PLEASANT SPRINGS HEALTHCARE CENTER

Based on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse or CNA when the facility had an average daily occupancy of 60 or more residents for 16 of 30 days reviewed for DON coverage. 1. The facility failed to ensure the DON did not serve as a charge nurse on 10/28/25. 2. The facility failed to ensure the DON did not serve as a CNA on 10/1/25, 10/4/25, 10/09/25, 10/10/25, 10/12/25, 10/15/25, 10/17/25, 10/18/25, 10/19/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/28/25, 10/29/25, and 10/30/25. 3. The facility did not ensure the DON was able to do her designated duty of DON in a 40 hour/week due to performing nurse and CNA duties. These failures could leave residents without the nursing administrative oversight that only the DON can provide.Findings include:Record review of the detailed census report dated 11/4/25 reflected the census was between 66-72 for the month of October 2025.Record review of the ADL task sheet dated October 2025 reflected the DON documenting care activities on 10/1/25, 10/04/25, 10/09/25, 10/10/25, 10/12/25, 10/15/25, 10/17/25, 10/18/25, 10/19/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/28/25, 10/29/25, and 10/30/25. An attempted interview on 08/05/25 at 7:58 a.m. with CNA D, the CNA for the 10p-6a shift, was unsuccessful.During a telephone interview on 11/05/25 at 7:59 a.m., LVN A stated the DON had come in to help when their short staff. LVN A stated she takes on the role of a CNA such as providing incontinent care and rounding. When asked how often she comes, LVN A stated, 2-3 times a week depending on how short staff they were when someone called in.During a telephone interview on 11/05/25 at 8:03 a.m., LVN B stated the DON did come on the 10p-6a shift doing CNA work such as providing incontinent care, getting them dressed when it was time for them to get up and rounding. LVN B stated she comes in at least 2-3 times a week due to short staff related to call-ins.An attempted interview on 08/05/25 at 8:09 a.m. with CNA C, the CNA for the 10p-6a shift, was unsuccessful. During an interview on 11/05/25 at 9:00 a.m., the ADON stated she works on the floor every day to help the nurses and CNAs out. The ADON stated she will provide incontinent care if needed, pass out water and assist others that may need help. The ADON stated she has had to come in to work as an aide due to call ins. The ADON stated it was usually few and far between. The ADON stated they were hiring and the ones that were hired get trained and call in. The ADON stated, when there is a call-off, when we take call, we must work the floor for whichever staff member called off, whether it be the nurse or aide. The ADON stated she was on call every three weeks. During an interview on 11/05/25 at 9:35 a.m., the DON stated she was not aware that she could not work as a CNA or charge nurse when the census was above 60. The DON stated if she were responsible for the care of the residents, why would she not provide care? The DON stated her duties were to oversee the CNAs and nurses, which meant if there were not enough staff, it was her responsibility to work the floor so the residents could be taken care of. The DON stated she had called and begged/pleaded for staff to help, but if they could not come in, she would come in and help on the floor. The DON stated she would take a hall and double team with other CNAs if someone needed help. The DON stated for the month of October she only had to work as a charge nurse for two hours until someone came in on 10/28/25 but she could not recall the other times. The DON stated if she works a shift as an aide or nurse, she did not work the next day as a DON, but she was available by phone if needed. The DON stated she has an ADON that was RN that would oversee staff that day. The DON stated if her duties as a DON were not completed, she would report to her RNC that staff have called in, and she had to work on the floor. The DON stated it was important for her to work as the DON and not work the floor as a charge nurse or CNA to ensure the systems were in place and things were being done.During a telephone interview on 11/05/25 at 9:45 a.m., the RNC stated she was aware the DON was working on the floor as a charge nurse or CNA. The RNC stated it was ok for the DON to work as a charge nurse or CNA if needed if the census was over 60. The RNC stated she could still take care of other residents while working as the DON.During an interview on 11/05/25 at 9:55 a.m., the Administrator stated he was aware that the DON was working on the floor as a charge nurse and CNA if there was a call in. The Administrator stated he was not aware there was a regulation stating the DON could not work the floor as a charge nurse or CNA if the census was over 60. The Administrator stated the DON came in later that day if she worked the day before as a charge nurse or CNA. The Administrator stated he did not know why the DON did not have to work the floor but if the DON knew her patients, she could be bad for the facility.Record review of document titled Job Description-Director or Nursing revised 05/15/24 reflected, . manage nursing staff through appropriate hiring, training, evaluation, assignment, and delegation of duties, within budget and resident census guidelines. Augment floor staffing if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 2 residents (Resident #1 and Resident #2) reviewed for pharmacy services.<BR/>The facility failed to ensure Resident #2's family member signed the medication release form for medications which included Ativan (also known as Lorazepam, a controlled medication used for anxiety) on 02/09/2024 and 02/16/2024.<BR/>The facility failed to ensure Resident #2's Ativan was accurately reconciliated when she returned to the facility on [DATE], 02/18/2024, and 12/15/2024. <BR/>The facility failed to ensure MA B administered Resident # 1's Eliquis during medication administration on 01/27/2025. <BR/>These failures could place the residents at risk of not having medications available for use, drug diversion, medications errors, and inaccurate records. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 01/27/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (a condition characterized by cognitive decline, memory loss, and difficulty with learning and problem-solving), parkinsonism (movement disorder of the nervous system), and generalized anxiety disorder. <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #2 was able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS summary score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 was independent for all ADLs. The MDS assessment indicated Resident #2 received antianxiety medication in the past 7 days.<BR/>Record review of Resident #2's Order Summary Report indicated she had an order for Ativan (also known as Lorazepam a controlled medication used for anxiety) 0.5 mg give 1 tablet by mouth three times a day for anxiety with a start date of 01/15/2023. <BR/>Record review of Resident #2's care plan last reviewed on 01/14/2025 indicated she used antianxiety medications related to an anxiety disorder. Interventions included to give antianxiety medications ordered by the physician.<BR/>Record review of Resident #2's Release of Responsibility for Medication, which included Ativan, indicated:<BR/>Leaving: 02/09/2024 at 12:00 PM, signed by RN D, the signature for the Resident/Family/Legal Representative was missing. <BR/>Returned: 02/11/2024 at 2:25 PM, signed by LVN C, the signature for the Resident/Family/Legal Representative was missing.<BR/>Record review of Resident #2's Release of Responsibility for Medication, which included Ativan, indicated:<BR/>Leaving: 02/16/2024 at 12:00 PM, signed by RN D, the signature for the Resident/Family/Legal Representative was missing. <BR/>Returned: 02/18/2024 at 3:30 PM, signed by LVN A, the signature for the Resident/Family/Legal Representative was missing.<BR/>Record review of Resident #2's Medication Release/Receipt, which included Ativan, indicated:<BR/>Leave of Absence from 12/13/2024-12/15/2024, signed by Resident #2's Resident Representative and dated 12/13 (no year indicated). There was no signature for person completing the form. The total number of pills returned was blank, not completed. Date/Time returned was blank, not completed.<BR/>Record review of Resident #2's Individual Patient's Narcotic Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 01/09/2024 indicated:<BR/>02/09 (no year) at 07:00 AM with amount remaining 3, below the entry there was a note resident came back with none on this card dated 02/11/2024 signed by MA F, the other staff members signature was illegible. <BR/>Record review of Resident #2's Individual Control Drug Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 02/08/2024 indicated:<BR/>an undated entry with a note resident back from out on pass with 23, no staff signatures. <BR/>Next entry dated 2/12 (no year) 7:00 AM, amount given 1, remaining balance 22. <BR/>This indicated between 02/09-02/11 10 tablets of Resident #2's Lorazepam were used. According to the directions for the Lorazepam only 8 tablets should have been used. <BR/>Record review of Resident #2's Individual Control Drug Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 02/08/2024 indicated:<BR/>An entry on 02/16 (no year) at 7:00 AM, amount given 1, remaining balance 11. <BR/>Next entry indicated came back with 1, signed by MA F with no date.<BR/>Next entry dated 02/18 (no year) at 7:00 PM, amount given 1, balance remaining 0. <BR/>This indicated between 02/16-02/18 10 tablets of Resident #2's Lorazepam were used. According to the directions for the Lorazepam only 7 tablets should have been used. <BR/>Record review of Resident #2's Individual Control Drug Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 12/10/2024 indicated:<BR/>12/13 (no year) at 1:00 PM, 1 tablet was administered, the balance was 22 and there was a note signed by LVN C to indicate sent with resident. <BR/>12/15 (no year) at 7:00 PM, 1 was given, balance indicated 21 then scratched off and balance of 13 noted with resident returned signed by MA E. There was no note prior to MA E's 7:00 PM entry to indicate how many Lorazepam tablets Resident #2 returned with. <BR/>This indicated between 12/13-12/15, 9 tablets of Resident #2's Lorazepam were used. According to the directions for the Lorazepam only 6 tablets should have been used. <BR/>During an interview on 01/27/2025 at 8:49 AM, MA E said there was a form filled out by the nurse when the residents went out on pass with their medications. MA E said if they noticed medications were missing when the resident returned it should be reported to the DON. <BR/>During an interview on 01/27/2025 at 9:37 AM, Resident #2 said when she went out on pass, she did not have to take any extra doses of Ativan, but sometimes when she was attempting to administer it to herself, she might drop one down the sink. <BR/>During an interview on 01/27/2025 at 11:03 AM, MA F said when residents went out on pass with their medications, they wrote down how many the resident left the facility with and when the resident returned, they wrote down how many the residents returned with. MA F said if there was a discrepancy noticed with the amount of the medications returned, she would report it to the nurse. MA F said when she started her shift usually Resident #2's medication was already on the medication cart. MA F said she had not noticed any discrepancies with Resident #2's Ativan. MA F said it was important to ensure the count was correct with controlled medications to ensure the resident was not abusing the drug and to ensure none were missing and nobody had taken any of the medications. <BR/>During an interview on 01/27/2025 at 12:21 PM, MA E said she had noticed a couple months ago, maybe 2-4 months ago, that Resident #2's count on Ativan was not correct because she had called the pharmacy to check on a refill and the pharmacy had informed her it was too soon to fill it. MA E said she notified LVN C, and LVN C said she would take care of it. <BR/>During an interview on 01/27/2025 at 12:24 PM, LVN C said when Resident #2 went out on pass the medication release form was completed, signed by Resident #2's family member that he was responsible for her taking the medications, and she signed the form as well. LVN C said usually, the charge nurse was responsible for completing the medication release form. LVN C said she always made sure she completed the form. LVN C said the narcotic book was also signed to indicate the resident was out on pass. LVN C said usually, the medication aide signed the narcotic book. LVN C said she would not say she noticed Ativan was missing, but one weekend she noticed Resident #2 had taken more Ativan than she was supposed to. LVN C said Resident #2 told her she might have dropped one. LVN C said she notified the NP but did not notify anyone else. LVN C said nobody had reported to her that there was a discrepancy in Resident #2's Ativan. LVN C said it was important to ensure the count for the Ativan was correct because it could be the employee or resident taking the medication, and they did not want the resident to over sedate themselves. <BR/>During an interview on 01/27/2025 at 12:53 PM, Resident #2's family member said when she went home Resident #2 administered her own medications with his assistance. Resident #2's family member said Resident #2 may have dropped a pill, but he was not sure of that. Resident #2's family member said if anything she did not take all her medications and missed some doses while at home. Resident #2's family member said he had not been contacted by the facility or been notified that there were more pills of the Ativan used or to ask if she had been taking too much Ativan while out on pass. <BR/>During an interview on 01/27/2025 at 1:52 PM, the Administrator said she had not been notified of any discrepancies with Resident #2's Ativan. The Administrator said the staff would not be required to report to her if 1-3 tabs of the Ativan were missing when Resident #2 returned to the facility. The Administrator said they could not dictate what the family did with the medications once they were released to them. <BR/>During an interview on 01/27/2025 at 2:28 PM, the DON said when the residents went out on pass the medications were counted and they ensured the responsible party knew how to administer the medications, and a form was filled out when the resident left and when the resident returned. The DON said if discrepancies with the medications were noted the staff should notify her. The DON said she had not been notified of any discrepancies with Resident #2's Ativan. The DON said she was unable to find Resident #2's Medication Release Form from 12/13/2024-12/15/2024. The DON said the copy she provided was given to them by Resident #2's family member because they took pictures of all the forms when they took Resident #2 home. The DON said she did not know what happened to the form. The DON said it was important for the counts to be accurate with the narcotics because they were supposed to keep up with it, there was a risk of overdose, or the nurse herself could be taking it. <BR/>During an interview on 01/27/2025 at 3:51 PM, the Administrator said she expected for the staff to educate the family on the residents' medications when they went out on pass with them. The Administrator said she expected the staff to complete the medication release form and have the representative sign when they took the medications. The Administrator said it was important for the medication release form to be completed correctly so they had the correct count in house, and they could check over the medications. <BR/>During an interview on 01/27/2025 at 4:04 PM, RN D said she was no longer employed at the facility. RN D said when Resident #2 went out on pass she would sign out the medications with the count on them and have the family member sign, and when she returned the family member was supposed to sign and the medications were counted again. RN D said she did not remember what happened because she always had the family sign the sheet. RN D said she never noticed a discrepancy in Resident #2's Ativan count. RN D said it was important to count the medications when the resident left and came back and ensure the count was correct to prevent misappropriation of narcotics. <BR/>2. Record review of a face sheet dated 01/27/2025 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation (irregular heart rhythm). <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated she was able to understand others and was understood by others. The MDS assessment indicated Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #1 was independent with eating, oral, toileting, and personal hygiene, and required set-up assistance with showering/bathing herself. The MDS assessment indicated Resident #1 had an anticoagulant during the last 7 days. <BR/>Record review of Resident #1's care plan last reviewed 12/03/2024 indicated she was on anticoagulant therapy. Resident #1's interventions included for the resident/family/caregiver teaching to include take/give the medication at the same time each day. <BR/>Record review of Resident #1's Order Summary Report dated 01/27/2025 indicated Eliquis 5 mg give 1 tablet by mouth two times a day for anticoagulant (blood thinner) with a start date of 09/10/2024. <BR/>Record review of Resident #1's January 2025 MAR indicated Eliquis 5 mg was administered by MA B on 01/27/2025 for the AM dose (precise time not indicated). <BR/>During an observation of medication administration on 01/27/2025 starting at 7:56 AM, MA B did not administer Resident #1's Eliquis 5 mg. <BR/>During an interview on 01/27/2025 at 8:59 AM, MA B said she had not administered Resident #1's Eliquis 5 mg. MA B said Resident #1 did not have any Eliquis. MA B said the pharmacy had not been sending Resident #1's Eliquis in a timely manner before the Eliquis ran out. MA B said she had notified the DON and Administrator that the pharmacy had not been sending refills out prior to the current supply running out. MA B said she had not heard back from them regarding the situation. MA B said Resident #1's last tablet of Eliquis was administered yesterday (01/26/2025), and that the Eliquis should arrive later today (01/27/2024). MA B said the Eliquis was available in the facility's emergency medication supply, and she would have the nurse administer it. MA B said, she had not administered the medication because it was her fault, she was rushing, and was not paying attention. MA B said it was important for the residents to receive their medications so they would not have any type of problems and to make sure the residents were on the right track. MA B said Resident #1 needed the Eliquis for her heart. <BR/>During an interview on 01/27/2025 at 2:28 PM, the DON said MA B should have gone through Resident #1's MAR pill by pill while administering her medications. The DON said MA B should not have signed off Resident #1's Eliquis as administered if she did not administer it. The DON said MA B should have realized Resident #1 did not have any Eliquis, stopped administering medications, and notified her to get it from the facility's emergency medications. The DON said she had not been notified by the staff of any issues refilling residents' medications from the pharmacy. The DON said it was important for the residents to receive their medications as ordered to treat their disease processes. <BR/>During an interview on 01/27/2025 at 3:44 PM, the Administrator said she expected for the staff to give medications as ordered on the MAR and administer them correctly. The Administrator said the DON was responsible for overseeing that this was done. The Administrator said not administering medications as ordered went against the doctor's orders, and they would not be giving the level of care they should to the resident. <BR/>Record review of the facility's policy titled, Nursing Facility Medication Administration, from the Pharmacy Policy & Procedure Manual 2003, indicated, .2. Facility staff administering medication shall comply with the following .b. Medications shall be administered unless the resident refuses or exhibits symptoms that contraindicate medication administration. c. If a medication is not administered, the staff member shall document in the resident's record why the medication was not administered .<BR/>Record review of the facility's policy titled, Leave of Absence with Medications, from the Pharmacy Policy & Procedure Manual 2003, indicated, .Current medication orders and directions for use are reviewed with the resident or responsible party before the resident leaves the facility . 4. The entire medication container with Rx labels is to be taken on pass, the resident or responsible party must sign out for it on a record of medication release . The policy did not address reconciliation of the medications when the resident returned to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 3 residents (Resident #45) reviewed for baseline care plans. <BR/>The facility failed to develop a baseline care plan that addressed Resident #45's use of a blood thinner. <BR/>This failure could place residents at risk of bleeding, excessive bruising, and not receiving care and services to meet their needs.<BR/>Findings included: <BR/>Record review of a face sheet dated 01/09/2024 indicated Resident #45 was an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which included sepsis due to methicillin susceptible staphylococcus aureus (serious infection that can lead to complications and death), arthritis due to other bacteria, right knee (inflammation of the right knee caused by a bacteria, fungus, virus), and chronic kidney disease stage 3B (moderate to severe loss of kidney function). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #45 was able to make himself understood and understood others. The MDS assessment indicated Resident #45 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #45 did not exhibit rejection of care. The MDS assessment indicated Resident #45 required partial/moderate assistance with personal, oral, and toileting hygiene, and dependent for shower/bathe. The MDS assessment indicated Resident #45 received an anticoagulant. <BR/>Record review of the Order Summary Report dated 01/09/2024 indicated Resident #45 had an order for Lovenox Injection Solution (also known as Enoxaparin Sodium a medication used to thin the blood to prevent blood clots) Inject 76 mg subcutaneously (beneath the skin) one time a day to prevent blood clots with a start date of 12/23/2023. <BR/>Record review of the January MAR indicated Resident #45 received Lovenox injections 01/01/2023-01/08/2023. <BR/>Record review of Resident #27's baseline care plan last reviewed 01/09/2024 did not indicate Resident #45 received Lovenox injections or received a blood thinner. <BR/>During an interview on 01/11/2024 at 5:22 p.m., the Administrator said baseline care plans were started by the nurses and then the MDS Coordinator completed the baseline care plan. The Administrator said the baseline care plan should include if a resident received a blood thinner like Lovenox. The Administrator said it was important for the baseline care plan to include blood thinners for continuity of care and so the staff knew how to take care of the residents. <BR/>During an interview on 01/11/2024 at 6:11 p.m., the DON said the baseline care plan was completed by the nurse managers upon admission. The DON said use of blood thinners like Lovenox should be included in the baseline care plan. The DON said the MDS Coordinator was responsible for ensuring the use of a blood thinner was included in Resident #45's baseline care plan. The DON said the nurse managers reviewed the orders and diagnosis daily to ensure they correlated with the care plans. The DON said it was important for this to be included in the baseline care plan to ensure they were providing the best care for the resident. <BR/>During an interview on 01/11/2024 at 6:30 PM, the MDS Coordinator said Resident #45's use of an anticoagulant (blood thinner) should have been included in his baseline care plan. The MDS Coordinator said if it was put on Resident #45's admission assessment it should have triggered to be included in his baseline care plan. The MDS Coordinator said Resident #45's comprehensive care plan had not been completed yet, the care plan in Resident #45's electronic health record was his baseline care plan. The MDS Coordinator said the nurses initiated the baseline care plan, and then in the morning meetings she went behind the nurses to update and add to the baseline care plans. The MDS Coordinator said Resident #45's use of an anticoagulant was not added to his care plan because it must not have been on his admission assessment, but it should have been added during the morning meeting. The MDS Coordinator said it was important for medications like an anticoagulant to be added to the baseline care plan so they can ensure they were providing person centered care. <BR/>Record review of the facility's undated policy titled, Base Line Care Plans, indicated, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- o Be developed within 48 hours of a resident's admission. o Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- Initial goals based on admission orders. Physician orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 20 residents (Resident #16, Resident # 37, and Resident #56) reviewed for comprehensive person-centered care plans.<BR/>1. The facility failed to care plan Resident #16's CPAP machine (machine used to deliver constant and steady air pressure to help you breathe while you sleep).<BR/>2. The facility failed to care plan Resident #56's contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both hands. <BR/>3. The facility failed to ensure Resident # 37 had a fall mat at bedside. <BR/>These failures could place the residents at increased risk of not having their individual needs met, injury, not receiving necessary services, and a decreased quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), sleep apnea (condition that causes you to stop breathing while you are sleeping), 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 #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs. The MDS assessment did not indicate Resident #16 used a CPAP. <BR/>Record review of Resident #16's Order Summary Report dated 01/10/2024 did not indicate he had orders for a CPAP machine. <BR/>Record review of the care plan last reviewed on 11/21/2023 did not indicate Resident #16's use of a CPAP machine. <BR/>During an observation and interview on 01/08/2024 at 10:45 a.m., Resident #16 had a CPAP machine in his room on top of his nightstand. Resident #16 said he had the CPAP machine since he admitted to the facility, and he used it. <BR/>During an interview on 01/10/2024 at 6:00 p.m., LVN E said Resident #16 used his CPAP machine at night. LVN E said Resident #16 should have an order for his CPAP to ensure the settings were set properly. <BR/>2. Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1), other reduced mobility, and adult failure to thrive. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was rarely/never understood by others and was rarely/never able to make himself understood. Record review of the MDS assessment indicated Resident #56 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #56 was dependent for all ADLs. The MDS assessment indicated Resident #56 had no impairment in functional limitation in range of motion to his upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. <BR/>Record review of the Order Summary Report dated 01/17/2024, did not indicate any orders for Resident #56's contractures. <BR/>Record review of a facility provided document titled Residents with contractures dated 01/08/2024 indicated Resident #56 was on the list as having contractures. <BR/>Record review of the care plan last revised 11/15/2023 did not indicate Resident #56's contractures to both of his hands were included in his care plan. <BR/>Record review of an Occupational Therapy Discharge Summary with dates of service 05/17/2023-06/13/2023 indicated Resident #56 had contractures to bilateral upper extremities. <BR/>During an observation on 01/08/2024 at 9:39 a.m., Resident #56 was lying in bed, contractures were noted to both of his hands. <BR/>During an interview on 01/11/2024 at 4:19 p.m., LVN D said she did not think the nurses completed the care plans, and she did not know who was responsible for the care plans. LVN D said she was aware Resident #56 had contractures to both of his hands. <BR/>During an interview on 01/11/2024 at 5:03 p.m., the Administrator said contractures and the use of a CPAP machine should be included in the residents' care plans. The Administrator said the IDT was responsible for completing the care plans. The Administrator said the IDT ensured the care plans included what was required for the residents in the daily clinical morning meetings. The Administrator said it was important for the residents' care plans to include contractures and the use of a CPAP machine for continuity of care and for staff to know how to care for the residents. <BR/>During an interview on 01/11/2024 at 5:50 p.m., the DON said comprehensive care plans were completed by the IDT. The DON said the MDS Coordinator was responsible for overseeing the care plans. The DON said the use of a CPAP machine and contractures should be included in the care plan. The DON said she was not aware Resident #56's contractures were not included in his care plan. The DON said Resident #16's CPAP was taken out of his care plan because they were working on getting him a new one. The DON said it was important for these to be included in his care plans because the care plan gave a detail of how they were supposed to care for the resident. <BR/>During an interview on 01/11/2024 at 6:23 p.m., the MDS Coordinator said she completed the comprehensive care plans. The MDS Coordinator said the IDT reviewed the care plans as a team quarterly to ensure everything was included in the residents' care plans. The MDS Coordinator said she was not aware Resident #56 had contractures because she had not seen any documentation, and she had not noticed it when doing his assessment. The MDS Coordinator said Resident #16 did not have an order for his CPAP, and that was why it was not included in his care plan. The MDS Coordinator said it was important for the use of a CPAP machine and contractures to be included in the care plan for the residents to get the care they needed and so the care plan was focused on them. <BR/>3. Record review of Resident # 37's face sheet dated 1/11/2024, revealed Resident # 37 was an [AGE] year old male with diagnoses of secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder, or another illness), Hypertension (blood pressure that is higher than normal), Iron Deficiency Anemia (a condition in which blood lacks adequate healthy red blood cells), muscle weakness (commonly due to lack of exercise, ageing, or muscle injury), history of falling (A history of falls has been previously reported to be a factor associated with falls). <BR/>Record review of Resident # 37's Quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #37 had a BIMS score of 8 which indicated her cognition was severely impaired. <BR/>Record review of Resident # 37's care plan dated 10/31/2023, indicated interventions for fall mat at bedside, facility fall protocol. <BR/>Record review of Resident # 37's order summary dated 1/11/2024, indicated fall mat to bedside. <BR/>During an observation on 01/08/2024 at 2:42 P.M., revealed Resident # 37 in bed a sleep with no fall mat in place.<BR/>During an observation on 01/09/2024 at 3:00 p.m., revealed Resident # 37 in bed a sleep with no fall mat in place.<BR/>During an interview on 01/11/2024 at 9:45 a.m., CNA N stated she had been employed with the facility for 90 days. CNA N stated she had no knowledge of Resident #37 needing a fall mat. CNA N stated the only way she would have known if Resident # 37 needed a fall mat was if it was posted or the nurses tell her. CNA N stated it was important for Resident # 37 to have a fall mat to prevent injury. CNA N stated the failure would be he could fall and hurt himself. <BR/>During an interview on 01/11/2024 at 9:52 a.m., LVN O stated it was her responsibility and the resident representative responsibility to ensure Resident #37 had a fall mat at bedside while sleeping. LVN O stated it was important for Resident # 37 to have a fall mat at bedside because he had previous falls. LVN O stated she had no idea why the fall mat was not at the bedside when Resident #37 was sleeping. LVN O stated the failure was Resident # 37 could fall and get hurt. <BR/>During an interview on 01/11/2024 at 4:48 p.m., the ADON G stated she had been employed with the facility since September 2023. The ADON G stated she did not really know who was responsible for ensuring Resident #37 had a fall mat at bedside while sleeping. The ADON G state it was important to have the fall mat at bedside as a form of protection. The ADON G stated the failure could be a possible head injury or broken bones. <BR/>During an interview on 01/11/2024 at 5:30 p.m., the DON stated Resident #37 should have a fall mat at bedside when in bed. The DON stated it was one of the ADON's responsibility for ensuring Resident #37's fall mat was at bedside. The DON stated the importance for a fall mat at bedside was in case Resident# 37 rolls out of bed and does not hit the hard floor. The DON stated she would reeducate the CNA's on place the fall mat at bedside while resident was in bed. The DON stated the failure was not providing safety. <BR/>During an interview on 01/11/2024 at 6:17 p.m., the Administrator stated it was the DON's responsibility for ensuring Resident #37's fall mat was at bedside. The Administrator stated It was important for Resident # 37 fall mat to be at bedside because it was a fall intervention. The Administrator stated she would monitor by doing rounds in the morning and evening to ensure interventions are done. The Administrator stated the failure was he could fall and hurt himself.<BR/>Record review of the facility's undated policy titled, Comprehensive Care Planning, indicated, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . <BR/>A request for the facility policy regarding fall mat was submitted to the Regional Nurse Consultant on 1/11/2024 at 6:17 p.m. A policy was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives necessary services to maintain personal hygiene were provided for 2 of 72 residents reviewed for ADLs (Resident #58, Resident #70).<BR/>1. The facility did not ensure Resident #58 received fingernail care.<BR/>2. The facility did not ensure Resident #70 received her showers.<BR/>These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.<BR/>The findings included:<BR/>1. Record Review of Resident #58's face sheet dated 2/26/25 at 1:43 p.m., indicated Resident #58 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of vascular dementia (reduce blood flow to the brain) with behavioral disturbance, Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), Pneumonia (an infection that affects one or both lungs), essential hypertension (high blood pressure).<BR/>Record Review of Resident #58's MDS assessment dated [DATE] indicated, Resident #58 usually understood others and made himself understood. The MDS assessment indicated Resident #58 had a BIMS score of 10, which indicated Resident #58 was moderately impaired. The MDS assessment indicated Resident #58's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment.<BR/>Record Review of Resident #58's care plan, dated on 2/7/25, indicated Resident #58 had an ADL Self Care Performance Deficit Stroke. The care plan goals indicated: the resident will improve current level of function in ADL's through the review date. The care plan interventions included bathing: requires staff x1 for assistance, Bed Mobility: requires staff x1 for assistance, Dressing: requires staff x1 for assistance, Eating: supervision as needed, the resident uses a wheelchair, Toilet use: requires staff x1 for assistance, encourage the resident to discuss feelings about self-care deficit and BATHING: Avoid scrubbing & pat dry sensitive skin.<BR/>During observation on 2/24/25 at11:20 a.m., Resident #58 fingernails were long and had not trimmed; fingernails had black debris underneath his nails.<BR/>During observation on 2/25/25 at 10:01 a.m., revealed Resident #58's fingernails were long and had not been trimmed. Resident #58's fingernails had black debris underneath his nails.<BR/>During an interview on 2/24/25 at 11:20 a.m., Resident #58 stated he would like to have his fingernails trimmed. Resident #58 stated he couldn't remember the last time his fingernails were trimmed.<BR/>2. Record Review of Resident #70's face sheet dated 2/26/25 at 1:40 p.m., indicated Resident #70 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), Hypothyroidism (thyroid gland does not produce enough thyroid hormone), essential hypertension (high blood pressure).<BR/>Record Review of Resident #70's MDS assessment dated [DATE] indicated, Resident #70 understood others and made herself understood. The MDS assessment indicated Resident #70 had a BIMS score of 5, which indicated Resident #70 was severely impaired. The MDS assessment indicated Resident #70 need for assistance with bathing, dressing, using the toilet, or eating was coded as independent on the MDS assessment.<BR/>Record Review of Resident #70's care plan, dated on 1/15/25, indicated Resident #70 had an ADL Self Care Performance Deficit. The care plan interventions included Bathing: requires staff x1 for assistance; Dressing: requires staff x1 for assistance; Eating: supervision as needed; Praise all efforts at self-care; Physical Therapy/Occupational Therapy evaluation and treatment as per MD orders.<BR/>During an interview on 2/24/25 at 10:19 a.m., Resident #70 stated she had shingles, and she did not get a shower. Resident #70 stated she would like her shower. Resident #70 stated her last shower was more than over a week and a half. Resident #70 stated she was supposed to get her showers on Monday, Wednesday and Friday. Resident #70 stated, it made her feel terrible when she did not get a shower because she feels nasty all the time. <BR/>During an interview on 2/26/25 at 10:15 a.m., Resident #70 stated to LVN G that she had not been receiving her showers. Resident #70 stated to LVN G, I thought I was supposed to give myself a shower because staff had not been giving me my showers. Resident #70 stated she started to get a rash on her stomach from not having a shower. Resident #70 stated, Showers help me with getting rid of rashes, but I have not had a shower in a while.<BR/>During an interview on 2/26/25 at 10:15 a.m., LVN G stated she was the charge nurse on the B hall. LVN G stated she worked the 6 am to 6 p.m. shift. LVN G stated the shower aides were responsible for giving Resident #70 her showers. LVN G stated if the shower aide was not available then the CNAs were responsible for giving showers on the B hall. LVN G stated Resident #70 was supposed to be showered on Monday, Wednesday and Friday. LVN G stated the CNAs were to bring the residents to the shower aide and then the shower aide was to shower each resident. LVN G stated she followed up with the CNAs and shower aide to ensure the residents got their showers. LVN G stated she was not always 100 percent sure with making sure the residents got their showers. LVN G stated Resident #70 had not ever refused showers since being admitted . LVN G stated she was not sure when her last in-service was last completed on ADL care. LVN G stated the ADON oversaw her. LVN G stated she oversaw the shower aide and CNAs. LVN G stated, It was important for the residents to get their showers for hygiene and to prevent skin breakdown, rashes and dignity so the resident felt good about themselves. LVN G stated she was not aware of Resident #70 not receiving her showers. LVN G stated that she was not aware of staff documenting that they were giving showers to the residents when the resident did not receive a shower LVN G stated if the resident was a diabetic that the charge nurse would be responsible for trimming the resident's nails. LVN G stated if the resident was not diabetic then the CNAs would be responsible for trimming the resident's nails. LVN G stated if a resident was a diabetic that their nails are trimmed on Sunday's. LVN G stated if the resident was not a diabetic that their nails were trimmed on shower days or as needed. LVN G stated she never notice that Resident #58 had long nails that needed to be trimmed and cleaned. LVN G stated the CNAs and shower aides were to let her know if the residents needed their nails trimmed. LVN G stated she did not remember the last time Resident #58's fingernails were trimmed and cleaned. LVN G stated to her knowledge the resident had not ever refused nail care. LVN G stated it was important to ensure the resident nails were trimmed and cleaned for hand hygiene and to prevent self-inflected injuries. <BR/>During an interview on 2/26/25 at 12:47 p.m., CNA A stated she normally worked the 6 am to 2 pm shift at the facility. CNA A stated she was not aware of Resident #70 not getting her showers. CNA A stated she was supposed to shower at least 3 times a week. CNA A stated the shower aid was responsible for giving the showers. CNA A stated the CNAs were responsible for bringing the residents to the shower room to be showered. CNA A stated in-services on ADL's was last completed about 3 weeks ago. CNA A stated Resident #70 had not ever refused a shower. CNA A stated it was important for resident to get showers because it helped with their health and mental status. CNA A stated if the resident was a diabetic that the charge nurse was supposed to trim and clean the resident's nails. CNA A stated if the resident was not a diabetic that the CNAs were responsible for trimming and cleaning the resident's nails. CNA A stated she was not aware of Resident #58 nails being long and having a black substance underneath his nails. CNA A stated, It was important to ensure the residents nails were timed and cleaned because its dirty, the resident hands goes to their mouth, and it can cause skin tears and infection control.<BR/>During an interview on 2/26/25 at 1:06 p.m., the ADON stated she had been employed at the facility for 3 weeks. ADON stated she was not aware of the showers not being provided to the residents. ADON stated she was not aware of Resident #58's nails not being trimmed. ADON stated in-services were completed a few weeks agoand she could not remember the exact date. ADON stated she had no knowledge of Resident #70 ever refusing her showers. ADON stated she had no knowledge of Resident #58 refusing nail care in the past. ADON stated CNAs could trim nondiabetic residents and RN staff could trim the diabetic residents' nails. ADON stated the DON oversaw her. ADON stated she oversaw the CNA's, charge nurse and shower aides. ADON stated it was important for ADL care to be provided to the residents for appearance and because she did not want the residents to feel unclean. <BR/>During an interview on 2/26/25 at 1:19 p.m., the Administrator stated she was not aware of the residents not getting their shower and fingernails were not being trimmed. The Administrator stated the last in-service on ADL's was conducted today (2/26/25). The Administrator stated Resident #70 had refused care in the past when she first admitted because she was very ill. The Administrator stated since Resident #70's family member talked with Resident #70 that Resident #70 had not refused care. The Administrator stated Resident #58 had never refused care. The Administrator stated the DON oversaw the nursing department. The Administrator stated the DON and herself were responsible for ensuring the residents received ADL care. The Administrator stated, It was important to ensure the residents received ADL care so the resident was healthy and so the residents would not decline medically.<BR/>During an attempted interview on 2/26/25 at 1:31 p.m., the Shower Aide was unavailable for an interview at the facility.<BR/>Record Review of the facility's Resident Rights policy, undated, indicated, the resident has a tight to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner. and m an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. The facility will provide the Resident Rights to each newly admitted resident and upon any revision to the Resident Rights to each resident and/or resident representatives. The facility did not provide a policy on ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the environment was free of accidents and hazards for 1 of 4 residents (Resident #16) reviewed for safety. <BR/>The facility failed to ensure Resident #16 did not have an electric heating blanket in his room. <BR/>This failure could place residents at risk for burns and injuries.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted 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) and legal blindness, as defined in USA. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs.<BR/>Record review of Resident #16's care plan last reviewed 11/21/2023 indicated Resident #16 had diabetes mellitus to avoid exposure to extreme heat or cold. <BR/>During an observation and interview on 01/08/2024 at 10:45 a.m., Resident #16 had an electric heating blanket laid out along with all his other blankets and sheets on a chair. Resident #16 said he had gotten it for Christmas because at times it got cold in his room. Resident #16 said he would use it when it got cold. <BR/>During an interview on 01/09/2024 at 9:05 a.m., LVN H said she had not been working at the facility very long and she was not sure if it was ok for Resident #16 to have an electric heating blanket in his room. <BR/>During an interview on 01/11/2024 at 4:28 p.m., ADON F said she had told Resident #16 not to use the electric heating blanket. ADON F said Resident #16 said he received the electric heating blanket as a gift for Christmas. ADON F said any of the staff going into his room should be checking for items not allowed in the residents' rooms. ADON F said it was important not to keep electric heating blankets in the residents' rooms because they were a fire hazard, and he could get severely burned. <BR/>During an interview on 01/11/2024 at 5:25 p.m., the Administrator said she was not aware Resident #16 had an electric heating blanket in his room. The Administrator said the CNAs usually told her if the residents had items in their room that were not allowed. The Administrator said the facility had champion rounds (where dedicated staff go to the residents' rooms to check on them) to check the residents' rooms. The Administrator said it was important for the residents not to keep electric heating blankets in their rooms because it could cause a fire and it could burn them. <BR/>During an interview on 01/11/2024 at 6:14 p.m., the DON said the residents should not keep electric heating blankets in their rooms. The DON said she was not aware Resident #16 had an electric heating blanket in his room. The DON said all the staff should be making sure the residents did not have them in their rooms. The DON said it was important for the residents not to keep electric heating blankets in their rooms for their safety and to prevent any burns. <BR/>Record review of a facility provided document dated May 6, 2005, titled, Nursing Home List of Items Not Allowed in Resident Room (This list is not all inclusive), indicated, . Safety Hazards . electric blankets .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 5 of 63 residents reviewed for respiratory care (Residents #23, #18, #41, #11 and #16). <BR/>1. The facility failed to ensure Resident #23's oxygen was in a bag when not in use.<BR/>2. The facility failed to ensure Resident #18 and Resident #41 oxygen concentrator filter was cleaned weekly. <BR/>3. The facility failed to ensure Resident #41 nebulizer tubing was placed inside a bag after her breathing treatment was administered.<BR/>4. The facility failed to ensure Resident #11's handheld nebulizer was stored in a bag. <BR/>5. The facility failed to ensure Resident #16 had an order for his CPAP machine (a machine used to deliver constant and steady air pressure to help you breathe while you sleep) and the facility failed to ensure Resident #16's CPAP mask was stored in a bag.<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 Resident #23's face sheet, dated 01/16/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE] with the diagnoses which included Congestive Heart Failure {CHF} (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), high blood pressure, depression (persistent feeling of sadness and loss of interest), and dementia(impaired ability to remember, think, or make decisions that interfere with doing everyday activities).<BR/>Record review of Resident #23's quarterly MDS assessment, dated 12/21/23, indicated Resident #23 was usually understood and usually understood by others. Resident #23's BIMs score was 01, which indicated she was cognitively severely impaired. The MDS indicated Resident #23 required total assistance with bathing and toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and supervision with eating. The MDS indicated Resident #23 was receiving oxygen during the look-back period. <BR/>Record review of Resident #23's physician's orders, dated 06/13/23, for Oxygen via NC at 2lpm as needed as needed related to acute respiratory failure. <BR/>Record review for Resident #23's comprehensive care plan, dated 06/09/23 indicated Resident #23 required Oxygen Therapy. The interventions were for staff to monitor for signs and symptoms of respiratory distress and report to the physician as needed and to wear Oxygen at 2 liters per nasal cannula as needed. <BR/>During an observation on 01/08/24 at 10:22 a.m., Resident #23 was being wheeled out of her room by a staff member. O2 tubing was noted sitting on the concentrator, not in a bag or dated. <BR/>During an observation and interview on 01/10/24 at 4:38 p.m., Resident #23 was sitting in her room and noted oxygen concentration was running at 2 liters. Oxygen tubing was noted as not bagged. LVN O came into the room and saw the O2 tubing sitting on the concentration and said Resident #23 does wear her oxygen periodically but it should be bagged when not used for infection control issues.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said O2 tubing should be changed weekly on Sunday nights and as needed. She said O2 tubing should be dated and bagged when changed or not in use. She said the ADONs should be doing a spot check daily and failure to place in bags when not in use could cause infection control issues.<BR/>During an interview on 01/11/24 at 4:37 p.m., ADON G said O2 tubing should be bagged when not in use. She said the charge nurses were responsible but the ADONs looked periodically to ensure they were bagged. She said if O2 tubing was not bagged it could cause some infection control issues.<BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said oxygen tubing should be stored in a bag when not in use. The Administrator said the nurses were responsible for ensuring they were stored in a bag. She said they did champion rounds with department heads as well and nurse managers should be making rounds to ensure oxygen tubing was stored in a bag when not in use. The Administrator said it was important for oxygen to be stored in a bag because if they were out in the open bacteria could get on it and the bacteria could be put into the resident's respiratory systems. Tubing should be bagged to prevent infection. <BR/>2. Record Review of Resident #18 face sheet, dated on 1/10/24, indicated Resident #18 was a [AGE] year-old female, admitted to the facility on the administration date of 3/30/18 with a diagnosis of Hemiplegia (part of the brain controlling movement is damaged) affecting right dominant side, Hemiparesis (a condition that causes weakness or paralysis on one side of the body, affecting daily activities and mobility), Dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life, limitations of activities due to disability and essential hypertension (high blood pressure). <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #18 made herself understood, understood others, and was cognitively intact. The MDS indicated Resident #18's BIMS Score was 08, which indicated moderate impairment. The MDS indicated Resident #18 required extensive assistance with bed mobility with a two-person physical assist, and extensive assistance with toileting and transfer with two-person physical assist. The MDS indicated Resident #18 received oxygen therapy. <BR/>Record review of the care plan updated dated on 2/09/21 indicated Resident #18 received oxygen therapy as needed. The comprehensive care plan indicated to give medications as ordered by the physician; observe/document side effects and effectiveness. The care plan did not address the oxygen concentrator filter.<BR/>Record Review of Resident #18's Oxygen and Respiratory orders on 1/9/24 at 1:16 p.m., indicated to clean or change the filter every night shift every Sunday. <BR/>During an observation on 1/10/24 at 8:30 a.m., Resident #18 oxygen concentrator filter was not cleaned.<BR/>During observation on 1/11/24 at 8:05 a.m., Resident #18 oxygen concentrator filter was not cleaned.<BR/>3.Record Review of Resident #41 face sheet, dated on 1/10/24, indicated Resident #41 was a [AGE] year-old female, admitted to the facility on the administration date of 12/12/23 with a diagnosis of emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness, chronic obstructive pulmonary disease, pneumonia, insomnia and limitation of activities due to disability. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #41 made herself understood, understood others, and was cognitively intact. The MDS indicated Resident #41 BIMS score was 08 which indicated moderate impairment. The MDS did not indicate Resident #41 assistance with bed mobility, toileting, and dressing. The MDS indicated Resident #41 received oxygen therapy. <BR/>Record review of the care plan updated dated on 12/14/23 indicated Resident #41 received oxygen therapy. The comprehensive care plan indicated to monitor for signs and symptoms of respiratory distress and report to Medical Doctor as needed; notify the nurse if oxygen is off the resident; oxygen set at 2 to 3 liters per minute. The care plan did not address the oxygen concentrator filter for Resident #41. The Care plan did not address the nebulizer for Resident #41.<BR/>Record Review of Resident #41 Oxygen and Respiratory orders on 1/9/24 at 12:56 p.m., indicated to clean or change the filter of nebulizer machine every night shift every Sunday. <BR/>During observation on 1/10/24 at 8:33 a.m., Resident #41 nebulizer tubing was not placed inside bag after use.<BR/>During observation on 1/11/24 at 8:08 a.m., Resident #41 nebulizer tubing was not placed inside bag after use.<BR/>During an interview on 1/10/24 at 6:01 p.m., LVN E stated she had been employed since November 2023 and has been working night shift since December 2023. LVN E stated she worked PRN on the night shift at the facility. LVN E stated she did not know how often filters were to be changed. LVN E stated she did not know how the filters were to be cleaned because she came from a hospital and did not have to clean the o2 filter. LVN E stated she changed the tubing for the oxygen concentrator as needed. LVN E stated she was not aware of the oxygen concentrator filter orders for Resident #41 and Resident #18. LVN E stated she did not complete in-services on nebulizer or o2 filter changing. LVN E stated she did not sign off on oxygen filter at night because she was not aware of the filters needing to be changed on Sunday by the night shift nurse. LVN E stated the DON oversaw what she did at the facility. LVN E stated it was important to follow doctor's orders for oxygen contractor for cleanliness and healthiness and to prevent residents from getting sick. <BR/>During an interview on 1/11/24 at 8:08 a.m., Resident #41 stated she used her nebulizer every day. Resident #41 stated the nurses never put her nebulizer in a bag after use.<BR/>During an interview on 1/11/24 at 10:07 the DON stated she had been the DON since Feb of 2023. The DON stated the ADON was responsible for monitoring the oxygen filter changes. The DON stated the ADON was responsible for monitoring the nebulizer was placed in a bag after use. The DON stated she did not know why the nebulizer was not place in a bag after use. The DON stated she was not aware that the oxygen filters were not being changed on Resident #18 and Resident #41. The DON stated she was aware of the oxygen concentrator orders for Resident #18 and Resident #41. The DON stated she did expect staff to follow physician orders as prescribed. The DON stated she monitors the oxygen orders during SOC meeting daily. The DON stated during SOC meetings she would ask the ADON for updated reported what needed to be done and the changing the resident oxygen filers was never brought to her attention. The DON stated she conducted daily rounds in the morning. The DON stated each morning the, ADON, treatment nurse and MDS coordinator were assigned to halls to conduct daily rounds every day. The DON stated it was important to ensure staff were following physician orders to ensure resident were getting the best care. <BR/>During an interview on 1/11/24 at 11:00 a.m., ADON F stated she had been the ADON since March of 2023. ADON F stated ADON G was in charge of the Oxygen filter changes and nebulizer. ADON F stated she did not know why the nebulizer tubing had not been placed in bag, but nurses' staff were aware of the nebulizer tubing being placed in bag after use. ADON F stated she was aware oxygen order for Resident #41 and Resident #18, but she did not check filter but will check oxygen filters for now on a daily base. ADON F stated she expected staff to ensure they were following the physician orders. ADON F stated her assigned hallway was the B hall and she monitored B hall only. ADON F stated ADON G was assigned to the C hall. ADON F stated the wound care nurse was assigned to D hall. ADON F stated in-service was last completed a few months ago on oxygen filter changes and nebulizer. ADON F stated she was not aware of LVN not being trained on how to clean oxygen filters. ADON F stated the DON oversaw her. ADON F stated, It was important for staff to follow physician orders because the orders were there for a reason, and it will help provide the best care for the resident. <BR/>During an interview on 1/11/24 at 11:36 a.m., The Administrator stated the nursing staff was responsible for changing the oxygen concentrator filters. The Administrator stated the nursing staff were responsible for ensuring the nebulizers were placed in bag. The Administrator stated she did expect staff to ensure they were changing the oxygen concentrator as prescribed by the doctor. The Administrator stated she was not aware that the oxygen concentrator filter were not being changed. The Administrator stated she was not aware of the nebulizer tubing not being placed in bags. The Administrator stated she monitored the filter changes by asking clinical staff in the morning meeting. The Administrator stated staff did completed nebulizer in-services training back in October 2023. The Administrator stated she did not recall the training in-services on filters changes. The Administrator stated it was important for staff to follow physician orders for the wellbeing of the resident. <BR/>During an interview on 1/11/24 at 11:44 a.m., Treatment Nurse L stated she was responsible for the monitoring the D hall. Treatment Nurse L stated she conducted rounds every day on the D Hall where Resident #18 and Resident #41 resided. Treatment Nurse L stated she would watch breakfast trays go out in the morning and then conduct rounds in the resident rooms on her assigned hall (D hall). Treatment Nurse L stated she never noticed that Resident #18 nebulizer tubing was not placed in bag after bag after Resident #18 breathing treatments were administered. Treatment Nurse L stated she the charge nurse and the ADON G were responsible for monitoring the nebulizer tubing was placed in bag after use. Treatment Nurse L stated her last round on D Hall was conducted on 1/11/24 7:40 a.m. Treatment Nurse L stated Resident #18 had one orders for the nebulizer and she was aware of Resident #18 nebulizer orders from the physician. Treatment Nurse L stated she stated resident #18 received a breathing treatment 3 times a day. Treatment Nurse L stated Resident #18 breathing treatment on her nebulizer were given at 9 a.m., 4 p.m., and 9p.m. Treatment Nurse L stated Resident #18 last used her nebulizer at 9 a.m. on 1/11/24. <BR/>During an interview on 1/11/24 at 12:19 p.m., ADON G stated she had been the ADON since sept of 2023. ADON G stated she was responsible for monitoring the oxygen filter changes and making sure the nebulizer tubing were placed in bag. ADON G stated she was not aware of the oxygen order for the filter changes for Resident #18 and Resident #41. ADON G stated she did expect staff to ensure they were following physician orders. ADON G stated she monitored staff by conducting follow-up after staff to ensure staff were putting the nebulizer in bags and changing the filters according to the physician orders. ADON G stated in the past she addressed concerns with staff upon finding issues with the oxygen concentrators and nebulizer. ADON G stated she was not aware of staff completing any in-service training for nebulizer or oxygen filter changing. ADON G stated she was not aware of staff not changing the oxygen filters. ADON G stated she had no idea that the night nurse LVN did not know how to change/clean the oxygen concentrator filters. ADON G stated she the DON oversaw her. ADON G stated it was important to ensure staff were following physician orders because the physician knows what's best for the residents.<BR/>4. Record review of a face sheet dated 01/11/2024 indicated Resident #11 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat that stops and starts) and asthma (lung disorder characterized by narrowing of the tubes which carry air into the lungs, that are inflamed and constricted, causing shortness of breath, wheezing and cough). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #11 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #11 required setup/clean-up assistance with eating, personal and oral hygiene, dependent for toilet hygiene, dressing, and substantial/maximal assistance with shower/bath. The MDS assessment indicated Resident #11 used oxygen therapy. <BR/>Record review of the Order Summary Report dated 01/10/2024 indicated Resident #11 had an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083% (Albuterol Sulfate- medication used to treat wheezing and shortness of breath) 1 inhalation inhale orally via nebulizer four times a day with a start date of 11/29/2023. <BR/>Record review of the care plan last reviewed 12/12/2023 did not address Resident #11's use of a handheld nebulizer. <BR/>During an observation on 01/08/2024 at 9:50 a.m., Resident #11's handheld nebulizer was on her nightstand and was not stored in a bag. <BR/>During an observation on 01/09/2024 at 8:14 a.m., Resident #11's handheld nebulizer was in her drawer and was not stored in a bag.<BR/>During an interview on 01/11/2024 at 4:07 p.m., LVN D said handheld nebulizers and oxygen masks should be stored in a sack dated and initialed. LVN D said she did not know why Resident #11's handheld nebulizer was not stored in a bag because she had not worked the previous two days. LVN D said the nurses were responsible for ensuring the handheld nebulizers and oxygen masks were stored properly. LVN D said it was important for handheld nebulizers and oxygen masks be stored in a bag for infection control. <BR/>5. Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), sleep apnea (condition that causes you to stop breathing while you are sleeping), 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 #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs. The MDS assessment did not indicate Resident #16 used a CPAP. <BR/>Record review of Resident #16's Order Summary Report dated 01/10/2024 did not indicate he had orders for a CPAP machine. <BR/>Record review of the care plan last reviewed on 11/21/2023 did not indicate Resident #16's use of a CPAP machine. <BR/>During an observation on 01/08/2024 at 10:45 a.m., Resident #16 had a CPAP machine in his room on top of his nightstand with the mask laying on the nightstand not stored in a bag. <BR/>During an observation on 01/10/2024 at 2:13 p.m., Resident #16 had his CPAP mask on top of his nightstand not stored in a bag. <BR/>During an interview on 01/10/2024 at 2:21 p.m., LVN D said she was not aware Resident #16 had a CPAP. LVN D said she had not seen his CPAP machine in his room. LVN D said Resident #16 should have an order for his CPAP and she did not know why he did not have one. LVN D said she did not know why his CPAP mask was not stored in a bag because the night nurse was the one that put it on him. <BR/>During an interview on 01/10/2024 at 6:00 p.m., LVN E said Resident #16 used his CPAP machine at night. LVN E said she had not looked at Resident #16's orders to see if he had an order for his CPAP. LVN E said Resident #16 should have an order for his CPAP to ensure the settings were set properly. LVN E said she was not sure why Resident #16's CPAP mask was not stored in a bag because when she worked it was stored in a bag. LVN E said it was important for CPAP masks to be stored in a bag for cleanliness and because she would not want it to touch the floor and then put it in the resident's airway. <BR/>During an interview on 01/11/2024 5:05 p.m., the Administrator said residents should have an order for a CPAP machine The Administrator said nursing was responsible for putting in the order for the CPAP. The Administrator said it was important to have an order for a CPAP machine to ensure the physician orders were being followed. The Administrator said her expectations were for the oxygen/CPAP masks, handheld nebulizers to be clean and always stored if not in use. The Administrator said these items should be stored in a bag. The Administrator said the nurses were responsible for ensuring they were stored in a bag. The Administrator said it was important for oxygen/CPAP masks and handheld nebulizers to be stored in a bag because if they were out in the open bacteria could get on it and the bacteria could be put in the residents' respiratory systems. <BR/>During an interview on 01/11/2024 at 5:53 p.m., the DON said Resident #16 should have an order for his CPAP. The DON said Resident #16 did not have an order because they were in the process of getting him a new one. The DON said ADON F was responsible for monitoring the orders. The DON said it was important to have an order for a CPAP because without an order the nurses would not know how he needed to wear it. The DON said handheld nebulizers/oxygen masks should be stored in a bag. The DON said ADON G was responsible for ensuring the nurses were storing the handheld nebulizers and oxygen masks properly. The DON said it was important to ensure the handheld nebulizers and oxygen masks were stored in a bag for infection control. <BR/>Record review of the facility's policy titled, Respiratory Policies and Procedures, revision date 06/01/2007, indicated, Bi-level Positive Airway Pressure (BiP AP) and/or Continuous Positive Airway Pressure (CPAP) is set up and monitored by a licensed nurse or respiratory therapist with a physician's order. Orders must include pressure and hours of use and may include supplemental oxygen and mask size. For BiPAP, orders must also include EPAP and TPAP and may include mode of delivery and respiratory rate . <BR/>Record review of the facility's policy titled, Aerosolized Hand-Held Nebulizer, from the Nursing Policy & Procedure Manual 2003, indicated, . Rinse the nebulizer and mouthpiece shake and store in a plastic bag the is labeled with the patient' s name and room number. 14. Chart to include medication, diluents, and dose on medication record. 15. Change nebulizer set-up every 7 days and more often if necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 2 residents (Resident #1 and Resident #2) reviewed for pharmacy services.<BR/>The facility failed to ensure Resident #2's family member signed the medication release form for medications which included Ativan (also known as Lorazepam, a controlled medication used for anxiety) on 02/09/2024 and 02/16/2024.<BR/>The facility failed to ensure Resident #2's Ativan was accurately reconciliated when she returned to the facility on [DATE], 02/18/2024, and 12/15/2024. <BR/>The facility failed to ensure MA B administered Resident # 1's Eliquis during medication administration on 01/27/2025. <BR/>These failures could place the residents at risk of not having medications available for use, drug diversion, medications errors, and inaccurate records. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 01/27/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (a condition characterized by cognitive decline, memory loss, and difficulty with learning and problem-solving), parkinsonism (movement disorder of the nervous system), and generalized anxiety disorder. <BR/>Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #2 was able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS summary score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 was independent for all ADLs. The MDS assessment indicated Resident #2 received antianxiety medication in the past 7 days.<BR/>Record review of Resident #2's Order Summary Report indicated she had an order for Ativan (also known as Lorazepam a controlled medication used for anxiety) 0.5 mg give 1 tablet by mouth three times a day for anxiety with a start date of 01/15/2023. <BR/>Record review of Resident #2's care plan last reviewed on 01/14/2025 indicated she used antianxiety medications related to an anxiety disorder. Interventions included to give antianxiety medications ordered by the physician.<BR/>Record review of Resident #2's Release of Responsibility for Medication, which included Ativan, indicated:<BR/>Leaving: 02/09/2024 at 12:00 PM, signed by RN D, the signature for the Resident/Family/Legal Representative was missing. <BR/>Returned: 02/11/2024 at 2:25 PM, signed by LVN C, the signature for the Resident/Family/Legal Representative was missing.<BR/>Record review of Resident #2's Release of Responsibility for Medication, which included Ativan, indicated:<BR/>Leaving: 02/16/2024 at 12:00 PM, signed by RN D, the signature for the Resident/Family/Legal Representative was missing. <BR/>Returned: 02/18/2024 at 3:30 PM, signed by LVN A, the signature for the Resident/Family/Legal Representative was missing.<BR/>Record review of Resident #2's Medication Release/Receipt, which included Ativan, indicated:<BR/>Leave of Absence from 12/13/2024-12/15/2024, signed by Resident #2's Resident Representative and dated 12/13 (no year indicated). There was no signature for person completing the form. The total number of pills returned was blank, not completed. Date/Time returned was blank, not completed.<BR/>Record review of Resident #2's Individual Patient's Narcotic Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 01/09/2024 indicated:<BR/>02/09 (no year) at 07:00 AM with amount remaining 3, below the entry there was a note resident came back with none on this card dated 02/11/2024 signed by MA F, the other staff members signature was illegible. <BR/>Record review of Resident #2's Individual Control Drug Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 02/08/2024 indicated:<BR/>an undated entry with a note resident back from out on pass with 23, no staff signatures. <BR/>Next entry dated 2/12 (no year) 7:00 AM, amount given 1, remaining balance 22. <BR/>This indicated between 02/09-02/11 10 tablets of Resident #2's Lorazepam were used. According to the directions for the Lorazepam only 8 tablets should have been used. <BR/>Record review of Resident #2's Individual Control Drug Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 02/08/2024 indicated:<BR/>An entry on 02/16 (no year) at 7:00 AM, amount given 1, remaining balance 11. <BR/>Next entry indicated came back with 1, signed by MA F with no date.<BR/>Next entry dated 02/18 (no year) at 7:00 PM, amount given 1, balance remaining 0. <BR/>This indicated between 02/16-02/18 10 tablets of Resident #2's Lorazepam were used. According to the directions for the Lorazepam only 7 tablets should have been used. <BR/>Record review of Resident #2's Individual Control Drug Record indicated a pharmacy label with directions for Lorazepam 0.5 mg give 1 tablet by mouth three times a day, dated 12/10/2024 indicated:<BR/>12/13 (no year) at 1:00 PM, 1 tablet was administered, the balance was 22 and there was a note signed by LVN C to indicate sent with resident. <BR/>12/15 (no year) at 7:00 PM, 1 was given, balance indicated 21 then scratched off and balance of 13 noted with resident returned signed by MA E. There was no note prior to MA E's 7:00 PM entry to indicate how many Lorazepam tablets Resident #2 returned with. <BR/>This indicated between 12/13-12/15, 9 tablets of Resident #2's Lorazepam were used. According to the directions for the Lorazepam only 6 tablets should have been used. <BR/>During an interview on 01/27/2025 at 8:49 AM, MA E said there was a form filled out by the nurse when the residents went out on pass with their medications. MA E said if they noticed medications were missing when the resident returned it should be reported to the DON. <BR/>During an interview on 01/27/2025 at 9:37 AM, Resident #2 said when she went out on pass, she did not have to take any extra doses of Ativan, but sometimes when she was attempting to administer it to herself, she might drop one down the sink. <BR/>During an interview on 01/27/2025 at 11:03 AM, MA F said when residents went out on pass with their medications, they wrote down how many the resident left the facility with and when the resident returned, they wrote down how many the residents returned with. MA F said if there was a discrepancy noticed with the amount of the medications returned, she would report it to the nurse. MA F said when she started her shift usually Resident #2's medication was already on the medication cart. MA F said she had not noticed any discrepancies with Resident #2's Ativan. MA F said it was important to ensure the count was correct with controlled medications to ensure the resident was not abusing the drug and to ensure none were missing and nobody had taken any of the medications. <BR/>During an interview on 01/27/2025 at 12:21 PM, MA E said she had noticed a couple months ago, maybe 2-4 months ago, that Resident #2's count on Ativan was not correct because she had called the pharmacy to check on a refill and the pharmacy had informed her it was too soon to fill it. MA E said she notified LVN C, and LVN C said she would take care of it. <BR/>During an interview on 01/27/2025 at 12:24 PM, LVN C said when Resident #2 went out on pass the medication release form was completed, signed by Resident #2's family member that he was responsible for her taking the medications, and she signed the form as well. LVN C said usually, the charge nurse was responsible for completing the medication release form. LVN C said she always made sure she completed the form. LVN C said the narcotic book was also signed to indicate the resident was out on pass. LVN C said usually, the medication aide signed the narcotic book. LVN C said she would not say she noticed Ativan was missing, but one weekend she noticed Resident #2 had taken more Ativan than she was supposed to. LVN C said Resident #2 told her she might have dropped one. LVN C said she notified the NP but did not notify anyone else. LVN C said nobody had reported to her that there was a discrepancy in Resident #2's Ativan. LVN C said it was important to ensure the count for the Ativan was correct because it could be the employee or resident taking the medication, and they did not want the resident to over sedate themselves. <BR/>During an interview on 01/27/2025 at 12:53 PM, Resident #2's family member said when she went home Resident #2 administered her own medications with his assistance. Resident #2's family member said Resident #2 may have dropped a pill, but he was not sure of that. Resident #2's family member said if anything she did not take all her medications and missed some doses while at home. Resident #2's family member said he had not been contacted by the facility or been notified that there were more pills of the Ativan used or to ask if she had been taking too much Ativan while out on pass. <BR/>During an interview on 01/27/2025 at 1:52 PM, the Administrator said she had not been notified of any discrepancies with Resident #2's Ativan. The Administrator said the staff would not be required to report to her if 1-3 tabs of the Ativan were missing when Resident #2 returned to the facility. The Administrator said they could not dictate what the family did with the medications once they were released to them. <BR/>During an interview on 01/27/2025 at 2:28 PM, the DON said when the residents went out on pass the medications were counted and they ensured the responsible party knew how to administer the medications, and a form was filled out when the resident left and when the resident returned. The DON said if discrepancies with the medications were noted the staff should notify her. The DON said she had not been notified of any discrepancies with Resident #2's Ativan. The DON said she was unable to find Resident #2's Medication Release Form from 12/13/2024-12/15/2024. The DON said the copy she provided was given to them by Resident #2's family member because they took pictures of all the forms when they took Resident #2 home. The DON said she did not know what happened to the form. The DON said it was important for the counts to be accurate with the narcotics because they were supposed to keep up with it, there was a risk of overdose, or the nurse herself could be taking it. <BR/>During an interview on 01/27/2025 at 3:51 PM, the Administrator said she expected for the staff to educate the family on the residents' medications when they went out on pass with them. The Administrator said she expected the staff to complete the medication release form and have the representative sign when they took the medications. The Administrator said it was important for the medication release form to be completed correctly so they had the correct count in house, and they could check over the medications. <BR/>During an interview on 01/27/2025 at 4:04 PM, RN D said she was no longer employed at the facility. RN D said when Resident #2 went out on pass she would sign out the medications with the count on them and have the family member sign, and when she returned the family member was supposed to sign and the medications were counted again. RN D said she did not remember what happened because she always had the family sign the sheet. RN D said she never noticed a discrepancy in Resident #2's Ativan count. RN D said it was important to count the medications when the resident left and came back and ensure the count was correct to prevent misappropriation of narcotics. <BR/>2. Record review of a face sheet dated 01/27/2025 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation (irregular heart rhythm). <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated she was able to understand others and was understood by others. The MDS assessment indicated Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #1 was independent with eating, oral, toileting, and personal hygiene, and required set-up assistance with showering/bathing herself. The MDS assessment indicated Resident #1 had an anticoagulant during the last 7 days. <BR/>Record review of Resident #1's care plan last reviewed 12/03/2024 indicated she was on anticoagulant therapy. Resident #1's interventions included for the resident/family/caregiver teaching to include take/give the medication at the same time each day. <BR/>Record review of Resident #1's Order Summary Report dated 01/27/2025 indicated Eliquis 5 mg give 1 tablet by mouth two times a day for anticoagulant (blood thinner) with a start date of 09/10/2024. <BR/>Record review of Resident #1's January 2025 MAR indicated Eliquis 5 mg was administered by MA B on 01/27/2025 for the AM dose (precise time not indicated). <BR/>During an observation of medication administration on 01/27/2025 starting at 7:56 AM, MA B did not administer Resident #1's Eliquis 5 mg. <BR/>During an interview on 01/27/2025 at 8:59 AM, MA B said she had not administered Resident #1's Eliquis 5 mg. MA B said Resident #1 did not have any Eliquis. MA B said the pharmacy had not been sending Resident #1's Eliquis in a timely manner before the Eliquis ran out. MA B said she had notified the DON and Administrator that the pharmacy had not been sending refills out prior to the current supply running out. MA B said she had not heard back from them regarding the situation. MA B said Resident #1's last tablet of Eliquis was administered yesterday (01/26/2025), and that the Eliquis should arrive later today (01/27/2024). MA B said the Eliquis was available in the facility's emergency medication supply, and she would have the nurse administer it. MA B said, she had not administered the medication because it was her fault, she was rushing, and was not paying attention. MA B said it was important for the residents to receive their medications so they would not have any type of problems and to make sure the residents were on the right track. MA B said Resident #1 needed the Eliquis for her heart. <BR/>During an interview on 01/27/2025 at 2:28 PM, the DON said MA B should have gone through Resident #1's MAR pill by pill while administering her medications. The DON said MA B should not have signed off Resident #1's Eliquis as administered if she did not administer it. The DON said MA B should have realized Resident #1 did not have any Eliquis, stopped administering medications, and notified her to get it from the facility's emergency medications. The DON said she had not been notified by the staff of any issues refilling residents' medications from the pharmacy. The DON said it was important for the residents to receive their medications as ordered to treat their disease processes. <BR/>During an interview on 01/27/2025 at 3:44 PM, the Administrator said she expected for the staff to give medications as ordered on the MAR and administer them correctly. The Administrator said the DON was responsible for overseeing that this was done. The Administrator said not administering medications as ordered went against the doctor's orders, and they would not be giving the level of care they should to the resident. <BR/>Record review of the facility's policy titled, Nursing Facility Medication Administration, from the Pharmacy Policy & Procedure Manual 2003, indicated, .2. Facility staff administering medication shall comply with the following .b. Medications shall be administered unless the resident refuses or exhibits symptoms that contraindicate medication administration. c. If a medication is not administered, the staff member shall document in the resident's record why the medication was not administered .<BR/>Record review of the facility's policy titled, Leave of Absence with Medications, from the Pharmacy Policy & Procedure Manual 2003, indicated, .Current medication orders and directions for use are reviewed with the resident or responsible party before the resident leaves the facility . 4. The entire medication container with Rx labels is to be taken on pass, the resident or responsible party must sign out for it on a record of medication release . The policy did not address reconciliation of the medications when the resident returned to the facility.

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature.<BR/>The facility failed to provide food that was palatable at the lunch meal on 1/9/24.<BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.<BR/>The findings included:<BR/>Record Review of the facility week 1 menu dated on 1/9/24, indicated the lunch meal items included Mississippi Pot roast, roasted baked potatoes halves, baby carrots, Honey kissed roll, sticky peach cake, and iced tea.<BR/>During an interview on 1/8/24 at 10:14 a.m., Resident #14 stated the food was terrible and the food was better with the old company.<BR/>During an interview on 1/8/24 at 10:49 a.m., Resident #42 stated food was terrible and he had hair in his spaghetti.<BR/>During an interview on 1/8/24 at 10:50 a.m., Resident #1 stated the food was horrible.<BR/>During an interview on 1/8/24 at 11:01 a.m., Resident #18 stated she did not like the food, the rice was dry, and the chicken dressing did not taste like dressings. Resident #18 stated the food tasted like it did not have salt in the food and no sugar was added in the sweet tea.<BR/>During an interview on 1/8/24 at 11:07 a.m., Resident #12 stated sometimes the food was warm and sometimes was cold; food did not get seasoning with salt.<BR/>During an interview on 1/8/24 at 3:12 p.m., Resident #46 stated she was on a mechanical soft diet and the food was no good.<BR/>During observation and interview on 1/9/24 at 12:25 p.m., pot roast was bland tasting to surveyors and the Dietary Manager stated the pot roast needed more seasoning. The carrots were bland tasting to surveyors and the Dietary Manager stated the carrots were okay. The cubed potatoes were bland tasting to surveyors and the Dietary Manager stated the cubed potatoes needed more seasoning. <BR/>During an attempted phone interview on 1/10/24 at 3:30 p.m., the Dietary Manager was called, and voice message left for a return phone call; call was not returned prior to exit on 1/11/24.<BR/>During an attempted interview on 1/10/24 at 3:38 p.m., the Dietician was called, voice message was left for a return call; phone call not returned prior to exit on 1/11/24<BR/>During an interview on 1/10/24 at 3:42 p.m., the DON stated she did not oversea the kitchen.<BR/>During an interview on 1/10/24 at 3:58 p.m., the Administrator stated she had been employed at the facility for 6 years. The Administrator stated she did have food complaints from the residents about food seasoning and biscuits being too hard in the morning. The Administrator stated she talked to the Dietary Manager and made sure food was good for the residents that complained. The Administrator stated she had some residents at the facility that she cannot please. The Administrator stated she had tried everything she could think of to please those residents. The Administrator stated the facility would make a special meal of the resident's favorite food for those that complain about food. The Administrator stated she was not getting food stuck in her door with a note from the residents. The Administrator said she used to get food struck in her underneath door with a complaint note from the residents, but she had not received any food complaint notes from residents recently. The Administrator stated she did get test trays once a month from the kitchen and if she got a lot of food complaints that she would get test trays weekly. The Administrator stated she did expect food to be palliative, attractive and at the right temperature. The Administrator stated it was important to ensure the food was palatable, attractive and at the right temperature because, Food was all the residents had to live for and food prevents the resident from losing weight; Residents not eating the food could cause skin breakdown because food give the residents joy.<BR/>During an interview on 1/11/24 at 8:31 a.m., CNA C stated she was hired in September of 2023. CNA C stated she had been a CNA for 19 years. CNA C stated she had taken food everyday back to the kitchen to be warmed up because by the time the food gets to the end of the hall the food was cold.<BR/>Record Review of the facility Resident Rights policy dated 2003, indicated (5) Each resident is encouraged and assisted, throughout the period of stay, to exercise his/her rights as a resident and as a citizen, and to this end, may voice grievances and recommend changes in policies and services to facility staff and / or to outside representatives of his/her choice, free from restraint, interference, coercion, discrimination or reprisal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. <BR/>The facility failed to ensure they followed the assessment information about the level of staff needed to meet each resident's needs. <BR/>This failure could place residents at risk of inadequate care or treatment.<BR/>Findings Included:<BR/>A record review of the facility's CMS 802 Resident Matrix dated 02/24/25 revealed the facility census to be 72 residents. <BR/>During a record review of the facility's assessment dated [DATE] and reviewed by QAPI on 08/21/24, revealed the staffing ratio was for the facility to have 5 aides for 6 am-2 pm, 4 aides for the 2 pm-10 pm, and 4 aides for the 10 pm-6 am shift.<BR/>During a record review of the Resident's roster given by the Administrator on 02/24/25, it indicated Hall A had 19 residents, Hall B had 20 residents, Hall C had 16 residents, and Hall D had 18 residents.<BR/>During a record review of the facility's Payroll-Based Journal, also known as PBJ (a system that nursing homes use to report staffing information to the Centers for Medicare and Medicaid Services), Staffing Data Report for Quarter 4 2024, dated July 1 through September 30, indicated they had a 1-star staff rating.<BR/>During an interview on 02/25/25 at 1:15 p.m., the Administrator said they had completed the facility assessment on 07/24/24 and it was the latest assessment done. She said all the information contained in the book was correct.<BR/>During an interview on 02/26/25 at 3:00 p.m., CNA M said she worked the 2 pm-10 pm shift. She said they usually had 3 aides and it was hard to get everything done. <BR/>During a phone interview on 02/26/25 at 3:45 p.m., CNA B said she worked 6 a.m.- 2 p.m. She said most days, they had 3 aides. She said they had 4 halls, and each aide would take a full hall, and then they would split the fourth hall. She said one aide took hall A, one aide took hall C, the other aide took hall D, and they split hall B. She said they worked hard but did not feel they gave the residents the care they deserved.<BR/>During an interview on 02/26/25 03:00 p.m., CNA M said she worked the 2 pm-10 pm shift. She said they usually had 3 aides and it was hard to get everything done. <BR/>During an interview on 02/26/25 05:11 p.m., LVN G said she worked 6 am- 6 pm and they had 3 aides most days on her 6 am-2 pm and 2 pm-6 pm shifts. She said it was hard some days, but they were able to get things done.<BR/>During an interview on 02/26/25 10:19 p.m., CNA E said he had been working at the facility about 2 years. He said he worked the 10 pm-6 am shift. He said they usually had 2-3 aides on his shift. He said when they had 2-3 aides it was very hard, and he felt they did not attend to every resident like they needed to. He said in other words, he could not make rounds every 2 hours like they should have been doing. He said the nurses tried to help when they could, but they were busy doing their work. He said sometimes it took them a while to answer the call lights because they were so busy. He said they had worked with 2-3 aides for the past 4-5 months. He said when there were 2 aides it was extremely hard, but they did the best they could. He said management would tell him they had no applications. He said the DON was aware and nothing had changed. <BR/>During an interview on 02/26/25 10:42 p.m., CNA C said she had worked at the facility for 6 months. She said she worked the 10 pm-6 am shift. She said most nights they had 2-3 aides, and only a handful of times they had 4 aides. She said when they had 2-3 aides, it was hard, and she said they could not make every 2-hour rounds like they should have been doing. She said call lights would stay on for long periods because they were busy helping other residents. She said they did answer the call lights as soon as they could. She said 1 night she was the only aide after the DON left about midnight. She said management was aware of how many staff they had to help the residents, but nothing had changed yet. <BR/>During an interview on 02/26/25 10:49 p.m., CNA F said she had been employed at the facility about 6-7 months. She said she worked the 10 pm-6 am shift. She said they usually had 2-3 aides on her shift. She said tonight (02/26/25) they had 4 because a PRN person came to work. She said when CNA E was on the schedule, there were only 2 aides most nights because they had not hired anyone for that rotation. She said when they had 2 aides, things were not getting done like rounding every 2 hours or answering call lights timely. She said when there were 3 aides, she felt she had time to better care for the residents, but it was still hard. She said she did the best she could each day she worked. She said she had not personally said anything to management but said management was aware of the staffing issue and nothing had changed. <BR/>During an interview on 02/26/25 at 10:55 p.m. LVN K said she was the charge nurse for the 10 pm-6 am shift. She said they usually had 3 aides on her shift, sometimes 2 aides. She said it was hard when they had 2-3 aides, but she did help the aides and they got things done. <BR/>During an interview on 02/27/25 09:20 a.m., MA N said she had been working at the facility for over 5 years. She said she usually worked 6 am- 8 pm as the medication aide. She said she was sometimes late with her morning medications because they did not have enough staff to help pass breakfast trays in the morning. She said she would stop passing her medications to help with breakfast because she thought nutrition was important. <BR/>Record review of facility staff punch sheets revealed: <BR/>On 02/01/25, the following aides: 4 on 6 am-2 pm, 3 on 2 pm-10 pm, and 3 on 10 pm- 6 am, <BR/>On 02/02/25, the following aides: 3 on 6 am-2 pm, 3 on 2 pm-10 pm, and 3 on 10 pm- 6 am, <BR/>On 02/03/25, the following aides: 4 on 6 am-2 pm, 4 on 2 pm-10 pm, and 3 on 10 pm- 6 am,<BR/>On 02/04/25, the following aides: 3 on 6 am-2 pm, 4 on 2 pm-10 pm, and 2 on 10 pm- 6 am,<BR/>On 02/05/25, the following aides: 3 on 6 am-2 pm, 4 on 2 pm-10 pm, and 3 on 10 pm- 6 am,<BR/>On 02/09/25, the following aides: 2 on 6 am-2 pm, 3 on 2 pm-10 pm, and 2 on 10 pm- 6 am,<BR/>On 02/10/25, the following aides: 4 on 6 am-2 pm, 4 on 2 pm-10 pm, and 2 on 10 pm- 6 am,<BR/>On 02/15/25, the following aides: 3 on 6 am-2 pm, 3 on 2 pm-10 pm, and 3 on 10 pm- 6 am,<BR/>On 02/16/25, the following aides: 3 on 6 am-2 pm, 3 on 2 pm-10 pm, and 2 on 10 pm- 6 am,<BR/>On 02/22/25, the following aides: 4 on 6 am-2 pm, 4 on 2 pm-10 pm, and 2 on 10 pm- 6 am,<BR/>On 02/23/25, the following aides: 3 on 6 am-2 pm, 3 on 2 pm-10 pm, and 3 on 10 pm- 6 am,<BR/>During an interview on 02/27/25 at 5:42 p.m., the Administrator and the Area Director of Operations said the Administrator had pulled the wrong sheet about staffing and placed it in the facility assessment book. The Area Director of Operations said they did not used any type of staffing sheet. She said they used the PPD formula daily (PPD stands for Per Patient Day, and calculations are determined by the number of residents in a skilled nursing facility and the number of clinical staff caring for them during each shift) and not the spreadsheet that was in the facility's assessment book. The Administrator said she was unaware she pulled the wrong sheet and placed it in the facility's assessment binder. She said they were supposed to be using the PPD formula and her PPD was supposed to be 3.0. She said she was using the PPD formula based off the staffing sheets and the punch sheets to ensure she had the correct number of staff daily. She said the software she was using would let her know if she was using enough staff per day. The Administrator said she could not let the surveyor see the software to verify what she was saying. The Administrator said she was not using the correct sheet related to staffing in the facility assessment binder. <BR/>Record review of the facility's policy titled, Facility Assessment, dated 11/2017, indicated, Purpose: The Facility Assessment a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations. The facility assessment identifies our capabilities as a skilled nursing services provider. The Facility Assessment will be the basis for surveyors to ascertain whether you are prepared to competently take care of the population you have identified that you serve. There are three components to the review: 1. <BR/>Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care 2. <BR/>Services and care offered based on resident needs (includes types of care your resident population requires; the focus is not to include individual level care plans in the facility assessment) 3. <BR/>Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, a facility-based and community-based risk assessment, and other information that you may choose. Guidelines for Conducting the Assessment: 2. <BR/>The facility must review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. For example, if the facility decides to admit residents with care needs who were previously not admitted , such as residents on ventilators or dialysis, the facility assessment must be reviewed and updated to address how the facility staff, resources, physical environment, etc., meet the needs of those residents and any areas requiring attention, such as any training or supplies required to provide care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the residents or responsible party had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #34) reviewed for psychoactive medications.<BR/>The facility failed to ensure Form 3713 was filled out completely based on Resident #34's diagnostic criteria, and assessment finding exhibited by the resident for the medication Seroquel, also known as Quetiapine (is an antipsychotic medication that treats several kinds of mental health conditions, including schizophrenia and bipolar disorder.<BR/>This failure could place residents at risk for receiving unnecessary antipsychotic medications, experiencing potential adverse reactions, and a potential decline in physical and mental health status.<BR/>Findings included:<BR/>Record review of Resident #34's face sheet, dated 03/4/25 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses which included stroke, Parkinson (a chronic brain disorder that causes movement problems, including tremors, stiffness, and balance issues), and Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).<BR/>Record review of Resident #34's quarterly MDS assessment, dated 02/19/25, indicated Resident #34 was understood and usually was understood by others. Resident #34's BIMS score was 04, which meant she was severely cognitively impaired. The MDS indicated Resident #34 required assistance with toileting, bed mobility, dressing, transfers, personal hygiene, and supervision with eating. The MDS indicated she took an Antipsychotic medication during the 7-day look-back period.<BR/>Record review of Resident #34's physician;s order dated 09/20/24 reflected, Seroquel oral tablet 25 MG (Quetiapine) Give 1 tablet by mouth two times a day related to depression.<BR/>Record review of Resident #34's medication administration record dated from 02/01/25 through 02/24/25 revealed, Resident#34 received Seroquel oral tablet 25 MG (Quetiapine) Give 1 tablet by mouth two times a day related to depression.<BR/>Record review of Resident #34's care plan dated 08/13/24 indicated she required anti-psychotic medications related to night terrors. The intervention of the care plan indicated staff would give medication as ordered. Staff would monitor/record/report to the doctor for side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.<BR/>Record review of Resident #34's consent for the use of psychotropic medication, Seroquel was documented in the chart signed 04/20/24 but was incomplete without diagnostic criteria and assessment finding exhibited by the resident for the use of the medication.<BR/>During an interview on 02/26/25 at 5:11 p.m., LVN G said consent(s) were obtained to notify the resident or the responsible party of their orders and to verify it was okay to give. She said consent(s) should have been obtained for all psychotropic medication before being given. She said the nurse who took the order for Resident #34's Seroquel should have filled out the form completely and had the doctor review and sign it. LVN G said she did not know the form's name but knew it should have been filled out completely.<BR/>During interviews on 02/27/25 at 9:33 a.m., Resident #34's RP said she was aware of the Seroquel but was not aware the form 3713 was not filled out completely to explain the benefits and or side effects.<BR/>During an interview on 02/27/25 at 1:54 p.m., the facility's Physician said he was not aware Resident #34's Form 3713 was not filled out completely. He said the form should have been filled out completely for the medication, the reason she was on the medication, any diagnostic criteria and assessment findings exhibited by the resident for the indication of being on the medication. He said Resident #34 was on the medication prior to being admitted to the facility. He said if the facility would let him know when he or his nurse practitioner were back in the facility, they would get the form completed.<BR/>During an interview on 02/27/25 at 4:47 p.m., the ADON said the nurse who received the order was responsible for getting the consent. The ADON said the consent for psychotropic medications should have been completed before the resident received the medication. The ADON said the form should have been filled out completely with all the correct diagnosis, criteria, and reason for the medication. She said she would get with the doctor and see what needed to be done to have the form completed.<BR/>During an interview on 02/27/25 at 5:12 p.m., the Administrator said a consent form should be filled out completely and should be obtained to inform families or residents of the risks and/or benefits of a medication. The Administrator said the DON oversaw that process. She said she was not sure why the form was not completed as it should have been.<BR/>Record review of the facility's policy titled, Psychoactive Medications, from the Policy and Procedure manual 03-6.20, reflected Policy: The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the residents highest practicable mental, physical, and psychosocial well-being. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. This drug includes but are not limited to drugs in the following categories: (1) antipsychotic, (2) antidepressant, etc. The facility must ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record The psychotropic consent form explains the risks and benefits of psychotropic medications. The resident or their representative must provide documented consent prior to administration of a newly ordered psychotropic medication. Consents for anti-psychotic medication must be in a written form. A verbal or phone consent is not allowed. Permission given by or a request made by the resident and or representative does not serve as a sole justification for the medication itself. Use of antipsychotic medications must be thoroughly documented in the medical record.

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in 19 of 63 Rooms (D hall) reviewed for a clean and homelike environment. <BR/>The facility failed to ensure (D hall) was cleaned daily, and in accordance with the facility's Housekeeping policy. <BR/>This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. <BR/>Findings included:<BR/>During an observation on 1/8/24 at 11:01 a.m., strong urine smell on D hall. <BR/>During an observation on 1/10/24 at 8:27 a.m., strong urine smell on D hall. <BR/>During an observation on 1/11/24 at 8:05 a.m., strong urine smell on D hall.<BR/>During an interview on 1/11/24 at 8:21 a.m., CNA C stated she had been a CNA for 19 years. CNA C stated the urine smell was always strong on D hall all the time especially in the morning. CNA C stated Resident #41 slept in a recliner and was a heavy wetter. CNA C stated Resident #41 was not being toileted like she should be. CNA C stated D hall was the heaviest hall in the facility. CNA C stated Resident #264 was also a heavy wetter on D hall and Resident #264 was not getting her showers like she was suppose too. CNA C stated it was only one CNA C worker per hall and the facility needed more CNA's. <BR/>During an interview on 1/11/24 at 9:21 a.m., housekeeping aide K stated he has been employed here for almost 2 months. Housekeeping aide K stated he worked 8:00 a.m. to 4:30 p.m. shift. Housekeeping aide K stated he was responsible for cleaning the resident rooms. Housekeeping aide K stated the rooms were to be cleaned every day and the orange tag rooms on the D hall were to be cleaned 3 times a day. Housekeeping aide K stated the orange tag rooms were for the residents who had hoarding issues. Housekeeping aide K stated the nurse's aide or laundry aide were to change the resident linens on their beds. Housekeeping aide K stated the resident nurse aides or nurses were responsible for cleaning the top of the resident mattresses. Housekeeping aide K stated the housekeeping supervisor oversaw him. Housekeeping aide K stated deep cleaning was to be done when a resident was discharging a room and before admission to the facility. Housekeeping aide K stated, The resident rooms were probably deep cleaned once a month. Housekeeping aide K stated deep cleaning considered cleaning under the resident's furniture, doors, dressers, sink, bathroom, floors, walls and lights. Housekeeping aide K stated the Housekeeping supervisor did spot checks, and he did not know how often the Housekeeping supervisor conducted spot checks in the resident's rooms. Housekeeping aide K stated the facility did not have a housekeeping checklist that housekeeping were to follow. Housekeeping aide K stated, He just did what the housekeeping supervisor told him to do when he came to work. Housekeeping aide K stated he was not aware of the urine smell on D hall. Housekeeping aide K stated he cleaned mostly on the B hall and sometimes cleaned D hall. Housekeeping aide K stated he worked Monday 1/8/24 and Thursday 1/11/24. Housekeeping aide K stated he did believe that the facility had enough cleaning supplies. Housekeeping aide K stated the nurse aids was responsible for cleaning urine or fecal matter off the floors and housekeeping was responsible for sanitizing the area after the nurses. Housekeeping aide K stated he completed cleaning and deep cleaning in-services last month. Housekeeping aide K stated, It was important to keep the facility clean and sanitized for basic human rights and if he had a family member in a facility that he would want their room cleaned.<BR/>During an interview at 1/11/24 at 9:35 a.m., The Housekeeping supervisor stated he has been employed at the facility for a year. The Housekeeping supervisor stated housekeeping was responsible for cleaning the resident's room. The Housekeeping supervisor stated the orange tag room were to be cleaned 3 times a day and the regular rooms were to be cleaned once a day. The Housekeeping supervisor stated he was aware of the strong urine smell on D hall. The Housekeeping supervisor stated housekeeping used a solution called Enzyme to get rid of the urine smell in the facility. The Housekeeping supervisor stated the nurse's aide were responsible for changing the resident linens. The Housekeeping supervisor stated deep cleaning were done for discharge, room changed, orange tag room or a death of a resident. The Housekeeping supervisor stated the Administrator oversaw him. The Housekeeping supervisor stated white glove came every 6 months to conduct follow up visit and reports are giving after inspections. The Housekeeping supervisor stated he did spot checks daily and also did champion rounds (checked his assigned rooms daily). The Housekeeping supervisor stated the facility had a cart checklist and the facility did not have a room cleaning checklist. The Housekeeping supervisor stated the facility did have enough cleaning supplies. The Housekeeping supervisor stated he ordered the cleaning supplies every month before the 24th of each month. The Housekeeping supervisor stated the last in-service on cleaning a deep cleaning was completed a few months ago. The Housekeeping supervisor stated he did expect housekeeping aids to clean and deep clean the rooms according to the facility policy. The Housekeeping supervisor stated it was important for residents because, The residents live here and for the public, we want to have a nice facility for someone to bring their families here and make sure the facility is in tip top shape.<BR/>During an interview on 1/11/24 at 10:07 a.m., the DON stated she did not oversee the Housekeeping department.<BR/>During an interview on 1/11/24 at 11:28 a.m., The Administrator stated Resident #18 did not want to sleep in a bed and Resident #18 preferred to sleep in a recliner chair. The Administrator stated housekeeping was responsible for cleaning the residents rooms. The Administrator stated the floor tech was responsible for cleaning the floors. The Administrator stated she was not aware of housekeeping completing any in-services on cleaning and deep cleaning. The Administrator stated a lot of housekeeping issues was the continuation of staff and having to constantly train new staff. The Administrator stated it was hard to find staff to work longer than a few months. The Administrator stated Housekeeping did not have a housekeeping checklist, but housekeeping were to follow the facility housekeeping policy. The Administrator stated she did expect housekeeping to ensure they were deep cleaning and cleaning the residents rooms. The Administrator stated she did champion rounds and if she saw an area of concern would address it in stand up meeting in the morning with the department heads. The Administrator stated the champion round had a checklist that staff were to complete. The Administrator stated she would then review the checklist and follow up after. The Administrator stated it was important for staff to follow the policy and procedures for housekeeping so the resident could have a clean homelike environment. <BR/>Record Review of the facility housekeeping policy for Cleaning and Disinfecting, dated 2022 indicated It is the policy of this facility to maintain cleanliness in an orderly manner. The goal is to keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image. The following cleaning tasks should be completed daily. (1) common area: dinning rooms, shower room(s), bathroom(s), lobby(s), sitting/tv room(s), hallway(s), door/entryway(s), beauty shop, therapy gym (2) resident room(s) including closets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the environment was free of accidents and hazards for 1 of 4 residents (Resident #16) reviewed for safety. <BR/>The facility failed to ensure Resident #16 did not have an electric heating blanket in his room. <BR/>This failure could place residents at risk for burns and injuries.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted 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) and legal blindness, as defined in USA. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs.<BR/>Record review of Resident #16's care plan last reviewed 11/21/2023 indicated Resident #16 had diabetes mellitus to avoid exposure to extreme heat or cold. <BR/>During an observation and interview on 01/08/2024 at 10:45 a.m., Resident #16 had an electric heating blanket laid out along with all his other blankets and sheets on a chair. Resident #16 said he had gotten it for Christmas because at times it got cold in his room. Resident #16 said he would use it when it got cold. <BR/>During an interview on 01/09/2024 at 9:05 a.m., LVN H said she had not been working at the facility very long and she was not sure if it was ok for Resident #16 to have an electric heating blanket in his room. <BR/>During an interview on 01/11/2024 at 4:28 p.m., ADON F said she had told Resident #16 not to use the electric heating blanket. ADON F said Resident #16 said he received the electric heating blanket as a gift for Christmas. ADON F said any of the staff going into his room should be checking for items not allowed in the residents' rooms. ADON F said it was important not to keep electric heating blankets in the residents' rooms because they were a fire hazard, and he could get severely burned. <BR/>During an interview on 01/11/2024 at 5:25 p.m., the Administrator said she was not aware Resident #16 had an electric heating blanket in his room. The Administrator said the CNAs usually told her if the residents had items in their room that were not allowed. The Administrator said the facility had champion rounds (where dedicated staff go to the residents' rooms to check on them) to check the residents' rooms. The Administrator said it was important for the residents not to keep electric heating blankets in their rooms because it could cause a fire and it could burn them. <BR/>During an interview on 01/11/2024 at 6:14 p.m., the DON said the residents should not keep electric heating blankets in their rooms. The DON said she was not aware Resident #16 had an electric heating blanket in his room. The DON said all the staff should be making sure the residents did not have them in their rooms. The DON said it was important for the residents not to keep electric heating blankets in their rooms for their safety and to prevent any burns. <BR/>Record review of a facility provided document dated May 6, 2005, titled, Nursing Home List of Items Not Allowed in Resident Room (This list is not all inclusive), indicated, . Safety Hazards . electric blankets .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (Resident #1) of 1 resident reviewed for an in-house acquired pressure ulcer. <BR/>The facility failed to ensure Resident #1 did not develop two avoidable facility acquired pressure injuries. <BR/>The facility failed to initiate new orders for Resident #1.<BR/>The facility failed to remove the immoblizer boot (a medical device worn during treatment and recovery of a variety of foot injuries - it is a form of immoblizing and weight bearing for injuries to foot areas) and accurately assess Resident #1's right lower leg during weekly skin assessments from 10/02/2023 - 10/18/2023.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/02/2023 and ended on 10/26/2023. The facility had corrected the noncompliance before the survey began. <BR/>These failures could place residents at risk for developing new pressure wounds, inconsistent care resulting in the deterioration of existing wounds, a decline in health, pain, and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated January 2, 2024, indicated she was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis of Displaced Tri malleolar Fracture of Right Lower Leg (fracture at the ankle joint), Subsequent Encounter For Closed Fracture with Routine Healing, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block air flow and makes it difficult to breathe), Muscle weakness, Senile Degeneration of Brain (a loss of intellectual ability).<BR/>Record review of Resident #1's physician's order summary dated 10/18/2023 indicated Resident #1 had no wound care orders for her right lower extremity.<BR/>Record review of the MDS Resident Assessment and care screening Nursing Home Comprehensive Item Set dated September 1, 2023, indicated Resident #1 was cognitively impaired with BIMS score of 07. She was at risk for pressure injuries, and none were noted on this assessment. Resident #1 had no issues with her skin.<BR/>Record review of the care plan updated on 10/25/2023, indicated Resident #1 had the potential for impairment to skin integrity related to hard case from fracture with a focus of 10/19/2023 pressure ulcer to right lateral calf, 10/19/2023 trauma wound to right medial calf and 10/19/2023 trauma wound to right medial ankle - resolved 10/25/2023. Interventions included 10/19/2023 resident to receive weekly wound care by wound care physician. Monitor and document location, size and treatment of skin injury, Report abnormalities, failure to heal, signs and symptoms infection, maceration etc. to MD. <BR/>Record review of Resident #1's weekly body skin assessments dated 10/05/2023, LVN B indicated Resident #1 did not have issues with her skin.<BR/>Record review of Resident #1's weekly body skin assessments dated 10/12/2023, LVN C indicated Resident #1 did not have issues with her skin.<BR/>Record review of Resident #1's weekly body skin assessments dated 10/19/2023, LVN C indicated Resident #1 did not have issues with her skin.<BR/>Record review of Resident #1's progress notes dated 10/02/2023, LVN A indicated Resident #1 had returned from a follow-up physician's appointments after removal of the hard cast from right lower extremity with new orders for range of motion to right ankle out of boot, continue with non- weight bearing to right lower extremity, clean ankle once daily with saline and follow-up in four weeks.<BR/>Record review of Resident #1's progress note dated 10/18/2023, indicated Resident #1 had developed two avoidable pressure injuries on her right lower leg resulting in surgical debridement and infection. On 10/18/2023, the wound care MD was notified of the areas and new treatments were initiated. The resident had a full thickness (the damage extends below the epidermis and dermis - all layers of the skin) wound to her right medial (middle) calf and an unstageable (the depth of the ulcer is obscured by slough - yellow, gray, green or brown substance in the wound bed) full thickness wound to her right lateral - (side) calf.<BR/>During an interview on 12/27/2023 at 11:15 AM, Resident #1's Responsible Party said Resident #1 was brought home on or about 11/22/2023. Resident #1 Responsible Party said the wounds are almost healed.<BR/>During an interview on 12/27/2023 at 01:05 PM, RN D said on 10/18/2023, Resident #1 complained of pain to her right lower leg. RN D removed the immobilizer boot and found the three ulcerated areas. RN D said she contacted the wound care physician, DON, and resident's family. RN D said she was the treatment nurse but had not received any notifications to treat Resident #1. RN D said it was the duty of the night charge nurse assigned to Resident' #1's room to do a weekly skin assessment. <BR/>Attempted telephone call at 12/27/2023 at 11:15 AM, unable to reach LVN B and left a request for return call. <BR/>Attempted telephone call at 12/27/2023 at 11:18 AM, unable to reach or leave a message for LVN C.<BR/>During an interview on 12/28/2023 at 1:18 PM, LVN A said Resident #1 returned from her physician's appointment on 10/02/2023 with the boot immobilizer on her right foot. LVN A said the transportation aide handed her the physician's orders for Resident #1. LVN A said she put a progress note into the Resident #1 electronic medical record but failed to enter the new orders she had received. LVN A said it had been a very busy day and she forgot. LVN A said she was Resident #1's nurse and she should have assessed Resident #1 upon her return from the appointment. LVN A said she was educated on the facility's policy regarding entering orders. LVN A said she was in serviced on the appropriate way to perform a head-to-toe assessment and received checkoffs weekly on performing skin assessments. LVN A stated she received disciplinary actions regarding her job duties. LVN A said a new system was in place due to the identified failure. LVN A said the new process was as follows: when a resident left the facility for any appointment and no new orders were received, then the DON contacted the physician's office to ensure there were no new orders. LVN A said the importance of orders entered timely and appropriately was to prevent the resident from neglect and a decline in the resident's health by not receiving services and care. <BR/>During an interview on 12/28/2023 at 1:30 PM, the DON said the charge nurse was responsible for assessing and updating/inputting any new orders upon a resident's return to the facility after any physician appointments. The DON said the weekly skin assessments were assigned by hall and divided out to the day or night nurse per a schedule. The DON said the night nurse was assigned to Resident #1's room. The DON said LVN B and LVN C had failed to perform proper head to toe assessments from 10/02/2023 through 10/19/2023 on Resident #1 by not removing the immobilizer. The DON said there was a failure in the system which had been identified and corrected by in servicing all licensed staff on job duties and responsibilities regarding entering orders and weekly head to toe assessments. The DON said she followed up on orders after all resident physician appointments by contacting that physician's office after each appointment to ensure no new orders were inadvertently not sent to the facility. The DON said all appointments were now discussed in the staff morning meeting. The DON said LVN A failed to enter the orders upon Resident #1 returning from the physician appointment on 10/02/2023. The DON said she expected head to toe assessments to be completed by removing immobilizers per orders and examining for skin integrity issues to prevent a decline in the health and healing of residents. The DON expected all orders to be entered into the system timely and appropriately to ensure the residents getting all the necessary services and care to promote healthy lifestyles. The DON said all licensed staff were educated with one-to-one weekly skills check-off on head-to-toe assessments, in-services were completed on job duties and responsibilities for charge nurses, staff in-services for abuse and neglect, and disciplinary actions were provided on staff involved in Resident #1's care. <BR/>During an interview on 12/28/2023 at 1:30 PM, the Administrator said there was a failure in the system which was identified and corrected by in servicing all licensed staff on job duties and responsibilities regarding entering orders and weekly head to toe assessments. The Administrator said the DON followed up on orders after all resident physician appointments by contacting that physician's office after each appointment to ensure no new orders had been inadvertently not sent to the facility. The Administrator said all appointments were discussed in the staff morning meeting. The Administrator said all staff was educated and in-serviced on abuse and neglect, and immobilizers. All licensed staff was educated and completed weekly skills check offs on head-to-toe assessments. The Administrator said LVN A, LVN B, LVN C had received disciplinary actions. The Administrator said LVN C was no longer employed at the facility. The Administrator said she expected all orders entered timely. The Administrator said she expected head to toe assessments done appropriately according to policy. The Administrator said entering orders timely and appropriate head to toe assessments were vital to providing and promoting healthy resident care. <BR/>During an interview on 12/28/2023 at 2:08 PM, LVN B said she was the night charge nurse for Resident #1. LVN B said her job duties included weekly skin assessments for Resident #1. LVN B said she should have removed the immobilizer boot and examined Resident's #1 skin. LVN B said she was not sure why she had not fully removed the immobilizer during 10/02/2023 - 10/18/2023. LVN B said the importance of removing the immobilizer and performing full head to toe assessments was to prevent any skin breakdowns that can lead to infections. LVN B said she was in-serviced on her job duties and responsibilities, abuse and neglect, one to one head to toe check offs with performance weekly. LVN B stated she received disciplinary actions from the facility. <BR/>Attempted telephone call at 12/27/2023 at 2:18 PM, unable to reach or leave a message for LVN C.<BR/>Record review of the facility's policy revised on 08/12/16 and titled, . Pressure Injury Prevention Program indicated All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries. 5. If a pressure injury/ skin breakdown is identified, the following will be done- If a pressure injury/ skin breakdown is identified, the following will be done- If new area found-if pressure injury- complete new wound evaluation / assessment if non-pressure area-complete new wound evaluation / assessment must include: Size, Stage (staged by RN or PT), Location, Drainage amount If odor if present Signs and symptoms of infection if present Wound bed description, Wound edge and surrounding tissue description, How the resident tolerated the wound care If pain with dressing change identified, treatment paused to allow for appropriate pain management before resumption. If pain with dressing change previously identified, confirm order for pain management in place and pre-medication completed per order. Any noted changes in condition requiring new or updated interventions Wound status Notify MD-obtain treatment orders Notify RP/ or family if they are RP or Resident has directed family to be updated Update care plan Note on 24-hour report Referrals to therapy, dietician or other consultant as deemed necessary Monitor weekly via weekly wound reporting and skin integrity quality assurance processes .<BR/>Record review of the facility's policy dated 2015 titled, .Physician's Orders indicated Written Orders by the Physician or Nurse Practitioner . 3. The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the order was received <BR/>Record review of in service dated 10/26/2023 of sixteen licensed staff with one-to-one education on skin integrity, pressure ulcer (injury) prevention and treatment, and abuse and neglect, and inputting MD orders included LVN A, LVN B, and LVN C.<BR/>Record Review of inservice dated 10/26/2023 of sixteen licensed staff completed competencies checks for performing skin assessments and inserviced on what to do when a resident was admitted with immobilizer/boot in place without orders to remove, when to remove to assess skin and pulses including LVN A, LVN B, and LVN C. <BR/>Record Review of the documented facility completed skin sweep dated 10/18/2023 of all residents resulted in no new concerns.<BR/>Record Review of Disciplinary Actions completed on 10/26/2023 with LVN B and LVN C over incomplete skin assessments and with LVN A who failed to put in the orders.<BR/>During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 8 CNAs (4 from each shift (CNA E, CNA F, CNA G, CNA H, CNA K, CNA L, CNA M, CNA N) were able to identify and define abuse and neglect, state the procedure of skin assessments and who to report to with questions and concerns. <BR/>During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 6 LVNs (3 from each shift (LVN A, LVN B, LVN O, LVN P, LVN Q, LVN R) all were able to identify and define abuse and neglect, state the procedure of skin assessments and immobilizer removal and care, and who to report to with questions and concerns. All were aware of the expectations of completing proper skin assessments and how to monitor pressure ulcers per protocol and to notify the DON/ADON and the Administrator immediately per procedures.<BR/>During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 4 RNs (RN T, DON, RN D, and the Regional Compliance Nurse) all were able to identify and define abuse and neglect, state the procedure of skin assessments and immobilizer removal and care, and who to report to with questions and concerns. All were aware of the expectations of completing proper skin assessments and how to monitor pressure ulcers per protocol and to notify the DON/ADON, physicians and/or the Administrator and family immediately per procedures. <BR/>During interviews on 01/02/2024 from 08:00 AM to 5:00 PM., the Administrator, DON, Regional Compliance Nurse and LVN A said the DON was responsible for following up on new orders by ensuring all orders were entered into the electronic health system after the residents' physician appointments, and by contacting the physician's office after each appointment to ensure no new orders had been inadvertently not sent to the facility. The Administrator, DON, Regional Compliance Nurse and LVN A said all appointments were discussed in the staff morning meeting. <BR/>Record review of a QAPI Committee Report dated 10/26/2023 indicated that there was a meeting held consisting of the Administrator, the assistant Administrator, the DON, the ADON, the MDS nurse, the social worker, and the Medical Director. The following interventions were put in place:<BR/>In-service: re-education to staff on how to maintain skin integrity<BR/>On 12/28/2023 at 03:46 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/02/2023 and ended on 10/26/2023. The facility had corrected the noncompliance before survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 1 of 5 residents (Resident #23) reviewed for right to be informed about consents. <BR/>The facility failed to ensure Resident #23 had signed psychotropic consent for Celexa (antidepressant). <BR/>This failure could place residents at risk of receiving medications without their prior knowledge or informed consent, or that of their responsible party.<BR/>The findings included:<BR/>Record review of Resident #23's face sheet, dated 01/16/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses which included Congestive Heart Failure {CHF} (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), high blood pressure, depression (persistent feeling of sadness and loss of interest), and dementia(impaired ability to remember, think, or make decisions that interfere with doing everyday activities).<BR/>Record review of Resident #23's quarterly MDS assessment, dated 12/21/23, indicated Resident #23 was usually understood and usually understood by others. Resident #23's BIMs score was 01, which indicated she was cognitively severely impaired. The MDS indicated Resident #23 required total assistance with bathing and toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and supervision with eating. The MDS indicated Resident #23 was taken antianxiety medication during the look-back period. <BR/>Record review for Resident #23's comprehensive care plan, dated 06/02/23 indicated Resident #23 required an antidepressant medication. The intervention of the care plan indicated staff would give medication as ordered, staff would monitor for side effects, and staff would monitor, document, and report to the MD as needed for ongoing signs and symptoms of depression. <BR/>Record review of Resident #23's physician's orders, dated 11/01/23, for Celexa 10 mg, give one tablet nightly for depression.<BR/>Record review for Resident #23's medication administration record, dated 01/31/24, indicated she received Celexa as ordered over the last 9 days.<BR/>Record review for Resident #23 consents for the use of antidepression medication, Celexa was not documented in her chart.<BR/>During an interview on 01/11/24 at 11:00 a.m., LVN O said consents should be obtained for all psychoactive medication before being given. LVN O said the ADONs usually obtained consents.<BR/>During an observation and interview on 01/11/24 at 4:28 p.m., the DON said the ADONs were responsible for monitoring to ensure consent forms were completed. The DON looked throughout Resident #23's medical records via point click care (facility electronic system) and did not see where her consent was located in the chart. The DON stated she was unsure why Resident #23 had no consent form for Celexa. The DON stated it was important to ensure consent forms were filled out so Resident #23 or her representative could make an informed decision. <BR/>During an interview on 01/11/24 at 4:37 p.m., the ADON said the DON/ADON gets consents for all new psychoactive medications. She said she was not sure why Resident #23 did not have her consent for Celexa. She said it was important to ensure residents or representatives signed consent forms so they could make an informed decision about their care.<BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said nurse management was responsible for ensuring psychotropic consent forms were signed and filled out. The Administrator said it was important to ensure consent forms were signed so the residents or representative understood and were able to give informed consent. She said they had a mock survey (given by the company) and they had no issues with consent. She said they may need to look at a different process for consent.<BR/>Record review of the facility's policy, Resident rights and consents to receive psychotropic medication, revised date 02/0I/07, indicated, The purpose of the policy and procedure for obtaining permission for psychotropic medications to be administered is to comply with the Department of Aging and Disability rule 19.1207 regarding informed consent for psychoactive medications. This provides residents the right to: Receive information about prescribed psychoactive medications, To have psychoactive medication prescribed and administered responsibly.<BR/>OBTAINING CONSENT: Consent must be obtained before the medication may be started . <BR/>Consent may be obtained by: 1. Residents or their legal representatives being given the required information on the medication and the resident or the legal representatives giving the facility consent as indicated by signing the psychotropic consent form .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 20 residents (Resident #12) reviewed for grievances. <BR/>The facility did not ensure a grievance was filed for Resident #12's black pants with a bow in the front when it was not returned from the laundry. <BR/>These failures could place residents at risk for grievances not being addressed or resolved promptly.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #12 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included other secondary Parkinsonism (a condition that causes tremor, muscle movement issues) and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain).<BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #12 was understood and understood others. The MDS assessment indicated Resident #12 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #12 was independent for eating, oral, toileting, personal and dental hygiene, dressing and required setup or clean up assistance for shower/bathe. <BR/>Record review of the grievances for the month of December 2023 and January 2024 did not indicate a grievance for Resident #12's black pants with a bow in the front. <BR/>During an interview on 01/09/2024 at 10:29 a.m., Resident #12 said within the last 2 months she had sent a pair of black pants with a bow on the front to the laundry and it was never returned. Resident #12 said she had notified the Housekeeping Supervisor and the Administrator. <BR/>During an interview on 01/09/2024 at 11:19 a.m., the Housekeeping Supervisor said he was over the laundry as well. The Housekeeping Supervisor said if a resident reported clothes missing, he would go look for the clothes in the laundry room and go through other residents' closets to see if the missing item was located. The Housekeeping Supervisor said if he was not able to locate the missing item, he would let the Administrator know and the laundry aides so they could look for the missing item. The Housekeeping Supervisor said he was aware Resident #12 was missing black pants with a bow on the front, and he had been aware of it since about a week ago. The Housekeeping Supervisor said he had not been able to locate Resident #12's black pants. The Housekeeping Supervisor said he had not let the Administrator know. The Housekeeping Supervisor said it was important for the residents' personal items to be returned to them because he would be pretty upset if he was missing something of his, and it was their belongings and personal items. <BR/>During an interview on 01/11/2024 at 4:30 p.m., ADON F said if a resident reported a lost clothing item, she would check the residents' rooms and the laundry, and if she did not find it that day, she would let the resident know. ADON F said the next day she would look for it again and once she was not able to find it, she would let the Administrator know. ADON F said she was not aware Resident #12's black pants were missing. ADON F said it was important for the residents' clothes to be returned to them because it was their personal belongings, and the facility was their home.<BR/>During an interview on 01/11/2024 at 5:26 p.m., the Administrator said if a resident reported missing clothes, they would ask the resident if they put their name on it, get a description of the item, search for the items in the laundry, check with other residents, and call the family if they were unable to find it. The Administrator said normally if clothes was missing, she did a grievance and if not found replaced the items. The Administrator said if the Housekeeping Supervisor had not found Resident #12's black pants he should have let her know so she could do a grievance. The Administrator said she was not aware Resident #12 was missing a pair of black pants. The Administrator said it was important for residents clothing and personal items to be returned to them because she wanted them to feel safe in the nursing home. <BR/>Record review of the facility's policy titled, Grievances, from the Social Services Manual 2003, indicated, .Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regard mg their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have . 3. The grievance official will: Oversee the grievance process oReceive and track grievances to their conclusion oLead any necessary investigations by the facility .6. <BR/>All written grievances decisions will include: oThe date the grievance was received oA summary statement of the residents grievance oThe steps taken to investigate the grievance oA summary of the pertinent findings or conclusions regarding the resident's concern(s) oA statement as to whether the grievance was confirmed or not confirmed oAny corrective action taken or to be taken by the facility as a result of the grievance oThe date the written decision was issued .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 20 residents (Resident #56) reviewed for MDS assessment accuracy. <BR/>The facility did not ensure Resident #56's MDS assessment was accurately coded to reflect his limitation in range of motion related to his contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both upper extremities. <BR/>This failure could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1), other reduced mobility, and adult failure to thrive. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was rarely/never understood by others and was rarely/never able to make himself understood. Record review of the MDS assessment indicated Resident #56 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #56 was dependent for all ADLs. The MDS assessment indicated Resident #56 had no impairment in functional limitation in range of motion to his upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. The MDS assessment indicated Resident #56 had an active diagnosis of other reduced mobility. <BR/>Record review of a facility provided document titled Residents with contractures dated 01/08/2024 indicated Resident #56 was on the list as having contractures. <BR/>Record review of an Occupational Therapy Discharge Summary with dates of service 05/17/2023-06/13/2023 indicated Resident #56 had contractures to bilateral upper extremities limiting range of motion. <BR/>During an observation on 01/08/2024 at 9:39 a.m., Resident #56 was lying in bed, contractures were noted to both of his hands. <BR/>During an interview on 01/11/2024 at 4:19 p.m., LVN D said she was aware Resident #56 had contractures to both of his hands. <BR/>During an interview on 01/11/2024 at 5:18 p.m., the Administrator said she expected for the coding on the MDS assessments to be accurate. The Administrator said the MDS Coordinator was responsible for completing the MDS assessments. The Administrator said it was important for the MDS assessments to be coded accurately for billing purposes, for care and so the claim shows an adequate picture of the residents. <BR/>During an interview on 01/11/2024 at 6:29 p.m., the MDS Coordinator said she had not coded Resident #56's contractures to both of his upper extremities because she had not noticed them, and she had not seen it in his documentation. The MDS Coordinator said she was responsible for completing the MDS assessments. The MDS Coordinator said it was important for the MDS assessments to be accurately coded to make sure they could provide the residents the care they needed. <BR/>During an interview on 01/11/2024 at 6:17 p.m., the Regional Compliance Nurse said the facility did not have a policy for MDS accuracy that they followed the RAI (Resident Assessment Instrument) Manual. <BR/>Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2023, indicated, GG0115 Definition Functional Limitation in Range of Motion Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 3 residents (Resident #45) reviewed for baseline care plans. <BR/>The facility failed to develop a baseline care plan that addressed Resident #45's use of a blood thinner. <BR/>This failure could place residents at risk of bleeding, excessive bruising, and not receiving care and services to meet their needs.<BR/>Findings included: <BR/>Record review of a face sheet dated 01/09/2024 indicated Resident #45 was an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which included sepsis due to methicillin susceptible staphylococcus aureus (serious infection that can lead to complications and death), arthritis due to other bacteria, right knee (inflammation of the right knee caused by a bacteria, fungus, virus), and chronic kidney disease stage 3B (moderate to severe loss of kidney function). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #45 was able to make himself understood and understood others. The MDS assessment indicated Resident #45 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #45 did not exhibit rejection of care. The MDS assessment indicated Resident #45 required partial/moderate assistance with personal, oral, and toileting hygiene, and dependent for shower/bathe. The MDS assessment indicated Resident #45 received an anticoagulant. <BR/>Record review of the Order Summary Report dated 01/09/2024 indicated Resident #45 had an order for Lovenox Injection Solution (also known as Enoxaparin Sodium a medication used to thin the blood to prevent blood clots) Inject 76 mg subcutaneously (beneath the skin) one time a day to prevent blood clots with a start date of 12/23/2023. <BR/>Record review of the January MAR indicated Resident #45 received Lovenox injections 01/01/2023-01/08/2023. <BR/>Record review of Resident #27's baseline care plan last reviewed 01/09/2024 did not indicate Resident #45 received Lovenox injections or received a blood thinner. <BR/>During an interview on 01/11/2024 at 5:22 p.m., the Administrator said baseline care plans were started by the nurses and then the MDS Coordinator completed the baseline care plan. The Administrator said the baseline care plan should include if a resident received a blood thinner like Lovenox. The Administrator said it was important for the baseline care plan to include blood thinners for continuity of care and so the staff knew how to take care of the residents. <BR/>During an interview on 01/11/2024 at 6:11 p.m., the DON said the baseline care plan was completed by the nurse managers upon admission. The DON said use of blood thinners like Lovenox should be included in the baseline care plan. The DON said the MDS Coordinator was responsible for ensuring the use of a blood thinner was included in Resident #45's baseline care plan. The DON said the nurse managers reviewed the orders and diagnosis daily to ensure they correlated with the care plans. The DON said it was important for this to be included in the baseline care plan to ensure they were providing the best care for the resident. <BR/>During an interview on 01/11/2024 at 6:30 PM, the MDS Coordinator said Resident #45's use of an anticoagulant (blood thinner) should have been included in his baseline care plan. The MDS Coordinator said if it was put on Resident #45's admission assessment it should have triggered to be included in his baseline care plan. The MDS Coordinator said Resident #45's comprehensive care plan had not been completed yet, the care plan in Resident #45's electronic health record was his baseline care plan. The MDS Coordinator said the nurses initiated the baseline care plan, and then in the morning meetings she went behind the nurses to update and add to the baseline care plans. The MDS Coordinator said Resident #45's use of an anticoagulant was not added to his care plan because it must not have been on his admission assessment, but it should have been added during the morning meeting. The MDS Coordinator said it was important for medications like an anticoagulant to be added to the baseline care plan so they can ensure they were providing person centered care. <BR/>Record review of the facility's undated policy titled, Base Line Care Plans, indicated, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- o Be developed within 48 hours of a resident's admission. o Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- Initial goals based on admission orders. Physician orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 20 residents (Resident #16, Resident # 37, and Resident #56) reviewed for comprehensive person-centered care plans.<BR/>1. The facility failed to care plan Resident #16's CPAP machine (machine used to deliver constant and steady air pressure to help you breathe while you sleep).<BR/>2. The facility failed to care plan Resident #56's contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both hands. <BR/>3. The facility failed to ensure Resident # 37 had a fall mat at bedside. <BR/>These failures could place the residents at increased risk of not having their individual needs met, injury, not receiving necessary services, and a decreased quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), sleep apnea (condition that causes you to stop breathing while you are sleeping), 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 #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs. The MDS assessment did not indicate Resident #16 used a CPAP. <BR/>Record review of Resident #16's Order Summary Report dated 01/10/2024 did not indicate he had orders for a CPAP machine. <BR/>Record review of the care plan last reviewed on 11/21/2023 did not indicate Resident #16's use of a CPAP machine. <BR/>During an observation and interview on 01/08/2024 at 10:45 a.m., Resident #16 had a CPAP machine in his room on top of his nightstand. Resident #16 said he had the CPAP machine since he admitted to the facility, and he used it. <BR/>During an interview on 01/10/2024 at 6:00 p.m., LVN E said Resident #16 used his CPAP machine at night. LVN E said Resident #16 should have an order for his CPAP to ensure the settings were set properly. <BR/>2. Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1), other reduced mobility, and adult failure to thrive. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was rarely/never understood by others and was rarely/never able to make himself understood. Record review of the MDS assessment indicated Resident #56 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #56 was dependent for all ADLs. The MDS assessment indicated Resident #56 had no impairment in functional limitation in range of motion to his upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. <BR/>Record review of the Order Summary Report dated 01/17/2024, did not indicate any orders for Resident #56's contractures. <BR/>Record review of a facility provided document titled Residents with contractures dated 01/08/2024 indicated Resident #56 was on the list as having contractures. <BR/>Record review of the care plan last revised 11/15/2023 did not indicate Resident #56's contractures to both of his hands were included in his care plan. <BR/>Record review of an Occupational Therapy Discharge Summary with dates of service 05/17/2023-06/13/2023 indicated Resident #56 had contractures to bilateral upper extremities. <BR/>During an observation on 01/08/2024 at 9:39 a.m., Resident #56 was lying in bed, contractures were noted to both of his hands. <BR/>During an interview on 01/11/2024 at 4:19 p.m., LVN D said she did not think the nurses completed the care plans, and she did not know who was responsible for the care plans. LVN D said she was aware Resident #56 had contractures to both of his hands. <BR/>During an interview on 01/11/2024 at 5:03 p.m., the Administrator said contractures and the use of a CPAP machine should be included in the residents' care plans. The Administrator said the IDT was responsible for completing the care plans. The Administrator said the IDT ensured the care plans included what was required for the residents in the daily clinical morning meetings. The Administrator said it was important for the residents' care plans to include contractures and the use of a CPAP machine for continuity of care and for staff to know how to care for the residents. <BR/>During an interview on 01/11/2024 at 5:50 p.m., the DON said comprehensive care plans were completed by the IDT. The DON said the MDS Coordinator was responsible for overseeing the care plans. The DON said the use of a CPAP machine and contractures should be included in the care plan. The DON said she was not aware Resident #56's contractures were not included in his care plan. The DON said Resident #16's CPAP was taken out of his care plan because they were working on getting him a new one. The DON said it was important for these to be included in his care plans because the care plan gave a detail of how they were supposed to care for the resident. <BR/>During an interview on 01/11/2024 at 6:23 p.m., the MDS Coordinator said she completed the comprehensive care plans. The MDS Coordinator said the IDT reviewed the care plans as a team quarterly to ensure everything was included in the residents' care plans. The MDS Coordinator said she was not aware Resident #56 had contractures because she had not seen any documentation, and she had not noticed it when doing his assessment. The MDS Coordinator said Resident #16 did not have an order for his CPAP, and that was why it was not included in his care plan. The MDS Coordinator said it was important for the use of a CPAP machine and contractures to be included in the care plan for the residents to get the care they needed and so the care plan was focused on them. <BR/>3. Record review of Resident # 37's face sheet dated 1/11/2024, revealed Resident # 37 was an [AGE] year old male with diagnoses of secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder, or another illness), Hypertension (blood pressure that is higher than normal), Iron Deficiency Anemia (a condition in which blood lacks adequate healthy red blood cells), muscle weakness (commonly due to lack of exercise, ageing, or muscle injury), history of falling (A history of falls has been previously reported to be a factor associated with falls). <BR/>Record review of Resident # 37's Quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #37 had a BIMS score of 8 which indicated her cognition was severely impaired. <BR/>Record review of Resident # 37's care plan dated 10/31/2023, indicated interventions for fall mat at bedside, facility fall protocol. <BR/>Record review of Resident # 37's order summary dated 1/11/2024, indicated fall mat to bedside. <BR/>During an observation on 01/08/2024 at 2:42 P.M., revealed Resident # 37 in bed a sleep with no fall mat in place.<BR/>During an observation on 01/09/2024 at 3:00 p.m., revealed Resident # 37 in bed a sleep with no fall mat in place.<BR/>During an interview on 01/11/2024 at 9:45 a.m., CNA N stated she had been employed with the facility for 90 days. CNA N stated she had no knowledge of Resident #37 needing a fall mat. CNA N stated the only way she would have known if Resident # 37 needed a fall mat was if it was posted or the nurses tell her. CNA N stated it was important for Resident # 37 to have a fall mat to prevent injury. CNA N stated the failure would be he could fall and hurt himself. <BR/>During an interview on 01/11/2024 at 9:52 a.m., LVN O stated it was her responsibility and the resident representative responsibility to ensure Resident #37 had a fall mat at bedside while sleeping. LVN O stated it was important for Resident # 37 to have a fall mat at bedside because he had previous falls. LVN O stated she had no idea why the fall mat was not at the bedside when Resident #37 was sleeping. LVN O stated the failure was Resident # 37 could fall and get hurt. <BR/>During an interview on 01/11/2024 at 4:48 p.m., the ADON G stated she had been employed with the facility since September 2023. The ADON G stated she did not really know who was responsible for ensuring Resident #37 had a fall mat at bedside while sleeping. The ADON G state it was important to have the fall mat at bedside as a form of protection. The ADON G stated the failure could be a possible head injury or broken bones. <BR/>During an interview on 01/11/2024 at 5:30 p.m., the DON stated Resident #37 should have a fall mat at bedside when in bed. The DON stated it was one of the ADON's responsibility for ensuring Resident #37's fall mat was at bedside. The DON stated the importance for a fall mat at bedside was in case Resident# 37 rolls out of bed and does not hit the hard floor. The DON stated she would reeducate the CNA's on place the fall mat at bedside while resident was in bed. The DON stated the failure was not providing safety. <BR/>During an interview on 01/11/2024 at 6:17 p.m., the Administrator stated it was the DON's responsibility for ensuring Resident #37's fall mat was at bedside. The Administrator stated It was important for Resident # 37 fall mat to be at bedside because it was a fall intervention. The Administrator stated she would monitor by doing rounds in the morning and evening to ensure interventions are done. The Administrator stated the failure was he could fall and hurt himself.<BR/>Record review of the facility's undated policy titled, Comprehensive Care Planning, indicated, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . <BR/>A request for the facility policy regarding fall mat was submitted to the Regional Nurse Consultant on 1/11/2024 at 6:17 p.m. A policy was not received 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 the environment was free of accidents and hazards for 1 of 4 residents (Resident #16) reviewed for safety. <BR/>The facility failed to ensure Resident #16 did not have an electric heating blanket in his room. <BR/>This failure could place residents at risk for burns and injuries.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted 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) and legal blindness, as defined in USA. <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs.<BR/>Record review of Resident #16's care plan last reviewed 11/21/2023 indicated Resident #16 had diabetes mellitus to avoid exposure to extreme heat or cold. <BR/>During an observation and interview on 01/08/2024 at 10:45 a.m., Resident #16 had an electric heating blanket laid out along with all his other blankets and sheets on a chair. Resident #16 said he had gotten it for Christmas because at times it got cold in his room. Resident #16 said he would use it when it got cold. <BR/>During an interview on 01/09/2024 at 9:05 a.m., LVN H said she had not been working at the facility very long and she was not sure if it was ok for Resident #16 to have an electric heating blanket in his room. <BR/>During an interview on 01/11/2024 at 4:28 p.m., ADON F said she had told Resident #16 not to use the electric heating blanket. ADON F said Resident #16 said he received the electric heating blanket as a gift for Christmas. ADON F said any of the staff going into his room should be checking for items not allowed in the residents' rooms. ADON F said it was important not to keep electric heating blankets in the residents' rooms because they were a fire hazard, and he could get severely burned. <BR/>During an interview on 01/11/2024 at 5:25 p.m., the Administrator said she was not aware Resident #16 had an electric heating blanket in his room. The Administrator said the CNAs usually told her if the residents had items in their room that were not allowed. The Administrator said the facility had champion rounds (where dedicated staff go to the residents' rooms to check on them) to check the residents' rooms. The Administrator said it was important for the residents not to keep electric heating blankets in their rooms because it could cause a fire and it could burn them. <BR/>During an interview on 01/11/2024 at 6:14 p.m., the DON said the residents should not keep electric heating blankets in their rooms. The DON said she was not aware Resident #16 had an electric heating blanket in his room. The DON said all the staff should be making sure the residents did not have them in their rooms. The DON said it was important for the residents not to keep electric heating blankets in their rooms for their safety and to prevent any burns. <BR/>Record review of a facility provided document dated May 6, 2005, titled, Nursing Home List of Items Not Allowed in Resident Room (This list is not all inclusive), indicated, . Safety Hazards . electric blankets .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #56) reviewed for indwelling urinary catheters.<BR/>The facility failed to ensure Resident #56's urinary (foley) catheter was properly secured to his leg. <BR/>This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1) and neuromuscular dysfunction of bladder (a type of bladder dysfunction caused by nerve, brain, or spinal cord damage). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #56 was rarely/never understood by others and was rarely/never able to make himself understood. Record review of the MDS assessment indicated Resident #56 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #56 was dependent for all ADLs. The MDS assessment indicated Resident #56 had an indwelling catheter. <BR/>Record review of the Order Summary Report dated 01/17/2024 indicated Resident #56 had an order to ensure catheter strap in place and holding every shift change as needed with an order start date of 11/21/2023.<BR/>Record review of the care plan last reviewed 11/15/2023 indicated Resident #56 had a chronic foley catheter with a goal for the resident will be/remain free from catheter related trauma through review date, and interventions to ensure the tubing was anchored to the resident's leg or linens so that tubing was not pulling on the urethra. <BR/>Record review of Resident #56's TAR for January 2024 indicated ensure catheter strap in place and holding every shift change as needed and was documented as completed by LVN D on 01/10/2024.<BR/>During an observation on 01/10/2024 at 9:10 a.m., Resident #56 did not have a catheter strap in place. Resident #56's catheter tubing was not anchored to his leg or the linens. Resident #56 was non-interviewable. <BR/>During an observation and interview with LVN D on 01/10/2024 at 9:19 a.m., Resident #56's catheter tubing was not anchored to his leg or the linens, and there was no catheter strap in place. LVN D said she was not aware Resident #56 should have a catheter strap in place to secure his catheter. LVN D said she had documented on the MAR for his catheter strap to be in place, but she did not realize that's what it meant. LVN D said she thought that referred to ensuring the catheter was still in place, not regarding the catheter being secured to his leg. LVN D said the nurses were responsible for ensuring the residents catheters were properly secured. LVN D said it was important for the catheter to be secured so it did not get pulled. LVN D said if the catheter was not properly secured it could cause damage to his penis. <BR/>During an interview on 01/11/2024 at 4:34 p.m., ADON F said the nurses and CNAs were responsible for ensuring the foley catheters were secured. ADON F said she monitored to ensure the foley catheters were secured by checking the MARs and tasks to ensure the nurses were documenting this was done. ADON F said it was important for foley catheters to be secured properly so they would not be dislodged. ADON F said if the foley catheters were not secured properly it could get lodged in the penis or cause blood in the urine. <BR/>During an interview on 01/11/2024 at 5:08 p.m., the Administrator said she expected for the nurses to ensure the foley catheters were secured properly. The Administrator said the nurses and nurse management were responsible for ensuring foley catheters were secured properly. The Administrator said it was important for the foley catheters to be secured properly so they did not pull them out or get hung on something.<BR/>During an interview on 01/11/2024 at 5:56 p.m., the DON said the Infection Control Preventionist was responsible for ensuring the catheters were secured properly. The DON said Resident #56 should have had a leg strap in place to secure his foley catheter, and she did not know why he did not. The DON said it was important for the catheters to be secured to ensure it did not get pulled out or cause irritation. <BR/>Record review of the facility's policy titled, Catheter Insertion, Male/Female, from the Nursing Policy & Procedure Manual 2003 did not address securement of a foley catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 5 of 63 residents reviewed for respiratory care (Residents #23, #18, #41, #11 and #16). <BR/>1. The facility failed to ensure Resident #23's oxygen was in a bag when not in use.<BR/>2. The facility failed to ensure Resident #18 and Resident #41 oxygen concentrator filter was cleaned weekly. <BR/>3. The facility failed to ensure Resident #41 nebulizer tubing was placed inside a bag after her breathing treatment was administered.<BR/>4. The facility failed to ensure Resident #11's handheld nebulizer was stored in a bag. <BR/>5. The facility failed to ensure Resident #16 had an order for his CPAP machine (a machine used to deliver constant and steady air pressure to help you breathe while you sleep) and the facility failed to ensure Resident #16's CPAP mask was stored in a bag.<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 Resident #23's face sheet, dated 01/16/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE] with the diagnoses which included Congestive Heart Failure {CHF} (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), high blood pressure, depression (persistent feeling of sadness and loss of interest), and dementia(impaired ability to remember, think, or make decisions that interfere with doing everyday activities).<BR/>Record review of Resident #23's quarterly MDS assessment, dated 12/21/23, indicated Resident #23 was usually understood and usually understood by others. Resident #23's BIMs score was 01, which indicated she was cognitively severely impaired. The MDS indicated Resident #23 required total assistance with bathing and toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and supervision with eating. The MDS indicated Resident #23 was receiving oxygen during the look-back period. <BR/>Record review of Resident #23's physician's orders, dated 06/13/23, for Oxygen via NC at 2lpm as needed as needed related to acute respiratory failure. <BR/>Record review for Resident #23's comprehensive care plan, dated 06/09/23 indicated Resident #23 required Oxygen Therapy. The interventions were for staff to monitor for signs and symptoms of respiratory distress and report to the physician as needed and to wear Oxygen at 2 liters per nasal cannula as needed. <BR/>During an observation on 01/08/24 at 10:22 a.m., Resident #23 was being wheeled out of her room by a staff member. O2 tubing was noted sitting on the concentrator, not in a bag or dated. <BR/>During an observation and interview on 01/10/24 at 4:38 p.m., Resident #23 was sitting in her room and noted oxygen concentration was running at 2 liters. Oxygen tubing was noted as not bagged. LVN O came into the room and saw the O2 tubing sitting on the concentration and said Resident #23 does wear her oxygen periodically but it should be bagged when not used for infection control issues.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said O2 tubing should be changed weekly on Sunday nights and as needed. She said O2 tubing should be dated and bagged when changed or not in use. She said the ADONs should be doing a spot check daily and failure to place in bags when not in use could cause infection control issues.<BR/>During an interview on 01/11/24 at 4:37 p.m., ADON G said O2 tubing should be bagged when not in use. She said the charge nurses were responsible but the ADONs looked periodically to ensure they were bagged. She said if O2 tubing was not bagged it could cause some infection control issues.<BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said oxygen tubing should be stored in a bag when not in use. The Administrator said the nurses were responsible for ensuring they were stored in a bag. She said they did champion rounds with department heads as well and nurse managers should be making rounds to ensure oxygen tubing was stored in a bag when not in use. The Administrator said it was important for oxygen to be stored in a bag because if they were out in the open bacteria could get on it and the bacteria could be put into the resident's respiratory systems. Tubing should be bagged to prevent infection. <BR/>2. Record Review of Resident #18 face sheet, dated on 1/10/24, indicated Resident #18 was a [AGE] year-old female, admitted to the facility on the administration date of 3/30/18 with a diagnosis of Hemiplegia (part of the brain controlling movement is damaged) affecting right dominant side, Hemiparesis (a condition that causes weakness or paralysis on one side of the body, affecting daily activities and mobility), Dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life, limitations of activities due to disability and essential hypertension (high blood pressure). <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #18 made herself understood, understood others, and was cognitively intact. The MDS indicated Resident #18's BIMS Score was 08, which indicated moderate impairment. The MDS indicated Resident #18 required extensive assistance with bed mobility with a two-person physical assist, and extensive assistance with toileting and transfer with two-person physical assist. The MDS indicated Resident #18 received oxygen therapy. <BR/>Record review of the care plan updated dated on 2/09/21 indicated Resident #18 received oxygen therapy as needed. The comprehensive care plan indicated to give medications as ordered by the physician; observe/document side effects and effectiveness. The care plan did not address the oxygen concentrator filter.<BR/>Record Review of Resident #18's Oxygen and Respiratory orders on 1/9/24 at 1:16 p.m., indicated to clean or change the filter every night shift every Sunday. <BR/>During an observation on 1/10/24 at 8:30 a.m., Resident #18 oxygen concentrator filter was not cleaned.<BR/>During observation on 1/11/24 at 8:05 a.m., Resident #18 oxygen concentrator filter was not cleaned.<BR/>3.Record Review of Resident #41 face sheet, dated on 1/10/24, indicated Resident #41 was a [AGE] year-old female, admitted to the facility on the administration date of 12/12/23 with a diagnosis of emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness, chronic obstructive pulmonary disease, pneumonia, insomnia and limitation of activities due to disability. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #41 made herself understood, understood others, and was cognitively intact. The MDS indicated Resident #41 BIMS score was 08 which indicated moderate impairment. The MDS did not indicate Resident #41 assistance with bed mobility, toileting, and dressing. The MDS indicated Resident #41 received oxygen therapy. <BR/>Record review of the care plan updated dated on 12/14/23 indicated Resident #41 received oxygen therapy. The comprehensive care plan indicated to monitor for signs and symptoms of respiratory distress and report to Medical Doctor as needed; notify the nurse if oxygen is off the resident; oxygen set at 2 to 3 liters per minute. The care plan did not address the oxygen concentrator filter for Resident #41. The Care plan did not address the nebulizer for Resident #41.<BR/>Record Review of Resident #41 Oxygen and Respiratory orders on 1/9/24 at 12:56 p.m., indicated to clean or change the filter of nebulizer machine every night shift every Sunday. <BR/>During observation on 1/10/24 at 8:33 a.m., Resident #41 nebulizer tubing was not placed inside bag after use.<BR/>During observation on 1/11/24 at 8:08 a.m., Resident #41 nebulizer tubing was not placed inside bag after use.<BR/>During an interview on 1/10/24 at 6:01 p.m., LVN E stated she had been employed since November 2023 and has been working night shift since December 2023. LVN E stated she worked PRN on the night shift at the facility. LVN E stated she did not know how often filters were to be changed. LVN E stated she did not know how the filters were to be cleaned because she came from a hospital and did not have to clean the o2 filter. LVN E stated she changed the tubing for the oxygen concentrator as needed. LVN E stated she was not aware of the oxygen concentrator filter orders for Resident #41 and Resident #18. LVN E stated she did not complete in-services on nebulizer or o2 filter changing. LVN E stated she did not sign off on oxygen filter at night because she was not aware of the filters needing to be changed on Sunday by the night shift nurse. LVN E stated the DON oversaw what she did at the facility. LVN E stated it was important to follow doctor's orders for oxygen contractor for cleanliness and healthiness and to prevent residents from getting sick. <BR/>During an interview on 1/11/24 at 8:08 a.m., Resident #41 stated she used her nebulizer every day. Resident #41 stated the nurses never put her nebulizer in a bag after use.<BR/>During an interview on 1/11/24 at 10:07 the DON stated she had been the DON since Feb of 2023. The DON stated the ADON was responsible for monitoring the oxygen filter changes. The DON stated the ADON was responsible for monitoring the nebulizer was placed in a bag after use. The DON stated she did not know why the nebulizer was not place in a bag after use. The DON stated she was not aware that the oxygen filters were not being changed on Resident #18 and Resident #41. The DON stated she was aware of the oxygen concentrator orders for Resident #18 and Resident #41. The DON stated she did expect staff to follow physician orders as prescribed. The DON stated she monitors the oxygen orders during SOC meeting daily. The DON stated during SOC meetings she would ask the ADON for updated reported what needed to be done and the changing the resident oxygen filers was never brought to her attention. The DON stated she conducted daily rounds in the morning. The DON stated each morning the, ADON, treatment nurse and MDS coordinator were assigned to halls to conduct daily rounds every day. The DON stated it was important to ensure staff were following physician orders to ensure resident were getting the best care. <BR/>During an interview on 1/11/24 at 11:00 a.m., ADON F stated she had been the ADON since March of 2023. ADON F stated ADON G was in charge of the Oxygen filter changes and nebulizer. ADON F stated she did not know why the nebulizer tubing had not been placed in bag, but nurses' staff were aware of the nebulizer tubing being placed in bag after use. ADON F stated she was aware oxygen order for Resident #41 and Resident #18, but she did not check filter but will check oxygen filters for now on a daily base. ADON F stated she expected staff to ensure they were following the physician orders. ADON F stated her assigned hallway was the B hall and she monitored B hall only. ADON F stated ADON G was assigned to the C hall. ADON F stated the wound care nurse was assigned to D hall. ADON F stated in-service was last completed a few months ago on oxygen filter changes and nebulizer. ADON F stated she was not aware of LVN not being trained on how to clean oxygen filters. ADON F stated the DON oversaw her. ADON F stated, It was important for staff to follow physician orders because the orders were there for a reason, and it will help provide the best care for the resident. <BR/>During an interview on 1/11/24 at 11:36 a.m., The Administrator stated the nursing staff was responsible for changing the oxygen concentrator filters. The Administrator stated the nursing staff were responsible for ensuring the nebulizers were placed in bag. The Administrator stated she did expect staff to ensure they were changing the oxygen concentrator as prescribed by the doctor. The Administrator stated she was not aware that the oxygen concentrator filter were not being changed. The Administrator stated she was not aware of the nebulizer tubing not being placed in bags. The Administrator stated she monitored the filter changes by asking clinical staff in the morning meeting. The Administrator stated staff did completed nebulizer in-services training back in October 2023. The Administrator stated she did not recall the training in-services on filters changes. The Administrator stated it was important for staff to follow physician orders for the wellbeing of the resident. <BR/>During an interview on 1/11/24 at 11:44 a.m., Treatment Nurse L stated she was responsible for the monitoring the D hall. Treatment Nurse L stated she conducted rounds every day on the D Hall where Resident #18 and Resident #41 resided. Treatment Nurse L stated she would watch breakfast trays go out in the morning and then conduct rounds in the resident rooms on her assigned hall (D hall). Treatment Nurse L stated she never noticed that Resident #18 nebulizer tubing was not placed in bag after bag after Resident #18 breathing treatments were administered. Treatment Nurse L stated she the charge nurse and the ADON G were responsible for monitoring the nebulizer tubing was placed in bag after use. Treatment Nurse L stated her last round on D Hall was conducted on 1/11/24 7:40 a.m. Treatment Nurse L stated Resident #18 had one orders for the nebulizer and she was aware of Resident #18 nebulizer orders from the physician. Treatment Nurse L stated she stated resident #18 received a breathing treatment 3 times a day. Treatment Nurse L stated Resident #18 breathing treatment on her nebulizer were given at 9 a.m., 4 p.m., and 9p.m. Treatment Nurse L stated Resident #18 last used her nebulizer at 9 a.m. on 1/11/24. <BR/>During an interview on 1/11/24 at 12:19 p.m., ADON G stated she had been the ADON since sept of 2023. ADON G stated she was responsible for monitoring the oxygen filter changes and making sure the nebulizer tubing were placed in bag. ADON G stated she was not aware of the oxygen order for the filter changes for Resident #18 and Resident #41. ADON G stated she did expect staff to ensure they were following physician orders. ADON G stated she monitored staff by conducting follow-up after staff to ensure staff were putting the nebulizer in bags and changing the filters according to the physician orders. ADON G stated in the past she addressed concerns with staff upon finding issues with the oxygen concentrators and nebulizer. ADON G stated she was not aware of staff completing any in-service training for nebulizer or oxygen filter changing. ADON G stated she was not aware of staff not changing the oxygen filters. ADON G stated she had no idea that the night nurse LVN did not know how to change/clean the oxygen concentrator filters. ADON G stated she the DON oversaw her. ADON G stated it was important to ensure staff were following physician orders because the physician knows what's best for the residents.<BR/>4. Record review of a face sheet dated 01/11/2024 indicated Resident #11 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat that stops and starts) and asthma (lung disorder characterized by narrowing of the tubes which carry air into the lungs, that are inflamed and constricted, causing shortness of breath, wheezing and cough). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #11 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #11 required setup/clean-up assistance with eating, personal and oral hygiene, dependent for toilet hygiene, dressing, and substantial/maximal assistance with shower/bath. The MDS assessment indicated Resident #11 used oxygen therapy. <BR/>Record review of the Order Summary Report dated 01/10/2024 indicated Resident #11 had an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083% (Albuterol Sulfate- medication used to treat wheezing and shortness of breath) 1 inhalation inhale orally via nebulizer four times a day with a start date of 11/29/2023. <BR/>Record review of the care plan last reviewed 12/12/2023 did not address Resident #11's use of a handheld nebulizer. <BR/>During an observation on 01/08/2024 at 9:50 a.m., Resident #11's handheld nebulizer was on her nightstand and was not stored in a bag. <BR/>During an observation on 01/09/2024 at 8:14 a.m., Resident #11's handheld nebulizer was in her drawer and was not stored in a bag.<BR/>During an interview on 01/11/2024 at 4:07 p.m., LVN D said handheld nebulizers and oxygen masks should be stored in a sack dated and initialed. LVN D said she did not know why Resident #11's handheld nebulizer was not stored in a bag because she had not worked the previous two days. LVN D said the nurses were responsible for ensuring the handheld nebulizers and oxygen masks were stored properly. LVN D said it was important for handheld nebulizers and oxygen masks be stored in a bag for infection control. <BR/>5. Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), sleep apnea (condition that causes you to stop breathing while you are sleeping), 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 #16 understood others and was able to make himself understood. The MDS assessment indicated Resident #16 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #16 was independent for all ADLs. The MDS assessment did not indicate Resident #16 used a CPAP. <BR/>Record review of Resident #16's Order Summary Report dated 01/10/2024 did not indicate he had orders for a CPAP machine. <BR/>Record review of the care plan last reviewed on 11/21/2023 did not indicate Resident #16's use of a CPAP machine. <BR/>During an observation on 01/08/2024 at 10:45 a.m., Resident #16 had a CPAP machine in his room on top of his nightstand with the mask laying on the nightstand not stored in a bag. <BR/>During an observation on 01/10/2024 at 2:13 p.m., Resident #16 had his CPAP mask on top of his nightstand not stored in a bag. <BR/>During an interview on 01/10/2024 at 2:21 p.m., LVN D said she was not aware Resident #16 had a CPAP. LVN D said she had not seen his CPAP machine in his room. LVN D said Resident #16 should have an order for his CPAP and she did not know why he did not have one. LVN D said she did not know why his CPAP mask was not stored in a bag because the night nurse was the one that put it on him. <BR/>During an interview on 01/10/2024 at 6:00 p.m., LVN E said Resident #16 used his CPAP machine at night. LVN E said she had not looked at Resident #16's orders to see if he had an order for his CPAP. LVN E said Resident #16 should have an order for his CPAP to ensure the settings were set properly. LVN E said she was not sure why Resident #16's CPAP mask was not stored in a bag because when she worked it was stored in a bag. LVN E said it was important for CPAP masks to be stored in a bag for cleanliness and because she would not want it to touch the floor and then put it in the resident's airway. <BR/>During an interview on 01/11/2024 5:05 p.m., the Administrator said residents should have an order for a CPAP machine The Administrator said nursing was responsible for putting in the order for the CPAP. The Administrator said it was important to have an order for a CPAP machine to ensure the physician orders were being followed. The Administrator said her expectations were for the oxygen/CPAP masks, handheld nebulizers to be clean and always stored if not in use. The Administrator said these items should be stored in a bag. The Administrator said the nurses were responsible for ensuring they were stored in a bag. The Administrator said it was important for oxygen/CPAP masks and handheld nebulizers to be stored in a bag because if they were out in the open bacteria could get on it and the bacteria could be put in the residents' respiratory systems. <BR/>During an interview on 01/11/2024 at 5:53 p.m., the DON said Resident #16 should have an order for his CPAP. The DON said Resident #16 did not have an order because they were in the process of getting him a new one. The DON said ADON F was responsible for monitoring the orders. The DON said it was important to have an order for a CPAP because without an order the nurses would not know how he needed to wear it. The DON said handheld nebulizers/oxygen masks should be stored in a bag. The DON said ADON G was responsible for ensuring the nurses were storing the handheld nebulizers and oxygen masks properly. The DON said it was important to ensure the handheld nebulizers and oxygen masks were stored in a bag for infection control. <BR/>Record review of the facility's policy titled, Respiratory Policies and Procedures, revision date 06/01/2007, indicated, Bi-level Positive Airway Pressure (BiP AP) and/or Continuous Positive Airway Pressure (CPAP) is set up and monitored by a licensed nurse or respiratory therapist with a physician's order. Orders must include pressure and hours of use and may include supplemental oxygen and mask size. For BiPAP, orders must also include EPAP and TPAP and may include mode of delivery and respiratory rate . <BR/>Record review of the facility's policy titled, Aerosolized Hand-Held Nebulizer, from the Nursing Policy & Procedure Manual 2003, indicated, . Rinse the nebulizer and mouthpiece shake and store in a plastic bag the is labeled with the patient' s name and room number. 14. Chart to include medication, diluents, and dose on medication record. 15. Change nebulizer set-up every 7 days and more often if necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' who used anticoagulant medications were adequately monitored and free from unnecessary drugs for 2 of 5 residents (Resident #11 and Resident #58) reviewed for unnecessary medications. <BR/>1. The facility failed to monitor Resident #11 for side effects of Eliquis (an anticoagulant medication-blood thinner). <BR/>2. The facility did not monitor Resident #58 for side effects/adverse reactions for the use of anticoagulant (blood-thinning) medications. <BR/>This failure could place residents at risk of bruising and bleeding. <BR/>Findings included:<BR/>1. Record review of Resident #11's face sheet dated 01/11/2024 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with routine healing (fracture at the end of the left leg bone), unsteadiness of feet, and paroxysmal atrial fibrillation (irregular heartbeat that stops and starts). <BR/>Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #11 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #11 required setup/clean-up assistance with eating, personal and oral hygiene, dependent for toilet hygiene, dressing, and substantial/maximal assistance with shower/bath. The MDS assessment indicated Resident #11 was taking an anticoagulant. <BR/>Record review of the Order Summary Report dated 01/10/2024 indicated Resident #11 had an order for Eliquis 5 mg give 1 tablet by mouth two times a day with a start date of 11/29/2023. Resident #11's Order Summary Report did not indicate to monitor for side effects of anticoagulant medication. <BR/>Record review of the care plan last reviewed 12/12/2023 indicated Resident #11 was on anticoagulant therapy to monitor/document/report to medical director as needed for signs and symptoms of anticoagulant complications. <BR/>Record review Resident #11's MAR for January 2024 indicated Resident #11 received Eliquis 5 mg every day from 01/01/2024 to 01/11/2024 with no monitoring for side effects for an anticoagulant medication indicated. <BR/>Record review Resident #11's TAR for January 2024 did not indicate to monitor for side effects of an anticoagulant medication. <BR/>Record review of Resident #11's Tasks in her electronic health record indicated no documentation of monitoring for side effects of Eliquis. <BR/>During an interview on 01/11/2024 at 4:12 p.m., LVN D said if she received an order for an anticoagulant medication she would put in an order for anticoagulant monitoring. LVN D said she was not aware if Resident #11 required anticoagulant monitoring. LVN D said if a resident was on anticoagulant medications, she would monitor them for bleeding and excessive bruising. LVN D said it was important to monitor when residents were taking anticoagulants to ensure they did not bleed excessively or having increased bruising. <BR/>During an interview on 01/11/2024 at 4:22 p.m., ADON F said she did not know who was responsible for ensuring the residents on anticoagulant medications were being monitored appropriately. ADON F said to her knowledge there was no process in place to ensure the residents receiving anticoagulant medications were being monitored appropriately. ADON F said it was important for residents receiving anticoagulant medications to be monitored because there was a potential for bleeding. <BR/>During an interview on 01/11/2024 at 5:13 p.m., the Administrator said the DON was responsible for ensuring the anticoagulant monitoring was being done. The Administrator said she expected for residents to be monitored appropriately when taking anticoagulant medications. The Administrator said this was important for their health. <BR/>During an interview on 01/11/2024 at 6:03 p.m., the DON said upon a resident's admission anticoagulant monitoring was put in the Tasks in the resident's electronic health record for the CNAs to document. The DON said she was not aware Resident #11 did not have anticoagulant monitoring in her electronic health record. The DON said ADON G was responsible for overseeing that anticoagulant monitoring was being done. The DON said it was important for anticoagulant monitoring to be done to ensure the risk for bleeding is assessed. <BR/>During an interview on 01/11/2024 at 6:21 p.m., ADON G said she did not oversee the anticoagulant monitoring. ADON G said she was not sure who was responsible for putting in the Tasks for anticoagulant monitoring or who was overseeing it. ADON G said it was important for anticoagulant monitoring to be in place because it could be a life-or-death situation for the residents. <BR/>2. Record review of Resident # 58's face sheet dated 01/11/2024, revealed Resident # 58 was an [AGE] year-old male with diagnoses of Alzheimer's disease (the most common type of Dementia), Hypertension (high blood pressure). Atrial Fibrillation (fast, irregular heartbeat), Chronic Systolic Congestive Heart Failure (a specific type of heart failure that occurs in the heart's left ventricle). <BR/>Record review of Resident # 58's order summary dated 01/11/2024, indicated Resident #58 received Apixaban (anticoagulant) 5mg 1 tablet by mouth two times a day ordered on 07/27/2023. <BR/>Record review of Resident # 58's care plan dated 01/2/2024, indicated Resident # 58 was taking anticoagulant with interventions to monitor, document, and report signs and symptoms of anticoagulant complications. <BR/>Record review of Resident # 58's Comprehensive MDS dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #58 had a BIMS score of 8 which indicated his cognition was moderately impaired.<BR/>Record review of Resident # 58's Task List dated 01/11/2024, indicated no documentation of monitoring for side effects of Apixaban an anticoagulant. <BR/>During an interview on 01/11/2024 at 4:30 p.m., LVN O stated when a resident was on Apixaban they are monitored for bleeding. LVN O stated it was supposed to be documented on the Task list so they can monitor for bleeding. LVN O stated she had no idea why it was not on the Task list. LVN O stated the failure was it not being documented on the task list you would have to do more digging to know what the resident was taking and could prolong the issue. <BR/>During an interview on 01/11/2024 at 4:48 p.m., the ADON G stated she has been employed with the facility since September2023. ADON G stated she did not know anticoagulant monitoring was supposed to be documented on the Task list. ADON G stated any of the nurse managers are responsible for monitoring documentation on the Task list. ADON G stated was important to document anticoagulant monitoring on the Task list because if the resident fell or had any type of injury that breaks the skin it could be life or death. ADON G stated the failure was a potential for harm. <BR/>During an interview on 01/11/2024 at 5:30 p.m., the DON stated anticoagulant monitoring should be added to the Task list immediately. The DON stated the ADON's are responsible for adding to the Task list. The DON stated it was important for anticoagulant monitoring to be on the Task list to monitor for bruising and bleeding. The DON stated it was an oversight that the anticoagulant monitoring was not added to the task list. The DON stated the failure was not assessing for bleeding. <BR/>During an interview on 01/11/2024 at 6:17 p.m., the Administrator stated anticoagulant monitoring should be added to the Task list upon order. The Administrator stated it was nurse managements responsibility for ensuring anticoagulant monitoring was added to the Task list. The Administrator stated it was important for anticoagulant monitoring to be added to the Task list so the staff taking care of Resident # 58 would know what medication he was on and to report any bruising or bleeding to the physician. The Administrator stated the failure would be Resident # 58 could have bruising and the staff would not know the reason. <BR/>Record review of an untitled undated document provided by the Regional Compliance Nurse on 01/11/2024 at 11:38 a.m., indicated, Adding the Anticoagulant Monitoring Task to the Kiosk 1. Go to the resident's chart 2. Click the Tasks Tab 3. Click New Task. A new box appears 4. Scroll &frac34; of the way down and place a check mark in 5. Click Save This is complete, and it will now show up on the kiosk. See below When the staff touches this task it will ask the following: 1. Did you observe any of the following: Bruising, Nosebleeds, Bleeding gums, Prolonged bleeding from wound, IV, or surgical sites, Blood in urine/feces/vomit, coughing up blood? If so, immediately report to the charge nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 6.67 %, based on 2 errors out of 30 opportunities, which involved 2 of 7 residents (Resident #60 and #30) reviewed for medication administration. <BR/>1.The facility failed to ensure LVN Q administered insulin correctly for Resident #60.<BR/>2.The facility failed to ensure LVN O administered insulin correctly for Resident #30.<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.Record review of Resident #60's face sheet dated 01/16/24, indicated a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including Diabetes mellites (diabetic), cerebral infarction (stroke), essential hypertension (high blood pressure), and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities).<BR/>Record review of Resident #60's quarterly MDS assessment dated [DATE], indicated he understood and was understood by others. Resident #60's BIMs score was 08, which indicated his cognition was moderately impaired. The MDS indicated Resident #60 required limited assistance with toileting, dressing, personal hygiene, transfers, bathing, and supervision with eating and bed mobility. The MDS indicated he received insulin injections during the look-back period. <BR/>Record review of Resident #60's comprehensive care plan dated 10/06/23, indicated he had Diabetes Mellitus placing him at increased risk of infection and skin breakdown. The goal was for him not to have any complications related to diabetes. <BR/>Record review of Resident #60's order summary report dated 09/21/23, indicated he had an insulin order for Humalog (Lispro): Inject as per sliding scale: if 0 - 174 = 0; 175 -999 = 0-15u use formula: Fingerstick reading -150/25= number of units to administer, subcutaneously (under the skin) before meals related to Diabetes Mellitus.<BR/>During an observation on 01/08/24 at 3:57 p.m., LVN Q checked Resident #60's blood sugar and revealed 195. LVN Q used the formula (195-150/25) to calculate the amount of insulin to give. She calculated 1.8. LVN Q said she was going to give Resident #60 1 unit of Humalog insulin. LVN Q went to the cart and drew up Humalog insulin of 1 unit. LVN Q administered Resident #60 1 unit of Humalog insulin to his left lower abdomen.<BR/>During an interview on 01/08/24 at 4:45 p.m., LVN K said she gave Resident #60 1 unit of insulin because she calculated 1.8. She said she had never rounded when giving his insulin based on the formula. She said she had never thought about calling the doctor to clarify the order because she thought she was calculating correctly. She said she realized after being questioned by the surveyor that she should have rounded up to 2. She said if Resident #60 does not receive the correct amount of insulin it could cause his blood sugar levels to increase and could affect his overall health.<BR/>During a phone interview on 01/09/24 at 1:20 p.m., The facility physician said if a nurse got a blood sugar of 195 then according to his orders, the nurse would subtract 195-150/25 =1.8. He said he would expect the nurse to give 2 units. He said if they were rounding appropriately, they were supposed to round up to 2 that was what he would expect the nurses to do. He said If they got 1.5 round to 1 but if they got 1.5 and higher round up to 2. He said they could always call him and ask him if they had any questions about an order. He said if Resident #60 received 1 unit of insulin it was incorrect, he should have received 2 units.<BR/>During an interview on 01/11/24 at 11:00 a.m., LVN O said before the DON told her about the new insulin orders for rounding, she never rounded. She said if she had gotten 1.8 as the calculated dosage, on Resident #60 as Nurse LVN Q did, she would have given 1 unit. She said in nursing school, she was taught not to round up. She said she now knows she should have called the physician because the resident was not receiving the prescribed dose.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said she expected nurses to give insulin correctly. She said LVN Q should have called the physician to clarify the reading of 1.8 after using the calculated formula. She said she called the physician and got the order clarified on 01/08/24 after LVN Q gave Resident #60 1 unit of Humalog. She said LVN Q should have given Resident #60 2 units of Humalog. She said Resident #30 did not receive the correct amount of insulin and it could affect her overall well-being such as hyperglycemia (high blood sugar levels). <BR/>During an interview on 01/11/24 at 4:37 p.m., the ADON G said she expected the nurses to give the insulin correctly. She said if she received 1.8 after using the calculated formula, she would have given 2 units of insulin. She said failure to give the correct amount of insulin could lead to hyperglycemia.<BR/>2.Record review of Resident #30's face sheet, dated 01/16/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Diabetes mellites (diabetic), cerebral infarction (stroke), and essential hypertension (high blood pressure).<BR/>Record review of Resident #30's quarterly MDS assessment, dated 11/21/23, indicated Resident #30 understood and was understood by others. Resident #30's BIMs score was 08, which indicated she was cognitively moderately impaired. The MDS indicated Resident #30 required total assistance with toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and bathing, and supervision with eating. The MDS indicated she received insulin injections during the look-back period. <BR/>Record review of Resident #30's physician's orders, dated 09/26/23, reflected Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 175 = units if blood sugar less than 60-80 and not symptomatic administer glucose gel and recheck in 1 hour; 176 - 500 = 999<BR/>inject per sliding scale fingerstick result -150/25=number of units, subcutaneously before meals and at bedtime for elevated glucose. <BR/>Record review of Resident #30's comprehensive care plan, dated 01/31/23 indicated Resident #30 had Diabetes Mellitus placing her at risk for infection and skin issues. The intervention of the care plan indicated staff would give medication as ordered by the physician. <BR/>During an observation on 01/11/24 at 10:48 a.m., LVN O took Resident #30's blood sugar. She received a reading of 352. LVN O went to the cart and drew up 8 units of Humalog as ordered. LVN O went into Resident #30's room and gave insulin to her left abdomen. LVN O did not wipe the end of the insulin pen off before connecting the cap, prime the insulin pen, or hold the insulin pen in the skin for 10 seconds to allow insulin to penetrate the skin therefore insulin was leaking out of the injection site.<BR/>During an interview on 01/11/24 at 11:00 a.m., LVN O said she saw the insulin dripping out of Resident #30's injection site. She said she did not know why the insulin was leaking from Resident #30's injection site. LVN O said she was not aware she was supposed to hold the insulin pen at the injection site for 10 seconds. She said she was not aware she needed to clean the insulin pen before connecting the cap or prime the insulin pen before setting the dial to the required insulin dosage. LVN O said she had not had competency training on giving insulin with an insulin pen from this facility. She said since an unknown amount of the insulin dripped out of Resident #30's injection site it would not have had the same effect as giving the ordered amount. She said it could affect her blood sugar levels and lead to higher levels. LVN O said as the nurse she was responsible for ensuring the medication was given as ordered. <BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said nurses needed to give insulin correctly. She said nursing staff were supposed to prime the insulin pen, set the dial to the ordered insulin, and make sure they held it at the injection site for 10 seconds to allow the medication to enter the subcutaneous tissues. She said if insulin were not given correctly, it could cause them to have an adverse reaction such as hyper/hypoglycemia (high or low blood sugars). She said she could not recall if LVN Q or LVN O had been checked off on competency of insulin.<BR/>During an interview on 01/11/24 at 4:37 p.m., ADON G said she expected the nurses to give the insulin correctly. She said nurses were supposed to set the amount on the insulin pen, put on the needle, clean the skin of the resident, press to the skin, and hold to the skin to allow insulin to penetrate the skin. She said she was not aware of any training on insulin pens as she was new to the ADON position. She said failure to deliver the ordered amount of insulin could affect the resident's blood sugars negatively.<BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected the nurses to give medication and insulin as ordered by the physician. She said the DON was the overseer of nursing. She said she could see not giving insulin correctly could affect a resident's blood sugars.<BR/>Record review of facility policy titled, Medication Administration Procedures, indicated 1. All medications are administered by licensed medical or nursing personnel.<BR/>2. Medications are to be poured, administered, and charted by the same licensed person. 13. <BR/>When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.14.A specific order must be obtained from the Physician to change the dosage form of a resident's medication (e.g., tablet to liquid form).15.Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence.<BR/>Record review of the facility's policy titled, Physician Orders revised 2015, indicated The purpose was to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.<BR/>Written Orders by the Physician or Nurse Practitioner. 1. The Nurse will review the order and if needed contact the prescriber for any clarifications.<BR/>Record review of facility's policy titled, Insulin Pen Use by Pharmacy Policy & Procedure Manual 2003 revised 04/01/15, indicated Important information for the use of an insulin pen:<BR/>o Always attach a new needle before each use.<BR/>o Always perform the safety test before each injection.<BR/>o Do not select a dose or press the injection button without a needle attached.<BR/>o This pen is only for one resident's use<BR/>Step 1. Check the insulin.<BR/>A. Check the label on the pen to make sure you have the correct insulin.<BR/>B. Take off the pen cap.<BR/>Step 2. Attach the needle.<BR/>Always use a new sterile needle for each injection. This helps prevent contamination and potential needle blocks.<BR/>A. Wipe the Rubber Seal with alcohol.<BR/>Step 3. Perform a Safety test A. Select a dose of 2 units by turning the dosage selector. B. Hold the pen with the needle pointing upwards. C. Tap the insulin reservoir so that any air bubbles rise towards the needle. D. Press the injection button in. Check if insulin comes out of the needle tip.<BR/>Step 4. Select the dose. A. Check that the dose window shows 0 following the safety test.<BR/>Step 5. Inject the dose. A. Insert the needle into the skin at a 90-degree angle. B. Deliver the dose by pressing the injection button all the way. The number in the dose window will return to 0 as you inject. C. Keep the injection button pressed all the way in and slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 2 of 6 residents reviewed for medication pass. (Resident #60 and Resident #30)<BR/>1. The facility failed to ensure LVN Q administered insulin correctly for Resident #60.<BR/>2. The facility failed to ensure LVN O administered insulin correctly for Resident #30<BR/>These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. <BR/>Findings included:<BR/>1.Record review of Resident #60's face sheet dated 01/16/24, indicated a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including Diabetes mellites (diabetic), cerebral infarction (stroke), essential hypertension (high blood pressure), and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities).<BR/>Record review of Resident #60's quarterly MDS assessment dated [DATE], indicated he understood and was understood by others. Resident #60's BIMs score was 08, which indicated his cognition was moderately impaired. The MDS indicated Resident #60 required limited assistance with toileting, dressing, personal hygiene, transfers, bathing, and supervision with eating and bed mobility. The MDS indicated he received insulin injections during the look-back period. <BR/>Record review of Resident #60's comprehensive care plan dated 10/06/23, indicated he had Diabetes Mellitus placing him at increased risk of infection and skin breakdown. The goal was for him not to have any complications related to diabetes. <BR/>Record review of Resident #60's order summary report dated 09/21/23, indicated he had an insulin order for Humalog (Lispro): Inject as per sliding scale: if 0 - 174 = 0; 175 -999 = 0-15u use formula: Fingerstick reading -150/25= number of units to administer, subcutaneously (under the skin) before meals related to Diabetes Mellitus.<BR/>During an observation on 01/08/24 at 3:57 p.m., LVN Q checked Resident #60's blood sugar and revealed 195. LVN Q used the formula (195-150/25) to calculate the amount of insulin to give. She calculated 1.8. LVN Q said she was going to give Resident #60 1 unit of Humalog insulin. LVN Q went to the cart and drew up Humalog insulin of 1 unit. LVN Q administered Resident #60 1 unit of Humalog insulin to his left lower abdomen.<BR/>During an interview on 01/08/24 at 4:45 p.m., LVN Q said she gave Resident #60 1 unit of insulin because she calculated 1.8. She said she had never rounded when giving his insulin based on the formula. She said she had never thought about calling the doctor to clarify the order because she thought she was calculating correctly. She said she realized after being questioned by the surveyor that she should have rounded up to 2. She said if Resident #60 does not receive the correct amount of insulin it could cause his blood sugar levels to increase and could affect his overall health.<BR/>During a phone interview on 01/09/24 at 1:20 p.m., The facility physician said if a nurse got a blood sugar of 195 then according to his orders, the nurse would subtract 195-150/25 =1.8. He said he would expect the nurse to give 2 units. He said if they were rounding appropriately, they were supposed to round up to 2; that was what he would expect the nurses to do. He said If they got 1.5 round to 1 but if they got 1.5 and higher round up to 2. He said they could always call him and ask him if they had any questions about an order. He said if Resident #60 received 1 unit of insulin it was incorrect, he should have received 2 units.<BR/>During an interview on 01/09/24 at 1:34 p.m., the Regional Nurse Consultant (RNC) said she would have to clarify with the physician related to how Resident #60's insulin orders were. She said if she got results of 1.8 after using the calculated formula, she would not know whether to give 1 unit or 2 units of insulin.<BR/>During an interview on 01/11/24 at 11:00 a.m., LVN O said before the DON told her about the new insulin orders for rounding, she never rounded when giving insulin using the calculated formula. She said if she had gotten 1.8 as the calculated dosage, for Resident #60 she would have given 1 unit. She said in nursing school, she was taught not to round up. She said she now knows she should have called the physician because the resident was not receiving the prescribed dose.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said she expected nurses to give insulin correctly. She said LVN Q should have called the physician to clarify the reading of 1.8 after using the calculated formula. She said she called the physician and got the order clarified on 01/09/24. She said LVN Q should have given Resident #60 2 units of Humalog. She said Resident #30 did not receive the correct amount of insulin and it could affect his overall well-being such as hyperglycemia (high blood sugar levels). <BR/>During an interview on 01/11/24 at 4:37 p.m., the ADON said she expected the nurses to give the insulin correctly. She said if she received 1.8 after using the calculated formula, she would have given 2 units of insulin. She said failure to give the correct amount of insulin could lead to hyperglycemia.<BR/>2.Record review of Resident #30's face sheet, dated 01/16/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Diabetes mellites (diabetic), cerebral infarction (stroke), and essential hypertension (high blood pressure).<BR/>Record review of Resident #30's quarterly MDS assessment, dated 11/21/23, indicated Resident #30 understood and was understood by others. Resident #30's BIMs score was 08, which indicated she was cognitively moderately impaired. The MDS indicated Resident #30 required total assistance with toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and bathing, and supervision with eating. The MDS indicated she received insulin injections during the look-back period. <BR/>Record review of Resident #30's physician's orders, dated 09/26/23, reflected Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 175 = units if blood sugar less than 60-80 and not symptomatic administer glucose gel and recheck in 1 hour; 176 - 500 = 999<BR/>inject per sliding scale fingerstick result -150/25=number of units, subcutaneously before meals and at bedtime for elevated glucose. <BR/>Record review of Resident #30's comprehensive care plan dated 01/31/23 indicated Resident #30 had Diabetes Mellitus placing her at risk for infection and skin issues. The intervention of the care plan indicated staff would give medication as ordered by the physician. <BR/>During an observation on 01/11/24 at 10:48 a.m., LVN O took Resident #30's blood sugar. She received a reading of 352. LVN O went to the cart and drew up 8 units of Humalog as ordered. LVN O went into Resident #30's room and gave insulin to her left abdomen. LVN O did not wipe the end of the insulin pen off before connecting the cap, prime the insulin pen, or hold the insulin pen in the skin for 10 seconds to allow insulin to penetrate the skin therefore insulin was leaking out of the injection site.<BR/>During an interview on 01/11/24 at 11:00 a.m., LVN O said she saw the insulin dripping out of Resident #30's injection site. She said she did not know why the insulin was leaking from Resident #30's injection site. LVN O said she was not aware she was supposed to hold the insulin pen at the injection site for 10 seconds. She said she was not aware she needed to clean the insulin pen before connecting the cap or prime the insulin pen before setting the dial to the required insulin dosage. LVN O said she had not had competency training on giving insulin with an insulin pen from this facility. She said since an unknown amount of the insulin dripped out of Resident #30's injection site it would not have had the same effect as giving the ordered amount. She said it could affect her blood sugar levels and lead to higher levels. LVN O said as the nurse she was responsible for ensuring the medication was given as ordered. <BR/>During an interview on 01/11/24 at 3:44 p.m., the HR Supervisor looked through LVN O's file and said LVN O was hired on 10/23 and she did not have her skills competencies done.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said nurses needed to give insulin correctly. She said nursing staff were supposed to prime the insulin pen, set the dial to the ordered insulin, and make sure they held it at the injection site for 10 seconds to allow the medication to enter the subcutaneous (SQ) tissues. She said if insulin were not given correctly, it could cause them to have an adverse reaction such as hyper/hypoglycemia (high or low blood sugars). She said she could not recall if LVN Q or LVN O had been checked off on competency of insulin.<BR/>During an interview on 01/11/24 at 4:37 p.m., ADON G said she expected the nurses to give the insulin correctly. She said nurses were supposed to set the amount on the insulin pen, put on the needle, clean the skin of the resident, press to the skin, and hold to the skin to allow insulin to penetrate the skin. She said she was not aware of any training on insulin pens as she was new to the ADON position. She said failure to deliver the ordered amount of insulin could affect the resident's blood sugars negatively.<BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected the nurses to give insulin as ordered by the physician. She said the DON was the overseer of nursing. She said she could see not giving insulin correctly could affect a resident's blood sugars.<BR/>Record review of LVN Q's proficiency audit did reveal she had been checked off on SQ medication and glucometer use on 07/23/23.<BR/>Record review of LVN O's competency did not reveal skill check-off on insulin administration.<BR/>Record review of the facility's policy Physician Orders revised 2015, indicated The purpose was to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.<BR/>Written Orders by the Physician or Nurse Practitioner. 1. The Nurse will review the order and if needed contact the prescriber for any clarifications.<BR/>Record review of facility's policy on Pharmacy Policy & Procedure Manual 2003 revised 04/01/15, Insulin Pen Use indicated Important information for the use of an insulin pen:<BR/>o Always attach a new needle before each use.<BR/>o Always perform the safety test before each injection.<BR/>o Do not select a dose or press the injection button without a needle attached.<BR/>o This pen is only for one resident's use<BR/>Step 1. Check the insulin.<BR/>A. Check the label on the pen to make sure you have the correct insulin.<BR/>B. Take off the pen cap.<BR/>Step 2. Attach the needle.<BR/>Always use a new sterile needle for each injection. This helps prevent contamination and potential needle blocks.<BR/>A. Wipe the Rubber Seal with alcohol.<BR/>Step 3. Perform a Safety test <BR/>A. Select a dose of 2 units by turning the dosage selector.<BR/>B. Hold the pen with the needle pointing upwards.<BR/>C. Tap the insulin reservoir so that any air bubbles rise towards the needle.<BR/>D. Press the injection button in. Check if insulin comes out of the needle tip.<BR/>Step 4. Select the dose.<BR/>A. Check that the dose window shows 0 following the safety test.<BR/>Step 5. Inject the dose.<BR/>A. Insert the needle into the skin at a 90-degree angle.<BR/>B. Deliver the dose by pressing the injection button all the way. The number in the dose window will return to 0 as you inject.<BR/>C. Keep the injection button pressed all the way in and slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 20 residents (Resident #45) reviewed for laboratory services. <BR/>The facility failed to ensure Resident #45's CBC (complete blood count blood test that measures the number of different types of red blood cells, white blood cells, and platelets), CMP (comprehensive metabolic panel blood test that is used to get a broad assessment of your overall physical health it can check several body functions and processes), ESR (Erythrocyte Sedimentation Rate- blood test that can show if you have inflammation in your body), and CRP (C-reactive protein- blood test that measures the level of a protein called C-reactive protein in the blood which increases when there is inflammation in the body) were drawn on 01/01/2024 and 01/08/2024.<BR/>This failure could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. <BR/>Findings included:<BR/>Record review of a face sheet dated 01/09/2024 indicated Resident #45 was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis due to methicillin susceptible staphylococcus aureus (serious infection that can lead to complications and death), arthritis due to other bacteria, right knee (inflammation of the right knee caused by a bacteria, fungus, virus), and chronic kidney disease stage 3B (moderate to severe loss of kidney function). <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #45 was able to make himself understood and understood others. The MDS assessment indicated Resident #45 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #45 did not exhibit rejection of care. The MDS assessment indicated Resident #45 required partial/moderate assistance with personal, oral, and toileting hygiene, and was dependent for showering/bathing. <BR/>Record review of the Order Summary Report dated 01/09/2024 indicated Resident #45 had an order for the following labs CBC, CMP, ESR, CRP every Monday and fax to the infectious disease doctor with a start date of 11/09/2023 and no end date. <BR/>Record review of the care plan last reviewed 01/09/2024 indicated Resident #45 had a potential risk for malnutrition to notify the physician for any negative findings, abnormal labs, or resident non-compliance. Resident #45's care plan indicated he had hypothyroidism (low thyroid) to obtain and monitor lab/diagnostic work as ordered. Resident #45's care plan indicated he had renal insufficiency related to acute kidney failure to monitor/document/report increased BUN and Creatinine (lab tests used to monitor kidney function and are included in the CMP). <BR/>Record review of Resident #45's electronic health record did not indicate a CBC, CMP, ESR, or CRP for 01/01/2024 and 01/08/2024.<BR/>During an interview on 01/09/2024 at 3:25 p.m., the DON said she did not have any labs for the month of January 2024 for Resident #45. <BR/>During an interview on 01/11/2024 at 4:08 p.m., LVN D said the TAR instructed her to which labs needed to be drawn daily. LVN D said she was not aware Resident #45 required labs every Monday. LVN D said she was not aware because the order was not put on the TAR. LVN D said when a lab order was received and put in the electronic health record the nurse that put the order in should ensure it was going to the TAR. LVN D said the nurses were responsible for ensuring the labs were being drawn. LVN D said it was important to draw labs as ordered so they would know if there were any changes in the resident's condition.<BR/>During an interview on 01/11/2024 at 4:38 p.m., ADON F said when lab orders were received it would be put in their lab book for the lab technician to know what lab to draw for the week ADON F said the nurses were responsible for filling out the lab sheet and putting it in the lab book. ADON F said the nurses should have been passing on in report that Resident #45 required weekly labs. ADON F said she was not aware Resident #45 required weekly labs to be drawn. ADON F said she was not sure who was responsible for overseeing that the labs were getting drawn as ordered. ADON F said it was important for Resident #45 to have labs drawn weekly per his orders because the doctor was monitoring how well the antibiotic was working. ADON F said not getting labs as ordered for Resident #45 could result in him being septic (infection in the blood stream) or having kidney complications. <BR/>During an interview on 01/11/2024 at 5:10 p.m., the Administrator said the labs were overseen by ADON F and the DON. The Administrator said she expected for the labs to be drawn as ordered. The Administrator said it was important to draw labs as ordered for the health of the resident. <BR/>During an interview on 01/11/2024 at 5:58 p.m., the DON said for a lab to be drawn the nurses would fill out a sheet and put it in the lab book and put in the order to draw the labs. The DON said ADON F was responsible for printing the labs and faxing them wherever they needed to go. The DON said ADON F was responsible for overseeing that labs were being drawn as ordered and follow-up was done as necessary. The DON was unable to provide an explanation as to why Resident #45's labs were not drawn. The DON said it was important for the labs to be drawn as ordered to ensure they were checking lab values. The DON said not drawing Resident #45's labs weekly, as ordered, could result in him becoming septic. <BR/>Record review of the facility's policy titled, Physician's Orders, from the Medical Records Manual 2015, indicated, . 3. The nurse will enter the order into PCC (point click care an electronic health record system) for the resident and select either verbal or telephone, depending on how the nurse received the order. 4. If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed. 5. The receiving nurse will contact any other department or external facilities as required, i.e., dietary department, pharmacy, lab provider, x-ray provider, etc.

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature.<BR/>The facility failed to provide food that was palatable at the lunch meal on 1/9/24.<BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.<BR/>The findings included:<BR/>Record Review of the facility week 1 menu dated on 1/9/24, indicated the lunch meal items included Mississippi Pot roast, roasted baked potatoes halves, baby carrots, Honey kissed roll, sticky peach cake, and iced tea.<BR/>During an interview on 1/8/24 at 10:14 a.m., Resident #14 stated the food was terrible and the food was better with the old company.<BR/>During an interview on 1/8/24 at 10:49 a.m., Resident #42 stated food was terrible and he had hair in his spaghetti.<BR/>During an interview on 1/8/24 at 10:50 a.m., Resident #1 stated the food was horrible.<BR/>During an interview on 1/8/24 at 11:01 a.m., Resident #18 stated she did not like the food, the rice was dry, and the chicken dressing did not taste like dressings. Resident #18 stated the food tasted like it did not have salt in the food and no sugar was added in the sweet tea.<BR/>During an interview on 1/8/24 at 11:07 a.m., Resident #12 stated sometimes the food was warm and sometimes was cold; food did not get seasoning with salt.<BR/>During an interview on 1/8/24 at 3:12 p.m., Resident #46 stated she was on a mechanical soft diet and the food was no good.<BR/>During observation and interview on 1/9/24 at 12:25 p.m., pot roast was bland tasting to surveyors and the Dietary Manager stated the pot roast needed more seasoning. The carrots were bland tasting to surveyors and the Dietary Manager stated the carrots were okay. The cubed potatoes were bland tasting to surveyors and the Dietary Manager stated the cubed potatoes needed more seasoning. <BR/>During an attempted phone interview on 1/10/24 at 3:30 p.m., the Dietary Manager was called, and voice message left for a return phone call; call was not returned prior to exit on 1/11/24.<BR/>During an attempted interview on 1/10/24 at 3:38 p.m., the Dietician was called, voice message was left for a return call; phone call not returned prior to exit on 1/11/24<BR/>During an interview on 1/10/24 at 3:42 p.m., the DON stated she did not oversea the kitchen.<BR/>During an interview on 1/10/24 at 3:58 p.m., the Administrator stated she had been employed at the facility for 6 years. The Administrator stated she did have food complaints from the residents about food seasoning and biscuits being too hard in the morning. The Administrator stated she talked to the Dietary Manager and made sure food was good for the residents that complained. The Administrator stated she had some residents at the facility that she cannot please. The Administrator stated she had tried everything she could think of to please those residents. The Administrator stated the facility would make a special meal of the resident's favorite food for those that complain about food. The Administrator stated she was not getting food stuck in her door with a note from the residents. The Administrator said she used to get food struck in her underneath door with a complaint note from the residents, but she had not received any food complaint notes from residents recently. The Administrator stated she did get test trays once a month from the kitchen and if she got a lot of food complaints that she would get test trays weekly. The Administrator stated she did expect food to be palliative, attractive and at the right temperature. The Administrator stated it was important to ensure the food was palatable, attractive and at the right temperature because, Food was all the residents had to live for and food prevents the resident from losing weight; Residents not eating the food could cause skin breakdown because food give the residents joy.<BR/>During an interview on 1/11/24 at 8:31 a.m., CNA C stated she was hired in September of 2023. CNA C stated she had been a CNA for 19 years. CNA C stated she had taken food everyday back to the kitchen to be warmed up because by the time the food gets to the end of the hall the food was cold.<BR/>Record Review of the facility Resident Rights policy dated 2003, indicated (5) Each resident is encouraged and assisted, throughout the period of stay, to exercise his/her rights as a resident and as a citizen, and to this end, may voice grievances and recommend changes in policies and services to facility staff and / or to outside representatives of his/her choice, free from restraint, interference, coercion, discrimination or reprisal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 4 residents (Resident #27) reviewed for preference.<BR/>The facility failed to honor Resident #27's preference for no toast. <BR/>This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. <BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #27 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, mild, with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with other behaviors) and dysphagia, oral phase (difficulty swallowing). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #27 was understood and understood others. The MDS assessment indicated Resident #27 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #27 required setup or clean-up assistance for eating. The MDS assessment indicated Resident #27 received a mechanically altered diet. <BR/>Record review of the care plan last reviewed 01/02/2024 indicated Resident #27 had potential nutritional problems related to a therapeutic regular mechanical soft diet to observe/document/report as needed any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. Resident #27's care plan indicated she was edentulous (toothless) to give diet as ordered and consult with dietician and change if any chewing/swallowing problems were noted.<BR/>Record review of an Order Summary Report dated 01/11/2024 indicated Resident #27 had an order for regular diet mechanical soft texture with an order start date of 12/27/2022. <BR/>During an observation and interview on 01/08/2024 at 10:51 a.m., Resident #27 said her only complaint was that every morning she had been getting toast and she had told the staff she wanted regular bread because she could not chew the toast. Resident #27 showed surveyor she had no teeth and repeated she was unable to chew the toast because she had no teeth. <BR/>During an observation, interview, and record review on 01/10/2024 at 7:38 a.m., Resident #27 was eating in her room. Resident #27 said they gave her toast again and she was not able to chew it. Resident #27 had 2 half slices of toast on her tray. Resident #27's breakfast meal ticket dated 01/10/2024 indicated Special Notes: Prefers regular bread no toast all soft foods no fried.<BR/>During an interview on 01/10/2023 at 7:43 a.m., CNA B said she gave Resident #27 her breakfast tray and helped her set it up. CNA B said when passing out trays she should check the meal ticket to ensure the residents were receiving their food according to what was on the meal ticket. CNA B said she did not check Resident #27's meal ticket when she gave her breakfast tray. CNA B said she did not check it because Resident #27 received the same meal every day. CNA B said she did not know Resident #27 was not supposed to receive toast on her tray. CNA B said it was important for the residents to receive meals according to the ticket to ensure they could eat the food and so they would not lose weight. <BR/>During an interview on 01/10/2024 at 7:47 AM, [NAME] A said she did not look at the resident's meal tickets when serving because she knew what all the residents were supposed to get. [NAME] A said after she served the food, the dietary aide checked the meals with the tickets. [NAME] A said Resident #27 requested to receive toast on her tray. Surveyor informed [NAME] A Resident #27 requested regular bread. [NAME] A and Surveyor went to Resident #27 to give her the regular bread. Resident #27 told [NAME] A she could not chew the toast because she had no teeth. [NAME] A said she did not know Resident #27 did not want toast because she was not the one who took the residents preferences. [NAME] A said the Dietary Manager took the resident preferences. [NAME] A said it was important for the residents to receive meals according to their tickets so they would eat and not lose weight. <BR/>During an interview on 01/11/2023 at 5:19 p.m., the Administrator said she expected for the meal tickets and for food preferences to be followed. The Administrator said the staff should be checking the meal tickets when serving. The Administrator said the Dietary Manager was responsible for ensuring the residents were served according to their meal tickets and preferences. The Administrator said it was important for their food preferences and meal tickets to be followed because it was their right and she did not want them to have weight loss and for the overall health of the resident. <BR/>During an attempted interview on 01/11/2024 at 6:45 p.m., the Dietary Manager did not answer the phone. <BR/>Record review of the facility's policy from the Dietary Services Policy & Procedure Manual 2012, revised 2016, titled, Menu approval and honoring resident special requests, and food brought to the facility from unapproved sources, indicated, .Every attempt will be made to honor resident food preferences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that:<BR/>1) The facility failed to seal, label and date refrigerator and freezer food items. <BR/>2) Dietary staff failed to dispose of expired foods items in the pantry and refrigerator.<BR/>3) Dietary Staff failed to test the dishwasher to ensure dishwasher chemical levels was at 50 PPM or above.<BR/>4) Dietary Staff failed to ensure the chemical strips for the 3 compartment sink were not expired.<BR/>5) Dietary Staff failed to ensure the ice machine was cleaned.<BR/>6) Dietary Staff failed to clean the juice nozzle.<BR/>7) Dietary Staff failed to clean the fryer. <BR/>These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings include:<BR/>During observation of Refrigerator #1 on 1/8/24 at 10:00 a.m.,<BR/>-(1) 2 quart container of Tomato sauce prepared 12/28/23, expired on 1/4/24.<BR/>-(1) 1/2 quart container of Ketchup prepared 12/28/23 expired on 1/4/24.<BR/>- (1) 5 pound bag of lettuce best by date of 1/4/24, bag not sealed and no open date.<BR/>-(1) 5 pound bag of lettuce unopened had a best by date of 1/4/24 and a received date of 12/23/23.<BR/>-(1) &frac12; quart of container of Italian dressing opened on 12/31/23, received on 12/23/23 and expired on 1/7/24.<BR/>During observation of Freezer#1 on 1/8/24 at 10:00a.m.,<BR/>-(1) 6 pound container of sliced strawberries with sugar received on 12/27/23, had no open date and no expiration date.<BR/>During observation and interview on 1/8/24 at 10:02 a.m., the ice machine was dirty with red substance in the inside. [NAME] A stated she did not know why the ice machine was dirty. [NAME] A stated housekeeping was responsible for cleaning the ice machine. [NAME] A stated she did not know how often the ice machine was supposed to be cleaned. [NAME] A stated she agreed the ice machine was dirty and needed to be cleaned. <BR/>During observation on 1/8/24 at 10:08 a.m., <BR/>-(1) 24 ounce of Rotisserie chicken seasoning had no open date, no expiration date and no received date.<BR/>-(1) 12 ounce of Poultry seasoning, had no open date, no expiration date and no received date.<BR/>-(1) 14 ounce of Ground cumin had no open date and no received date, expired on 11/29/25.<BR/>-(1) 18 ounce of Ground cinnamon had no open date, no received date, expired on 1/21/26.<BR/>-(1) 16 ounce of Ground Gloves had no open date, received on 1/18/19, and no expiration date.<BR/>-(1) 12.5 Ground Ginger had no open date, received on 7/22/22, and no expiration date.<BR/>-(1) 16 ounce of Ground Nut [NAME] had no open date, no received date and expired on 2/11/25.<BR/>-(1) 5 pound black pepper had no open date, no received date and no expiration date.<BR/>During observation and interview on 1/8/24 at 10:17 a.m., the juice machine nasal nozzle had a red gooey substance inside and outside the nozzle. [NAME] A stated the juice machine nasal nozzle was dirty and needed to be cleaned. [NAME] A stated the juice machine was to be cleaned every day by the dietary staff. [NAME] A stated the juice did not appear to be cleaned the day prior by the dietary staff. <BR/>During observation and interview on 1/8/24 at 10:18 a.m., the fryer was not cleaned. The fryer was black in color with brown crumbs floating at the top. [NAME] A stated the fryer was last cleaned on 12/28/23. [NAME] A stated the fryer was supposed to have been cleaned on 1/4/24. [NAME] A stated she did not know why the fryer was not cleaned on 1/4/24.<BR/>During observation and interview on 1/8/23 at 10:15 a.m., the 3 compartments sink chemical test strips were expired. The chemical test strips expired June 1, 2023. [NAME] A stated she only tested the 3rd sink water temperature with a thermometer and she never tested the chemical level using the test strips for the 3-compartment sink. <BR/>During observation and interview on 1/8/24 at 10:25 a.m., [NAME] M stated she did not know how to test the chemical levels in the dish washer. [NAME] M stated she was not aware that she should be testing the chemical levels for the dish washer. [NAME] M did not know how often she was supposed to test the chemicals in the dishwasher. [NAME] M stated she did not remember if she completed in-services on how to operate the dishwasher. [NAME] M stated she was not the dishwasher person. [NAME] M stated she was just filling in for the dishwasher since the dishwasher person was off work. During observation of [NAME] M, the dishwasher tested at 10 ppm (parts per million). [NAME] M did not know that the chemical levels were to be at 50 ppm or above. <BR/>During observation and interview on 1/8/24 at 12:00 p.m., the dietary staff served the lunch meal on paper plates. [NAME] A stated she informed the Administrator that the dishwasher chemical levels were low. [NAME] A stated the Administrator told her to serve the lunch meal on 1/8/23 on paper until the dishwasher was fixed. <BR/>During an attempted phone interview on 1/10/24 at 3:30 p.m., the Dietary Manager was called, and voice message left for a return phone call; call was not returned prior to exit on 1/11/24.<BR/>During an attempted phone interview on 1/10/24 at 3:38 p.m., the Dietician was called, voice message was left for a return call; phone call not returned prior to exit on 1/11/24.<BR/>During an interview on 1/10/24 at 3:42 p.m., the DON stated she did not oversea the kitchen.<BR/>During an interview on 1/10/24 at 3:48 p.m., the Administrator stated she had been employed at the facility for 6 years. The Administrator stated the dietary manager was over the kitchen and she oversaw the Dietary Manager. The Administrator stated Maintenance was responsible for cleaning the ice machine once a month. The Administrator stated she was not aware of the expired test strips for the 3 compartment sink. The Administrator stated she was not aware of staff not testing the chemical levels in the 3rd compartment dish sink. The Administrator stated she was not aware of the red substance found in the ice machine. The Administrator stated she was not aware of the dish washer chemicals were empty. The Administrator stated she was not aware of the dietary staff not knowing how to operate the dishwasher because all dietary staff should have been aware of how to operate the dishwasher. The Administrator stated she was not aware of the Coffee tempting at 136 degrees and not 140 degrees. The Administrator stated the cook should have tempted the coffee prior to the coffee going out to the residents. The Administrator stated she believed the coffee sat for a while. The Administrator stated she tried to be in the kitchen daily. The Administrator stated she went through the kitchen and threw away a lot of seasoning prior to survey and she did not know why the seasonings got missed. The Administrator stated she walked through the kitchen 2-3 times a week. The Administrator stated on 1/8/23 the dietary staff completed in-services on the dishwasher temps and how to operate the dishwasher. The Administrator stated she expected staff to ensure they were following policies and procedures of the facility kitchen policy. The administrator stated it was important for dietary staff to follow facility policies and procedures to protect residents and to deliver good care.<BR/>Record Review of the facility Food safety policy dated 2012, indicated (2) food is to be wrapped or sealed and coved in clean container. Opened food shall be labeled, dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used as long as the quality of the product is maintained.

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 3 of 6 staff (CNA B, CNA C, Treatment Nurse) and 2 of 4 Halls (Hall D and Hall A) reviewed for infection control.<BR/>1. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while providing wound care to Resident #44. <BR/>2. The facility failed to ensure CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #165. <BR/>3. The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident # 60<BR/>4. The facility failed to ensure the linen carts on Hall D and Hall A were covered. <BR/>These failures could place residents and staff at risk for cross-contamination and the spread of infection.<BR/>Findings included:<BR/>1. During an observation of wound care on Resident #44 with the Treatment Nurse on 01/08/2024 beginning at 2:53 p.m., the Treatment Nurse removed Resident #44's dirty dressing and disposed of it. The Treatment Nurse then grabbed the wound cleanser, cleansed the wound, and patted it dry with gauze. The Treatment Nurse did not change gloves or perform hand hygiene prior to cleaning the wound and patting it dry. The Treatment Nurse then changed gloves and performed hand hygiene and patted the wound dry again with gauze. The Treatment Nurse then applied collagen fibers, the oil emulsion dressing, black foam and completed the wound care. <BR/>During an interview on 01/08/24 at 4:20 p.m., the Treatment Nurse, also the Infection Control Preventionist, said when performing wound care, she should perform hand hygiene put on gloves take off the old dressing, get the wound cleanser, clean the wound, throw it away, then take gloves off and hand sanitize. The Treatment Nurse said then she should put new gloves on and continue the wound care. The Treatment Nurse said she had not changed her gloves after removing the dirty dressing and before cleaning the wound because the wound was a dirty wound, but she should have because she touched the bottle of the wound cleanser with her dirty gloves. The Treatment Nurse said it was important not to touch clean items with her dirty gloves because it could result in the spread of germs and for infection control. The Treatment Nurse said it was important to change gloves and perform hand hygiene during wound care to ensure the wound stayed clean. The Treatment Nurse said the last time she had a competency check off for wound care was 2 years ago. <BR/>2. During an observation of incontinent care with CNA C and CNA B on 01/10/2024 beginning at 9:24 AM, CNA C put on gloves, unfastened Resident #165's soiled brief and wiped her front peri area. CNA C then turned Resident #165 on her side with the assistance of CNA B. CNA C said Resident #165's wound care dressing was also soiled with stool, and she needed the wound care nurse to change it. CNA C using the dirty gloves laid Resident #165 on her back and covered her up. CNA C then removed her gloves and left the room. CNA C did not perform hand hygiene after removing her gloves. The Treatment Nurse came into the room and removed the soiled dressing, dirty brief, and put a clean brief underneath her. CNA C put on gloves and wiped Resident #165's buttocks, then stepped aside for the Treatment Nurse to do the wound care. CNA C did not remove her dirty gloves and stood at the foot of the bed grabbing on to Resident #165's foot of the bed with her dirty gloves. The Treatment Nurse provided wound care, and then CNA C using her dirty gloves straightened up Resident #165's clean brief and fastened it. CNA C repositioned Resident #165 in the bed, covered her up and touched her pillows, still using the dirty gloves. After this, CNA C removed her gloves and performed hand hygiene. <BR/>During an interview on 01/10/2024 at 9:55 a.m., CNA C said hand hygiene should be performed before and after providing incontinent care. CNA C said gloves should only be changed when visibly soiled. CNA C said hand hygiene should be performed after glove removal. CNA C said she did not change her gloves while providing incontinent care because they were not visibly soiled. CNA C said she did not realize she had not performed hand hygiene after removing her gloves. CNA C said it was important to perform hand hygiene and change gloves for infection control. CNA C said it was important to provide proper incontinent care to keep urinary tract infections down.<BR/>During an interview on 01/11/2024 at 4:14 p.m., LVN D said the charge nurses were responsible for ensuring the CNAs were providing proper incontinent care. LVN D said the CNAs were trained so she hoped they were doing correctly. LVN D said she checked after the CNAs performed incontinent care to make sure they were doing it properly, and she had not noticed any issues. LVN D said she would not know if the CNAs were changing gloves and performing hand hygiene appropriately during incontinent care because she was checking after. LVN D said she had not noticed any issues with incontinent care. LVN D said if hand hygiene and glove changes were not done adequately during incontinent care this could result in the residents getting urinary tract infections. <BR/>During an interview on 01/11/2024 at 4:43 p.m., ADON F said she did not know if anybody was overseeing that the CNAs were providing proper incontinent care. ADON F said the DON and herself had done an in-service on incontinent care maybe 4-5 months ago. ADON F said she was not doing random checks to ensure the CNAs were providing proper incontinent care. ADON F said hand hygiene should be performed before and after providing care, and if gloves were contaminated gloves should be removed and hand hygiene performed. ADON F said hand hygiene should be performed in between glove changes. ADON F said gloves should be changed when putting on a clean brief, and if they were removing a dirty brief they should remove the dirty gloves, perform hand hygiene, and put on new gloves. ADON F said gloves should be changed when in contact with urine or feces, even if the gloves were not visibly soiled. ADON F said it was important to change gloves and perform hand hygiene when providing incontinent care, so the residents did not end up with urinary tract infections. ADON F said not performing proper hand hygiene and glove changes could result in cross contamination and skin breakdown. <BR/>During an interview on 01/11/2024 at 4:52 p.m., the Infection Control Preventionist said nurse management was responsible for ensuring the CNAs were providing proper incontinent care. The Infection Control Preventionist said they were monitoring the CNAs by having them provide care on the dummy every 6 months. The Infection Control Preventionist said they had not been monitoring the CNAs providing incontinent care on the floor. The Infection Control Preventionist said the CNAs should wash their hands before and after incontinent care, if their gloves were visibly soiled, they should change gloves and perform hand hygiene. The Infection Control Preventionist said the CNAs should perform hand hygiene in between glove changes and they should change gloves and perform hand hygiene after removing a dirty brief. The Infection Control Preventionist said if the CNAs were cleaning urine or poop, they should change their gloves before touching anything clean. The Infection Control Preventionist said it was important for the CNAs to change gloves and perform hand hygiene appropriately when providing incontinent care, so they did not have increased infections, to decrease the spread of disease and not pass bacteria throughout the facility. <BR/>During an interview on 01/11/2024 at 5:15 p.m., the Administrator said she expected wound care to be provided according to infection control practices, for glove changes and hand hygiene to be performed adequately. The Administrator said the DON was responsible for overseeing the Treatment Nurse. The Administrator said she expected for incontinent care to be done according to the skill as far as hand hygiene and infection control policies. The Administrator said the DON was responsible for monitoring that incontinent care was performed adequately. The Administrator said it was important for wound care and incontinent care to be provided properly for the health of the residents.<BR/>During an interview on 01/11/2024 at 6:05 p.m., the DON said she was responsible for ensuring the Treatment Nurse performed wound care properly. The DON said she monitored the wound care by going three times a week with the Treatment Nurse to perform wound care. The DON said she had not noticed any issues with the wound care provided by the Treatment Nurse. The DON said hand hygiene should be performed before and after providing wound care. The DON said gloves should be changed and hand hygiene performed after removing the soiled dressing. The DON said it was important to change gloves and perform hand hygiene while providing wound care for infection control. The DON said the nurse managers were responsible for ensuring incontinent care was provided properly. The DON said while providing incontinent care hand hygiene should be performed before and after and in between glove changes. The DON said gloves should be changed if they were visibly dirty and hand hygiene performed. The DON said if the CNA cleaned stool or urine, they would need to change their gloves and perform hand hygiene. The DON said she observed the CNAs providing incontinent care about four times a day, and she had not noticed any issues. The DON said it was important to properly change gloves and perform hand hygiene while providing incontinent care for infection control. <BR/>3. During an observation on 01/10/24 at 3:51 p.m., CNA B and CNA R were providing incontinent care to Resident #60. He had a Foley catheter. They explained what they were going to do, washed their hands, and applied gloves. CNA B cleaned the Foley catheter tubing and changed her gloves but did not do hand hygiene, she then cleaned his peri-area, reached into her pocket, took out a pair of gloves, and changed her gloves but did not perform hand hygiene. She then turned him on his side and wiped his buttocks back to front and front to back in several areas using the same wipe and then changed her gloves without hand hygiene. She pulled up his covers, made him comfortable, washed her hands, and exited the room.<BR/>During an interview on 01/10/24 at 4:17 p.m., CNA B said she did an excellent job on incontinent care. After being questioned by the surveyor CNA B said she did not realize she took gloves out of her pocket during care or that she used 1 wipe in several different areas on his buttock. She said she should have performed hand hygiene between dirty to clean, used 1 wipe and then discarded, and wiped front to back only to prevent cross-contamination. She said she knew all of this but was nervous and forgot. <BR/>During an interview on 01/11/24 at 11:19 a.m., ADON G said she expected proper cleaning during incontinent care. She said she expected them to change their gloves if they were soiled and when going from dirty to clean. She said staff should do this to prevent infection and cross-contamination.<BR/>During an interview on 01/11/24 at 3:44 p.m., the HR supervisor said CNA B should have had her competency training on 04/23 but it was missed.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said she expected staff to perform incontinent care correctly. The DON said she expected the CNAs to perform hand hygiene before and after providing incontinent care, to change their gloves when going from dirty to clean, and in between glove changes. She said she did not expect staff to get gloves out of their pockets while providing care. She said they should have incontinence care checkoffs on hire, yearly, and as needed. The DON said not performing incontinent care correctly could lead to infection control issues. <BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected staff to perform incontinent care properly. The Administrator said she expected the CNAs to perform hand hygiene before and after incontinent care and change their gloves after going from dirty to clean. She said the nurse managers/DON were responsible for ensuring staff performed incontinent care and hand hygiene correctly. The Administrator said if improper incontinent care or hand hygiene were performed it could lead to infection control and contamination issues. She said they had been using online training as part of their training on incontinent care and handwashing but they would start a skills fair.<BR/>4. During an observation on 01/08/2024 at 10:09 a.m., CNA B collected clean linens from the Hall A linen care, placed them in a bag, and went into a resident's room. CNA B did not cover the linen cart prior to going into the resident's room. <BR/>During an observation on 01/10/2024 at 7:26 a.m., the clean linen cart on Hall D was not covered. <BR/>During an interview on 01/11/2024 at 8:41 a.m., CNA B said the linen carts should be covered. CNA B said it was the staff's responsibility to ensure they always remained covered. CNA B said it was important for the linen carts to be covered for infection control. CNA B said sometimes she forgot to cover the linen carts because she was in a hurry. <BR/>During an interview on 01/11/2024 at 7:50 p.m., the Administrator said the linen carts should always be covered. The Administrators said the CNAs should make sure the linen carts were covered, and the staff when doing rounds should also make sure they were covered. The Administrator said the linen carts should be covered for infection control purposes. <BR/>During an interview on 01/11/2024 at 7:51 p.m., the DON said the linen carts should always be covered. The DON said all the staff were responsible for ensuring the linen carts were covered. The DON said it was important for the linen carts to be covered for infection control. <BR/>Record review of the facility's policy titled, Perineal Care, with an effective date of 05/11/2022, indicated, 10) <BR/>Perform hand hygiene 11) <BR/>Don gloves and all other PPE per standard precautions . remove an adequate number of pre-moistened cleansing wipes . Gently perform perineal care . Gently perform care to the buttocks and anal area . 24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding . 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . <BR/>Record review of the facility's policy titled, Linens, from the Infection Control Policy and Procedure Manual 2018, indicated, . 12. All clean linen will be stored in a secured area. The linen cart will be covered .<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, indicated, This facility considers hand hygiene the primary means to prevent the spread of infection.<BR/>Record review of the facility's policy titled, Infection Control Policy & Procedure Manual, dated 2019, indicated, Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. Preventing Spread of Infection:(3) The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Linens: Personnel will handle, store, process, and transport linens to prevent the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to meet professional standards of care, for 1 of 19 residents (Resident #18) reviewed for professional standards. <BR/>The facility failed to ensure Resident #18 was weighed weekly as ordered by the physician. <BR/>These failures could place residents at risk for harm and not receiving the care and services to meet their individual needs.<BR/>Findings included:<BR/>Record review of a face sheet, dated 11/09/22, indicated Resident #18 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of congestive heart failure (heart is unable to pump enough force to push enough blood into circulation), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes (chronic condition that affects the way the body processes blood sugar), and high blood pressure. <BR/>Record Review of the annual MDS assessment, dated 05/18/22 indicated Resident #18 was understood and understood others. Resident #18 BIMs (Brief Interview for Mental Status) score was an 8 indicating moderate impaired cognition. The MDS assessment for Resident #18 under Section K Swallowing/Nutritional Status did not indicate any weight loss or weight gain of 5% or more in the last month or 10% or more in the last 6 months. <BR/>Record review of the order summary report, dated 11/09/22, indicated Resident #18 had an order with a start date of 10/12/21 for weekly weights on Tuesdays due to her diagnosis of congestive heart failure.<BR/>Record review of an undated care plan revealed Resident # 18 had a risk for shortness of breath, swelling, and fluctuating weights due to her diagnosis of congestive heart failure. Interventions included to observe/document/report any signs and symptoms of congestive heart failure for example, swelling to legs and feet, weight gain unrelated to intake and weakness.<BR/>Record review of the weights and vitals summary report dated 11/09/22 did not reveal Resident #18's weight for the 2nd and 3rd weeks of July; the 2nd and 3rd weeks of August; 1st week of September; 4th week of October; 1st week of November. <BR/>During an interview on 11/9/22 at 1:32 PM, LVN C indicated she was not aware Resident #18 had an order for weekly weights and that the restorative aide was responsible for weighing the residents. LVN C indicated the charge nurse was responsible for putting in the physician orders and ensuring they were followed. LVN C indicated she was responsible for following all the physician's orders. LVN C indicated not following the physician's orders could cause harm to the residents, and for Resident #18 not following the order for weekly weights could lead to Resident #18 being in fluid overload. <BR/>During an interview on 11/9/22 at 1:46 PM, CNA B (restorative aide) indicated she was responsible for weighing residents. CNA B indicated the nurses gave her a list with the names of the residents she needed to weigh and the frequency of the weights. CNA B indicated she gave the DON the weights and the DON placed the weights in the residents' electronic health record. CNA B indicated she missed weighing residents, including not weighing Resident #18 weekly, due to having to work the floor. CNA B indicated if she had to work the floor, she did not weigh residents and nobody else did. CNA B indicated weighing residents per the physician's orders was important to make sure they were not losing weight too fast or to make sure they do not have water weight. CNA B indicated not weighing Resident #18 weekly could cause harm because Resident #18 could gain too much weight and the doctor would not know to adjust medications adequately. <BR/>During an interview on 11/9/22 at 1:54 PM, the ADON indicated she expected the nurses to follow the physician's orders. The ADON indicated the physician's orders and weights are reviewed weekly by risk management to ensure things were not missed. The ADON indicated she did not know why Resident #18's weekly weights were not done. The ADON indicated not following the physician's orders could lead to missed medications and treatments. The ADON indicated for Resident #18 not having the weekly weights could cause worsening of her congestive heart failure and kidney failure issues. <BR/>During an interview on 11/9/22 at 4:03 PM the ADM indicated the DON was responsible for putting in physician's orders and ensuring the nurses followed them. The ADM indicated she expected the DON to do this. <BR/>During an interview on 11/9/22 at 4:17 PM the DON indicated she put the weights in when received from the restorative aide and she did not think any weights were missing. The DON indicated the nurses were responsible for putting in physician's orders and management staff was responsible for reviewing the physician's orders to ensure they were executed. The DON indicated she expected all the nurses to follow the physician's orders. The DON indicated not following the physician's orders put the residents' health at risk and affected the care they received. <BR/>Record review of the facility's policy titled Physician's Orders dated 3/2/22 indicated .ensure the accuracy and completeness of the medication orders, treatment orders and ADL order for each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives necessary services to maintain personal hygiene were provided for 2 of 72 residents reviewed for ADLs (Resident #58, Resident #70).<BR/>1. The facility did not ensure Resident #58 received fingernail care.<BR/>2. The facility did not ensure Resident #70 received her showers.<BR/>These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.<BR/>The findings included:<BR/>1. Record Review of Resident #58's face sheet dated 2/26/25 at 1:43 p.m., indicated Resident #58 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of vascular dementia (reduce blood flow to the brain) with behavioral disturbance, Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), Pneumonia (an infection that affects one or both lungs), essential hypertension (high blood pressure).<BR/>Record Review of Resident #58's MDS assessment dated [DATE] indicated, Resident #58 usually understood others and made himself understood. The MDS assessment indicated Resident #58 had a BIMS score of 10, which indicated Resident #58 was moderately impaired. The MDS assessment indicated Resident #58's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment.<BR/>Record Review of Resident #58's care plan, dated on 2/7/25, indicated Resident #58 had an ADL Self Care Performance Deficit Stroke. The care plan goals indicated: the resident will improve current level of function in ADL's through the review date. The care plan interventions included bathing: requires staff x1 for assistance, Bed Mobility: requires staff x1 for assistance, Dressing: requires staff x1 for assistance, Eating: supervision as needed, the resident uses a wheelchair, Toilet use: requires staff x1 for assistance, encourage the resident to discuss feelings about self-care deficit and BATHING: Avoid scrubbing & pat dry sensitive skin.<BR/>During observation on 2/24/25 at11:20 a.m., Resident #58 fingernails were long and had not trimmed; fingernails had black debris underneath his nails.<BR/>During observation on 2/25/25 at 10:01 a.m., revealed Resident #58's fingernails were long and had not been trimmed. Resident #58's fingernails had black debris underneath his nails.<BR/>During an interview on 2/24/25 at 11:20 a.m., Resident #58 stated he would like to have his fingernails trimmed. Resident #58 stated he couldn't remember the last time his fingernails were trimmed.<BR/>2. Record Review of Resident #70's face sheet dated 2/26/25 at 1:40 p.m., indicated Resident #70 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), Hypothyroidism (thyroid gland does not produce enough thyroid hormone), essential hypertension (high blood pressure).<BR/>Record Review of Resident #70's MDS assessment dated [DATE] indicated, Resident #70 understood others and made herself understood. The MDS assessment indicated Resident #70 had a BIMS score of 5, which indicated Resident #70 was severely impaired. The MDS assessment indicated Resident #70 need for assistance with bathing, dressing, using the toilet, or eating was coded as independent on the MDS assessment.<BR/>Record Review of Resident #70's care plan, dated on 1/15/25, indicated Resident #70 had an ADL Self Care Performance Deficit. The care plan interventions included Bathing: requires staff x1 for assistance; Dressing: requires staff x1 for assistance; Eating: supervision as needed; Praise all efforts at self-care; Physical Therapy/Occupational Therapy evaluation and treatment as per MD orders.<BR/>During an interview on 2/24/25 at 10:19 a.m., Resident #70 stated she had shingles, and she did not get a shower. Resident #70 stated she would like her shower. Resident #70 stated her last shower was more than over a week and a half. Resident #70 stated she was supposed to get her showers on Monday, Wednesday and Friday. Resident #70 stated, it made her feel terrible when she did not get a shower because she feels nasty all the time. <BR/>During an interview on 2/26/25 at 10:15 a.m., Resident #70 stated to LVN G that she had not been receiving her showers. Resident #70 stated to LVN G, I thought I was supposed to give myself a shower because staff had not been giving me my showers. Resident #70 stated she started to get a rash on her stomach from not having a shower. Resident #70 stated, Showers help me with getting rid of rashes, but I have not had a shower in a while.<BR/>During an interview on 2/26/25 at 10:15 a.m., LVN G stated she was the charge nurse on the B hall. LVN G stated she worked the 6 am to 6 p.m. shift. LVN G stated the shower aides were responsible for giving Resident #70 her showers. LVN G stated if the shower aide was not available then the CNAs were responsible for giving showers on the B hall. LVN G stated Resident #70 was supposed to be showered on Monday, Wednesday and Friday. LVN G stated the CNAs were to bring the residents to the shower aide and then the shower aide was to shower each resident. LVN G stated she followed up with the CNAs and shower aide to ensure the residents got their showers. LVN G stated she was not always 100 percent sure with making sure the residents got their showers. LVN G stated Resident #70 had not ever refused showers since being admitted . LVN G stated she was not sure when her last in-service was last completed on ADL care. LVN G stated the ADON oversaw her. LVN G stated she oversaw the shower aide and CNAs. LVN G stated, It was important for the residents to get their showers for hygiene and to prevent skin breakdown, rashes and dignity so the resident felt good about themselves. LVN G stated she was not aware of Resident #70 not receiving her showers. LVN G stated that she was not aware of staff documenting that they were giving showers to the residents when the resident did not receive a shower LVN G stated if the resident was a diabetic that the charge nurse would be responsible for trimming the resident's nails. LVN G stated if the resident was not diabetic then the CNAs would be responsible for trimming the resident's nails. LVN G stated if a resident was a diabetic that their nails are trimmed on Sunday's. LVN G stated if the resident was not a diabetic that their nails were trimmed on shower days or as needed. LVN G stated she never notice that Resident #58 had long nails that needed to be trimmed and cleaned. LVN G stated the CNAs and shower aides were to let her know if the residents needed their nails trimmed. LVN G stated she did not remember the last time Resident #58's fingernails were trimmed and cleaned. LVN G stated to her knowledge the resident had not ever refused nail care. LVN G stated it was important to ensure the resident nails were trimmed and cleaned for hand hygiene and to prevent self-inflected injuries. <BR/>During an interview on 2/26/25 at 12:47 p.m., CNA A stated she normally worked the 6 am to 2 pm shift at the facility. CNA A stated she was not aware of Resident #70 not getting her showers. CNA A stated she was supposed to shower at least 3 times a week. CNA A stated the shower aid was responsible for giving the showers. CNA A stated the CNAs were responsible for bringing the residents to the shower room to be showered. CNA A stated in-services on ADL's was last completed about 3 weeks ago. CNA A stated Resident #70 had not ever refused a shower. CNA A stated it was important for resident to get showers because it helped with their health and mental status. CNA A stated if the resident was a diabetic that the charge nurse was supposed to trim and clean the resident's nails. CNA A stated if the resident was not a diabetic that the CNAs were responsible for trimming and cleaning the resident's nails. CNA A stated she was not aware of Resident #58 nails being long and having a black substance underneath his nails. CNA A stated, It was important to ensure the residents nails were timed and cleaned because its dirty, the resident hands goes to their mouth, and it can cause skin tears and infection control.<BR/>During an interview on 2/26/25 at 1:06 p.m., the ADON stated she had been employed at the facility for 3 weeks. ADON stated she was not aware of the showers not being provided to the residents. ADON stated she was not aware of Resident #58's nails not being trimmed. ADON stated in-services were completed a few weeks agoand she could not remember the exact date. ADON stated she had no knowledge of Resident #70 ever refusing her showers. ADON stated she had no knowledge of Resident #58 refusing nail care in the past. ADON stated CNAs could trim nondiabetic residents and RN staff could trim the diabetic residents' nails. ADON stated the DON oversaw her. ADON stated she oversaw the CNA's, charge nurse and shower aides. ADON stated it was important for ADL care to be provided to the residents for appearance and because she did not want the residents to feel unclean. <BR/>During an interview on 2/26/25 at 1:19 p.m., the Administrator stated she was not aware of the residents not getting their shower and fingernails were not being trimmed. The Administrator stated the last in-service on ADL's was conducted today (2/26/25). The Administrator stated Resident #70 had refused care in the past when she first admitted because she was very ill. The Administrator stated since Resident #70's family member talked with Resident #70 that Resident #70 had not refused care. The Administrator stated Resident #58 had never refused care. The Administrator stated the DON oversaw the nursing department. The Administrator stated the DON and herself were responsible for ensuring the residents received ADL care. The Administrator stated, It was important to ensure the residents received ADL care so the resident was healthy and so the residents would not decline medically.<BR/>During an attempted interview on 2/26/25 at 1:31 p.m., the Shower Aide was unavailable for an interview at the facility.<BR/>Record Review of the facility's Resident Rights policy, undated, indicated, the resident has a tight to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner. and m an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. The facility will provide the Resident Rights to each newly admitted resident and upon any revision to the Resident Rights to each resident and/or resident representatives. The facility did not provide a policy on ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 19 residents reviewed for quality of care. (Resident #59)<BR/>The facility did not ensure Resident #59 had a contracture prevention device in place for the treatment of his right contracted wrist. <BR/>This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures.<BR/>The findings included:<BR/>Record review of Resident #59's face sheet (undated) indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis caused from a stroke), limitation of activities due to disability, and cognitive social or emotional deficit following cerebrovascular disease. <BR/>Record review of Resident #59's consolidated physician orders, dated 11/8/2022, revealed an order, starting on 6/8/2022, to Apply hand splint to right wrist and hand each shift. Remove for bathing or hygiene. Apply back to clean, dry skin. Monitor for signs or symptoms of compromised skin integrity or edema every shift for contracture. <BR/>Record review of the MDS assessment, dated 9/27/2022, revealed Resident #59 was usually understood by the facility staff. The MDS revealed Resident #59 had clear speech. The MDS revealed Resident #59 rarely or never understands the facility staff. The MDS revealed a BIMS score of 08 which indicates moderately impaired cognition. The MDS revealed Resident #59 had no behaviors or rejection of care. The MDS revealed Resident #59 required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. The MDS revealed Resident #59 had an impairment in functional limitation and range of motion to one side. The MDS revealed Resident #59 had received restorative nursing for passive and active ROM during 4 days of the 7 day lookback period. <BR/>Record review of the comprehensive care plan, last revised on 9/27/2022, revealed Resident #59 was receiving restorative care with splint or brace assistance. The interventions included: Nursing, rehab, or restorative: splint to right upper extremity when out of bed.<BR/>During observations on 11/07/22 at 10:19 AM and 1:57 PM Resident #59 was sitting up in his wheelchair and did not have a splint on his right wrist or hand.<BR/>During observations on 11/08/22 at 7:45 AM and 3:32 PM Resident #59 was sitting up in his wheelchair and did not have a splint on his right wrist or hand.<BR/>During an observation and interview on 11/08/22 at 7:41 AM Resident #59 was sitting up in wheelchair and did not have a splint of his right wrist or hand. Resident #59 stated he was supposed to wear a splint to his right hand and wrist daily. Resident #59 stated the splint was in the top drawer of his dresser beside the bed. Resident #59 stated he was unable to apply the splint himself and the staff did not offer to apply it. Resident #59 stated he did not ask the staff to apply it. Resident #59 stated he was able to tolerate the splint for 4 to 6 hours every day. Resident #59 stated the splint did not hurt him when he wore it. <BR/>During an interview on 11/09/22 at 12:49 PM, CNA A stated therapy staff were responsible for applying Resident #59's splint. CNA A stated Resident #59 was supposed to wear the splint every day. CNA A stated Resident #59's splint hurts when he wore it. CNA A stated she told the charge nurse, and she believed the rehab manager was aware it needed to be adjusted. CNA A stated the failure to Resident #59 for not wearing his splint would be worsening of his contracture. <BR/>During an interview on 11/09/22 at 1:15 PM, the Rehab Manager stated Resident #59 was not receiving therapy services. The Rehab Manger stated Resident #59 was discharged and established on a restorative plan for splinting to his right wrist. The Rehab Manager stated Resident #59's splint should be applied daily. The Rehab Manager stated when the restorative aid was pulled from restorative to work as a CNA the responsibility of placing Resident #59's splint was on the nursing staff. The Rehab Manager stated nursing staff were trained on how to apply Resident #59's splint and she stated it was ordered by the physician. The Rehab Manager stated she was unaware that Resident #59 was having pain while wearing his splint. The Rehab Manager stated the pain was not reported to her. The Rehab Manager stated the failure to Resident #59 for not wearing his splint would be decrease in ROM and worsening of his contracture. <BR/>During an interview on 11/09/22 at 1:30 PM, CNA B stated she was the restorative CNA. CNA B stated the last time she did restorative was last week. CNA B stated when she was pulled to work as a CNA therapy was responsible for applying the splints or braces. CNA B stated CNAs could apply them as well. CNA B stated Resident #59 did complain of pain sometimes when she applied the splint. CNA B stated she reported to the pain to the nurse and therapy department. CNA B stated the failure to Resident #59 for not wearing his splint would be worsening of contractures or stiffness in his wrist and fingers. <BR/>During an interview on 11/09/22 at 1:55 PM, LVN C stated Resident #59 was supposed to wear a splint to his right wrist every day. LVN C stated Resident #59 preferred certain staff members to apply his splint. LVN C stated she attempted to apply Resident #59's splint this morning and he would not let her. LVN C stated she was unsure if Resident #59 had his splint applied the last two days. LVN C stated the charge nurses were responsible for ensuring Resident #59 had his splint applied every shift. LVN C stated Resident #59 did not complain of pain while wearing his splint. LVN C stated the failure for Resident #59 not wearing his splint would be worsening of his contracture. <BR/>During an interview on 11/09/22 at 2:20 PM, the DON stated Resident #59's splint was applied by the nurses. The DON stated it alerted the nurses to apply the splint in their electronic charting system. The DON stated Resident #59 refused his splint today according to the charting system, but he did not refuse it any other time this week. The DON stated that Resident #59 was on a restorative program and the restorative CNA would put on his splint sometimes. The DON stated ultimately the charge nurse was responsible for ensuring Resident #59's splint was applied. The DON stated she did not recall Resident #59 complaining of pain while wearing the splint. The DON stated the failure to Resident #59 for not wearing his splint would be worsening of his contracture. <BR/>During an interview on 11/09/22 at 2:55 PM, the Administrator stated the CNAs, nurses, and therapy were responsible for monitoring the placement of Resident #59's splint. The Administrator stated she expected her staff to ensure the contracture device was applied. The Administrator stated the failure to Resident #59 for not wearing his splint would be worsening of his contracture. <BR/>Record review of the Immobilization Devices, Splints/Slings/Collars/Straps undated policy and procedure revealed step-by-step instructions on how to apply a splint. No further policies were provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 1 resident (Resident #22) reviewed for quality of care.<BR/>The facility failed to keep ongoing communication with the dialysis facility for Resident #22. <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/>Record review of a face sheet, dated 11/09/22, indicated Resident #22 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes (chronic condition that affects the way the body processes blood sugar), end stage renal disease (kidneys cease functioning on a permanent basis), and was dependent on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).<BR/>Record review of the annual MDS assessment, dated 09/10/22, indicated Resident #22 was understood and understood others. The MDS revealed Resident #22 BIMS (Brief Interview for Mental Status) score was a 10, indicating moderate impaired cognition. The MDS indicated Resident #22 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Resident #22 was totally dependent on bathing. The MDS under Section O (special treatments, procedures, and programs), had dialysis checked.<BR/>Record review of the order summary report dated 11/09/22 revealed Resident #22 had an order to transport via facility van on Monday, Wednesday, Friday to the dialysis center.<BR/>Record review of an undated care plan revealed Resident #22 had end stage renal disease and required dialysis which placed him at risk for fluid imbalance, fluctuating blood pressure, and diarrhea. <BR/>Record review of the electronic health record for Resident #22 indicated there was no documentation between the facility and dialysis facility for Resident #22's dialysis treatments on the following dates:<BR/>*10/3/22<BR/>*10/5/22<BR/>*10/7/22<BR/>*10/10/22<BR/>*10/12/22<BR/>*10/14/22<BR/>*10/17/22<BR/>*10/19/22<BR/>*10/21/22<BR/>*10/24/22<BR/>*10/26/22<BR/>*10/28/22<BR/>*10/31/22<BR/>*11/2/22<BR/>*11/4/22<BR/>*11/7/22<BR/>*11/9/22<BR/>During an interview on 11/9/22 at 12:47 PM the RN at the dialysis facility indicated they filled out dialysis communication forms when they were sent to them. The RN indicated they had not been receiving communication forms for Resident #22. The RN confirmed Resident #22 had not missed any dialysis treatments for the month of October 2022 and November 2022. The RN indicated the dialysis communication form was used for the nursing facility to know what goes on with the residents at the dialysis facility and to have clear communication regarding the resident's care between the nursing facility and the dialysis facility. The RN indicated not having the communication between the dialysis facility and the nursing home facility could result in lack of communication regarding Resident #22 dialysis care. <BR/>During an interview on 11/9/22 at 1:28 PM, LVN C indicated her shift was 6-2 Monday through Friday and Resident #22 went to dialysis on Monday, Wednesday, and Friday. LVN C indicated she did not communicate with the dialysis facility every time Resident #22 went for dialysis treatments. LVN C indicated she would only call the dialysis facility if there was a problem. LVN C indicated she had been working at the facility for two months and she was not aware she was required to communicate with the dialysis facility. LVN C indicated not communicating with the dialysis facility could negatively affect Resident #22 because his blood pressure could be low from dialysis and the facility would not know, and the facility would not be aware of complications that occurred at the dialysis facility and the need to monitor Resident #22 for dialysis related complications. <BR/>During an interview on 11/9/22 at 1:34 PM the DON indicated the night nurse should have been sending the dialysis communication form via fax and the dialysis clinic would return it via fax when the dialysis treatments were over and then the dialysis communication form would be uploaded to the electronic health record. The DON indicated there was currently no system in place to ensure the nurses were communicating with the dialysis facility. The DON indicated she did not see the harm in not communicating with the dialysis facility, and that communication between the two facilities was the responsibility of the dialysis facility. <BR/>During an interview on 11/9/22 at 4:03 PM the ADM indicated she expected the nurses to fill out a dialysis communication form, send it to the dialysis facility and ensure it returned for the safety of the resident. The ADM indicated it was the DON's responsibility to ensure that was occurring. <BR/>On 11/9/22 at 4:37 phone interview attempted with LVN K, the night nurse, with no success. <BR/>Record review of the nursing policy and procedure titled Dialysis, revised on 11/2013 indicated .The resident's clinical record will be documented with this information. The date and time that the resident leaves the facility will be recorded by the nurse .The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information .<BR/>Record review of the Long Term Care Facility Outpatient Dialysis Services Coordination Agreement signed 12/3/15 indicated .both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long Term Care Facility and ESRD Dialysis Unit .

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 3 of 6 staff (CNA B, CNA C, Treatment Nurse) and 2 of 4 Halls (Hall D and Hall A) reviewed for infection control.<BR/>1. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while providing wound care to Resident #44. <BR/>2. The facility failed to ensure CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #165. <BR/>3. The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident # 60<BR/>4. The facility failed to ensure the linen carts on Hall D and Hall A were covered. <BR/>These failures could place residents and staff at risk for cross-contamination and the spread of infection.<BR/>Findings included:<BR/>1. During an observation of wound care on Resident #44 with the Treatment Nurse on 01/08/2024 beginning at 2:53 p.m., the Treatment Nurse removed Resident #44's dirty dressing and disposed of it. The Treatment Nurse then grabbed the wound cleanser, cleansed the wound, and patted it dry with gauze. The Treatment Nurse did not change gloves or perform hand hygiene prior to cleaning the wound and patting it dry. The Treatment Nurse then changed gloves and performed hand hygiene and patted the wound dry again with gauze. The Treatment Nurse then applied collagen fibers, the oil emulsion dressing, black foam and completed the wound care. <BR/>During an interview on 01/08/24 at 4:20 p.m., the Treatment Nurse, also the Infection Control Preventionist, said when performing wound care, she should perform hand hygiene put on gloves take off the old dressing, get the wound cleanser, clean the wound, throw it away, then take gloves off and hand sanitize. The Treatment Nurse said then she should put new gloves on and continue the wound care. The Treatment Nurse said she had not changed her gloves after removing the dirty dressing and before cleaning the wound because the wound was a dirty wound, but she should have because she touched the bottle of the wound cleanser with her dirty gloves. The Treatment Nurse said it was important not to touch clean items with her dirty gloves because it could result in the spread of germs and for infection control. The Treatment Nurse said it was important to change gloves and perform hand hygiene during wound care to ensure the wound stayed clean. The Treatment Nurse said the last time she had a competency check off for wound care was 2 years ago. <BR/>2. During an observation of incontinent care with CNA C and CNA B on 01/10/2024 beginning at 9:24 AM, CNA C put on gloves, unfastened Resident #165's soiled brief and wiped her front peri area. CNA C then turned Resident #165 on her side with the assistance of CNA B. CNA C said Resident #165's wound care dressing was also soiled with stool, and she needed the wound care nurse to change it. CNA C using the dirty gloves laid Resident #165 on her back and covered her up. CNA C then removed her gloves and left the room. CNA C did not perform hand hygiene after removing her gloves. The Treatment Nurse came into the room and removed the soiled dressing, dirty brief, and put a clean brief underneath her. CNA C put on gloves and wiped Resident #165's buttocks, then stepped aside for the Treatment Nurse to do the wound care. CNA C did not remove her dirty gloves and stood at the foot of the bed grabbing on to Resident #165's foot of the bed with her dirty gloves. The Treatment Nurse provided wound care, and then CNA C using her dirty gloves straightened up Resident #165's clean brief and fastened it. CNA C repositioned Resident #165 in the bed, covered her up and touched her pillows, still using the dirty gloves. After this, CNA C removed her gloves and performed hand hygiene. <BR/>During an interview on 01/10/2024 at 9:55 a.m., CNA C said hand hygiene should be performed before and after providing incontinent care. CNA C said gloves should only be changed when visibly soiled. CNA C said hand hygiene should be performed after glove removal. CNA C said she did not change her gloves while providing incontinent care because they were not visibly soiled. CNA C said she did not realize she had not performed hand hygiene after removing her gloves. CNA C said it was important to perform hand hygiene and change gloves for infection control. CNA C said it was important to provide proper incontinent care to keep urinary tract infections down.<BR/>During an interview on 01/11/2024 at 4:14 p.m., LVN D said the charge nurses were responsible for ensuring the CNAs were providing proper incontinent care. LVN D said the CNAs were trained so she hoped they were doing correctly. LVN D said she checked after the CNAs performed incontinent care to make sure they were doing it properly, and she had not noticed any issues. LVN D said she would not know if the CNAs were changing gloves and performing hand hygiene appropriately during incontinent care because she was checking after. LVN D said she had not noticed any issues with incontinent care. LVN D said if hand hygiene and glove changes were not done adequately during incontinent care this could result in the residents getting urinary tract infections. <BR/>During an interview on 01/11/2024 at 4:43 p.m., ADON F said she did not know if anybody was overseeing that the CNAs were providing proper incontinent care. ADON F said the DON and herself had done an in-service on incontinent care maybe 4-5 months ago. ADON F said she was not doing random checks to ensure the CNAs were providing proper incontinent care. ADON F said hand hygiene should be performed before and after providing care, and if gloves were contaminated gloves should be removed and hand hygiene performed. ADON F said hand hygiene should be performed in between glove changes. ADON F said gloves should be changed when putting on a clean brief, and if they were removing a dirty brief they should remove the dirty gloves, perform hand hygiene, and put on new gloves. ADON F said gloves should be changed when in contact with urine or feces, even if the gloves were not visibly soiled. ADON F said it was important to change gloves and perform hand hygiene when providing incontinent care, so the residents did not end up with urinary tract infections. ADON F said not performing proper hand hygiene and glove changes could result in cross contamination and skin breakdown. <BR/>During an interview on 01/11/2024 at 4:52 p.m., the Infection Control Preventionist said nurse management was responsible for ensuring the CNAs were providing proper incontinent care. The Infection Control Preventionist said they were monitoring the CNAs by having them provide care on the dummy every 6 months. The Infection Control Preventionist said they had not been monitoring the CNAs providing incontinent care on the floor. The Infection Control Preventionist said the CNAs should wash their hands before and after incontinent care, if their gloves were visibly soiled, they should change gloves and perform hand hygiene. The Infection Control Preventionist said the CNAs should perform hand hygiene in between glove changes and they should change gloves and perform hand hygiene after removing a dirty brief. The Infection Control Preventionist said if the CNAs were cleaning urine or poop, they should change their gloves before touching anything clean. The Infection Control Preventionist said it was important for the CNAs to change gloves and perform hand hygiene appropriately when providing incontinent care, so they did not have increased infections, to decrease the spread of disease and not pass bacteria throughout the facility. <BR/>During an interview on 01/11/2024 at 5:15 p.m., the Administrator said she expected wound care to be provided according to infection control practices, for glove changes and hand hygiene to be performed adequately. The Administrator said the DON was responsible for overseeing the Treatment Nurse. The Administrator said she expected for incontinent care to be done according to the skill as far as hand hygiene and infection control policies. The Administrator said the DON was responsible for monitoring that incontinent care was performed adequately. The Administrator said it was important for wound care and incontinent care to be provided properly for the health of the residents.<BR/>During an interview on 01/11/2024 at 6:05 p.m., the DON said she was responsible for ensuring the Treatment Nurse performed wound care properly. The DON said she monitored the wound care by going three times a week with the Treatment Nurse to perform wound care. The DON said she had not noticed any issues with the wound care provided by the Treatment Nurse. The DON said hand hygiene should be performed before and after providing wound care. The DON said gloves should be changed and hand hygiene performed after removing the soiled dressing. The DON said it was important to change gloves and perform hand hygiene while providing wound care for infection control. The DON said the nurse managers were responsible for ensuring incontinent care was provided properly. The DON said while providing incontinent care hand hygiene should be performed before and after and in between glove changes. The DON said gloves should be changed if they were visibly dirty and hand hygiene performed. The DON said if the CNA cleaned stool or urine, they would need to change their gloves and perform hand hygiene. The DON said she observed the CNAs providing incontinent care about four times a day, and she had not noticed any issues. The DON said it was important to properly change gloves and perform hand hygiene while providing incontinent care for infection control. <BR/>3. During an observation on 01/10/24 at 3:51 p.m., CNA B and CNA R were providing incontinent care to Resident #60. He had a Foley catheter. They explained what they were going to do, washed their hands, and applied gloves. CNA B cleaned the Foley catheter tubing and changed her gloves but did not do hand hygiene, she then cleaned his peri-area, reached into her pocket, took out a pair of gloves, and changed her gloves but did not perform hand hygiene. She then turned him on his side and wiped his buttocks back to front and front to back in several areas using the same wipe and then changed her gloves without hand hygiene. She pulled up his covers, made him comfortable, washed her hands, and exited the room.<BR/>During an interview on 01/10/24 at 4:17 p.m., CNA B said she did an excellent job on incontinent care. After being questioned by the surveyor CNA B said she did not realize she took gloves out of her pocket during care or that she used 1 wipe in several different areas on his buttock. She said she should have performed hand hygiene between dirty to clean, used 1 wipe and then discarded, and wiped front to back only to prevent cross-contamination. She said she knew all of this but was nervous and forgot. <BR/>During an interview on 01/11/24 at 11:19 a.m., ADON G said she expected proper cleaning during incontinent care. She said she expected them to change their gloves if they were soiled and when going from dirty to clean. She said staff should do this to prevent infection and cross-contamination.<BR/>During an interview on 01/11/24 at 3:44 p.m., the HR supervisor said CNA B should have had her competency training on 04/23 but it was missed.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said she expected staff to perform incontinent care correctly. The DON said she expected the CNAs to perform hand hygiene before and after providing incontinent care, to change their gloves when going from dirty to clean, and in between glove changes. She said she did not expect staff to get gloves out of their pockets while providing care. She said they should have incontinence care checkoffs on hire, yearly, and as needed. The DON said not performing incontinent care correctly could lead to infection control issues. <BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected staff to perform incontinent care properly. The Administrator said she expected the CNAs to perform hand hygiene before and after incontinent care and change their gloves after going from dirty to clean. She said the nurse managers/DON were responsible for ensuring staff performed incontinent care and hand hygiene correctly. The Administrator said if improper incontinent care or hand hygiene were performed it could lead to infection control and contamination issues. She said they had been using online training as part of their training on incontinent care and handwashing but they would start a skills fair.<BR/>4. During an observation on 01/08/2024 at 10:09 a.m., CNA B collected clean linens from the Hall A linen care, placed them in a bag, and went into a resident's room. CNA B did not cover the linen cart prior to going into the resident's room. <BR/>During an observation on 01/10/2024 at 7:26 a.m., the clean linen cart on Hall D was not covered. <BR/>During an interview on 01/11/2024 at 8:41 a.m., CNA B said the linen carts should be covered. CNA B said it was the staff's responsibility to ensure they always remained covered. CNA B said it was important for the linen carts to be covered for infection control. CNA B said sometimes she forgot to cover the linen carts because she was in a hurry. <BR/>During an interview on 01/11/2024 at 7:50 p.m., the Administrator said the linen carts should always be covered. The Administrators said the CNAs should make sure the linen carts were covered, and the staff when doing rounds should also make sure they were covered. The Administrator said the linen carts should be covered for infection control purposes. <BR/>During an interview on 01/11/2024 at 7:51 p.m., the DON said the linen carts should always be covered. The DON said all the staff were responsible for ensuring the linen carts were covered. The DON said it was important for the linen carts to be covered for infection control. <BR/>Record review of the facility's policy titled, Perineal Care, with an effective date of 05/11/2022, indicated, 10) <BR/>Perform hand hygiene 11) <BR/>Don gloves and all other PPE per standard precautions . remove an adequate number of pre-moistened cleansing wipes . Gently perform perineal care . Gently perform care to the buttocks and anal area . 24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding . 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . <BR/>Record review of the facility's policy titled, Linens, from the Infection Control Policy and Procedure Manual 2018, indicated, . 12. All clean linen will be stored in a secured area. The linen cart will be covered .<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, indicated, This facility considers hand hygiene the primary means to prevent the spread of infection.<BR/>Record review of the facility's policy titled, Infection Control Policy & Procedure Manual, dated 2019, indicated, Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. Preventing Spread of Infection:(3) The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Linens: Personnel will handle, store, process, and transport linens to prevent the spread of infection.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for existing staff, consistent with their expected roles for 2 of 21 employees (Dietician and LVN P) reviewed for required annual trainings. <BR/>The facility failed to ensure the Dietician and LVN P received required restraint and HIV training annually. <BR/>This failure could place residents at risk for inappropriate restraints and exposure to HIV.<BR/>Findings included:<BR/>Record review of the employee files revealed there was no required annual restraint training completed for the following staff:<BR/>*Dietician hired on 11/01/2022<BR/>Record review of the employee files revealed there was no required annual HIV training completed for the following staff:<BR/>*LVN P hired on 12/01/2022<BR/>During an interview on 01/11/2024 at 12:09 PM, the Human Resource Specialist stated she expected all staff to have the required trainings. The Human Resource Specialist stated by not having the annual required training on HIV and restraints, the staff would not have the proper education to properly care for those residents. The Human Resource Specialist stated she was responsible for ensuring the required trainings were completed along with the nurse managers. <BR/>During an interview on 01/11/2024 at 6:17 p.m., the Administrator stated she expected the staff to receive HIV and restraint training upon hire and annually on their anniversary date. The Administrator stated it was the Human Resource Specialist's responsibility for ensuring training was done. The Administrator stated the training was important because it updated the staff on how to protect themselves and others on the spread of HIV. The Administrator stated restraint training was important so staff would be able identify if someone had a restraint or not to restraint a resident. The Administrator stated by not having the proper training the staff would not be able to properly care for those residents. The Administrator stated she would use a check list to monitor annual training assessments.<BR/>A request for the facility policy regarding Required Training was submitted to the Regional Nurse Consultant on 1/11/2024 at 6:17p.m. A policy was not received prior to exit.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of the 5 medication carts reviewed for medications storage. (Hall C)<BR/>The facility failed to ensure Resident #5 and Resident #52's Humalog (fast-acting insulin to control high blood sugar) insulin were taken off the cart after the opening date had expired on Hall C's nurse cart.<BR/>The facility failed to ensure Resident # 17 Breo Ellipta inhaler (medication used to prevent and decrease symptoms of wheezing and trouble breathing), was dated when opened on Hall C's nurse cart.<BR/>These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion.<BR/>Findings included:<BR/>During an observation on 01/11/24 at 3:12 p.m., Hall C's nurse's cart revealed Resident #5's Humalog insulin was open and dated 12/09/23 and Resident #52's Humalog insulin pen was open and dated 11/17/23. Resident #17 Breo Ellipta inhaler manufacture label was 10/09/23 was opened but had no opened date. <BR/>During an interview on 01/11/24 at 3:24 p.m., LVN D said she was not aware of how long insulin was good for. She said she went by the expiration date on the label. She said inhalers should be dated when opened to ensure they were getting an effective dose. LVN D said after the DON explained how long insulin was good for she was aware that Humalog insulin expired after 28 days therefore the insulin was not as effective as it should have been.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said she expected the nurses and medication aides to audit their carts at least weekly to check for expired medications. The DON said the pharmacy consultant was at the facility monthly and checked for expired medications as well. She said it was the ADON's responsibility to oversee that the carts were being audited. The DON said she expected the insulin to be removed from the cart after being opened for 28 days and the inhaler to be dated when opened. She said whoever opened the inhaler should have been responsible for dating it. The DON said the residents were at risk for medications to be ineffective. <BR/>During an interview on 01/11/24 at 4:37 p.m., the ADON said she expected the medication aides and nurses to check their carts daily. She said the insulin should be dated when opened and discarded when expired. The ADON said the medication aide or nurse who opened the inhaler was responsible for dating it. The ADON said by not dating the inhalers when opened the staff would be unaware of when the inhalers expired. She said since the insulin had expired from the opening date, it could have been ineffective. <BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected the medication carts to not have any expired medications. The Administrator said she expected the insulin pens to be dated when opened and discarded after expiration days. She said she expected the inhalers to be dated when opened and by not doing so, the staff would be unaware of when it expired. The Administrator said the carts were checked by the pharmacist consultant and the nurse managers. The Administrator said the resident was at risk of receiving expired medication that could be ineffective.<BR/> Record review of the facility's policy titled, Insulin Pen Use by Pharmacy Policy & Procedure Manual 2003 revised 04/01/15, indicated, To take the insulin pen out of cool storage you can use it for up to 28 days. Ensure that the pen is dated when placed into use. During this time, it can be safely kept at room temperature. Do not use it after this time.<BR/>Record review of the facility's policy titled, Recommended Medication Storage, Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened: (fluticasone) -Expires 6 weeks (50mcg strength) or 2 months (100 and 250 mcg strengths) after initial use.<BR/>INSULINS (Vials, Cartridge, Pens) Humalog and Humalog Mix, <BR/>Humalog Flex Pen 75/25 and 50/50 pens expire 10 days after opening. Novolog and Novolog Mix<BR/>oExpires 28 days after initial use regardless of product storage (refrigerated or room temperature).<BR/>Record review https://www.mybreo.com revealed, BREO ELLIPTA (fluticasone furoate and vilanterol) to store BREO in the unopened foil tray and only open when ready for use. Safely throw away BREO in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first.

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in 19 of 63 Rooms (D hall) reviewed for a clean and homelike environment. <BR/>The facility failed to ensure (D hall) was cleaned daily, and in accordance with the facility's Housekeeping policy. <BR/>This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. <BR/>Findings included:<BR/>During an observation on 1/8/24 at 11:01 a.m., strong urine smell on D hall. <BR/>During an observation on 1/10/24 at 8:27 a.m., strong urine smell on D hall. <BR/>During an observation on 1/11/24 at 8:05 a.m., strong urine smell on D hall.<BR/>During an interview on 1/11/24 at 8:21 a.m., CNA C stated she had been a CNA for 19 years. CNA C stated the urine smell was always strong on D hall all the time especially in the morning. CNA C stated Resident #41 slept in a recliner and was a heavy wetter. CNA C stated Resident #41 was not being toileted like she should be. CNA C stated D hall was the heaviest hall in the facility. CNA C stated Resident #264 was also a heavy wetter on D hall and Resident #264 was not getting her showers like she was suppose too. CNA C stated it was only one CNA C worker per hall and the facility needed more CNA's. <BR/>During an interview on 1/11/24 at 9:21 a.m., housekeeping aide K stated he has been employed here for almost 2 months. Housekeeping aide K stated he worked 8:00 a.m. to 4:30 p.m. shift. Housekeeping aide K stated he was responsible for cleaning the resident rooms. Housekeeping aide K stated the rooms were to be cleaned every day and the orange tag rooms on the D hall were to be cleaned 3 times a day. Housekeeping aide K stated the orange tag rooms were for the residents who had hoarding issues. Housekeeping aide K stated the nurse's aide or laundry aide were to change the resident linens on their beds. Housekeeping aide K stated the resident nurse aides or nurses were responsible for cleaning the top of the resident mattresses. Housekeeping aide K stated the housekeeping supervisor oversaw him. Housekeeping aide K stated deep cleaning was to be done when a resident was discharging a room and before admission to the facility. Housekeeping aide K stated, The resident rooms were probably deep cleaned once a month. Housekeeping aide K stated deep cleaning considered cleaning under the resident's furniture, doors, dressers, sink, bathroom, floors, walls and lights. Housekeeping aide K stated the Housekeeping supervisor did spot checks, and he did not know how often the Housekeeping supervisor conducted spot checks in the resident's rooms. Housekeeping aide K stated the facility did not have a housekeeping checklist that housekeeping were to follow. Housekeeping aide K stated, He just did what the housekeeping supervisor told him to do when he came to work. Housekeeping aide K stated he was not aware of the urine smell on D hall. Housekeeping aide K stated he cleaned mostly on the B hall and sometimes cleaned D hall. Housekeeping aide K stated he worked Monday 1/8/24 and Thursday 1/11/24. Housekeeping aide K stated he did believe that the facility had enough cleaning supplies. Housekeeping aide K stated the nurse aids was responsible for cleaning urine or fecal matter off the floors and housekeeping was responsible for sanitizing the area after the nurses. Housekeeping aide K stated he completed cleaning and deep cleaning in-services last month. Housekeeping aide K stated, It was important to keep the facility clean and sanitized for basic human rights and if he had a family member in a facility that he would want their room cleaned.<BR/>During an interview at 1/11/24 at 9:35 a.m., The Housekeeping supervisor stated he has been employed at the facility for a year. The Housekeeping supervisor stated housekeeping was responsible for cleaning the resident's room. The Housekeeping supervisor stated the orange tag room were to be cleaned 3 times a day and the regular rooms were to be cleaned once a day. The Housekeeping supervisor stated he was aware of the strong urine smell on D hall. The Housekeeping supervisor stated housekeeping used a solution called Enzyme to get rid of the urine smell in the facility. The Housekeeping supervisor stated the nurse's aide were responsible for changing the resident linens. The Housekeeping supervisor stated deep cleaning were done for discharge, room changed, orange tag room or a death of a resident. The Housekeeping supervisor stated the Administrator oversaw him. The Housekeeping supervisor stated white glove came every 6 months to conduct follow up visit and reports are giving after inspections. The Housekeeping supervisor stated he did spot checks daily and also did champion rounds (checked his assigned rooms daily). The Housekeeping supervisor stated the facility had a cart checklist and the facility did not have a room cleaning checklist. The Housekeeping supervisor stated the facility did have enough cleaning supplies. The Housekeeping supervisor stated he ordered the cleaning supplies every month before the 24th of each month. The Housekeeping supervisor stated the last in-service on cleaning a deep cleaning was completed a few months ago. The Housekeeping supervisor stated he did expect housekeeping aids to clean and deep clean the rooms according to the facility policy. The Housekeeping supervisor stated it was important for residents because, The residents live here and for the public, we want to have a nice facility for someone to bring their families here and make sure the facility is in tip top shape.<BR/>During an interview on 1/11/24 at 10:07 a.m., the DON stated she did not oversee the Housekeeping department.<BR/>During an interview on 1/11/24 at 11:28 a.m., The Administrator stated Resident #18 did not want to sleep in a bed and Resident #18 preferred to sleep in a recliner chair. The Administrator stated housekeeping was responsible for cleaning the residents rooms. The Administrator stated the floor tech was responsible for cleaning the floors. The Administrator stated she was not aware of housekeeping completing any in-services on cleaning and deep cleaning. The Administrator stated a lot of housekeeping issues was the continuation of staff and having to constantly train new staff. The Administrator stated it was hard to find staff to work longer than a few months. The Administrator stated Housekeeping did not have a housekeeping checklist, but housekeeping were to follow the facility housekeeping policy. The Administrator stated she did expect housekeeping to ensure they were deep cleaning and cleaning the residents rooms. The Administrator stated she did champion rounds and if she saw an area of concern would address it in stand up meeting in the morning with the department heads. The Administrator stated the champion round had a checklist that staff were to complete. The Administrator stated she would then review the checklist and follow up after. The Administrator stated it was important for staff to follow the policy and procedures for housekeeping so the resident could have a clean homelike environment. <BR/>Record Review of the facility housekeeping policy for Cleaning and Disinfecting, dated 2022 indicated It is the policy of this facility to maintain cleanliness in an orderly manner. The goal is to keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image. The following cleaning tasks should be completed daily. (1) common area: dinning rooms, shower room(s), bathroom(s), lobby(s), sitting/tv room(s), hallway(s), door/entryway(s), beauty shop, therapy gym (2) resident room(s) including closets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 20 residents (Resident #12) reviewed for grievances. <BR/>The facility did not ensure a grievance was filed for Resident #12's black pants with a bow in the front when it was not returned from the laundry. <BR/>These failures could place residents at risk for grievances not being addressed or resolved promptly.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/11/2024 indicated Resident #12 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included other secondary Parkinsonism (a condition that causes tremor, muscle movement issues) and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain).<BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #12 was understood and understood others. The MDS assessment indicated Resident #12 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #12 was independent for eating, oral, toileting, personal and dental hygiene, dressing and required setup or clean up assistance for shower/bathe. <BR/>Record review of the grievances for the month of December 2023 and January 2024 did not indicate a grievance for Resident #12's black pants with a bow in the front. <BR/>During an interview on 01/09/2024 at 10:29 a.m., Resident #12 said within the last 2 months she had sent a pair of black pants with a bow on the front to the laundry and it was never returned. Resident #12 said she had notified the Housekeeping Supervisor and the Administrator. <BR/>During an interview on 01/09/2024 at 11:19 a.m., the Housekeeping Supervisor said he was over the laundry as well. The Housekeeping Supervisor said if a resident reported clothes missing, he would go look for the clothes in the laundry room and go through other residents' closets to see if the missing item was located. The Housekeeping Supervisor said if he was not able to locate the missing item, he would let the Administrator know and the laundry aides so they could look for the missing item. The Housekeeping Supervisor said he was aware Resident #12 was missing black pants with a bow on the front, and he had been aware of it since about a week ago. The Housekeeping Supervisor said he had not been able to locate Resident #12's black pants. The Housekeeping Supervisor said he had not let the Administrator know. The Housekeeping Supervisor said it was important for the residents' personal items to be returned to them because he would be pretty upset if he was missing something of his, and it was their belongings and personal items. <BR/>During an interview on 01/11/2024 at 4:30 p.m., ADON F said if a resident reported a lost clothing item, she would check the residents' rooms and the laundry, and if she did not find it that day, she would let the resident know. ADON F said the next day she would look for it again and once she was not able to find it, she would let the Administrator know. ADON F said she was not aware Resident #12's black pants were missing. ADON F said it was important for the residents' clothes to be returned to them because it was their personal belongings, and the facility was their home.<BR/>During an interview on 01/11/2024 at 5:26 p.m., the Administrator said if a resident reported missing clothes, they would ask the resident if they put their name on it, get a description of the item, search for the items in the laundry, check with other residents, and call the family if they were unable to find it. The Administrator said normally if clothes was missing, she did a grievance and if not found replaced the items. The Administrator said if the Housekeeping Supervisor had not found Resident #12's black pants he should have let her know so she could do a grievance. The Administrator said she was not aware Resident #12 was missing a pair of black pants. The Administrator said it was important for residents clothing and personal items to be returned to them because she wanted them to feel safe in the nursing home. <BR/>Record review of the facility's policy titled, Grievances, from the Social Services Manual 2003, indicated, .Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regard mg their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have . 3. The grievance official will: Oversee the grievance process oReceive and track grievances to their conclusion oLead any necessary investigations by the facility .6. <BR/>All written grievances decisions will include: oThe date the grievance was received oA summary statement of the residents grievance oThe steps taken to investigate the grievance oA summary of the pertinent findings or conclusions regarding the resident's concern(s) oA statement as to whether the grievance was confirmed or not confirmed oAny corrective action taken or to be taken by the facility as a result of the grievance oThe date the written decision was issued .

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of the 5 medication carts reviewed for medications storage. (Hall C)<BR/>The facility failed to ensure Resident #5 and Resident #52's Humalog (fast-acting insulin to control high blood sugar) insulin were taken off the cart after the opening date had expired on Hall C's nurse cart.<BR/>The facility failed to ensure Resident # 17 Breo Ellipta inhaler (medication used to prevent and decrease symptoms of wheezing and trouble breathing), was dated when opened on Hall C's nurse cart.<BR/>These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion.<BR/>Findings included:<BR/>During an observation on 01/11/24 at 3:12 p.m., Hall C's nurse's cart revealed Resident #5's Humalog insulin was open and dated 12/09/23 and Resident #52's Humalog insulin pen was open and dated 11/17/23. Resident #17 Breo Ellipta inhaler manufacture label was 10/09/23 was opened but had no opened date. <BR/>During an interview on 01/11/24 at 3:24 p.m., LVN D said she was not aware of how long insulin was good for. She said she went by the expiration date on the label. She said inhalers should be dated when opened to ensure they were getting an effective dose. LVN D said after the DON explained how long insulin was good for she was aware that Humalog insulin expired after 28 days therefore the insulin was not as effective as it should have been.<BR/>During an interview on 01/11/24 at 4:28 p.m., the DON said she expected the nurses and medication aides to audit their carts at least weekly to check for expired medications. The DON said the pharmacy consultant was at the facility monthly and checked for expired medications as well. She said it was the ADON's responsibility to oversee that the carts were being audited. The DON said she expected the insulin to be removed from the cart after being opened for 28 days and the inhaler to be dated when opened. She said whoever opened the inhaler should have been responsible for dating it. The DON said the residents were at risk for medications to be ineffective. <BR/>During an interview on 01/11/24 at 4:37 p.m., the ADON said she expected the medication aides and nurses to check their carts daily. She said the insulin should be dated when opened and discarded when expired. The ADON said the medication aide or nurse who opened the inhaler was responsible for dating it. The ADON said by not dating the inhalers when opened the staff would be unaware of when the inhalers expired. She said since the insulin had expired from the opening date, it could have been ineffective. <BR/>During an interview on 01/11/24 at 5:44 p.m., the Administrator said she expected the medication carts to not have any expired medications. The Administrator said she expected the insulin pens to be dated when opened and discarded after expiration days. She said she expected the inhalers to be dated when opened and by not doing so, the staff would be unaware of when it expired. The Administrator said the carts were checked by the pharmacist consultant and the nurse managers. The Administrator said the resident was at risk of receiving expired medication that could be ineffective.<BR/> Record review of the facility's policy titled, Insulin Pen Use by Pharmacy Policy & Procedure Manual 2003 revised 04/01/15, indicated, To take the insulin pen out of cool storage you can use it for up to 28 days. Ensure that the pen is dated when placed into use. During this time, it can be safely kept at room temperature. Do not use it after this time.<BR/>Record review of the facility's policy titled, Recommended Medication Storage, Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened: (fluticasone) -Expires 6 weeks (50mcg strength) or 2 months (100 and 250 mcg strengths) after initial use.<BR/>INSULINS (Vials, Cartridge, Pens) Humalog and Humalog Mix, <BR/>Humalog Flex Pen 75/25 and 50/50 pens expire 10 days after opening. Novolog and Novolog Mix<BR/>oExpires 28 days after initial use regardless of product storage (refrigerated or room temperature).<BR/>Record review https://www.mybreo.com revealed, BREO ELLIPTA (fluticasone furoate and vilanterol) to store BREO in the unopened foil tray and only open when ready for use. Safely throw away BREO in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first.

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in 19 of 63 Rooms (D hall) reviewed for a clean and homelike environment. <BR/>The facility failed to ensure (D hall) was cleaned daily, and in accordance with the facility's Housekeeping policy. <BR/>This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. <BR/>Findings included:<BR/>During an observation on 1/8/24 at 11:01 a.m., strong urine smell on D hall. <BR/>During an observation on 1/10/24 at 8:27 a.m., strong urine smell on D hall. <BR/>During an observation on 1/11/24 at 8:05 a.m., strong urine smell on D hall.<BR/>During an interview on 1/11/24 at 8:21 a.m., CNA C stated she had been a CNA for 19 years. CNA C stated the urine smell was always strong on D hall all the time especially in the morning. CNA C stated Resident #41 slept in a recliner and was a heavy wetter. CNA C stated Resident #41 was not being toileted like she should be. CNA C stated D hall was the heaviest hall in the facility. CNA C stated Resident #264 was also a heavy wetter on D hall and Resident #264 was not getting her showers like she was suppose too. CNA C stated it was only one CNA C worker per hall and the facility needed more CNA's. <BR/>During an interview on 1/11/24 at 9:21 a.m., housekeeping aide K stated he has been employed here for almost 2 months. Housekeeping aide K stated he worked 8:00 a.m. to 4:30 p.m. shift. Housekeeping aide K stated he was responsible for cleaning the resident rooms. Housekeeping aide K stated the rooms were to be cleaned every day and the orange tag rooms on the D hall were to be cleaned 3 times a day. Housekeeping aide K stated the orange tag rooms were for the residents who had hoarding issues. Housekeeping aide K stated the nurse's aide or laundry aide were to change the resident linens on their beds. Housekeeping aide K stated the resident nurse aides or nurses were responsible for cleaning the top of the resident mattresses. Housekeeping aide K stated the housekeeping supervisor oversaw him. Housekeeping aide K stated deep cleaning was to be done when a resident was discharging a room and before admission to the facility. Housekeeping aide K stated, The resident rooms were probably deep cleaned once a month. Housekeeping aide K stated deep cleaning considered cleaning under the resident's furniture, doors, dressers, sink, bathroom, floors, walls and lights. Housekeeping aide K stated the Housekeeping supervisor did spot checks, and he did not know how often the Housekeeping supervisor conducted spot checks in the resident's rooms. Housekeeping aide K stated the facility did not have a housekeeping checklist that housekeeping were to follow. Housekeeping aide K stated, He just did what the housekeeping supervisor told him to do when he came to work. Housekeeping aide K stated he was not aware of the urine smell on D hall. Housekeeping aide K stated he cleaned mostly on the B hall and sometimes cleaned D hall. Housekeeping aide K stated he worked Monday 1/8/24 and Thursday 1/11/24. Housekeeping aide K stated he did believe that the facility had enough cleaning supplies. Housekeeping aide K stated the nurse aids was responsible for cleaning urine or fecal matter off the floors and housekeeping was responsible for sanitizing the area after the nurses. Housekeeping aide K stated he completed cleaning and deep cleaning in-services last month. Housekeeping aide K stated, It was important to keep the facility clean and sanitized for basic human rights and if he had a family member in a facility that he would want their room cleaned.<BR/>During an interview at 1/11/24 at 9:35 a.m., The Housekeeping supervisor stated he has been employed at the facility for a year. The Housekeeping supervisor stated housekeeping was responsible for cleaning the resident's room. The Housekeeping supervisor stated the orange tag room were to be cleaned 3 times a day and the regular rooms were to be cleaned once a day. The Housekeeping supervisor stated he was aware of the strong urine smell on D hall. The Housekeeping supervisor stated housekeeping used a solution called Enzyme to get rid of the urine smell in the facility. The Housekeeping supervisor stated the nurse's aide were responsible for changing the resident linens. The Housekeeping supervisor stated deep cleaning were done for discharge, room changed, orange tag room or a death of a resident. The Housekeeping supervisor stated the Administrator oversaw him. The Housekeeping supervisor stated white glove came every 6 months to conduct follow up visit and reports are giving after inspections. The Housekeeping supervisor stated he did spot checks daily and also did champion rounds (checked his assigned rooms daily). The Housekeeping supervisor stated the facility had a cart checklist and the facility did not have a room cleaning checklist. The Housekeeping supervisor stated the facility did have enough cleaning supplies. The Housekeeping supervisor stated he ordered the cleaning supplies every month before the 24th of each month. The Housekeeping supervisor stated the last in-service on cleaning a deep cleaning was completed a few months ago. The Housekeeping supervisor stated he did expect housekeeping aids to clean and deep clean the rooms according to the facility policy. The Housekeeping supervisor stated it was important for residents because, The residents live here and for the public, we want to have a nice facility for someone to bring their families here and make sure the facility is in tip top shape.<BR/>During an interview on 1/11/24 at 10:07 a.m., the DON stated she did not oversee the Housekeeping department.<BR/>During an interview on 1/11/24 at 11:28 a.m., The Administrator stated Resident #18 did not want to sleep in a bed and Resident #18 preferred to sleep in a recliner chair. The Administrator stated housekeeping was responsible for cleaning the residents rooms. The Administrator stated the floor tech was responsible for cleaning the floors. The Administrator stated she was not aware of housekeeping completing any in-services on cleaning and deep cleaning. The Administrator stated a lot of housekeeping issues was the continuation of staff and having to constantly train new staff. The Administrator stated it was hard to find staff to work longer than a few months. The Administrator stated Housekeeping did not have a housekeeping checklist, but housekeeping were to follow the facility housekeeping policy. The Administrator stated she did expect housekeeping to ensure they were deep cleaning and cleaning the residents rooms. The Administrator stated she did champion rounds and if she saw an area of concern would address it in stand up meeting in the morning with the department heads. The Administrator stated the champion round had a checklist that staff were to complete. The Administrator stated she would then review the checklist and follow up after. The Administrator stated it was important for staff to follow the policy and procedures for housekeeping so the resident could have a clean homelike environment. <BR/>Record Review of the facility housekeeping policy for Cleaning and Disinfecting, dated 2022 indicated It is the policy of this facility to maintain cleanliness in an orderly manner. The goal is to keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image. The following cleaning tasks should be completed daily. (1) common area: dinning rooms, shower room(s), bathroom(s), lobby(s), sitting/tv room(s), hallway(s), door/entryway(s), beauty shop, therapy gym (2) resident room(s) including closets.

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through the means other than a postal service for 11 of 11 confidential residents reviewed for resident rights.<BR/>The facility failed to ensure 11 confidential residents received their mail on the weekend.<BR/>This failure could place residents 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 include:<BR/>During a confidential group interview, 11 residents said mail was not being distributed on Saturdays. They said they received mail everyday, Monday through Friday. They said their mail was delivered to them by the AD. <BR/>During an interview with the AD on 11/08/22 at 10:14 AM, she said the facility did not deliver mail on Saturdays, but someone would receive and place the mail in a slot for the AD, at the front of the facility, over the weekends. The AD said she would get the mail out of the slot on Monday and deliver the mail to the residents. She said she did not know exactly what happened because she was not in the facility on the weekends. <BR/>During an interview with the Administrator on 11/09/2022 at 1:15 PM, she said that the facility did not have a mailbox. She said the postman brought the mail in on Monday through Friday and gave the mail to the Social Worker. The Social Worker would then sort through the mail and give the AD the residents' mail. On Saturdays, the Administrator said the postman brought the mail into the facility to the charge nurse on duty. The charge nurse gave the residents their mail and placed the other mail under the business office door or in the Administrator's door slot. The nurses were expected to hand out the mail to the residents on Saturday. <BR/>During an interview on 11/09/22 at 01:35 PM, the AD said that she would receive the residents' mail in the slot in the front of the building on Mondays and it had to be from Saturday. The AD said she was there, in the facility, Monday through Friday, and she passed mail out to the residents every day. The AD said the mail man brought the mail to the facility, and the business office sorted the mail and brought the resident mail to the AD. The AD said that after a weekend off, there were some Mondays that mail had not been placed in the slot, but at times there was mail available to pass out. The AD said that she expected the mail to be delivered when it was received, but she was not there on the weekend, and they had a lot of agency staff in the building. She said it was the residents' right to have mail when it is delivered daily. <BR/>Record review of the undated facility policy for<BR/> Resident Mail Delivery and Distribution<BR/>Standard: <BR/>The health care center will develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations.<BR/>Practice Guidelines:<BR/>1.The Activity Department appoints a specific staff member or volunteers to coordinate mail delivery every day that the facility receives mail or parcels .