated she was not aware that Resident #12 needed an eye appointment and her family never reported to her that Resident #12 needed an eye appointment. The DON stated Resident #12 should have been assessed upon admission for vision issues and staff should have been working as a team to monitor Resident #12's need for vision services. <BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected Resident #12 to of had received vision care. The Administrator stated staff was responsible for reporting Resident #12's need for vision services and she was responsible for getting a physician order and sending the referral to Health drive immediately. <BR/>Record review of the policy on Assistive Devices and Equipment dated 01/2020 indicated the facility provides the resident with assistance in locating available resources to obtain assistive devices that were not provided by the facility, including glasses and magnifying devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 17 (Resident #64) residents reviewed for monitoring and supervision. <BR/>The facility failed to provide supervision and interventions as evidenced by Resident #64's wandering behaviors. <BR/>This failure could place residents at an increased risk for injury and for future resident-resident altercation. <BR/>The findings included:<BR/>Record review of a face sheet dated 02/16/2023 revealed, Resident #64 was a [AGE] year-old female initially admitted on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), schizoaffective disorder, unspecified (mood disorder characterized by abnormal thought processes and unstable mood), and anxiety disorder, unspecified (severe, ongoing anxiety that interferes with daily activities). <BR/>Record review of the comprehensive MDS assessment with assessment reference date of 07/01/2022 revealed Resident #64 was sometimes understood and sometimes understood others. The MDS assessment revealed Resident #64 had a BIMS score of 02, indicating cognition was severely impaired. The MDS assessment revealed Resident #64 exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed towards others on 1 to 3 days in the 7 day look back. The MDS assessment revealed Resident #64 rejected evaluation or care that was necessary to achieve the resident's goals for health and well-being on 1 to 3 days in the 7 day look back. The MDS assessment revealed Resident #64 wandered 4 to 6 days in the 7 day look back. The MDS assessment revealed Resident #64's wandering significantly intruded on the privacy or activities of others. The MDS assessment revealed Resident #64's current behavior status, care rejection, or wandering was worse compared to the prior assessment. The MDS assessment revealed Resident #64 required limited assistance for bed mobility, dressing, and personal hygiene and supervision for transfer, walk in room and corridor, and eating. <BR/>Record review of the order summary report dated 02/16/2023, revealed Resident #64 had an order for behavioral monitoring for anxiety, depression, and visual and audible hallucinations. <BR/>Record review of Resident #64's care plan last revised 09/04/2022, revealed, Resident #64 required psychotropic medication Seroquel and interventions included administer medications as ordered, monitor/document for side effects and effectiveness, monitor interaction of resident with others for appropriateness, and the resident was on a behavior management program with alternatives to prn medication use such as 1 on 1, activity, adjust room temperature, backrub, change position, give fluids, give food, redirect, refer to nurses notes for specific interventions, remove resident from environment. Resident #64's care plan revealed she required residing on secure unit due to wandering-and elopement risk with at goal of will have reduced episodes of wandering with continuous supervision over the next 90 days interventions included keep environment free of hazards, monitor q 1 hour and prn for safety. <BR/>Record review of the provider investigation report, dated 12/29/2022, revealed a resident-to-resident altercation. The provide investigation report revealed Resident #64 was hit by another resident when she was walking in the hallway (incident was witnessed by a CNA). The provider investigation report revealed provider response of: Resident #64 was moved to safe area and assessed. The perpetrator was placed on 1:1 until placement at a behavioral health unit could be found. <BR/>Record review of the provider investigation report, dated 01/02/2023, revealed a resident-to-resident altercation. The provide investigation report revealed Resident #64 was attempting to go into another resident's room and while staff was redirecting Resident #64 the other resident hit her multiple times in her mid-back (incident was witnessed by a CNA). The provider investigation report revealed provider response of: Resident #64 was removed from situation and assessed. The perpetrator was tested for urinary tract infection and treated accordingly. <BR/>During an observation on 02/14/2023 4:50 PM. Resident #64 was observed wandering up and down the hallway had to be redirected by staff to stop her from entering the other residents' rooms.<BR/>During an observation on 02/15/2023 at 5:46 PM, Resident #64 was observed during dining at dinner wandering around the dining room. Resident #64 went to a different residents table and tried to put down her tea on the other residents table and the residents held their hands up and told her to leave. CNA Y was trying to pass trays and CNA F was assisting another resident. CNA F had to redirect her back to her table to sit down. <BR/>During an observation on 02/15/2023 at 6:40 PM, Resident #64 was observed sitting on her roommate's bed she had pulled the sheet off and was pulling at it, her roommate was not in the room. CNA F was in the dining area with the other residents. <BR/>During an interview on 02/15/23 at 06:02 PM, CNA Y stated she was a float CNA between the women's and men's secured unit. CNA Y stated she would float between both units, but there usually was only one CNA for the secured unit. CNA Y stated she was on the secured unit only for dinner. CNA Y stated Resident #64 wandered a lot and went into other residents' rooms, and some of the residents would get upset and holler at her to get out. CNA Y stated Resident #64 liked to get other residents' things and she liked to touch others. <BR/>During an observation on 02/15/23 at 06:10 PM, Resident #64 was in the dining area, CNA Y and CNA F were assisting other residents and Resident #64 grabbed a piece of food from a resident's plate. CNA F was alerted to the situation when the resident hollered at Resident #64 to stop. CNA F redirected resident to her table. After this, Resident #64 started wandering again and went to a different residents table and grabbed her water and poured it on the floor. CNA F and CNA Y were helping other residents, when they noticed she was pouring the water out they went over to Resident #64 to redirect her back to her table, but Resident #64 continued to wander in the dining area. <BR/>During an observation on 02/15/2023 at 6:16 PM, Resident #64 was in her room moving the sheets on her bed and her roommate's bed (roommate was not in room at the time). CNA F was assisting a resident to the bathroom and CNA Y was picking up the dining trays. <BR/>During an observation on 02/15/2023 at 06:21 PM, Resident #64 was wandering up and down the hallways touched a resident's arm and the resident yelled quit. CNA F was watching and went to redirect Resident #64. Resident #64 continued to wander around the hall. <BR/>During an interview on 02/15/2023 at 06:41 PM, CNA F stated she had to know where Resident #64 was always because Resident #64 wandered and grabbed food from other residents' plates. The residents got upset when Resident #64 took their food and told Resident #64 not to take their food that it was theirs. CNA F stated when Resident #63 went into other residents' rooms they would holler and tell her she needed to get out. CNA F stated Resident #64 liked to touch resident and told them that she loved them. CNA F stated some residents reacted negatively to Resident #64 touching them. CNA F stated some residents pushed her away. CNA F stated she tried to redirect Resident #64 and gave her snacks. CNA F stated it was not okay for her to be by herself on the secured unit because of safety concerns. CNA F stated she might have to toilet the other residents and she would not be able to watch Resident #64. CNA F stated the facility tried to put a float CNA to help, but there was not 2 CNAs on the women's secured unit all the time. CNA F stated if there was a resident-to-resident altercation she would have to report it immediately, to get help she would yell until somebody came for assistance because she would remain with the residents for safety. <BR/>During an interview on 02/16/2023 at 11:09 AM, CNA W stated most of the time there was one person on the women's secured unit. CNA W stated she was not able to take care of Resident #64 when she was on the secured unit alone. CNA W stated Resident #64 wandered a lot and at mealtimes she ate her food fast and then tried to take other residents' food. CNA W stated when Resident #64 took other residents' food they would swing at her. CNA W stated she tried to redirect Resident #64. CNA W stated Resident #64 wandered into other residents' rooms and some of them got frustrated and tried to hit her. CNA W stated if she was alone and there was a resident altercation, she didn't know how she would get help.<BR/>During an interview on 02/16/2023 at 11:19 AM, CNA X stated sometimes there was one person on the women's secured unit. CNA X stated Resident #64 grabbed things and wandered into other residents' rooms. CNA X stated Resident #64 is constantly going I try to keep a close eye on her. CNA X stated residents have tried to hit Resident #64 when she grabbed food from their trays. CNA X stated residents hollered at Resident #64 when she tried to go in their rooms, but she had not witnessed any of them try to hit her. CNA X stated if there was a resident altercation, she would call for help with her cell phone. <BR/>During an interview on 02/16/2023 at 11:39 AM, LVN B stated Resident #64 wandered in the hallways, other residents' rooms, and everywhere. LVN B stated when Resident #64 went into other residents' rooms they hollered at her and tried to hit her. LVN B stated Resident #64 tried to take other residents' food and they holler at her. LVN B stated preferably there should be two CNAs on the women's secured unit, but usually there was one CNA. LVN B stated one CNA cannot supervise all the residents. LVN B stated Resident #64's behaviors and not having adequate supervision placed her at risk because the other residents could be combative with her. <BR/>During an interview on 02/16/2023 at 7:21 PM, the ADON stated Resident #64 at one time was one on one, but she was not anymore. The ADON stated the facility should make sure there was enough staff on the secured unit to adequately supervise Resident #64. The ADON stated Resident #64 did require extra supervision for her safety. The ADON stated Resident #64's behaviors placed her at risk for future altercations. The ADON stated staff should redirect Resident #64 to her room and give her activities to do. The ADON stated the goal was to keep all the residents safe and with one CNA on the secured unit it was not possible. <BR/>During an interview on 02/16/2023 at 8:12 PM, the DON stated the CNAs on the secured unit should ensure Resident #64 was adequately supervised. The DON stated there was one CNA on the unit most shifts and a float CNA that came to help throughout the shift. The DON stated at one time Resident #64 was one on one, but she did not recall it. The DON stated Resident #64's behaviors placed her at risk for further altercations. The DON stated she guessed she needed to provide more activities for Resident #64 to redirect her. <BR/>During an interview on 02/16/2023 at 9:06 PM, the administrator stated the staff on the secured unit should try to redirect Resident #64. The administrator stated she did not know Resident #64's care plan included an intervention that she was one on one, but if it was there, it should have been done. The administrator stated the staff on the secured unit should supervise Resident #64 at all times. The administrator stated due to the current census they could only have one CNA on the secured unit. The administrator stated one CNA did not allow enough supervision for Resident #64 and it placed her at risk for harm. <BR/>Record review of the facility's policy titled, Safety and Supervision of Residents, last revised July 2017, revealed, . Resident safety and supervision and assistance to prevent accidents are facility-wide priorities 1. Our facility-oriented approach to safety addresses risks of groups of residents . our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training as necessary; d. ensuring that interventions are implemented; and e. documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; b. evaluating the effectiveness of interventions; c. modifying or replacing interventions as needed; and d. evaluating the effectiveness of new or revised interventions . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 17 residents (Resident #17) reviewed for respiratory care and services. <BR/>The facility failed to administer oxygen at 3-4 liters per minute via nasal cannula as prescribed by the physician for Resident #17. <BR/>This failure could place residents who receive respiratory care at risk for developing respiratory complications.<BR/>The findings included:<BR/>Record review of Resident #17's face sheet, dated 02/16/2023, revealed she was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified (lung disease that causes obstructed air flow in the lungs), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and dependence on supplemental oxygen. <BR/>Record review of the MDS comprehensive assessment with an assessment reference date of 04/25/2022, indicated Resident #17 was understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 13, indicating Resident #17's cognition was intact. The MDS assessment indicated Resident #17 did not reject evaluation or care. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing, toilet use and limited assistance with personal hygiene and supervision for eating. The MDS assessment indicated Resident #17 received oxygen therapy while a resident in the facility. <BR/>Record review of Resident #17's care plan last revised 09/29/2022 revealed an intervention to give oxygen therapy as ordered 3 to 4 LPM (liters per minute) via NC (nasal cannula) as ordered by the physician.<BR/>Record review of Resident #17's order summary report dated 02/16/2023, revealed a physician's order for oxygen at 3-4 L via nasal cannula continuous every shift related to chronic obstructive pulmonary disease, unspecified with start date of 08/14/2022. <BR/>Record review of Resident #17's respiratory administration record for February 2023, revealed O2@ 3-4 L via NC continuous every shift related to chronic obstructive pulmonary disease, signed off completed for 02/14/2023 (day shift and evening shift). <BR/>During an observation on 02/14/2023 at 9:15 AM, Resident #17 was lying in bed with oxygen via nasal cannula and oxygen was set between 2-3 liters per minute. <BR/>During an observation on 02/14/2023 at 3:33 PM, Resident #17 was lying in bed with oxygen via nasal cannula and oxygen was set between 2-3 liters per minute.<BR/>During an observation on 02/14/2023 at 5:10 PM Resident #17 was lying in bed with oxygen via nasal cannula and oxygen was set between 2-3 liters per minute. <BR/>During an observation and interview on 02/14/2023 at 5:20 PM, LVN T stated she was Resident #17's nurse this shift 2PM-10PM. LVN T verified Resident #17's oxygen was set at 2.5 liters per minute. LVN T stated she was responsible for following the physician's orders and the oxygen for Resident #17 should be set at 3-4 liter per minute. LVN T stated earlier in her evening shift she had signed off that Resident #17's oxygen was set at 3-4 liters per minute, and there was not reason the oxygen was set at 2.5 liters per minute, but she had signed that it was set at 3-4 liters per minute. LVN T stated Resident #17's oxygen not being set at the correct liters per minute could cause her hypoxia (low oxygen) and result in her death. <BR/>During an interview on 2/15/2023 at 11:35 AM, RN P stated she was the charge nurse on the 6AM-2PM shift on Monday-Friday. RN P stated she worked on 2/14/2023 6AM-2PM and provided care for Resident #17. RN P stated Resident #17 usually had her oxygen set at 3 liters per minute, so she just signed it off completed on 2/14/23 for day shift. RN P stated she did not verify that the oxygen was set at 3-4 liters per minute, but she should have. RN P stated the oxygen not being set at the correct level could cause problems such as confusion. <BR/>During an interview on 02/16/2023 at 6:46 PM, the ADON stated the nurse working the floor was responsible for ensuring the residents' oxygen was set correctly. The ADON stated the nurse should have signed off the respiratory administration record at the same time the oxygen setting was verified. The ADON stated she walked around the halls and did random checks every couple hours to check on the nurses. The ADON stated the oxygen not being set correctly could affect the residents' oxygen saturations and result in falls and altered mental status. <BR/>During an interview on 02/16/2023 at 7:30 PM, the DON stated the nurse working the floor was responsible for ensuring the physicians orders were followed and the oxygen was set correctly. The DON stated she did random checks throughout the day to make sure things were being done correctly. The DON stated the oxygen should be set correctly to maintain the residents' oxygen saturation levels. The DON stated the oxygen not being set correctly could result in hypoxia (low oxygen) and could cause altered mental status. <BR/>During an interview on 02/16/2023 at 8:43 PM, the administrator stated she expected the nurses to follow the physician orders, including setting the oxygen correctly. The administrator stated nursing was responsible for ensuring the oxygen was set correctly for all the residents. The administrator stated it was important for the oxygen to be set correctly because oxygen was needed to breathe and live. <BR/>Record review of the facility's policy titled, Oxygen Administration, last revised October 2010, revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident . Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 3 of 17 (Resident #12, Resident #26, and Resident #47) residents reviewed for dental services.<BR/>The facility did not assist Resident #12 with obtaining dental services when she had broken and missing teeth. <BR/>The facility failed to ensure Resident #26 received dental services when she had severe cavities and oral pain. <BR/>The facility failed to ensure Resident #47 received dental services when she had missing teeth, broken teeth, and oral pain.<BR/>This failure could place residents at risk of not having their oral health care needs met and oral pain while chewing.<BR/>Findings included: <BR/>1. Record review of the consolidated physician orders dated 02/16/23 indicated Resident #12 was a [AGE] year-old female that was admitted to the facility on [DATE] and had a diagnoses of Schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), Asthma (inflamed airways that make it difficult to breath) and HTN (force of blood against the artery walls is too high). <BR/>Record review of the Comprehensive MDS dated [DATE] indicated Resident #12 usually made herself understood and usually understands. Resident #12's BIMS score was a 7 indicating severe impairment. The MDS indicated Resident #12 was on a mechanically altered diet. The MDS indicated no issues with swallowing or dental status. The MDS indicated no weight loss of 5% over the last 6 months.<BR/>Record review of Resident #12's order summary dated 07/28/22 indicated a regular diet with soft and bite-size food (Level 6 texture). The order summary indicated dental care as needed. The order summary indicated Tylenol #3 300-30mg q6h prn for arthopathy and Tylenol 325mg q4h PRN.<BR/>Record review of Resident #12's care plan dated 07/03/22 indicated a potential nutritional problem related to new admit. Interventions included for the Dietary manager to discuss food preferences with the resident and family upon admission to meet dietary needs.<BR/>Record review of Resident #12's oral and dental status assessment completed on 07/04/22 indicated Resident #12 did not have any upper teeth and broken teeth on the bottom. <BR/>During an observation and interview on 2/15/23 at 3:00 p.m., Resident #12's teeth were broken, missing and discolored. Resident #12 stated her teeth hurt when she chewed and she, almost choked on broccoli the other day because she was not able to chew properly. Resident #12 stated she had reported her teeth hurting to staff but was unable to verbalize which staff members or when.<BR/>During an interview on 02/14/23 at 10:01a.m., family member stated she had reported to facility staff when Resident #12 was admitted on [DATE] that resident had issues with dental. Family member stated she also notified the Administrator again in January 2023 that Resident #12 needed a dental evaluation.<BR/>During an interview on 02/15/23 at 8:00 a.m., the Administrator stated, I was not aware of Resident #12 having any dental issues. The Administrator stated she did not remember Resident #12's family member had reported a dental issue to her. The Administrator stated all dental request were referred to Health drive and she was responsible for completing the referrals because the facility did not have a social worker. <BR/>During an interview on 02/15/2023 at 8:38 a.m., the Customer Care Rep at Health drive denied having a dental referral for Resident #12.<BR/>During an interview on 02/15/23 at 4:20 p.m., CNA F stated Resident #12's family member made weekly visits to the facility. CNA F stated she was aware that Resident #12 was complaining of tooth pain and needing a dental eval. CNA F stated she did not report it to the Administrator because the family member told her she had already reported the dental pain to the Administrator and the facility should be taking care of it.<BR/>During an interview on 02/15/23 at 11:14 a.m., the MDS nurse stated she completed Resident #12's MDS and indicated on the MDS Resident #12 did not have any dental issues. The MDS nurse stated she was not aware of the oral and dental assessment found in Resident #12's chart that indicated dental issues and that was not where she looked when she filled out the MDS. The MDS nurse stated she only looked at the nursing assessment that was completed on admit to help with filling out the MDS. The MDS nurse reported she completed her own assessment on Resident #12 for the MDS and, she might have marked no dental issues on the MDS because Resident #12 would not let her look at her teeth. The MDS nurse stated she was responsible for filling out the MDS correctly and not indicating dental issues on the MDS, or tooth pain could result in distress to the patient. <BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated all referrals for podiatry, dental and vision were sent to Health drive. The DON stated the Administrator was responsible for making Resident #12's dental referral and appointment. The DON stated she was not aware that Resident #12 needed a dental evaluation and Resident #12's family had never notified her of the dental issue. The DON stated Resident #12 should have been assessed upon admission for dental issues and staff should have been working as a team to monitor Resident #12 for dental issues. The DON stated the MDS nurse was responsible for making sure the MDS was filled out correctly. The DON stated she was responsible for looking over the MDS and making sure it was correct. The DON stated not getting dental care could make Resident #12 feel bad due to pain.<BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she had been at the facility since October 2022, and she was responsible for getting the physician order and completing dental referrals. The Administrator stated if residents do not have the right Medicaid and cannot afford dental, then she was responsible for looking for other pay alternatives. The Administrator stated she expected staff to report any dental issues to her. The Administrator reported she does not follow up on the dental referrals once she sends them to Health Drive and the only way she would know if it was not completed would be if someone complains again. The Administrator reported she expected the MDS to be accurate and the MDS nurse was responsible for making sure the MDS was correct. The Administrator stated the Corporate MDS team was responsible for making sure the MDS nurse filled out the MDS correctly. <BR/>Record Review of the policy on Dental Services Revised on 12/2016 indicated routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services were provided to residents via contract agreement with a licensed dentist that came to the facility monthly. Social services representatives assisted residents with appointments, transportation arrangements and reimbursement of dental services under the state plan.<BR/>2. Record review of Resident #26's face sheet dated 02/16/2023 indicated, Resident #26 was re-admitted on [DATE] with diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), schizoaffective disorder, bipolar type (mood disorder characterized by abnormal thought processes and unstable mood), and type 2 diabetes mellitus with other diabetic neurological complication (high blood glucose levels with nerve damage). <BR/>Record review of Resident #26's comprehensive MDS assessment with an assessment reference date of 11/27/2022 indicated, Resident #26 was usually understood and usually understood others. The MDS assessment indicated Resident #26 had a BIMS score of 13, indicating her cognition was intact. The MDS assessment indicated Resident #26 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and supervision for eating. Resident #26's MDS assessment indicated she did not have broken or loosely fitting full or partial denture, no natural teeth or tooth fragments, abnormal mouth tissue obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort, or difficulty with chewing. <BR/>Record review of Resident #26's Order Summary Report dated 02/16/2023 indicated physician's orders for dental care PRN (as needed) with start date of 03/09/2020 and amoxicillin oral capsule 500 mg give 1 capsule by mouth every 8 hours for tooth abscess for 10 days until finished with start date of 02/11/2023. <BR/>Record review of Resident #26's care plan with target date of 12/17/2022 did not reveal Resident #26's dental problems.<BR/>During an observation and interview on 02/15/23 at 8:13 AM, Resident #26 stated in the past maybe the year before last she had her upper teeth in the back one on the right and one on the left side smoothed down because they were cavities. Resident #26 stated her other teeth were now being affected because she needs those 2 teeth pulled out and had not been able to see the dentist. Resident #26 stated her Medicaid did not pay for dental and she did not have money to pay the dentist. Resident #26 stated she had told the nurses her teeth were causing her pain and they needed to be taken out. Resident #26 stated one of the facility staff was supposed to refer her to a dentist that would take her Medicaid, but she had not heard back from them. Resident #26 was unable to recall who the staff member was. Resident #26 stated about a week ago she got an abscess on her left side related to her teeth and the facility physician order antibiotics for this. Observation of Resident #26's teeth indicated 2 upper teeth in the back one on the right and one on the left side were jagged and black with the left side having [NAME]/corrosion than the right. Resident #26 stated the pain was worse throughout the day and when she ate food. Resident #26 stated she had tramadol for chronic pain, and this helped with her teeth pain as well. Resident #26 stated sometimes she could not sleep related to the pain to her teeth, but that her pain had improved since starting the antibiotics. During the interview Resident #26 was calm and did not display any non-verbal signs and symptoms of severe pain. <BR/>During an interview on 02/15/2023 at 8:38 AM, the customer service representative with Health Drive stated Resident #26 was referred in November of 2022, but her Medicaid did not cover dental services.<BR/>During an interview on 02/15/2023 at 8:46 AM, the administrator stated she would have to ask the nurses what they do if a resident is having dental pain if they send to the ER or what. The administrator stated the social worker was responsible for referring the residents for dental services, but there was currently no social worker. The administrator stated currently she was making referrals for dental services. The administrator stated the nurses reported to her and she would fill out the form for Health Drive, then give it back to the nurses to get the doctors signature and then fax it back to Health Drive. The administrator stated if Health Drive would not see the residents because they had Medicaid, they would try to reach a dentist that does take their insurance. <BR/>During an interview on 02/16/2023 at 6:24 PM, LVN A stated prior to last week on Wednesday (02/08/2023) or Thursday (02/09/2023), when Resident #26 asked her for pain medication for pain to her teeth, she was not aware of Resident #26 having dental issues. LVN A stated she was aware of Resident #26 having some swelling to the left side of her face and was started on antibiotics for an abscess on 02/11/2023, but she did not look at Resident #26's teeth to see what was going on. LVN A stated she should have looked at Resident #26's teeth. LVN A stated she did not know if Resident #26 had been referred to dental services. LVN A stated if a resident needed to be referred for dental services the nurses should notify the DON. LVN A stated she should have checked with the DON to see if any of the other nurses had notified her Resident #26 needed to be referred for dental services. LVN A stated she had not notified the DON of Resident #26 needing dental services because everybody knew about her teeth hurting. LVN A stated it was important for Resident #26 to be referred for dental services because of the tooth pain and she could have more infections. <BR/>During an interview on 02/16/2023 at 7:12 PM, the ADON stated she did not know how a resident would be referred to the dentist. The ADON stated the social worker was responsible for making referrals for dental services, but the facility currently did not have social worker. The ADON stated, Right now we are all the social worker. The ADON stated in the past Resident #26 had asked to be referred for dental services, but she was not sure about this. The ADON stated Resident #26 should be referred for dental services, and it was important for her to receive dental services because she could get another infection. <BR/>During an interview on 02/16/2023 at 8:05 PM, the DON stated if a resident needed to go to the dentist the facility had Health Drive that came to the facility. The DON stated she was not aware that Resident #26 needed to be referred for dental services. The DON stated the social worker was the one who did the referrals but with no social worker the facility staff tried to work as a team to make sure the resident received what they needed. The DON stated none of the nurses had told her Resident #26 was on antibiotics for a tooth abscess. The DON stated it was important for residents to be referred for dental services to help maintain their health. <BR/>During an interview on 02/16/2023 at 8:59 PM, the administrator stated nobody had told her Resident #26 was having oral pain and needed to be referred for dental services. The administrator stated it was important for the residents to receive dental services for their quality of life and self-esteem. <BR/>3. Record review of Resident #47's face sheet, dated 02/16/2023, revealed Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acquired absence of left leg below knee (left leg amputation below the knee). <BR/>Record review of Resident #47's order summary report, dated 02/16/2023, revealed an order which started on 09/19/2022, for dental care as needed. <BR/>Record review of the comprehensive MDS assessment, dated 10/02/2022, revealed Resident #47 had clear speech and was understood by staff. The MDS revealed Resident #47 was able to understand others. The MDS revealed Resident #47 had a BIMS score of 15 which indicated no cognitive impairment. The MDS revealed Resident #47 had no obvious or likely cavity or broken natural teeth. The MDS revealed no significant weight loss. <BR/>Record review of the medication administration record, dated February 2023, revealed no pain medications were given for complaints of dental pain. The MAR further revealed tramadol (pain medication) 50 mg was given several days for complaints of wrist pain, leg pain, or back pain. <BR/>Record review of the comprehensive care plan, last revised on 9/24/2022, revealed no plan of care for oral or dental status. <BR/>Record review of the admit or readmit screener assessment - section D, dated 09/20/2022 revealed Resident #47 had broken and carious teeth. <BR/>Record review of the oral or dental status assessment, dated 09/19/2022, revealed Resident #47 had missing teeth. <BR/>During an observation and interview on 02/15/2023 at 8:11 AM, Resident #47 stated she was having pain to her lower jaw in the back on the right side. Resident #47 stated the pain was 9 out of 10 on the pain scale during the last month. Resident #47 stated the pain was worse during meals when she was eating. Resident #47 was smiling with no facial grimacing observed. Resident #47 was working on her small gem puzzle during the interview. Resident #47 had missing teeth and inflamed gums. Resident #47's natural teeth were black with obvious cavities. Resident #47 had a split tooth to her lower jaw in the back on the right side that was rubbing on her tongue. Resident #47 stated she told the DON about her dental pain approximately 1 month ago. Resident #47 stated the DON told her she would see about the dentist. Resident #47 stated she had not been told anything else regarding a dental appointment.<BR/>During an interview on 02/15/2023 at 8:24 AM, the DON stated the facility did not have a current social worker. The DON stated the facility used a mobile dental program for residents to receive dental services. The DON stated the administrator had been setting up the appointments through the mobile dental program. The DON stated when a referral was made, the mobile dental program had to run the residents funding. The DON stated if the resident was not eligible to receive services, then the facility looked for other dentists. The DON stated Resident #47 had not reported dental pain. <BR/>During an interview on 2/15/2023 at 8:38 AM, a Customer Care Representative from the mobile dental program stated no referral had been made for Resident #47. <BR/>During an interview on 02/16/2023 at 3:26 PM, CNA U stated Resident #47 had not complained of dental pain. CNA U stated Resident #47 did not ask for assistance with oral hygiene and was independent with ADLs. CNA U stated she was unaware of the oral status of Resident #47. CNA U stated broken teeth, missing teeth, and dental caries could have caused pain and illness to residents if not addressed. <BR/>During an interview on 02/16/2023 at 5:20 PM, LVN T stated Resident #47 had not complained of dental pain. LVN T stated she was aware Resident #47 had broken and missing teeth and obvious dental caries. LVN T stated broken teeth, missing teeth, and dental caries could have caused pain to residents if not addressed. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated she was not aware of Resident #47's dental pain. The DON stated she was unsure of Resident #47's dental status. The DON stated the MDS assessment should have accurately reflected Resident #47's oral or dental status so interventions could have been implemented to prevent Resident #47 from having oral or dental pain. <BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she was unaware of Resident #47's dental pain. The ADM stated she expected nursing staff to adequately assess and monitor residents' oral or dental status. The ADM stated it was important to adequately assess and monitor residents' oral status to ensure a baseline is obtained and to prevent oral decline. <BR/>Record review of the policy titled Dental Services, revised on 12/2016, indicated Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to our residents through a. A contract agreement with a licensed dentist that comes to the facility monthly; b. referral to the resident's personal dentist; c. Referral to community dentist; or d. Referral to other health care organizations that provide dental services . Social services representatives will assist residents with appointments, transportation arrangements and for reimbursement of dental services under the state plan, if eligible .

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 17 residents (Residents #15, #3 and #23) reviewed for palatable food. <BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was served cold and did not taste good for Residents #15, #3, and #23. <BR/>This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>Findings include:<BR/>1. During an interview on 02/13/2023 at 10:54 a.m., Resident #15 stated the food was lousy and did not have enough flavor. Resident #15 stated she reported this to staff but could not recall their names. <BR/>2. During an interview on 02/13/2023 at 3:08 p.m., Resident #3 stated the meat was tough. Resident #3 stated sometimes the aides could not even cut the meat up for her. <BR/>3. During an interview on 02/13/2023 at 3:10 p.m., Resident #23 stated the food was nasty. Resident #23 stated, It looks like somebody chewed it up and spit it out. Resident #23 stated she reported this to staff but could not recall their names. <BR/>4. During an observation and interview on 02/14/2023 at 12:52 p.m., a lunch tray was sampled by the Dietary Manager and five surveyors. The sample tray consisted of barbecue chicken, baked beans, coleslaw, tangerine oranges, and a roll. The Dietary Manager stated the appearance could have been neater and a smaller piece of chicken. The Dietary Manager stated the barbecue chicken was cold, bland, and dry. The Dietary Manager stated the baked beans was cold, coleslaw tangy taste, and the tangerine oranges was bland. The Dietary Manager stated the roll was cold and cooked to long at the bottom. <BR/>During an interview on 02/16/2023 at 11:47 a.m., CNA N stated residents complained to her daily about the food being cold, not seasoned, and overcooked. CNA N stated she offered the residents an alternative when they complained to her. CNA N stated all food complaints were reported to the charge nurse. CNA N stated residents not eating their food could potentially cause weight loss. <BR/>During an interview on 02/16/2023 at 12:22 p.m., CNA O stated residents complained to her about the food being cold, not seasoned, and overcooked. CNA O stated Resident #23 had complained to her and stated the food was nasty. CNA O stated residents were offered an alternative. CNA O stated all complaints were reported to the dietary staff. CNA O was unable to recall names. CNA O stated the failure could potentially put residents at risk for weight loss. <BR/>During an interview on 02/16/2023 at 12:40 p.m., RN P stated residents had complained to her about the food. RN P stated staff also had reported to her that residents complained about the food. RN P stated when staff or residents reports to her about the food, she ensures the residents was offered an alternative. RN P stated she had never reported the issue to anyone. RN P stated she should have reported complaints to the Dietary Manager. RN P stated this failure could potentially put residents at risk for weight loss. <BR/>During an interview on 02/16/2023 at 2:47 p.m., the Dietary Manager stated residents and staff had complained to her about the food. The Dietary Manager stated some of the complaints where the food was cold or lack of flavor. The Dietary Manager stated most of the complaints are noted during resident council. The Dietary Manager stated she visits with residents randomly to see if there were any complaints with the food. The Dietary Manager stated she random goes behind the cooks to ensure the temperature was at the correct settings. The Dietary Manager stated if there were any issues, staff was verbally in-serviced immediately. The Dietary Manager stated test trays were done once a month with the dietician. The Dietary Manager stated she had not complained about the temperature or flavor. The Dietary Manager stated residents not eating their food could potentially cause weight loss or death. <BR/>During an interview on 02/16/2023 at 5:56 p.m., the Administrator stated she expected all food to be palatable and at the correct temperature. The Administrator stated she had received complaints about the meat being too tough. The Administrator stated an alternative was offered. The Administrator stated a test tray was done randomly to ensure the food was palatable and at the correct temperature. The Administrator stated there was no issues noted with the test tray. The Administrator stated residents not eating their food could potentially cause weight loss or decrease in their independence. <BR/>Record review of the Food and Nutrition Services policy, last revised on 10/2017, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal was provided to each resident, the food appears palatable and attractive, and it was served at a safe and appetizing temperature .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure:<BR/>1. Food items were dated and labeled. <BR/>2. Expired food item was discarded.<BR/>3. The ice machine was clean and free from debris <BR/>4. K-Quat (sanitation) test strips were not expired<BR/>5. The juice machine spigot was clean<BR/>6. The toaster was clean and free of food debris.<BR/>7. The cooking grease in the deep fryer was kept clean.<BR/>8. The deep fryer was free of grease build up.<BR/>These failures could place residents at risk for foodborne illness.<BR/>Findings include:<BR/>1. During an observation in the refrigerators and freezers on 02/13/2023 starting at 11:20 a.m. revealed a plastic storage bag labeled ham with an opened date 02/02/2023 and used by date 02/09/2023; plastic storage bag that was identified by the Dietary Manager as sliced ham undated; 5 lb. container labeled tuna salad undated; plastic bag identified by the Dietary Manager as hamburger patties. <BR/>2. During an observation in the dry storage room on 02/13/2023 starting at 11:38 a.m. revealed two packages of hamburger buns undated. <BR/>3. During an observation in the kitchen on 02/13/2023 at 11:42 a.m., revealed the toaster with food particles, grease buildup around the deep fryer, and dark brown grease noted inside the deep fryer, red gooey substance observed on the juice machine spigot, and K-Quat sanitation solution test strips with an expiration date of 11/01/2022. <BR/>4. During an observation on the A/B Hall on 02/13/2023 at 12:09 p.m., revealed an ice machine with a white liquid substance on the exterior part of the machine. The ice scoop container had a white substance noted inside. <BR/>During an observation and interview on 02/16/2023 at 10:53 a.m., the Housekeeping Supervisor stated her staff was responsible for cleaning the exterior of the ice machine. The Housekeeping Supervisor observed with the surveyor the exterior of the ice machine and the container that hold the scoop. The Housekeeping Supervisor agreed they both needed to be cleaned. The Housekeeping Supervisor stated it should be cleaned once a week. The Housekeeping Supervisor stated the last time it was cleaned was last week by her. The Housekeeping Supervisor stated she was unaware that her staff was responsible for cleaning the scoop container until surveyor intervention. The Housekeeping Supervisor stated this failure could put residents at risk for a food-borne illness. <BR/>During an interview on 02/16/2023 at 2:37 p.m., [NAME] S stated all kitchen staff were responsible for labeling, dating food products, discarding items prior to the expiration date, and cleaning the juice machine spigot, and toaster. [NAME] S stated the fryer grease should be changed weekly and the grease buildup should be cleaned daily. [NAME] S stated these failures could potentially cause a food-borne illness.<BR/>During an interview on 02/16/2023 at 2:47 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so her staff are not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager said all food should be labeled with date received and the date it was opened. The Dietary Manager stated when the food truck comes and delivers, whoever touched the item should label and date the item. The Dietary Manager stated all kitchen staff were responsible for ensuring the toaster, juice spigot and the fryer grease buildup was cleaned daily. The Dietary Manager stated all staff were responsible for ensuring expired items were discarded daily. The Dietary Manager stated the grease should be changed weekly. The Dietary Manager stated due to being short staff on 02/13/2023, these issues were not addressed. The Dietary Manager stated she was responsible for ensuring the test strips was not expired. The Dietary Manager stated she was unaware the test strips were expired until surveyor intervention. The Dietary Manager stated she did daily rounds during the day and address any issues. The Dietary Manager stated she has had issues in the past and tried to address them daily by verbal reminders. The Dietary Manager stated she did not have a cleaning schedule prior to surveyor intervention. The Dietary Manager stated the last in-service besides the verbal reminders was about three months ago. The Dietary Manager stated these failures could potentially cause a food borne illness or cross contamination. <BR/>During an interview on 02/13/2023 at 5:56 p.m., the Administrator stated she expected the kitchen to be clean and staff preventing cross contamination. The Administrator stated he expected all food to be labeled and dated. He said food items should be discarded prior to the expiration date. The Administrator stated the toaster should be cleaned after every use. The Administrator stated the juice machine spigot should be cleaned nightly and the grease should be changed weekly. The Administrator stated the exterior part of the ice machine, and the scoop container should be cleaned daily. The Administrator stated she did superficial rounds to ensure the logs was up to date, cleanliness, and overall appearance. The Administrator stated she inspected the refrigerator at least twice a week. The Administrator stated the last time she inspected was last week and did not notice any issues. The Administrator stated she inspected the ice machine at least once a week. The Administrator stated these failures could potentially cause a food borne illness.<BR/>Record review of the Refrigerators and Freezers policy, last revised on 12/2014, revealed this facility will ensure safety refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines 7. All food shall be appropriately dated to ensure proper rotation by expiration dates, Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food was opened. <BR/>Record review of the Food Receiving and Storage policy, last revised on 10/2017, revealed food shall be received and stored in a manner that complies with safe food handling practices . 1. Food services, or designated staff, will maintain clean food storage areas at all times. 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 1 of 17 residents (Resident #271) reviewed for accuracy of medical records.<BR/>The facility failed to ensure Resident #271's medication administration record was accurate and complete. <BR/>This failure could place residents at risk of not receiving care and services to meet their needs.<BR/>The findings included:<BR/>Record review of Resident #271's face sheet, dated 02/16/2023, revealed Resident #271 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and cerebrovascular disease (a group of conditions that affect the blood flow and the blood vessels in the brain). <BR/>Record review of the MDS assessment, dated 2/10/2023, revealed Resident #271 had clear speech and was understood by staff. The MDS revealed Resident #271 was usually able to understand others. The MDS revealed Resident #271 had a BIMS score of 5 which indicated severe cognitive impairment. The MDS revealed Resident #271 had no refusal of care. <BR/>Record review of the comprehensive care plan, last revised on 02/14/2023, revealed Resident #271 had a thyroid condition and took medications. The care plan revealed Resident #271 had diabetes and was at risk for high or low blood sugar. The interventions included: diabetes medication and accuchecks (blood glucose monitoring) as ordered by the physician.<BR/>Record review of the medication administration record (MAR), dated October 2022, revealed levothyroxine 100 mg by mouth every morning at 5:30 AM was not signed out as administered on 10/04/2022 or 10/14/2022. The MAR further revealed finger stick blood sugars twice daily was not signed out as administered on 10/23/2022, 10/27/2022, or 10/30/2022 at 5:00 PM. <BR/>During an interview on 02/16/2023 at 4:53 PM, CMA V stated a blank box on a MAR would mean a medication was not given or was not documented it was given. CMA V stated all medications should have been signed out on the MAR. CMA V was unsure why Resident #271 had several blanks on her MAR. CMA V stated it was important to document medication administration to prove that medications were given according to the doctor's orders. <BR/>During an interview on 02/16/2023 at 5:20 PM, LVN T stated a blank box on a MAR would indicate a medication was not given or was not documented it was given. LVN T stated all medication and blood sugar checks should have been signed out of the MAR. LVN T stated she was unsure why Resident #271 had several blanks on her MAR. LVN T stated it was important to ensure documentation was completed for continuity of care and follow up by staff. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated a blank box on a MAR would indicate a medication was not given or was not documented it was given. The DON stated the nurses and medication aides were responsible for ensuring no blanks were on the MAR. The DON stated accurate documentation of MAR were monitored by performing random checks. The DON was unsure why Resident #271 had blank boxes on her MAR. The DON stated accurate documentation was important to ensure residents were receiving their medications. <BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she expected nursing staff to ensure no blanks were on the MAR. The ADM stated the importance of accurately documenting medication administration was the health and safety of the residents and to prevent medication errors. <BR/>Record review of the Documentation of Medication Administration policy, last revised in April of 2007, revealed 1. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. name and strength of the drug; b. dosage; c. method of administration (e.g., oral, injection (and site), etc.); d. date and time of administration; e. reasons why a medication was withheld, not administered, or refused (as applicable); f. signature and title of the person administering the medication; and g. resident response to the medication, if applicable.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 staff (LVN T) reviewed for infection control.<BR/>The facility failed to ensure LVN T performed hand hygiene while checking blood sugars for Resident #2 and Resident #7 and when administering insulin to Resident #7. <BR/>This failure could place residents and staff at risk for cross-contamination and the spread of infection. <BR/>Findings included:<BR/>During an observation on 02/13/2023 at 3:56 PM, LVN T put on a pair of gloves and went into Resident #2's room to check her blood sugar. LVN T came out of Resident #2's room with the gloves still on and removed them at the medication cart and started charting on her tablet (used for documentation of medications). LVN T did not perform hand hygiene after glove removal. After this, LVN T put on gloves and went into Resident #7's and checked her blood sugar. LVN T came out of Resident #7's room and removed the gloves at the medication cart. LVN T did not perform hand hygiene after removing her gloves. LVN T prepared insulin and put on another pair of gloves and administered the insulin to Resident #7. LVN T came out of the room and removed her gloves at the medication cart and did not perform hand hygiene. <BR/>During an interview on 02/13/2023 4:03 PM, LVN T stated she should have performed hand hygiene before and after glove removal. LVN T stated she did not perform hand hygiene because there was no hand sanitizer. LVN T stated she did not have any hand sanitizer on her medication cart. LVN T stated she had looked and was not able to find any hand sanitizer in the facility. LVN T stated, I do not know who I have told about it, referring to not being able to find any hand sanitizer. LVN T stated performing hand hygiene was important for infection control and to prevent cross contamination. <BR/>During an interview on 02/16/2023 at 9:28 AM, Medical Records Staff Z stated she was responsible for ordering supplies. She stated she ordered the hand sanitizer a case a month, and that she was aware, the facility always had hand sanitizer available for the staff. <BR/>During an interview on 02/16/2023 at 11:48 AM, LVN B stated hand sanitizer was readily available for the staff and she had never struggled to get any hand sanitizer. LVN B stated it was important to perform hand hygiene to prevent the spread of infection.<BR/>During an interview on 02/16/2023 at 6:37 PM, the infection control preventionist stated staff should perform hand hygiene before and after providing care, before putting on gloves and after taking gloves off. The infection control preventionist stated the staff could do alcohol-based hand sanitizer up to 3 times when checking blood sugars and then they would have to perform hand hygiene with soap and water. The infection control preventionist stated she did check offs on random staff for hand hygiene every 6 weeks. The infection control preventionist stated it was important to perform hand hygiene to cut down on bloodborne pathogens, for the staff to protect themselves and the residents. The infection control preventionist stated not performing hand hygiene placed the residents at risk for COVID, germs and any bloodborne pathogen. The infection control preventionist stated no staff member had ever reported to her there was no hand sanitizer available that the facility always had hand sanitizer available. <BR/>During an interview on 02/16/2023 at 7:15 PM, the ADON stated hand hygiene should be performed before all care, before entering a room, when hands were soiled, before putting on gloves and after removing gloves. The ADON stated all staff were responsible for performing hand hygiene. The ADON stated anytime she walked on the floor she watched staff to see if they were performing hand hygiene. The ADON stated it had not been reported to her that there was no hand sanitizer available. The ADON stated that she knew of the facility always had hand sanitizer available for the staff. The ADON stated not performing hand hygiene placed the residents at risk for the spread of infection. <BR/>During an interview on 02/16/2023 at 8:07 PM, the DON stated hand hygiene should be performed prior to resident interaction, after providing care, and after removal of gloves. The DON stated LVN T should have performed hand hygiene after removing her gloves, while checking blood sugars and administering insulin. The DON stated all the staff knew they were supposed to perform hand hygiene. The DON stated she did spot checks to check for staff performing hand hygiene. The DON stated the facility had never not had hand sanitizer, if they were to get low, she would go to the store and buy some. The DON stated not performing hand hygiene placed the residents at risk for cross contamination. <BR/>During an interview on 02/16/2023 at 9:03 PM, the administrator stated she expected all the staff to perform hand hygiene. The administrator stated the DON was ultimately responsible for ensuring the staff were performing hand hygiene. The administrator stated not performing hand hygiene was an infection control issue. <BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, last revised on August 2019, revealed, The facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); F. Before donning sterile gloves . m. After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 17 resident incidents (Resident #58 and Resident #44) reviewed for abuse and neglect.<BR/> The facility failed to have evidence that a thorough investigation was conducted. The Provider Investigation Report involving Resident #58 and Resident #44 failed to include witness statements from staff who witnessed the incident.<BR/>These failures could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being.<BR/>Findings include:<BR/>1.Record Review of Resident #58's face sheet dated 02/16/23 indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #58 had a diagnosis of vascular dementia (impaired supply of blood to the brain), psychotic disorder with delusions (disconnection from reality) and major depression (persistently depressed mood or loss of interest in activities).<BR/> Record review of Resident #58's MDS dated [DATE] indicated a BIMS score of 1 indicating severely impaired cognition.<BR/>2.Record review of Resident #44's face sheet indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #44 had a diagnosis of schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), psychotic disorder (disconnection from reality) and hypertension (force of blood against the artery walls is too high).<BR/>Record review of Resident #44's MDS dated [DATE] indicated a BIMS score of 5 indicating severe impairment. <BR/>Record review of progress notes included in the facility investigation report involving Resident #58 and Resident #44 were dated 10/12/22-11/10/22. The date of the reported incident was on 11/29/22. The investigation report indicated Resident #58 pushed Resident #44 causing him to fall.<BR/>During an interview on 02/16/23 at 11:00 a.m., LVN B was listed as a witness on Resident #58 and Resident #44's facility investigation report. LVN B stated she did not work on 11/29/22 and did not witness the incident. <BR/>During an interview on 02/16/23 at 2:29 p.m., LVN A was listed as a witness on Resident #58 and Resident #44's facility investigation report. LVN A stated she remembered when the incident occurred, but she did not work during the time of the incident. LVN A stated she worked the following shift. <BR/>During an interview on 02/16/23 at 2:19 p.m., CNA P stated she witnessed the incident involving Resident #58 and Resident #44 and LVN A and LVN B were not working that shift. CNA P stated an agency nurse worked during the incident and she did not know the agency nurse's name. CNA P stated she wrote a witness statement after the incident occurred, but she did not know why it was not included in the facility investigation report. CNA P stated she was asked to write another statement today on Resident #58 and Resident #44's incident that happen on 11/29/22. <BR/>During an interview on 02/16/23 at 3:44 p.m., the Administration stated she was responsible for filling out the Provider Investigation Reports. The Administrator stated, if the incident report was not filled out correctly, it could result in a delay of making sure that person was ok and result in miscommunication. The Administrator stated she thought nursing notes would work as witness statements on incidents, but that Corporate informed her today that she was required to have written witness statements from staff in the facility investigation report going forward. The Administrator stated she should have the witness statements completed after the incident occurred on 11/29/22 instead of having CNA fill it out today because she would of had a more accurate statement of what happen due to safety.<BR/>Record review of the policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation revised 4/2021 indicated that notices included: the names of all persons involved in the alleged incident, all allegations are thoroughly investigated, and witness statements are obtained in writing, signed, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, clean, and comfortable environment for 2 of 17 residents in rooms (#205-B and room#104-B) reviewed for environment.<BR/>The facility did not repair the chipped paint on the walls in room [ROOM NUMBER]-B.<BR/>The facility did not repair the torn away baseboards in room#205-B.<BR/>The facility failed to ensure room#104-B was clean.<BR/>These failures could place the residents at risk for an unsafe environment.<BR/>Findings included:<BR/>1.During an observation and interview on 02/14/23 at 12:00 p.m., Resident in room [ROOM NUMBER]-B was sitting in her bed watching TV, observation made of baseboard trim tearing away from the walls in room. Resident in room [ROOM NUMBER]-B stated the shower next door leaked water in her closet and she thought that was why the trim was messed up. Observation made of paint chipped around the baseboards in room#205-B. Resident in room [ROOM NUMBER]-B stated she did not like the trim tearing away from the wall and would like for it to be fixed because bugs would run out from under the trim. Resident in room [ROOM NUMBER]-B stated she had notified staff but could not remember which ones.<BR/>During an interview on 02/14/23 at 10:01 a.m., Resident in room [ROOM NUMBER]-B's family member stated the resident's room was next to the shower room and when other residents took a shower it would leak in the closet next to the trim that was torn away. Family member stated maintenance had recently worked on the shower, but the baseboards remained torn away from the wall.<BR/>During an interview on 02/15/23 at 4:20 p.m., CNA F stated resident in room [ROOM NUMBER]-B's family member visited the facility weekly. CNA F stated the resident in room [ROOM NUMBER]-B's family member had never complained to her of the trim and she never noticed the trim. CNA F stated room repairs should have been logged in the maintenance book at the nursing station and it was everyone's responsibility to report needed repairs. <BR/>During an interview on 02/16/23 at 11:00 a.m., LVN B stated resident in room [ROOM NUMBER]-B had never complained of the chipped paint or the trim tearing away from the wall. LVN B stated all staff was responsible for reporting needed repairs and for filling out the form in the maintenance log at the nursing station. LVN B stated she did not know about the trim, or she would have reported it. LVN B stated the trim could have been a fall hazard. <BR/>During an interview on 02/15/23 at 11:35 a.m., the maintenance supervisor stated he had repaired the shower 2 weeks ago that was leaking in room [ROOM NUMBER]-B. The maintenance supervisor stated, he was not aware of the trim coming off the wall in room [ROOM NUMBER]-B, but he was having to repair all the trim in the facility. The maintenance supervisor stated he had started the repairs in the men's unit on 02/14/23 and was completing repairs one unit at a time. The maintenance supervisor stated he, does not walk into each room to look for repairs and he depended on staff to put needed repairs in the Maintenance logbook. The maintenance supervisor reported nurses were required to do quality rounds and log any maintenance issues. <BR/>Record review of the maintenance log dated 2/14/23-4/12/23 indicated no issues with room [ROOM NUMBER]-B.<BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she expected the trim to be reported and fixed in room [ROOM NUMBER]-B. The DON stated, All staff was responsible for reporting repairs when they see them. The DON reported trim coming off the wall could have been a potential for injury. <BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected the trim to be fixed and all staff was responsible for reporting. The Administrator stated the trim was a trip hazard and it could have led to building damage if not repaired. <BR/>Record review of the policy on Homelike Environment revised 2/2021 indicated staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as clean, sanitary, and orderly environment. <BR/>2.During an observation made on 2/14/23 at 12:24 p.m., Resident in room#104-B's closet had a dark brown substance dried on the trim of the closet door in his room. <BR/>During an observation and interview on 02/15/23 at 12:05 p.m., room#104-B had a dark brown substance dried on the wall above his bed, next to the window. The dark brown substance remained on the closet door frame of room#104-B. CNA E stated she did not know the dark brown substance was on the wall in the room and she was responsible for checking the rooms every 2 hours. CNA E stated housekeeping just left the room. <BR/>During an attempted interview on 02/15/23 at 12:15 p.m., resident in room#104-B was not interviewable. <BR/>During an interview on 02/16/23 at 4:36 p.m., CNA H stated she did not know about the dark brown substance on the wall or door trim in room#104-B or she would have notified housekeeping. CNA H stated the CNAs were responsible for making room checks every 2 hours and cleaning feces on the wall if they saw it.<BR/>During an interview on 02/16/23 at 9:27 a.m., the housekeeping supervisor stated she expected housekeeping staff to clean the dark brown substance on the walls and trim in resident rooms and housekeeping was responsible. Housekeeping supervisor stated she noticed the dark brown substance on the wall on 02/16/23 about 8:15 a.m. and she notified Housekeeper L that the dark brown substance needed to be cleaned. Housekeeping Supervisor stated she was responsible for making daily rounds in resident rooms, but she also worked on a hall and did not always have time to check every room. Housekeeper Supervisor stated she will start making daily rounds to make sure each room was clean. Housekeeping Supervisor stated housekeeping was responsible for cleaning rooms 3 times a day and housekeeping was expected to check every room. Housekeeper Supervisor stated she expected dark brown substance to be cleaned to prevent germs and make sure other residents did not get sick. <BR/>During an interview on 02/16/23 at 10:56 a.m., housekeeper L stated she worked on the men's unit on 02/15/23 and 02/16/23. Housekeeper L stated she was expected to check resident rooms once daily. Housekeeper L stated she did not see the dark brown substance dried on the door trim on 2/15/23 or 2/16/23. Housekeeper L stated she did not see the dark brown substance on the wall in room#104-B during her rounds on 2/16/23. Housekeeper L stated she did not know about the dark brown substance until CNA E had notified her on 2/16/23 and she cleaned it. Housekeeper L stated, she cannot see without glasses and was not wearing them on 02/15/23 or 02/16/23. Housekeeper L stated the Housekeeper Supervisor did not inform her on 02/16/23 that she needed to clean the dark brown substance. Housekeeper L stated she was expected to look for things such as dark brown substances and make sure they were cleaned. Housekeeper L stated, the feces had been on the wall a while because it was hard to scrub off and it was in a bunch of areas. Housekeeper L stated she did not know if anyone checked behind the housekeepers to make sure the rooms were clean. Housekeeper L stated it was important to make sure the rooms were clean because of infection control and the residents or employees could have got sick. <BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she expected the dark brown substances to be cleaned off the walls in resident rooms and housekeeping was responsible for making sure the rooms were clean. The DON stated housekeeping checked resident rooms daily. The DON stated staff will start having to do angel rounds (administrative staff assigned to make daily rounds to check rooms) to make sure resident rooms were clean and not in need of repairs.<BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected housekeeping to clean dark brown substances dried on the walls in resident rooms and housekeeping was responsible for making sure the rooms were clean. The Administrator stated housekeeping should have been constantly doing rounds and all staff were responsible for reporting feces on the walls. <BR/>Record review of the policy on Homelike Environment revised 2/2021 indicated staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as clean, sanitary, and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved 1 of 8 residents (Resident #61) reviewed for medication administration.<BR/>The facility failed to ensure Resident #61 received docusate sodium tablet 100 mg and naproxen tablet 250 mg between 6:00 a.m. and 8:00 a.m. <BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. <BR/>Findings included:<BR/>Record review of Resident #61's order summary report, dated 02/16/2023, indicated Resident #61 was a [AGE] year-old-female, admitted to the facility on [DATE] with a diagnosis which included congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), constipation, and pain in right hip. <BR/>Further review of order summary report dated 02/16/2023, indicated Resident #61 was prescribed Naproxen tablet, 250 mg by mouth, one time a day for pain with start date 09/04/2022. The order summary report indicated Resident #61 was prescribed docusate sodium tablet, 100 mg by mouth, two times a day for constipation with start date 08/10/2021. <BR/>Record review of the MAR dated 02/01/2023-02/28/2023 revealed Resident #61 had an order for naproxen 250 mg to be given at 7:00 a.m. <BR/>Record review of the MAR dated 02/02/2023-02/28/2023 revealed Resident #61 had an order for docusate sodium 100 mg to be given at 7:00 a.m. and 7:00 p.m. <BR/>During an observation on 02/14/2023 at 8:57 a.m., CMA M administered docusate sodium tablet 100 mg for constipation and naproxen tablet 250 mg for pain at 8:57 a.m. to Resident #61. <BR/>During an interview on 02/16/2023 at 2:21 p.m., CMA M stated the medications should be given between 6:00 a.m. and 8:00 a.m. CMA M stated Resident #61's medications was giving late due to her preparing the 9:00 a.m. medications to be given with the surveyor. CMA M stated the failure of not giving medications on time could cause an interaction with other medications. <BR/>During an interview on 02/16/2023 at 4:21 p.m., the DON stated she expected the nurses and CMAs to administer medications at the correct time. The DON stated she had not witnessed any late medications during her weekly random checks. The DON stated her last random check was done on last week. The DON stated she did not notice any issues. The DON stated the purpose was that each resident could receive their medications in a time frame. The DON stated the failure of not administering naproxen on time put Resident #61 at risk for increased pain. The DON stated she did not believe the resident would be harmed with getting a scheduled stool softener 57 minutes late. <BR/>During an interview on 02/16/2023 at 5:56 p.m., the Administrator stated she expected the nurses to follow the physician orders and to have given the medications per order. The Administrator indicated she did not know what the harm could be because she did not have clinical background.<BR/>Record review of the facility's policy titled, Administering Medications, revised on 12/2012 revealed, . medications shall be administered in a safe and timely manner, and as prescribed . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medication must be administered withing one (1) hour of their prescribed time, unless otherwise specified .<BR/>

Based on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition for 1 (Resident # 35) of 17 residents reviewed for safe operating patient care equipment. <BR/>The facility failed to ensure Resident #35's headboard was not broken. <BR/>This failure could place resident at risk of injury. <BR/>Findings included: <BR/>During an observation and interview made on 02/14/23 at 11:50 a.m., Resident #35' s headboard was missing the rubber trim on the top left side and the rubber was sticking straight up on the right top side. Resident #35 was not interviewable.<BR/>During an observation and interview on 02/15/23 at 12:05p.m., CNA E stated she had never noticed the headboard, or she would have written it in the maintenance logbook. <BR/>During an interview on 02/15/23 at 12:15 p.m., CNA D stated she did not know Resident #35's headboard was broken. CNA D stated items that needed to be fixed should be put in the maintenance logbook at the nursing station. CNA D stated she might not always write needed repairs in the maintenance logbook because it was hard to leave the unit. CNA D stated if she did not log the repair, she would verbally inform Maintenance when things needed to be repaired. CNA D stated the headboard could have scratched Resident #35 if not fixed.<BR/>During an interview on 02/16/23 at 11:00 a.m., LVN C stated the broken headboard should have been reported in the maintenance logbook and could have caused Resident #35 to have a skin tear. LVN C stated all staff was responsible for reporting items that needed to be fixed.<BR/>During an interview on 02/15/23 at 11:35 a.m., the maintenance supervisor stated he was not aware of Resident #35's headboard, but he also did not have any beds to change it out with. The maintenance supervisor stated the facility had ordered new beds because several were broken, and they just received two of the new beds. Maintenance stated, He does not walk into each room to look for needed repairs and he depends on staff to put repairs in the Maintenance logbook. The maintenance supervisor reported that nurses are required to do quality rounds and log any maintenance issues in the logbook. <BR/>During an interview on 02/16/23 at 3:30 p.m., the DON stated she expected broken headboards to be reported and fixed. The DON stated, All staff was responsible for reporting repairs when they see them. The DON reported the broken headboard could have been a potential injury. <BR/>During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she expected the headboard to be fixed and all staff was responsible for reporting. <BR/>Record review of the policy on Homelike Environment revised 2/2021 indicated staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics included clean bed and bath linens that were in good condition. <BR/>Record review of the policy on Assistive Devices and Equipment revised on 01/2020 indicated devices and equipment were maintained on schedule and according to manufactured instructions. Defective or worn devises were discarded or repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain at least 80 square feet per residents in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 1 of 31 multiple-residents bedroom, reviewed for bedroom measurement.<BR/>room [ROOM NUMBER] measured 147.4 square feet. <BR/>This failure could place residents at risk of having inadequate space for personal belongings and guest. <BR/>Findings included: <BR/>During an observation of room [ROOM NUMBER] from 02/13/2023 through 02/16/2023 measure 147.4 square feet which was less than the 160 square feet required for a two-bedroom. There was no resident residing in room [ROOM NUMBER]. <BR/>During an interview on 02/16/2023 at 6:06 p.m., the VP of Clinical Operations stated a waiver was requested from CMS in August 2021 and October 2021. The VP of Clinical Operations stated the waiver was approved from Texas HHSC. The VP of Clinical Operations stated the facility must state on the 2567/3724 that they had submitted the request, the waiver would be initiated with CMS. The VP of Clinical Operations stated there was nothing else the facility had to do except document the request on the POC with a date. The VP of Clinical Operations stated there was not a policy and procedure regarding room size.

Based on observation, interview and record review, the facility failed to ensure that each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community, in that:<BR/>The facility failed to serve meals, at the specific times posted, in the main dining room.<BR/>This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth.<BR/>Findings included:<BR/>Record Review of in-services on time management was last completed by staff on 4/29/25.<BR/>Record review of the facility's posted meal service reflected breakfast mealtime was 7:00 AM; lunch mealtime was 12:00 PM; and dinner mealtime was 5:00 PM.<BR/>During an interview in the dining room on 5/28/25 at 9:00 a.m., Resident #38 stated that the breakfast and lunch meal was always served late. <BR/>During observations on 05/28/25 at 12:42 PM, in the facility's main room, lunch meal service had not begun, and the residents had not begun to eat lunch. <BR/>During an interview on 5/29/25 at 8:15 a.m., the Dietary manager stated he had been employed at the facility for 7 months. The Dietary Manager stated the meal serving times were 7am for breakfast, 12pm for lunch and 5pm for dinner. The Dietary Manager stated the reason why the lunch meal on 5/28/25 was late was because the cook folded under pressure and because the cook was in his own head. The Dietary Manager stated staff had been in serviced on serving the meals timely. The Dietary Manager stated it was important to serve the meals timely because the residents were in routine and the residents needed to be fed on time. <BR/>During an interview on 5/29/25 at 8:37 a.m., the Administrator stated he had been the Administrator since November of 2024. The Administrator stated he was made aware of the lunch meal being served late on 5/28/25 (lunch meal) by the Dietary Manager. The Administrator stated staff had been in serviced on serving the meals timely. The Administrator stated in the past the Dietary staff had been 5 minutes late serving the meals and he in serviced staff on being on time to serve the meals timely. The Administrator stated, It was important to serve the meals timely because the residents needed to eat on time, for weight loss and for blood sugars; we have to keep the residents on their schedules.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 2 of 4 medication carts (Nurse E Hall and Med Aide E Hall) reviewed for storage of drugs. <BR/>The facility failed to ensure E Hall nurse and Med Aide medication carts were locked when unattended. <BR/>This deficient practice could place residents at risk of medication misuse and diversion.<BR/>Findings include: <BR/>1. During an observation on 02/13/2023 at 3:54 p.m., LVN A left the E Hall medication cart unlocked and unattended in Resident #28's door while administering Resident #28's medication. <BR/>During an interview on 02/16/2023 at 10:33 a.m., LVN A stated she should have locked the medication cart prior to going in Resident #28's room. LVN A stated she was nervous and forgot to lock the cart. LVN A stated she noticed the medication cart not locked after administering the medication. LVN A stated this failure could potentially put residents/staff at risk for overdose. <BR/>2. During an observation on 02/14/2023 at 8:57 a.m., CMA M left the E Hall med aide medication cart unlocked and unattended in Resident #61's door while administering Resident #61's medications. <BR/>During an interview on 2/16/2023 at 2:16 p.m., CMA M stated she was responsible for ensuring her medication cart was locked prior to entering Resident #61's room. CMA M stated she forgot to lock the cart because Resident #61's roommate had called out for assistance. CMA M stated once the medications were pulled from the cart, and verified that all medications were correct, the medication cart should be locked prior to entering the resident's room. CMA M stated not locking the medication cart could allow other residents/staff to retrieve the medications and misuse the medications. <BR/>During an interview on 02/16/2023 at 4:21 p.m., the DON stated she expected medication carts to be locked when unattended. The DON stated the charge nurses and CMAs were responsible for monitoring their own medication cart. The DON stated she performed daily checks throughout the day to ensure medication carts were locked when unattended. The DON stated she was unaware of any issues. The DON stated this failure could allow residents to get in the medications and cause an adverse reaction. <BR/>During an interview on 02/16/2023 at 5:56 p.m., the Administrator stated she expected medication carts to be locked when unattended. The Administrator stated nursing staff were responsible for ensuring medications carts are locked when unattended. The Administrator stated this failure could potentially cause an overdose. <BR/>Record review of the Storage of Medications policy, last revised on 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner 7. Compartments (including, but not limited to, drawers cabinets rooms, refrigerator, carts, and boxes) containing drugs and biologicals shall be locked when not in use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 17 residents (Resident #47) reviewed for accuracy of assessments.<BR/>The facility failed to complete Resident #47's MDS assessment within 14 days of admission to the facility. <BR/>This failure could place residents at risk of not having their needs met. <BR/>The findings included:<BR/>Record review of Resident #47's face sheet, dated 02/16/2023, revealed Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acquired absence of left leg below knee (left leg amputation below the knee). <BR/>Record review of Resident #47's comprehensive MDS assessment with an ARD (assessment reference date) of 10/02/2022, revealed it was an admission assessment (required by day 14). The MDS assessment for Resident #49 revealed an entry date of 09/19/2022. The MDS assessment for Resident #49 revealed the CAA (Care Area Assessment) was signed completed on 10/07/2022, indicating the MDS assessment for Resident #47 was completed 5 days late.<BR/>During an interview on 02/16/2023 at 5:33 PM, the MDS Coordinator stated an admission MDS assessment should have been completed within 14 days of admission, including the CAA process and care plan decisions. The MDS Coordinator stated Resident #47's admission MDS should have been completed by 10/02/2022. The MDS Coordinator was unsure why Resident #47's admission MDS was not completed by day 14. The MDS Coordinator stated completing MDS assessments timely was important, so the residents were taken care of in a timely manner. <BR/>During an interview on 02/16/2023 at 6:14 PM, the DON stated she was the RN responsible for signing the MDS assessments as completed. The DON stated she was unsure why Resident #47's admission MDS assessment was not completed by day 14. The DON stated the importance of completing the MDS assessment in a timely manner was to ensure the billing department was able to complete the billing for funding to continue caring for the residents.<BR/>During an interview on 02/16/2023 at 6:45 PM, the ADM stated she expected MDS assessments to be completed accurately and timely. The ADM stated the importance of completing MDS assessments timely was ensuring residents were not receiving delays in care and the facility was not receiving delays in billing. <BR/>Review of the RAI (Resident Assessment Instrument) manual, last revised in October of 2019, revealed on page 2-21, Assessment Management Requirements and Tips for admission Assessments: The CAA(s) completion date (item V0200B2) must be no later than day 14.

Based on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 smoking area.<BR/>The facility failed to ensure cigarette butts were disposed of appropriately.<BR/>The facility failed to provide ashtrays of a safe design and a self-closing metal container to open empty ashes. <BR/>These failures could place residents at risk for injury, burns and an unsafe smoking environment.<BR/>Findings include: <BR/>During an observation on 02/13/2023 at 3:37 PM, the designated smoking area had 1 chimney-type ashtray and no self-closing metal container. <BR/>During an observation on 02/16/2023 at 12:00 PM, the designated smoking area had 1 chimney-type ashtray and no self-closing metal container. There were 3 cigarette butts on the ground close by the chimney-type ashtray. <BR/>During an interview on 02/26/2023 at 7:54 PM, the DON stated she was not responsible for the smoking area, and she did not know who was. The DON stated the self-closing metal container was replaced by the cigarette butt holder that was outside and to her knowledge that was the correct type of ashtray. The DON stated whoever was smoking with the residents should make sure the cigarette butts were not thrown on the ground. The DON stated usually the staff took the cigarette butts from the residents and put them in the chimney-type ashtray. The DON stated if a resident missed the hole trying to put the cigarette butt in the chimney-type ashtray, they could burn themselves. The DON stated the cigarettes thrown on the ground could cause a fire. <BR/>During an interview on 02/16/23 at 8:48 PM, the administrator stated the maintenance supervisor was responsible for the smoking area, but ultimately, she was responsible to help the maintenance supervisor to follow the regulations. The administrator stated the ashtrays should be the type that were metal and fire retardant with a lock, and there should be a red bucket that was fire retardant. The administrator stated the chimney-type ashtray met all the safety needs, but it needed to be emptied on a regular basis. The administrator stated she made rounds of the smoking area daily to check for cigarette butts on the ground. The administrator stated cigarette butts should not be on the ground, and the person who monitored the residents smoking should ensure cigarette butts were not thrown on the ground. The administrator stated not using the correct ashtrays could cause a fire. The administrator stated using chimney-type ashtrays could result in the residents burning themselves. The administrator stated the cigarette butts should not be thrown on the ground because it did not look good, and it was a potential for a fire. <BR/>Record review of an undated facility policy titled, Smoking Regulations revealed, . Smoking areas are provided with ashtrays made of non-combustible material and safe design and a self-closing metal container to empty ashtrays .