PARIS HEALTHCARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident incontinent of urine and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident reviewed for bladder and bowel incontinence. (Resident #28)<BR/>CNA M cleansed Resident #28's perineal area and buttocks using the same washcloth.<BR/>CNA M failed to remove her soiled gloves prior to touching the clean brief, Resident #28's night clothes and the bed linen. <BR/>This failure could place residents at the facility requiring incontinent care at risk for discomfort, skin breakdown, cross contamination, and urinary tract infections. <BR/>Findings included:<BR/>Record review of a face sheet dated 6/30/2022 indicated Resident #28 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart disease, muscle weakness, and chronic pain. <BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #28 usually understands and was usually understood. Resident #28's BIMS (brief interview memory score) was score of 5 indicating severe cognitive impairment. The MDS indicated Resident #28 required extensive assistance of one staff for toilet use and personal hygiene. The MDS indicated Resident #28 was frequently incontinent of bowel and bladder.<BR/>Record review of a comprehensive care plan dated 11/17/2020 and updated on 5/20/2022 indicated Resident #28 was incontinent of bladder with the intervention of checking for incontinence a minimum of every 2 hours and provide toileting as requested and assess needs a minimum of every 2 hours.<BR/>Record review of a nursing note dated 6/15/2022 at 11:23 p.m., LVN E indicated Resident #28 complained of dysuria stating, It just burns every time I get started peeing. The note indicated Resident #28 complained of urgency and frequency. The note indicated a new order for a urinalysis with a culture and sensitivity was ordered.<BR/>Record review of a nursing note dated 6/17/2022 at 4:00 p.m.,LVN G indicated Resident #28 had a new order for Nitrofurantoin 100 mg twice daily for 7 days ordered for a UTI.<BR/>Record review of a urinalysis dated 6/15/2022 indicated Resident #28 had greater than 100,000 colony count with the cultured Escherichia coli bacteria (bacteria commonly from fecal material).<BR/>During an interview on 6/28/2022 at 2:00 p.m., Resident #28 indicated she was being left sitting in urine and sometimes feces for long periods of time waiting on staff to assist her with changing her brief.<BR/>During an observation and interview on 6/28/2022 at 9:38 p.m., Resident #28's call light was answered by CNA M. Resident #28 indicated she was incontinent of urine and wanted to go to bed. CNA M assisted Resident #28 on to her bed to provide incontinent care. CNA M removed Resident #28's brief revealing the brief material had become saturated with urine and had broken down leaving the filler material on Resident #28's perineal area and buttocks. CNA M began providing incontinent care using one washcloth made several wiping motions in the perineal area without turning the washcloth to a clean area. Then CNA M rolled Resident #28 on her left side and began wiping her buttocks with same washcloth not rotating the clothe between wipes. CNA M applied a new brief, adjusted Resident #28's clothing and covered her with the bed linen without changing her gloves.<BR/>During an interview on 6/28/2022 at 10:20 p.m., CNA M indicated she has always provided better incontinent care. CNA M indicated she had worked her entire shift; she had not had a break or even lunch and was just tired. CNA M indicated she had not changed Resident #28 since 5:00 p.m. this evening. CNA M indicated the brief was leaving jelly like material on Resident #28. CNA M indicated not changing Resident #28 and the poor incontinent could cause urinary tract infections. <BR/>During an interview on 6/28/2022 at 10:39 p.m., CNA M indicated she had provided incontinent care appropriately to Resident #28. CNA M when asked why she indicated she just could not leave Resident #28 without better incontinent care.<BR/>Record review of an Incontinent Care for the Female Resident Check off form dated 6/10/2021 for CNA M indicated she was skilled in the areas of using a clean washcloth with peri wash to cleanse the buttocks without contaminating the perineal area. CNA M was checked off on washing and drying her hands, reapply gloves and assist the resident with repositioning and dressing.<BR/>During an interview on 6/30/2022 at 2:33 p.m., the DON indicated she expected incontinent care to be done with 1 wipe and discard method using wipes. The DON indicated she expected rounds to be completed every 2-3 hours or more often if needed. The DON indicated she was aware Resident #28 just completed antibiotics for a urinary tract infection. The DON indicated she was responsible for ensuring appropriate incontinent care was taught. She indicated the CNAs were checked off annually.<BR/>During an interview on 6/30/2022 at 3:24 p.m., the ADM indicated she expected incontinent care to be provided as needed.<BR/>Record review of a Urinary Incontinence policy dated April 2018 indicated 4. For incontinent individuals, the nursing staff will identify, and document circumstances related to incontinence; for example, frequency, nocturia, dysuria, or relationship to coughing/sneezing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for 1 of 4 residents (Resident #15) reviewed for unnecessary medications/ gradual dose reduction.<BR/>The facility failed to do a gradual dose reduction or document contraindication for a gradual dose reduction for Resident #15's ordered Risperdal 2mg orally twice daily ordered 08/14/2023 and Risperdal Consta suspension extended release 25mg/ml (2ml) intramuscular every 14 days ordered 02/22/2024. <BR/>These failures could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.<BR/>Findings included:<BR/>Review of the resident face sheet revealed, Resident #15 was a [AGE] year-old male that admitted on [DATE] with the diagnoses of schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), seizure disorder, and cerebral infarction (stroke).<BR/>Review of Resident #15'squarterly MDS dated [DATE] indicated Resident #15 had a BIMS (brief interview of mental status) of 00, which indicated a severe cognitive impairment. The MDS revealed Resident #15 had short- and long-term memory impairment. The MDS revealed Resident #15 required limited assistance with ADLs. No hallucinations, delusions, behavior, rejection of care or wandering was noted on the MDS. Resident #15 received antipsychotic medication 7 days out of 7 days. <BR/>Review of Resident #15's physician consolidated orders dated 09/01/2024 to 09/30/2024 revealed the following:<BR/>* Risperdal 2 mg orally twice daily originally ordered on 08/14/2023. <BR/>*Risperdal Consta suspension extended release 25mg/2ml. Give 2ml intramuscularly every 14 days original order date 02/22/2024.<BR/>Review of Resident #15's MAR (medication reconciliation record) for September 2024 revealed the following refusals:<BR/>Risperdal 2mg twice daily<BR/>09/02/2024-a.m. dose<BR/>09/03/2024-a.m. dose<BR/>09/04/2024-a.m. dose<BR/>09/06/2024-a.m. dose<BR/>09/07/2024-a.m. dose<BR/>09/08/2024-a.m. dose<BR/>09/11/2024- a.m. dose<BR/>09/12/2024- a.m. dose<BR/>09/16/2024- a.m. dose<BR/>09/17/2024- a.m. dose<BR/> Risperdal Consta 2ml intramuscular injection<BR/>09/19/24<BR/>Further review revealed Risperdal Consta 2ml intramuscular injection was administered on 09/05/2024.<BR/>Record review of the consultant pharmacist recommendations for January through September 2024 and August to December 2023 revealed there was not a GDR for Resident #15's Risperdal 2mg oral twice daily medication nor a GDR for the Risperdal Consta 2ml intramuscular injection. <BR/>During an interview on 10/02/2024 at 1:15p.m., RPH D stated she made recommendations for the decrease of Resident #15's Risperdal 2mg orally twice daily to be decreased to 1mg in the morning and 2 mg at bedtime. She stated she sent the recommendation to the facility on [DATE] after the DON informed her the GDR for Resident #15 were late. She stated she understood the GDR was supposed to be done every 6 months for the 1st year and annually thereafter for antipsychotic medications. She stated the facility had a lot of GDRs that were out of compliance when she took the building over and she was trying to gradually get everyone on a schedule. She stated it was important to do GDRs so the resident will be on the lowest effective dose of psychotropic medications.<BR/>During an interview on 10/02/2024 at 2:00 p.m., the DON stated she could not find the GDR for Resident #15 due in February and August 2024 for his Risperdal 2mg orally twice daily. She stated she could not find the GDR for Resident #15's Risperdal Consta 2 ml intramuscularly every 14 days that was due in August. She stated she called the pharmacist after the surveyor asked about the GDR for Resident #15. She stated it was important for GDR to be done so residents did not suffer ill effects of psychotropic medications. She stated she would have to make a system to check behind the pharmacist and ensure the GDRs are done on all residents timely.<BR/>Review of a facility policy titled 'Psychoactive Medications' dated 07/2024 indicated . Residents who use psychotropic medications shall be evaluated for gradual dose reduction unless clinically contraindicated, in a effort to discontinue these drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 16 residents reviewed for medications. (Resident #26)<BR/>The facility failed to ensure Resident #26 received his full eight-week course of Mavyret (antiviral medication used to treat Hepatitis C, which is a disease of the liver caused by a virus that causes damage to the liver) ordered by the Infectious Disease physician and started on 11/15/23. <BR/>This failure could cause prolonged illness and increased recovery time for residents.<BR/>Findings included:<BR/>Record review of Resident #26's face sheet dated 9/30/24 indicated he was [AGE] years old and admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses including Chronic Hepatitis C, encephalopathy (any brain disease that alters brain function or structure).<BR/>Record review of Resident #26's significant change MDS assessment dated [DATE] indicated he had a BIMS of 4, which indicated he had severe cognitive impairment and required moderate staff assistance to supervision for most ADLs. The MDS indicated Resident #26 had cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure).<BR/>Record review of Resident #26's undated care plan indicated he had a diagnosis of Hepatitis C with an intervention to administer medications per MD orders with a start date of 11/17/23.<BR/>Record review of Resident #26's Progress Notes dated 11/01/23 indicated RN B received a call from the Specialty Pharmacy to notify the facility of new orders for Mavyret 100/40 mg 3 tabs daily for sixty days from the Infectious Disease doctor. RN B documented the Specialty Pharmacy would send a 30-day supply pending approval.<BR/>Record review of Resident #26's Progress Notes dated 11/15/23 written by * indicated LVN A documented the new medication for treatment of Resident #26's Hepatitis C was received from the Specialty Pharmacy and the Infectious Disease doctor was notified of the initial dose. LVN A documented she notified Resident #26's primary care physician for order clarification of discontinuing the resident's atorvastatin and pantoprazole until the completion of Mavyret eight-week treatment for chronic Hepatitis C. LVN A documented the medication was to be given daily with food and MUST AVOID ANY MISSED DOSES FOR successful treatment of chronic Hepatitis C and MARs updated.<BR/>Record review of Resident #26's order history from 11/01/23 revealed an order for Mavyret 100-40 mg three tablets once daily with food with a start date of 11/15/23 and an end date of 12/12/23 entered by LVN A.<BR/>Record review of Resident #26's MAR dated 11/01/23-11/30/23 indicated Mavyret 100-40 mg 3 tablets once daily with food for Chronic viral Hepatitis C with a start date of 11/15/23 and an end date of 12/12/23. The MAR indicated Resident #26 received the medication 11/16/23 through 11/19/23 and 11/28/23 through 11/30/23.<BR/>Record review of Resident #26's progress notes dated 11/19/23-11/27/23 indicated he was admitted to the hospital on [DATE] and returned to the facility on [DATE] with diagnoses of respiratory failure and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood that affects the brain). <BR/>Record review of Resident #26's hospital Infectious Disease Progress Note dated 11/20/23 documented his assessment and plan included Resident #26 had cirrhosis with Hepatitis C and he was on a direct antiviral therapy, Mavyret, and the hospital was going to call his nursing facility and would continue the medication. On 11/23/23, the Infectious Disease Progress Note indicated his assessment and plan included Resident #26 had an underlying cirrhosis and Hepatitis C and he was receiving treatment and he had his medication from the nursing facility, and they would continue the medication.<BR/>Record review of Resident #26's MAR dated 12/01/23-12/31/23 indicated Mavyret 100-40 mg 3 tablets once daily with food for Chronic viral Hepatitis C with a start date of 11/15/23 and an end date of 12/12/23. The MAR indicated Resident #26 received the medication 12/01/23 through 12/12/23.<BR/>Record review of Resident #26's Infectious Disease physician's progress note dated 5/28/24 indicated Resident #26 failed his first treatment of Mavyret for his Hepatitis C because he only received four weeks of an eight-week treatment.<BR/>During an interview on 10/01/24 at 10:07 AM, the Specialty Pharmacy stated they delivered a 28-day supply of Resident #26's Mavyret on 11/15/23. The Specialty Pharmacy said the physician had ordered a 28-day supply with one refill of the medication and it was not refilled. <BR/>During an interview on 10/01/24 at 12:24 PM, LVN A said she had worked at the facility for 3-4 years until February 2024. LVN A said she was the infection control nurse and worked from home and would come to facility 1-2 days a week. LVN A said she vaguely remembered the order for Resident #26 starting on Mavyret. LVN A said Mavyret was an antiviral medication for his Hepatitis C. LVN A said it seemed like they had some trouble getting the medication, but she did not really remember. LVN A said, maybe Resident #26 had a reaction to the medication or maybe he only received 4 weeks of the Mavyret because he was supposed to go back to the Infectious Disease doctor to see if he was going to continue the medication. LVN A said it seemed like maybe Resident #26 went into the hospital and thought the hospital stopped the medication. LVN A said if Resident #26 was supposed to get 8 weeks of the medication and he did not complete it, it could have kept his Hepatitis C from being controlled. LVN A said she remembered they were in constant communication with the Infectious Disease doctor's nurse during that time. LVN A said she was the infectious disease nurse at that time, and she was on top of it, but it had been almost a year and she just could not remember the specifics.<BR/>Attempted to call RN B on 10/01/24 at 1:50 PM and 4:35 PM, there was no answer and was unable to leave a message.<BR/>During an interview on 10/01/24 at 2:35 PM, LVN C said she did not remember much about Resident #26 taking Mavyret for his Hepatitis C. LVN C said she did not remember much about the medication, but she did remember they took the medication to the hospital when he admitted to the hospital shortly after starting the Mavyret. LVN C said she did not remember exactly how long Resident #26 was supposed to have taken the Mavyret, but she thought it was ordered for a couple of months. LVN C said if the Mavyret was ordered for eight weeks and he only received four weeks of the medication, then it could have affected his Hepatitis C and lab results, and the medication would not have effectively treated Resident #26's Hepatitis C as it was meant to.<BR/>During an interview on 10/01/24 at 4:58 PM, the Regional Nurse said she did not work at the facility in November of 2023, but in reviewing Resident #26's chart, it appeared the nurse made a transcription error and only put the Mavyret in for 28 days when it appeared to have been ordered for 8 weeks. The Regional Nurse said she was still trying to get the original order from the Infectious Disease Physician.<BR/>During an interview on 10/02/24 at 10:25 AM, LVN AA, the Infectious Disease doctor's nurse, said she had called the facility and spoke to LVN A on 1/08/24 to see what day Resident #26 was scheduled to complete his Mavyret to determine when labs would need to be drawn. LVN AA said LVN A told her Resident #26 had completed the medication on 12/12/23. LVN AA said she told LVN A that Resident #26 should not have completed the medication until 1/10/24 by her calculations. LVN AA said LVN A said she would check on it and call her back. LVN AA said LVN A called her back and said it looked like he had gone into the hospital and then it was not restarted when he returned to the facility. LVN AA said Resident #26 was ordered Mavyret for a total of 8 weeks to treat his Hepatitis C. LVN AA said after learning Resident #26 did not complete the course of treatment, LVN AA informed the Infectious Disease doctor, and he ordered labs. LVN AA said they checked his viral load (the amount of virus in an infected person's blood) that week and none was detected and then they repeated the lab at 3 months (standard procedure) and his viral load was high, which indicated the 4 weeks of Mavyret did not cure his Hepatitis C. LVN AA said Resident #26 had to receive another 12-week course of treatment for his Hepatitis C. LVN AA said by Resident #26 not receiving the correct duration of the medication, it resulted in failed treatment of his Hepatitis C and he had to receive another course of treatment. LVN AA said the Specialty Pharmacy will only fill a month at a time for the medication due to the cost of the medication and that was why it was called into the Pharmacy as a 28 day with one refill. LVN AA said she had spoken with RN B and LVN A prior to Resident #26 starting Mavyret and explained the duration of the medication was for eight weeks and the importance of not missing any doses. <BR/>During an interview on 10/02/24 at 12:50 PM, the DON said she started work at the facility in February of 2024. The DON said she was not working at the facility in November of 2023, but since then, Resident #26's Infectious Disease doctor had ordered another treatment for Resident #26's Hepatitis C. The DON said Resident #26 completed the new treatment and his Hepatitis C was in remission. The DON said Resident #26's end result of not completing the ordered eight-week course of Mavyret resulted in Resident #26 having a failed treatment for his Hepatitis C. The DON said at the time of when Resident #26's Mavyret was ordered in November 2023, there was no oversight, lack of documentation, and everything that could have gone wrong did and it resulted in Resident #26 not receiving the full course of the medication. The DON said they now have systems in place to prevent these types of things from happening in the future.<BR/>During an interview on 10/02/24 at 1:17 PM, the ADM said she came to the facility in January 2024 and did not have any firsthand knowledge of Resident #26's missed medication issue, but it appeared the nurse that entered the medication order into the software, made a transcription error in the order. The ADM said it could have delayed Resident #26's treatment of his Hepatitis C by not completing the prescribed course of the medication. The ADM said she would expect staff to transcribe medication orders correctly and follow the physician's orders. <BR/>Record review of the facility's policy titled Specific Medication Administration Procedures dated 6/01/22, indicated . the purpose was to administer oral medications in a safe, accurate, and effective manner . review and confirm medication orders for each individual resident on the Medication Administration Record prior to administering medications to each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 3 of 5 residents reviewed for right to be informed. (Resident #12, #13, and #39)<BR/>1. The facility failed to ensure Resident #12 had a signed psychotropic consent form for ziprasidone (an antipsychotic medication). <BR/>2. The facility failed to ensure Resident #13 had signed a psychotropic consent form for Seroquel 100mg (antipsychotic).<BR/>3. The facility failed to obtain Resident #39's written consent prior to administration of an anti-psychotic medication.<BR/>These failures could place residents at risk for treatment or services provided without informed consent.<BR/>The findings included:<BR/>1. Record review of the face sheet, dated 08/25/23, revealed Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia with behaviors (group of symptoms that affects memory, thinking and interferes with daily life), bipolar disorder (serious mental illness characterized by extreme mood swings), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). <BR/>Record review of the MDS assessment, dated 06/23/23, revealed Resident #12 had clear speech and was understood by staff. The MDS revealed Resident #12 was able to understand others. The MDS revealed Resident #12 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #12 had trouble concentration on things, such as reading the newspaper or watching television 12 - 14 days during the 14-day look-back period. The MDS revealed Resident #12 had no behaviors or refusal of care. The MDS revealed Resident #12 received an antipsychotic medication 6 out of 7 days during the look-back period. <BR/>Record review of the comprehensive care plan, edited on 08/18/23, revealed Resident #12 had a diagnosis of bipolar disorder and took medications. <BR/>Record review of the physician order report dated 07/25/23 - 08/25/23, revealed Resident #12 had an order, which started on 05/12/23, for ziprasidone 80 mg (antipsychotic) for bipolar disorder. <BR/>Record review of the Consent for Antipsychotic or Neuroleptic Medication Treatment form, signed by the physician on 04/28/23, revealed no resident or resident representative signature. <BR/>During an observation and interview on 08/21/23 at 10:28 AM, Resident #12 was sitting up on the side of her bed with clean clothing and her hair combed neatly. Resident #12 stated she was aware she was taking an antipsychotic medication but was unable to remember if she signed a consent form. Resident #12 stated she had no adverse effects from her medication. <BR/>During an interview on 08/25/23 at 10:07 AM, LVN C stated she was unsure who was responsible for completing the psychotropic medication consents. LVN C stated if a new order was received for a psychotropic medication, she relied on upper management to obtain the consent. LVN C stated it was important to obtain consent prior to administering a psychotropic medication so the residents were aware of the risks and what they were taking. LVN C also stated it was important so the residents could decide to take the medication if they wanted to. <BR/>During an interview on 08/25/23 at 12:21 PM, the DON stated she was responsible for filling out the psychotropic consent forms and getting them signed by the physician and the resident or responsible party. The DON stated the staff would have made her aware of the new orders, she would have filled out the consent form and sent it to the physician for a signature, then had the resident or responsible party sign. The DON stated the medications were being administered without the consent form being signed per the facilities current process. The DON stated she was thankful it was brought to her attention, and she was now reviewing the current process for obtaining consents. The DON stated it was important to obtain psychotropic consents prior to medication administration so the residents were not given a medication they did not consent to. <BR/>2. Record review of the face sheet, dated 08/22/23, revealed Resident #13 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia (affects a person's ability to think, feel and behave clearly), COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), and bipolar (a disorder associated with episodes of mood swings).<BR/>Record review of the MDS assessment, dated 07/28/23, revealed Resident #13 had clear speech and was understood by staff. The MDS revealed Resident #13 was able to understand others. The MDS revealed Resident #23 had a BIMS of 11, which indicated moderately impaired. The MDS revealed Resident #13 had delusions and received antipsychotic medication for the last 7 days and on a routine basis.<BR/>Record review of the comprehensive care plan, dated 09/20/22, revealed Resident #13 exhibited mood state and to take meds as ordered.<BR/>Record review of the comprehensive care plan, dated 09/20/22, revealed Resident #13 exhibited behavioral symptoms and to always ask for help if resident becomes abusive or resistive.<BR/>Record review of the comprehensive care plan, dated 09/20/22, revealed Resident #13 exhibited psychotropic drug use and to do gradual dose reduction and monitor for side effects.<BR/>Record review of the order summary report, dated 08/22/23, revealed Resident #13 had an order, which started on 09/08/22, for Seroquel 100mg twice a day (antipsychotic). <BR/>Record review of the uploaded consent files, dated 06/18/23, revealed Resident #13 had no psychotropic consent form for the antipsychotic medication Seroquel.<BR/>During an observation and interview on 08/21/23 at 10:01 AM, Resident #13 was sitting in his wheelchair watching television, no behavior issues observed. Resident #13 stated he did not know if he signed a consent form to take the medication. <BR/>During an interview on 08/24/23 at 10:23 AM, the DON stated she was responsible for making sure the psychotropic consent forms were signed prior to taking the medication. The process was to have the order first, then get the form signed and to begin giving the medication. The importance was to make sure the medication was reviewed for gradual dose reduction and the consent was a requirement. The DON stated if there was no consent, then Resident #13 could have received a medication that he had not agreed to.<BR/>3. Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal).<BR/>Record review of the consolidated physician's orders dated 7/25/2023 - 8/25/2023 indicated Resident #39 had an order for quetiapine (antipsychotic medication) 200 mg at bedtime. The physician's order indicated Resident #39's physician prescribed this medication on 2/15/2023.<BR/>Record review of the comprehensive care plan dated 2/15/2023 and edited on 8/18/2023 indicated Resident #39 used psychotropic drugs and would benefit from the use without side effects. The care plan failed to address Resident #39 consented to the use of Seroquel.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy.<BR/>Record review of Resident #39's electronic medical record on 8/24/2023 indicated there was not a consent for the use of quetiapine (antipsychotic medication).<BR/>During an interview on 8/24/2023 at 4:05 p.m., the DON said there was not a consent for the use of Resident #39's quetiapine (antipsychotic medication). When the DON was asked had the nursing staff administered the quetiapine without the consent of Resident #39, she replied looks like we have. <BR/>During an interview on 825/2023 at 10:07 a.m., LVN C said she was unaware of who was responsible for getting the consents for psychotropic drug use. LVN C said she relied on the nurse management team to obtain the consent. LVN C said it was important for residents to know what medications they are receiving, and the risks of the medication.<BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful.<BR/>Record review of a Medication Monitoring policy dated 1/2022 indicated .Procedures 10. A resident and/or representative has the right to be informed about the resident's condition; treatment options, relative risks, and benefits of treatment, required monitoring, expected outcomes of the treatment; and has the right to refuse care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #36) of 14 residents reviewed for call lights.<BR/>The facility failed to ensure Resident #36's call light was accessible. <BR/>This failure could cause residents to encounter preventable injuries, health complications, and decreased quality of life.<BR/>Findings included:<BR/>Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #36 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (force of the blood against the artery walls is too high) and personal history of transient ischemic attack (temporary blockage of blood flow to the brain).<BR/>Record review of the MDS dated [DATE] indicated Resident #36 understood others, made himself understood. The MDS indicated Resident #36 was severely cognitively impaired (BIMS score of 3). The MDS indicated he required total dependence with transfers, dressing, toileting, and bathing: extensive assistance with bed mobility and personal hygiene. The MDS indicated Resident #36 had active diagnoses of hypertension, cerebrovascular accident (CVA), transient ischemic attack (TIA) or stroke and diabetes mellitus. The MDS revealed Resident #36 had upper and lower extremity impairment on one side. The MDS revealed Resident #36 had no falls since admission/entry, reentry, or prior assessment.<BR/>Record review of the care plan dated 6/13/22 indicated Resident #36 had a history of falls and at risk for increased falls related to CVA with left sided paralysis and poor safety skills. The care plan indicated long-term goals of resident will remain free of injuries and falls. Interventions included assess resident's footwear for proper fit and non-skid soles dated 6/13/22, encourage use of call light dated 6/13/22, keep call light within reach dated 6/13/22 and instruct resident on safety measures dated 6/13/22.<BR/>During an observation on 6/27/22 at 10:31 a.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. <BR/>During an observation on 6/27/22 at 3:24 p.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. <BR/>During an interview and observation on 6/28/22 at 8:08 a.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. Resident #36's call light was on the floor and when asked where it was, he shrugged his shoulders. Resident #36 told the surveyor he needs his hands cleaned; this surveyor had to get assistance for resident.<BR/>During an observation on 6/28/22 at 10:02 a.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach.<BR/>During an interview and observation on 6/28/22 at 1:55 p.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. Resident #36's family member said his call light was normally not near him. Resident #36 family member said she usually had to get assistance for him. <BR/>During an observation on 6/28/22 at 8:56 p.m., Resident was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach.<BR/>During an observation on 6/28/22 at 10:46 p.m., Resident was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach.<BR/>During an interview and observation on 6/29/22 at 11:12 a.m., the DON was called in Resident #36 room by the surveyor to show that Resident #36 call light has been in the same position since 6/27/22. The DON had to call LVN F to come assist her to get the call light untangle from the end of the bed. <BR/>During an interview on 6/30/22 at 10:55 a.m., CNA Q said all staff were expected to put the call lights within reach of the residents. CNA Q said Resident #36 did not use his call light, usually he hollered out for help. CNA Q said the call light should be clipped on the residents clothing or sheet. CNA Q said nurses and CNAs should make rounds every two hours and periodically to ensure call light was in reach. CNA Q said it was important for residents to have their call light in reach because it was their way to notify staff and prevent a fall. <BR/>During an interview on 6/30/22 at 11:00 p.m., CNA L said all staff were expected to put the call lights within reach of the residents. CNA L said Resident #36 verbally called out instead of using the call light. CNA L said the call light should be clipped on the resident's sheet or by the head of the pillow. CNA L said nurses and CNAs should make rounds every 30-45 minutes to ensure call light was in reach. CNA L said it was important for the call light to be in reach because this alert the staff that the resident need something and prevent the resident from falling. <BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said all staff were expected to put the call lights within reach of the residents. LVN G said Resident #36 did not know how to use his call light but the call light should still be in reach. LVN G said it was important for the call light to be in reach because it was their way calling out for help. LVN G said not having call lights in reach could result in falls, incontinence issues, and unmet resident needs.<BR/>During an interview on 6/30/22 at 11:35 a.m., LVN F said call lights should be always in reach so that the residents can call out for help. LVN F said nurses and CNAs should make rounds every two hours to ensure call light was in reach. LVN F said Resident #36 yelled out for help instead of using his call light. LVN F said not having call lights in reach could result in falls and distress. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said she expected the nurses and CNAs to put the call lights within reach of the residents. The DON said call lights being in reach was important for the resident to be able to communicate their needs with the staff. The DON said that not having call lights in reach could result in falls, incontinence issues, and unmet resident needs. She said it was the responsibility of the charge nurse to ensure all direct care staff was placing the call lights within reach of each resident. The DON said angel rounds were done every morning before stand-up meeting to ensure call lights were in reach and there was an issue it would be reported during meeting. <BR/>During an interview on 6/30/22 at 3:24 p.m., the Administrator said she expected for residents to have their call light within reach for safety. The Administrator stated call lights were important for communication with staff and not having a call light in reach could potentially cause falls. <BR/>Record review of a facility answering the call light policy revised on 3/2021 revealed . the purpose of this procedure is to ensure timely responses to the residents request and needs . when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . some residents many not be able to use their call light. Be sure you check these residents frequently .

**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 neglect and abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7).<BR/>The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him.<BR/>The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. <BR/>The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed.<BR/>The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy.<BR/>The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you.<BR/>The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. <BR/>The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry.<BR/>The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. <BR/>The facility abuse coordinator failed to ensure staff were able to report allegations of abuse without fear of reprisal. <BR/>This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.<BR/>This failure could place residents at risk of unreported abuse, neglect, exploitation and a decreased quality of life.<BR/>Findings included: <BR/>1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. <BR/>Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. <BR/>Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath.<BR/>During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. <BR/>Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. <BR/>Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. <BR/>2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. <BR/>Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. <BR/>Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE].<BR/>During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. <BR/>During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. <BR/>3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations).<BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. <BR/>Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. <BR/>During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview.<BR/>4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter).<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. <BR/>During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident.<BR/>5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. <BR/>During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again.<BR/>6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility.<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview.<BR/>7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. <BR/>During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. <BR/>During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. <BR/>During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. <BR/>During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests.<BR/>During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them.<BR/>During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. <BR/>Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. <BR/>During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. <BR/>During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. <BR/>During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. <BR/>During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. The DON said it was important to follow the abuse policy because it was the residents' right not to be abused. The DON said the abuse policy needed to be followed so that people understood they could not abuse the residents. The DON said the abuse policy protected the residents from abuse and gave the facility a guideline to follow so abuse could be identified and reported. The DON said if the residents experienced verbal abuse it could result in them being scared, withdrawn and cause failure to thrive.<BR/>During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said in-services were provided to the staff. The Administrator said she expected all of the staff to follow the abuse policy. The Administrator said it was important to follow the abuse policy to ensure the safety of the residents. The Administrator said not follow[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 16 residents reviewed for abuse and neglect (Resident #29).<BR/>The facility did not report abuse when Resident #29's family member visited the facility on 08/13/23 and was yelling at resident and threw his personal belongings outside of his room within the 2-hour time frame. <BR/>This failure could place the residents at risk for unreported allegations of abuse, neglect, and injuries of unknown origin.<BR/>Findings included:<BR/>Record review of the face sheet, dated 08/22/23, revealed Resident #29 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), dementia (impaired memory) and Parkinson's disease (disorder that impacts the nervous system and movement).<BR/>Record review of Resident #29's physician orders indicated lorazepam 1mg three times a day.<BR/>Record review of the MDS assessment, dated 07/20/23, revealed Resident #29 was usually understood and usually understood others. Resident #29 had a BIMS score of 4 indicating severely impaired.<BR/>Record review of the comprehensive care plan, edited 08/09/23, revealed Resident #29 had behavioral symptoms combative and elopement. The approach indicated Resident #29 became upset due to his sister came to the facility and was yelling at him and the resident's behaviors stem from his sister visits.<BR/>Record review of LVN E's progress note dated 08/13/23 indicated Resident #29's family member was in his room throwing Resident #29's clothing outside of the room and yelling at Resident #29. LVN E indicated he notified the nurse supervisor.<BR/>During an interview on 08/25/23 at 1:42 PM, LVN E stated he was completing his medication pass on 08/13/23 when Resident #29's family member came to the facility. LVN E stated he heard a loud voice and yelling coming from Resident #29's room. LVN E stated when he got closer to the room, he observed clothing being thrown out of Resident #29's room and Resident #29's family member was, Getting loud towards resident and he was upset. LVN E stated he told Resident #29's family member that he would handle the situation if she would tell him what the problem was and then he redirected Resident #29 towards the dresser. LVN E stated he then assisted Resident #29 with picking out what clothing he wanted to wear for the day and stayed with Resident #29 until he calmed down. LVN E stated Resident #29's family member left the building quickly and he notified the DON and Administrator. <BR/>During an interview on 08/24/23 at 10:23 AM, the DON reported she was not at the facility during the incident so she could not say what happen. The DON reported the Administrator was notified and she was responsible for determining if abuse needed to be reported.<BR/>During an interview on 08/24/23 at 4:10 PM, the Administrator stated, I would not say the family member was yelling, but if she was yelling at him then it should have been reported. The Administrator stated she should have done an investigation and it should have been reported if it was indicated in the progress note that the family member was yelling at Resident #29. The Administrator stated the importance of reporting abuse was to keep the resident safe and the resident could have been harmed if the incident was not investigated.<BR/>Record review of the policy on, Abuse Prevention Program, revised June 2021, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by Center management .The Administrator has the overall responsibility for the coordination and implementation of the Center's abuse prevention program . The alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately and reported no later than 2 hours if the alleged violation involves abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of suspected abuse was thoroughly investigated for 2 of 12 (Resident #'s 39 and 41) residents reviewed for abuse. <BR/>The facility failed to thoroughly investigate when the administrator received a report that Resident #29 attempted to stab Resident #41 in the eye with a fork and threw coffee on her.<BR/>The facility failed to thoroughly investigate when Resident #39 reported an allegation of abuse regarding CNA B. <BR/>The facility failed to report the Resident #'s 39 and 41's allegations of abuse to HHSC. <BR/>This failure resulted in an Immediate Jeopardy (IJ) identified on 08/23/23. While the IJ was removed on 08/25/23, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective system<BR/>This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.<BR/>Findings included: <BR/>1.Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. <BR/>Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. <BR/>Record review of Resident #41's a care plan with dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth.<BR/>Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having coffee threw at her or attempted stabbing with a fork. <BR/>During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents.<BR/>During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents.<BR/>During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. <BR/>During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen.<BR/>During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated after the incidents she had to move out of the way to avoid injuries when both incidents occurred. <BR/>During an interview on 08/23/23 at 11:45 AM, CNA A stated she was not for sure when the incidents happened. CNA A stated staff were picking up trays during dinner that was when Resident #29 threw the coffee on Resident # 41 in the hallway. CNA A stated Resident # 29 got a fork from somewhere and tried to stab Resident #41 at the nurse's station. He did not go to her room. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork and got rid of it. CNA A stated she wasn't aware of any further incidents. <BR/>During an interview on 08/23/23 at 4:12 PM RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. <BR/>2)Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal).<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy.<BR/>During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you.<BR/>During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA B was allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. <BR/>During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations.<BR/>Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: <BR/>7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day.<BR/>7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. <BR/>7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day.<BR/>7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m.<BR/>7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. <BR/>During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations.<BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the facility's policy, titled, Abuse Prevention Program, last revised on 06/2021, indicated, . The Administrator is responsible for the overall coordination and implementation of our center's abuse prevention program policies and procedures. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Our center will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/ neglect to their supervisor and to the Abuse Prevention Coordinator immediately. Our center will protect residents from harm, reprisal, discrimination, or coercion during investigation of abuse allegation. Our center will provide protections for the health, warfare and rights of each resident residing in the center to ensure the reporting of crimes. Develop and implement polices and procedures to aid to our center in preventing abuse, neglect, or mistreatment of our residents.<BR/>Identify and assess all possible incidents of abuse: investigate and report any allegations of abuse within timeframe as required by federal requirements; protect resident during abuse investigation; the Administrator will suspend immediately any employees who has been accused of resident abuse, pending the outcome of the investigation; all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the center's Administrator, or his/her designee, to the following person or agencies as required: <BR/>The Administrator was notified on 08/23/2023 at 1:05 PM, that an immediate jeopardy situation was identified due to the above failures. The Regional Director of Operations and Administrator was provided the immediate jeopardy template on 08/23/23 at 9:47 AM. The template was amended on 08/23/23 at 5:33 and returned to the he Regional Director of Operations and Administrator.<BR/>The facility's plan of removal was accepted on 8/24/2023 at 3:04 p.m. and included:<BR/>Action: Resident #29 was discharged from the facility on 8/22/2023 to a safe alternative location and will not return to the facility <BR/>Date: 8/22/2023<BR/>Action: Administrator, Maintenance Director, and 2 CNAs have been suspended pending investigation to include verbal abuse towards resident (s).<BR/>Date 8/23/2023<BR/>Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related.<BR/>Date 8/23/2023<BR/>Action: Progress notes and event reports reviewed to ensure no other additional resident to resident altercations have occurred without appropriate interventions being place in the care plan, notifications made to psychiatric services and the MD. Date: 8/23/2023 by 3:00 p.m.<BR/>Action: Employee (all) interviews conducted to include: <BR/>Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions)<BR/>If yes, who was the employee, who was the resident, and when about did this occur?<BR/>Were there other witnesses to this event?<BR/>Did you report this information to anyone and if so, to who?<BR/>Date: 8/23/2023<BR/>Action: Residents involved in resident-to-resident altercations, identified in the previous 30-days, had their care plans reviewed to ensure proper interventions are in place. Any identified lacking proper interventions have been reviewed with the IDT and added.<BR/>Date: 8/23/2023 at 3:00 p.m.<BR/>Action: <BR/>Education provided:<BR/>All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.)<BR/>All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing.<BR/>Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. <BR/>All staff to be in-serviced prior to working their next/first shift.<BR/>Date 8/23/2023 by 4:00 p.m.<BR/>All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator).<BR/>All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line.<BR/>Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect.<BR/>Date: 8/24/2023<BR/>Action: 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting.<BR/>Education regarding investigating allegations and implementing interventions.<BR/>Date:8/23/2003 by 2:00 p.m.<BR/>Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal<BR/>Date: 8/23/2023 by 2:00 p.m.<BR/>Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol.<BR/>On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of Resident #29's medical record indicated he discharged on 8/22/2023 to a sister facility.<BR/>Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of the safe survey results for the residents.<BR/>Record review of the employee Abuse Questionnaires.<BR/>Record review of the education provided regarding documentation of events/incidents in the medical record and documented follow up regarding the events.<BR/>Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination.<BR/>Record review of the 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting.<BR/>Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. <BR/>Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. <BR/>Interview of all staff (DA W, [NAME] P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. <BR/>Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. <BR/>Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. <BR/>On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview 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 16 residents (Resident #247) reviewed for accuracy of assessments.<BR/>The facility failed to complete Resident #247's admission MDS assessment within 14 days of admission. <BR/>This failure could place residents at risk of not having their needs met.<BR/>Findings included:<BR/>Record review of a face sheet dated 08/22/2023 indicated Resident #247 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (problems with your metabolism cause brain dysfunction), malignant neoplasm of skin (skin cancer), and chronic kidney disease stage 3 (moderate damage to the kidneys and loss of kidney function). <BR/>Record review of Resident #247's comprehensive MDS assessment with an ARD (assessment reference date) of 08/08/2023 indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #247 indicated in Section A1600 an entry date of 08/01/2023. The MDS assessment in Section Z0500B was signed completed on 08/18/2023, which indicated the MDS assessment for Resident #247 was completed 4 days late. <BR/>During an interview on 08/25/2023 at 11:21 AM, the Regional Reimbursement Manager said Resident #247's admission MDS assessment was completed late. The Regional Reimbursement Manager said she did not pay close enough attention because usually the MDS Coordinator completed the MDS assessments timely. The Regional Reimbursement Manager said she performed audits randomly on the MDS assessments to check them for timeliness. The Regional Reimbursement Manager said it was important to complete the MDS assessments timely because it was the regulation, and the admission assessment triggered the care area assessment. The Regional Reimbursement Manager said the care area assessment was needed to develop the residents plans of care. <BR/>During an interview on 08/25/2023 at 11:37 AM, the MDS Coordinator said the admission MDS assessment should be completed within 14 days of admission. The MDS Coordinator said Resident #247's admission assessment was completed late. The MDS Coordinator said she was not able to complete Resident #247's MDS assessment on time because she was working the floor. The MDS Coordinator said it was important for the MDS assessments to be completed timely for the facility to have an accurate assessment and for them to be able to initiate the plan of care in a timely manner. <BR/>During an interview on 08/25/2023 at 12:41 PM, the DON said she signed the MDS assessments completed, but she was not aware of the required timeframes. The DON said the MDS Coordinator just told her when she was supposed to sign them, and she signed them. The DON said it was important for the MDS assessments to be completed timely because the MDS assessments told a story and helped develop the residents plan of care. <BR/>During an attempted phone interview on 08/25/2023 at 4:36 PM, the Administrator did not answer the phone. <BR/>Record review of the facility's policy titled, MDS Completion and Submission Timeframes, last revised July 2017, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . <BR/>Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 updated October 2023 indicated, For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 16 residents (Resident #12, Resident #34, and Resident #247) reviewed for MDS assessment accuracy. <BR/>The facility did not ensure Resident #12's MDS assessment was accurately coded to reflect her level II PASRR status for mental illness.<BR/>The facility failed to accurately reflect Resident #34's use of oxygen. <BR/>The facility failed to accurately document Resident #247's tobacco use.<BR/>This failure could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>1. Record review of the face sheet, dated 08/25/23, revealed Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of bipolar disorder (serious mental illness characterized by extreme mood swings) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). <BR/>Record review of the MDS assessment, dated 12/23/22, indicated Resident #12 was not considered by the state level II PASRR process to have serious mental illness. <BR/>Record review of the comprehensive care plan, edited on 08/11/23, revealed Resident #12 was identified as having mental illness PASRR positive status related to bipolar disorder and was receiving services. <BR/>Record review of level II PASSR evaluation, dated 02/18/22, revealed Resident #12 met the PASRR definition of mental illness. <BR/>During an interview on 08/25/23 at 11:03 AM, the Regional Reimbursement Manager stated the MDS should have accurately reflected the level II PASRR status. The Regional Reimbursement Manager stated she performed random audits to ensure MDS assessments were completed accurately. The Regional Reimbursement Manager stated she was unsure why Resident #12's comprehensive MDS assessment was not accurately coded to reflect the level II PASRR status. The Regional Reimbursement Manager stated it was important to ensure the MDS was accurately coded to paint of a clear picture of the resident's status and help develop the plan of care. <BR/>Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2019, revealed Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness .<BR/>2. Record review of a face sheet dated 08/22/2023, indicated Resident #34 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and asthma (chronic disease that affects millions of people worldwide, making it hard to breathe and causing coughing, wheezing, and chest tightness). <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #34 was understood and understood others. The MDS assessment indicated Resident #34 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment did not indicate the use of oxygen therapy in the last 14 days for Resident #34. <BR/>Record review of the care plan last edited 08/10/2023 indicated Resident #34 had a diagnosis of asthma and was at risk for shortness of breath and respiratory failure. Resident #34 had approaches that indicated to administer oxygen for unrelieved shortness of breath. <BR/>Record review of the Physician Order Report dated 07/22/2023-08/22/2023 indicated Resident #34 had an order for oxygen at 2 liters per minute via nasal cannula continuously every shift with a start date of 12/19/2022. <BR/>Record review of the Medication Administration Record dated 06/01/2023-06/30/2023, indicated Resident #34 received oxygen via nasal cannula at 2 liters per minute as ordered for the entire month of June. <BR/>During an observation on 08/21/2023 at 10:52 AM, Resident #34 was wearing oxygen via nasal cannula at 5 liters per minute. Resident #34 said he wore it all the time because it helped him breathe better. <BR/>3. Record review of a face sheet dated 08/22/2023 indicated Resident #247 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (problems with your metabolism cause brain dysfunction), malignant neoplasm of skin (skin cancer), and chronic kidney disease stage 3 (moderate damage to the kidneys and loss of kidney function). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #247 was able to make himself understood and usually understood others. The MDS assessment indicated Resident #247 had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment did not indicate Resident #247 used tobacco. <BR/>Record review of the care plan last reviewed on 08/08/2023 did not indicate Resident #247 used tobacco or smoked cigarettes.<BR/>Record review of the Smoking Risk (Acuity) completed on 08/01/2023 indicated Resident #247 used cigarettes and was a safe smoker. The Smoking Risk (Acuity) indicated to initiate the plan of care. <BR/>During an interview on 08/21/2023 at 11:41 AM, Resident #247 said he smoked. <BR/>During an interview on 08/25/2023 at 10:55 AM, the Regional Reimbursement Manager said Resident #34's use of oxygen should have been coded on his MDS assessment. The Regional Reimbursement Manager said Resident #247's tobacco use should have been on the MDS assessment because he smoked. The Regional Reimbursement Manager said she performed random audits of the MDS assessments, and she tried to hit the high points like the ADLs, medications, therapy, physician's orders, and behaviors when she reviewed the MDS assessments. The Regional Reimbursement Manager said it was important for the MDS to be coded correctly to pain a clear picture of the resident and what was going on with the resident to care plan appropriately. <BR/>During an interview on 08/25/2023 at 11:24 AM, the MDS Coordinator said she was aware Resident #247 smoked, and Resident #34 used oxygen. The MDS Coordinator said she guess she missed it. The MDS Coordinator said it was important to accurately code on the MDS assessment because it directed the plan of care and payment for the facility. <BR/>During an interview on 08/25/2023 at 12:31 PM, the DON said she tried to review the MDS assessments for accuracy when she signed them, but the MDS Coordinator was responsible for completing the MDS assessments and she signed them. The DON said Resident #247's use of tobacco should have been on his MDS assessment, and Resident #34's use of oxygen should have been on the MDS assessment. The DON said it was important for the MDS to be completed accurately because it assisted with developing the plan of care. <BR/>During an attempted phone interview on 08/25/2023 at 4:36 PM, the Administrator did not answer the phone. <BR/>Record review of the facility's policy titled, Certifying Accuracy of the Resident Assessment, revised November 2019, indicated, 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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 14 residents reviewed for care plans. (Resident #10 and Resident #5). <BR/>The facility failed to ensure Resident #10 abdominal binder was applied, as ordered by the physician. <BR/>The facility failed to implement Resident #5's smoking care plan intervention. <BR/>These failures could place the residents at risk for not receiving the care and/or services to meet their individual needs.<BR/>Findings included:<BR/>1. Record review of the physician order report dated 6/7/22-7/7/22 indicated Resident #10 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including epilepsy (uncontrolled electrical disturbance in the brain), cerebral palsy (congenital disorder of movement muscle tone, or posture), hypokalemia (deficiency of potassium in the bloodstream) and lack of coordination. <BR/>Further review of the physician order report indicated Resident #10 was had an order to check abdominal wrap for placement over G tube site every shift with a start date 5/24/22 and discontinued date 6/30/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #10 usually understood others, usually made himself understood. The MDS indicated Resident #10 was severely cognitively impaired (BIMS score of 1). The MDS indicated he required total dependence with bed mobility, transfers, dressing eating toileting, personal hygiene, and bathing. The MDS indicated Resident #10 had a feeding tube. <BR/>Record review of the care plan dated 12/11/20 indicated Resident #10 was at risk for malnutrition related to NPO (nothing by mouth) and tube feedings. The care plan intervention did not address the abdominal binder. <BR/>Record review of Resident #10's MAR dated 6/1/22-6/29/22 indicated to check abdominal wrap for placement over G tube every shift. The MAR indicated LVN G checked off that she applied the abdominal binder on 6/28/22 and LVN F checked off that she applied the abdominal binder on 6/29/22. <BR/>During an observation on 6/28/22 at 10:45 a.m., Resident #10 was returned to his room by CNA L. CNA L allowed an observation of Resident #10 G tube site and there was no abdominal binder present. <BR/>During an observation on 6/28/22 at 2:14 p.m., Resident #10 was returned to his room by CNA P. CNA P allowed an observation of Resident #10 G tube site and there was no abdominal binder present. <BR/>During an observation and interview on 6/29/22 at 10:15 a.m., Resident #10 was returned to his room by the DON. The DON observed with the surveyor Resident #10 G tube site with no abdominal binder present. The DON said Resident #10 was supposed to have an abdominal binder on to prevent him from pulling out his G tube. The DON said not having the abdominal binder on could result in an infection. <BR/>During an interview and observation on 6/29/22 at 10:20 a.m., LVN F observed with the surveyor Resident #10 G tube site with no abdominal binder present. LVN F said the order should have had being discontinued but she forgot to call the physician. LVN F said she did not know why she checked off that she completed the task of applying the abdominal binder to Resident #10. LVN F said before checking off that she applied the abdominal binder she should have applied it first. LVN F said the abdominal binder was ordered to keep Resident #10 pulling his G tube out. LVN F said not having the abdominal binder on could result in an infection or closer of the stomach. <BR/>2. Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and atherosclerotic heart disease (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of the MDS dated [DATE] indicated Resident #5 understood others, made herself understood. The MDS indicated Resident #5 was cognitively intact (BIMS score of 13). The MDS indicated she required limited assistance bed mobility, transfers, dressing, toileting, and personal hygiene: supervision with eating and extensive assistance with bathing. <BR/>Record review of the care plan dated 11/11/21 indicated Resident #5 was a smoker. The care plan interventions were to assess quarterly for safe smoking. <BR/>Record review indicated the most recent smoking risk assessment was completed on 11/19/21. <BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said the charges nurses were responsible for completing smoking assessments. LVN G said the care plans were guides to know how to care for each resident's individual needs. LVN G stated she does not look at the care plans daily but does look at them if she has questions about someone's care. LVN G said she could not remember if she applied Resident #10 abdominal binder on 6/28/22. LVN G said usually the binder was placed after ADL care. LVN G said not having the abdominal binder on could result in Resident #10 pulling the G tube out. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said she expected all physician orders to be followed. The DON said the charges nurses were responsible for ensuring physician orders were followed. She said she expected the staff to read the care plans for interventions on how to care for each residents' individual needs. The DON said care plans were important for the residents to have so the staff would be aware of individual needs of residents. The DON said she was unaware that Resident #5 has not had a smoking assessment since 11/19/21. The DON said she was under the assumption that smoking assessments were completed by the charge nurse annually until 6/29/22. The DON said smoking assessments were to be done quarterly. The DON said not following the physician orders or care plan could result in residents not receiving proper care. The DON indicated she monitored incomplete assessments by running reports but due to her recent illness she was unable to complete this task. <BR/>Record review of the facility's smoking policy titled Smoking-Residents revised 8/2019 indicated, the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, determine if they need a smoking apron resident care plans will reflect that the resident is a smoker and if a protective smoking apron is indicated for the resident . <BR/>During an interview on 6/30/22 at 2:31 p.m., a care plan policy was requested from the DON but not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to meet professional standards of care, for 2 of 7 residents (Resident #4 and Resident #42) reviewed for professional standards with medication administration. <BR/>The facility did not ensure Resident #4 was given Calcium with Vitamin D3 600mg-12.5 mcg. <BR/>The facility did not ensure Resident #42 was given Gentamicin into one eye instead of both eyes. <BR/>These failures could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs.<BR/>Findings included:<BR/>1. Record review of Resident #4's face sheet, dated 08/24/2023, indicated Resident #4 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis included bilateral (both sides) primary osteoarthritis (joint pain) of knee. <BR/>Record review of Resident #4's physician order report, dated 08/24/2023, indicated Resident #4 was prescribed (2) calcium capsule with vitamin D3, 600mg-12.5 mcg by mouth one time a day with a start date 06/02/2023. <BR/>Record review of the medication administration history dated 08/01/2023-08/24/2023, revealed Resident #4 received (2) calcium capsule with vitamin D3, 600mg-12.5 mcg by mouth one time a day. <BR/>During an observation on 08/22/2023 at 9:25 a.m., MA L was preparing Resident #4's medication for administration. MA L obtained a bottle of calcium with vitamin D 600 mg-10 mcg and placed 2 oval white tablets in the cup. MA L finished preparing the remainder of Resident #4's morning medications. MA L obtained a plastic glass of water and went into Resident #4's room. MA L gave Resident #4 her medication cup, which included the calcium with vitamin D, and Resident #4 swallowed the medication.<BR/>During an interview on 08/25/23 at 11:12 a.m., MA L stated the medication should be verified with the MAR prior to administering medication. MA L stated if the medication label did not match the physicians order she should have notified the nurse for clarification. MA L stated she was unaware the dosage was different for Resident #4's calcium with vitamin D. MA L stated it was important to clarify discrepancies in the medication orders prior to medication administration so medication errors or adverse reactions did not occur.<BR/>2. Record review of Resident #42's face sheet, dated 08/24/2023, indicated Resident #42 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis included abscess (confined pocket of pus) of eyelid to right eye. <BR/>Record review of Resident #42's physician order report, dated 08/223/2023 did not address the gentamicin drops. <BR/>Record review of the medication administration history dated 08/01/2023-08/24/2023, revealed Resident #42 received 2 gtt of gentamicin (antibiotic) to right eye four times a day times 5 days with a start date 08/18/2023.<BR/>During an observation and interview on 08/22/23 at 12:32 p.m., MA L was standing at the medication cart, preparing to administer gentamicin 0.3% eye drops, to Resident #42. The medication label on the eye drops box read as follows: gentamicin 0.3% - 2 drops to both eyes twice daily. MA L obtained the eye drops, gloves, and tissues and went into Resident #42's room. MA L administered the gentamicin 0.3% eye drops to Resident #42's right eye. MA L stated the eye drops were started yesterday and she only administered them to Resident #42's right eye. MA L then read the label on the gentamicin 0.3% eye drop box and stated Oh, I didn't realize it was both eyes. MA L then prepared the gentamicin eye drops, went into Resident #42's room, and administered the eye drops to the left eye.<BR/>During an interview on 08/23/23 at 4:54 p.m., MA L stated the medication label on a medication from the pharmacy should have matched the physicians order in the computer. MA L stated if the medication label did not match the physicians order she should have notified the nurse for clarification. MA L stated when the surveyor intervened, she reported the discrepancy to the nurse and DON. MA L stated she should have notified the nurse for clarification prior to administering the eye medication. MA L stated it was important to clarify discrepancies in the medication orders prior to medication administration so medication errors or adverse reactions did not occur. <BR/>During an interview on 08/25/2023 at 4:26 p.m., the DON stated she expected medications to be given per MD orders. The DON stated staff who pass medications should follow the rights medication administration, including correct dose. The DON stated staff had been in serviced on that. The DON stated it was important to compare the MAR to the medication label and the staff should have completed this during medication administration. The DON stated the staff should have held the medication and notified the physician if medication dosage did not match. The DON stated it was important to verify and administer the correct dose to prevent adverse reaction to resident. <BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the facility's policy titled Administering Medications last revised on 04/2019, indicated, medications are administered in a safe and timely manner, and as prescribed 4. Medications are administered in accordance with prescriber orders . 10. The individual administering the medication checks the label Three (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication

**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 unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 13 residents reviewed for ADLs (Residents #9, Resident #11)<BR/>The facility did not provide scheduled showers for Resident #9 and Resident #11.<BR/>These failures could place residents at risk of not receiving services/care and decreased quality of life.<BR/>1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two-person assist for bathing. <BR/>Record review of the care plan last revised 05/24/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. <BR/>During an interview and observation on 06/13/2023 at 02:06 PM, Resident #9 said she had not had a bath/shower since last Tuesday, June 6, 2023. Resident #9 said she was supposed to receive a shower three times weekly on Tuesday, Thursday, and Saturday on the 2 - 10 shifts. Resident #9 said she had not been offered a shower since last Tuesday, June 6th, 2023. Resident #9 said she would really like to get her hair washed and a good shower because she can smell herself. Resident #9 said she had asked the CNA on Thursday for the shower, but the CNA told Resident #9 maybe around 4PM that she could help her bath, but they never come back and offered the shower. Resident #9 said she asked over the weekend, for a shower but the CNA told her she was the only CNA and no time to perform the requested shower. Resident #9 said she would have liked to go play bingo, but she was always waiting on her shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room. The odor was stronger with Resident #9's body movements. <BR/>During an interview and observation on 06/14/2023 at 12:00 PM, Resident #9 said she had not received a shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room.<BR/>During an observation on 06/15/2023 at 04:00 PM, Resident #9 was lying in bed her hair was oily and disheveled, and a strong musty odor lingered in the room.<BR/>Record Review of the Resident Showers Log indicated Resident #9 received showers on the following dates: <BR/>06/06/2023 - Tuesday, 06/08/2023 - Thursday, 06/10/2023 - Saturday, 06/13/2023 - Tuesday<BR/>During interview and observation on 06/16/2023 at 05:20 PM, Resident #9 said she received a shower yesterday evening on 06/15/2023. Resident #9 said she felt better after the shower. Resident's #9 was observed with clean and combed hair. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #9 had asked for a shower on Wednesday, 06/14/2023, because she had not had one. CNA C said she told Resident #9 she would give her a shower tomorrow (Thursday 06/15/2023). CNA C said Resident #9 refused a lot of showers. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. The MDS indicated Resident #11 did not reject care. The MDS indicated Resident #11 did not exhibit any behavioral symptoms.<BR/>Record review of the care plan with a start date of 12/08/2021 indicated, Resident #11 required physical assistance of one person for bathing. The care plan indicated Resident #11 was to receive showers on Monday, Wednesday, and Fridays. <BR/>During an interview on 06/13/2023 at 01:49 PM, Resident #11 said he had not received a shower/bath for as long as he could remember probably around the time COVID hit. Resident #11 said he was not able to stand on his own. Resident #11 said the CNAs had not offered a shower. Resident #11 said he used the sink to bathe himself the best he could. Resident #11 said, you can only keep some of the odor away using a sink as a shower. Resident #11 said he had not requested a bath because he should not have had to ask. Resident #11 said he needed his toenails clipped but staff was never available to offer the services that are care planned. Resident #11 said his toenails got caught on the sheets and on his socks. Resident #11 said his feet hurt when he wore his shoes because his toenails are too long. Resident #11 said he had purchased clippers so he could cut his own hair. Resident #11 said he had not refused to have a shower, or his toenails clipped because the staff had never tried. Residents #11's toenails were thick, yellow, and approximately &frac12; inch long. <BR/>During an interview on 06/14/2023 at 11:42 AM, Resident #11 said he had not received a shower. <BR/>During an interview on 06/15/2023 at 03:50 PM, Resident #11 said he had not received a shower.<BR/>Record Review of the Resident Showers Log indicated Resident #11 received showers on the following dates: <BR/>06/02/2023, 06/05/2023, 06/07/2023, 06/09/2023, 06/12/2023, 06/14/2023<BR/>During an interview and observation on 06/16/2023 at 05:18 PM, Resident #11 said he had not received a shower and no staff had offered a shower this week. Resident #11 said my toenails had not been trimmed. Resident #11 said he had never told staff not to clip his toenails. Residents #11's toenails on both feet were thick, yellow, and approximately &frac12; inch long. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #11 does everything by his own self. CNA C said she had never offered to clip Resident # 11 nails. CNA C said the nurses were responsible for clipping the resident's toenails. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said it was important to clip the resident's nails to prevent hangnails. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>During an interview on 06/16/2023 at 06:33 PM, the ADON said the CNAs are responsible to give the residents showers/baths. The ADON said the nurses are responsible to review the shower sheets daily. The ADON said nobody had reported to her any refusals this week. The ADON said that Resident # 9 received a shower on Wednesday. The ADON said that Resident #11 frequently refuses showers. The ADON said that CNAs could clip Resident #11's toenails.<BR/>During an interview on 06/16/2023 at 06:22 PM, the DON said the CNAs are responsible for baths/showers. The DON said the nurse could give baths/showers if needed also. The DON said the CNAs and nurses should fill out the shower sheets daily. The DON said Resident #9 did not like to get showers. The DON said Resident #9 is random. The DON said Resident #9 had not refused baths/shower this week. The DON said Resident #11 wouldn't let anybody give him a shower that he refused MWF on the 2 -10 shift. The DON said the residents should be able to get a bath/shower if they asked for one. The DON said it was important for the residents to get their baths/showers to help them feel good about themselves and keep the skin clear. The DON said if the residents had not received baths/showers they would feel dirty and be at a risk for wounds and infection. The DON said if the resident is a diabetic the facility podiatrist or the nurse could clip toenails. The DON said if the resident did not have the diabetic diagnosis the CNA could trim the resident's toenails. The DON said it was important for toenails to get trimmed, so the residents didn't experience ingrown toenail/infection control. The DON said she had never offered to trim Resident #11's toenails. <BR/>During an interview 06/16/2023 at 08:18 PM, the administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical management is responsible for making sure the baths/showers were provided. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good. <BR/>Record review of facility policy and procedure titled, Activities of Daily Living (ADLs), Supporting revised March 2018, indicated . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 16 (Resident #35) residents reviewed for quality of care.<BR/>The facility failed to provide wound care for Resident #35 per the physician's orders.<BR/>This failure could place residents of risk for not receiving appropriate care and treatment.<BR/>Findings included:<BR/>Record review of a face sheet dated 08/22/2023, indicated Resident #35 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), peripheral vascular disease (narrowed blood vessels which results in reduce blood flow to the limbs), and acquired absence of left leg above knee. <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #35 was able to make self-understood and was understood by others. The MDS assessment indicated Resident #35 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #35 did not exhibit rejection of care. The MDS assessment indicated Resident #35 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS assessment indicated Resident #35 had 7 venous and arterial ulcers present. The MDS assessment indicated Resident #35 had open lesions on the foot. <BR/>Record review of the care plan last reviewed 08/21/2023, indicated Resident #35 had a right lateral knee arterial ulcer (wounds on your skin that develop because of problems with blood circulation), right 2nd toe arterial ulcer, right 3rd toe arterial ulcer, right 5th toe arterial ulcer, right calf venous ulcer, right lateral leg venous ulcer, right distal lateral leg arterial ulcer and right medial foot arterial ulcer. The approaches included dressing change per physician's order to right proximal leg, apply calcium alginate silver and wrap with unna boot (special gauze bandage used for the treatment of ulcers of the legs), dressing change per physician's order apply calcium alginate and silver to right calf and wrap with unna boot, dressing change per physician's order apply calcium alginate silver and wrap with unna boot, dressing change per physician's order apply calcium alginate silver to 5th toe and wrap with unna boot, dressing change per physician's order apply calcium alginate and silver to right medial foot and wrap with unna boot. <BR/>Record review of Resident #35's Physician Order Report dated 07/22/2023-08/22/2023 indicated an order with a start date of 07/21/2023 to cleanse wounds to left lower extremity with normal saline, pat dry, apply calcium alginate silver to open areas, wrap with unna boots and rolled gauze as needed, and an order with a start date of 08/04/2023 to cleanse wounds to left lower extremity with normal saline, pat dry, apply calcium alginate silver to open areas, wrap with unna boots, then rolled gauze, and compression bandage wrap once a day on Tuesday, Thursday, Saturday on the 6:00 PM-6:00 AM shift. <BR/>Record review of the Medication Administration Record dated 08/01/2023-08/21/2023 indicated Resident #35's wound care was completed on 08/19/2023 as ordered by RN G. <BR/>During an observation and interview on 08/21/2023 at 10:07 AM, Resident #35 said his dressing to his right leg was not changed on Saturday (08/19/2023). Resident #35 said the last time his dressing was changed was Thursday (08/17/2023). Resident #35 said sometimes the wound care on his right leg was not done as scheduled. Resident #35's right lower leg and foot had gauze and a wrapped bandage that was falling off of his leg and the wound to his calf was exposed. <BR/>During an interview on 08/21/2023 at 5:21 PM, LVN H said she had not noticed Resident #35's dressing was coming off when she checked on him earlier. LVN H said the night nurse on Saturday should have done his wound care, but she would change it. LVN H said it was important to perform wound care as ordered to prevent the wound from worsening or getting an infection. <BR/>During an interview on 08/21/2023 at 5:43 PM, RN G said she probably had signed off on the Medication Administration Record that she completed the wound care for Resident #35. RN G said she had not performed the wound care on Resident #35's right lower leg on Saturday (08/19/2023). RN G said she was unable to respond to why she had not done the wound care. RN G said she had not realized Resident #35's order for wound care was incorrect. RN G said Resident #35's ulcers were on his right lower leg. RN G said it was important to provide wound care as ordered by the physician to prevent infections to the wound. <BR/>During an interview on 08/25/2023 at 12:50 PM, the DON said the nurses were responsible for performing wound care. The DON said she was not aware Resident #35's wound care was not done on Saturday. The DON said the ADON was responsible for putting in the wound care orders. The DON said she was not aware Resident #35's wound care order indicated to provide wound care to his left lower extremity. The DON said Resident #35's wounds were on his right lower extremity. The DON said she could not answer what the process for reviewing the residents' orders was. The DON said the ADON monitored wound care. The DON said it was important for the wound care orders to be entered correctly because it could cause medication errors, and the wound care could be performed on the wrong leg. The DON said if wound care was not provided as ordered by the physician the wound could worsen and the resident could get an infection and become septic (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever).<BR/>During an attempted phone interview on 08/25/2023 at 4:36 PM, the Administrator did not answer the phone. <BR/>During an interview on 08/25/2023 at 4:48 PM, the ADON said she was responsible for wound care. The ADON said she expected the nurses to provide wound care as ordered. The ADON said Resident #35's ulcers were on his right lower extremity. The ADON said she had not noticed Resident #35's orders indicated to perform wound care on his left lower extremity. The ADON said she did not know why the order was incorrect. The ADON said it was important for the nurses to perform wound care and for the orders to be correct for the wounds to heal. <BR/>Record review of the facility's policy titled, Wound Care, last revised June 2022, indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 3 residents reviewed for smoking-accidents and hazards. (Resident #'s 34 and 91)<BR/>The facility failed to ensure Resident #34's oxygen E-tank canister was stored securely while she smoked.<BR/>The facility failed to ensure Resident # 91 did not smoke near a gas grill with propane gas attached. <BR/>This failure could place residents at risk for injury.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 6/30/2022 indicated Resident #34 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnoses of pneumonia, and a lung disease that blocks air flow.<BR/>Record review of a comprehensive care plan dated 12/27/2019 and updated on 5/12/2022 indicated Resident #34 had decreased oxygen saturations and required the intervention of applying oxygen at 2 liters per nasal canula. <BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #34 usually understands and was usually understood. The MDS indicated Resident #34 had no cognitive impairment. The MDS under the section of Special Treatments, Procedures, and Programs indicated Resident #34 received oxygen therapy.<BR/>Record review of a smoking assessment dated [DATE] indicated Resident #34 was scored a risk of zero indicating she was a safe smoker. The assessment indicated she wears oxygen, and the oxygen was to be removed and stored while smoking. <BR/>During an observation on 6/27/2022 at 3:10 p.m., an E-tank oxygen cannister was placed in the upright position of a dining room chair. <BR/>During an interview on 6/27/2022 at 3:27 p.m., the Housekeeping Supervisor indicated she placed the oxygen cylinder in the dining room chair while Resident #34 smoked outside. The Housekeeping Supervisor indicated she was not aware unsecured oxygen cannister could become harmful if it were to fall. <BR/>During an interview on 6/27/2022 at 3:47 p.m., the DON indicated the oxygen sitting upright unsecured in a dining room chair could become unsafe if the tank was to fall from the chair. She indicated there had been an oxygen cannister rack in the dining room for oxygen. The DON said she was unsure why the oxygen cannister rack was removed.<BR/>During an interview on 6/27/2022 at 5:00 p.m., the ADM indicated she was made aware of the oxygen cannister unsecured in the dining room chair. The Administrator indicated an in-service had been completed.<BR/>2. Record review of a face sheet dated 6/30/2022 indicated Resident #91 was [AGE] years old, admitted on [DATE] with the diagnoses of a lung disease that blocks airflow and heart disease.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #91 was understood and understands. The MDS indicated Resident #91's BIMs score (brief interview of memory score) was a 7 indicating severe impairment.<BR/>Record review of a comprehensive care plan dated 5/19/2022 and updated on 6/07/2022 indicated Resident #91 was a smoker and would smoke in designed areas without occurrence of injury over the next 90 days. The care plan interventions included to explain show where designated smoking areas and monitor when smoking to assure resident safety.<BR/>Record review of a Smoking Risk assessment dated [DATE] indicated Resident #91 was a safe smoker.<BR/>During an observation on 6/27/2022 at 12:10 p.m., the gas grill on the patio had a propane bottle attached. <BR/>During an observation on 6/27/2022 between 3:10 p.m. and 3:37 p.m., Resident #91 was observed smoking with the Housekeeping Supervisor near the gas grill which had propane attached. <BR/>During an observation on 6/28/2022 at 9:10 a.m., Resident #91 was sitting near the gas grill with propane attached smoking a cigarette. <BR/>During an interview on 6/28/2022 at 9:16 a.m., the maintenance supervisor indicated he had forgotten the propane gas remained attached to the gas grill. The maintenance supervisor indicated he was responsible for storing of the propane gas after use. He indicated the gas grill was used last week and he failed remember to remove the propane gas from the grill. He indicated with smoking around a propane grill an explosion could occur. <BR/>During an interview on 6/28/2022 at 3:16 p.m., the ADM indicated she had been made aware of the propane gas being attached to the grill and the resident smoking within proximity. The Adm indicated the gas was not turned on.<BR/>Record review of a Fire Safety and Prevention policy dated 2021 indicated all personnel must learn methods of fire prevention and must report conditions that could result in a potential fire hazard. Fire prevention is the responsibility of all personnel, residents, visitors, and general public. Flammable Items: a. smoke only in designated areas f. Store flammable liquids in a locked cabinet oxygen safety: c. Prohibit smoking, open flames, and spark-producing devices in oxygen storage or administration areas f. Store oxygen cylinders in racks with chains, sturdy portable carts or approved stands. Never leave oxygen cylinders free standing. 4. H. all personnel must report observations of violation of fire safety rules.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 2 of 7 residents (Resident #23 and Resident #15) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #23's oxygen concentrator filter was free of gray, fuzzy material. <BR/>The facility failed to ensure Resident #23 and Resident #15 nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing was changed weekly. <BR/>The facility failed to ensure the nasal cannula tubing was dated for Resident #15.<BR/>The facility failed to ensure Resident #23 oxygen nasal cannula tubing was changed weekly.<BR/>The facility did not store nasal canula or nebulizer in a plastic bag when it was not in use for Resident #23 and Resident #15. <BR/>The facility failed to document and monitor Resident #15's use of oxygen.<BR/>These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings included:<BR/>1.Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #23 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys cease functioning on a permanent basis), COPD-chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (force of the blood against the artery walls is too high) and 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). <BR/>Record review of the physician order report indicated Resident #23 received oxygen at 2L/Min per nasal cannula @ HS (at bedtime) and PRN (as needed) related to SOB (shortness of breath) with a start date 5/27/22. There was an order to clean nebulizer filter weekly on Sunday with a start date 5/27/22. <BR/>Further review of consolidated physicians' orders dated 5/29/22-6/29/22 did not indicate Resident #15 had an order for oxygen. <BR/>Record review of the MDS dated [DATE] indicated Resident #23 understood others and made himself understood. The MDS indicated Resident #23 was cognitively intact (BIMS score of 14). The MDS indicated he required supervision with bed mobility, transfers, eating toileting, and bathing: limited assistance with dressing and personal hygiene. The MDS indicated Resident #23 had active diagnoses of renal insufficiency, renal failure or end stage renal disease, hypertension and Asthma, COPD, or Chronic Lung Disease. The MDS indicated Resident #23 became short of breath or trouble breathing with exertion. The MDS indicated Resident #23 was receiving oxygen therapy.<BR/>Record review of the care plan dated 6/7/22 indicated Resident #23 had episodes of SOB and was at risk for respiratory distress/failure related to COPD. The care plan interventions were to apply o2 (oxygen) per order, encourage to take deep breaths, monitor for signs of relief from SOB and provide respiratory treatments as ordered. The care plan did not address oxygen concentrator filters, nebulizer, or nasal cannula tubing. <BR/>During an interview and observation on 6/27/22 at 11:46 a.m., Resident #23 was sitting on the side of the bed and oxygen was being used by the resident via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. The nasal cannula was dated 6/5/22. Resident #23's nebulizer mask was on the bedside dresser not covered. Resident #23 said he wears oxygen as needed, mainly at night for SOB. Resident #23 said he received breathing treatments daily. <BR/>During an observation on 6/28/22 at 8:38 a.m., Resident #23 was sitting on the side of the bed visiting a friend and oxygen was being used by the resident via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. The nasal cannula was dated 6/5/22. Resident #23's nebulizer mask was on the bedside dresser not covered.<BR/>During an observation on 6/29/22 at 11:15 a.m. Resident #23 was lying in bed and oxygen was being used by the resident via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. The nasal cannula was dated 6/5/22. Resident #23's nebulizer mask was on the bedside dresser not covered.<BR/>2. Record review of the physician order report dated 5/29/22-6/29/22 indicated Resident #15 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including essential hypertension (force of the blood against the artery walls is too high), chronic diastolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation), and type 2 diabetes mellitus with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar that induces nerves damage that is caused by diabetic). The order did not indicate Resident #15 had an order for oxygen therapy. <BR/>Record review of the MDS dated [DATE] indicated Resident #15 understood others, made herself understood. The MDS indicated Resident #15 was cognitively intact (BIMS score of 15). The MDS indicated she required extensive assistance with bed mobility, transfers, dressing toileting and personal hygiene: total dependence with bathing. The MDS indicated Resident #15 had active diagnoses of hypertension, heart failure, and diabetes mellitus. The MDS did not indicate if Resident #15 became short of breath or trouble breathing with/without activity. The MDS indicated Resident #15 was receiving oxygen therapy.<BR/>Record review of the care plan dated 4/16/22 indicated Resident #15 had decreased cardiac output related to changes in myocardial contractility. The care plan interventions were to administer oxygen as prescribed and monitor oxygen saturation every shift. <BR/>During an interview and observation on 6/27/22 at 11:52 a.m., Resident #15 was lying in bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing. The handheld nebulizer tubing was dated 6/19/22 and was on the overbed table not covered. Resident #15 said she wears oxygen continuously and received breathing treatments every 4 hours. <BR/>During an observation on 6/28/22 at 9:15 a.m., Resident #15 was lying in bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing. The handheld nebulizer tubing was dated 6/19/22 and was on the overbed table not covered.<BR/>During an observation on 6/29/22 at 11:30 a.m., Resident #15 was lying in bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing. The handheld nebulizer tubing was dated 6/19/22 and was on the overbed table not covered.<BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said she was Resident #23 and Resident #15's 6a-6p charge nurse. LVN G said nursing staff on Sunday nights were responsible for cleaning the oxygen concentrator filters, changing and labeling tubing. LVN G said all staff were responsible for making sure it was done. LVN G said she did not notice that the oxygen tubing, and nebulizer equipment was not dated or properly stored. LVN G said she should have placed Resident #15 mask in a bag when the treatment and her post assessment was completed. LVN G said she did not give Resident #23 a breathing treatment but the nurse providing the nebulizer treatment should be placing the mask in a bag when the treatment and their post assessment was completed. She said these failures could place residents at risk for respiratory infection. LVN G said Resident #15 had been on oxygen since she was admitted . She said she was not aware that Resident #15 did not have an order for oxygen. LVN G said nurses must have an order for oxygen to administer it and if there was no order for oxygen, the nurse should call the physician to get an order. LVN G said she did not know why Resident #15 did not have an order for oxygen. LVN G said this failure could potentially place Resident #15 at risk for falls and confusion. <BR/>During an interview on 6/30/22 at 11:17 a.m., RN K said she was the 10p-6a charge nurse on 6/26/22. RN K said she were responsible for cleaning the oxygen concentrator filters, changing and labeling tubing weekly. RN K said she did not change or clean Resident #23's or 15's oxygen concentrator filter Sunday because she was busy taking care of a resident and their issue. She said these failures could place residents at risk for respiratory infection. <BR/>During an interview on 6/30/22 at 11:35 a.m., LVN F said she was not aware that Resident #15 did not have an order for oxygen. LVN F said nurses must have an order for oxygen to administer it and if there was no order for oxygen, the nurse should call the physician to get an order. LVN F said Resident #15 was admitted with oxygen. LVN F said this failure could potentially place Resident #15 at risk for dizziness and lightheadedness. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said nursing staff on Sunday nights were responsible for cleaning the oxygen concentrator filters, changing and labeling tubing. The DON said angel rounds were done daily before morning stand up meeting. She said it was her responsibility to make sure the nursing staff were properly checking and dating the respiratory equipment. She said she did not know why it has not been done. She said she expected the respiratory equipment to be dated and changed out properly. The DON said she expected nasal canula and nebulizers be stored in bags when not in use. She said she understood this failure could place resident's respiratory health at risk. She said Resident #15 had always been on oxygen since her admission. The DON said she was not aware that Resident #15 did not have did not have an order for oxygen. The DON said not having an order for oxygen could cause Resident #15 to go into respiratory arrest. The DON said it was her responsibility for ensuring residents had orders for the services/treatments they were receiving. The DON said she checked orders daily before stand-up meeting. The DON said the order must have been missed.<BR/>Record review of the facility's oxygen policy tilted Departmental (Respiratory Therapy)-Prevention of Infection revised on 11/2011 indicated . the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . change the oxygen cannula and tubing every (7) days or as needed . keep the oxygen cannula and tubing used PRN in a plastic bag when not in use . Wash filters from oxygen concentrators every (7) days with soap and water . check filters once weekly while they are in continuous use. <BR/>Record review of the facility policy titled Oxygen Administration revise on 10/2010 indicated . the purpose if this procedure is to provide guidelines for safe oxygen administration . verify that there is a physician's order for this procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents' (Resident #6) reviewed for trauma-informed care.<BR/>1. The facility did not ensure Resident #30 had a trauma screening that identified possible triggers when Resident #30 had a history of trauma. <BR/>2. The facility did not ensure Resident #30 was protected from triggers of previous emotional trauma. Resident #297 yelled at Resident #30 in the dining room. Resident #297 was aggressive and had the same name as a man from Resident #30's past that triggered her previous emotional trauma. <BR/>3. The facility did not ensure trauma screenings were completed upon admission to the facility. <BR/>These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. <BR/>The findings included:<BR/>Record review of the face sheet, dated 08/21/23, revealed Resident #30 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of acute on chronic systolic (congestive) heart failure (progressive heart disease that affects pumping action of the heart muscles that can cause fatigue and shortness of breath). <BR/>Record review of the MDS assessment, dated 06/14/23, revealed Resident #30 had clear speech and was understood by staff. The MDS revealed Resident #30 was able to understand others. The MDS revealed Resident #30 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed no behaviors or refusal of care. <BR/>Record review of the comprehensive care plan, edited on 08/10/23, revealed Resident #30 was allegedly hit on the face by another resident. The interventions included: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). The care plan did not address history of trauma.<BR/>Record review of the event report, dated 07/09/23, revealed Resident #30 was hit on the left side of her face by another resident, which was unwitnessed. The event report revealed a head-to-toe assessment was completed. <BR/>During an observation and interview on 08/21/23 at 11:39 AM, Resident #30 was walking down the hallway using a rolling walker. Resident #30 walked to the dining room entrance and turned around and backed out. Resident #30 stated she normally sat at the dining room table closest to the entrance, but she was not going to sit there because the black man [Resident #297], sitting at the end of the table, had hit her previously. Resident #30 stated he was not supposed to sit at the table with her, but he does sit there frequently. Resident #297 wheeled himself away from the dining table and Resident #30 stated she was going to sit down. Resident #30 sat at the dining room and was talking pleasantly with several other residents at the table. <BR/>During an observation on 08/21/23 at 11:42 AM, Resident #297 wheeled himself back to the dining table sitting near Resident #30. Resident #30 appeared scared with her back turned toward Resident #297 and her eyes opened wide. Resident #297 was attempting to yell and accuse Resident #30 of getting her moved out of his room. Resident #30 continued to ignore Resident #297 and he attempted to reach out to touch Resident #30, unsuccessfully. Several staff members were observed at the dining table during the exchange with no interventions put into place. Resident #30 placed her head down on her hands and started audibly crying with tears rolling down her cheeks. CNA K stopped at the dining table and assisted Resident #30 back to her room. <BR/>During an interview on 08/21/23 at 11:49 AM, CNA K stated Resident #30 was upset and wanted to go back to her room. CNA K stated she walked with Resident #30 back to her room to make sure she was okay. CNA K stated Resident #30 and several other ladies at the dining room table were afraid of Resident #297 because he talked loudly at them and had a history of hitting other residents. CNA K stated Resident #30 had her support dog in her room and she wanted to be near the dog because it made her feel safe. <BR/>During an observation and interview on 08/21/23 at 11:57 AM, Resident #30 was sitting up on her bed with a support dog lying beside her. Resident #30 was smiling and visited pleasantly during the interview. Resident #30 stated she had a good relationship with Resident #297 when she first admitted to the facility. Resident #30 stated Resident #297 would come up to her in the dining room and ask her questions because no one could understand him. Resident #30 stated Resident #297 would become angry and started verbally abusing the staff. Resident #30 stated he then started becoming angry and saying mean things to her until one day he hit her. Resident #30 stated staff immediately kept them separated and a few days later Resident #297 was sent to the behavior hospital to have his medications adjusted. Resident #30 stated he was in the hospital for approximately half of July and August 2023. Resident #30 stated he just returned to the facility during the last week, and he was moved to another hallway. Resident #30 also stated signage was placed on the hall that stated do not enter to try and keep Resident #297 off the hallway. Resident #30 stated she did not want to be around Resident #297. Resident #30 stated Resident #297 came straight to the dining table she had been sitting at since returning to the facility. Resident #30 stated she had reported to staff that she felt uncomfortable sitting at the dining room table with Resident #297, but the staff told her Resident #297 had a right to sit at the table. Resident #30 stated she wanted to eat lunch with her friends but was unable to because he was sitting there, and she did not feel safe. Resident #30 stated she reported the situation to RN D, LVN H, ADON, DON, and some CNAs, whose name she was unable to recall.<BR/>During an interview on 08/21/23 at 2:52 PM, Resident #11 stated she sat the dining room table with Resident #30 and Resident #297. Resident #11 stated Resident #297 had run off 3 of her friends at the dining room table. Resident #11 stated the staff told her You can't claim the table, anyone that wants to sit there can. Resident #11 stated she did not feel safe at the dining room table. Resident #11 stated Resident #297 could have gone off at any second and tried to hit them. Resident #11 stated Resident #297 had tried to hit her several times. Resident #11 stated the facility staff were aware of the situation and have not done anything.<BR/>During an interview on 08/21/23 at 3:29 PM, LVN H stated no residents have reported feeling unsafe or uncomfortable sitting at the dining room table. LVN H stated Resident #30 became anxious a lot and stayed in her room most of the time. LVN H stated Resident #30 recently obtained her dog and that helped with her anxiety. LVN H stated Resident #30 went to the dining room for lunch and dinner and had not reported feeling unsafe or uncomfortable. LVN H stated she was unsure if Resident #30 and Resident #297 had been eating at the same dining table. LVN H stated Resident #297 had swung at Resident #30 a couple of months ago, but he left the facility for treatment. LVN H stated Resident #297 had his medications adjusted and his demeanor had improved after returning to the facility. <BR/>During an interview on 08/21/23 at 3:50 PM, Resident #10 stated she was not afraid of Resident #297, but he was always causing trouble at the dining room table. Resident #10 stated Resident #297 talked loudly and got on her nerves. Resident #10 stated Resident #297 had just returned to the facility after being sent out for hitting another resident.<BR/>During an interview on 08/21/23 at 4:18 PM, the ADON stated Resident #30 admitted from the hospital was pretty much independent with ADLs. The ADON stated Resident #30 was very sweet. The ADON stated Resident #30 had not had many anxiety issues since she obtained her dog. The ADON stated Resident #30 did have some confusion and was occasionally forgetful. The ADON stated Resident #30 had not told her that she felt uncomfortable or unsafe sitting at the dining table with Resident #297. The ADON stated Resident #30 and Resident #297 had an altercation a few months previously but had not had any issues since. The ADON stated no facility staff had reported that Resident #30 did not feel safe or comfortable. The ADON stated Resident #30 normally sat in the dining room for meals with no issues reported. The ADON stated it was reported today that Resident #30 had become upset in the dining room, but she was already out of the dining room and the CNA had comforted Resident #30. The ADON stated she was unaware if any other residents had concerns. The ADON stated the only concerns that had been reported on Resident #297 was he was too loud.<BR/>During an interview on 08/21/23 at 4:27 PM, the DON stated Resident #30 made up stories every now and then. The DON stated not too long ago one of the residents allegedly hit Resident #30 and it was not observed. The DON stated the incident was not witnessed and it was not proven that it happened. The DON stated she was just made aware, within the last hour, that Resident #30 felt uncomfortable and unsafe in the dining room. The DON stated she was unsure what staff member reported it. The DON stated she was fixing to go talk to Resident #30 because that was what she would normally do. <BR/>During an interview on 08/21/23 at 5:00 PM, the DON stated a safe survey was completed on Resident #30. The DON stated Resident #30 told her Resident #297 had not been aggressive or spoken rudely to her. The DON stated Resident #30 said the name Paul was a trigger for her and she did not deal well with strong, loud personalities because of past traumas. The DON stated she asked Resident #30 if a referral could have been made for psychological services and Resident #30 agreed. <BR/>During an interview on 08/22/23 at 8:23 AM, Resident #30 stated the DON talked to her yesterday. Resident #30 stated she believed her past trauma was making her feel uncomfortable around Resident #297. Resident #30 stated she had a cousin who threatened to kill the whole family at a wedding, and he had the same name as Resident #297. Resident #30 stated she also remembered getting spanked by her grandfather at young age and the incident had made her fearful of men with strong personalities. Resident #30 stated the relationship with Resident #297 was okay until he hit her. Resident #30 stated she still did not want to sit at the dining room table with Resident #297 because she felt uncomfortable. Resident #30 stated she had never been asked by the facility if she had a history of trauma. <BR/>During an interview on 08/22/23 at 9:48 PM, the DON stated trauma informed care observations were supposed to have been completed on admission to the facility. The DON stated the electronic charting system was not alerting anyone the observation needed to be completed. The DON stated none of the residents at the facility had a trauma screening completed. <BR/>During an interview on 08/22/23 at 10:13 AM, the DON stated the Social Worker was responsible for completing the trauma screening on every resident upon admission to the facility. The DON stated the facility had not had a Social Worker since 10/20/22. The DON stated the electronic charting system had a feature that sent an alert to the dashboard that an observation was needed. The DON stated the electronic system was not sending an alert for the trauma screening assessment, so it was not being completed. The DON stated there was no process in place for monitoring to ensure the trauma screen observations were being completed.<BR/>During an interview on 08/23/23 at 4:15 PM, RN D stated she normally cared for Resident #30. RN D stated Resident #30 had not been eating in the dining room as frequently. RN D stated Resident #297 did not typically sit at the same dining table as Resident #30. RN D stated Resident #30 was social and talkative. RN D stated Resident #30 was pleasant and cooperative and was cognitively intact. RN D stated Resident #30 or other staff member had not reported to her that she felt unsafe or uncomfortable eating lunch at the dining table. RN D stated Resident #30 could have reported that she felt unsafe with Resident #297 prior to being sent to the behavior hospital. RN D stated facility staff did move Resident #297's room away from Resident #30 as an intervention. RN D stated she was unaware of Resident #30's previous history of trauma. <BR/>During an interview on 08/25/23 at 12:12 PM, the DON stated the system for completing and monitoring trauma screens was broken. The DON stated it was important to ensure trauma screens were completed so staff would know what triggers the residents with a history of trauma and to avoid those triggers to prevent re-traumatization and provide more individualized care. <BR/>During an interview on 08/25/23 at 3:25 PM, the Director of Social Services stated she oversaw the facility's social services program. The Director of Social Services stated the process for trauma screens was that were to be completed upon admission to the facility. The Director of Social Services stated the facility was responsible for monitoring to ensure trauma screens were completed upon admission. The Director of Social Services stated she did complete random audits and assisted the facility in education training. The Director of Social Services stated none had been completed on trauma informed care since she had been with the company, approximately 2 months. The Director of Social Services stated it was important to ensure trauma screening was completed to identify past trauma and avoid resident triggers to prevent re-traumatization. <BR/>During an attempted telephone interview on 08/25/23 at 4:33 PM to gather more information, the Administrator did not answer. No phone call was returned upon exit of the facility. <BR/>Record review of the Trauma Informed Care policy, revised December 2019, revealed 3. Include trauma-informed care as part of the QAPI plan, so that needs, and problem areas are identified and addressed. The policy further revealed 6. Implement universal screening of residents for trauma. The policy revealed 1. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of the physician order report dated 5/29/22-6/29/22 indicated Resident #191 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including hypothyroidism ((thyroid gland does not produce enough thyroid hormone), bipolar disorder (Bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs) and hyperlipidemia (blood has too many lipids (or fats).<BR/>Further review of the physician order report indicated Resident #191 was prescribed Levothyroxine tablet, 11 mcg by mouth, one time a day for hypothyroidism with start date 6/15/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #191 understood others and made herself understood. The MDS indicated Resident #191 was cognitively intact (BIMS score of 13). The MDS indicated she required supervision with bed mobility, transfers, eating toileting, and personal hygiene: extensive assistance with bathing. The MDS indicated Resident #191 had active diagnoses of thyroid disorder, arthritis, and bipolar disorder. <BR/>Record review of the care plan dated 6/28/22 indicated Resident #191 had a diagnosis of hypothyroidism and take levothyroxine. The care plan interventions were to administer medications as ordered and monitor weight loss. <BR/>Record review of the medication administration record dated 6/1/22-6/18/22 revealed Resident #191 had an order for levothyroxine 112 mcg, give 1 tablet by mouth every morning. The report indicated Resident #191 received levothyroxine at 5:00 a.m. on 6/24/22 given by LVN H, 5:00 a.m. on 6/25/22 given by RN K and 5:00 a.m. on 6/26/22 given by LVN F. <BR/>During an interview on 6/27/22 at 11:55 a.m., Resident #191 said she did not receive her thyroid medication over the weekend. Resident #191 indicated she had not experienced any ill effects from not receiving medication. <BR/>Record review of the medication blister packs (help keep track of the resident's medication) indicated one dose of levothyroxine was missed.<BR/>During an interview on 6/27/22 at 12:15 p.m., the DON and Administrator agreed there was one medication administration missed.<BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said Resident #191 told her she did not received her thyroid medication the last couple of days on 6/27/22. LVN G said she reported it to the DON. LVN G said thyroid medication should be given on time and daily for therapeutic thyroid levels. LVN G said if thyroid medication was not given it could affect the resident's lab levels and caused her to become fatigue (tired). <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said thyroid medications given on an empty stomach was important, that was why it is scheduled at 5am. The DON said if thyroid medication was not given on an empty stomach it could affect Resident #191 lab levels and cause her to become confused. The DON said the physician was notified and labs were ordered. The DON said it was her responsibility to ensure medications were given. She said corporate run reports every week on medication administration times and they would notify her if there were any missed doses. The DON said she had not received a report this week. <BR/>Record review of the facility's policy tilted Documentation of Medication Administration revised on 4/2007 indicated . administration of medication must be documented immediately after (never before) it is given . <BR/>Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 5 (Residents #6, #7, #25, #38, #191) of 6 residents reviewed for pharmacy services.<BR/>The facility failed to ensure Resident #191 received her Levothyroxine (thyroid medication) as ordered by the physician. <BR/>The facility failed to ensure Residents #6, #7, #25 and #38 received scheduled medication on time during medication administration pass. <BR/>These failures could place the residents at risk of not receiving the intended therapeutic benefit of their medications.<BR/>Findings included:<BR/>1. Record review of the consolidated physician orders dated 6/30/22 revealed Resident #6 was [AGE] year-old, female admitted to the facility on [DATE] with diagnosis including stroke, low red blood cell count, elevated cholesterol, seasonal allergies, muscle weakness, difficulty walking, impaired thought organization, secondary high blood pressure, anxiety disorder, and major depressive disorder. The consolidated physician orders revealed Resident #6 was prescribed Lexapro 5 mg tab at bedtime for depression. Resident #6 was prescribed pyridostigmine bromide 60 mg 1 tab 3 times a day for muscle weakness. <BR/>2. Record review of the most recent MDS dated [DATE] revealed Resident #6 had an intact cognition. The MDS revealed Resident #6 required supervision for eating, transfers, and toilet use. Resident #6 required limited assistance with personal hygiene and bathing. Resident #6 did not have a history of refusing care. <BR/>Record review of the care plan dated 6/8/2022 revealed Resident #6 had a history of stroke and takes pyridostigmine bromide for muscle weakness. <BR/>Review of the Medication Administration History Report dated 06/01/2022-06/30/2022 revealed Resident #6 received pyridostigmine bromide 60 mg (due at 8 AM, 12 PM and 8 PM) on 6/7/2022 at 9:05 AM by LVN A, on 6/9/2022 at 9:10 AM, on 6/10/2022 at 9:48 AM by LVN C, on 6/11/2022 at 9:18 AM by LVN A, on 6/14/2022 at 9:07 AM by LVN C, on 6/16/2022 at 9:13 AM by LVN A, on 6/16/2022, at 9:22 PM by LVN D, on 6/20/22 at 9:31 AM by LVN A, 0n 9/21/2022 at 9:04 AM by LVN A, on 6/25/2022 at 9:34 AM by RN B, on 6/25/22, at 1:09 PM by RN B, on 6/25/2022 at 9:10 PM by LVN E, on 6/26/2022 at 9:22 AM by RN B, and on 9/28/2022 at 9:44 AM by LVN C. No reasons were given for late administration.<BR/>3.Record review of consolidated physician orders dated 6/30/2022 revealed Resident #7 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure, Parkinson's disease, muscle weakness, chronic obstructive pulmonary disease, chronic pain, essential (not the result of a medical condition) hypertension, bone arthritis, and bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed Aldactone 50 mg tab twice a day for essential hypertension. The consolidated physician orders revealed Resident #7 was prescribed benztropine 1 mg tab twice daily for Parkinson's disease. The consolidated physician orders revealed Resident #7 was prescribed chlorzoxazone 500 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed clonazepam 0.5 mg tab twice a day for bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed gabapentin 300 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed oxycodone-acetaminophen 5-325 tab three times a day for pain. The consolidated physician orders revealed Resident #7 was prescribed pregabalin 50 mg tab three times a day for pain. <BR/>Review of the most recent MDS dated [DATE] revealed Resident #7 was cognitively intact, was independent for dressing, toilet use, and required supervision for eating and personal hygiene. Resident #7 did not have a history of rejecting care. <BR/>Record review of the most recent care plan dated 6/22/2022 revealed Resident #7 had history of hypertension and took Aldactone. Resident #7 had a history of bipolar disorder and took trazodone and clonazepam. Resident #7 had a potential for pain related to chronic pain and arthritis, and takes oxycodone, pregabalin, gabapentin, and chlorzoxazone. Resident #7 was at risk for increased falls related to Parkinson's disease. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Aldactone (due at 9:00AM and 9:00 PM) at 10:12 AM on 6/1/2022 given by LVN F, at 10:04 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 10:21 AM on 6/4/2022 given by LVN H, at 10:12 AM on 6/6/2022 given by LVN F, at 10:12 AM on 6/7/2022 given by LVN F, at 1:19 AM on 6/8/2022 given by LVN D, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 AM on 6/9/2022 given by RN B, at 10:11 AM on 6/14/2022 given by CMA C, at 10:08 AM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 10:08 on 6/21/22 by LVN F, at 11:38 PM on 6/21/2022 by RN K, at 10:25 PM on 6/24/2022 by RN K, at 10:25 PM on 6/25/2022 given by RN K, at 10:25 on 6/26/22 by RN K, and at 11:46 PM on 6/26/22 by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Chlorzoxazone (due at 8 AM and 8 PM) at 10:03 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 9:40 AM on 6/3/2022 given by LVN H, at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/8/2022 given by LVN G, at 9:40 on 6/8/2022 AM given by LVN G, at 10:25 AM, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 AM on 6/24/2022 given RN J, at 9:01 AM on 6/25/22 given by LVN F, at 11:59 AM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26/2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Clonazepam (due at 5 AM and 1 PM) at 2:36 PM on 6/1/2022 given by LVN F, at 2:01 PM on 6/2/2022 given by LVN F, at 2:42 PM on 6/7/2022 given by LVN F, at 7:42 AM on 6/9/2022 given by LVN G, at 6:34 AM on 6/12/2022 given by LVN A, at 4:55 PM on 6/15/2022 given by LVN A, at 7:08 AM on 6/25/2022 given by LVN F, at 2:13 PM on 6/25/2022 given by LVN H, and at 6:51 AM on 6/27/2022 given by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Gabapentin (due at 8 AM and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13 on 6/3/2022 given by LVN G, at 9:40 AP on 6/3/2022 given by LVN H,. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA, on 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Oxycodone-Acetaminophen (due at 8 AM, 2 PM, and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13AM on 6/3/2022 given by LVN G, at 3:53 PM on 6/3/2022 by LVN G, at 9:40 PM on 6/3/2022 given by LVN H. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 4:17 PM on 6/10/2022 given by LVN A at 9:13 AM on 6/11/2022 given by LVN A, at 4:39 PM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 4:55 PM on 6/15/2022 given by LVN A, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C , at 3:02 PM on 6/19/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 4:52 PM on 6/23/2022 given by LVN G at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>3. <BR/>Record review of consolidated physician orders dated 6/30/2022 revealed Resident #7 was a [AGE] year old[AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure, Parkinson's disease, muscle weakness, chronic obstructive pulmonary disease, chronic pain, essential (not the result of a medical condition) hypertension, bone arthritis, and bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed Aldactone 50 mg tab twice a day for essential hypertension. The consolidated physician orders revealed Resident #7 was prescribed benztropine 1 mg tab twice daily for Parkinson's disease. The consolidated physician orders revealed Resident #7 was prescribed chlorzoxazone 500 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed clonazepam 0.5 mg tab twice a day for bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed gabapentin 300 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed oxycodone-acetaminophen 5-325 tab three times a day for pain. The consolidated physician orders revealed Resident #7 was prescribed pregabalin 50 mg tab three times a day for pain. <BR/>Review of the most recent MDS dated [DATE] revealed Resident #7 was cognitively intact, was independent for dressing, toilet use, and required supervision for eating and personal hygiene. Resident #7 did not have a history of rejecting care. <BR/>Record review of the most recent care plan dated 6/22/2022 revealed Resident #7 had history of hypertension and took Aldactone. Resident #7 had a history of bipolar disorder and took trazodone and clonazepam. Resident #7 had a potential for pain related to chronic pain and arthritis, and takes oxycodone, pregabalin, gabapentin, and chlorzoxazone. Resident #7 was at risk for increased falls related to Parkinson's disease. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Aldactone (due at 9:00AM and 9:00 PM) at 10:12 AM on 6/1/2022 given by LVN F, at 10:04 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 10:21 AM on 6/4/2022 given by LVN H, at 10:12 AM on 6/6/2022 given by LVN F, at 10:12 AM on 6/7/2022 given by LVN F, at 1:19 AM on 6/8/2022 given by LVN D, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 AM on 6/9/2022 given by RN B, at 10:11 AM on 6/14/2022 given by CMA C, at 10:08 AM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 10:08 on 6/21/22 by LVN F, at 11:38 PM on 6/21/2022 by RN K, at 10:25 PM on 6/24/2022 by RN K, at 10:25 PM on 6/25/2022 given by RN K, at 10:25 on 6/26/22 by RN K, and at 11:46 PM on 6/26/22 by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Chlorzoxazone (due at 8 AM and 8 PM) at 10:03 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 9:40 AM on 6/3/2022 given by LVN H, at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/8/2022 given by LVN G, at 9:40 on 6/8/2022 AM given by LVN G, at 10:25 AM, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 AM on 6/24/2022 given RN J, at 9:01 AM on 6/25/22 given by LVN F, at 11:59 AM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26/2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Clonazepam (due at 5 AM and 1 PM) at 2:36 PM on 6/1/2022 given by LVN F, at 2:01 PM on 6/2/2022 given by LVN F, at 2:42 PM on 6/7/2022 given by LVN F, at 7:42 AM on 6/9/2022 given by LVN G, at 6:34 AM on 6/12/2022 given by LVN A, at 4:55 PM on 6/15/2022 given by LVN A, at 7:08 AM on 6/25/2022 given by LVN F, at 2:13 PM on 6/25/2022 given by LVN H, and at 6:51 AM on 6/27/2022 given by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Gabapentin (due at 8 AM and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13 on 6/3/2022 given by LVN G, at 9:40 AP on 6/3/2022 given by LVN H,. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA, on 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Oxycodone-Acetaminophen (due at 8 AM, 2 PM, and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13AM on 6/3/2022 given by LVN G, at 3:53 PM on 6/3/2022 by LVN G, at 9:40 PM on 6/3/2022 given by LVN H. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 4:17 PM on 6/10/2022 given by LVN A at 9:13 AM on 6/11/2022 given by LVN A, at 4:39 PM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 4:55 PM on 6/15/2022 given by LVN A, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C , at 3:02 PM on 6/19/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 4:52 PM on 6/23/2022 given by LVN G at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>4.Record review of the consolidated physician orders dated 6/30/2022 revealed Resident #25 was [AGE] years old, female and admitted on [DATE] with diagnoses including chronic atrial fibrillation (irregular and rapid heartbeat), congestive heart failure, hypertension, anxiety disorder, muscle weakness, type 2 diabetes, left lower abdomen pain, heart disease of coronary artery, end stage kidney disease, and hypothyroidism (thyroid not producing enough thyroid hormone). The consolidated physician orders revealed Resident # 25 was prescribe Lorazepam 0.5 mg tab three times a day for anxiety. The consolidated physician orders revealed Resident #25 was prescribed Buspirone 5 mg tab twice a day for anxiety. The consolidated physician orders revealed Resident #25 was prescribed Apixaban 2.5 mg tab twice a day for chronic atrial fibrillation. The consolidated physician orders revealed Resident #25 was prescribed Metoprolol 12.5 mg tab twice a day for heart disease of coronary artery. heart disease of coronary artery, and hypertension. <BR/>Record review of the most recent MDS dated [DATE] revealed Resident #25 had a mild cognitive impairment, was usually able to make self-understood and understand others, and need limited assistance with dressing, personal hygiene. Resident #25 did not reject care. <BR/>Review of the most recent care plan dated 6/1/2022 revealed Resident #25 had a cardiac diagnosis of congestive heart failure, chronic atrial fibrillation, and hypertension with interventions to administer apixaban. Resident #25 required one person assistance with bathing. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Lorazepam (due at 8 AM, 12 PM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, at 10:11 PM on 6/24/2022 by LVN E, and at 1:29 PM on 6/25/2022 by RN B. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Buspirone (due at 8 AM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, and at 10:11 PM on 6/24/2022 by LVN E. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Apixaban (due at 8 AM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, and at 10:11 PM on 6/24/2022 by LVN E. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Metoprolol (due at 8 AM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, and at 10:11 PM on 6/24/2022 by LVN E. No reasons were given for late administration.<BR/>5. Record review of the consolidated physician orders dated 6/30/2022 revealed Resident #38 was [AGE] year-old, female and admitted on [DATE] with diagnoses including type 2 diabetes, end stage kidney disease, atrial fibrillation (irregular and rapid heartbeat), chronic lung disease, pain, and muscle weakness. The consolidated physician orders revealed Resident #38 was prescribed Gabapentin 100 mg tab three times a day for pain. The consolidated physician orders revealed Resident #38 was prescribed Hydrocodone-acetaminophen 5-325 mg tab three times a day for pain . <BR/>Record review of the most recent MDS dated [DATE] revealed Resident #38 was able to make herself understood and understood others and was cognitively intact. Resident #38 required limited assistance with toilet use, dressing and bathing. Resident #38 occasionally had pain at a moderate level. Resident #38 did not reject care. <BR/>Record review of the most recent care plan dated 6/9/2022 revealed Resident #38 had pain with intervention to administer pain medications as ordered. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #38 received Hydrocodone-acetaminophen 5-325 mg (due at 6:00 AM, 12:00 PM, and 8:00 PM) at 10:10 AM on 6/20/2022 given by LVN E, at 9:59 PM on 6/24/2022 given by LVN E, at 9:13 PM on 6/25/2022 given by LVN E, and at 1:011 PM on 6/27/2022 given by LVN D. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #38 received Gabapentin (due at 8:00 AM, 2:00 PM, and 8:00 PM) at 3:38 PM on 6/20/2022 given by LVN F, at 10:10 PM on 6/20/2022 given by LVN E, at 4:16 PM on 6/24/2022 given by LVN A, at 9:59 PM on 6/24/2022 given by LVN E, and at 9:13 PM on 6/25/2022 given by LVN E. No reasons were given for late administration.<BR/>During interview on 6/30/2022 at 11:32 AM, LVN F said she had been working at the facility for 2 years. Nurse F said when a nurse administers medication, a timestamp was made to record when the medication was given. LVN F said they had a two-hour window to administer medication, one hour before and after the time it was due. LVN F said sometimes the staff got busy and medications were late. LVN F said when a medication was only 30 minutes late, it would have no effect on resident. LVN F said late administration could throw off the medication schedule, and adversely affect the resident. <BR/>During interview on 6/30/2022 at 1:55 PM, LVN A said she had been working at the facility for 4 months. LVN A said medication times were entered when the nurse administers medications to the resident. LVN A said they had 1 hour before and after the time was due to given medications. LVN A said staffing issues had sometimes caused medications to be given late. LVN A said administering medication late could result in a resident having pain, or their blood pressure being high. <BR/>During interview on 6/30/2022 at 2:34 PM, the DON said corporate had looked at reports weekly for late medication administration. The DON said she also gets a report listing of late medication administration . The DON said medications administered late were a different color than medications given on time. The DON said she could ensure medications were given on time using these reports. The DON said medications were considered late when they were administered more than 1 hour after their due time. The DON said medications were timestamped in the computer when they were administered. The DON said the facility has a policy of administering medications 1 hour before and after the time they were due. The DON said residents could experience pain or have blood pressure problems when medications were not administered when due.<BR/>During interview on 6/30/2022 at 3:12 PM, the Administrator said she expected medications to be administered on time. The administrator said when medications were administered late, residents could have critical lab results.

Based on observation, interview and record review, 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 6.9 %, based on 2 errors out of 29 opportunities, which involved 2 of 7 residents (Resident #4 and #42) reviewed for medication administration. <BR/>1. The facility did not ensure Resident #4 was given calcium with vitamin D3 600mg-12.5 mcg. <BR/>2. The facility failed to administer Resident #42's gentamicin eye drops (antibiotic eye drops) as ordered by the physician. <BR/>These failures 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/>1. During an observation on 08/22/2023 at 9:25 a.m., MA L was preparing Resident #4's medication for administration. MA L obtained a bottle of calcium with vitamin D 600 mg-10 mcg and placed 2 oval white tablets in the cup. MA L finished preparing the remainder of Resident #4's morning medications. MA L obtained a plastic glass of water and went into Resident #4's room. MA L gave Resident #4 her medication cup, which included the calcium with vitamin D, and Resident #4 swallowed the medication.<BR/>Record review of Resident #4's physician order report, dated 08/24/2023, indicated Resident #4 was prescribed (2) calcium capsule with vitamin D3, 600mg-12.5 mcg by mouth one time a day with a start date 06/02/2023. <BR/>Record review of the medication administration history dated 08/01/2023-08/24/2023, revealed Resident #4 received (2) calcium capsule with vitamin D3, 600mg-12.5 mcg by mouth one time a day. <BR/>During an interview on 08/25/23 at 11:12 a.m., MA L stated the medication should be verified with the MAR prior to administering medication. MA L stated if the medication label did not match the physicians order she should have notified the nurse for clarification. MA L stated she was unaware the dosage was different for Resident #4's calcium with vitamin D. MA L stated it was important to clarify discrepancies in the medication orders prior to medication administration so medication errors or adverse reactions did not occur.<BR/>2. During an observation and interview on 08/22/23 at 12:32 p.m., MA L was standing at the medication cart, preparing to administer gentamicin 0.3% eye drops, to Resident #42. The medication label on the eye drops box read as follows: gentamicin 0.3% - 2 drops to both eyes twice daily. MA L obtained the eye drops, gloves, and tissues and went into Resident #42's room. MA L administered the gentamicin 0.3% eye drops to Resident #42's right eye. MA L stated the eye drops were started yesterday and she only administered them to Resident #42's right eye. MA L then read the label on the gentamicin 0.3% eye drop box and stated Oh, I didn't realize it was both eyes. MA L then prepared the gentamicin eye drops, went into Resident #42's room, and administered the eye drops to the left eye.<BR/>Record review of Resident #42's physician order report, dated 07/25/2023-08/25/2023, indicated an order for gentamicin drops 0.3 %; 2 drops in the right eye four times a day; 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM with a start date of 08/18/2023 and end date 08/23/2023. <BR/>Record review of the medication administration history dated 08/01/2023-08/24/2023, revealed Resident #42 received 2 drops of gentamicin (antibiotic) to right eye four times a day times 5 days with a start date 08/18/2023.<BR/>During an interview on 08/23/23 at 4:54 p.m., MA L stated the medication label on a medication from the pharmacy should have matched the physicians order in the computer. MA L stated if the medication label did not match the physicians order she should have notified the nurse for clarification. MA L stated when the surveyor intervened, she reported the discrepancy to the nurse and DON. MA L stated she should have notified the nurse for clarification prior to administering the eye medication. MA L stated it was important to clarify discrepancies in the medication orders prior to medication administration so medication errors or adverse reactions did not occur. <BR/>During an interview on 08/25/2023 at 4:26 p.m., the DON stated she expected medications to be given per MD orders. The DON stated staff who pass medications should follow the rights medication administration, including correct dose. The DON stated staff had been in serviced on that. The DON stated it was important to compare the MAR to the medication label and the staff should have completed this during medication administration. The DON stated the staff should have held the medication and notified the physician if medication dosage did not match. The DON stated it was important to verify and administer the correct dose to prevent adverse reaction to resident. <BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the facility's policy titled Administering Medications last revised on 04/2019, indicated, medications are administered in a safe and timely manner, and as prescribed 4. Medications are administered in accordance with prescriber orders . 10. The individual administering the medication checks the label Three (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication

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 a skillet was free from encrusted black colored grease buildup coating the entire outside and most of the inside surface.<BR/>The facility failed to ensure the windowsill over the 3-compartment sink was free from insect carcasses. <BR/>The facility failed to ensure the plastic condiment bins were free from a tan colored buildup (grease like).<BR/>The facility failed to repair a leaking drainpipe under the 3-compartment sink.<BR/>The facility failed to ensure the juice machine nozzle was free from a brownish pink gooey substance where the juice was dispersed.<BR/>The facility failed to ensure the dishwashing machine's heating element panel was replaced to cover the electrical wiring. <BR/>These failures could place the residents at risk for food-borne illness, and food contamination.<BR/>Findings included:<BR/>During an observation on 6/27/2022 at 9:55 a.m., the following was observed:<BR/>*There were bug carcasses in the windowsill above the 3-compartment sink. <BR/>*the 3-compartment sink had the drainage pipe leaking into a red sanitation bucket.<BR/>*plastic condiment containers with a tan colored grease like buildup. <BR/>*juice machine nozzle with a gooey brownish/pink substance inside where the juice was dispersed.<BR/>*the dish machine had a panel off a site which appeared to be covering electrical wiring.<BR/>*a skillet on the stove top had an encrusted black colored grease buildup on the entire outside surface and most of the inside surface.<BR/>During an interview on 6/27/2022 at 10:08 a.m., the DM indicated the drainpipe has been leaking for several months. The DM indicated she had attempted replace the panel on the dish machine, but the panel continues to fall off. The DM indicated the repair man had come to work on the dish machine approximately 2 weeks ago. <BR/>During an observation on 6/28/2022 at 8:56 a.m., the juice machine nozzle continued to have a gooey brownish/pink buildup inside where the juice was dispersed. The grease encrusted skillet was on the stove top and appeared to have been used to fry eggs. <BR/>During an observation and interview on 6/28/2022 at 9:04 a.m., the ADM indicated the facility had plumbing issues. The ADM indicated the window was included in a bid for replacement but did not reply on the bug carcasses. The ADM indicated she would purchase another fry skillet for the kitchen. She indicated she expected the kitchen to be clean. The ADM indicated she was responsible for the dietary department.<BR/>During an interview on 6/28/2022 at 9:15 a.m., the DM indicated the encrusted black colored skillet could not be cleaned. The DM indicated the maintenance supervisor fixed the pipe today and reapplied the panel cover to the box containing electrical wiring. The DM indicated she comes to deep clean each Sunday. The DM manager indicated she had soaked the juice nozzle in bleach on the prior Sunday 6/26/2022.<BR/>During an interview on 6/28/2022 at 10:35 a.m., the [NAME] indicated she had used the encrusted skillet was used to fry eggs every morning. The [NAME] indicated the encrusted skillet was cleaned using a steel wool pad. The [NAME] indicated deep cleaning day was each Sunday.<BR/>During an interview on 6/30/2022 at 8:30 a.m., the DM validated the tan colored build up on the plastic storage bins. She indicated the cook was responsible for cleaning the bins. The DM indicated the encrusted black skillet was the only skillet the kitchen had to use. <BR/>Record review of an undated Sample Weekly Cleaning Schedule indicated the containers were assigned for cleaning weekly to the cook.<BR/>Record review of a General Kitchen Sanitation policy dated 2018 indicated the facility recognizes that a food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil.<BR/>Record review of FDA Food Code 2017; accessed on 7/7/2022<BR/>4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOODCONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated 113 WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.<BR/>4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 44 of 44 residents who resided in the facility.<BR/>The Administrator failed to follow abuse policies and report incidents of abuse.<BR/>The Administrator failed to follow abuse policies and protect Resident #39 from further abuse by allowing CNA B to work when she was supposed to be suspended for an allegation of abuse.<BR/>The Administrator failed to ensure residents were not fearful of retaliation.<BR/>The Administrator allowed CNA B to work during suspension from an alleged abuse allegation.<BR/>The Administrator was aware of multiple staff verbally abusing residents and did not place any protective measures in place. <BR/>An Immediate Jeopardy (IJ) situation was identified on 8/23/2023 at 5:15 p.m. The IJ template was provided to the facility on 8/23/2023 at 5:56 p.m. While the IJ was removed on 8/25/2023 at 3:53 p.m., the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could residents at an increased risk for abuse, further abuse, increased anxiety, emotional distress, depression, neglect, and retaliation. <BR/>Findings included:<BR/>1)Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. <BR/>Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. <BR/>Record review of Resident #41's a care plan with dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth.<BR/>Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having had coffee thrown at her or an attempted stabbing with a fork. <BR/>During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents.<BR/>During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents.<BR/>During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. <BR/>During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen.<BR/>During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated she had to move out of the way to avoid injuries when both incidents occurred. <BR/>During an interview on 08/23/23 at 11:45 AM, CNA A stated she was unsure the date the incidents happened but indicated was a couple of months ago. CNA A stated Resident #29 threw coffee on Resident #41 in the hallway as staff was picking up the dinner trays in the dining room. CNA A stated Resident # 29 used a fork and attempted to stab Resident #41 at the nurse's station. CNA A said Resident #41 was able to jump back to miss getting hurt. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork from Resident #29. <BR/>During an interview on 08/23/23 at 4:12 PM, RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. <BR/>2) Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal).<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy.<BR/>During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you.<BR/>During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA A was allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. <BR/>During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations.<BR/>Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: <BR/>7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day.<BR/>7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. <BR/>7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day.<BR/>7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m.<BR/>7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. <BR/>During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations.<BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the Abuse Prevention Program policy and procedure dated June 2021 indicated 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 5. Our center will condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 6. Our center will protect resident from harm, reprisal, discrimination, or coercion during investigations of abuse allegations. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. Investigation .6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.<BR/>The Administrator/Corporate Regional Director was notified on 8/2323 at 5:45 p.m., that an Immediate Jeopardy situation was identified due to the above failure. The Administrator/Corporate Regional Director was provided the Immediate Jeopardy template on 8/23/2023 at 5:56 p.m.<BR/>The facility's Plan of Removal was accepted on 8/24/2023 at 3:46 p.m. and included: <BR/>Action: Regional Director of Operations reviewed intake #438802. Employee identified as allegedly abusing the resident has suspension paperwork in place, resident was assessed and interviewed and states the following: <BR/>Do you feel safe here: yes<BR/>Do you feel kike staff is treating you with respect: yes<BR/>Do you feel comfortable reporting to staff any problems or concerns: yes<BR/>Any questions for me: no<BR/>Date: 7/26/2023<BR/>Person responsible: Regional Director of Operations<BR/>Action: Administrator received 1:1 education with the Regional Director of Operations regarding Abuse/Neglect Reporting.<BR/>Administrator and Director of Nursing received 1:1 education regarding suspending of alleged perpetrators until the investigation is completed. Alleged perpetrators can then return to work if the allegation is confirmed, inconclusive, or unfounded.<BR/>Date: 8/24/2023 at 4:40 p.m.<BR/>Action: Administrator has been suspended pending an investigation by the Regional Director of Operations. Parties assisting with the investigation include Regional Director of Operations and the Chief Nursing Officer. <BR/>Date 8/23/2023 at 4:40 p.m.<BR/>Action: Maintenance Director, and 2 CNAs have been suspended pending investigation to include: verbal abuse towards resident (s).<BR/>Date: 8/23/2023 by 4:40 p.m.<BR/>Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related.<BR/>Date 8/23/2023<BR/>Action: Employee (all) interviews conducted to include: <BR/>Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions)<BR/>If yes, who was the employee, who was the resident, and when about did this occur?<BR/>Were there other witnesses to this event?<BR/>Did you report this information to anyone and if so, to who?<BR/>Date: 8/23/2023<BR/>Action: <BR/>Education provided:<BR/>All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.)<BR/>All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing.<BR/>All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator).<BR/>All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line.<BR/>Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. <BR/>All staff to be in-serviced prior to working their next/first shift.<BR/>Date 8/23/2023 by 4:00 p.m.<BR/>Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect.<BR/>Date: 8/24/2023<BR/>Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal<BR/>Date: 8/23/2023 by 2:00 p.m.<BR/>Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol.<BR/>On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record of the Employee memorandum indicated CNA A was provided a suspension dated 7/23/2023.<BR/>Record review of a safe survey with Resident #39 dated 7/26/2023.<BR/>Record review of the safe survey results for the residents.<BR/>Record review of the attestation from the MDS nurse ensured all care plans were reviewed for the last 30 days for resident-to-resident altercations.<BR/>Record review of the attestation from the ADON nurse ensured all progress notes and/or event reports for the previous 30 days.<BR/>Record review of the attestation from the Corporate RN indicated she ensured the progress notes and/or event reports.<BR/>Record review of the signed In-service sign in sheet indicated the Regional Director of Operations in-serviced the Administrator and the DON was provided material related to reporting allegations of abuse to HHSC, completing through investigations, follow the abuse policy, implementation of interventions, suspending alleged perpetrators dated 8/23/2023.<BR/>Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. <BR/>Record review of the employee Abuse Questionnaires.<BR/>Record review of the Abuse and Neglect In-service dated 8/23/2023 indicated to report abuse from vendors, family, or staff toward our residents.<BR/>Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination.<BR/>Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. <BR/>Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Licensed Nurses were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported. <BR/>Interview of all staff (DA W, [NAME] P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. All employees were interviewed to inquire about incidents of abuse. All staff members were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported.<BR/>Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. <BR/>Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. <BR/>On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not iImmediate jeopardy and at a scope of widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #7) reviewed for hospice services.<BR/>The facility did not ensure Resident #7's hospice records were a part of their records in the facility. <BR/>This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings included: <BR/>Record review of the face sheet, dated 08/25/23, revealed Resident #7 was an [AGE] year-old female who initially admitted to the facility on [DATE] with a diagnosis of unspecified dementia, without behaviors (group of symptoms that affects memory, thinking and interferes with daily life). <BR/>Record review of the MDS assessment, dated 08/11/23, revealed Resident #7 had no speech and was rarely or never understood by staff. The MDS revealed Resident #7 was rarely or never able to understand others. The MDS revealed Resident #7 was unable to complete the BIMS assessment. The MDS revealed Resident #7 had a life expectancy of less than 6 months and received hospice services. <BR/>Record review of the comprehensive care plan, edited on 08/17/23, revealed Resident #7 required hospice as evidenced by a terminal illness of dementia. The goal was dignity will be maintained, and the resident will be kept comfortable and pain free with in one hour of interventions over next 90 days. The interventions included repot decline in condition to hospice agency. <BR/>Record review of the physician order report dated 07/25/23 - 08/25/23, revealed Resident #7 had an order, which started on 02/10/22, to admit to hospice.<BR/>Record review of Resident #7's hospice binder, accessed on 08/23/23 at 4:56 PM, revealed no updated hospice documentation since March of 2023. <BR/>During an interview on 08/24/23 at 9:16 AM, the Assistant Clinical Director for the hospice company stated the last nurse visit for Resident #7 was on 08/22/23. The Assistant Clinical Director stated the nurses were required to see Resident #7 two times per week. The Assistant Clinical Director stated typically the nurses would have seen the resident, then would have printed the notes, and brought them during the next scheduled visit. The Assistant Clinical Director stated that each facility was different, but she believed the facility kept a hospice binder and either the hospice updated it, or the nurses gave it to the medical records. The Assistant Clinical Director stated the plan of care and hospice certification should have been updated when the IDT meetings were conducted, every 2 weeks. The Assistant Clinical Director stated the process for collaborating with the facility was completed verbally with the nurses, ADON, and DON. <BR/>During an interview on 08/24/23 at 9:28 AM, the DON stated the hospice nurse did not normally bring the visit notes to leave with the facility. The DON stated the hospice nurse met with the DON and Administrator prior to leaving the facility but did not leave any notes that she was aware. The DON stated she was going to call the hospice nurse to verify. <BR/>During an interview on 08/24/23 at 9:37 AM, the DON stated there were no notes in the facility after March 2023 from the hospice company.<BR/>During an interview on 08/25/23 at 10:05 AM, LVN C stated the hospice nurse did not leave visit notes. LVN C stated the hospice nurse communicated verbally. LVN C stated the hospice binder at the nurses' station had information to use as a resource for Resident #7. LVN C stated it was important to ensure the hospice binder had updated information to ensure the hospice and facility were on the same page. LVN C stated it was important for the care of the residents that the hospice was not left out. <BR/>During an interview on 08/25/23 at 12:29 PM, the DON stated the hospice company brought Resident #7's updated paperwork. The DON stated there was no process in place for monitoring the hospice binders and documentation to ensure the most up to date information was in the facility. The DON stated the hospice nurse had been communicating with the facility staff verbally. The DON stated it was important to ensure recent hospice documentation was in the facility for continuity of care. <BR/>During an attempted telephone interview on 08/25/23 at 4:33 PM to gather more information, the Administrator did not answer. No phone call was returned upon exit of the facility.<BR/>Record review of the Nursing Facility Services Agreement, dated 10/28/21, revealed e) provision of information . At a minimum, Hospice shall provide the following information to Facility for each Hospice Patient residing at the Facility: i) plan of care, medication, and orders. The most recent plan of care, medication information and physician orders specific to each hospice patient residing at the facility, iii) certifications. Physician certifications and recertification of terminal illness.<BR/>Record review of the Hospice Program policy, revised July 2017, revealed d. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident .

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 2 of 4 staff (CNA D and CNA F) reviewed for infection control.<BR/>The facility failed to ensure CNA D and CNA F changed their gloves and performed hand hygiene while providing incontinent care to Resident #8.<BR/>These failures could place residents and staff at risk for cross-contamination and the spread of infection.<BR/>Findings included:<BR/>During an observation on 06/13/2023 starting at 1:39 PM, CNA D and CNA F provided incontinent care to Resident #8. CNA D and CNA F put on gloves. CNA D removed the dirty sheets and placed them on the floor. CNA D and CNA F unfastened Resident #8's brief. CNA D tucked the dirty brief under Resident #8's side and both CNAs turned him on his side. Resident #8 had a yellow-brownish ring on his sheets and his bed pad that extended up to his shoulders and down to his knees. CNA F wiped Resident #8's back peri area and removed the dirty brief. CNA F threw the dirty brief in the trashcan. CNA D and CNA F did not remove their dirty gloves and they did not perform hand hygiene. CNA D and CNA F applied the clean brief with dirty gloves. CNA F proceeded to apply zinc barrier cream to Resident #8's buttocks due to slight redness to his buttocks. The CNAs fastened the brief, and CNA F went to Resident #8's drawers to look for clean clothes. CNA D removed Resident #8's hospital gown and then helped CNA F dress Resident #8. CNA D and CNA F did not remove their gloves and they did not perform hand hygiene prior to applying Resident #8's clean clothes. CNA F went out of the room to get the Hoyer lift still wearing the same gloves. CNA D and CNA F transferred Resident #8 to his wheelchair. After transferring him to his wheelchair CNA D removed her gloves and did not perform hand hygiene, and CNA F wheeled Resident #8 to the lobby area still wearing the same gloves. CNA F removed her gloves after leaving Resident #8 in the lobby area. CNA F did not perform hand hygiene. <BR/>During an interview on 06/13/2023 at 2:09 PM, CNA D said she had not been to check on Resident #8 today because she was working in a team with CNA F. CNA D said she would not have done anything differently when providing incontinent care. CNA D said hand hygiene should be performed before starting and when you leave the room. CNA D said she should have performed hand hygiene when she finished providing incontinent care to Resident #8. CNA D said hand hygiene should be performed after glove removal. CNA D said she changed her gloves when she should have changed them when she left the room. CNA D said she did not remember when her last check off or training on incontinent care had been. CNA D said it was important to provide prompt incontinent care to prevent skin breakdown. CNA D said it was important to perform glove changes and hand hygiene while providing incontinent care because of cross contamination and germs. <BR/>During an interview on 06/13/2023 at 2:20 PM, CNA F said the last time she checked on Resident #8 was at 11:30 AM that morning. CNA F said she was supposed to check on the residents every 2 hours. CNA F said she was not able to do this due to being short. CNA F said she should have changed gloves and washed her hands after removing the dirty brief. CNA F said she should not have placed the dirty linens on the floor, but she did not have a trash bag to put them in. CNA F said she did not wash her hands because there was no soap or paper towels in Resident #8's room. CNA F said this had been happening a lot and she had notified the Housekeeping Supervisor and the Maintenance Supervisor. CNA F said her last training on providing incontinent care was 3 months ago. CNA F said it was important to provide prompt incontinent care to prevent skin breakdown, redness, and rashes. CNA F said it was important to perform hand hygiene and change gloves while providing incontinent care for cross contamination. <BR/>During an interview on 06/14/2023 at 6:17 AM, LVN G said there was no soap or paper towels that this happened randomly. LVN G said sometimes they had them and sometimes they did not. LVN G said had notified the DON, ADON, and the maintenance man. LVN G said he was told it was on back order. <BR/>During an interview on 06/14/2023 at 5:48 PM, the Housekeeping Supervisor said she did not know how the facility had come up short on paper towels and soap that this had been going on for about a week. The Housekeeping Supervisor said they were short because she forgot to order earlier in the month and she usually had a stash, but she guessed people used it up. The Housekeeping Supervisor said it was important to have soap and paper towels available to the staff to keep clean and for the staff to be able to wash their hands. <BR/>During an interview on 06/16/2023 at 6:15 PM, the ADON said nurse management was responsible for making sure the CNAs provided proper incontinent care. The ADON said nurse management monitored the CNAs to ensure they were providing proper incontinent care by performing the yearly competencies. The ADON said the CNAs should be checking on the residents every 2 hours. The ADON said while providing incontinent care gloves should be changed after removing the dirty brief and after providing perineal care. The ADON said gloves should be changed and hand hygiene performed anytime you moved from dirty to clean. The ADON said the CNAs should not leave the room with the dirty gloves. The ADON said it was important to provide prompt incontinent are to prevent skin breakdown. The ADON said not performing hand hygiene and not changing gloves adequately while providing incontinent care placed the residents at risk for infection. <BR/>During an interview on 6/16/23 at 7:08 PM, the DON said while providing incontinent care the CNAs should perform hand hygiene when they enter the room and prior to applying gloves. The DON said the CNAs should change gloves when moving from dirty to clean. The DON said while providing incontinent care the CNAs should change gloves and perform hand hygiene several times. The DON said proficiencies for the CNAs on incontinent care were performed yearly by her or the ADON. The DON said she randomly went into rooms to observe the CNAs provide incontinent care. The DON said there was a time when she observed CNA D and CNA F provide incontinent care and she had to tell them to change their gloves. The DON said she could not remember when this occurred. The DON said it was important to provide prompt and proper incontinent care so the residents would not get a UTI, skin breakdown, and to make sure their skin was clean. <BR/>During an interview on 06/16/2023 at 8:26 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said clinical management should make sure the CNAs are providing proper incontinent care. The Administrator said it was important to provide proper incontinent care and to perform hand hygiene to reduce infection. <BR/>Record review of the facility's policy titled, Perineal Care, last revised, 01/20/2023, indicated Steps in the Procedure .3. Perform hand hygiene and don gloves. 4. Arrange the supplies so they can be easily reached . 6. Remove clothing enough to perform peri-care. Avoid unnecessary exposure of the resident's body. 7. Remove the soiled clothing, linens, and brief. Place items in the proper receptacle . B. For a Male Resident: (1) Use a cleansing wipe. (2) Clean perineal area starting with urethra and working outward . (5) Clean urethral area with a cleansing wipe using a circular motion. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. Use a new cleansing wipe, as needed. (6) Continue to clean the perineal area including the penis, scrotum, inner thighs. (7) Thoroughly clean perineal area in same order, using a new cleansing wipe as needed . (12) Clean the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks, change the cleansing wipe, as needed. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. 10. Dry area thoroughly. 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. 13. Perform Hand Hygiene. 14. Reposition the bed covers. Make the resident comfortable. 15. Place the call light within easy reach of the resident. 16. Perform Hand Hygiene .<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene , last revised 01/20/2023, indicated, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Hand hygiene must be performed prior to donning and after doffing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their own established smoking policy for 1 of 12 residents (Resident #13) reviewed for smoking. <BR/>The facility failed to ensure Resident #13 followed the facility's policy on smoking. <BR/>The facility failed to follow their safety and supervision policy and allowed cigarette smoking outside of the only smoking area.<BR/>The facility failed to ensure smoked cigarettes were extinguished in a fire-retardant receptacle. <BR/>This failure could place residents at risk of an unsafe smoking environment and injury.<BR/>This deficient practice could place residents at risk for injury and burns due to the presence of discarded and used cigarette butts. <BR/>Findings included:<BR/>Record review of the face sheet, dated 08/22/23, revealed Resident #13 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia (affects a person's ability to think, feel and behave clearly), COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), and bipolar (a disorder associated with episodes of mood swings).<BR/>Record review of the MDS assessment, dated 07/28/23, revealed Resident #13 had clear speech and was understood by staff. The MDS revealed Resident #13 was able to understand others. The MDS revealed Resident #23 had a BIMS of 11, which indicated moderately impaired. <BR/>Record review of Resident #13's care plan, edited 08/10/23, indicated he was a smoker and was explained/shown where designated smoking areas were and smoking times. The care plan indicated Resident #13 was monitored when smoking to assure residents safety.<BR/>Record review of Resident #13's smoking assessment, dated 09/08/22 indicated he was not careless with smoking materials and was able to understand the facilities safe smoking policy. The smoking assessment did not indicate any behavior issues.<BR/>Record review of the facility's smoke break times: 6:30 a.m., 9:00 a.m., 1:00 p.m., 3:30 p.m., 7:00 p.m., and 9:00 p.m.<BR/>Record review of the facility's smoker list indicated the facility had 12 residents who smoke. <BR/>During observations on 8/21/2023 at 9:30 a.m. - 8/24/2023 at 4:00 p.m., the following was observed:<BR/>*A plastic flowerpot next to the front door had numerous cigarette butts on top of the potting soil. These cigarette butts remained in the plastic flower pot the entire observation period.<BR/>*Numerous cigarette butts were lying on the ground next to a chair sitting outside of the laundry room. These cigarette butts remained lying on the ground around the chair outside of the laundry room the entire observation period.<BR/>During an observation and interview made on 08/24/23 at 2:01 PM, Resident #13 was sitting in his wheelchair in his room with 2 cigarette butts on the armrest of his wheelchair. Resident #13 stated he brought his butts inside every time he smoked and threw them in the trash can either in his room or in the kitchen trash can. Resident #13 stated the cigarette butts could not start a fire because the cigarettes were not lit. <BR/>During an interview on 8/22/23 at 12:05 PM, CNA K stated she was responsible for taking Resident #13 out to smoke during the last smoke break. CNA K stated she was responsible for making sure residents did not bring any cigarette butts back inside of the facility and she did not notice Resident #13 had 2 cigarette butts on his arm rest or she would have thrown them away. CNA K stated Resident #13 had a history of bringing cigarette butts back inside the building and she had thrown them away previously. CNA K stated the cigarette butts in the front of the building in the flowerpots were from her taking the residents out to smoke a while back. CNA K stated it was raining outside and the residents did not want to go to the designated smoking area to smoke and she let them go in the front of the building. CNA K stated she did not know residents had to smoke in designated areas, and she was instructed by management not to do anymore. CNA K stated the importance of making sure Resident #13 did not bring cigarette butts back into the building was make sure he could not give them to another resident or cause a fire in the facility. <BR/>During an interview on 8/24/2023 at 3:35 p.m., the maintenance supervisor said the facility had only one smoking area. The maintenance supervisor said the only smoking area was in the courtyard underneath the pavilion. The maintenance supervisor said everyone was responsible for ensuring the cigarette butts were discarded properly. The maintenance supervisor said he makes rounds and picks up the cigarette butts every two weeks. The maintenance supervisor said the discard cigarette butts could initiate a fire due to the current weather conditions.<BR/>During an interview on 8/24/23 at 10:23 AM, the DON stated staff was responsible for observing the residents during smoking times and responsible for collecting all of the cigarettes butts when the resident returned to the building. The DON stated she expected staff to have thrown away the cigarette butts outside in the designed trash can. The DON stated she was not aware of Resident #13 bringing cigarette butts into his room or throwing them away in the kitchen trash can. The DON stated the importance of making sure cigarette butts were disposed of in the designated area was to make sure other residents did not try to eat the cigarette butts or start a fire in the facility.<BR/>An interview was attempted on 08/25/23 at 4:33 PM and 4:36 PM with the Administrator and was not successful. <BR/>Record review of the facility's policy on, Smoking, (no date) indicated Residents and visitors shall not be permitted to smoke in any area that is not designed as a smoking area.<BR/>Record review of a Safety and Supervision of Residents policy and procedure dated July 2017 indicated the facility strived to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety 1. The facility-oriented approach to safety addresses risks for groups of residents .4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: .d. Smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7)<BR/>The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him.<BR/>The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. <BR/>The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed.<BR/>The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy.<BR/>The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you.<BR/>The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. <BR/>The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry.<BR/>The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. <BR/>This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.<BR/>This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.<BR/>Findings included: <BR/>1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. <BR/>Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. <BR/>Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath.<BR/>During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. <BR/>Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. <BR/>Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. <BR/>2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. <BR/>Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. <BR/>Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE].<BR/>During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. <BR/>During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. <BR/>3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations).<BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. <BR/>Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. <BR/>During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview.<BR/>4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter).<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. <BR/>During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident.<BR/>5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. <BR/>During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again.<BR/>6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility.<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview.<BR/>7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. <BR/>During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. <BR/>During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. <BR/>During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. <BR/>During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests.<BR/>During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them.<BR/>During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. <BR/>Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. <BR/>During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. <BR/>During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. <BR/>During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. <BR/>During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said, I am not saying she never missed a shower because there were problems. The DON said she tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F.<BR/>During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. <BR/>Record review of LVN A's personnel file did not indicate any previous disciplinary actions. LVN A's personnel file did not indicate a termination date. <BR/>During an interview on [DATE] at 5:15 PM (LVN A returned phone call after facility exit), LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop passing out medications to give them their cigarettes. LVN A said after she told them this Resident #4 got really pissed of[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 6 Residents (Resident #1) reviewed for care plans.<BR/>The facility did not have a quarterly care plan meetings to discuss Resident #1's care.<BR/>This failure could cause residents not to be able to participate in the planning of their care, not receiving the care they want or need, and not being informed of all services offered by the facility. <BR/>The findings were: <BR/>Record review the face sheet dated 8/10/23 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses including traumatic brain injury (brain dysfunction caused by an outside force usually a violent blow to the head), depression, need for assistance with personal care, lack of coordination, muscle weakness, and hemiplegia and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body following a stroke).<BR/>Record review of the MDS dated [DATE] indicated Resident #1 was understood by other and understood others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, and toileting. The MDS indicated Resident #1 required limited assistance with personal hygiene. <BR/>Record review of the care plan last revised 8/09/23 indicated Resident #1 had depression. The care plan indicated Resident #1 had potential for impaired psychosocial well-being with a goal of expressing/exhibiting satisfaction. Interventions were to allow the resident to participate in daily care and decision/goal making and listen carefully and be non-judgmental.<BR/>Record review of the care conference report dated 8/09/23 indicated Resident #1 had a care plan conference on 7/06/22 and 8/09/23. <BR/>During an interview on 8/09/23 at 9:15 a.m. the Ombudsman said she had been trying to get a care plan meeting scheduled with the facility for Resident #1 for several months. The Ombudsman said the facility had not scheduled a care plan meeting or responded to her request. <BR/>During an interview on 8/09/23 at 12:04 p.m. Resident #1 said he had been trying to get a care plan meeting for 6-8 months. Resident #1 said he had asked several facility staff members about scheduling a care plan meeting. Resident #1 said staff will not schedule him a care plan meeting.<BR/>During an interview on 8/09/23 at 1:40 p.m. the Corporate Nurse said the last care plan meeting/conference with Resident #1 was on 7/6/22. The Corporate Nurse said care plan meeting should be done quarterly. <BR/>During an interview on 8/10/23 at 2:00 p.m. the DON said she was responsible for ensuring care plan were completed. The DON said care plans were completed/revised on admission, quarterly, and with a change of condition. The DON said residents were not routinely invited to care plan meetings. The DON said a care plan meeting/conference would be performed on a resident's request. The DON said she was unaware of Resident #1 or the Ombudsman requesting a care plan meeting. The DON said it was important to involve residents in care plan meetings because it was their care and an inter-departmental meeting that would inform residents of different services the facility had to offer they might not be aware of. <BR/>During an interview on 8/10/23 at 2:18 p.m. the Administrator said care plans were performed on admission, quarterly, and with a change in condition. The Administrator said residents and their families/responsible parties were invited to care plan meeting quarterly. The Administrator said Resident #1's care plan meetings had fell through the crack. The Administrator said she was aware the Ombudsman had requested a care plan meeting, but the resident had refused the meeting at the time the facility wanted to conduct the meeting. The Administrator said Resident #1 wanted things including care plan meetings done on his time. The Administrator said it was important for residents to attend care plan meetings to be able to voice their opinions and to be able to take part in their own care. <BR/>Record review of the facility's undated Care Planning and Care Plan Meeting Workflow policy indicated, .The Care Plan Meeting (Initial and Quarterly): Scheduling the Care Plan Conference: The date and time are confirmed with the resident and responsible representative. The care conference is scheduled in the Resident Calendar. Invitations to the Care Plan Meeting: .This care plan invitation can be delivered to the resident and/or mailed to the resident's responsible representative .Documenting the Care Plan Meeting: . Notes-Summarize the IDT progress discussed at the care conference and the plan for the next 90 days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 6 Residents (Resident #1) reviewed for care plans.<BR/>The facility did not have a quarterly care plan meetings to discuss Resident #1's care.<BR/>This failure could cause residents not to be able to participate in the planning of their care, not receiving the care they want or need, and not being informed of all services offered by the facility. <BR/>The findings were: <BR/>Record review the face sheet dated 8/10/23 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses including traumatic brain injury (brain dysfunction caused by an outside force usually a violent blow to the head), depression, need for assistance with personal care, lack of coordination, muscle weakness, and hemiplegia and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body following a stroke).<BR/>Record review of the MDS dated [DATE] indicated Resident #1 was understood by other and understood others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, and toileting. The MDS indicated Resident #1 required limited assistance with personal hygiene. <BR/>Record review of the care plan last revised 8/09/23 indicated Resident #1 had depression. The care plan indicated Resident #1 had potential for impaired psychosocial well-being with a goal of expressing/exhibiting satisfaction. Interventions were to allow the resident to participate in daily care and decision/goal making and listen carefully and be non-judgmental.<BR/>Record review of the care conference report dated 8/09/23 indicated Resident #1 had a care plan conference on 7/06/22 and 8/09/23. <BR/>During an interview on 8/09/23 at 9:15 a.m. the Ombudsman said she had been trying to get a care plan meeting scheduled with the facility for Resident #1 for several months. The Ombudsman said the facility had not scheduled a care plan meeting or responded to her request. <BR/>During an interview on 8/09/23 at 12:04 p.m. Resident #1 said he had been trying to get a care plan meeting for 6-8 months. Resident #1 said he had asked several facility staff members about scheduling a care plan meeting. Resident #1 said staff will not schedule him a care plan meeting.<BR/>During an interview on 8/09/23 at 1:40 p.m. the Corporate Nurse said the last care plan meeting/conference with Resident #1 was on 7/6/22. The Corporate Nurse said care plan meeting should be done quarterly. <BR/>During an interview on 8/10/23 at 2:00 p.m. the DON said she was responsible for ensuring care plan were completed. The DON said care plans were completed/revised on admission, quarterly, and with a change of condition. The DON said residents were not routinely invited to care plan meetings. The DON said a care plan meeting/conference would be performed on a resident's request. The DON said she was unaware of Resident #1 or the Ombudsman requesting a care plan meeting. The DON said it was important to involve residents in care plan meetings because it was their care and an inter-departmental meeting that would inform residents of different services the facility had to offer they might not be aware of. <BR/>During an interview on 8/10/23 at 2:18 p.m. the Administrator said care plans were performed on admission, quarterly, and with a change in condition. The Administrator said residents and their families/responsible parties were invited to care plan meeting quarterly. The Administrator said Resident #1's care plan meetings had fell through the crack. The Administrator said she was aware the Ombudsman had requested a care plan meeting, but the resident had refused the meeting at the time the facility wanted to conduct the meeting. The Administrator said Resident #1 wanted things including care plan meetings done on his time. The Administrator said it was important for residents to attend care plan meetings to be able to voice their opinions and to be able to take part in their own care. <BR/>Record review of the facility's undated Care Planning and Care Plan Meeting Workflow policy indicated, .The Care Plan Meeting (Initial and Quarterly): Scheduling the Care Plan Conference: The date and time are confirmed with the resident and responsible representative. The care conference is scheduled in the Resident Calendar. Invitations to the Care Plan Meeting: .This care plan invitation can be delivered to the resident and/or mailed to the resident's responsible representative .Documenting the Care Plan Meeting: . Notes-Summarize the IDT progress discussed at the care conference and the plan for the next 90 days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 14 residents reviewed for care plans. (Resident #10 and Resident #5). <BR/>The facility failed to ensure Resident #10 abdominal binder was applied, as ordered by the physician. <BR/>The facility failed to implement Resident #5's smoking care plan intervention. <BR/>These failures could place the residents at risk for not receiving the care and/or services to meet their individual needs.<BR/>Findings included:<BR/>1. Record review of the physician order report dated 6/7/22-7/7/22 indicated Resident #10 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including epilepsy (uncontrolled electrical disturbance in the brain), cerebral palsy (congenital disorder of movement muscle tone, or posture), hypokalemia (deficiency of potassium in the bloodstream) and lack of coordination. <BR/>Further review of the physician order report indicated Resident #10 was had an order to check abdominal wrap for placement over G tube site every shift with a start date 5/24/22 and discontinued date 6/30/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #10 usually understood others, usually made himself understood. The MDS indicated Resident #10 was severely cognitively impaired (BIMS score of 1). The MDS indicated he required total dependence with bed mobility, transfers, dressing eating toileting, personal hygiene, and bathing. The MDS indicated Resident #10 had a feeding tube. <BR/>Record review of the care plan dated 12/11/20 indicated Resident #10 was at risk for malnutrition related to NPO (nothing by mouth) and tube feedings. The care plan intervention did not address the abdominal binder. <BR/>Record review of Resident #10's MAR dated 6/1/22-6/29/22 indicated to check abdominal wrap for placement over G tube every shift. The MAR indicated LVN G checked off that she applied the abdominal binder on 6/28/22 and LVN F checked off that she applied the abdominal binder on 6/29/22. <BR/>During an observation on 6/28/22 at 10:45 a.m., Resident #10 was returned to his room by CNA L. CNA L allowed an observation of Resident #10 G tube site and there was no abdominal binder present. <BR/>During an observation on 6/28/22 at 2:14 p.m., Resident #10 was returned to his room by CNA P. CNA P allowed an observation of Resident #10 G tube site and there was no abdominal binder present. <BR/>During an observation and interview on 6/29/22 at 10:15 a.m., Resident #10 was returned to his room by the DON. The DON observed with the surveyor Resident #10 G tube site with no abdominal binder present. The DON said Resident #10 was supposed to have an abdominal binder on to prevent him from pulling out his G tube. The DON said not having the abdominal binder on could result in an infection. <BR/>During an interview and observation on 6/29/22 at 10:20 a.m., LVN F observed with the surveyor Resident #10 G tube site with no abdominal binder present. LVN F said the order should have had being discontinued but she forgot to call the physician. LVN F said she did not know why she checked off that she completed the task of applying the abdominal binder to Resident #10. LVN F said before checking off that she applied the abdominal binder she should have applied it first. LVN F said the abdominal binder was ordered to keep Resident #10 pulling his G tube out. LVN F said not having the abdominal binder on could result in an infection or closer of the stomach. <BR/>2. Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and atherosclerotic heart disease (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of the MDS dated [DATE] indicated Resident #5 understood others, made herself understood. The MDS indicated Resident #5 was cognitively intact (BIMS score of 13). The MDS indicated she required limited assistance bed mobility, transfers, dressing, toileting, and personal hygiene: supervision with eating and extensive assistance with bathing. <BR/>Record review of the care plan dated 11/11/21 indicated Resident #5 was a smoker. The care plan interventions were to assess quarterly for safe smoking. <BR/>Record review indicated the most recent smoking risk assessment was completed on 11/19/21. <BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said the charges nurses were responsible for completing smoking assessments. LVN G said the care plans were guides to know how to care for each resident's individual needs. LVN G stated she does not look at the care plans daily but does look at them if she has questions about someone's care. LVN G said she could not remember if she applied Resident #10 abdominal binder on 6/28/22. LVN G said usually the binder was placed after ADL care. LVN G said not having the abdominal binder on could result in Resident #10 pulling the G tube out. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said she expected all physician orders to be followed. The DON said the charges nurses were responsible for ensuring physician orders were followed. She said she expected the staff to read the care plans for interventions on how to care for each residents' individual needs. The DON said care plans were important for the residents to have so the staff would be aware of individual needs of residents. The DON said she was unaware that Resident #5 has not had a smoking assessment since 11/19/21. The DON said she was under the assumption that smoking assessments were completed by the charge nurse annually until 6/29/22. The DON said smoking assessments were to be done quarterly. The DON said not following the physician orders or care plan could result in residents not receiving proper care. The DON indicated she monitored incomplete assessments by running reports but due to her recent illness she was unable to complete this task. <BR/>Record review of the facility's smoking policy titled Smoking-Residents revised 8/2019 indicated, the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, determine if they need a smoking apron resident care plans will reflect that the resident is a smoker and if a protective smoking apron is indicated for the resident . <BR/>During an interview on 6/30/22 at 2:31 p.m., a care plan policy was requested from the DON but not provided prior to exit.

**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 unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 13 residents reviewed for ADLs (Residents #9, Resident #11)<BR/>The facility did not provide scheduled showers for Resident #9 and Resident #11.<BR/>These failures could place residents at risk of not receiving services/care and decreased quality of life.<BR/>1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two-person assist for bathing. <BR/>Record review of the care plan last revised 05/24/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. <BR/>During an interview and observation on 06/13/2023 at 02:06 PM, Resident #9 said she had not had a bath/shower since last Tuesday, June 6, 2023. Resident #9 said she was supposed to receive a shower three times weekly on Tuesday, Thursday, and Saturday on the 2 - 10 shifts. Resident #9 said she had not been offered a shower since last Tuesday, June 6th, 2023. Resident #9 said she would really like to get her hair washed and a good shower because she can smell herself. Resident #9 said she had asked the CNA on Thursday for the shower, but the CNA told Resident #9 maybe around 4PM that she could help her bath, but they never come back and offered the shower. Resident #9 said she asked over the weekend, for a shower but the CNA told her she was the only CNA and no time to perform the requested shower. Resident #9 said she would have liked to go play bingo, but she was always waiting on her shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room. The odor was stronger with Resident #9's body movements. <BR/>During an interview and observation on 06/14/2023 at 12:00 PM, Resident #9 said she had not received a shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room.<BR/>During an observation on 06/15/2023 at 04:00 PM, Resident #9 was lying in bed her hair was oily and disheveled, and a strong musty odor lingered in the room.<BR/>Record Review of the Resident Showers Log indicated Resident #9 received showers on the following dates: <BR/>06/06/2023 - Tuesday, 06/08/2023 - Thursday, 06/10/2023 - Saturday, 06/13/2023 - Tuesday<BR/>During interview and observation on 06/16/2023 at 05:20 PM, Resident #9 said she received a shower yesterday evening on 06/15/2023. Resident #9 said she felt better after the shower. Resident's #9 was observed with clean and combed hair. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #9 had asked for a shower on Wednesday, 06/14/2023, because she had not had one. CNA C said she told Resident #9 she would give her a shower tomorrow (Thursday 06/15/2023). CNA C said Resident #9 refused a lot of showers. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. The MDS indicated Resident #11 did not reject care. The MDS indicated Resident #11 did not exhibit any behavioral symptoms.<BR/>Record review of the care plan with a start date of 12/08/2021 indicated, Resident #11 required physical assistance of one person for bathing. The care plan indicated Resident #11 was to receive showers on Monday, Wednesday, and Fridays. <BR/>During an interview on 06/13/2023 at 01:49 PM, Resident #11 said he had not received a shower/bath for as long as he could remember probably around the time COVID hit. Resident #11 said he was not able to stand on his own. Resident #11 said the CNAs had not offered a shower. Resident #11 said he used the sink to bathe himself the best he could. Resident #11 said, you can only keep some of the odor away using a sink as a shower. Resident #11 said he had not requested a bath because he should not have had to ask. Resident #11 said he needed his toenails clipped but staff was never available to offer the services that are care planned. Resident #11 said his toenails got caught on the sheets and on his socks. Resident #11 said his feet hurt when he wore his shoes because his toenails are too long. Resident #11 said he had purchased clippers so he could cut his own hair. Resident #11 said he had not refused to have a shower, or his toenails clipped because the staff had never tried. Residents #11's toenails were thick, yellow, and approximately &frac12; inch long. <BR/>During an interview on 06/14/2023 at 11:42 AM, Resident #11 said he had not received a shower. <BR/>During an interview on 06/15/2023 at 03:50 PM, Resident #11 said he had not received a shower.<BR/>Record Review of the Resident Showers Log indicated Resident #11 received showers on the following dates: <BR/>06/02/2023, 06/05/2023, 06/07/2023, 06/09/2023, 06/12/2023, 06/14/2023<BR/>During an interview and observation on 06/16/2023 at 05:18 PM, Resident #11 said he had not received a shower and no staff had offered a shower this week. Resident #11 said my toenails had not been trimmed. Resident #11 said he had never told staff not to clip his toenails. Residents #11's toenails on both feet were thick, yellow, and approximately &frac12; inch long. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #11 does everything by his own self. CNA C said she had never offered to clip Resident # 11 nails. CNA C said the nurses were responsible for clipping the resident's toenails. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said it was important to clip the resident's nails to prevent hangnails. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>During an interview on 06/16/2023 at 06:33 PM, the ADON said the CNAs are responsible to give the residents showers/baths. The ADON said the nurses are responsible to review the shower sheets daily. The ADON said nobody had reported to her any refusals this week. The ADON said that Resident # 9 received a shower on Wednesday. The ADON said that Resident #11 frequently refuses showers. The ADON said that CNAs could clip Resident #11's toenails.<BR/>During an interview on 06/16/2023 at 06:22 PM, the DON said the CNAs are responsible for baths/showers. The DON said the nurse could give baths/showers if needed also. The DON said the CNAs and nurses should fill out the shower sheets daily. The DON said Resident #9 did not like to get showers. The DON said Resident #9 is random. The DON said Resident #9 had not refused baths/shower this week. The DON said Resident #11 wouldn't let anybody give him a shower that he refused MWF on the 2 -10 shift. The DON said the residents should be able to get a bath/shower if they asked for one. The DON said it was important for the residents to get their baths/showers to help them feel good about themselves and keep the skin clear. The DON said if the residents had not received baths/showers they would feel dirty and be at a risk for wounds and infection. The DON said if the resident is a diabetic the facility podiatrist or the nurse could clip toenails. The DON said if the resident did not have the diabetic diagnosis the CNA could trim the resident's toenails. The DON said it was important for toenails to get trimmed, so the residents didn't experience ingrown toenail/infection control. The DON said she had never offered to trim Resident #11's toenails. <BR/>During an interview 06/16/2023 at 08:18 PM, the administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical management is responsible for making sure the baths/showers were provided. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good. <BR/>Record review of facility policy and procedure titled, Activities of Daily Living (ADLs), Supporting revised March 2018, indicated . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); .

**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 3 of 3 halls (East, South, and [NAME] halls), 1 of 1 dining rooms, 1 of 1 lobby area, and 2 of 13 residents (Resident #9 and Resident #11) reviewed for a homelike environment.<BR/>The facility failed to ensure the East, South and [NAME] halls, lobby, and dining room were free of offensive odors. <BR/>The facility failed to ensure Resident #9 and Resident #11's bed linens were changed. <BR/>This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two- person assist for bathing. <BR/>Record review of the care plan with a target date of 07/16/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. <BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. <BR/>Record review of the care plan with a target date of 07/06/2023 indicated, Resident #11 required two-person assistance or total assistance for dressing and grooming needs, and total assistance for toileting. <BR/>During an observation upon entrance of the facility on 06/13/2023 at 09:03 AM a strong odor of urine was detected in the lobby area and East Hall. <BR/>During an observation on 06/13/2023 at 11:45 AM, a strong odor of urine was detected in the South Hall and in the dining room.<BR/>During an observation and interview starting on 06/13/2023 1:05 PM, the [NAME] and South Hall had a strong, pungent urine odor. While walking down the South Hall the Administrator said she thought it was because one of the residents had incontinent episode in the hallway or maybe it was somebody that had walked by. <BR/>During an observation and interview on 06/13/2023 at 1:49 PM, Resident #11 said the sheets on his bed had not been changed in a long time. The sheets had dirty yellow and orange stains on them, and the pillow was light brownish tinged. Resident #11 said he should not have to ask the CNAs to change his sheets they should be doing this. <BR/>During an observation and interview on 06/13/2023 at 2:06 PM, Resident #9 had light brownish tinged sheets on her bed, the blue pad on the bed had smears of feces on them. There was a musty, pungent, feces odor. Resident #9 said the CNAs told her they could not change her sheets because they did not have enough staff to do it. Resident #9 said the CNAs told her they want her to do those things herself. Resident #9 said she was not able to change her own sheets and she cannot wipe herself good enough after she had a bowel movement. <BR/>During an observation and interview starting on 06/14/2023 5:07 AM, the [NAME] Hall and South Hall had a strong urine odor. There were trash barrels in the [NAME] and South Hall with no lids and flies around them. CNA G said she had left them uncovered because she was changing people.<BR/>During an observation and interview starting on 06/14/2023 at 9:14 AM, a strong odor of urine was detected in the South Hall. Resident #10 said she kept the door to her room closed because it smells like pee out there. Resident #10 said the urine odor made her feel sick and disgusting. <BR/>During an observation on 06/15/2023 at 3:11 PM, there was an odor of urine on the [NAME] and South Halls. <BR/>During an observation and interview on 06/16/2023 at 11:10 AM, there was an odor of urine on the [NAME] and South Halls. <BR/>During an observation and interview on 06/16/2023 at 5:18 PM, Resident #11 said his sheets had not been changed. Resident #11's sheets had dirty yellow and orange stains on them, and the pillow had a light browning tinge to it. <BR/>During an observation and interview on 06/16/2023 at 5:20 PM, Resident #9 said her blue pad had been changed but not the sheets on her bed. Resident #9's sheets were light brownish tinged, and there was a musty odor. <BR/>During an interview on 06/16/2023 at 5:35 PM, CNA C said she changed Resident #9's sheets last night, but she had not changed Resident #11's. CNA C said Resident #11 does his own thing when he wants to. CNA C said it was important to change the residents' sheets because it was their home, and it was their right. <BR/>During an interview on 06/16/2023 at 6:24 PM, the ADON said she had noticed a urine odor on East Hall. The ADON said the residents had not complained to her about a urine odor. The ADON said all the staff were responsible for making sure the facility did not have offensive odors. The ADON said the offensive odors could make the residents not want to leave their room, and it could affect their mental health. <BR/>During an interview on 06/16/2023 at 8:01 PM, the DON said she had noticed the offensive odors in the facility, and she had reported it to the Administrator and the housekeepers. The DON did not provide specific dates. The DON said she expected the CNAs to change the residents' sheets and she was not aware that any of the residents' sheets had not been changed. The DON said all the staff should be making sure the facility did not have offensive odors. The DON said it was important to keep the facility free of offensive odors because I don't like to smell bad odors. The DON said it was important for the residents to have clean sheets because she wanted to provide a clean and safe environment for the residents.<BR/>During an interview on 06/16/2023 at 8:27 PM, the Administrator said she had noticed the urine odor in the facility. The Administrator said urine odor was not a normal thing at the facility, and she did not know what was happening this week that there was a urine odor in the facility. The Administrator said all the staff were responsible for making sure there were no offensive odors in the facility. The Administrator said she expected for the staff to provide a homelike environment for the residents. <BR/>Record review of the facility's policy titled, Homelike Environment, last revised February of 2021, indicated, Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .clean bed and bath linens that are in good condition .The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: . institutional odors .

**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 neglect and abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7).<BR/>The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him.<BR/>The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. <BR/>The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed.<BR/>The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy.<BR/>The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you.<BR/>The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. <BR/>The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry.<BR/>The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. <BR/>The facility abuse coordinator failed to ensure staff were able to report allegations of abuse without fear of reprisal. <BR/>This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.<BR/>This failure could place residents at risk of unreported abuse, neglect, exploitation and a decreased quality of life.<BR/>Findings included: <BR/>1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. <BR/>Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. <BR/>Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath.<BR/>During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. <BR/>Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. <BR/>Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. <BR/>2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. <BR/>Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. <BR/>Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE].<BR/>During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. <BR/>During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. <BR/>3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations).<BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. <BR/>Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. <BR/>During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview.<BR/>4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter).<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. <BR/>During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident.<BR/>5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. <BR/>During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again.<BR/>6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility.<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview.<BR/>7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. <BR/>During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. <BR/>During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. <BR/>During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. <BR/>During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests.<BR/>During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them.<BR/>During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. <BR/>Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. <BR/>During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. <BR/>During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. <BR/>During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. <BR/>During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. The DON said it was important to follow the abuse policy because it was the residents' right not to be abused. The DON said the abuse policy needed to be followed so that people understood they could not abuse the residents. The DON said the abuse policy protected the residents from abuse and gave the facility a guideline to follow so abuse could be identified and reported. The DON said if the residents experienced verbal abuse it could result in them being scared, withdrawn and cause failure to thrive.<BR/>During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said in-services were provided to the staff. The Administrator said she expected all of the staff to follow the abuse policy. The Administrator said it was important to follow the abuse policy to ensure the safety of the residents. The Administrator said not follow[TRUNCATED]

**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 unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 13 residents reviewed for ADLs (Residents #9, Resident #11)<BR/>The facility did not provide scheduled showers for Resident #9 and Resident #11.<BR/>These failures could place residents at risk of not receiving services/care and decreased quality of life.<BR/>1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two-person assist for bathing. <BR/>Record review of the care plan last revised 05/24/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. <BR/>During an interview and observation on 06/13/2023 at 02:06 PM, Resident #9 said she had not had a bath/shower since last Tuesday, June 6, 2023. Resident #9 said she was supposed to receive a shower three times weekly on Tuesday, Thursday, and Saturday on the 2 - 10 shifts. Resident #9 said she had not been offered a shower since last Tuesday, June 6th, 2023. Resident #9 said she would really like to get her hair washed and a good shower because she can smell herself. Resident #9 said she had asked the CNA on Thursday for the shower, but the CNA told Resident #9 maybe around 4PM that she could help her bath, but they never come back and offered the shower. Resident #9 said she asked over the weekend, for a shower but the CNA told her she was the only CNA and no time to perform the requested shower. Resident #9 said she would have liked to go play bingo, but she was always waiting on her shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room. The odor was stronger with Resident #9's body movements. <BR/>During an interview and observation on 06/14/2023 at 12:00 PM, Resident #9 said she had not received a shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room.<BR/>During an observation on 06/15/2023 at 04:00 PM, Resident #9 was lying in bed her hair was oily and disheveled, and a strong musty odor lingered in the room.<BR/>Record Review of the Resident Showers Log indicated Resident #9 received showers on the following dates: <BR/>06/06/2023 - Tuesday, 06/08/2023 - Thursday, 06/10/2023 - Saturday, 06/13/2023 - Tuesday<BR/>During interview and observation on 06/16/2023 at 05:20 PM, Resident #9 said she received a shower yesterday evening on 06/15/2023. Resident #9 said she felt better after the shower. Resident's #9 was observed with clean and combed hair. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #9 had asked for a shower on Wednesday, 06/14/2023, because she had not had one. CNA C said she told Resident #9 she would give her a shower tomorrow (Thursday 06/15/2023). CNA C said Resident #9 refused a lot of showers. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. The MDS indicated Resident #11 did not reject care. The MDS indicated Resident #11 did not exhibit any behavioral symptoms.<BR/>Record review of the care plan with a start date of 12/08/2021 indicated, Resident #11 required physical assistance of one person for bathing. The care plan indicated Resident #11 was to receive showers on Monday, Wednesday, and Fridays. <BR/>During an interview on 06/13/2023 at 01:49 PM, Resident #11 said he had not received a shower/bath for as long as he could remember probably around the time COVID hit. Resident #11 said he was not able to stand on his own. Resident #11 said the CNAs had not offered a shower. Resident #11 said he used the sink to bathe himself the best he could. Resident #11 said, you can only keep some of the odor away using a sink as a shower. Resident #11 said he had not requested a bath because he should not have had to ask. Resident #11 said he needed his toenails clipped but staff was never available to offer the services that are care planned. Resident #11 said his toenails got caught on the sheets and on his socks. Resident #11 said his feet hurt when he wore his shoes because his toenails are too long. Resident #11 said he had purchased clippers so he could cut his own hair. Resident #11 said he had not refused to have a shower, or his toenails clipped because the staff had never tried. Residents #11's toenails were thick, yellow, and approximately &frac12; inch long. <BR/>During an interview on 06/14/2023 at 11:42 AM, Resident #11 said he had not received a shower. <BR/>During an interview on 06/15/2023 at 03:50 PM, Resident #11 said he had not received a shower.<BR/>Record Review of the Resident Showers Log indicated Resident #11 received showers on the following dates: <BR/>06/02/2023, 06/05/2023, 06/07/2023, 06/09/2023, 06/12/2023, 06/14/2023<BR/>During an interview and observation on 06/16/2023 at 05:18 PM, Resident #11 said he had not received a shower and no staff had offered a shower this week. Resident #11 said my toenails had not been trimmed. Resident #11 said he had never told staff not to clip his toenails. Residents #11's toenails on both feet were thick, yellow, and approximately &frac12; inch long. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #11 does everything by his own self. CNA C said she had never offered to clip Resident # 11 nails. CNA C said the nurses were responsible for clipping the resident's toenails. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said it was important to clip the resident's nails to prevent hangnails. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>During an interview on 06/16/2023 at 06:33 PM, the ADON said the CNAs are responsible to give the residents showers/baths. The ADON said the nurses are responsible to review the shower sheets daily. The ADON said nobody had reported to her any refusals this week. The ADON said that Resident # 9 received a shower on Wednesday. The ADON said that Resident #11 frequently refuses showers. The ADON said that CNAs could clip Resident #11's toenails.<BR/>During an interview on 06/16/2023 at 06:22 PM, the DON said the CNAs are responsible for baths/showers. The DON said the nurse could give baths/showers if needed also. The DON said the CNAs and nurses should fill out the shower sheets daily. The DON said Resident #9 did not like to get showers. The DON said Resident #9 is random. The DON said Resident #9 had not refused baths/shower this week. The DON said Resident #11 wouldn't let anybody give him a shower that he refused MWF on the 2 -10 shift. The DON said the residents should be able to get a bath/shower if they asked for one. The DON said it was important for the residents to get their baths/showers to help them feel good about themselves and keep the skin clear. The DON said if the residents had not received baths/showers they would feel dirty and be at a risk for wounds and infection. The DON said if the resident is a diabetic the facility podiatrist or the nurse could clip toenails. The DON said if the resident did not have the diabetic diagnosis the CNA could trim the resident's toenails. The DON said it was important for toenails to get trimmed, so the residents didn't experience ingrown toenail/infection control. The DON said she had never offered to trim Resident #11's toenails. <BR/>During an interview 06/16/2023 at 08:18 PM, the administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical management is responsible for making sure the baths/showers were provided. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good. <BR/>Record review of facility policy and procedure titled, Activities of Daily Living (ADLs), Supporting revised March 2018, indicated . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable for 2 of 13 residents (Resident #5 and Resident #11) reviewed for dietary services. <BR/>The facility failed to provide palatable food to Resident #5 and Resident #11.<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 included:<BR/>1. Record review of the face sheet dated 06/16/2023 indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS assessment indicated Resident #5 was understood and understood others. The MDS assessment indicated Resident #5 required supervision for eating. <BR/>Record review of the Physician Order Report dated 05/16/2023-06/16/2023 indicated, Resident #5 had a regular diet with low concentrated sweets and regular texture with a start date of 01/21/2023. <BR/>During an interview on 06/13/2023 at 2:40 PM, Resident #5 said the food tasted bad, looked bad, and smelled bad. <BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for eating. <BR/>Record review of the Physician Order Report dated 05/16/2023-06/16/2023 indicated, Resident #11 had a regular diet, regular texture with a start date of 04/25/2023. <BR/>During an interview on 06/13/2023 at 1:49 PM Resident #11 said the food did not taste good. <BR/>During an observation and interview on 06/14/2023 starting at 12:11 PM, a lunch tray was sampled by the Dietary Manager and 2 surveyors. The sample tray consisted of spaghetti and meatballs, Italian vegetables, a garlic biscuit, and white cake. The spaghetti and meatballs were bland. The Dietary Manager said the spaghetti and meatballs were okay. The Italian vegetables were mushy and bland. The Dietary Manager said the Italian vegetables were mushy and bland. The garlic biscuit was soggy and bland. The Dietary Manager said the biscuit was soggy and it should not be that way. <BR/>During an interview on 06/16/2023 at 12:10 PM, the Dietary Manager said she was responsible for making sure the food tasted good. The Dietary Manager said she only sampled some food prior to it being served. The Dietary Manager said she walked around the dining room at mealtimes and asked the residents if they liked the food. The Dietary Manager said she had received complaints about how the food tastes, and she would offer the resident an alternative. The Dietary Manager said it was important for the meals to be palatable because the facility was the residents' home, and if they did not like the food they would stop eating and have weight loss. <BR/>During an interview on 6/16/2023 at 6:55 PM, the DON said in the past she had received complaints from different residents about the food. The DON said the dietary staff should make sure the food was palatable. The DON said in the past she had a test tray and noticed the vegetables were mushy. The DON said it was important for the food to taste good for the residents' quality of life. The DON said if the food was not good the residents would not eat, and they would have weight loss. <BR/>During an interview on 06/16/2023 at 8:21 PM, the Administrator said all the staff were responsible for making sure the food was palatable. The Administrator said she expected all the residents to receive food that was palatable. The Administrator said it was important for the residents to receive food that was palatable so they would not have weight loss. <BR/>Record review of the facility's policy titled, Food and Nutrition Services Staff, last revised October 2017, indicated, . Food will be palatable, attractive, and served in a timely manner at proper temperatures .

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 2 of 4 staff (CNA D and CNA F) reviewed for infection control.<BR/>The facility failed to ensure CNA D and CNA F changed their gloves and performed hand hygiene while providing incontinent care to Resident #8.<BR/>These failures could place residents and staff at risk for cross-contamination and the spread of infection.<BR/>Findings included:<BR/>During an observation on 06/13/2023 starting at 1:39 PM, CNA D and CNA F provided incontinent care to Resident #8. CNA D and CNA F put on gloves. CNA D removed the dirty sheets and placed them on the floor. CNA D and CNA F unfastened Resident #8's brief. CNA D tucked the dirty brief under Resident #8's side and both CNAs turned him on his side. Resident #8 had a yellow-brownish ring on his sheets and his bed pad that extended up to his shoulders and down to his knees. CNA F wiped Resident #8's back peri area and removed the dirty brief. CNA F threw the dirty brief in the trashcan. CNA D and CNA F did not remove their dirty gloves and they did not perform hand hygiene. CNA D and CNA F applied the clean brief with dirty gloves. CNA F proceeded to apply zinc barrier cream to Resident #8's buttocks due to slight redness to his buttocks. The CNAs fastened the brief, and CNA F went to Resident #8's drawers to look for clean clothes. CNA D removed Resident #8's hospital gown and then helped CNA F dress Resident #8. CNA D and CNA F did not remove their gloves and they did not perform hand hygiene prior to applying Resident #8's clean clothes. CNA F went out of the room to get the Hoyer lift still wearing the same gloves. CNA D and CNA F transferred Resident #8 to his wheelchair. After transferring him to his wheelchair CNA D removed her gloves and did not perform hand hygiene, and CNA F wheeled Resident #8 to the lobby area still wearing the same gloves. CNA F removed her gloves after leaving Resident #8 in the lobby area. CNA F did not perform hand hygiene. <BR/>During an interview on 06/13/2023 at 2:09 PM, CNA D said she had not been to check on Resident #8 today because she was working in a team with CNA F. CNA D said she would not have done anything differently when providing incontinent care. CNA D said hand hygiene should be performed before starting and when you leave the room. CNA D said she should have performed hand hygiene when she finished providing incontinent care to Resident #8. CNA D said hand hygiene should be performed after glove removal. CNA D said she changed her gloves when she should have changed them when she left the room. CNA D said she did not remember when her last check off or training on incontinent care had been. CNA D said it was important to provide prompt incontinent care to prevent skin breakdown. CNA D said it was important to perform glove changes and hand hygiene while providing incontinent care because of cross contamination and germs. <BR/>During an interview on 06/13/2023 at 2:20 PM, CNA F said the last time she checked on Resident #8 was at 11:30 AM that morning. CNA F said she was supposed to check on the residents every 2 hours. CNA F said she was not able to do this due to being short. CNA F said she should have changed gloves and washed her hands after removing the dirty brief. CNA F said she should not have placed the dirty linens on the floor, but she did not have a trash bag to put them in. CNA F said she did not wash her hands because there was no soap or paper towels in Resident #8's room. CNA F said this had been happening a lot and she had notified the Housekeeping Supervisor and the Maintenance Supervisor. CNA F said her last training on providing incontinent care was 3 months ago. CNA F said it was important to provide prompt incontinent care to prevent skin breakdown, redness, and rashes. CNA F said it was important to perform hand hygiene and change gloves while providing incontinent care for cross contamination. <BR/>During an interview on 06/14/2023 at 6:17 AM, LVN G said there was no soap or paper towels that this happened randomly. LVN G said sometimes they had them and sometimes they did not. LVN G said had notified the DON, ADON, and the maintenance man. LVN G said he was told it was on back order. <BR/>During an interview on 06/14/2023 at 5:48 PM, the Housekeeping Supervisor said she did not know how the facility had come up short on paper towels and soap that this had been going on for about a week. The Housekeeping Supervisor said they were short because she forgot to order earlier in the month and she usually had a stash, but she guessed people used it up. The Housekeeping Supervisor said it was important to have soap and paper towels available to the staff to keep clean and for the staff to be able to wash their hands. <BR/>During an interview on 06/16/2023 at 6:15 PM, the ADON said nurse management was responsible for making sure the CNAs provided proper incontinent care. The ADON said nurse management monitored the CNAs to ensure they were providing proper incontinent care by performing the yearly competencies. The ADON said the CNAs should be checking on the residents every 2 hours. The ADON said while providing incontinent care gloves should be changed after removing the dirty brief and after providing perineal care. The ADON said gloves should be changed and hand hygiene performed anytime you moved from dirty to clean. The ADON said the CNAs should not leave the room with the dirty gloves. The ADON said it was important to provide prompt incontinent are to prevent skin breakdown. The ADON said not performing hand hygiene and not changing gloves adequately while providing incontinent care placed the residents at risk for infection. <BR/>During an interview on 6/16/23 at 7:08 PM, the DON said while providing incontinent care the CNAs should perform hand hygiene when they enter the room and prior to applying gloves. The DON said the CNAs should change gloves when moving from dirty to clean. The DON said while providing incontinent care the CNAs should change gloves and perform hand hygiene several times. The DON said proficiencies for the CNAs on incontinent care were performed yearly by her or the ADON. The DON said she randomly went into rooms to observe the CNAs provide incontinent care. The DON said there was a time when she observed CNA D and CNA F provide incontinent care and she had to tell them to change their gloves. The DON said she could not remember when this occurred. The DON said it was important to provide prompt and proper incontinent care so the residents would not get a UTI, skin breakdown, and to make sure their skin was clean. <BR/>During an interview on 06/16/2023 at 8:26 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said clinical management should make sure the CNAs are providing proper incontinent care. The Administrator said it was important to provide proper incontinent care and to perform hand hygiene to reduce infection. <BR/>Record review of the facility's policy titled, Perineal Care, last revised, 01/20/2023, indicated Steps in the Procedure .3. Perform hand hygiene and don gloves. 4. Arrange the supplies so they can be easily reached . 6. Remove clothing enough to perform peri-care. Avoid unnecessary exposure of the resident's body. 7. Remove the soiled clothing, linens, and brief. Place items in the proper receptacle . B. For a Male Resident: (1) Use a cleansing wipe. (2) Clean perineal area starting with urethra and working outward . (5) Clean urethral area with a cleansing wipe using a circular motion. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. Use a new cleansing wipe, as needed. (6) Continue to clean the perineal area including the penis, scrotum, inner thighs. (7) Thoroughly clean perineal area in same order, using a new cleansing wipe as needed . (12) Clean the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks, change the cleansing wipe, as needed. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. 10. Dry area thoroughly. 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. 13. Perform Hand Hygiene. 14. Reposition the bed covers. Make the resident comfortable. 15. Place the call light within easy reach of the resident. 16. Perform Hand Hygiene .<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene , last revised 01/20/2023, indicated, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Hand hygiene must be performed prior to donning and after doffing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 3 of 3 halls, 1 of 1 dining room, and 2 of 13 (Resident #6 and Resident #8) residents reviewed for pest control. <BR/>The facility did not maintain an effective pest control program to ensure the facility was free of flies. <BR/>This failure could place residents at risk for an unsanitary environment and a decreased quality of life. <BR/>Findings included: <BR/>1. Record review of a face sheet dated 06/16/2023 indicated Resident #6 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including diffuse traumatic brain injury (head injury causing damage to the brain), paraplegic (paralysis of the lower body), neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), bipolar disorder (changes in mood and energy levels).<BR/>Record review of Quarterly MDS assessment dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS assessment indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS assessment indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of Resident #6's care plan last revised 06/11/2023 did not indicate to provide an environment free of pests.<BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #8 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral palsy (a group of disorders that affect movement and muscle tone or posture caused by damage to the brain before birth), essential primary hypertension (high blood pressure), and epilepsy unspecified, not intractable, with status epilepticus (seizures that occur back to back with no time in between). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #8 was sometimes understood and was usually understood. The MDS assessment indicated Resident #8 had a BIMS score of 3, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #8 was totally dependent on staff for bed mobility, transfers, dressing, personal hygiene, and bathing.<BR/>Record review of Resident #8's care plan last revised 06/11/2023 did not indicate to provide an environment free of pests.<BR/>During an observation of the facility's only dining room on 06/13/2023 at 12:04 PM, numerous amounts of flies were present while the residents were eating their lunch meal.<BR/>During an observation on 06/13/2023 starting at 1:32 PM, multiple flies observed flying around and on Resident #8 while he was in bed. Resident #8 was non-interviewable. <BR/>During an observation on 06/14/2023 starting at 5:07 AM, numerous flies were observed in the east, west, and south hall. <BR/>During an observation and interview on 06/14/2023 at 5:05 PM, Resident #6 said there were flies and gnats in his room all the time. Resident #6 said it bothered him because they kept landing on him, and he did not like that. Resident #6 said the staff were aware of the flies and the gnats in his room and in the facility. Multiple flies observed in his room. <BR/>During an interview on 06/16/2023 9:49 AM, the Maintenance Director said the exterminator went to the facility once a month to spray for ants, spiders, and roaches for pest control. The Maintenance Director said he was aware the facility had gnats and flies, and the residents had complained to him about the gnats and flies. The Maintenance Director said the exterminator said he could not spray for the gnats that the facility needed to pour hot water down the drain. The Maintenance Director said he had not asked the exterminator if he could spray for the flies. The Maintenance Director said he would not like to live in an environment with flies because they would aggravate him. The Maintenance Director said it was important to provide the residents an environment free of gnats and flies because he would not want a living environment with flies or gnats in it. <BR/>During an interview on 06/16/23 at 2:48 PM, the exterminator said he went once a month to the facility, unless the facility needed him to go more often. The exterminator said he was at the facility 2 or 3 days ago and he sprayed for spiders. The exterminator said he noticed the gnats and spoke with housekeeping and the kitchen and gave them instructions to pour boiling water down the drains. The exterminator said the facility had not reported to him that there were flies in the facility. The exterminator said there was an aerosol he could use for the flies.<BR/>During an interview on 06/16/2023 at 8:01 PM, the DON said she had noticed the flies in the halls, dining area, and in the rooms. The DON said all the staff should be making sure there were no flies in the facility. The DON said it was important to keep an environment free of flies for the residents because it was an infection control issue. The DON said she personally would not want to have flies in her food or around her. The DON said she wanted to provide a clean and safe environment for the residents, <BR/>During an interview on 06/16/2023 at 8:27 PM, the Administrator said none of the resident had complained to her about the gnats or flies in the facility. The Administrator said all the staff were responsible for making sure the residents had an environment free of gnats/flies, and she expected them to provide this for the residents. The Administrator said it was important to keep an environment free of gnats and flies to provide a homelike environment to the residents. <BR/>Record review of the facility's Pest Control Chemical & Log Sheets dated 01/12/2023, 02/04/2023, 03/10/2023, 04/11/2023 04/19/2023, 05/18/2023 did not indicate the facility was treated for flies. <BR/>Record review of the facility's policy, titled, Pest Control, last reviewed May 2008, indicated, Policy Statement Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .6. Maintenance services assist, when appropriate and necessary, in providing pest control services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #36) of 14 residents reviewed for call lights.<BR/>The facility failed to ensure Resident #36's call light was accessible. <BR/>This failure could cause residents to encounter preventable injuries, health complications, and decreased quality of life.<BR/>Findings included:<BR/>Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #36 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (force of the blood against the artery walls is too high) and personal history of transient ischemic attack (temporary blockage of blood flow to the brain).<BR/>Record review of the MDS dated [DATE] indicated Resident #36 understood others, made himself understood. The MDS indicated Resident #36 was severely cognitively impaired (BIMS score of 3). The MDS indicated he required total dependence with transfers, dressing, toileting, and bathing: extensive assistance with bed mobility and personal hygiene. The MDS indicated Resident #36 had active diagnoses of hypertension, cerebrovascular accident (CVA), transient ischemic attack (TIA) or stroke and diabetes mellitus. The MDS revealed Resident #36 had upper and lower extremity impairment on one side. The MDS revealed Resident #36 had no falls since admission/entry, reentry, or prior assessment.<BR/>Record review of the care plan dated 6/13/22 indicated Resident #36 had a history of falls and at risk for increased falls related to CVA with left sided paralysis and poor safety skills. The care plan indicated long-term goals of resident will remain free of injuries and falls. Interventions included assess resident's footwear for proper fit and non-skid soles dated 6/13/22, encourage use of call light dated 6/13/22, keep call light within reach dated 6/13/22 and instruct resident on safety measures dated 6/13/22.<BR/>During an observation on 6/27/22 at 10:31 a.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. <BR/>During an observation on 6/27/22 at 3:24 p.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. <BR/>During an interview and observation on 6/28/22 at 8:08 a.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. Resident #36's call light was on the floor and when asked where it was, he shrugged his shoulders. Resident #36 told the surveyor he needs his hands cleaned; this surveyor had to get assistance for resident.<BR/>During an observation on 6/28/22 at 10:02 a.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach.<BR/>During an interview and observation on 6/28/22 at 1:55 p.m., Resident #36 was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach. Resident #36's family member said his call light was normally not near him. Resident #36 family member said she usually had to get assistance for him. <BR/>During an observation on 6/28/22 at 8:56 p.m., Resident was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach.<BR/>During an observation on 6/28/22 at 10:46 p.m., Resident was lying in bed with a fall mat at the bedside. Resident #36's call light was at the end of the bed out of reach.<BR/>During an interview and observation on 6/29/22 at 11:12 a.m., the DON was called in Resident #36 room by the surveyor to show that Resident #36 call light has been in the same position since 6/27/22. The DON had to call LVN F to come assist her to get the call light untangle from the end of the bed. <BR/>During an interview on 6/30/22 at 10:55 a.m., CNA Q said all staff were expected to put the call lights within reach of the residents. CNA Q said Resident #36 did not use his call light, usually he hollered out for help. CNA Q said the call light should be clipped on the residents clothing or sheet. CNA Q said nurses and CNAs should make rounds every two hours and periodically to ensure call light was in reach. CNA Q said it was important for residents to have their call light in reach because it was their way to notify staff and prevent a fall. <BR/>During an interview on 6/30/22 at 11:00 p.m., CNA L said all staff were expected to put the call lights within reach of the residents. CNA L said Resident #36 verbally called out instead of using the call light. CNA L said the call light should be clipped on the resident's sheet or by the head of the pillow. CNA L said nurses and CNAs should make rounds every 30-45 minutes to ensure call light was in reach. CNA L said it was important for the call light to be in reach because this alert the staff that the resident need something and prevent the resident from falling. <BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said all staff were expected to put the call lights within reach of the residents. LVN G said Resident #36 did not know how to use his call light but the call light should still be in reach. LVN G said it was important for the call light to be in reach because it was their way calling out for help. LVN G said not having call lights in reach could result in falls, incontinence issues, and unmet resident needs.<BR/>During an interview on 6/30/22 at 11:35 a.m., LVN F said call lights should be always in reach so that the residents can call out for help. LVN F said nurses and CNAs should make rounds every two hours to ensure call light was in reach. LVN F said Resident #36 yelled out for help instead of using his call light. LVN F said not having call lights in reach could result in falls and distress. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said she expected the nurses and CNAs to put the call lights within reach of the residents. The DON said call lights being in reach was important for the resident to be able to communicate their needs with the staff. The DON said that not having call lights in reach could result in falls, incontinence issues, and unmet resident needs. She said it was the responsibility of the charge nurse to ensure all direct care staff was placing the call lights within reach of each resident. The DON said angel rounds were done every morning before stand-up meeting to ensure call lights were in reach and there was an issue it would be reported during meeting. <BR/>During an interview on 6/30/22 at 3:24 p.m., the Administrator said she expected for residents to have their call light within reach for safety. The Administrator stated call lights were important for communication with staff and not having a call light in reach could potentially cause falls. <BR/>Record review of a facility answering the call light policy revised on 3/2021 revealed . the purpose of this procedure is to ensure timely responses to the residents request and needs . when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . some residents many not be able to use their call light. Be sure you check these residents frequently .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 14 residents reviewed for care plans. (Resident #10 and Resident #5). <BR/>The facility failed to ensure Resident #10 abdominal binder was applied, as ordered by the physician. <BR/>The facility failed to implement Resident #5's smoking care plan intervention. <BR/>These failures could place the residents at risk for not receiving the care and/or services to meet their individual needs.<BR/>Findings included:<BR/>1. Record review of the physician order report dated 6/7/22-7/7/22 indicated Resident #10 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including epilepsy (uncontrolled electrical disturbance in the brain), cerebral palsy (congenital disorder of movement muscle tone, or posture), hypokalemia (deficiency of potassium in the bloodstream) and lack of coordination. <BR/>Further review of the physician order report indicated Resident #10 was had an order to check abdominal wrap for placement over G tube site every shift with a start date 5/24/22 and discontinued date 6/30/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #10 usually understood others, usually made himself understood. The MDS indicated Resident #10 was severely cognitively impaired (BIMS score of 1). The MDS indicated he required total dependence with bed mobility, transfers, dressing eating toileting, personal hygiene, and bathing. The MDS indicated Resident #10 had a feeding tube. <BR/>Record review of the care plan dated 12/11/20 indicated Resident #10 was at risk for malnutrition related to NPO (nothing by mouth) and tube feedings. The care plan intervention did not address the abdominal binder. <BR/>Record review of Resident #10's MAR dated 6/1/22-6/29/22 indicated to check abdominal wrap for placement over G tube every shift. The MAR indicated LVN G checked off that she applied the abdominal binder on 6/28/22 and LVN F checked off that she applied the abdominal binder on 6/29/22. <BR/>During an observation on 6/28/22 at 10:45 a.m., Resident #10 was returned to his room by CNA L. CNA L allowed an observation of Resident #10 G tube site and there was no abdominal binder present. <BR/>During an observation on 6/28/22 at 2:14 p.m., Resident #10 was returned to his room by CNA P. CNA P allowed an observation of Resident #10 G tube site and there was no abdominal binder present. <BR/>During an observation and interview on 6/29/22 at 10:15 a.m., Resident #10 was returned to his room by the DON. The DON observed with the surveyor Resident #10 G tube site with no abdominal binder present. The DON said Resident #10 was supposed to have an abdominal binder on to prevent him from pulling out his G tube. The DON said not having the abdominal binder on could result in an infection. <BR/>During an interview and observation on 6/29/22 at 10:20 a.m., LVN F observed with the surveyor Resident #10 G tube site with no abdominal binder present. LVN F said the order should have had being discontinued but she forgot to call the physician. LVN F said she did not know why she checked off that she completed the task of applying the abdominal binder to Resident #10. LVN F said before checking off that she applied the abdominal binder she should have applied it first. LVN F said the abdominal binder was ordered to keep Resident #10 pulling his G tube out. LVN F said not having the abdominal binder on could result in an infection or closer of the stomach. <BR/>2. Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and atherosclerotic heart disease (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). <BR/>Record review of the MDS dated [DATE] indicated Resident #5 understood others, made herself understood. The MDS indicated Resident #5 was cognitively intact (BIMS score of 13). The MDS indicated she required limited assistance bed mobility, transfers, dressing, toileting, and personal hygiene: supervision with eating and extensive assistance with bathing. <BR/>Record review of the care plan dated 11/11/21 indicated Resident #5 was a smoker. The care plan interventions were to assess quarterly for safe smoking. <BR/>Record review indicated the most recent smoking risk assessment was completed on 11/19/21. <BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said the charges nurses were responsible for completing smoking assessments. LVN G said the care plans were guides to know how to care for each resident's individual needs. LVN G stated she does not look at the care plans daily but does look at them if she has questions about someone's care. LVN G said she could not remember if she applied Resident #10 abdominal binder on 6/28/22. LVN G said usually the binder was placed after ADL care. LVN G said not having the abdominal binder on could result in Resident #10 pulling the G tube out. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said she expected all physician orders to be followed. The DON said the charges nurses were responsible for ensuring physician orders were followed. She said she expected the staff to read the care plans for interventions on how to care for each residents' individual needs. The DON said care plans were important for the residents to have so the staff would be aware of individual needs of residents. The DON said she was unaware that Resident #5 has not had a smoking assessment since 11/19/21. The DON said she was under the assumption that smoking assessments were completed by the charge nurse annually until 6/29/22. The DON said smoking assessments were to be done quarterly. The DON said not following the physician orders or care plan could result in residents not receiving proper care. The DON indicated she monitored incomplete assessments by running reports but due to her recent illness she was unable to complete this task. <BR/>Record review of the facility's smoking policy titled Smoking-Residents revised 8/2019 indicated, the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, determine if they need a smoking apron resident care plans will reflect that the resident is a smoker and if a protective smoking apron is indicated for the resident . <BR/>During an interview on 6/30/22 at 2:31 p.m., a care plan policy was requested from the DON but not provided prior to exit.

**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 unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 13 residents reviewed for ADLs (Residents #9, Resident #11)<BR/>The facility did not provide scheduled showers for Resident #9 and Resident #11.<BR/>These failures could place residents at risk of not receiving services/care and decreased quality of life.<BR/>1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two-person assist for bathing. <BR/>Record review of the care plan last revised 05/24/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. <BR/>During an interview and observation on 06/13/2023 at 02:06 PM, Resident #9 said she had not had a bath/shower since last Tuesday, June 6, 2023. Resident #9 said she was supposed to receive a shower three times weekly on Tuesday, Thursday, and Saturday on the 2 - 10 shifts. Resident #9 said she had not been offered a shower since last Tuesday, June 6th, 2023. Resident #9 said she would really like to get her hair washed and a good shower because she can smell herself. Resident #9 said she had asked the CNA on Thursday for the shower, but the CNA told Resident #9 maybe around 4PM that she could help her bath, but they never come back and offered the shower. Resident #9 said she asked over the weekend, for a shower but the CNA told her she was the only CNA and no time to perform the requested shower. Resident #9 said she would have liked to go play bingo, but she was always waiting on her shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room. The odor was stronger with Resident #9's body movements. <BR/>During an interview and observation on 06/14/2023 at 12:00 PM, Resident #9 said she had not received a shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room.<BR/>During an observation on 06/15/2023 at 04:00 PM, Resident #9 was lying in bed her hair was oily and disheveled, and a strong musty odor lingered in the room.<BR/>Record Review of the Resident Showers Log indicated Resident #9 received showers on the following dates: <BR/>06/06/2023 - Tuesday, 06/08/2023 - Thursday, 06/10/2023 - Saturday, 06/13/2023 - Tuesday<BR/>During interview and observation on 06/16/2023 at 05:20 PM, Resident #9 said she received a shower yesterday evening on 06/15/2023. Resident #9 said she felt better after the shower. Resident's #9 was observed with clean and combed hair. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #9 had asked for a shower on Wednesday, 06/14/2023, because she had not had one. CNA C said she told Resident #9 she would give her a shower tomorrow (Thursday 06/15/2023). CNA C said Resident #9 refused a lot of showers. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. The MDS indicated Resident #11 did not reject care. The MDS indicated Resident #11 did not exhibit any behavioral symptoms.<BR/>Record review of the care plan with a start date of 12/08/2021 indicated, Resident #11 required physical assistance of one person for bathing. The care plan indicated Resident #11 was to receive showers on Monday, Wednesday, and Fridays. <BR/>During an interview on 06/13/2023 at 01:49 PM, Resident #11 said he had not received a shower/bath for as long as he could remember probably around the time COVID hit. Resident #11 said he was not able to stand on his own. Resident #11 said the CNAs had not offered a shower. Resident #11 said he used the sink to bathe himself the best he could. Resident #11 said, you can only keep some of the odor away using a sink as a shower. Resident #11 said he had not requested a bath because he should not have had to ask. Resident #11 said he needed his toenails clipped but staff was never available to offer the services that are care planned. Resident #11 said his toenails got caught on the sheets and on his socks. Resident #11 said his feet hurt when he wore his shoes because his toenails are too long. Resident #11 said he had purchased clippers so he could cut his own hair. Resident #11 said he had not refused to have a shower, or his toenails clipped because the staff had never tried. Residents #11's toenails were thick, yellow, and approximately &frac12; inch long. <BR/>During an interview on 06/14/2023 at 11:42 AM, Resident #11 said he had not received a shower. <BR/>During an interview on 06/15/2023 at 03:50 PM, Resident #11 said he had not received a shower.<BR/>Record Review of the Resident Showers Log indicated Resident #11 received showers on the following dates: <BR/>06/02/2023, 06/05/2023, 06/07/2023, 06/09/2023, 06/12/2023, 06/14/2023<BR/>During an interview and observation on 06/16/2023 at 05:18 PM, Resident #11 said he had not received a shower and no staff had offered a shower this week. Resident #11 said my toenails had not been trimmed. Resident #11 said he had never told staff not to clip his toenails. Residents #11's toenails on both feet were thick, yellow, and approximately &frac12; inch long. <BR/>During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #11 does everything by his own self. CNA C said she had never offered to clip Resident # 11 nails. CNA C said the nurses were responsible for clipping the resident's toenails. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said it was important to clip the resident's nails to prevent hangnails. CNA C said not giving the residents their showers could affect the residents emotionally. <BR/>During an interview on 06/16/2023 at 06:33 PM, the ADON said the CNAs are responsible to give the residents showers/baths. The ADON said the nurses are responsible to review the shower sheets daily. The ADON said nobody had reported to her any refusals this week. The ADON said that Resident # 9 received a shower on Wednesday. The ADON said that Resident #11 frequently refuses showers. The ADON said that CNAs could clip Resident #11's toenails.<BR/>During an interview on 06/16/2023 at 06:22 PM, the DON said the CNAs are responsible for baths/showers. The DON said the nurse could give baths/showers if needed also. The DON said the CNAs and nurses should fill out the shower sheets daily. The DON said Resident #9 did not like to get showers. The DON said Resident #9 is random. The DON said Resident #9 had not refused baths/shower this week. The DON said Resident #11 wouldn't let anybody give him a shower that he refused MWF on the 2 -10 shift. The DON said the residents should be able to get a bath/shower if they asked for one. The DON said it was important for the residents to get their baths/showers to help them feel good about themselves and keep the skin clear. The DON said if the residents had not received baths/showers they would feel dirty and be at a risk for wounds and infection. The DON said if the resident is a diabetic the facility podiatrist or the nurse could clip toenails. The DON said if the resident did not have the diabetic diagnosis the CNA could trim the resident's toenails. The DON said it was important for toenails to get trimmed, so the residents didn't experience ingrown toenail/infection control. The DON said she had never offered to trim Resident #11's toenails. <BR/>During an interview 06/16/2023 at 08:18 PM, the administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical management is responsible for making sure the baths/showers were provided. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good. <BR/>Record review of facility policy and procedure titled, Activities of Daily Living (ADLs), Supporting revised March 2018, indicated . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 3 residents reviewed for smoking-accidents and hazards. (Resident #'s 34 and 91)<BR/>The facility failed to ensure Resident #34's oxygen E-tank canister was stored securely while she smoked.<BR/>The facility failed to ensure Resident # 91 did not smoke near a gas grill with propane gas attached. <BR/>This failure could place residents at risk for injury.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 6/30/2022 indicated Resident #34 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnoses of pneumonia, and a lung disease that blocks air flow.<BR/>Record review of a comprehensive care plan dated 12/27/2019 and updated on 5/12/2022 indicated Resident #34 had decreased oxygen saturations and required the intervention of applying oxygen at 2 liters per nasal canula. <BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #34 usually understands and was usually understood. The MDS indicated Resident #34 had no cognitive impairment. The MDS under the section of Special Treatments, Procedures, and Programs indicated Resident #34 received oxygen therapy.<BR/>Record review of a smoking assessment dated [DATE] indicated Resident #34 was scored a risk of zero indicating she was a safe smoker. The assessment indicated she wears oxygen, and the oxygen was to be removed and stored while smoking. <BR/>During an observation on 6/27/2022 at 3:10 p.m., an E-tank oxygen cannister was placed in the upright position of a dining room chair. <BR/>During an interview on 6/27/2022 at 3:27 p.m., the Housekeeping Supervisor indicated she placed the oxygen cylinder in the dining room chair while Resident #34 smoked outside. The Housekeeping Supervisor indicated she was not aware unsecured oxygen cannister could become harmful if it were to fall. <BR/>During an interview on 6/27/2022 at 3:47 p.m., the DON indicated the oxygen sitting upright unsecured in a dining room chair could become unsafe if the tank was to fall from the chair. She indicated there had been an oxygen cannister rack in the dining room for oxygen. The DON said she was unsure why the oxygen cannister rack was removed.<BR/>During an interview on 6/27/2022 at 5:00 p.m., the ADM indicated she was made aware of the oxygen cannister unsecured in the dining room chair. The Administrator indicated an in-service had been completed.<BR/>2. Record review of a face sheet dated 6/30/2022 indicated Resident #91 was [AGE] years old, admitted on [DATE] with the diagnoses of a lung disease that blocks airflow and heart disease.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #91 was understood and understands. The MDS indicated Resident #91's BIMs score (brief interview of memory score) was a 7 indicating severe impairment.<BR/>Record review of a comprehensive care plan dated 5/19/2022 and updated on 6/07/2022 indicated Resident #91 was a smoker and would smoke in designed areas without occurrence of injury over the next 90 days. The care plan interventions included to explain show where designated smoking areas and monitor when smoking to assure resident safety.<BR/>Record review of a Smoking Risk assessment dated [DATE] indicated Resident #91 was a safe smoker.<BR/>During an observation on 6/27/2022 at 12:10 p.m., the gas grill on the patio had a propane bottle attached. <BR/>During an observation on 6/27/2022 between 3:10 p.m. and 3:37 p.m., Resident #91 was observed smoking with the Housekeeping Supervisor near the gas grill which had propane attached. <BR/>During an observation on 6/28/2022 at 9:10 a.m., Resident #91 was sitting near the gas grill with propane attached smoking a cigarette. <BR/>During an interview on 6/28/2022 at 9:16 a.m., the maintenance supervisor indicated he had forgotten the propane gas remained attached to the gas grill. The maintenance supervisor indicated he was responsible for storing of the propane gas after use. He indicated the gas grill was used last week and he failed remember to remove the propane gas from the grill. He indicated with smoking around a propane grill an explosion could occur. <BR/>During an interview on 6/28/2022 at 3:16 p.m., the ADM indicated she had been made aware of the propane gas being attached to the grill and the resident smoking within proximity. The Adm indicated the gas was not turned on.<BR/>Record review of a Fire Safety and Prevention policy dated 2021 indicated all personnel must learn methods of fire prevention and must report conditions that could result in a potential fire hazard. Fire prevention is the responsibility of all personnel, residents, visitors, and general public. Flammable Items: a. smoke only in designated areas f. Store flammable liquids in a locked cabinet oxygen safety: c. Prohibit smoking, open flames, and spark-producing devices in oxygen storage or administration areas f. Store oxygen cylinders in racks with chains, sturdy portable carts or approved stands. Never leave oxygen cylinders free standing. 4. H. all personnel must report observations of violation of fire safety rules.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident incontinent of urine and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident reviewed for bladder and bowel incontinence. (Resident #28)<BR/>CNA M cleansed Resident #28's perineal area and buttocks using the same washcloth.<BR/>CNA M failed to remove her soiled gloves prior to touching the clean brief, Resident #28's night clothes and the bed linen. <BR/>This failure could place residents at the facility requiring incontinent care at risk for discomfort, skin breakdown, cross contamination, and urinary tract infections. <BR/>Findings included:<BR/>Record review of a face sheet dated 6/30/2022 indicated Resident #28 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart disease, muscle weakness, and chronic pain. <BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #28 usually understands and was usually understood. Resident #28's BIMS (brief interview memory score) was score of 5 indicating severe cognitive impairment. The MDS indicated Resident #28 required extensive assistance of one staff for toilet use and personal hygiene. The MDS indicated Resident #28 was frequently incontinent of bowel and bladder.<BR/>Record review of a comprehensive care plan dated 11/17/2020 and updated on 5/20/2022 indicated Resident #28 was incontinent of bladder with the intervention of checking for incontinence a minimum of every 2 hours and provide toileting as requested and assess needs a minimum of every 2 hours.<BR/>Record review of a nursing note dated 6/15/2022 at 11:23 p.m., LVN E indicated Resident #28 complained of dysuria stating, It just burns every time I get started peeing. The note indicated Resident #28 complained of urgency and frequency. The note indicated a new order for a urinalysis with a culture and sensitivity was ordered.<BR/>Record review of a nursing note dated 6/17/2022 at 4:00 p.m.,LVN G indicated Resident #28 had a new order for Nitrofurantoin 100 mg twice daily for 7 days ordered for a UTI.<BR/>Record review of a urinalysis dated 6/15/2022 indicated Resident #28 had greater than 100,000 colony count with the cultured Escherichia coli bacteria (bacteria commonly from fecal material).<BR/>During an interview on 6/28/2022 at 2:00 p.m., Resident #28 indicated she was being left sitting in urine and sometimes feces for long periods of time waiting on staff to assist her with changing her brief.<BR/>During an observation and interview on 6/28/2022 at 9:38 p.m., Resident #28's call light was answered by CNA M. Resident #28 indicated she was incontinent of urine and wanted to go to bed. CNA M assisted Resident #28 on to her bed to provide incontinent care. CNA M removed Resident #28's brief revealing the brief material had become saturated with urine and had broken down leaving the filler material on Resident #28's perineal area and buttocks. CNA M began providing incontinent care using one washcloth made several wiping motions in the perineal area without turning the washcloth to a clean area. Then CNA M rolled Resident #28 on her left side and began wiping her buttocks with same washcloth not rotating the clothe between wipes. CNA M applied a new brief, adjusted Resident #28's clothing and covered her with the bed linen without changing her gloves.<BR/>During an interview on 6/28/2022 at 10:20 p.m., CNA M indicated she has always provided better incontinent care. CNA M indicated she had worked her entire shift; she had not had a break or even lunch and was just tired. CNA M indicated she had not changed Resident #28 since 5:00 p.m. this evening. CNA M indicated the brief was leaving jelly like material on Resident #28. CNA M indicated not changing Resident #28 and the poor incontinent could cause urinary tract infections. <BR/>During an interview on 6/28/2022 at 10:39 p.m., CNA M indicated she had provided incontinent care appropriately to Resident #28. CNA M when asked why she indicated she just could not leave Resident #28 without better incontinent care.<BR/>Record review of an Incontinent Care for the Female Resident Check off form dated 6/10/2021 for CNA M indicated she was skilled in the areas of using a clean washcloth with peri wash to cleanse the buttocks without contaminating the perineal area. CNA M was checked off on washing and drying her hands, reapply gloves and assist the resident with repositioning and dressing.<BR/>During an interview on 6/30/2022 at 2:33 p.m., the DON indicated she expected incontinent care to be done with 1 wipe and discard method using wipes. The DON indicated she expected rounds to be completed every 2-3 hours or more often if needed. The DON indicated she was aware Resident #28 just completed antibiotics for a urinary tract infection. The DON indicated she was responsible for ensuring appropriate incontinent care was taught. She indicated the CNAs were checked off annually.<BR/>During an interview on 6/30/2022 at 3:24 p.m., the ADM indicated she expected incontinent care to be provided as needed.<BR/>Record review of a Urinary Incontinence policy dated April 2018 indicated 4. For incontinent individuals, the nursing staff will identify, and document circumstances related to incontinence; for example, frequency, nocturia, dysuria, or relationship to coughing/sneezing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 2 of 7 residents (Resident #23 and Resident #15) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #23's oxygen concentrator filter was free of gray, fuzzy material. <BR/>The facility failed to ensure Resident #23 and Resident #15 nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing was changed weekly. <BR/>The facility failed to ensure the nasal cannula tubing was dated for Resident #15.<BR/>The facility failed to ensure Resident #23 oxygen nasal cannula tubing was changed weekly.<BR/>The facility did not store nasal canula or nebulizer in a plastic bag when it was not in use for Resident #23 and Resident #15. <BR/>The facility failed to document and monitor Resident #15's use of oxygen.<BR/>These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings included:<BR/>1.Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #23 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys cease functioning on a permanent basis), COPD-chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (force of the blood against the artery walls is too high) and 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). <BR/>Record review of the physician order report indicated Resident #23 received oxygen at 2L/Min per nasal cannula @ HS (at bedtime) and PRN (as needed) related to SOB (shortness of breath) with a start date 5/27/22. There was an order to clean nebulizer filter weekly on Sunday with a start date 5/27/22. <BR/>Further review of consolidated physicians' orders dated 5/29/22-6/29/22 did not indicate Resident #15 had an order for oxygen. <BR/>Record review of the MDS dated [DATE] indicated Resident #23 understood others and made himself understood. The MDS indicated Resident #23 was cognitively intact (BIMS score of 14). The MDS indicated he required supervision with bed mobility, transfers, eating toileting, and bathing: limited assistance with dressing and personal hygiene. The MDS indicated Resident #23 had active diagnoses of renal insufficiency, renal failure or end stage renal disease, hypertension and Asthma, COPD, or Chronic Lung Disease. The MDS indicated Resident #23 became short of breath or trouble breathing with exertion. The MDS indicated Resident #23 was receiving oxygen therapy.<BR/>Record review of the care plan dated 6/7/22 indicated Resident #23 had episodes of SOB and was at risk for respiratory distress/failure related to COPD. The care plan interventions were to apply o2 (oxygen) per order, encourage to take deep breaths, monitor for signs of relief from SOB and provide respiratory treatments as ordered. The care plan did not address oxygen concentrator filters, nebulizer, or nasal cannula tubing. <BR/>During an interview and observation on 6/27/22 at 11:46 a.m., Resident #23 was sitting on the side of the bed and oxygen was being used by the resident via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. The nasal cannula was dated 6/5/22. Resident #23's nebulizer mask was on the bedside dresser not covered. Resident #23 said he wears oxygen as needed, mainly at night for SOB. Resident #23 said he received breathing treatments daily. <BR/>During an observation on 6/28/22 at 8:38 a.m., Resident #23 was sitting on the side of the bed visiting a friend and oxygen was being used by the resident via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. The nasal cannula was dated 6/5/22. Resident #23's nebulizer mask was on the bedside dresser not covered.<BR/>During an observation on 6/29/22 at 11:15 a.m. Resident #23 was lying in bed and oxygen was being used by the resident via nasal cannula. The filter on the oxygen concentrator was grey with fuzzy material. The nasal cannula was dated 6/5/22. Resident #23's nebulizer mask was on the bedside dresser not covered.<BR/>2. Record review of the physician order report dated 5/29/22-6/29/22 indicated Resident #15 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including essential hypertension (force of the blood against the artery walls is too high), chronic diastolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation), and type 2 diabetes mellitus with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar that induces nerves damage that is caused by diabetic). The order did not indicate Resident #15 had an order for oxygen therapy. <BR/>Record review of the MDS dated [DATE] indicated Resident #15 understood others, made herself understood. The MDS indicated Resident #15 was cognitively intact (BIMS score of 15). The MDS indicated she required extensive assistance with bed mobility, transfers, dressing toileting and personal hygiene: total dependence with bathing. The MDS indicated Resident #15 had active diagnoses of hypertension, heart failure, and diabetes mellitus. The MDS did not indicate if Resident #15 became short of breath or trouble breathing with/without activity. The MDS indicated Resident #15 was receiving oxygen therapy.<BR/>Record review of the care plan dated 4/16/22 indicated Resident #15 had decreased cardiac output related to changes in myocardial contractility. The care plan interventions were to administer oxygen as prescribed and monitor oxygen saturation every shift. <BR/>During an interview and observation on 6/27/22 at 11:52 a.m., Resident #15 was lying in bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing. The handheld nebulizer tubing was dated 6/19/22 and was on the overbed table not covered. Resident #15 said she wears oxygen continuously and received breathing treatments every 4 hours. <BR/>During an observation on 6/28/22 at 9:15 a.m., Resident #15 was lying in bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing. The handheld nebulizer tubing was dated 6/19/22 and was on the overbed table not covered.<BR/>During an observation on 6/29/22 at 11:30 a.m., Resident #15 was lying in bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing. The handheld nebulizer tubing was dated 6/19/22 and was on the overbed table not covered.<BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said she was Resident #23 and Resident #15's 6a-6p charge nurse. LVN G said nursing staff on Sunday nights were responsible for cleaning the oxygen concentrator filters, changing and labeling tubing. LVN G said all staff were responsible for making sure it was done. LVN G said she did not notice that the oxygen tubing, and nebulizer equipment was not dated or properly stored. LVN G said she should have placed Resident #15 mask in a bag when the treatment and her post assessment was completed. LVN G said she did not give Resident #23 a breathing treatment but the nurse providing the nebulizer treatment should be placing the mask in a bag when the treatment and their post assessment was completed. She said these failures could place residents at risk for respiratory infection. LVN G said Resident #15 had been on oxygen since she was admitted . She said she was not aware that Resident #15 did not have an order for oxygen. LVN G said nurses must have an order for oxygen to administer it and if there was no order for oxygen, the nurse should call the physician to get an order. LVN G said she did not know why Resident #15 did not have an order for oxygen. LVN G said this failure could potentially place Resident #15 at risk for falls and confusion. <BR/>During an interview on 6/30/22 at 11:17 a.m., RN K said she was the 10p-6a charge nurse on 6/26/22. RN K said she were responsible for cleaning the oxygen concentrator filters, changing and labeling tubing weekly. RN K said she did not change or clean Resident #23's or 15's oxygen concentrator filter Sunday because she was busy taking care of a resident and their issue. She said these failures could place residents at risk for respiratory infection. <BR/>During an interview on 6/30/22 at 11:35 a.m., LVN F said she was not aware that Resident #15 did not have an order for oxygen. LVN F said nurses must have an order for oxygen to administer it and if there was no order for oxygen, the nurse should call the physician to get an order. LVN F said Resident #15 was admitted with oxygen. LVN F said this failure could potentially place Resident #15 at risk for dizziness and lightheadedness. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said nursing staff on Sunday nights were responsible for cleaning the oxygen concentrator filters, changing and labeling tubing. The DON said angel rounds were done daily before morning stand up meeting. She said it was her responsibility to make sure the nursing staff were properly checking and dating the respiratory equipment. She said she did not know why it has not been done. She said she expected the respiratory equipment to be dated and changed out properly. The DON said she expected nasal canula and nebulizers be stored in bags when not in use. She said she understood this failure could place resident's respiratory health at risk. She said Resident #15 had always been on oxygen since her admission. The DON said she was not aware that Resident #15 did not have did not have an order for oxygen. The DON said not having an order for oxygen could cause Resident #15 to go into respiratory arrest. The DON said it was her responsibility for ensuring residents had orders for the services/treatments they were receiving. The DON said she checked orders daily before stand-up meeting. The DON said the order must have been missed.<BR/>Record review of the facility's oxygen policy tilted Departmental (Respiratory Therapy)-Prevention of Infection revised on 11/2011 indicated . the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . change the oxygen cannula and tubing every (7) days or as needed . keep the oxygen cannula and tubing used PRN in a plastic bag when not in use . Wash filters from oxygen concentrators every (7) days with soap and water . check filters once weekly while they are in continuous use. <BR/>Record review of the facility policy titled Oxygen Administration revise on 10/2010 indicated . the purpose if this procedure is to provide guidelines for safe oxygen administration . verify that there is a physician's order for this procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 4 resident reviewed for dialysis services. (Residents #23)<BR/>The facility failed to keep ongoing communication with the dialysis facility for Resident #23. <BR/>This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.<BR/>Findings included: <BR/>1.Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #23 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys cease functioning on a permanent basis), COPD-chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (force of the blood against the artery walls is too high) and 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). The physician order did not address dialysis. <BR/>Record review of the MDS dated [DATE] indicated Resident #23 understood others and made himself understood. The MDS indicated Resident #23 was cognitively intact (BIMS score of 14). The MDS indicated he required supervision with bed mobility, transfers, eating toileting, and bathing: limited assistance with dressing and personal hygiene. The MDS indicated Resident #23 had active diagnoses of renal insufficiency, renal failure or end stage renal disease, hypertension and Asthma, COPD, or Chronic Lung Disease. The MDS indicated Resident #23 received dialysis treatments during the 14 day look back period. <BR/>Record review of the care plan dated 5/27/22 indicated Resident #23 had a diagnosis of end stage renal disease and required dialysis. The care plan interventions were to adjust the intensity of activities to accommodate energy level and tolerance and provide rest periods between activities. <BR/>Record review of the medical record for Resident #23 indicated there was no<BR/>documentation between the facility and dialysis for Resident #23 on the following dates:<BR/>*Saturday 6/11/22<BR/>*Tuesday 6/14/22<BR/>*Thursday 6/16/22<BR/>*Saturday 6/25/22<BR/>During an interview on 6/27/22 at 11:46 a.m. Resident #23 said he had dialysis on Tuesdays, Thursdays, and Saturdays. Resident #23 said she had not been hospitalized or missed any dialysis appointments since she was admitted to the facility. <BR/>During an interview on 6/29/22 at 10:30 a.m., the Dialysis Administrator said Resident #23 received dialysis treatment on the following dates:<BR/>*Saturday 6/11/22<BR/>*Tuesday 6/14/22<BR/>*Thursday 6/16/22<BR/>*Saturday 6/25/22<BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said she had worked at the facility approximately 3 months. She said she worked the 6am-6pm shift. LVN G said the charge nurses were responsible for ensuring the dialysis communication record was sent and received when a resident went to and came back from dialysis. LVN G said residents receiving dialysis treatment should be assessed before and after dialysis and the assessments should be recorded on the dialysis communication report. LVN G said the assessments included vital signs, checking the shunt for bruit (a specific sound heard through a stethoscope) and thrill (a vibration felt on the skin overlying an area of turbulence), checking the shunt for bleeding and signs of infection, and monitoring weights. LVN G said the facility would fax a dialysis communication report to dialysis and ensure that a confirmation receipt was received. LVN G said if the dialysis facility does not send the communication sheet back with the resident the nurse should call dialysis to obtain communication sheet. LVN G said residents not assessed before or after dialysis could experience complications including fluid overload (too much fluid in your body which can cause shortness of breath, confusion and swelling) and decrease blood pressure. <BR/>During an interview on 6/30/22 at 11:35 a.m., LVN F said she had worked at the facility for 2 years. She said she worked the 6am-6pm shift. LVN F said the charge nurses were responsible for ensuring the dialysis communication record was sent and received when a resident went to and came back from dialysis. LVN F said residents receiving dialysis treatment should be assessed before and after dialysis and the assessments should be recorded on the dialysis communication report. LVN F said the purpose of the form was communication between the facility and dialysis. LVN F said they facility would send a dialysis communication report with the resident and via fax. LVN F said if the dialysis facility does not send the communication sheet back with the resident the nurse should call dialysis to obtain communication sheet. LVN F said residents can experience decrease blood pressure if they were not assessed before or after dialysis. <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said residents receiving dialysis should be assessed pre and post dialysis and the assessment should be recorded on the dialysis communication report. The DON said the dialysis communication report was a communication between the facility and dialysis. The DON said if the dialysis facility did not send the communication report back with the resident it was the charge nurses' responsibility for calling the dialysis center and requesting the communication report. The DON said ADON D was responsible for monitoring dialysis residents to ensure communication was being maintained between the facility and the dialysis center. The DON said she reviewed the book from time to time to ensure the forms were completed. The DON said residents not assessed before or after dialysis could experience complications including bleeding and decrease blood pressure. <BR/>Record review of the facility's dialysis policy tilted End-Stage Renal Disease revised on 9/2010 indicated, agreements between the facility and the contracted ESRD (end stage renal disease) facility include all aspects of how the resident's care will be managed, including: how information will be exchanged between the facilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of the physician order report dated 5/29/22-6/29/22 indicated Resident #191 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including hypothyroidism ((thyroid gland does not produce enough thyroid hormone), bipolar disorder (Bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs) and hyperlipidemia (blood has too many lipids (or fats).<BR/>Further review of the physician order report indicated Resident #191 was prescribed Levothyroxine tablet, 11 mcg by mouth, one time a day for hypothyroidism with start date 6/15/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #191 understood others and made herself understood. The MDS indicated Resident #191 was cognitively intact (BIMS score of 13). The MDS indicated she required supervision with bed mobility, transfers, eating toileting, and personal hygiene: extensive assistance with bathing. The MDS indicated Resident #191 had active diagnoses of thyroid disorder, arthritis, and bipolar disorder. <BR/>Record review of the care plan dated 6/28/22 indicated Resident #191 had a diagnosis of hypothyroidism and take levothyroxine. The care plan interventions were to administer medications as ordered and monitor weight loss. <BR/>Record review of the medication administration record dated 6/1/22-6/18/22 revealed Resident #191 had an order for levothyroxine 112 mcg, give 1 tablet by mouth every morning. The report indicated Resident #191 received levothyroxine at 5:00 a.m. on 6/24/22 given by LVN H, 5:00 a.m. on 6/25/22 given by RN K and 5:00 a.m. on 6/26/22 given by LVN F. <BR/>During an interview on 6/27/22 at 11:55 a.m., Resident #191 said she did not receive her thyroid medication over the weekend. Resident #191 indicated she had not experienced any ill effects from not receiving medication. <BR/>Record review of the medication blister packs (help keep track of the resident's medication) indicated one dose of levothyroxine was missed.<BR/>During an interview on 6/27/22 at 12:15 p.m., the DON and Administrator agreed there was one medication administration missed.<BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said Resident #191 told her she did not received her thyroid medication the last couple of days on 6/27/22. LVN G said she reported it to the DON. LVN G said thyroid medication should be given on time and daily for therapeutic thyroid levels. LVN G said if thyroid medication was not given it could affect the resident's lab levels and caused her to become fatigue (tired). <BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said thyroid medications given on an empty stomach was important, that was why it is scheduled at 5am. The DON said if thyroid medication was not given on an empty stomach it could affect Resident #191 lab levels and cause her to become confused. The DON said the physician was notified and labs were ordered. The DON said it was her responsibility to ensure medications were given. She said corporate run reports every week on medication administration times and they would notify her if there were any missed doses. The DON said she had not received a report this week. <BR/>Record review of the facility's policy tilted Documentation of Medication Administration revised on 4/2007 indicated . administration of medication must be documented immediately after (never before) it is given . <BR/>Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 5 (Residents #6, #7, #25, #38, #191) of 6 residents reviewed for pharmacy services.<BR/>The facility failed to ensure Resident #191 received her Levothyroxine (thyroid medication) as ordered by the physician. <BR/>The facility failed to ensure Residents #6, #7, #25 and #38 received scheduled medication on time during medication administration pass. <BR/>These failures could place the residents at risk of not receiving the intended therapeutic benefit of their medications.<BR/>Findings included:<BR/>1. Record review of the consolidated physician orders dated 6/30/22 revealed Resident #6 was [AGE] year-old, female admitted to the facility on [DATE] with diagnosis including stroke, low red blood cell count, elevated cholesterol, seasonal allergies, muscle weakness, difficulty walking, impaired thought organization, secondary high blood pressure, anxiety disorder, and major depressive disorder. The consolidated physician orders revealed Resident #6 was prescribed Lexapro 5 mg tab at bedtime for depression. Resident #6 was prescribed pyridostigmine bromide 60 mg 1 tab 3 times a day for muscle weakness. <BR/>2. Record review of the most recent MDS dated [DATE] revealed Resident #6 had an intact cognition. The MDS revealed Resident #6 required supervision for eating, transfers, and toilet use. Resident #6 required limited assistance with personal hygiene and bathing. Resident #6 did not have a history of refusing care. <BR/>Record review of the care plan dated 6/8/2022 revealed Resident #6 had a history of stroke and takes pyridostigmine bromide for muscle weakness. <BR/>Review of the Medication Administration History Report dated 06/01/2022-06/30/2022 revealed Resident #6 received pyridostigmine bromide 60 mg (due at 8 AM, 12 PM and 8 PM) on 6/7/2022 at 9:05 AM by LVN A, on 6/9/2022 at 9:10 AM, on 6/10/2022 at 9:48 AM by LVN C, on 6/11/2022 at 9:18 AM by LVN A, on 6/14/2022 at 9:07 AM by LVN C, on 6/16/2022 at 9:13 AM by LVN A, on 6/16/2022, at 9:22 PM by LVN D, on 6/20/22 at 9:31 AM by LVN A, 0n 9/21/2022 at 9:04 AM by LVN A, on 6/25/2022 at 9:34 AM by RN B, on 6/25/22, at 1:09 PM by RN B, on 6/25/2022 at 9:10 PM by LVN E, on 6/26/2022 at 9:22 AM by RN B, and on 9/28/2022 at 9:44 AM by LVN C. No reasons were given for late administration.<BR/>3.Record review of consolidated physician orders dated 6/30/2022 revealed Resident #7 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure, Parkinson's disease, muscle weakness, chronic obstructive pulmonary disease, chronic pain, essential (not the result of a medical condition) hypertension, bone arthritis, and bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed Aldactone 50 mg tab twice a day for essential hypertension. The consolidated physician orders revealed Resident #7 was prescribed benztropine 1 mg tab twice daily for Parkinson's disease. The consolidated physician orders revealed Resident #7 was prescribed chlorzoxazone 500 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed clonazepam 0.5 mg tab twice a day for bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed gabapentin 300 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed oxycodone-acetaminophen 5-325 tab three times a day for pain. The consolidated physician orders revealed Resident #7 was prescribed pregabalin 50 mg tab three times a day for pain. <BR/>Review of the most recent MDS dated [DATE] revealed Resident #7 was cognitively intact, was independent for dressing, toilet use, and required supervision for eating and personal hygiene. Resident #7 did not have a history of rejecting care. <BR/>Record review of the most recent care plan dated 6/22/2022 revealed Resident #7 had history of hypertension and took Aldactone. Resident #7 had a history of bipolar disorder and took trazodone and clonazepam. Resident #7 had a potential for pain related to chronic pain and arthritis, and takes oxycodone, pregabalin, gabapentin, and chlorzoxazone. Resident #7 was at risk for increased falls related to Parkinson's disease. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Aldactone (due at 9:00AM and 9:00 PM) at 10:12 AM on 6/1/2022 given by LVN F, at 10:04 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 10:21 AM on 6/4/2022 given by LVN H, at 10:12 AM on 6/6/2022 given by LVN F, at 10:12 AM on 6/7/2022 given by LVN F, at 1:19 AM on 6/8/2022 given by LVN D, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 AM on 6/9/2022 given by RN B, at 10:11 AM on 6/14/2022 given by CMA C, at 10:08 AM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 10:08 on 6/21/22 by LVN F, at 11:38 PM on 6/21/2022 by RN K, at 10:25 PM on 6/24/2022 by RN K, at 10:25 PM on 6/25/2022 given by RN K, at 10:25 on 6/26/22 by RN K, and at 11:46 PM on 6/26/22 by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Chlorzoxazone (due at 8 AM and 8 PM) at 10:03 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 9:40 AM on 6/3/2022 given by LVN H, at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/8/2022 given by LVN G, at 9:40 on 6/8/2022 AM given by LVN G, at 10:25 AM, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 AM on 6/24/2022 given RN J, at 9:01 AM on 6/25/22 given by LVN F, at 11:59 AM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26/2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Clonazepam (due at 5 AM and 1 PM) at 2:36 PM on 6/1/2022 given by LVN F, at 2:01 PM on 6/2/2022 given by LVN F, at 2:42 PM on 6/7/2022 given by LVN F, at 7:42 AM on 6/9/2022 given by LVN G, at 6:34 AM on 6/12/2022 given by LVN A, at 4:55 PM on 6/15/2022 given by LVN A, at 7:08 AM on 6/25/2022 given by LVN F, at 2:13 PM on 6/25/2022 given by LVN H, and at 6:51 AM on 6/27/2022 given by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Gabapentin (due at 8 AM and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13 on 6/3/2022 given by LVN G, at 9:40 AP on 6/3/2022 given by LVN H,. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA, on 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Oxycodone-Acetaminophen (due at 8 AM, 2 PM, and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13AM on 6/3/2022 given by LVN G, at 3:53 PM on 6/3/2022 by LVN G, at 9:40 PM on 6/3/2022 given by LVN H. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 4:17 PM on 6/10/2022 given by LVN A at 9:13 AM on 6/11/2022 given by LVN A, at 4:39 PM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 4:55 PM on 6/15/2022 given by LVN A, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C , at 3:02 PM on 6/19/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 4:52 PM on 6/23/2022 given by LVN G at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>3. <BR/>Record review of consolidated physician orders dated 6/30/2022 revealed Resident #7 was a [AGE] year old[AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure, Parkinson's disease, muscle weakness, chronic obstructive pulmonary disease, chronic pain, essential (not the result of a medical condition) hypertension, bone arthritis, and bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed Aldactone 50 mg tab twice a day for essential hypertension. The consolidated physician orders revealed Resident #7 was prescribed benztropine 1 mg tab twice daily for Parkinson's disease. The consolidated physician orders revealed Resident #7 was prescribed chlorzoxazone 500 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed clonazepam 0.5 mg tab twice a day for bipolar disorder. The consolidated physician orders revealed Resident #7 was prescribed gabapentin 300 mg tab twice a day for pain. The consolidated physician orders revealed Resident #7 was prescribed oxycodone-acetaminophen 5-325 tab three times a day for pain. The consolidated physician orders revealed Resident #7 was prescribed pregabalin 50 mg tab three times a day for pain. <BR/>Review of the most recent MDS dated [DATE] revealed Resident #7 was cognitively intact, was independent for dressing, toilet use, and required supervision for eating and personal hygiene. Resident #7 did not have a history of rejecting care. <BR/>Record review of the most recent care plan dated 6/22/2022 revealed Resident #7 had history of hypertension and took Aldactone. Resident #7 had a history of bipolar disorder and took trazodone and clonazepam. Resident #7 had a potential for pain related to chronic pain and arthritis, and takes oxycodone, pregabalin, gabapentin, and chlorzoxazone. Resident #7 was at risk for increased falls related to Parkinson's disease. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Aldactone (due at 9:00AM and 9:00 PM) at 10:12 AM on 6/1/2022 given by LVN F, at 10:04 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 10:21 AM on 6/4/2022 given by LVN H, at 10:12 AM on 6/6/2022 given by LVN F, at 10:12 AM on 6/7/2022 given by LVN F, at 1:19 AM on 6/8/2022 given by LVN D, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 AM on 6/9/2022 given by RN B, at 10:11 AM on 6/14/2022 given by CMA C, at 10:08 AM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 10:08 on 6/21/22 by LVN F, at 11:38 PM on 6/21/2022 by RN K, at 10:25 PM on 6/24/2022 by RN K, at 10:25 PM on 6/25/2022 given by RN K, at 10:25 on 6/26/22 by RN K, and at 11:46 PM on 6/26/22 by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Chlorzoxazone (due at 8 AM and 8 PM) at 10:03 PM on 6/2/2022 given by LVN D, at 10:13 AM on 6/3/2022 given by LVN G, at 9:40 AM on 6/3/2022 given by LVN H, at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/8/2022 given by LVN G, at 9:40 on 6/8/2022 AM given by LVN G, at 10:25 AM, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 AM on 6/24/2022 given RN J, at 9:01 AM on 6/25/22 given by LVN F, at 11:59 AM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26/2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Clonazepam (due at 5 AM and 1 PM) at 2:36 PM on 6/1/2022 given by LVN F, at 2:01 PM on 6/2/2022 given by LVN F, at 2:42 PM on 6/7/2022 given by LVN F, at 7:42 AM on 6/9/2022 given by LVN G, at 6:34 AM on 6/12/2022 given by LVN A, at 4:55 PM on 6/15/2022 given by LVN A, at 7:08 AM on 6/25/2022 given by LVN F, at 2:13 PM on 6/25/2022 given by LVN H, and at 6:51 AM on 6/27/2022 given by RN K. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Gabapentin (due at 8 AM and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13 on 6/3/2022 given by LVN G, at 9:40 AP on 6/3/2022 given by LVN H,. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 9:13 AM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA, on 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #7 received Oxycodone-Acetaminophen (due at 8 AM, 2 PM, and 8 PM) at 10:03 AM on 6/2/2022 given by LVN D, at 10:13AM on 6/3/2022 given by LVN G, at 3:53 PM on 6/3/2022 by LVN G, at 9:40 PM on 6/3/2022 given by LVN H. at 10:21 PM on 6/4/2022 given by LVN H, at 9:31 AM on 6/5/2022 given by LVN G, at 9:42 PM on 6/5/2022 given by LVN H, at 9:09 PM on 6/6/2022 given by LVN D, at 9:10 AM on 6/7/2022 given by LVN F, at 9:40 AM on 6/08/2022 given by LVN G, at 10:25 AM on 6/9/2022 given by LVN G, at 11:40 PM on 6/9/2022 given by LVN H, at 4:17 PM on 6/10/2022 given by LVN A at 9:13 AM on 6/11/2022 given by LVN A, at 4:39 PM on 6/11/2022 given by LVN A, at 9:25 AM on 6/12/2022 given by RN B, at 4:55 PM on 6/15/2022 given by LVN A, at 10:08 PM on 6/16/2022 given by LVN D, at 10:21 AM on 6/17/2022 given by CMA C , at 3:02 PM on 6/19/2022 given by CMA C, at 9:06 AM on 6/20/2022 given by LVN A, at 9:35 AM on 6/22/2022 given by LVN G, at 9:50 AM on 6/23/2022 given by LVN G, at 4:52 PM on 6/23/2022 given by LVN G at 10:25 PM on 6//24/2022 given by RN K, at 9:01 AM on 6/25/2022 given by LVN F, at 11:59 PM on 6/25/2022 given by RN K, at 9:23 AM on 6/26/2022 given by LVN F, at 11:46 PM on 6/26.2022 given by RN K, and at 9:49 AM on 6/27/2022 given by LVN G. No reasons were given for late administration.<BR/>4.Record review of the consolidated physician orders dated 6/30/2022 revealed Resident #25 was [AGE] years old, female and admitted on [DATE] with diagnoses including chronic atrial fibrillation (irregular and rapid heartbeat), congestive heart failure, hypertension, anxiety disorder, muscle weakness, type 2 diabetes, left lower abdomen pain, heart disease of coronary artery, end stage kidney disease, and hypothyroidism (thyroid not producing enough thyroid hormone). The consolidated physician orders revealed Resident # 25 was prescribe Lorazepam 0.5 mg tab three times a day for anxiety. The consolidated physician orders revealed Resident #25 was prescribed Buspirone 5 mg tab twice a day for anxiety. The consolidated physician orders revealed Resident #25 was prescribed Apixaban 2.5 mg tab twice a day for chronic atrial fibrillation. The consolidated physician orders revealed Resident #25 was prescribed Metoprolol 12.5 mg tab twice a day for heart disease of coronary artery. heart disease of coronary artery, and hypertension. <BR/>Record review of the most recent MDS dated [DATE] revealed Resident #25 had a mild cognitive impairment, was usually able to make self-understood and understand others, and need limited assistance with dressing, personal hygiene. Resident #25 did not reject care. <BR/>Review of the most recent care plan dated 6/1/2022 revealed Resident #25 had a cardiac diagnosis of congestive heart failure, chronic atrial fibrillation, and hypertension with interventions to administer apixaban. Resident #25 required one person assistance with bathing. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Lorazepam (due at 8 AM, 12 PM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, at 10:11 PM on 6/24/2022 by LVN E, and at 1:29 PM on 6/25/2022 by RN B. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Buspirone (due at 8 AM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, and at 10:11 PM on 6/24/2022 by LVN E. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Apixaban (due at 8 AM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, and at 10:11 PM on 6/24/2022 by LVN E. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #25 received Metoprolol (due at 8 AM, and 8 PM) at 9:16 AM on 6/1/2022 given by LVN A, at 10:15 AM on 6/7/2022 given by LVN A, at 9:19 AM on 6/11/2022 given by LVN A, at 9:30 AM on 6/16 by LVN A, at 9:26 PM on 6/16 by LVN D, at 9:27 AM on 6/20/2022 by LVN A, and at 10:11 PM on 6/24/2022 by LVN E. No reasons were given for late administration.<BR/>5. Record review of the consolidated physician orders dated 6/30/2022 revealed Resident #38 was [AGE] year-old, female and admitted on [DATE] with diagnoses including type 2 diabetes, end stage kidney disease, atrial fibrillation (irregular and rapid heartbeat), chronic lung disease, pain, and muscle weakness. The consolidated physician orders revealed Resident #38 was prescribed Gabapentin 100 mg tab three times a day for pain. The consolidated physician orders revealed Resident #38 was prescribed Hydrocodone-acetaminophen 5-325 mg tab three times a day for pain . <BR/>Record review of the most recent MDS dated [DATE] revealed Resident #38 was able to make herself understood and understood others and was cognitively intact. Resident #38 required limited assistance with toilet use, dressing and bathing. Resident #38 occasionally had pain at a moderate level. Resident #38 did not reject care. <BR/>Record review of the most recent care plan dated 6/9/2022 revealed Resident #38 had pain with intervention to administer pain medications as ordered. <BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #38 received Hydrocodone-acetaminophen 5-325 mg (due at 6:00 AM, 12:00 PM, and 8:00 PM) at 10:10 AM on 6/20/2022 given by LVN E, at 9:59 PM on 6/24/2022 given by LVN E, at 9:13 PM on 6/25/2022 given by LVN E, and at 1:011 PM on 6/27/2022 given by LVN D. No reasons were given for late administration.<BR/>Review of Medications Administration History dated 6/1/2022-6/27/2022 revealed Resident #38 received Gabapentin (due at 8:00 AM, 2:00 PM, and 8:00 PM) at 3:38 PM on 6/20/2022 given by LVN F, at 10:10 PM on 6/20/2022 given by LVN E, at 4:16 PM on 6/24/2022 given by LVN A, at 9:59 PM on 6/24/2022 given by LVN E, and at 9:13 PM on 6/25/2022 given by LVN E. No reasons were given for late administration.<BR/>During interview on 6/30/2022 at 11:32 AM, LVN F said she had been working at the facility for 2 years. Nurse F said when a nurse administers medication, a timestamp was made to record when the medication was given. LVN F said they had a two-hour window to administer medication, one hour before and after the time it was due. LVN F said sometimes the staff got busy and medications were late. LVN F said when a medication was only 30 minutes late, it would have no effect on resident. LVN F said late administration could throw off the medication schedule, and adversely affect the resident. <BR/>During interview on 6/30/2022 at 1:55 PM, LVN A said she had been working at the facility for 4 months. LVN A said medication times were entered when the nurse administers medications to the resident. LVN A said they had 1 hour before and after the time was due to given medications. LVN A said staffing issues had sometimes caused medications to be given late. LVN A said administering medication late could result in a resident having pain, or their blood pressure being high. <BR/>During interview on 6/30/2022 at 2:34 PM, the DON said corporate had looked at reports weekly for late medication administration. The DON said she also gets a report listing of late medication administration . The DON said medications administered late were a different color than medications given on time. The DON said she could ensure medications were given on time using these reports. The DON said medications were considered late when they were administered more than 1 hour after their due time. The DON said medications were timestamped in the computer when they were administered. The DON said the facility has a policy of administering medications 1 hour before and after the time they were due. The DON said residents could experience pain or have blood pressure problems when medications were not administered when due.<BR/>During interview on 6/30/2022 at 3:12 PM, the Administrator said she expected medications to be administered on time. The administrator said when medications were administered late, residents could have critical lab results.

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 a skillet was free from encrusted black colored grease buildup coating the entire outside and most of the inside surface.<BR/>The facility failed to ensure the windowsill over the 3-compartment sink was free from insect carcasses. <BR/>The facility failed to ensure the plastic condiment bins were free from a tan colored buildup (grease like).<BR/>The facility failed to repair a leaking drainpipe under the 3-compartment sink.<BR/>The facility failed to ensure the juice machine nozzle was free from a brownish pink gooey substance where the juice was dispersed.<BR/>The facility failed to ensure the dishwashing machine's heating element panel was replaced to cover the electrical wiring. <BR/>These failures could place the residents at risk for food-borne illness, and food contamination.<BR/>Findings included:<BR/>During an observation on 6/27/2022 at 9:55 a.m., the following was observed:<BR/>*There were bug carcasses in the windowsill above the 3-compartment sink. <BR/>*the 3-compartment sink had the drainage pipe leaking into a red sanitation bucket.<BR/>*plastic condiment containers with a tan colored grease like buildup. <BR/>*juice machine nozzle with a gooey brownish/pink substance inside where the juice was dispersed.<BR/>*the dish machine had a panel off a site which appeared to be covering electrical wiring.<BR/>*a skillet on the stove top had an encrusted black colored grease buildup on the entire outside surface and most of the inside surface.<BR/>During an interview on 6/27/2022 at 10:08 a.m., the DM indicated the drainpipe has been leaking for several months. The DM indicated she had attempted replace the panel on the dish machine, but the panel continues to fall off. The DM indicated the repair man had come to work on the dish machine approximately 2 weeks ago. <BR/>During an observation on 6/28/2022 at 8:56 a.m., the juice machine nozzle continued to have a gooey brownish/pink buildup inside where the juice was dispersed. The grease encrusted skillet was on the stove top and appeared to have been used to fry eggs. <BR/>During an observation and interview on 6/28/2022 at 9:04 a.m., the ADM indicated the facility had plumbing issues. The ADM indicated the window was included in a bid for replacement but did not reply on the bug carcasses. The ADM indicated she would purchase another fry skillet for the kitchen. She indicated she expected the kitchen to be clean. The ADM indicated she was responsible for the dietary department.<BR/>During an interview on 6/28/2022 at 9:15 a.m., the DM indicated the encrusted black colored skillet could not be cleaned. The DM indicated the maintenance supervisor fixed the pipe today and reapplied the panel cover to the box containing electrical wiring. The DM indicated she comes to deep clean each Sunday. The DM manager indicated she had soaked the juice nozzle in bleach on the prior Sunday 6/26/2022.<BR/>During an interview on 6/28/2022 at 10:35 a.m., the [NAME] indicated she had used the encrusted skillet was used to fry eggs every morning. The [NAME] indicated the encrusted skillet was cleaned using a steel wool pad. The [NAME] indicated deep cleaning day was each Sunday.<BR/>During an interview on 6/30/2022 at 8:30 a.m., the DM validated the tan colored build up on the plastic storage bins. She indicated the cook was responsible for cleaning the bins. The DM indicated the encrusted black skillet was the only skillet the kitchen had to use. <BR/>Record review of an undated Sample Weekly Cleaning Schedule indicated the containers were assigned for cleaning weekly to the cook.<BR/>Record review of a General Kitchen Sanitation policy dated 2018 indicated the facility recognizes that a food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil.<BR/>Record review of FDA Food Code 2017; accessed on 7/7/2022<BR/>4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOODCONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated 113 WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.<BR/>4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 14 residents reviewed for quality of care. ( Resident #36)<BR/>The facility failed to document Resident #36's left knee abrasion (surface layers of the skin (epidermis) had been broken. <BR/>This failure could place residents at risk for decreased quality of care and injury. <BR/>Findings included:<BR/>1. Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #36 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (force of the blood against the artery walls is too high) and personal history of transient ischemic attack (temporary blockage of blood flow to the brain).<BR/>Record review of the MDS dated [DATE] indicated Resident #36 understood others, made himself understood. The MDS indicated Resident #36 was severely cognitively impaired (BIMS score of 3). The MDS indicated he required total dependence with transfers, dressing, toileting, and bathing: extensive assistance with bed mobility and personal hygiene. The MDS indicated Resident #36 had active diagnoses of hypertension, cerebrovascular accident (CVA), transient ischemic attack (TIA) or stroke and diabetes mellitus. The assessment did not indicate Resident #36 had an abrasion.<BR/>Record review of the care plan dated 6/29/22 indicated Resident #36 had an abrasion to left outer knee. The care plan indicated long-term goals of area will be healed by next review date. Interventions included to monitor site daily for signs and symptoms of infection, notify MD of any abnormality dated 6/29/22, treatment per MD orders-clean with normal saline, apply collagen and cover with dry dressing dated 6/29/22, weekly skin assessment and document finding dated 6/29/22. <BR/>Record review of an observation report dated 6/12/22 written by LVN N indicated . skin color is normal. Skin moisture was dry. No alterations in skin. <BR/>Record review of an untitled note dated 6/21/22 indicated Resident #36 had a small, dried scab to his left knee. <BR/>Further review of consolidated physicians' orders dated 5/29/22-6/29/22 indicated Resident #36 had an order for wound care to right knee with a start date 6/29/22.<BR/>Record review of a TAR dated 6/1/22-6/30/22 did not indicate Resident #36 was receiving wound care to his left knee until surveyor intervention 6/29/22. <BR/>During an interview and observation on 6/27/22 at 10:31 a.m., Resident #36 was lying in bed with a band-aid on his left knee. Resident was not able to tell surveyor what happened to his knee. <BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said she was Resident #36 and Resident #15 charge nurse on the 6a-6p shift. LVN G said she noticed an abrasion to Resident #36's left knee on 6/27/22 when she was feeding him breakfast. LVN G said Resident #36's left knee was leaning on the wall and she noticed the knee was bleeding, and she applied a band aid to his left knee. LVN G said she reported the area to ADON D on 6/27/22. LVN G said the charge nurse was responsible for completing a skin assessment upon admission. LVN G said if there was no order for wound care and the wound was not reported to the next nurse in report there would not be a way to monitor the wound effectively. LVN G said this failure could potentially place Resident #36 at risk for infection. <BR/>During an interview on 6/30/22 at 12:38 p.m., the Transportation Aide said she noticed the area to Resident #36 left knee when she was preparing him for transport to this facility on 6/6/22. <BR/>During an interview on 6/30/22 at 11:35 a.m., LVN F said she noticed the abrasion to Resident #36 left knee when she admitted him. LVN F said she completed a skin assessment upon admission, but she must have not click saved. LVN F said the physician was not notified. LVN F said the physician should have been notified. She said nurses could not monitor the area if there was no communication and it was not showing up on the TAR. LVN F said the potential risk for not monitoring or documenting the area on Resident #36 left knee was nurses would not know the cause of the injury and could put Resident #36 at risk for infection.<BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said the charge nurse was responsible for completing a skin assessment within 2 hours upon admission. The DON said all residents with a wound should have an order for wound care and it should be documented on the TAR. The DON said the process for notifying the physician was when the wound was identified, the staff would be informed, the primary care is notified, an order is written. The DON said she was not notified of the abrasion to Resident #36 left knee until surveyor intervention. She said if there was no order there could be failure in following up on the wound which could cause an infection. The DON said she checked orders daily before stand-up meeting. The DON said she does a skin sweep audit every Thursday. The DON said the order must have been missed.<BR/>Record review of the facility's policy tilted Physician Services revised on 10/2021 did not address skin assessments.

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 2 of 4 staff (CNA D and CNA F) reviewed for infection control.<BR/>The facility failed to ensure CNA D and CNA F changed their gloves and performed hand hygiene while providing incontinent care to Resident #8.<BR/>These failures could place residents and staff at risk for cross-contamination and the spread of infection.<BR/>Findings included:<BR/>During an observation on 06/13/2023 starting at 1:39 PM, CNA D and CNA F provided incontinent care to Resident #8. CNA D and CNA F put on gloves. CNA D removed the dirty sheets and placed them on the floor. CNA D and CNA F unfastened Resident #8's brief. CNA D tucked the dirty brief under Resident #8's side and both CNAs turned him on his side. Resident #8 had a yellow-brownish ring on his sheets and his bed pad that extended up to his shoulders and down to his knees. CNA F wiped Resident #8's back peri area and removed the dirty brief. CNA F threw the dirty brief in the trashcan. CNA D and CNA F did not remove their dirty gloves and they did not perform hand hygiene. CNA D and CNA F applied the clean brief with dirty gloves. CNA F proceeded to apply zinc barrier cream to Resident #8's buttocks due to slight redness to his buttocks. The CNAs fastened the brief, and CNA F went to Resident #8's drawers to look for clean clothes. CNA D removed Resident #8's hospital gown and then helped CNA F dress Resident #8. CNA D and CNA F did not remove their gloves and they did not perform hand hygiene prior to applying Resident #8's clean clothes. CNA F went out of the room to get the Hoyer lift still wearing the same gloves. CNA D and CNA F transferred Resident #8 to his wheelchair. After transferring him to his wheelchair CNA D removed her gloves and did not perform hand hygiene, and CNA F wheeled Resident #8 to the lobby area still wearing the same gloves. CNA F removed her gloves after leaving Resident #8 in the lobby area. CNA F did not perform hand hygiene. <BR/>During an interview on 06/13/2023 at 2:09 PM, CNA D said she had not been to check on Resident #8 today because she was working in a team with CNA F. CNA D said she would not have done anything differently when providing incontinent care. CNA D said hand hygiene should be performed before starting and when you leave the room. CNA D said she should have performed hand hygiene when she finished providing incontinent care to Resident #8. CNA D said hand hygiene should be performed after glove removal. CNA D said she changed her gloves when she should have changed them when she left the room. CNA D said she did not remember when her last check off or training on incontinent care had been. CNA D said it was important to provide prompt incontinent care to prevent skin breakdown. CNA D said it was important to perform glove changes and hand hygiene while providing incontinent care because of cross contamination and germs. <BR/>During an interview on 06/13/2023 at 2:20 PM, CNA F said the last time she checked on Resident #8 was at 11:30 AM that morning. CNA F said she was supposed to check on the residents every 2 hours. CNA F said she was not able to do this due to being short. CNA F said she should have changed gloves and washed her hands after removing the dirty brief. CNA F said she should not have placed the dirty linens on the floor, but she did not have a trash bag to put them in. CNA F said she did not wash her hands because there was no soap or paper towels in Resident #8's room. CNA F said this had been happening a lot and she had notified the Housekeeping Supervisor and the Maintenance Supervisor. CNA F said her last training on providing incontinent care was 3 months ago. CNA F said it was important to provide prompt incontinent care to prevent skin breakdown, redness, and rashes. CNA F said it was important to perform hand hygiene and change gloves while providing incontinent care for cross contamination. <BR/>During an interview on 06/14/2023 at 6:17 AM, LVN G said there was no soap or paper towels that this happened randomly. LVN G said sometimes they had them and sometimes they did not. LVN G said had notified the DON, ADON, and the maintenance man. LVN G said he was told it was on back order. <BR/>During an interview on 06/14/2023 at 5:48 PM, the Housekeeping Supervisor said she did not know how the facility had come up short on paper towels and soap that this had been going on for about a week. The Housekeeping Supervisor said they were short because she forgot to order earlier in the month and she usually had a stash, but she guessed people used it up. The Housekeeping Supervisor said it was important to have soap and paper towels available to the staff to keep clean and for the staff to be able to wash their hands. <BR/>During an interview on 06/16/2023 at 6:15 PM, the ADON said nurse management was responsible for making sure the CNAs provided proper incontinent care. The ADON said nurse management monitored the CNAs to ensure they were providing proper incontinent care by performing the yearly competencies. The ADON said the CNAs should be checking on the residents every 2 hours. The ADON said while providing incontinent care gloves should be changed after removing the dirty brief and after providing perineal care. The ADON said gloves should be changed and hand hygiene performed anytime you moved from dirty to clean. The ADON said the CNAs should not leave the room with the dirty gloves. The ADON said it was important to provide prompt incontinent are to prevent skin breakdown. The ADON said not performing hand hygiene and not changing gloves adequately while providing incontinent care placed the residents at risk for infection. <BR/>During an interview on 6/16/23 at 7:08 PM, the DON said while providing incontinent care the CNAs should perform hand hygiene when they enter the room and prior to applying gloves. The DON said the CNAs should change gloves when moving from dirty to clean. The DON said while providing incontinent care the CNAs should change gloves and perform hand hygiene several times. The DON said proficiencies for the CNAs on incontinent care were performed yearly by her or the ADON. The DON said she randomly went into rooms to observe the CNAs provide incontinent care. The DON said there was a time when she observed CNA D and CNA F provide incontinent care and she had to tell them to change their gloves. The DON said she could not remember when this occurred. The DON said it was important to provide prompt and proper incontinent care so the residents would not get a UTI, skin breakdown, and to make sure their skin was clean. <BR/>During an interview on 06/16/2023 at 8:26 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said clinical management should make sure the CNAs are providing proper incontinent care. The Administrator said it was important to provide proper incontinent care and to perform hand hygiene to reduce infection. <BR/>Record review of the facility's policy titled, Perineal Care, last revised, 01/20/2023, indicated Steps in the Procedure .3. Perform hand hygiene and don gloves. 4. Arrange the supplies so they can be easily reached . 6. Remove clothing enough to perform peri-care. Avoid unnecessary exposure of the resident's body. 7. Remove the soiled clothing, linens, and brief. Place items in the proper receptacle . B. For a Male Resident: (1) Use a cleansing wipe. (2) Clean perineal area starting with urethra and working outward . (5) Clean urethral area with a cleansing wipe using a circular motion. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. Use a new cleansing wipe, as needed. (6) Continue to clean the perineal area including the penis, scrotum, inner thighs. (7) Thoroughly clean perineal area in same order, using a new cleansing wipe as needed . (12) Clean the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks, change the cleansing wipe, as needed. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. 10. Dry area thoroughly. 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. 13. Perform Hand Hygiene. 14. Reposition the bed covers. Make the resident comfortable. 15. Place the call light within easy reach of the resident. 16. Perform Hand Hygiene .<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene , last revised 01/20/2023, indicated, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Hand hygiene must be performed prior to donning and after doffing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 7 of 13 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights.<BR/>The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him.<BR/>The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. <BR/>The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed.<BR/>The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy.<BR/>The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you.<BR/>The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. <BR/>The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry.<BR/>The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. <BR/>This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.<BR/>This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.<BR/>Findings included: <BR/>1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. <BR/>Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. <BR/>Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath.<BR/>During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. <BR/>Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. <BR/>Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. <BR/>2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. <BR/>Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. <BR/>Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE].<BR/>During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. <BR/>During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. <BR/>3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations).<BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. <BR/>Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. <BR/>During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview.<BR/>4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter).<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. <BR/>During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident.<BR/>5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. <BR/>During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again.<BR/>6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility.<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview.<BR/>7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. <BR/>During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. <BR/>During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. <BR/>During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. <BR/>During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests.<BR/>During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them.<BR/>During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. <BR/>Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. <BR/>During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. <BR/>During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. <BR/>During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. <BR/>During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F.<BR/>During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said it was important to treat the residents with dignity and respect because it was their right. The Administrator said not treating a resident with dignity and respect could affect their well-being and make them feel bad. <BR/>During an interview on [DATE] at 5:15 PM, LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop pas[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7)<BR/>The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him.<BR/>The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. <BR/>The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed.<BR/>The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy.<BR/>The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you.<BR/>The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. <BR/>The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry.<BR/>The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. <BR/>This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.<BR/>This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.<BR/>Findings included: <BR/>1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. <BR/>Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. <BR/>Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath.<BR/>During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. <BR/>Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. <BR/>Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. <BR/>2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. <BR/>Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. <BR/>Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE].<BR/>During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. <BR/>During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. <BR/>3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations).<BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. <BR/>Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. <BR/>During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview.<BR/>4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter).<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. <BR/>During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident.<BR/>5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. <BR/>During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again.<BR/>6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility.<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview.<BR/>7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. <BR/>During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. <BR/>During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. <BR/>During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. <BR/>During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests.<BR/>During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them.<BR/>During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. <BR/>Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. <BR/>During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. <BR/>During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. <BR/>During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. <BR/>During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said, I am not saying she never missed a shower because there were problems. The DON said she tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F.<BR/>During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. <BR/>Record review of LVN A's personnel file did not indicate any previous disciplinary actions. LVN A's personnel file did not indicate a termination date. <BR/>During an interview on [DATE] at 5:15 PM (LVN A returned phone call after facility exit), LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop passing out medications to give them their cigarettes. LVN A said after she told them this Resident #4 got really pissed of[TRUNCATED]

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2023 for the second quarter (January 1, 2023, to March 31, 2023) reviewed for administration. <BR/>The facility failed to submit accurate RN hours for: 1/3 (TU); 1/6 (FR); 1/16 (MO); 1/17 (TU); 1/20 (FR); 1/25 (WE); 1/31 (TU); 2/8 (WE); 2/15 (WE) <BR/>These failures could place residents at risk for personal needs not being identified and met.<BR/>Findings included:<BR/>Record review of the CMS PBJ report for the second quarter of 2023 (January 1, 2023, through March 31, 2023) indicated there was no RN hours for the following dates: 1/3 (TU); 1/6 (FR); 1/16 (MO); 1/17 (TU); 1/20 (FR); 1/25 (WE); 1/31 (TU); 2/8 (WE); 2/15 (WE) <BR/>Record review of a RN punch detail report for January and February 2023 indicated RN hours on 1/3/2023, 1/6/2023, 1/16/2023, 1/17/2023, 1/20/2023, 1/25/2023, 1/31/2023, 2/8/2023 and 2/15/2023. <BR/>During an interview on 08/24/2023 at 1:58 p.m., the Compliance Officer stated he was responsible for ensuring the PBJ data was submitted. The Compliance Officer stated due to organizational changes in the PBJ reporting it was possible there may be direct care hours that were worked but not reporting in the PBJ submission. The Compliance Officer stated the source he used during January 1st, 2023-March 31st, 2023, to pull the hours were not picking up the RN hours accurately. The Compliance Officer stated he has now figured out a more accurate way of submitting RN hours. The Compliance Officer stated it was important to submit the PBJ data to have a more accurate reflection of the exact care the facility was given. <BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the facility's policy titled Staffing last revised on 07/2021, indicated, 4. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 7 of 13 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights.<BR/>The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him.<BR/>The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. <BR/>The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed.<BR/>The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy.<BR/>The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you.<BR/>The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. <BR/>The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry.<BR/>The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. <BR/>This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.<BR/>This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.<BR/>Findings included: <BR/>1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. <BR/>Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. <BR/>Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath.<BR/>During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. <BR/>Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. <BR/>Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. <BR/>2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. <BR/>Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. <BR/>Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE].<BR/>During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. <BR/>During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. <BR/>3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations).<BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. <BR/>Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. <BR/>During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview.<BR/>4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter).<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. <BR/>During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident.<BR/>5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side.<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. <BR/>During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again.<BR/>6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility.<BR/>Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview.<BR/>7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. <BR/>Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. <BR/>During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. <BR/>During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. <BR/>During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. <BR/>During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. <BR/>During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests.<BR/>During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them.<BR/>During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. <BR/>Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. <BR/>During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. <BR/>During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. <BR/>During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. <BR/>During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F.<BR/>During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said it was important to treat the residents with dignity and respect because it was their right. The Administrator said not treating a resident with dignity and respect could affect their well-being and make them feel bad. <BR/>During an interview on [DATE] at 5:15 PM, LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop pas[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility.<BR/>The facility did not update their facility assessment when they admitted Resident #35 and #43 who required hemodialysis (a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy) treatment. <BR/>The facility did not update their facility assessment when they admitted Resident #39 with a wound vac (a type of therapy to help heal wounds). <BR/>These deficient practices could affect the resident by not having the necessary resources to ensure appropriate care is provided. <BR/>Findings included: <BR/>Record review of the facility assessment dated [DATE] revealed it did not address residents who used a wound vac or received dialysis. <BR/>1. Record review of Resident #35's face sheet, dated 08/24/2023, indicated Resident #35 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included dependence on renal dialysis, hypertension (high blood pressure), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of the physician order report, dated 08/24/2023, indicated Resident #35 to attend hemodialysis Tuesdays, Thursdays, and Saturdays with chair time at 12:10 p.m. with a start date 05/23/2023. <BR/>2. Record review of Resident #43's face sheet, dated 08/24/2023, indicated Resident #43 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dependence on renal dialysis, hypertension (high blood pressure), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Record review of the physician order report, dated 08/24/2023, indicated Resident #43 to attend hemodialysis Mondays, Wednesdays, and Fridays with a start date 06/28/2023. <BR/>3. Record review of Resident #39's face sheet, dated 08/24/2023, indicated Resident #39 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included hypertension (high blood pressure), muscle weakness, and acute kidney failure with tubular necrosis (kidney disorder involving damage to the tubule cells of the kidneys). <BR/>Record review of the physician order report, dated 08/24/2023, indicated Resident #43 had a wound vac to his right lateral leg with a start date 07/06/2023. <BR/>During an interview on 08/24/2023 at 1:40 p.m., the Survey Resource stated the Administrator was responsible for completing and updating the facility assessment. <BR/>During an interview on 08/25/2023 at 4:15 p.m., the DON stated the Administrator was responsible for completing and updating the facility assessment. The DON stated the facility assessment should have been reviewed and updated to reflect Resident #35 and #43 who required hemodialysis and Resident #39 who had a wound vac to his right lateral leg. The DON stated it was important to update the facility assessment to reflect changes in the care and services the facility provides. <BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the facility's policy titled Center Assessment last revised on 10/2021, indicated, a center assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. 9. The center assessment is reviewed and updated annually, and as needed. Center or resident changes or modifications that may prompt a reassessment sooner included: a. A decision to provide specialized care or services that had not been previously available to residents; c. A significant change in the resident census and/or overall acuity of our residents 10. The QAPI Committee is responsible for reviewing center and resident information quarterly to determine if a reassessment is warranted

**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 3 of 3 halls (East, South, and [NAME] halls), 1 of 1 dining rooms, 1 of 1 lobby area, and 2 of 13 residents (Resident #9 and Resident #11) reviewed for a homelike environment.<BR/>The facility failed to ensure the East, South and [NAME] halls, lobby, and dining room were free of offensive odors. <BR/>The facility failed to ensure Resident #9 and Resident #11's bed linens were changed. <BR/>This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two- person assist for bathing. <BR/>Record review of the care plan with a target date of 07/16/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. <BR/>2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. <BR/>Record review of the care plan with a target date of 07/06/2023 indicated, Resident #11 required two-person assistance or total assistance for dressing and grooming needs, and total assistance for toileting. <BR/>During an observation upon entrance of the facility on 06/13/2023 at 09:03 AM a strong odor of urine was detected in the lobby area and East Hall. <BR/>During an observation on 06/13/2023 at 11:45 AM, a strong odor of urine was detected in the South Hall and in the dining room.<BR/>During an observation and interview starting on 06/13/2023 1:05 PM, the [NAME] and South Hall had a strong, pungent urine odor. While walking down the South Hall the Administrator said she thought it was because one of the residents had incontinent episode in the hallway or maybe it was somebody that had walked by. <BR/>During an observation and interview on 06/13/2023 at 1:49 PM, Resident #11 said the sheets on his bed had not been changed in a long time. The sheets had dirty yellow and orange stains on them, and the pillow was light brownish tinged. Resident #11 said he should not have to ask the CNAs to change his sheets they should be doing this. <BR/>During an observation and interview on 06/13/2023 at 2:06 PM, Resident #9 had light brownish tinged sheets on her bed, the blue pad on the bed had smears of feces on them. There was a musty, pungent, feces odor. Resident #9 said the CNAs told her they could not change her sheets because they did not have enough staff to do it. Resident #9 said the CNAs told her they want her to do those things herself. Resident #9 said she was not able to change her own sheets and she cannot wipe herself good enough after she had a bowel movement. <BR/>During an observation and interview starting on 06/14/2023 5:07 AM, the [NAME] Hall and South Hall had a strong urine odor. There were trash barrels in the [NAME] and South Hall with no lids and flies around them. CNA G said she had left them uncovered because she was changing people.<BR/>During an observation and interview starting on 06/14/2023 at 9:14 AM, a strong odor of urine was detected in the South Hall. Resident #10 said she kept the door to her room closed because it smells like pee out there. Resident #10 said the urine odor made her feel sick and disgusting. <BR/>During an observation on 06/15/2023 at 3:11 PM, there was an odor of urine on the [NAME] and South Halls. <BR/>During an observation and interview on 06/16/2023 at 11:10 AM, there was an odor of urine on the [NAME] and South Halls. <BR/>During an observation and interview on 06/16/2023 at 5:18 PM, Resident #11 said his sheets had not been changed. Resident #11's sheets had dirty yellow and orange stains on them, and the pillow had a light browning tinge to it. <BR/>During an observation and interview on 06/16/2023 at 5:20 PM, Resident #9 said her blue pad had been changed but not the sheets on her bed. Resident #9's sheets were light brownish tinged, and there was a musty odor. <BR/>During an interview on 06/16/2023 at 5:35 PM, CNA C said she changed Resident #9's sheets last night, but she had not changed Resident #11's. CNA C said Resident #11 does his own thing when he wants to. CNA C said it was important to change the residents' sheets because it was their home, and it was their right. <BR/>During an interview on 06/16/2023 at 6:24 PM, the ADON said she had noticed a urine odor on East Hall. The ADON said the residents had not complained to her about a urine odor. The ADON said all the staff were responsible for making sure the facility did not have offensive odors. The ADON said the offensive odors could make the residents not want to leave their room, and it could affect their mental health. <BR/>During an interview on 06/16/2023 at 8:01 PM, the DON said she had noticed the offensive odors in the facility, and she had reported it to the Administrator and the housekeepers. The DON did not provide specific dates. The DON said she expected the CNAs to change the residents' sheets and she was not aware that any of the residents' sheets had not been changed. The DON said all the staff should be making sure the facility did not have offensive odors. The DON said it was important to keep the facility free of offensive odors because I don't like to smell bad odors. The DON said it was important for the residents to have clean sheets because she wanted to provide a clean and safe environment for the residents.<BR/>During an interview on 06/16/2023 at 8:27 PM, the Administrator said she had noticed the urine odor in the facility. The Administrator said urine odor was not a normal thing at the facility, and she did not know what was happening this week that there was a urine odor in the facility. The Administrator said all the staff were responsible for making sure there were no offensive odors in the facility. The Administrator said she expected for the staff to provide a homelike environment for the residents. <BR/>Record review of the facility's policy titled, Homelike Environment, last revised February of 2021, indicated, Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .clean bed and bath linens that are in good condition .The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: . institutional odors .

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (medication and nurse carts) reviewed for storage of medications. <BR/>The facility failed to ensure [NAME] Hall nurse's cart and Southeast medication cart was secured and unable to be accessed by unauthorized personnel. <BR/>This failure could place residents at risk of medication misuse and diversion.<BR/>Findings included:<BR/>1. During an observation on 08/22/2023 at 11:51 a.m., LVN C was preparing to give Resident #9 insulin (a product used to lower blood sugar). LVN C drew the insulin in the syringe, gathered an alcohol pad and closed the cart. LVN C then entered the room of Resident #9 and left [NAME] Hall nurse's cart unlocked, and out of sight, while administering Resident #9's insulin into his right arm. <BR/>During an interview on 08/22/2023 at 12:22 p.m., LVN C stated the medication cart should be locked anytime she walked away from it, or out of her sight. LVN C stated she forgot to lock the cart because the surveyor was present. LVN C stated it was important to keep the medication locked at all times for safety. <BR/>2. During an observation on 08/22/2023 at 12:32 p.m., MA L was preparing to administer Resident #42 eye drops. MA L gathered Resident #42's eye drops and left the Southwest medication cart unlocked, and out of sight, while administering Resident #42's eye drops. <BR/>During an interview on 08/23/2023 at 4:54 p.m., MA L stated she had been working the medication cart all morning and she had not left her cart unlocked until it was observed by the surveyor. MA L stated she should have verified her cart was locked prior to entering Resident #42's room. MA L stated it was left unlocked because she was nervous. MA L stated it was important to ensure the medication cart was locked to prevent residents from taking medication and harming themselves. <BR/>During an interview on 08/25/2023 at 4:15 p.m., the DON stated she expected staff to ensure medication carts were locked. The DON stated it was monitored by random daily observations and education. The DON stated it was important because a residents could get in it, and it was dangerous. The DON stated it was dangerous because of overdose or adverse reaction. <BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the facility's policy titled Storage of Medications last revised on 11/2020, indicated, the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended <BR/>Record review of the facility's policy titled Administering Medications last revised on 04/2019, indicated, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 5 of 5 meetings (March 2023, April 2023, May 2023, June 2023, and July 2023) reviewed for QAPI. <BR/>The facility did not ensure the ADON attended QAPI meetings in March 2023, April 2023, and May 2023. <BR/>The facility did not ensure the DON attended QAPI meeting in June 2023. <BR/>The facility did not ensure one additional staff member attended QAPI meetings in April 2023, May 2023, June 2023, and July 2023. <BR/>This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. <BR/>Findings included: <BR/>Record review of the facility's QAPI Committee sign-in-sheets for March 2023, April 2023, and May 2023 indicated the ADON did not sign in for their meetings. <BR/>Record review of the facility's QAPI Committee sign-in-sheets for June 2023 indicated the DON did not sign in for their meetings. <BR/>Record review of the facility's QAPI Committee sign-in-sheets for April 2023, May 2023, June 2023, and July 2023 indicated one additional staff member did not sign in for the meetings. <BR/>Record review of an undated form titled QAA/QAPI Committee indicated the committee members were the Administrator, DON, ADON, Maintenance, Director of Rehab, Housekeeping Supervisor, Director of Dining Services, and the MDS Coordinator. <BR/>During an interview on 08/24/2023 at 2:38 p.m., the ADON stated her role as a ADON was not until 03/27/2023. The ADON stated, honestly I couldn't tell you why I didn't attend the meetings in April and May. The ADON stated it was important to attend the meetings so the facility can identify any trends that needed intervention. <BR/>During an interview on 08/25/2023 at 4:15 p.m., the DON stated she normally attended QAPI once a month. The DON stated she believed she attended in June 2023 and was unsure why she did not sign the minutes. The DON stated she was unsure why one additional staff member did not attend the meetings in April 2023, May 2023, June 2023, and July 2023. The DON stated if other staff members attended the meetings or reviewed the minutes after the meetings, they should have signed the sign in sheet. The DON stated it was important to make sure QAPI minutes were signed to prove she was there and so she could monitor the resident's care and communicate with the nursing staff. <BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program last revised on 02/08/2023, indicated, this center shall develop, implement, and maintain an ongoing, center-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents Authority 3. The Administrator is responsible for assuring that this center's QAPI program complies with federal, state, and local regulatory agency requirements. Implementation 1. The QAPI Committee oversees implementation of our QAPI Plan, which is the written component describing the specifics of the QAPI program, how the center will conduct its QAPI functions, and the activities of the QAPI Committee. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 14 residents reviewed for quality of care. ( Resident #36)<BR/>The facility failed to document Resident #36's left knee abrasion (surface layers of the skin (epidermis) had been broken. <BR/>This failure could place residents at risk for decreased quality of care and injury. <BR/>Findings included:<BR/>1. Record review of the physician order report dated 5/30/22-6/30/22 indicated Resident #36 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (force of the blood against the artery walls is too high) and personal history of transient ischemic attack (temporary blockage of blood flow to the brain).<BR/>Record review of the MDS dated [DATE] indicated Resident #36 understood others, made himself understood. The MDS indicated Resident #36 was severely cognitively impaired (BIMS score of 3). The MDS indicated he required total dependence with transfers, dressing, toileting, and bathing: extensive assistance with bed mobility and personal hygiene. The MDS indicated Resident #36 had active diagnoses of hypertension, cerebrovascular accident (CVA), transient ischemic attack (TIA) or stroke and diabetes mellitus. The assessment did not indicate Resident #36 had an abrasion.<BR/>Record review of the care plan dated 6/29/22 indicated Resident #36 had an abrasion to left outer knee. The care plan indicated long-term goals of area will be healed by next review date. Interventions included to monitor site daily for signs and symptoms of infection, notify MD of any abnormality dated 6/29/22, treatment per MD orders-clean with normal saline, apply collagen and cover with dry dressing dated 6/29/22, weekly skin assessment and document finding dated 6/29/22. <BR/>Record review of an observation report dated 6/12/22 written by LVN N indicated . skin color is normal. Skin moisture was dry. No alterations in skin. <BR/>Record review of an untitled note dated 6/21/22 indicated Resident #36 had a small, dried scab to his left knee. <BR/>Further review of consolidated physicians' orders dated 5/29/22-6/29/22 indicated Resident #36 had an order for wound care to right knee with a start date 6/29/22.<BR/>Record review of a TAR dated 6/1/22-6/30/22 did not indicate Resident #36 was receiving wound care to his left knee until surveyor intervention 6/29/22. <BR/>During an interview and observation on 6/27/22 at 10:31 a.m., Resident #36 was lying in bed with a band-aid on his left knee. Resident was not able to tell surveyor what happened to his knee. <BR/>During an interview on 6/30/22 at 9:41 a.m., LVN G said she was Resident #36 and Resident #15 charge nurse on the 6a-6p shift. LVN G said she noticed an abrasion to Resident #36's left knee on 6/27/22 when she was feeding him breakfast. LVN G said Resident #36's left knee was leaning on the wall and she noticed the knee was bleeding, and she applied a band aid to his left knee. LVN G said she reported the area to ADON D on 6/27/22. LVN G said the charge nurse was responsible for completing a skin assessment upon admission. LVN G said if there was no order for wound care and the wound was not reported to the next nurse in report there would not be a way to monitor the wound effectively. LVN G said this failure could potentially place Resident #36 at risk for infection. <BR/>During an interview on 6/30/22 at 12:38 p.m., the Transportation Aide said she noticed the area to Resident #36 left knee when she was preparing him for transport to this facility on 6/6/22. <BR/>During an interview on 6/30/22 at 11:35 a.m., LVN F said she noticed the abrasion to Resident #36 left knee when she admitted him. LVN F said she completed a skin assessment upon admission, but she must have not click saved. LVN F said the physician was not notified. LVN F said the physician should have been notified. She said nurses could not monitor the area if there was no communication and it was not showing up on the TAR. LVN F said the potential risk for not monitoring or documenting the area on Resident #36 left knee was nurses would not know the cause of the injury and could put Resident #36 at risk for infection.<BR/>During an interview on 6/30/22 at 2:31 p.m., the DON said the charge nurse was responsible for completing a skin assessment within 2 hours upon admission. The DON said all residents with a wound should have an order for wound care and it should be documented on the TAR. The DON said the process for notifying the physician was when the wound was identified, the staff would be informed, the primary care is notified, an order is written. The DON said she was not notified of the abrasion to Resident #36 left knee until surveyor intervention. She said if there was no order there could be failure in following up on the wound which could cause an infection. The DON said she checked orders daily before stand-up meeting. The DON said she does a skin sweep audit every Thursday. The DON said the order must have been missed.<BR/>Record review of the facility's policy tilted Physician Services revised on 10/2021 did not address skin assessments.

Based on observation, interview, and record review the facility failed to ensure residents received their mail that was delivered on Saturdays for 3 of 9 confidential residents reviewed for weekend mail delivery.<BR/>The facility failed to ensure residents received their mail on the weekend.<BR/>This failure could affect all residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life.<BR/>Findings included:<BR/>During a confidential group interview on 6/28/2022 at 2:00 p.m., 3 of the 9 residents said mail was not being distributed on Saturdays. They had been told the mailbox was locked outside the building and the weekend staff did not have a key to the mailbox. <BR/>During an interview on 6/29/2022 at 12:34 p.m., the BOM indicated the mailbox was located outside and was a locking mailbox. The BOM indicated during the weekdays she would obtain the mail from the locked mailbox and would give the AD the resident mail. The BOM said the mail was not available to the residents on Saturdays. The BOM indicated she was unaware of the requirement for the residents to have access to their mail on Saturdays. The BOM indicated she would come up on the weekends to ensure the residents had their mail. <BR/>During an interview on 6/30/2022 at 3:24 p.m., the ADM indicated she expected the residents to receive their mail on Saturdays. <BR/>Record review of the Resident Rights policy dated February 2021 indicated employees shall treat all residents with kindness, respect, and dignity cc. access to a telephone, mail and email. <BR/>Record review of HUMAN RESOURCES CODE CHAPTER 102. RIGHTS OF THE ELDERLY (texas.gov) accessed on 7/06/2022 read:<BR/>Sec. 102.003. RIGHTS OF THE ELDERLY. (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.<BR/>An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident councils. An elderly person may send and receive unopened mail, and the person providing services shall ensure that the individual's mail is sent and delivered promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to ensure the facility corridors were equipped with firmly secured handrails on each side of the corridor for 2 of 3 corridors reviewed for secured handrails. (South and [NAME] Halls)<BR/>The facility failed to ensure the [NAME] hall's handrails were affixed to the walls securely. <BR/>The facility failed to ensure the handrail were properly secured between room [ROOM NUMBER] and #18, room [ROOM NUMBER] and room [ROOM NUMBER], and room [ROOM NUMBER] and #25 on South Hall. <BR/>This failure could affect residents by placing them at risk for injury, and falls.<BR/>Findings included:<BR/>During an observation on 08/21/23 between 10:18 AM and 10:59 AM, The handrails between room [ROOM NUMBER] and room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER], and room [ROOM NUMBER] and room [ROOM NUMBER] were visibly loose, hanging from the wall, with the screws exposed. <BR/>During an observation on 8/21/2023 at 11:08 a.m., the handrails were loosened from the wall when touched.<BR/>During an observation on 8/23/2023 at 9:14 a.m., the handrails remained loosened from the wall. <BR/>During an observation on 8/23/2023 at 12:00 p.m., the handrails remained loosened from the wall when touched.<BR/>During an interview on 8/24/2023 at 3:35 p.m., the maintenance supervisor said the walls on the west hall were made of concrete blocks. The maintenance supervisor said the handrails were hung with a toggle bolt. The maintenance supervisor said the toggle bolt was not the correct bolt to use in concrete. The maintenance supervisor said his regional supervisor was supposed to ensure the company who hung the handrails returned to ensure the handrails were hung properly. The maintenance supervisor said the handrails had been loosened from the walls for 2-3 months.<BR/>An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. <BR/>Record review of an Accommodation of Needs policy and procedure dated March 2021 indicated our facility's environment and staff behaviors were directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being .2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include: <BR/>A. <BR/>Providing access to assistive devices, such as grab bars

Based on observation, interview, and record review the facility failed to ensure residents received their mail that was delivered on Saturdays for 3 of 9 confidential residents reviewed for weekend mail delivery.<BR/>The facility failed to ensure residents received their mail on the weekend.<BR/>This failure could affect all residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life.<BR/>Findings included:<BR/>During a confidential group interview on 6/28/2022 at 2:00 p.m., 3 of the 9 residents said mail was not being distributed on Saturdays. They had been told the mailbox was locked outside the building and the weekend staff did not have a key to the mailbox. <BR/>During an interview on 6/29/2022 at 12:34 p.m., the BOM indicated the mailbox was located outside and was a locking mailbox. The BOM indicated during the weekdays she would obtain the mail from the locked mailbox and would give the AD the resident mail. The BOM said the mail was not available to the residents on Saturdays. The BOM indicated she was unaware of the requirement for the residents to have access to their mail on Saturdays. The BOM indicated she would come up on the weekends to ensure the residents had their mail. <BR/>During an interview on 6/30/2022 at 3:24 p.m., the ADM indicated she expected the residents to receive their mail on Saturdays. <BR/>Record review of the Resident Rights policy dated February 2021 indicated employees shall treat all residents with kindness, respect, and dignity cc. access to a telephone, mail and email. <BR/>Record review of HUMAN RESOURCES CODE CHAPTER 102. RIGHTS OF THE ELDERLY (texas.gov) accessed on 7/06/2022 read:<BR/>Sec. 102.003. RIGHTS OF THE ELDERLY. (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.<BR/>An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident councils. An elderly person may send and receive unopened mail, and the person providing services shall ensure that the individual's mail is sent and delivered promptly.

Based on observation, interview, and record review the facility failed to post Nursing Staffing Data information daily as required for 27 days of 30 days of reviewed for June 2022 nursing staffing.<BR/>The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides or the daily census for the month of June except for June 12, June 15, and June 16 of 2022. <BR/>This failure could cause residents, families, and visitors to be unaware of the facility daily staffing requirements.<BR/>Findings included:<BR/>During an observation on 6/30/2022 at 8:40 a.m., the staffing sheets were hanging in a plastic sleeve at the nurse's station.<BR/>During a record review and interview on 6/30/2022 at 8:45 a.m., the DON provided documentation of the staffing requirements for June 12, June 15, and June 16 of 2022. The staffing requirements form dated June 12, 2022 indicated the census was 41. The staffing requirements were 2 LVNs on days and 1 RN and 1 LVN on nights each working 12 hours. The staffing requirement form indicated 2 CNAs worked 8 hours on day, evening, and night shifts. The staffing requirement form dated June 15, 2022 indicated the day shift required 2 LVNs working 12 hours and 2 LVNs working 12 hours on the night shift. The staffing requirement form indicated 2 CNAs worked 8 hours on day, evening, and night shifts. The staffing requirement form dated June 16, 2022 indicated the facility required 2 LVNs working 12 hours shifts on days and nights. The staffing requirement form indicated 3 CNAs working 8 hours on day shift, 2 CNAs on evening shift working 8 hours, and 2 CNAs on night shift working 8 hours. There were no other days for the month of June available in the plastic sleeve. The DON indicated she was ultimately responsible for ensuring the staffing was posted daily. She said upon her reinstatement as DON in May of 2022 she had not been aware the nurses were not posting the staffing needs. <BR/>During an interview on 6/30/2022 at 3:24 p.m., the ADM said she expected the staffing to be posted daily. The ADM indicated there was a new process and the DON would ensure the staffing was posted each day prior to the morning meeting. <BR/>Record review of a policy dated July 2021 indicated the center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment. 6. Staffing levels for direct care staffing is updated each shift and posted in a public area.