OAK PARK NURSING AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan including the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 1 (Resident #30) of 30 residents reviewed, in that: <BR/>Resident #30's baseline care plan was not completed within 48 hours of the resident's admission on [DATE]. <BR/>This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services. <BR/>The findings were: <BR/>Record review of Resident #30's face sheet, dated 12/19/2024, revealed she was an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses which included: Chronic Kidney Disease-Stage 3; Type 2 Diabetes Mellitus (chronic condition where the body has trouble controlling blood sugar); Dementia (a general term for loss of memory, and other cognitive abilities) ; Schizophrenia (mental illness that affects how a person thinks, feels and behaves); Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Anxiety Disorder (mental health disorder characterized by feelings of worry, fear and anxiety strong enough to interfere with daily life). <BR/>Record review of Resident #30's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating intact cognition. Further review revealed she was assessed as needing a wheelchair for mobility, and was dependent in toileting hygiene, lower body dressing and personal hygiene and needed substantial/maximal assistance with showering, and upper body dressing.<BR/>Record review of Resident #30's Care Plans Screen in her clinical record as of 12/19/2024, revealed her initial Care Plan completed was her Comprehensive Care Plan completed 08/21/2024, 9 days after her admission on [DATE].<BR/>During an interview with MDS-F and MDS-G on 12/19/2024 at 11:39 a.m., MDS-F stated she was one of 2 MDS Nurses at the facility and she had been at the facility 2 months. MDS-G stated he just started in the position 2 weeks ago. MDS-F stated baseline care plans were due within 48 hours of a resident's admission and confirmed that Resident #30's Baseline Care Plan was not done within 48 hours after her admission, and stated Resident #30's first Care Plan done was the Comprehensive Care Plan completed 9 days after her Admission. MDS-F stated that completion of Baseline Care Plans was the responsibility of the MDS Nurse, but noted there has been a lot of turnover in the MDS Nurse position in the past few months and that was probably why Resident #30's Baseline Care Plan was not completed on time. MDS-F further stated that not having the Baseline Care Plan completed within 48 hours could result in staff not having all the information they needed to provide good care to the resident. <BR/>Record review of the facility policy, Care Plans - Baseline, revised 2016, revealed, To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission and The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 3 of 30 residents (Resident #22, Resident #31, and Resident #53) reviewed for quality of care.<BR/>1. The facility failed to ensure Resident #22's Humalog KwikPen insulin (a lightweight pen that is prefilled with insulin, a hormone that helps the body use glucose for energy) was given per physician order.<BR/>2. The facility failed to ensure Resident #31's HgA1c lab (a blood test that measure the average blood sugar level of the past 3 months) was drawn every 3 months as per physician order.<BR/>3. The facility failed to ensure Resident #53's Midodrine HCl (a medication used to treat low blood pressure) was given per physician order.<BR/>These failures could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health.<BR/>Findings included:<BR/>1. Record review of Resident #22's admission Record, dated 12/18/2024, reflected Resident #22 was initially admitted on [DATE] and readmitted on [DATE]. Resident #22 was noted to be [AGE] years old and on hospice services. <BR/>Record review of Resident #22's Diagnosis Report, undated, accessed 12/18/2024, reflected Resident #22 was diagnosed with dementia (a general term for impaired ability to remember, think, or make decisions), senile degeneration of brain (loss of intellectual ability associated with old age), and type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel) with hyperglycemia (high sugar levels in the blood). <BR/>Record review of Resident #22's Quarterly MDS assessment, dated 09/18/2024 and signed as completed on 09/22/2024 by the DON, reflected Resident #22 had a BIMS of 2, indicating severe cognitive impairment, had an active diagnosis of diabetes mellitus, had a life expectancy of less than 6 months, and received insulin injections 7 of the last 7 days monitored for insulin injections. <BR/>Record review of Resident #22's Care Plan, undated, accessed 12/18/2024, reflected Resident #22 had a history of noncompliance with her medication regimen; date initiated: 12/08/2024. One of the interventions included, Allow the resident to make decisions about treatment regimen, to provide sense of control; date initiated: 12/08/2024. Resident #22 was also noted as having a desired weight loss and on a controlled carbohydrate diet; date initiated: 08/16/2024 and revised on 08/16/2024. One of the interventions included Administer medications as ordered. Monitor/Document for side effects and effectiveness; date initiated: 08/16/2024. <BR/>Record review of Resident #22's Order Audit Report for physician order, order date 07/10/2024, status noted as active, Humalog KwikPen 100 Unit/Ml Solution pen-injector, revealed the following procedure: Inject as per sliding scale:<BR/> If 150 - 200 = 2 units;<BR/> 201 - 250 = 4 units;<BR/> 251 - 300 = 6 units;<BR/> 301 - 350 = 8 units, <BR/> subcutaneously [applied under the skin] before meals and at bedtime related to type 2 diabetes mellitus with diabetic chronic kidney disease.<BR/>Record review of Resident #22's December 2024 MAR revealed on 12/05/2024 and 12/07/2024, Resident #22's BS (blood sugar) was 150 for her 0600 (06:00 a.m.) administration; however, the code 13, noted under chart codes as No Insulin Required, was coded by LPN K.<BR/>Record review of Resident #22's Progress Notes on 12/05/2024 and 12/07/2024 did not reveal notes regarding insulin not required. <BR/>During an interview with Resident #22 on 12/19/2024 at 10:28 a.m., she stated she had no concerns with her insulin administration. She stated her blood sugars go up and down. <BR/>During an interview with MD D on 12/19/2024 at 10:43 a.m., MD D revealed he had not been notified of any insulin errors or concerns. He stated Resident #22's sliding scale order was arbitrary (based on personal choice) and her having not received her prescribed 2 units when her blood sugar was at 150 would have had no impact on her health. <BR/>During an interview with LPN K on 12/19/2024 at 11:13 a.m., LPN K stated Resident #22's blood sugars were always in range, and he did not need to administer insulin for her. LPN K stated that to him, when Resident #22's blood sugar was at 150, he did not see a reason to administer insulin because Resident #22 was in range, so he would hold the insulin. He stated that having held the insulin when Resident #22 was at 150 had not caused any harm and Resident #22 was very aware and able to notify him if she had concerns. <BR/>During an interview with the DON on 12/19/2024 at 03:18 p.m., the DON stated to monitor medication administrations, the facility performed check-offs with the nurses, held in-services, and reviewed daily reports that show which medication administrations were coded with an exception code or those marked as not completed. The DON stated that if the physician order said to give insulin at 150, she would expect the nurse to administer the insulin and follow the physician order. She stated that the nurse was to call the physician and obtain a hold order if they are not giving the insulin. The DON stated that the impact on the resident for not administering the insulin when the blood sugar was 150 would depend on the resident and on when and what the resident's next meal was. <BR/>2. Record review of Resident #31's face sheet dated 12/18/2024, revealed she was a [AGE] year-old woman initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included: cerebral infarction (stroke), quadriplegia (paralysis which affects all 4 limbs), and type 1 diabetes mellitus without complications (lifelong condition where the pancreas makes little or no insulin, leading to high blood sugar levels). <BR/>Record review of Resident #31's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment and active diagnosis of Diabetes Mellitus.<BR/>Record review of Resident #31's care plan initiated on 08/17/2021 reflected a focus area of Diabetes Mellitus with goal of will have no complications related to diabetes .<BR/>Record review of Resident #31's Physician Order Summary dated 12/19/2024 revealed an order dated 07/29/2024 for: HgA1C Q 3 months<BR/>Record review of Resident #31's lab results in her clinical record reveal her only HgA1C lab was drawn 07/27/2024.<BR/>During an interview with the DON on 12/19/2024 at 10:50 a.m., the DON confirmed the last HgA1C lab for Resident #31 was drawn on 07/27/2024, and that per physician orders, another HgA1C should have been drawn 3 months later in October 2024. She stated she contacted the Doctor, who changed the order effective today to HgA1C every 6 months, however, she confirmed that per existing orders at the time, Resident #31's HgA1C lab was due in October and was not done. The DON stated she did not know why the lab was not drawn but will look into it. The DON further stated that it was important to draw labs as ordered by the Physician to monitor Resident #31's diabetic status.<BR/>3. Record review of Resident #53's admission Record, dated 12/16/2024, reflected Resident #53 was initially admitted on [DATE] and readmitted on [DATE]. Resident #53 was noted to be [AGE] years old. <BR/>Record review of Resident #53's Diagnosis Report, undated, accessed 12/18/2024, reflected Resident #53 was diagnosed with dysphagia (difficulty swallowing) following cerebral infarction (a disruption in the brain's blood flow), heart failure (heart muscle is weakened and cannot pump enough blood to meet the body's needs), and end stage renal disease (condition where the kidneys reach an advanced state of loss of function) with dependence on renal dialysis (a medical procedure that replicates the function of the kidneys by removing waste products and excess fluid from the blood). <BR/>Record review of Resident #53's Quarterly MDS assessment, dated 10/02/2024 and signed as completed on 10/07/2024 by the DON, reflected Resident #53 had a BIMS of 15, indicating he was cognitively intact. His primary medical condition for admission was stroke (when blood flow to a part of the brain is interrupted). He had active diagnoses of heart failure, hypertension (high blood pressure), renal insufficiency, renal failure, or end-stage renal disease; and diabetes mellitus. He was taking antianxiety and anticoagulant medications and received dialysis treatment. <BR/>Record review of Resident #53's Care Plan, undated, accessed 12/16/2024, reflected Resident #53 had several medications with a black box warning (required warnings for certain medications that carry serious safety risks), including Midodrine, which indicated a need for staff to closely evaluate and monitor the potential benefits and risks of the medication; date initiated: 08/16/2022 and date revised: 10/16/2024. Resident #53 was also noted as having congestive heart failure; date initiated: 04/30/2022 and revised on 10/19/2022. One of the interventions included Give cardiac medications as ordered.; date initiated: 04/30/2022. <BR/>Record review of Resident #53's Order Audit Report for physician order, order date 10/04/2024, status Active, Midodrine HCl Tablet 10 mg, revealed the following procedure: Give 1 tablet by mouth one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for hypotension [low blood pressure] give on dialysis days only. Hold if SBP > 110. <BR/>Record review of Resident #53's December 2024 MAR revealed on 12/06/2024, Resident #53's SBP was 119 for his 0400 (04:00 a.m.) administration; however, his record indicated the medication was checked as Administered by LPN K.<BR/>Record review of Resident #53's Progress Notes on 12/06/2024 did not reveal notes regarding Midodrine HCl given outside physician order parameters.<BR/>During an interview with Resident #53 on 12/19/2024 at 10:11 a.m., he stated he only took the blood pressure pill on dialysis days, and it was given only when his blood pressure was low. He stated his blood pressure had been controlled with the medications. <BR/>During an interview with MD D on 12/19/2024 at 10:43 a.m., MD D revealed he could not recall having been notified of Resident #53's Midodrine HCl having been administered outside parameters. He stated the Midodrine HCl having been administered with Resident #53's systolic blood pressure at 119 would be less worrisome than if it was 130 or 140. He stated 119 was not that high and he did not believe the medication would have caused any harm to Resident #53 with his systolic blood pressure at that level. <BR/>During an interview with LPN K on 12/19/2024 at 11:13 a.m., LPN K stated he did not recall administering Resident #53's Midodrine HCl on 12/06/2024 with a systolic blood pressure at 119. He stated he did recall holding Resident #53's blood pressure mediation before, and also recalled being called by the dialysis center because Resident #53's blood pressure was bottoming out (getting too low) during his dialysis appointment. LPN K stated, orders are orders but I use my nursing judgment. He stated that he would give Resident #53 his Midodrine HCl because he knows that the dialysis treatment will cause Resident #53's blood pressure to drop. LPN K stated, in his nursing opinion, he would not have held Resident #53's Midodrine HCl when the systolic blood pressure was 119 because Resident #53 would have been going to dialysis right after the medication administration and the dialysis would make Resident #53's blood pressure go down. LPN K stated he would give the medication to ensure Resident #53's blood pressure remained stable at an appropriate level. <BR/>During an interview with the DON on 12/19/2024 at 03:18 p.m., the DON indicated that if the physician order said to hold the medication if the systolic blood pressure was over 110, then the Midodrine HCl should have been held when the systolic blood pressure was 119. She stated that the nurse was to reach out to the physician and get approval to administer the medication if outside parameters. The DON revealed she was not aware of this medication administration outside parameters. <BR/>Record review of facility policy, Administering Medications, dated revised December 2012, reflected Policy Statement<BR/>Medications shall be administered in a safe and timely manner, and as prescribed.<BR/>Policy Interpretation and Implementation .<BR/>3. Medications must be administered in accordance with the orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 1 of 2 residents (Resident #13) reviewed for physician services.<BR/>The facility failed to ensure Resident #13 was seen by a physician within the first 30 days of his admission to the facility.<BR/>This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status.<BR/>The findings included:<BR/>Record review of Resident #13's admission Record, dated 12/16/2024, reflected Resident #13 was admitted on [DATE]. Resident #13 was noted to be [AGE] years old. <BR/>Record review of Resident #13's Diagnosis Report, undated, accessed 12/19/2024, reflected Resident #13 was diagnosed with quadriplegia (paralysis of all four limbs), polyneuropathy (a disorder that damages the peripheral nerves, which control the movement of the arms and legs), and hypertensive heart disease (heart problems caused by high blood pressure) without heart failure (heart muscle is weakened and cannot pump enough blood to meet the body's needs). <BR/>Record review of Resident #13's Quarterly MDS assessment, dated 11/13/2024 and signed as completed on 11/15/2024 by the DON, reflected Resident #13 had a BIMS of 15, indicating he was cognitive intact. His primary medical condition for admission was traumatic spinal cord dysfunction (a debilitating condition caused by spinal cord damage). He was noted as having received PRN (as needed) pain medication with reported pain almost constantly over a 5-day period. <BR/>Record review of Resident #13's Physician Progress Notes, reviewed on 12/18/2024, revealed Resident #13 was first seen by a physician, MD D, on 07/06/2024, 60 days after Resident #13's admission. <BR/>During an interview with Resident #13 on 12/16/2024 at 12:10 a.m., Resident #13 stated he had problems with his doctor when he was first admitted . He stated the doctor was not responding to his medication concerns and/or the nurses were not telling the doctor about his concerns. He stated he had seen his physician and the nurse practitioners since he was admitted and he was getting better, but he felt the communication with the physician team was a problem. <BR/>During an interview with MD D on 12/19/2024 at 10:43 a.m., MD D revealed as a group, his team goes to the nursing facility two to three times a week. He stated he goes to the facility every week to two weeks. MD D stated for the initial visit, it would depend on who will see the patient, either himself, one of the nurse practitioners, or another physician. MD D stated he could not recall when he first completed a visit with Resident #13, but he would hate for his documentation to be viewed as if he had not been seeing the resident. MD D stated he would often see and visit with Resident #13 in the hall, but he was not sure if he had documented those visits. MD D confirmed the physician note dated July 2024 was his first comprehensive note for Resident #13. MD D revealed Resident #13's care would not have been impacted by a late physician visit because Resident #13 was seen by the nurse practitioner who was able to provide a high level of care. <BR/>On 12/19/2024 at 04:14 p.m., a Request List, dated 12/19/2024, was sent to the ADMIN. The list included a request for a facility policy on Physician Services- Frequency of visits and Initial Assessment. The Texas Administrative Code, Title 26, Part 1, Chapter 554, Subchapter M, Rule title Frequency of Physician Visits was provided by the facility. <BR/>Record review of Texas Administrative Code, Frequency of Physician Visits, dated transferred effective January 15, 2021, reflected Physician visits must confirm to the following schedule: .<BR/>(2) Medicaid-certified facilities and Medicare skilled nursing facilities.<BR/> (A) The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.<BR/> (B) A physician visit is considered timely if it occurs no later than ten days after the date the visit was required.<BR/> (C) Except as provided in paragraph (3) of this section 19.1205(c) of this subchapter (relating to Physician Delegation of Tasks), all required visits must be made by the physician personally.<BR/>(3) Medicare skilled nursing facilities. At the option of the physician, required visits in Medicare skilled nursing facilities after the initial visit may alternate between personal visits by the physician and visits by a physician assistant or an advanced practice registered nurse in accordance with 19.1205 of this subchapter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 of 12 residents (Residents #1 and #2) reviewed for pharmacy services and medication administration in that: <BR/>The facility failed to administer medications as prescribed for Residents #1 and #2.<BR/>This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. <BR/>The findings included:<BR/>Record review of the admission face sheet, dated 11/9/2023, reflected Resident #1 was a female initially admitted on [DATE], readmitted [DATE], with a diagnosis included: hypertensive heart disease without heart failure (high blood pressure without affecting the pumping action of the heart muscles), atherosclerotic heart disease of native coronary artery without angina pectoris (the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall without chest pain), peripheral vascular disease (slow and progressive circulation disorder), and essential hypertension (high blood pressure).<BR/>Record review of the care plan with a start date of 11/7/2023, reflected Resident #1 had a Focus of The resident has hypertension (high blood pressure) with associated intervention of: Give anti-hypertensive medications as ordered.<BR/>had a Focus of The resident has coronary artery disease r/t hypercholesterolemia with associated intervention of: Give all cardiac meds as ordered by the physician Give meds for hypertension <BR/>Record Review of Resident #1's Order Summary Report dated 11/9/2023 revealed: Isosorbide Dinitrate Oral Tablet 30 MG, Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE Hold if SBP less than 110, DBP less than 60 or HR less than 60 and NIFEdipine Oral Capsule 10 MG, Give 3 tablets by mouth one time a day for HTN Administer 3 tablets to equal total dosage of 30mg Hold if SBP less than 110, DBP less than 60 or HR less than 60<BR/>Record review of the MAR for Resident #1 from 10/1/2023 to 10/31/2023, reflected the following medications were administered outside of parameters:<BR/>Isosorbide Dinitrate Oral Tablet 30 MG, Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE Hold if SBP less than 110, DBP less than 60 or HR less than 60<BR/>*10/18/2023 0900: [SBP/DBP: 135/56 and HR: 48];<BR/>*10/22/2023 0900: [SBP/DBP: 121/71 and HR: 53];<BR/>*10/28/2023 0900: [SBP/DBP: 133/74 and HR: 52]<BR/>NIFEdipine Oral Capsule 10 MG, Give 3 tablets by mouth one time a day for HTN Administer 3 tablets to equal total dosage of 30mg Hold if SBP less than 110, DBP less than 60 or HR less than 60<BR/>*10/18/2023 0930: [SBP/DBP: 135/56 and HR: 48];<BR/>*10/29/2023 0930: [SBP/DBP: 120/70 and HR: 55]<BR/>Record review of the admission face sheet, dated 11/9/2023, reflected Resident #2 was a male initially admitted on [DATE], readmitted [DATE], with a diagnosis included: pulmonary heart disease, peripheral vascular disease.<BR/>Record review of the care plan reflected Resident #2 did not mention to Give all cardiac meds as ordered by the physician or Give meds for hypotension.<BR/>Record Review of Resident #2's Order Summary Report dated 11/9/2023 revealed: Midodrine HCl Oral Tablet, Give 15 mg by mouth three times a day for Hypotension Hold if SBP greater than 120.<BR/>Record review of the MAR for Resident #2 from 11/1/2023 to 11/9/2023, reflected, the following medication being administered outside of parameters on:<BR/>Midodrine HCl Oral Tablet, Give 15 mg by mouth three times a day for Hypotension Hold if SBP greater than 120<BR/>*11/1/2023 1100: [SBP 129];<BR/>*11/3/2023 2200: [SBP 136];<BR/>*11/9/2023 1100: [SBP 123]<BR/>During interview on 11/13/2023 at 10:14 AM, the ADON A revealed that Resident #1 was incorrectly given Isosorbide Dinitrate and Nifedipine on October 28th and 29th , confirming blood pressure was outside of parameters and should not have received heart medications. The ADON A further revealed that Resident #2 was incorrectly given Midodrine on October 26th, 28th, and 30th because blood pressure was outside of parameters. <BR/>During an interview on 11/13/2023 at 10:58 AM, the LVN A verified that Midodrine was administered to Resident #2 outside of blood pressure parameters on October 26th, 28th , and 30th. <BR/>During an interview on 11/13/2023 at 1:26 PM, the DON revealed that the nurses were administering heart medications outside of blood pressure parameters.<BR/>Record Review of Administering Medications policy, revised April 2019, reflected the following step in the preparation stage: 4. Medications are administered in accordance with prescriber orders . and 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

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 the facility's only kitchen.<BR/>The 3-compartment sink was not maintained in working condition.<BR/>Undercooked eggs were served to residents.<BR/>These deficient practices could affect residents who ate from the kitchen and could contribute to food-borne illnesses.<BR/>The findings include:<BR/>In an observation on 09/19/22 at 9:43 AM, the 3-compartment sink was revealed to be draining shortly after being filled.<BR/>In an observation and interview on 09/19/22 at 1:02 PM revealed when [NAME] B added water to the first compartment of the 3-compartment sink, the water started to drain out. [NAME] B stated when he filled the first compartment up, the water will drain down to being half full in a short while. He showed the surveyor the water coming out of the drainpipe underneath the 3-compartment sink.<BR/>In an interview on 09/19/22 at 01:12 PM, the DM stated he would provide a work order for the 3-compartment sink.<BR/>Record review of a maintenance work order titled sink drain leaking revealed the order was created on 09/18/2022 3:53 PM by the Maintenance Director and the order was fulfilled on 09/20/2022 at 9:17 AM by the Maintenance Director. Additionally revealed was the request was submitted by the DM with work order #9546 with a priority setting of Medium.<BR/>In an interview on 09/19/22 at 2:29 PM, the Maintenance Director stated he was told by the kitchen the 3-compartment sink was not operating and proceeded to create a work order and then fix the equipment.<BR/>In an observation of the kitchen on 09/20/22 at 02:04 PM, the following was noted: The 3-compartment sink was observed to be operating, with a small stream of water draining from the first compartment. Eggs within the walk-in refrigerator had white, unmarked eggshells within a container that stated, Fresh Shell Eggs, USDA AA Grade, Wholesome Farms, and 9/17 on the box. Within the container, approximately 9 of 48 eggs were observed to have broken shells and atop a wet paper egg tray.<BR/>In an interview on 09/20/22 at 02:26 PM the DM stated he had never had concern with using unpasteurized eggs. He stated he had instructed his staff to make only eggs that will be completely cooked both ways with a mechanism that will cook both sides, describing a hard egg.<BR/>In an interview on 09/20/22 at 04:06 PM, the Dietician stated the facility ordered pasteurized eggs, but recently since they're being sent unpasteurized eggs, they are not to use them whatsoever. The Dietitian stated that if the facility received unpasteurized eggs, the kitchen was not to use the eggs even indirectly. She stated there was at least 1 resident who had requested over-easy eggs.<BR/>In an interview on 9/21/2022 at 8:25 AM, Resident #41 stated she understood fried eggs or sunny side up eggs to mean eggs with a liquid yoke. Resident #41 stated she had asked for sunny side eggs but received scrambled eggs this morning. Resident #41 stated she had sunny side eggs the day prior [9/20/2022]. Resident #41 stated she had sunny side up eggs approximately once or twice a week.<BR/>In an interview on 9/21/2022 at 8:50 AM, Resident #51 stated eggs sunny side up meant an egg where one would use toast to soak up the liquid yoke. Resident #51 stated that he received sunny side up eggs yesterday [9/20/2022] to the best of his recollection. Resident # 51 stated he was not sure, but thought he had sunny side up eggs a few times in the last month but also stated that he had memory problems. Resident #51 stated he would not ever turn down eggs with a runny yoke. Resident #51 stated he received scrambled eggs for breakfast this morning, but he preferred eggs sunny side up.<BR/>In an interview on 09/21/22 at 9:30 AM, Resident #308 stated she gets her eggs as over-easy and sunny side up where the yolk is runny.<BR/>In an interview on 09/21/22 at 9:36 AM, Resident #310 stated he gets his eggs over easy, but the yolk is firm and hard<BR/>In an interview on 09/21/22 at AM, Resident #312 stated he gets his eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 9:42 AM, Resident #314 stated she gets her eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 9:45 AM, Resident #413 stated he gets his eggs scrambled, but will also like his eggs over easy and that the yolk is runny.<BR/>In an interview on 9/21/2022 at 9:45 AM, Resident #25 stated he liked sunny side up eggs with a runny [liquid] yoke. Resident # 25 stated he had sunny side up eggs for breakfast the day prior [9/20/2022]. Resident #25 stated he had sunny side up eggs a few times in the past month.<BR/>In an interview on 09/21/22 at 9:57 AM R#421A stated she gets her eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 10:02 AM R#123A stated she gets her eggs scrambled but sometimes over easy but the eggs are firm and hard<BR/>In an interview on 09/21/22 at 10:19 AM R#127A stated he gets his eggs scrambled but if it's not scrambled, it's firm all the way through<BR/>In an interview on 09/21/22 at 03:18 PM, the DM stated the 3-compartment sink was reported to him on 09/17/2022 by [NAME] A, and that same day the DM reported the work order request to the Maintenance Director verbally. The DM stated the protocol for equipment that was not operating to manufacturer specifications would be to stop using the equipment immediately and to report the malfunctioning equipment immediately.<BR/>In an interview on 09/21/22 at 03:22 PM, The DM stated the fried egg that is made is cooked both sides. The DM stated that an over-easy egg is one where it is runny. He stated the last time R#314-B had an over-easy egg was 10-15 days ago. The DM stated that R#128-A told him a month and a half ago, he was told that the resident was telling her she does not like hard eggs. The DM stated that the Dietician has not stated he cannot use unpasteurized eggs.<BR/>In an interview on 09/22/22 at 11:20 AM, the DON stated she is unaware if the kitchen has made undercooked eggs<BR/>In an interview on 09/22/22 at 11:21 AM, the DON stated she was not aware of the risks associated with using unpasteurized eggs. The DON stated the risks associated with undercooked eggs would be salmonella, or other foodborne illness. The DON stated that nausea or vomiting would be to call the physician, and such a CoC would be completed.<BR/>In an interview on 09/22/22 at 11:34 AM, the Admin stated he was unaware if the residents have requested undercooked eggs for meals. The Admin stated he was aware that the kitchen has received unpasteurized eggs and has ordered them. The Admin stated his expectation for the kitchen once received a substitution for eggs, they are to decline it. The Admin stated the policy for having only unpasteurized eggs would be to cook the eggs thoroughly.<BR/>In an interview on 09/22/22 at 11:37 AM, the Admin stated that he was unaware of a previous deficiency related to the 3-compartment sink. The Admin stated his expectation when equipment was malfunctioning was for the DM to report the equipment as not operating and was to do so either verbally, in paper, or online in the electronic work order system. The Admin stated the risk associated with the 3-compartment sink not operating would be the that the potential for disinfecting not being completed properly. The Admin stated the facility does not have policy for the 3 compartment sink or kitchen equipment.<BR/>Record review of dietary order submitted on 09/20/2022 revealed a line item described as EGG SHELL LARGE GR AA USDA WHT from brand name WHLFCLS.<BR/>Record review of the facility's policy, undated, titled [The Facility] Egg Safety revealed that if a [facility] has a resident who prefers undercooked eggs . [The Facility] will use pasteurized eggs when available but if the facility uses unpasteurized eggs eggshells for individual resident consumption, those eggs must be cooked until both the yolk and white are completed firm and served immediately.<BR/>Record review of the United Stated Food & Drug Administration Food Code dated 01/01/2017 revealed only pasteurized eggs are used in recipes if eggs are undercooked and if eggs are combined, unless there is a cook step or HACCP plan to control Salmonella enteriditis within the section titled Highly Susceptible Population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. <BR/>The facility failed to ensure Resident #1's EMR reflected accurate wound care documentation on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024.<BR/>These deficient practices could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, computer dated 11/8/2024, revealed he was a [AGE] year old male with an initial admit date of 2/21/24 and readmitted on [DATE] with diagnoses which included cerebral vascular accident(cva-medical term for a stroke. When blood flow to a part of the brain is stopped.), left side affected, Diabetes Mellitus 2( the body has a problem regulating sugar and the way it uses it.),hyperlipidemia(abnormally high levels of fat in the blood, it can cause blocked arteries and can lead to serious health conditions),anxiety(excessive,persistent and uncontrollable worry and fear about everyday situations),dementia(deterioration in mental status),arterial sclerotic heart disease(plaque buildup in the artery walls. can cause conditions such as heart attack and peripheral artery disease(disorder of blood vessels can affect the legs,feet,brain and other organs.).<BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 13, which indicated cognitively intact.<BR/>Record review of Resident #1's Care plan dated 9/6/2024 with revision 10/10/2024 revealed the resident had a diabetic ulcer of the right lateral foot related to diabetes pressure ulcer or potential for pressure ulcer development. 10/15/24-Stage 4 decubitus left heel.<BR/>Record review of Resident #1's physician Order Summary Report dated 10/1/2024-10/31/2024 revealed the following wound treatment orders: Right foot diabetic ulcer proximal Phalanx of great toe: cleanse with normal saline, pat dry with 4 x 4 gauze,apply skin prep to peri wound apply santyl to wound bed, cover with calcium alginate and dry dressing every day shift.(start date 9/5/2024 dc date 11/3/2024). Wound care left heel deep tissue injury with open area:cleanse with normal saline and or wound cleanser,pat dry with 4 x 4 gauze, apply santyl nickel thick to wound bed,cover with calcium alginate and cover with bordered gauze dressing every day shift for wound healing.(start date 10/18/2024-10/31/24). (10/15-10/17/2024) Wound care left heel deep tissue injury with open area: cleanse with normal saline and or wound cleanser,pat dry with 4 x 4 gauze apply calcium alginate and cover with bordered gauze dressing every day shift for wound healing.<BR/>Record review of Resident #1's TAR (treatment administration record) for October 2024 revealed there were blank spaces for Resident #1's treatment administration for the following days:10/24/2024,10/26/2024,10/27/2024 and 10/31/2024.<BR/>Record review of facility staffing sheet for October 2024 revealed LVN A worked on 10/24/24 and Treatment Nurse worked on 10/26,10/27,10/31.<BR/>During an interview on 11/12/2024 at 10:15 am LVN A stated she worked on 10/24/2024 but forgot to sign (Resident #1's) TAR after doing Resident #1's treatment on his feet. She further revealed it was a very hectic day and she just did not go back and sign the sheet, but she did do his ordered treatments on his feet. She stated it was important to document when a treatment was done.<BR/>During an interview on 11/12/2024 at 10:35 am Treatment Nurse stated he worked on 10/26/24,10/27/24 and 10/31/2024 but forgot to sign (Resident #1's) TAR after doing Resident #1's treatment on his feet. He stated it was very important to document when a treatment was done so that it showed it was done. <BR/>During an interview on 11/12/2024 at 2:00 p.m. facility DON confirmed LVN A and Treatment Nurse did not document on the wound administration record on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024 for Resident #1. The DON stated the treatments were most likely done but were not documented. Further interview with [NAME] revealed it was her expectation for staff to document in the electronic record of each resident whenever a treatment was done.<BR/>Record review of the facility's policy titled Charting and Documentation dated 2001 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response of care. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided and the name and title of the individual who provided the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 2 residents (Resident #22) reviewed for hospice services.<BR/>The facility failed to maintain required hospice forms and documentation, that included the current hospice plan of care to ensure Resident #22 received adequate end-of-life care.<BR/>This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. <BR/>The findings included: <BR/>Record review of Resident #22's admission Record, dated 12/18/2024, reflected Resident #22 was initially admitted on [DATE] and readmitted on [DATE]. Resident #22 was noted to be [AGE] years old and on hospice services. <BR/>Record review of Resident #22's Diagnosis Report, undated, accessed 12/18/2024, reflected Resident #22 was diagnosed with dementia (a general term for impaired ability to remember, think, or make decisions), senile degeneration of brain (loss of intellectual ability associated with old age), and type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel) with hyperglycemia (high sugar levels in the blood). <BR/>Record review of Resident #22's Quarterly MDS assessment, dated 09/18/2024 and signed as completed on 09/22/2024 by the DON, reflected Resident #22 had a BIMS of 2, indicating severe cognitive impairment and had a life expectancy of less than 6 months. <BR/>Record review of Resident #22's Care Plan, undated, accessed 12/18/2024, reflected Resident #22 was on hospice and had a terminal prognosis (medical condition with likely outcome of eventual death) related to senile degeneration of brain; date initiated: 08/21/2024 and revised on 10/26/2024.<BR/>Record review of Resident #22's Order Summary Report, dated 12/18/2024, reflected order Admit to [Hospice S] dx [diagnosis]: senile degeneration of brain. Order dated 07/31/2024 and status noted as Active. <BR/>Observation and record review of Resident #22's physical hospice binder on 12/19/2024 at 10:25 a.m. revealed initial hospice plan of care, certification period and current benefit period/range: 07/24/2024 to 10/21/2024. <BR/>During an interview with LPN J on 12/19/2024 at 10:26 a.m., LPN J stated the Hospice S nurse for Resident #22 had recently changed. LPN J stated she did not know if the Hospice S nurse brought any paperwork with her at her last visit. <BR/>During an interview with Resident #22 on 12/19/2024 at 10:28 a.m., Resident #22 stated she felt the facility was communicating well with Hospice S and she had not had any problems with her care provided by Hospice S or Nursing Facility R. <BR/>Record review of Resident #22's electronic record on 12/19/2024 at 01:25 p.m. revealed no evidence of the current hospice plan of care. <BR/>During an observation and interview with ADON B on 12/19/2024 at 02:14 p.m., ADON B stated he, ADON A, and the DON coordinate with the hospice providers. He stated that the ADONs were typically assigned their own halls, he was assigned Resident #22's hall, but that they coordinated with each other as well. He stated the current care plan should be up to the hospice to bring in. ADON B was observed reviewing Resident #22's hospice binder and confirmed the current plan of care was not present. ADON B stated the facility social worker, SW I, and the MDS Nurse would typically get the forms from the hospice, but it was primarily the social worker, who was involved in the facility contracts. ADON B stated he could call Hospice S and they would send the updated plan of care. <BR/>During an interview with SW I on 12/19/2024 at 02:23 p.m., SW I stated she communicated with the hospice companies regarding the referral process, but the nursing staff did facilitation of care. SW I stated the facility did review the hospice books, both nursing staff and herself. SW I stated for hospice, she primarily provided assistance with certain forms (identified two Medicare and Medicaid forms that allow for billing), but was unsure who was responsible in verifying a current plan of care form was present. SW I stated that responsibility would be nursing. SW I stated Resident #22 had a care plan meeting since she went on hospice and her hospice care had been very good. SW I stated the facility not having an updated hospice Plan of Care for Resident #22 would not have impacted her care. <BR/>During an interview with the DON on 12/19/2024 at 03:18 p.m., the DON stated the social worker was in charge of the hospice binders. She stated the nurses help but the system fell on the social worker. The DON stated that the facility had facility care plans for residents, so the hospice care plan would only refer to the hospice's care. The DON stated Resident #22's care would not have been impacted by not having a current hospice plan of care because the facility care was based on the facility care plan. The DON stated that if there were any changes in the hospice's plan of care, it would have been communicated to the nursing staff on the facility's internal communication report. The DON stated there had not been any concerns with communication with the hospice providers. <BR/>During an observation and record review on 12/19/2024 at 03:48 p.m., received updated hospice plan of care, benefit period dates: 10/22/2024 to 12/19/2024. Document noted to have been printed on 12/19/2024 at 04:18 p.m. Eastern Time Zone (03:18 p.m. Central Standard Time). Nursing Facility R was in Central Standard Time zone. <BR/>Record review of Hospice S contract with Nursing Facility R, dated as signed 10/21/2022, by Area of [NAME] President of Operations for Hospice S and the ADMIN of Nursing Facility R. The contract reflected under 1. Definitions .<BR/> 1.11 'Plan of Care' means a written care plan established, maintained, reviewed and modified, if necessary, at intervals identified by the Hospice IDG [group of qualified individuals employed or contracted by Hospice] in coordination with Facility and each Patient's attending physician, if any. The Plan of Care must reflect goals of each Patient and his or her family and interventions based on the problems identified in each Patient's assessments. The Plan of Care will reflect the participation of the Hospice, Facility, a Patient and his or her family to the extent possible. Specifically, the Plan of Care includes: (i) identification of the Hospice Services, including interventions for pain management and symptom relief, and Facility Services needed to meet a Patient's needs and the related needs of his or her family; (ii) a statement of the scope and frequency of such Hospice Services and Facility Services; (iii) measurable outcomes anticipated from implementing and coordinating the Plan of Care; (iv) drugs and treatment necessary to meet the needs of the Patient; (v) medical supplies and appliances necessary to meet the needs of the Patient; and (vi) documentation of the Patient's or representative's level of understanding, involvement and agreement with the Plan of Care . <BR/>2. Responsibilities of Facility .<BR/> 2.1.2.3 Facility Representative. Facility shall designate the Director of Nursing as the individual in Facility who shall be responsible for implementation of the provisions of this Agreement (Facility Representative). Facility shall notify Hospice if an individual other than the Director of Nursing is designated as the Facility Representative .<BR/> 2.8 Coordination of Care .<BR/> 2.8.4 Designated Facility Member. Facility shall designate a member of Facility's interdisciplinary team who is responsible for working with Hospice representative to coordinate care to each Patient provided by Facility and Hospice .Facility's designated team member shall be responsible for: .(v) obtaining patient-specific information from Hospice as required by applicable laws and regulations; . <BR/>Record review of facility policy, Hospice Program, dated revised July 2017, reflected under Policy Interpretation and Implementation, 12. Our facility has designated See Administrator for Contract (Name) (Title) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT [Interdisciplinary Team] with clinical and assessment skills who is operating within the State scope of practice act). He or she is responsible for the following: .<BR/>d. Obtaining the following information from the hospice:<BR/> (1) The most recent hospice plan of care specific to each resident;.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure they maintained an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 Residents (Resident #207) who was observed for COVID-19 precautions.<BR/>Resident #207 whose vaccinated status was unknown for COVID-19 upon admission was not placed on isolation precautions.<BR/>This deficient practice could affect residents in the women's secured unit and could lead to the spread of infections.<BR/>The findings were:<BR/>Review of Resident #207's face sheet, dated 9/22/22, revealed he was admitted to the facility on [DATE] with diagnosis, unvaccinated for COVID-19.<BR/>Review of Resident #207's initial Baseline Advanced Care Plan, dated 9/15/22, revealed the Resident was not on transmission based precautions.<BR/>Review of a progress note, dated 9/15/22, did not address Resident #207's isolation status.<BR/>Review of Resident #207's physician orders for September 2022 revealed an order dated 9/19/22 for: Rapid COVID-19 test x 1 Now due to unvaccinated status.<BR/>Observation on 09/18/22 at 10:05 AM revealed #207 was in the common area along with 7 other residents in the women's secured unit. <BR/>Interview on 09/18/22 at 10:08 AM with LVN G revealed Resident #207 remained in the women's unit because he was not vaccinated or his vaccination status was unknown. She stated he was most recently admitted to the facility from the hospital and to her knowledge the Resident was named as his own responsible party. LVN G further stated Resident #207 was not transferred to the men's secured unit because at least one of the Resident's was diagnosed with COVID-19 and they did not want to place him at risk for exposure. However, LVN G stated it did not make any sense because he could be placing the women in the secured unit at risk for exposure due to his unknown vaccination status.<BR/>Observation and interview on 9/19/22 at 12:15 PM with ADON F revealed Resident #207 was still on the unit and was on isolation based on facility protocol. ADON F stated all new and unvaccinated admissions were placed on isolation. ADON F stated Resident #207's family member reported he was vaccinated but they had to secure his immunization record before releasing him from isolation. ADON F stated he added the PPE cart upon reporting to work this morning and stated Resident #207 was also supposed to be on 1 to 1 supervision in his room so that he did not wander out of his room. He stated the Resident was non-complaint about staying in his room. Observation, at this same time, revealed Resident #207's door to his room was closed. There was a sign to see the nurse before entering the room and a PPE cart was outside of his room. ADON F stated he understood staff was not following protocol yesterday (9/18/22) per administrative report and was aware Resident #207 was mingling with other residents in the women's secured unit and could place them at risk of potentially being exposed to COVID-19.<BR/>Interview on 09/19/22 at 05:05 PM with the ADM revealed Resident #207 was admitted from the hospital and stated he was placed on isolation and his isolation status should have been included on the nursing admission assessment. The ADM stated he learned staff did not place the Resident on isolation but stated that was the plan for Resident #207 upon admission. He stated a PPE cart should have been posted outside his door for nursing staff to access upon entering his room.<BR/>Interview on 09/19/22 at 05:23 PM with the DON revealed she talked with Resident #207's family member who told her the Resident had received both COVID vaccinations at two different facilities. She stated she called and spoke with a representative at both of facilities and a representative stated Resident #207 received a COVID vaccination at their facility. However, Resident #207's immunization record had not been secured. The DON stated Corporate Office instructed her to place the Resident on isolation until she received his immunization records and could ensure he was fully vaccinated. The DON stated Resident #207 was supposed to be placed on 1 to 1 supervision until his vaccination status was confirmed. <BR/>Interview on 09/20/22 at 02:29 PM with LVN G revealed Resident #207 was admitted on Thursday, 9/15/22, and was supposed to be placed on isolation precautions. She stated the admission nurse did not document the Resident's isolation status on a nurse's progress note or on the 24 hour report which she should have done. LVN G stated she was not sure why Resident #207 was in the women's secured unit and she inquired about it. She was informed it was because his COVID vaccination status was unknown. LVN G stated after the last interview with Surveyor, she read Resident #207's hospital records and talked with the DON. The DON stated he was supposed to be on isolation and on 1 to 1 supervision in his room. LVN G stated they Made him 1 to 1 supervision as best as they could but did not have the extra person to supervise him. LVN G stated she reached out to a family member, listed in Resident #207's hospital records, who said he had been vaccinated at two different facilities. LVN G stated Resident #207 was sent back out to the hospital on 9/19/22 related to abdominal pain. Further interview with LVN G revealed Resident #207's vaccination status was unknown at the time she talked with the DON.<BR/>Review of facility policy, Policies and Practices - Infection Control revised on October 2018 read in part: This facilities policies and practices are intended to manage transmission of diseases and infections. 2. The objectives of our infection control policies and practices are to a. prevent, detect, investigate and control infections in the facility. c. establish guidelines for implementing isolation precautions including standard and transmission based precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (R #2) reviewed for abuse.<BR/>The facility did not properly monitor or put in place preventative measures for R #2 to prevent an act of sexual abuse on 05/04/2024 by R#1.<BR/>On 05/04/24 around 9:30 PM, R #1, intoxicated and aggressive, was not monitored and left unsupervised in his room for 15 minutes. R #1 left his room and was found at 9:45 PM by CNA C engaged in a sexual act with R#2 (non-consenting adult). R#1 had undressed R#2's top and engaged in sucking her breast. <BR/>The non-compliance was identified as PNC. The IJ began 05/04/24 and ended 11/25/24. The facility had corrected the non-compliance before the survey began.<BR/>This failure could place residents at risk for sexual abuse, suffering injury, a diminished quality of life, psychosocial harm, and/or death. <BR/>The findings were:<BR/>Record review of R #1's EMR and face sheet, dated 12/02/24, reflected an admission date of 03/14/23, re-admitted [DATE], discharged [DATE] with diagnoses that included: alcohol abuse with alcohol induced anxiety disorder, alcohol use, major depressive disorder, lack of coordination, and difficulty in walking. The resident was a male age [AGE] years old. Resident #1 was his own RP and had a family listed as an emergency contact. <BR/>Record review of R# 1's Care Plan, dated 04/05/24, did not include the resident drank alcohol. <BR/>Record review of R#1's MDS, dated [DATE], reflected: the resident's BIMS Score was 15 (cognitively intact). <BR/>ADLs included: R #1 had a urostomy and was occasionally incontinent of bowel. Range of motion was upper extremity no impairment, lower extremity impairment on one side. R #1 utilized a wheelchair. Independent with walking/transfers (01/20/24 MDS).<BR/>Record review of R#1's order summary dated 05/06/24 reflected: diagnoses given to the resident included Alcohol Abuse with alcohol-induced anxiety .Alcohol Use, unspecified with unspecified alcohol-induced disorder . No orders were present involving any interventions for alcohol abuse or use. No order to stop medications when the resident was actively drinking. Order existed for managing anxiety and depression. Resident had order for anxiety (Duloxetine 30 mg 1 tab for Major Depression). <BR/>Record review of R#2's EMR and face sheet, dated 12/02/24, reflected an admission date of 03/21/22 and re-admission [DATE] with diagnoses that included: dementia unspecified severity with other behavioral disturbance, anxiety disorder, need for assistance with personal care, seizures, depression, and history of falling. The resident was a female age [AGE] years old. Resident #2 was listed as her own RP.<BR/>Record review of R#2's Care Plan, dated 09/26/24, revealed, the goals and interventions included: (hospice care) dementia and administer medications as scheduled, ADL self-care deficit, impaired cognitive function/impaired thought processes related to dementia-administer medications as ordered and keep the routine consistent and try to provide consistent care givers as much as possible to decrease confusion. R#2 had communication problem related to cognition and senile degeneration of brain. R #2 also had impaired visual function. <BR/>Record review of R#2 's MDS, dated [DATE], reflected: BIMS Score was 00 (severe impairment). ADLs were listed as always incontinent. Transfer and bed Mobility were dependent on staff assistance. ROM was listed as no impairment.<BR/>Record review of facility's Form 3613 dated 05/10/24 reflected: Incident: R#1went into R#2's room and was witnessed making sexual contact on R#2's breast. R#2 was assessed with no injuries or psychosocial trauma. R#1 was placed on one-to-one monitoring pending arrest by law enforcement. R#1 was arrested for public intoxication and immediately discharged from the facility. Form 3613 read, [R#1] was issued a citation for coming in contact with [R#2's] breast while she was sleeping. <BR/>Record review of R#1's nurse note dated 5/5/24 authored LVN B reflected: law enforcement was called and Case # assigned (SAPD 24097970 officer #1786). R#2 was arrested for PI. <BR/>Record review of R#2's nurse note dated 05/04/24 at 10:50 PM, authored by LVN B, reflected resident was assessed and no negative findings. Q 15 minutes checks were initiated. <BR/>Record review of R#2's 72-hour 15 minutes monitoring sheet revealed checks were done every 15 minutes from 5/04/24 to 5/06/24 every shift.<BR/>Record review of R#2's nurse note dated 05/05/24 authored by LVN B reflected resident was sent to the ER for an assessment and returned the same day. <BR/>Observation and interview on 12/02/24 at 2:30 PM, R#2 was in bed, not alert or oriented. Music playing as an activity. Resident yelled out noises with no meaning. Resident could not answer any direct questions. Resident did not recognize or acknowledged the presence of the surveyor in the room.<BR/>During an interview on 12/02/24 at 2:45 PM, Hospice LVN D stated: the resident was under hospice care for senile degeneration of the brain since May 2024 LVN D stated the resident was unable to protect herself or yell out for help. LVN D stated that another resident [R#1] walked into her room in the past [05/04/24], and the resident [R#2] was sent to the ER for an evaluation involving an allegation of sexual abuse.<BR/>During an interview on 12/02/24 at 3:15 PM, LVN E stated, nursing practice was to notify the MD and law enforcement when a resident was belligerent, under the influence, and refused an assessment. LVN E stated that a belligerent resident who could be a danger to self or others would need close monitoring pending new orders from the MD; and any directions from law enforcement. <BR/>During an interview on 12/02/24 at 4:44 PM, the DON stated: she did not know what nurse allowed R#1 who was intoxicated to enter the facility on 05/04/24. The DON stated that the nursing practice for an intoxicated resident was to check vitals, call MD for guidance and monitor the resident for vital sign, and changes and behaviors. The DON stated that resident had to be monitored; but she could not give an explanation why R#1 was not monitored for a lapse of 10-15 minutes on 5/4/24 from 9:30 PM-9:45 PM. <BR/>During an interview on 12/03/24 at 9:20 AM, LVN D stated she got a call from either LVN E or the DON that R#1 was found in R#2's room and suckling R#2's nipple or breast. LVN D stated by nursing practice the nurse that escorted the resident to the room should had maintain visual contact of the resident pending MD or nurse management guidance. <BR/>During a telephone interview on 12/03/24 at 9:55 AM, LVN B stated: R#1 returned late at night intoxicated by himself and LVN A let him in the facility. LVN B stated, no assessment outside the facility was done because resident was belligerent. LVN B stated, whenever a resident was drinking an assessment was required; but the resident refused. LVN B sated, We took him [R#1] to his room and call 911 and the MD, because the resident was belligerent and refused an assessment. By the time the police came the resident was not in his room. [ CNA C] found him in another room performing an inappropriate sexual act. LVN B stated I had to do documentation and lost sight of the resident. When the law enforcement arrived, it was when we realized the resident was missing It was 15 minutes I lost sight of the resident. LVN stated, that through hindsight she would have had the other nurse [LVN A] watch over R#1. <BR/>During an interview on 12/03/24 at 11:00 AM, the Administrator stated: HHS was contacted on 05/04/24 at 11:45 PM; incident occurred on 05/04/24 at 10:30 PM. The Administrator stated the Incident involved R #1 going into R#2's 's room and was witnessed making sexual contact on R#2's breast. R#2 was assessed with no injuries or psychosocial trauma. The Administrator stated R#1 was placed on one-to-one monitoring pending arrest by law enforcement. The Administrator stated that an assessment needed to be completed when a resident returned intoxicated or smelled of alcohol and it required that the MD was notified. The Administrator stated that monitoring of a resident did not require constant visual contact and every two hours check on the resident was nursing practice. The Administrator stated that R#1 had issues with alcohol. The Administrator stated that it was not the first time the resident appeared to use alcohol in the past; but the resident was not a sexual predator. The Administrator stated that in the past the facility would allow the resident back into his room; but there were no documented interventions for R#1's use of alcohol. The Administrator stated the nursing staff based on history believed the resident would remain in his room. The Administrator stated, It did not rise to the level of one-on-one .we let him stay in his room .cannot explain what was going through his head .there was no indication he was going to do this . The Administrator stated that there was no indication that R#1was a danger to self or others requiring constant one on one monitoring. The Administrator stated, after the incident preventative measures put in place included: non-verbal residents were assigned roommates; R#1 was arrested. Staff completed 100 % in-service on abuse and neglect. The Administrator stated a head-to-toe assessment was done on all non-verbal residents. R#1 was assigned a temporary roommate and moved closer to the nurse station. <BR/>During telephone interview on 12/03/24 at 2:25 PM, Law Enforcement Officer F stated that R#1 was arrested on 05/04/24 for public intoxication and was a suspect for sexual abuse of R#2.<BR/>During telephone interview on 12/03/24 at 5:00 PM, LVN A stated the timeline was: she and LVN B escorted R#1 into the facility on [DATE] around 8:30 PM. R#1 was intoxicated and belligerent and refused an assessment. The ADON [LVN E] and MD were called. The ADON recommended to LVN A and LVN B to call law enforcement. Pending the arrival of law enforcement R#1 was taken to his room in Hall 300. LVN A stated that she returned to her duties in another hall and expected LVN B to monitor R#1. LVN A stated that when the resident [R#1] was not found in his room around 9:30 PM, she participated in the search of R#1. LVN A stated that around 9:45 PM, R#1 was found in R#2's room by CNA C. <BR/>During a telephone interview on 12/4/24 at 8:00 PM, CNA C, (employed for 9 weeks), stated,: on 05/4/24 she was in another hall doing ADL care for a resident. She responded to LVN A's request at 9:30 PM to assist in the search for R#1 in Hall 300. CNA C stated she found R#1, at 9:45 PM, in R#2's room kneeling on the floor mat and having in his mouth R#2's breast. CNA C startled R#1 and he stopped the behavior and said nothing about the incident. CNA C requested nursing assistance and R#1 was escorted to his room and monitored one-on-one until law enforcement arrived.<BR/>Record review of written statement dated 05/04/24 authored by CNA C stated: around 9:30 PM, LVN A walked in the facility with paramedics in search of R#1. LVN A stated that R#1 was not in his room (room [ROOM NUMBER]) and a search was started and R#1 was found in R#2's room where I (CNA C) witnessed [R#2] asleep in bed with her eyes closed and [R#1] on his knees on the floor mat kneeling over [R#2] with her shirt up .I loudly said, what are you doing? [R#1] at this time removed his mouth off [R#2's] left breast . LVN A and LVN B were informed of the incident. CNA C stayed with R#1 until he was escorted by the police out of the facility. <BR/>Record review of LVN B's written statement undated reflected: R#1 was escorted to facility by [LVN A] given the resident had fallen outside. R#1 was under the influence of alcohol and refused an assessment and was belligerent. LVN B called the ADON and was directed to call 911. LVN B stated, By the time the police arrived, and fire dept. arrived patient went out of his room. The resident was found in R#2's room. <BR/>Record review of R#1's Nurse note dated 05/05/24 by LVN B repeated the same information as the written statement namely: R#1 was escorted to facility by [LVN A] given the resident had fallen outside. R#1 was under the influence of alcohol and refused an assessment and was belligerent. LVN B called the ADON and was directed to call 911. LVN B stated, By the time the police arrived, and fire dept. arrived patient went out of his room. The resident was found in R#2's room. <BR/>Observation on 12/05/24 at 1:45 PM to 1:52 PM of Snap shots from the Administrator's iPhone reflected that at 20:30 (8:30 PM) R#1 was at the nurse station near hall 300. Next snapshot reflected that R#1 came out of his room at 21:27 (9:27 PM). No other snapshots were provided by the Administrator after R#1 exited his room at 9:27 PM. <BR/>During an interview on 12.05/24 at 1:52 PM, after observing the snap shots with the administrator, the administrator stated: from 8:30 PM to 9:27 PM the resident was being monitored by nursing staff. The Administrator stated that based on the CNA's note (CNA C) the resident had left his room between 9:30 PM to 9:45 PM. Administrated stated, based on CNA C's written statement, R#1 was found at 9:45 PM in R#2's room involved in an inappropriate sexual behavior. The Administrator stated that no documentation existed that the facility did 15-minute checks from 8:30 PM to 9:27 PM. [surveyor requested evidence that 15-minute checks were done and documented on 05/04/24 because the facility stated 15 minutes checked were done.].<BR/>Record review of the facility's Abuse policy dated April 2001 read: <BR/>2. <BR/>Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.<BR/>a <BR/>Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that<BR/>are necessary to attain or maintain physical, mental, and psychosocial well-being.<BR/>b. <BR/>Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.<BR/>c. <BR/>Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .<BR/>3. <BR/>Sexual abuse is non-consensual sexual conduct of any type with a resident.<BR/>a. <BR/>Sexual contact with a resident who lacks the cognitive ability to consent is considered non-consensual and therefore, constitutes abuse.<BR/>b. <BR/>Consent that is obtained through intimidation, coercion or fear is not valid.<BR/>c. <BR/>The resident's capacity to consent to sexual conduct is carefully evaluated as part of the initial assessment and care planning process.<BR/>Verification of PNC<BR/>Observation on 12/05/24 at 9:50 AM, R#2 was in her room, door open, sitting on a special W/C facing TV (TV was on). R#2 was not alert or oriented. Resident was clean, no smell of odors. There was no signs of pain or distress. Resident did not have a roommate.<BR/>Observation on 12/05/24 from 3:00 PM-3:15 PM reflected three residents with dementia and a BIMS of zero and could not communicate had a roommate that was alert and oriented. <BR/>During interviews on 12/03/24 from 11:00 AM to 12/04/24 to 9:30 AM, 9 day shift staff 1 (7 AM-3 PM) (1 SW, 5 LVN, 2 CNA, and 1 Housekeeper), and 2 staff evening shift (3 PM-11PM) and 2 nigh shift staff (2 LVN) reflected return demonstration on abuse and neglect with the highlight to report any act or suspicion of abuse or neglect to the Abuse Coordinator, the Administrator.<BR/>Record review of facility's investigation file reflected: <BR/>HHS contacted on 5/4/24 at 11:45 PM; incident occurred on 05/05/24 at 10:30 PM. t R#2 was assessed and showed no signs and symptoms of injuries or change of conditions or behaviors. R#1 was immediately discharged from the facility. Inservice training was started 05/05/24 and ended 11/25/24. <BR/>Police report # 24097970 was present; type of offense was PI. Head to toe assessment for all non-interview-able residents was completed. Interview with all verbal residents reflect no abuse. Lastly, alert, and oriented residents were placed with residents with dementia that could not communicate. <BR/>Record review of R#1's nurse note dated 5/5/24 authored LVN B reflected: law enforcement was called and Case # assigned (SAPD 24097970 officer #1786). R#2 was arrested for PI. <BR/>Record review of R#2's nurse note dated 05/04/24 at 10:50 PM, authored by LVN B, reflected resident was assessed and no negative findings. Q 15 minutes checks were initiated. <BR/>Record review of R#2's 72-hour 15 minutes monitoring sheet revealed checks were done every 15 minutes from 5/04/24 to 5/06/24 every shift.<BR/>Record review of R#2's nurse note dated 05/05/24 authored by LVN B reflected resident was sent to the ER for an assessment and returned the same day. <BR/>Record review of R#2's skin assessments dated 05/01/24 and 05/06/24 reflected skin intact. <BR/>Record review of R#2's pain assessment dated [DATE] reflected no distress, pain, or discomfort. <BR/>Record review of facility's assessment of resident safety sheets dated 05/04/24 reflected that 10 interview-able residents were interviewed, and all felt safe. <BR/>Record review of facility's staff roster dated 12/02/24 reflected 158 employees.<BR/>Record review of facility's abuse/neglect signed in sheets reflected 100 % of staff attended the training from 05/05/24 to 11/25/25 [total staff on 12/02/24 was 158]. <BR/>Record review of list provided by facility on 12/05/24 reflected three alert and oriented residents were placed with residents with dementia and a BIMs of zero and could not communicate. R#2 had no roommate.<BR/>Record review of facility's Abuse, neglect, Exploitation or Misappropriation policy, dated revised April 2021, reflected one was present and in effect and required staff to report incidents or suspicion of abuse and/or neglect. <BR/>The non-compliance was identified as PNC. The IJ began 05/04/24 and ended 11/25/24. The facility had corrected the non-compliance before the survey began.<BR/>At exit, the Administrator did not provide written evidence that on 05/04/24 from 8:30 PM to 9:27 PM the facility documented 15-minute checks for R#1 while resident was in his room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 2 residents (Resident #3 and #7) reviewed for care plans.<BR/>The facility failed to ensure proactive, measurable interventions were in place to address focus areas listed involving falls and other injuries for Residents #3 and #7. Different interventions were not identified after each fall to prevent future falls. <BR/>This failure could place residents at risk for not receiving proper care and services due to inaccurate or incomplete care plan interventions. <BR/>The findings included:<BR/>Record review of Resident #3's face sheet, dated 10/17/23, reflected a [AGE] year-old female initially admitted to facility 03/23/23 with the latest admission of 05/23/23. Resident #3's diagnoses included encephalopathy, unspecified (a term for any brain disease that alters brain function or structure), atherosclerotic heart disease of native coronary artery without angina pectoris (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), unspecified dementia (impaired ability to remember, think or make decisions that interferes with everyday activities), generalized anxiety disorder (excessive, and persistent worry and fear about everyday situations), muscle wasting and atrophy, and difficulty in walking, not elsewhere classified.<BR/>Record review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 2 indicating severe cognitive impairment and reception of hospice services. Section J1800 (Any Falls since Admission/Entry or Reentry or Prior Assessment) was coded 1 - Yes and J1900 (Number of Falls Since Admission/Entry or Reentry or Prior Assessment) was coded 1 - A. No injury. Under Section O - O0400 - Therapies - Item B - Occupational Therapy - 116 minutes of therapy was received with a Start Date of 09/11/2023 and Item C - Physical Therapy - 80 minutes of therapy was received with a start date of 09/01/2023. <BR/>Record review of Resident #3's Care Plan reflected:<BR/>- Focus: The resident is High risk for falls related to history of multiple falls prior to admission Date Initiated: 03/25/23 <BR/> - Goal: The resident will be free of falls through the review date. Date Initiated: 03/25/23 Target Date: 12/24/23. <BR/>- Interventions: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Date initiated: 03/25/23.<BR/>- Focus: The resident is high risk for falls related to dementia Date Initiated: 05/28/23 and revised on 06/05/23<BR/>- Goal: The resident will be free of falls through the review date. - Date Initiated: 03/25/23 Target Date: 12/24/23 <BR/>- Interventions: Anticipate and meet the resident's needs; Date Initiated: 05/28/23; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Date initiated: 05/28/23.<BR/>- Focus: 8/9/23 Resident had an actual unwitnessed fall with no injury noted Date Initiated: 08/09/23 <BR/>- Goal: Resident will remain free from injury through review date Date Initiated: 09/09/23 with Target Date: 12/24/23 <BR/>- Interventions: Assist resident from floor to w/c X 2; Educate on call light usage for assistance; Head to toe assessment; Notify MD, RP and ADON; Obtain vitals; Perform ROM Date Initiated 09/09/23<BR/>- Focus: The resident had an actual fall 08/29/23 unwitnessed fall no injuries Date Initiated: 08/30/23<BR/>- Goal: Resident will resume usual activities without further incident through the review date Date Initiated: 08/30/23 with a Target Date of 12/24/23.<BR/> - Interventions: Monitor/document report PRN x 72 h to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation; Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound Date Initiated: 08/30/23<BR/>- Focus: Resident had an actual witnessed fall with no injury Date Initiated: 10/15/23<BR/> - Goal: Resident will resume usual activities without further incident through the review date Date Initiated: 10/18/23 with a Target Date of 12/24/23<BR/> - Interventions: Continue interventions on the at-risk plan; Monitor/document report PRN x 72 h to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation; Take BP lying/sitting/standing x 1 in first 24 hr. Date Initiated: 10/16/23<BR/>-Focus: 05/15/23 Resident had injury to right hand due to propelling w/c and hand got <BR/>caught between wheel and chair. Dated Initiated: 05/17/23<BR/>-Goal: The resident will have no complications from right hand incident through the review date. Revision on: 05/17/23 Target Date: 12/24/23<BR/>-Interventions: Seek medical attention if resident complains of uncontrollable pain. Date Initiated: 05/17/23<BR/>Observation and interview on 10/19/23 at 2:25 PM, Resident #3's fall mats were observed on both sides of the bed and the bed was in the low position. Resident #3 stated she felt safe and said the care staff were fine. <BR/>2. <BR/>Record review of Resident #7's Face Sheet dated 10/17/23 documented resident initially admitted to facility 03/28/23 with the latest admission of 03/28/23. Resident #7's diagnoses included difficulty walking, muscle wasting and atrophy, unspecified dementia (impaired ability to remember, think or make decisions that interferes with everyday activities), unspecified lack of coordination, encounter for other orthopedic aftercare, and other specified disorders of bone density and structure. <BR/>Record review of Resident #7's Quarterly MDS dated [DATE] documented a BIMS score of 0 indicating severe cognitive impairment. <BR/>Record review of Resident #7's Care Plan revealed:<BR/>- Focus: 8/18/23- The resident has had an actual fall with no injury Date Initiated: 08/18/23 <BR/> - Goal: The resident will resume usual activities without further incident through the review date. Date Initiated: 09/05/23 Target Date: 12/06/23 <BR/>- Interventions: Monitor/document/report PRN x72h to MD for s/sx: Pain, bruises. Change in mental status. New onset: confusion, sleepiness, inability to maintain posture, agitation; Perform head to toe assessment; prn pain med as ordered Date initiated: 08/18/23<BR/>- Focus: 8/24/23- The resident has had an actual fall with no injury Date Initiated: 08/24/23 <BR/>- Goal: The resident will resume usual activities without further incident through the review date. Date Initiated: 09/05/23 Target Date: 12/06/23 <BR/>- Interventions: Monitor/document/report PRN x72h to MD for s/sx: Pain, bruises. Change in mental status. New onset: confusion, sleepiness, inability to maintain posture, agitation; Perform head to toe assessment; PRN PAIN MED AS ORDERED Date initiated: 08/24/23<BR/>During an observation with Resident #7 on 10/18/23 at 11:30 am, resident's bed was in the lowest position. Resident was not able to conversate at this time. Resident #7's RP was present. During an interview with Resident #7's RP on 10/18/23 at 11:30 am, resident was ambulatory prior to 07/31/23. Resident #7's RP revealed that resident had a history of falls. After resident changed rooms, RP reported that resident had received more care. <BR/>Interview on 10/20/23 at 9:46 AM, the MDS Nurse stated that when care plan meetings were held, the team discussed how they could prevent a fall and injury from happening again such as implementing fall mats. The MDS Nurse stated the DON and ADON wrote Acute Care Plans and that chronic conditions were her own responsibility. The MDS Nurse stated If we see an intervention is not working then we discuss what else can be implemented. The purpose of an intervention is what we do to keep it from happening again. The MDS Nurse further stated that falls and changes in condition were discussed in their morning meeting with the department managers and licensed nurses at shift change. The MDS Nurse further stated that the charge nurses were trained about how to access the care plan and stated, it would be important to have interventions in the care plan to make sure everyone knows the situation - if everyone is not aware of the situation, then they won't know what to do.<BR/>Interview on 10/20/23 at 11:32 AM, the CCO and DON were interviewed about the lack of measurable interventions in the care plans. The CCO stated the purpose of care plans was to make sure the facility is meeting the resident's needs and was a source of information for nurses. The CCO stated After a fall, we want to make sure of the cause and if needed, to do an SBAR . There should also be interventions and we should be updating interventions. It is important since this is the guide for the plan of care. The CCO further stated a PIP on care plans was completed on 10/19/2023. The CCO stated We make sure staff is following policy and ensuring the residents are safe. Interventions should include doing different things like use of fall mats, check medications, etc and when we exhaust all interventions, we should put we will try to prevent further falls. <BR/>Interview on 10/20/23 at 1:24 PM, the ADM stated the purpose of care plans was to identify the resident and indicate behaviors. The ADM stated the team gets together with the resident and family to discuss possible interventions and what may work for each resident. The ADM stated the current care plan interventions are more reactive than proactive and do not indicate actions being taken to keep the resident safe. <BR/>The care plan policy, titled Comprehensive Assessments and the Care Delivery Process, dated as revised December 2016 reflected: Comprehensive assessments will be conducted to assist in developing person centered care plans. Comprehensive Assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Monitoring results and adjusting interventions includes: Periodically reviewing progress and adjusting treatments; Continue to define or refine the objectives of specific treatments as well as overall care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. <BR/>The facility failed to ensure Resident #1's EMR reflected accurate wound care documentation on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024.<BR/>These deficient practices could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, computer dated 11/8/2024, revealed he was a [AGE] year old male with an initial admit date of 2/21/24 and readmitted on [DATE] with diagnoses which included cerebral vascular accident(cva-medical term for a stroke. When blood flow to a part of the brain is stopped.), left side affected, Diabetes Mellitus 2( the body has a problem regulating sugar and the way it uses it.),hyperlipidemia(abnormally high levels of fat in the blood, it can cause blocked arteries and can lead to serious health conditions),anxiety(excessive,persistent and uncontrollable worry and fear about everyday situations),dementia(deterioration in mental status),arterial sclerotic heart disease(plaque buildup in the artery walls. can cause conditions such as heart attack and peripheral artery disease(disorder of blood vessels can affect the legs,feet,brain and other organs.).<BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 13, which indicated cognitively intact.<BR/>Record review of Resident #1's Care plan dated 9/6/2024 with revision 10/10/2024 revealed the resident had a diabetic ulcer of the right lateral foot related to diabetes pressure ulcer or potential for pressure ulcer development. 10/15/24-Stage 4 decubitus left heel.<BR/>Record review of Resident #1's physician Order Summary Report dated 10/1/2024-10/31/2024 revealed the following wound treatment orders: Right foot diabetic ulcer proximal Phalanx of great toe: cleanse with normal saline, pat dry with 4 x 4 gauze,apply skin prep to peri wound apply santyl to wound bed, cover with calcium alginate and dry dressing every day shift.(start date 9/5/2024 dc date 11/3/2024). Wound care left heel deep tissue injury with open area:cleanse with normal saline and or wound cleanser,pat dry with 4 x 4 gauze, apply santyl nickel thick to wound bed,cover with calcium alginate and cover with bordered gauze dressing every day shift for wound healing.(start date 10/18/2024-10/31/24). (10/15-10/17/2024) Wound care left heel deep tissue injury with open area: cleanse with normal saline and or wound cleanser,pat dry with 4 x 4 gauze apply calcium alginate and cover with bordered gauze dressing every day shift for wound healing.<BR/>Record review of Resident #1's TAR (treatment administration record) for October 2024 revealed there were blank spaces for Resident #1's treatment administration for the following days:10/24/2024,10/26/2024,10/27/2024 and 10/31/2024.<BR/>Record review of facility staffing sheet for October 2024 revealed LVN A worked on 10/24/24 and Treatment Nurse worked on 10/26,10/27,10/31.<BR/>During an interview on 11/12/2024 at 10:15 am LVN A stated she worked on 10/24/2024 but forgot to sign (Resident #1's) TAR after doing Resident #1's treatment on his feet. She further revealed it was a very hectic day and she just did not go back and sign the sheet, but she did do his ordered treatments on his feet. She stated it was important to document when a treatment was done.<BR/>During an interview on 11/12/2024 at 10:35 am Treatment Nurse stated he worked on 10/26/24,10/27/24 and 10/31/2024 but forgot to sign (Resident #1's) TAR after doing Resident #1's treatment on his feet. He stated it was very important to document when a treatment was done so that it showed it was done. <BR/>During an interview on 11/12/2024 at 2:00 p.m. facility DON confirmed LVN A and Treatment Nurse did not document on the wound administration record on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024 for Resident #1. The DON stated the treatments were most likely done but were not documented. Further interview with [NAME] revealed it was her expectation for staff to document in the electronic record of each resident whenever a treatment was done.<BR/>Record review of the facility's policy titled Charting and Documentation dated 2001 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response of care. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided and the name and title of the individual who provided the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs 2 of 10 resident rooms (Resident #328 and Resident #26) reviewed for call lights, in that:<BR/>The facility failed to ensure Resident #328's and Resident #26's call light were within reach and placed for easy access.<BR/>The deficient practice could place residents at risk of not receiving care or attention when needed. <BR/>Findings included:<BR/>1. Record review of Resident #328's face sheet, dated 11/17/23, revealed the resident was originally admitted to the facility on [DATE] with diagnoses which included: dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities).<BR/>Record review of Resident #328's MDS assessment, dated 11/07/23, revealed the resident's BIMS score was 12/15, which indicated moderate cognitive impairment. The resident needed help with self-care (bathing, dressing, eating, or using the toilet). <BR/>Record review of Resident #328's care plan revealed Resident #328 had a focus of This resident has an ADL self-care performance deficit r/t UNSPECIFIED DEMENTIA and interventions reflected to Encourage the resident to use bell to call for assistance. <BR/>During an interview and observation on 11/14/23 at 11:01 AM, Resident #328's call light was on the floor, in the middle of the room, against the wall where the call lights are connected to their respective plugs. Resident #328 reported not knowing where his call light was. <BR/>During an interview and observation on 11/14/23 at 11:05 AM, CNA L picked up the call light from the floor and tied it to the bed frame where it was within reach of Resident #328. The CNA L revealed that someone else may have left the call light on the floor because she usually tied the call light cord around the resident's bed frame. The CNA L revealed that Resident #328 may end up on the floor because the resident was fidgety, however, if this was the case, the call light would have been next to his bed, on the floor, and not where she found it. <BR/>2. Record review of Resident #26's face sheet, dated 11/17/23, revealed the resident was originally admitted to the facility on [DATE] with diagnoses which included: dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities), lack of coordination, muscle wasting and atrophy, and muscle weakness.<BR/>Record review of Resident #26's MDS assessment, dated 9/2/23, revealed the resident's BIMS score was 9/15, which indicated moderate cognitive impairment. The resident was dependent on toileting hygiene. The resident needed partial/moderate assistance for lying to sitting on side of bed, sit to stand, and sit to lying. <BR/>Record review of Resident #26's care plan, revised 9/19/2022, revealed Resident #26 had a focus of [Resident #26] is high risk for falls . and interventions reflected to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. <BR/>During an interview and observation on 11/14/23 at 3:33 PM, CNA M placed Resident #26's call light within in their reach. CNA M had to pick up the call light that was on the floor, in between the wall and head of the bed frame, out of reach. CNA M resident revealed that call lights should be near all of the residents. CNA M revealed that Resident #26 used her call light to let staff know when she is wet. <BR/>During an interview on 11/14/23 starting at 6:26 PM, the ADM revealed that every shift call lights were to be checked that they functioned and that they were within reach of the residents to ensure the safety of the residents. <BR/>Record Review of the facility's Answering the Call Light policy, revised September 2022, revealed under General Guidelines, 5. Ensure that the call light is accessible to the resident when in bed . <BR/>Record Review of the facility's Call System, Resident policy, September 2022, revealed under Policy Interpretation and Implementation, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed the facility failed to ensure that residents had the right to a safe, clean, and comfortable homelike environment for 2 of 7 Residents (Resident #67 and Resident #103) whose rooms and equipment were checked.<BR/>1. The MS failed to repair Resident #67's room door and the bathroom door so they did not stick making it difficult to open; and failed to clean the air vent in the Resident's bathroom.<BR/>2. The MS failed to ensure Resident #103's wheelchair armrests were replaced and the wheelchair was free of debris and build up.<BR/>These deficient practices could affect residents in the women's and men's secured unit and could place them at risk of dissatisfaction of their environment.<BR/>The findings were:<BR/>1. Review of Resident #67's face sheet, dated 9/18/22, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia with behavior disturbance, unspecified Psychosis not due to a substance or known physiological condition and Bipolar disorder.<BR/>Observation and interview on 09/20/22 at 11:15 AM in Resident #67's room revealed the entry door would get stuck and was hard to open and the bathroom door was also difficult to open. Further observation revealed a vent on the wall by the ceiling in the right hand side of the bathroom was black inside and along the outer edges on the wall. Resident #67's family member stated she told the MS about the doors sticking and the dirty air vent last week. She stated nothing had been done.<BR/>Interview on 09/22/22 at 09:10 AM with the MS revealed he made daily rounds of resident rooms and would make notes of anything needing repair; anything residents or staff brought to his attention. He stated he also had an automated program in place that he used as a guide for rotating maintenance of facility equipment. The MS stated Resident #67's family member told him last week about the door to the room and the bathroom door sticking and they were hard to open. He stated he did not remember her saying anything about a dirty air vent. The MS stated he had a to do list and made repairs in the order they were reported or according to priority. The MS stated he should have given the doors a higher priority because they could be a safety hazard to Resident #67 who was in the women's secured unit. <BR/>Interview on 09/22/22 at 04:10 PM with the MS revealed he stated the inside of the air vent in Resident #67's bathroom was black inside and along the outer edges on the wall. He stated the air vent was dirty he had not noticed it during rounds but cleaned it earlier on this date. <BR/>2. Review of Resident #103's face sheet, dated 9/22/22, revealed he was admitted to the facility on [DATE] with diagnoses including other specified disorders of the brain, Cerebral vascular disease and unspecified Dementia, unspecified severity w/o behavior disturbance, psychotic disturbance, mood disturbance and anxiety disturbance.<BR/>Review of Resident #103's quarterly MDS, dated [DATE], revealed his BIMS score was 01 indicating severe cognitive impairment.<BR/>Observation and interview on 09/20/22 at 04:46 PM revealed Resident #103 sitting in his wheelchair in the dining room in the men's secured unit. The right armrest did not have a cushion and the left armrest was peeling off around the edges. The wheelchair frame and wheels had built up residue. Resident #103 presented as being very confused and did not answer any questions. CNA H stated she started working at the NF 1 month ago and the wheelchair looked cleaner then. CNA H stated the cushion to the right armrest was missing and the left armrest was peeling around the edges. She stated the wheelchair looked very dirty. CNA H stated she thought the MS power washed the wheelchairs once a month but was not sure. She stated Resident #103 often spilled his food while eating. <BR/>Observation and interview on 09/21/22 at 4:30 PM revealed Resident #103 sitting in his wheelchair in the dining room in the men's secured unit. The right armrest did not have a cushion and the left armrest was peeling off around the edges. The wheelchair frame and wheels had built up residue. LVN C stated the wheelchair was filthy and the right armrest was missing. LVN C also stated the MS was responsible for ensuring all resident wheelchairs were power washed. LVN further stated she had not noticed the condition of the wheelchair.<BR/>Interview on 09/22/22 at 09:10 AM with the MS revealed he made daily rounds of resident rooms and would make notes of anything needing repair; anything residents or staff brought to his attention. He stated he also had an automated program in place that he used as a guide for rotating maintenance of facility equipment. He stated nursing staff told him about Resident #103's wheelchair on 9/21/22. He believed the wheelchair belonged to Hospice but stated Resident #103 was not on Hospice. The MS stated he was not sure where the wheelchair came from but confirmed the wheelchair had a missing armrest and it was dirty. The MS stated resident's wheelchairs were power washed on a rotating and monthly basis. He stated he had an assistant and they checked the wheelchair in the men's secured unit at the beginning of the month (September 2022) and did not notice the condition of Resident #103's wheelchair. The MS also stated he would replace the armrests as needed. <BR/>Review of facility policy, Cleaning and Disinfecting of Resident Care Items and Equipment, revised August 2019, read in part: Resident care equipment including reusable items and durable medication equipment will be cleaned and disinfected according to CDC recommendations for disinfection. c. Non-critical items are those that come in contact with intact skin but not mucous membrane.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 7 Residents (Resident #77 ) whose rooms were observed for safety hazards.<BR/>Two bottles of cleansers were found in Resident #77's bathroom on top of the safety grab bar by the toilet.<BR/>This deficient practice could affect residents in the women's secured unit and could place them at risk of having serious avoidable accidents.<BR/>The findings were:<BR/>Review of Resident #77's face sheet, dated 9/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included unspecified Dementia with behavior disturbance, Anxiety disorder, unspecified Psychosis not due to a known substance or known physiological condition and Schizophrenia (a serious mental disorder in which people interpret reality abnormally).<BR/>Review of Resident #77's admission MDS, dated [DATE] revealed her BIMS score was 00 indicating severe cognitive impairment. Further review revealed Resident #77 required supervision, oversight or cueing by 1 person physical assist for locomotion on the unit and set up help only for toileting . Further review revealed Resident #77 did not use any devices for mobility. <BR/>Review of Resident #77's Care Plan, dated 7/30/22, revealed Resident #77 required ADL assistance related to confusion, Dementia, history of wandering and impaired cognition. Further review revealed Resident #77 required assistance with toileting by 1 to 2 staff. <BR/>Observation on 09/21/22 at 12:28 PM in Resident 77's bathroom revealed two plastic bottles with cleaning chemicals in them on top of the safety grab bar by the toilet. One of the labels on the plastic bottle read in part: Odor Couteractant Concentrate for Professional Use: Warning Harmful if swallowed. Keep out of the reach of children. The label on the second plastic bottled read in part: Crew Clinging Toilet Bowl Cleaner. Keep out of Reach of Children Danger: If swallowed call Poison Control Center immediately and doctor. <BR/>Interview on 09/21/22 at 12:30 PM with LVN G revealed Resident #77 was very confused. She stated the cleansers could be a safety hazard and harmful to the Resident if ingested. LVN G further stated most of the resident's in the women's secured unit including Resident #77 wandered in and out of each other's rooms. She stated the chemicals presented a potential safety hazard for any resident who wandered into Resident #77's room. LVN G stated the housekeeper must have left them because she had just left the unit. LVN G further stated that although staff closely supervised the residents in the unit they could not guarantee supervision at all times.<BR/>Interview on 09/21/22 at 1:30 PM with the DON revealed she was aware about the two plastic bottles of cleaning chemicals left in Resident 77's bathroom. She stated the chemicals could harm the residents if ingested and it could potentially be fatal. The DON stated nursing staff knew they should be vigilant about safety hazards in the secured unit.<BR/>Review of facility policy, Secured Memory Care Neighborhood undated read in part: Policy: To provide a safe environment for all residents living in the secure memory care unit. To prevent accidents related to wandering and cognitive disability.<BR/>Review of facility policy, Safety and Supervision of Residents revised July 2017 read in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. 2. Safety risks and environmental hazards are identified on an on-going basis through a combination of employee training, employee monitoring and reporting processes. 4. Employees shall demonstrate competency on how to identify and and report accident hazards and try to prevent avoidable accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 resident (Resident #63) reviewed for respiratory care.<BR/>Facility failed to clean and replace the filter for Resident #63's oxygen concentrator.<BR/>This deficient practice could affect residents who receive oxygen therapy which could contribute to respiratory infections.<BR/>The findings were: <BR/>Record review of Resident #63's face sheet, dated 11/14/2023, revealed Resident #63 was admitted on [DATE] with an original admission date of 02/08/2019 with diagnoses which included: chronic obstructive pulmonary disease with (acute) exacerbation, acute bronchitis, generalized anxiety, acute respiratory failure with hypoxia, personal history of other disease of the respiratory system and dependence on supplemental oxygen. <BR/>Record review of Resident #63's Quarterly MDS, dated [DATE], revealed Resident #63's BIMS score was 15 with intact cognition with section O Special Treatments, Procedures and Programs of the MDS noting Resident #63 received oxygen therapy while a resident. <BR/>Record review of Resident #63's care plan with an initiated date of 03/23/2021 and a targeted date 12/24/2023, revealed Resident #63 had a Focus: [resident name] has oxygen therapy r/t COPD and Interventions: Clean Oxygen air filter and change oxygen tubing every Sunday.<BR/>Record review of Resident #63's physician order summary report, dated, 11/16/2023, revealed an order for Clean Oxygen air filter and change Oxygen tubing every Sunday every night shift every Sun. <BR/>Observation and interview on 11/14/2023 at 11:31 a.m. Resident #63's oxygen filter noted to have dust particles and white from lint like substance gathered on the filter. Resident #63 stated the nurse changed the tubing every Sunday, but he did not think there was a filter on the concentrator. <BR/>Observation and interview on 11/16/2023 at 3:50 p.m. Resident #63 was in his bed with oxygen being used watching television with bed in lowest position. Observation revealed Resident #63's filter in the same condition as prior observation with dust particles and covered in white lint like substance having not been changed or cleaned. During the observation LVN G revealed he was not sure when the filters for the concentrators were changed and did not know the protocol. LVN G further stated he would have to probably have to get another concentrator for the resident. <BR/>During an observation and interview on 11/16/2023 at 4:00 p.m. the ADM stated the filter looked like it needed to be cleaned. The ADM further stated he was not sure of the protocol regarding cleaning or changing the filter and he would get policy. <BR/>During an observation and interview on 11/16/2023 beginning at 4:05 p.m. the LVN G returned to Resident #63's and stated he did not know how to change the filter and again stated he may have to get another one to replace it. The DON entered Resident #63's room checked the filter on the oxygen concentrator then stated it looked as if it was a washable filter and should be cleaned. The DON stated the filter to the oxygen concentrator was dirty with a lint like substance on it. The DON further stated she felt the filter should have been cleaned when the tubing was changed once a week and as needed, but she would need to review the protocol.<BR/>During an interview on 11/17/2023 at 10:43 a.m. the ADM stated there was not a policy which address concentrators, however the facility followed the manufacture recommendations and provided recommendations. <BR/>During an interview on 11/17/2023 at 6:12 p.m. the DON stated by not cleaning or changing the filter of the oxygen concentrator it could cause the machine to malfunction, affect the quality of the air received by the resident and would not provide clean air. <BR/>Record review of oxygen manufacture recommendations, revealed, under Maintenance section 7.3 Cleaning the Cabinet Filter: Caution! Risk of Damage; To avoid damage to the internal components of the unit: -DO NOT operate the concentrator without the filter installed or with a dirty filter. 1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 3 of 3 residents (Resident #29, Resident #40, Resident #79) reviewed for dialysis in that:<BR/>The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #29, #40, and #79.<BR/>This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. <BR/>The findings were: <BR/>Record review of Resident #29's face sheet, dated 11/17/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with type 2 diabetes mellites, hyperlipidemia (elevated cholesterol), and Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (condition in which the kidneys cease functioning on a permanent basis).<BR/>Record review of Resident #29's most recent admission MDS assessment, dated 10/27/23, revealed the resident cognition was intact for daily decision-making skills and required dialysis treatments.<BR/>Record review of Resident #29's comprehensive care plan, revision date 11/03/23 revealed the resident needs hemodialysis related to end stage renal disease initiated on 08/05/23 with interventions Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. <BR/>Record review of Resident #29's Order Summary Report, dated 10/26/23 revealed the following:<BR/>- Resident receives Dialysis M,W,F . chair time is 11 am with order date of 09/25/23 and no end date.<BR/>- Resident has dialysis MWF @ 1050am with an order date of 11/10/23 and no end date. <BR/>- CHECK VITALS POST DIALYSIS every evening shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. <BR/>- CHECK VITALS PRE DIAYLSIS every shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. <BR/>Record review of Resident #29's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for: no date listed, 09/06/23, 09/13/23, 10/11/23, 10/16/23, 10/18/23, 10/30/23, 11/08/23, 11/13/23, and 11/15/23. The Post-Dialysis section of the Dialysis Communication form for the aforementioned dates were blank. The post assessment area on the form was to be completed by facility nurse upon return to the facility, requested: Blood pressure, respirations, pulse, temperature, pain, assessment of the AV site (area accessed for dialysis treatment), bruit/thrill (an abnormal sound that can be heard through an artery caused by turbulent blood flow due to narrowing of the artery, a blood clot or aneurysm. Thrill is an abnormal feeling that can be felt when palpating an artery) presence, bleeding, a nurse's signature, date and time. Various forms were also blank in the section for the dialysis center to fill out the resident's vitals and other pertinent information during dialysis.<BR/>Record review of Resident #40's face sheet, dated 11/17/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with type 2 diabetes mellites with hyperglycemia (high blood sugar), hyperlipidemia (elevated cholesterol), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), and dependence on renal dialysis.<BR/>Record review of Resident #40's most recent admission MDS assessment, dated 10/30/23, revealed the resident was severely cognitively impaired for daily decision-making skills and did not indicate the resident required dialysis treatments.<BR/>Record review of Resident #40's comprehensive care plan, revision date 05/02/23 revealed the resident needs hemodialysis related to renal failure initiated on 03/25/21 with interventions Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. Monitor AV shunt/fistula to site for thrill and bruit Q shift .<BR/>Record review of Resident #40's Order Summary Report, dated 10/26/23 revealed the following:<BR/>-Resident attends .dialysis clinic .Monday, Wednesday, and Friday chair time of 1030 with order date 11/10/23 and no end date.<BR/>- CHECK VITALS POST DIALYSIS every evening shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. <BR/>- CHECK VITALS PRE DIAYLSIS every shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date.<BR/>Record review of Resident #40's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for: no date listed, 09/06/23, 09/13/23, 09/20/23, 09/29/23, 10/16/23, 10/25/23, 11/10/23, and 11/13/23. The post assessment area on the form was to be completed by facility nurse upon return to the facility, requested: Blood pressure, respirations, pulse, temperature, pain, assessment of the AV site (area accessed for dialysis treatment), bruit/thrill (an abnormal sound that can be heard through an artery caused by turbulent blood flow due to narrowing of the artery, a blood clot or aneurysm. Thrill is an abnormal feeling that can be felt when palpating an artery) presence, bleeding, a nurse's signature, date and time. Various forms were also blank in the section for the dialysis center to fill out the resident's vitals and other pertinent information during dialysis.<BR/>Record review of Resident #79's face sheet, dated 11/17/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with type 1 diabetes mellites and chronic kidney disease. <BR/>Record review of Resident #79's most recent admission MDS assessment, dated 09/18/23, revealed intact cognition for daily decision-making skills and indicated the resident required dialysis treatments.<BR/>Record review of Resident #79's comprehensive care plan, revision date 11/10/23 revealed the resident needs hemodialysis related to renal failure initiated on 04/17/23 with interventions to Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. Assess shunt for any redness, swelling or pain.<BR/>Record review of Resident #79's Order Summary Report, dated 10/26/23 revealed the following:<BR/>-Renal Dialysis Monday, Wednesday, and Friday chair time 0530 with order date 07/05/23 and no end date.<BR/>- CHECK VITALS POST DIALYSIS every evening shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. <BR/>- CHECK VITALS PRE DIAYLSIS every shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date.<BR/>Record review of Resident #79's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for: 10/16/23, 10/23/23, 10/27/23, 10/30/23, 11/06/23, 11/08/23, and 11/13/23. The post assessment area on the form was to be completed by facility nurse upon return to the facility, requested: Blood pressure, respirations, pulse, temperature, pain, assessment of the AV site (area accessed for dialysis treatment), bruit/thrill (an abnormal sound that can be heard through an artery caused by turbulent blood flow due to narrowing of the artery, a blood clot or aneurysm. Thrill is an abnormal feeling that can be felt when palpating an artery) presence, bleeding, a nurse's signature, date and time. Various forms were also blank in the section for the dialysis center to fill out the resident's vitals and other pertinent information during dialysis. <BR/>During an interview on 11/16/23 at 1:50 p.m. the DON stated they already had a plan of correction started for the dialysis communication forms. The DON stated they were in contact with the dialysis facilities to fill out their portion of the communication form. The DON stated facility staff is expected to fill out the communication form prior to dialysis and upon return from dialysis. The DON stated one dialysis center stated they had began logging if they received a communication form with the residents upon arrival for dialysis. The DON stated she stated doing an in service on November 13th, 2023 and LVN O had already completed it. The DON stated she had not yet in serviced the night shift nurses. <BR/>During an interview on 11/16/23 at 1:58 p.m. LVN O stated he looked at resident #29 upon return from dialysis to the facility on [DATE]. LVN O stated looking at the resident meant he took the residents vitals and assessed the resident but did not document the findings. <BR/>Record review of a nursing progress note, created on 11/16/23 at 2:18 p.m., revealed an effective date of 11/15/23 at 2:45 p.m. and stated Resident arrived at approx. 1045, BP 141/68, P 74, R 18, T 97.6, 96% RA, pt. denies pain, pressure dressing to LUE at HD site, bruit is audible, thrill is palpable, resident is assisted to bed, is assessed for BM incont. episode, is then up to power chair. [Resident] then proceeds to sign self out d/t goes off property to go smoke . The note was created by LVN O. <BR/>During a follow up interview on 11/17/23 at 9:19 a.m. The DON stated the facility did not have a dialysis policy. <BR/>Record review of document titled Performance Improvement Plan Pre-Post Dialysis Communication, dated 11/13/23, stated Pre-Post Dialysis Communication to include pre-post dialysis weight, V/S and medications administered and treatment provided to include but not limited to fluid removed and duration of dialysis has been identified as an area of improvement. DON/designee to in-service nursing department on filling the dialysis communication form to include all of the above upon transfer to dialysis and upon returning to the facility. Document will be maintained as part of the medical record. Ongoing visual observation of compliance will be done daily on dialysis days by DON/designee and document will be made part of medical record. Failure to receive the communication document, DON will contact the DON of dialysis center to obtain information needed for compliance. The document was signed by LVN O.

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 the facility's only kitchen.<BR/>The 3-compartment sink was not maintained in working condition.<BR/>Undercooked eggs were served to residents.<BR/>These deficient practices could affect residents who ate from the kitchen and could contribute to food-borne illnesses.<BR/>The findings include:<BR/>In an observation on 09/19/22 at 9:43 AM, the 3-compartment sink was revealed to be draining shortly after being filled.<BR/>In an observation and interview on 09/19/22 at 1:02 PM revealed when [NAME] B added water to the first compartment of the 3-compartment sink, the water started to drain out. [NAME] B stated when he filled the first compartment up, the water will drain down to being half full in a short while. He showed the surveyor the water coming out of the drainpipe underneath the 3-compartment sink.<BR/>In an interview on 09/19/22 at 01:12 PM, the DM stated he would provide a work order for the 3-compartment sink.<BR/>Record review of a maintenance work order titled sink drain leaking revealed the order was created on 09/18/2022 3:53 PM by the Maintenance Director and the order was fulfilled on 09/20/2022 at 9:17 AM by the Maintenance Director. Additionally revealed was the request was submitted by the DM with work order #9546 with a priority setting of Medium.<BR/>In an interview on 09/19/22 at 2:29 PM, the Maintenance Director stated he was told by the kitchen the 3-compartment sink was not operating and proceeded to create a work order and then fix the equipment.<BR/>In an observation of the kitchen on 09/20/22 at 02:04 PM, the following was noted: The 3-compartment sink was observed to be operating, with a small stream of water draining from the first compartment. Eggs within the walk-in refrigerator had white, unmarked eggshells within a container that stated, Fresh Shell Eggs, USDA AA Grade, Wholesome Farms, and 9/17 on the box. Within the container, approximately 9 of 48 eggs were observed to have broken shells and atop a wet paper egg tray.<BR/>In an interview on 09/20/22 at 02:26 PM the DM stated he had never had concern with using unpasteurized eggs. He stated he had instructed his staff to make only eggs that will be completely cooked both ways with a mechanism that will cook both sides, describing a hard egg.<BR/>In an interview on 09/20/22 at 04:06 PM, the Dietician stated the facility ordered pasteurized eggs, but recently since they're being sent unpasteurized eggs, they are not to use them whatsoever. The Dietitian stated that if the facility received unpasteurized eggs, the kitchen was not to use the eggs even indirectly. She stated there was at least 1 resident who had requested over-easy eggs.<BR/>In an interview on 9/21/2022 at 8:25 AM, Resident #41 stated she understood fried eggs or sunny side up eggs to mean eggs with a liquid yoke. Resident #41 stated she had asked for sunny side eggs but received scrambled eggs this morning. Resident #41 stated she had sunny side eggs the day prior [9/20/2022]. Resident #41 stated she had sunny side up eggs approximately once or twice a week.<BR/>In an interview on 9/21/2022 at 8:50 AM, Resident #51 stated eggs sunny side up meant an egg where one would use toast to soak up the liquid yoke. Resident #51 stated that he received sunny side up eggs yesterday [9/20/2022] to the best of his recollection. Resident # 51 stated he was not sure, but thought he had sunny side up eggs a few times in the last month but also stated that he had memory problems. Resident #51 stated he would not ever turn down eggs with a runny yoke. Resident #51 stated he received scrambled eggs for breakfast this morning, but he preferred eggs sunny side up.<BR/>In an interview on 09/21/22 at 9:30 AM, Resident #308 stated she gets her eggs as over-easy and sunny side up where the yolk is runny.<BR/>In an interview on 09/21/22 at 9:36 AM, Resident #310 stated he gets his eggs over easy, but the yolk is firm and hard<BR/>In an interview on 09/21/22 at AM, Resident #312 stated he gets his eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 9:42 AM, Resident #314 stated she gets her eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 9:45 AM, Resident #413 stated he gets his eggs scrambled, but will also like his eggs over easy and that the yolk is runny.<BR/>In an interview on 9/21/2022 at 9:45 AM, Resident #25 stated he liked sunny side up eggs with a runny [liquid] yoke. Resident # 25 stated he had sunny side up eggs for breakfast the day prior [9/20/2022]. Resident #25 stated he had sunny side up eggs a few times in the past month.<BR/>In an interview on 09/21/22 at 9:57 AM R#421A stated she gets her eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 10:02 AM R#123A stated she gets her eggs scrambled but sometimes over easy but the eggs are firm and hard<BR/>In an interview on 09/21/22 at 10:19 AM R#127A stated he gets his eggs scrambled but if it's not scrambled, it's firm all the way through<BR/>In an interview on 09/21/22 at 03:18 PM, the DM stated the 3-compartment sink was reported to him on 09/17/2022 by [NAME] A, and that same day the DM reported the work order request to the Maintenance Director verbally. The DM stated the protocol for equipment that was not operating to manufacturer specifications would be to stop using the equipment immediately and to report the malfunctioning equipment immediately.<BR/>In an interview on 09/21/22 at 03:22 PM, The DM stated the fried egg that is made is cooked both sides. The DM stated that an over-easy egg is one where it is runny. He stated the last time R#314-B had an over-easy egg was 10-15 days ago. The DM stated that R#128-A told him a month and a half ago, he was told that the resident was telling her she does not like hard eggs. The DM stated that the Dietician has not stated he cannot use unpasteurized eggs.<BR/>In an interview on 09/22/22 at 11:20 AM, the DON stated she is unaware if the kitchen has made undercooked eggs<BR/>In an interview on 09/22/22 at 11:21 AM, the DON stated she was not aware of the risks associated with using unpasteurized eggs. The DON stated the risks associated with undercooked eggs would be salmonella, or other foodborne illness. The DON stated that nausea or vomiting would be to call the physician, and such a CoC would be completed.<BR/>In an interview on 09/22/22 at 11:34 AM, the Admin stated he was unaware if the residents have requested undercooked eggs for meals. The Admin stated he was aware that the kitchen has received unpasteurized eggs and has ordered them. The Admin stated his expectation for the kitchen once received a substitution for eggs, they are to decline it. The Admin stated the policy for having only unpasteurized eggs would be to cook the eggs thoroughly.<BR/>In an interview on 09/22/22 at 11:37 AM, the Admin stated that he was unaware of a previous deficiency related to the 3-compartment sink. The Admin stated his expectation when equipment was malfunctioning was for the DM to report the equipment as not operating and was to do so either verbally, in paper, or online in the electronic work order system. The Admin stated the risk associated with the 3-compartment sink not operating would be the that the potential for disinfecting not being completed properly. The Admin stated the facility does not have policy for the 3 compartment sink or kitchen equipment.<BR/>Record review of dietary order submitted on 09/20/2022 revealed a line item described as EGG SHELL LARGE GR AA USDA WHT from brand name WHLFCLS.<BR/>Record review of the facility's policy, undated, titled [The Facility] Egg Safety revealed that if a [facility] has a resident who prefers undercooked eggs . [The Facility] will use pasteurized eggs when available but if the facility uses unpasteurized eggs eggshells for individual resident consumption, those eggs must be cooked until both the yolk and white are completed firm and served immediately.<BR/>Record review of the United Stated Food & Drug Administration Food Code dated 01/01/2017 revealed only pasteurized eggs are used in recipes if eggs are undercooked and if eggs are combined, unless there is a cook step or HACCP plan to control Salmonella enteriditis within the section titled Highly Susceptible Population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. <BR/>The facility failed to ensure Resident #1's EMR reflected accurate wound care documentation on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024.<BR/>These deficient practices could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, computer dated 11/8/2024, revealed he was a [AGE] year old male with an initial admit date of 2/21/24 and readmitted on [DATE] with diagnoses which included cerebral vascular accident(cva-medical term for a stroke. When blood flow to a part of the brain is stopped.), left side affected, Diabetes Mellitus 2( the body has a problem regulating sugar and the way it uses it.),hyperlipidemia(abnormally high levels of fat in the blood, it can cause blocked arteries and can lead to serious health conditions),anxiety(excessive,persistent and uncontrollable worry and fear about everyday situations),dementia(deterioration in mental status),arterial sclerotic heart disease(plaque buildup in the artery walls. can cause conditions such as heart attack and peripheral artery disease(disorder of blood vessels can affect the legs,feet,brain and other organs.).<BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 13, which indicated cognitively intact.<BR/>Record review of Resident #1's Care plan dated 9/6/2024 with revision 10/10/2024 revealed the resident had a diabetic ulcer of the right lateral foot related to diabetes pressure ulcer or potential for pressure ulcer development. 10/15/24-Stage 4 decubitus left heel.<BR/>Record review of Resident #1's physician Order Summary Report dated 10/1/2024-10/31/2024 revealed the following wound treatment orders: Right foot diabetic ulcer proximal Phalanx of great toe: cleanse with normal saline, pat dry with 4 x 4 gauze,apply skin prep to peri wound apply santyl to wound bed, cover with calcium alginate and dry dressing every day shift.(start date 9/5/2024 dc date 11/3/2024). Wound care left heel deep tissue injury with open area:cleanse with normal saline and or wound cleanser,pat dry with 4 x 4 gauze, apply santyl nickel thick to wound bed,cover with calcium alginate and cover with bordered gauze dressing every day shift for wound healing.(start date 10/18/2024-10/31/24). (10/15-10/17/2024) Wound care left heel deep tissue injury with open area: cleanse with normal saline and or wound cleanser,pat dry with 4 x 4 gauze apply calcium alginate and cover with bordered gauze dressing every day shift for wound healing.<BR/>Record review of Resident #1's TAR (treatment administration record) for October 2024 revealed there were blank spaces for Resident #1's treatment administration for the following days:10/24/2024,10/26/2024,10/27/2024 and 10/31/2024.<BR/>Record review of facility staffing sheet for October 2024 revealed LVN A worked on 10/24/24 and Treatment Nurse worked on 10/26,10/27,10/31.<BR/>During an interview on 11/12/2024 at 10:15 am LVN A stated she worked on 10/24/2024 but forgot to sign (Resident #1's) TAR after doing Resident #1's treatment on his feet. She further revealed it was a very hectic day and she just did not go back and sign the sheet, but she did do his ordered treatments on his feet. She stated it was important to document when a treatment was done.<BR/>During an interview on 11/12/2024 at 10:35 am Treatment Nurse stated he worked on 10/26/24,10/27/24 and 10/31/2024 but forgot to sign (Resident #1's) TAR after doing Resident #1's treatment on his feet. He stated it was very important to document when a treatment was done so that it showed it was done. <BR/>During an interview on 11/12/2024 at 2:00 p.m. facility DON confirmed LVN A and Treatment Nurse did not document on the wound administration record on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024 for Resident #1. The DON stated the treatments were most likely done but were not documented. Further interview with [NAME] revealed it was her expectation for staff to document in the electronic record of each resident whenever a treatment was done.<BR/>Record review of the facility's policy titled Charting and Documentation dated 2001 revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response of care. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided and the name and title of the individual who provided the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure they maintained an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 Residents (Resident #207) who was observed for COVID-19 precautions.<BR/>Resident #207 whose vaccinated status was unknown for COVID-19 upon admission was not placed on isolation precautions.<BR/>This deficient practice could affect residents in the women's secured unit and could lead to the spread of infections.<BR/>The findings were:<BR/>Review of Resident #207's face sheet, dated 9/22/22, revealed he was admitted to the facility on [DATE] with diagnosis, unvaccinated for COVID-19.<BR/>Review of Resident #207's initial Baseline Advanced Care Plan, dated 9/15/22, revealed the Resident was not on transmission based precautions.<BR/>Review of a progress note, dated 9/15/22, did not address Resident #207's isolation status.<BR/>Review of Resident #207's physician orders for September 2022 revealed an order dated 9/19/22 for: Rapid COVID-19 test x 1 Now due to unvaccinated status.<BR/>Observation on 09/18/22 at 10:05 AM revealed #207 was in the common area along with 7 other residents in the women's secured unit. <BR/>Interview on 09/18/22 at 10:08 AM with LVN G revealed Resident #207 remained in the women's unit because he was not vaccinated or his vaccination status was unknown. She stated he was most recently admitted to the facility from the hospital and to her knowledge the Resident was named as his own responsible party. LVN G further stated Resident #207 was not transferred to the men's secured unit because at least one of the Resident's was diagnosed with COVID-19 and they did not want to place him at risk for exposure. However, LVN G stated it did not make any sense because he could be placing the women in the secured unit at risk for exposure due to his unknown vaccination status.<BR/>Observation and interview on 9/19/22 at 12:15 PM with ADON F revealed Resident #207 was still on the unit and was on isolation based on facility protocol. ADON F stated all new and unvaccinated admissions were placed on isolation. ADON F stated Resident #207's family member reported he was vaccinated but they had to secure his immunization record before releasing him from isolation. ADON F stated he added the PPE cart upon reporting to work this morning and stated Resident #207 was also supposed to be on 1 to 1 supervision in his room so that he did not wander out of his room. He stated the Resident was non-complaint about staying in his room. Observation, at this same time, revealed Resident #207's door to his room was closed. There was a sign to see the nurse before entering the room and a PPE cart was outside of his room. ADON F stated he understood staff was not following protocol yesterday (9/18/22) per administrative report and was aware Resident #207 was mingling with other residents in the women's secured unit and could place them at risk of potentially being exposed to COVID-19.<BR/>Interview on 09/19/22 at 05:05 PM with the ADM revealed Resident #207 was admitted from the hospital and stated he was placed on isolation and his isolation status should have been included on the nursing admission assessment. The ADM stated he learned staff did not place the Resident on isolation but stated that was the plan for Resident #207 upon admission. He stated a PPE cart should have been posted outside his door for nursing staff to access upon entering his room.<BR/>Interview on 09/19/22 at 05:23 PM with the DON revealed she talked with Resident #207's family member who told her the Resident had received both COVID vaccinations at two different facilities. She stated she called and spoke with a representative at both of facilities and a representative stated Resident #207 received a COVID vaccination at their facility. However, Resident #207's immunization record had not been secured. The DON stated Corporate Office instructed her to place the Resident on isolation until she received his immunization records and could ensure he was fully vaccinated. The DON stated Resident #207 was supposed to be placed on 1 to 1 supervision until his vaccination status was confirmed. <BR/>Interview on 09/20/22 at 02:29 PM with LVN G revealed Resident #207 was admitted on Thursday, 9/15/22, and was supposed to be placed on isolation precautions. She stated the admission nurse did not document the Resident's isolation status on a nurse's progress note or on the 24 hour report which she should have done. LVN G stated she was not sure why Resident #207 was in the women's secured unit and she inquired about it. She was informed it was because his COVID vaccination status was unknown. LVN G stated after the last interview with Surveyor, she read Resident #207's hospital records and talked with the DON. The DON stated he was supposed to be on isolation and on 1 to 1 supervision in his room. LVN G stated they Made him 1 to 1 supervision as best as they could but did not have the extra person to supervise him. LVN G stated she reached out to a family member, listed in Resident #207's hospital records, who said he had been vaccinated at two different facilities. LVN G stated Resident #207 was sent back out to the hospital on 9/19/22 related to abdominal pain. Further interview with LVN G revealed Resident #207's vaccination status was unknown at the time she talked with the DON.<BR/>Review of facility policy, Policies and Practices - Infection Control revised on October 2018 read in part: This facilities policies and practices are intended to manage transmission of diseases and infections. 2. The objectives of our infection control policies and practices are to a. prevent, detect, investigate and control infections in the facility. c. establish guidelines for implementing isolation precautions including standard and transmission based precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 of 12 residents (Residents #1 and #2) reviewed for pharmacy services and medication administration in that: <BR/>The facility failed to administer medications as prescribed for Residents #1 and #2.<BR/>This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. <BR/>The findings included:<BR/>Record review of the admission face sheet, dated 11/9/2023, reflected Resident #1 was a female initially admitted on [DATE], readmitted [DATE], with a diagnosis included: hypertensive heart disease without heart failure (high blood pressure without affecting the pumping action of the heart muscles), atherosclerotic heart disease of native coronary artery without angina pectoris (the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall without chest pain), peripheral vascular disease (slow and progressive circulation disorder), and essential hypertension (high blood pressure).<BR/>Record review of the care plan with a start date of 11/7/2023, reflected Resident #1 had a Focus of The resident has hypertension (high blood pressure) with associated intervention of: Give anti-hypertensive medications as ordered.<BR/>had a Focus of The resident has coronary artery disease r/t hypercholesterolemia with associated intervention of: Give all cardiac meds as ordered by the physician Give meds for hypertension <BR/>Record Review of Resident #1's Order Summary Report dated 11/9/2023 revealed: Isosorbide Dinitrate Oral Tablet 30 MG, Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE Hold if SBP less than 110, DBP less than 60 or HR less than 60 and NIFEdipine Oral Capsule 10 MG, Give 3 tablets by mouth one time a day for HTN Administer 3 tablets to equal total dosage of 30mg Hold if SBP less than 110, DBP less than 60 or HR less than 60<BR/>Record review of the MAR for Resident #1 from 10/1/2023 to 10/31/2023, reflected the following medications were administered outside of parameters:<BR/>Isosorbide Dinitrate Oral Tablet 30 MG, Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE Hold if SBP less than 110, DBP less than 60 or HR less than 60<BR/>*10/18/2023 0900: [SBP/DBP: 135/56 and HR: 48];<BR/>*10/22/2023 0900: [SBP/DBP: 121/71 and HR: 53];<BR/>*10/28/2023 0900: [SBP/DBP: 133/74 and HR: 52]<BR/>NIFEdipine Oral Capsule 10 MG, Give 3 tablets by mouth one time a day for HTN Administer 3 tablets to equal total dosage of 30mg Hold if SBP less than 110, DBP less than 60 or HR less than 60<BR/>*10/18/2023 0930: [SBP/DBP: 135/56 and HR: 48];<BR/>*10/29/2023 0930: [SBP/DBP: 120/70 and HR: 55]<BR/>Record review of the admission face sheet, dated 11/9/2023, reflected Resident #2 was a male initially admitted on [DATE], readmitted [DATE], with a diagnosis included: pulmonary heart disease, peripheral vascular disease.<BR/>Record review of the care plan reflected Resident #2 did not mention to Give all cardiac meds as ordered by the physician or Give meds for hypotension.<BR/>Record Review of Resident #2's Order Summary Report dated 11/9/2023 revealed: Midodrine HCl Oral Tablet, Give 15 mg by mouth three times a day for Hypotension Hold if SBP greater than 120.<BR/>Record review of the MAR for Resident #2 from 11/1/2023 to 11/9/2023, reflected, the following medication being administered outside of parameters on:<BR/>Midodrine HCl Oral Tablet, Give 15 mg by mouth three times a day for Hypotension Hold if SBP greater than 120<BR/>*11/1/2023 1100: [SBP 129];<BR/>*11/3/2023 2200: [SBP 136];<BR/>*11/9/2023 1100: [SBP 123]<BR/>During interview on 11/13/2023 at 10:14 AM, the ADON A revealed that Resident #1 was incorrectly given Isosorbide Dinitrate and Nifedipine on October 28th and 29th , confirming blood pressure was outside of parameters and should not have received heart medications. The ADON A further revealed that Resident #2 was incorrectly given Midodrine on October 26th, 28th, and 30th because blood pressure was outside of parameters. <BR/>During an interview on 11/13/2023 at 10:58 AM, the LVN A verified that Midodrine was administered to Resident #2 outside of blood pressure parameters on October 26th, 28th , and 30th. <BR/>During an interview on 11/13/2023 at 1:26 PM, the DON revealed that the nurses were administering heart medications outside of blood pressure parameters.<BR/>Record Review of Administering Medications policy, revised April 2019, reflected the following step in the preparation stage: 4. Medications are administered in accordance with prescriber orders . and 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that all visitors enjoy full and equal visitation privileges consistent with resident preferences for 1 of 5 residents (Resident #1) reviewed for Visitation Rights, in that:<BR/>The facility put stipulations on the form of Resident #1's visits with family members that went against the resident's choices. <BR/>This deficient practice could place residents at risk for decreased quality of life, depression, and isolation. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 10/30/2023, revealed the resident was admitted [DATE]. Resident #1's diagnoses included: major depressive disorder, schizophrenia, anxiety, and insomnia. <BR/>Record review of Resident #1's Quarterly MDS Assessment, dated 9/11/2023, revealed Resident #1 had a BIMS of 15 which indicated Resident #1 was cognitively intact. <BR/>Record review of Resident #1's care plan, with an effective date 8/30/2023, stated, (Resident #1) is independent in activities in room and out of room. (Resident #1) at times requires some encouragement to attend activities. Leads group activities, assists in facilitating BINGO, cooking class or other activities of choice. Assists others in playing or coming to activities. Very helpful personality to both residents and staff. Spends time with family often, frequent visits from family or visits to home. Has two (family members) who visit and (family member) provides with some of her needs. (Resident #1) signs herself out the facility as desired and shops for herself, others. (Resident #1) is President of the Resident Council meeting. Goals included, (Resident #1) will maintain involvement in cognitive stimulation, social activities as desired through review date. <BR/>Interview on 10/27/2023 at 10:31 AM, SW stated Resident #1 was one of the younger residents and was very helpful with activities. SW said Resident #1 was unhappy with her the last several days because SW required Resident #1 and her (family member) to meet in common areas due to allegations Resident #1's (family member) was coming into the facility and laying next to the resident and taking a shower in the facility, and also eating facility food. SW said she spoke to Resident #1's (family member) in law and said there may be some psychological issues with the Resident #1's (family member). SW indicated she told Resident #1 that she would prefer that if/when her (family member) visits that he do so in the common areas. SW also said there were times when Resident #1 would leave the facility but Resident #1's (family member) would stay at the facility at the time which was prohibited. <BR/>Observation and interview on 10/27/2023 at 10:48 AM, Resident #1 was observed in her bed. Resident #1 requested this investigator turn on her light and close the door so she could speak in private. Resident #1 said SW required Resident #1's (family member) only visit her in common areas because a staff alleged Resident #1's (family member) was eating facility food, spending the night and sleeping in the bed next to hers, and also taking showers in her room. Resident #1 said her (family member) checks on her because he worries about her and denied all allegations made by staff. Resident #1 expressed that she should be able to meet with her (family member) in her own room as she does not have a roommate. <BR/>Record review of facility policy, titled, Visitation, revised 2/2021, stated, 2. The facility provides 24-hour access to individuals visiting with the consent of the resident. Some visitation may be subject to reasonable restrictions that protect the safety, security and/or rights of the facility's residents . 9.All visitors are given full and equal visitation privileges consistent with resident preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 2 residents (Resident #3 and #7) reviewed for care plans.<BR/>The facility failed to ensure proactive, measurable interventions were in place to address focus areas listed involving falls and other injuries for Residents #3 and #7. Different interventions were not identified after each fall to prevent future falls. <BR/>This failure could place residents at risk for not receiving proper care and services due to inaccurate or incomplete care plan interventions. <BR/>The findings included:<BR/>Record review of Resident #3's face sheet, dated 10/17/23, reflected a [AGE] year-old female initially admitted to facility 03/23/23 with the latest admission of 05/23/23. Resident #3's diagnoses included encephalopathy, unspecified (a term for any brain disease that alters brain function or structure), atherosclerotic heart disease of native coronary artery without angina pectoris (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), unspecified dementia (impaired ability to remember, think or make decisions that interferes with everyday activities), generalized anxiety disorder (excessive, and persistent worry and fear about everyday situations), muscle wasting and atrophy, and difficulty in walking, not elsewhere classified.<BR/>Record review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 2 indicating severe cognitive impairment and reception of hospice services. Section J1800 (Any Falls since Admission/Entry or Reentry or Prior Assessment) was coded 1 - Yes and J1900 (Number of Falls Since Admission/Entry or Reentry or Prior Assessment) was coded 1 - A. No injury. Under Section O - O0400 - Therapies - Item B - Occupational Therapy - 116 minutes of therapy was received with a Start Date of 09/11/2023 and Item C - Physical Therapy - 80 minutes of therapy was received with a start date of 09/01/2023. <BR/>Record review of Resident #3's Care Plan reflected:<BR/>- Focus: The resident is High risk for falls related to history of multiple falls prior to admission Date Initiated: 03/25/23 <BR/> - Goal: The resident will be free of falls through the review date. Date Initiated: 03/25/23 Target Date: 12/24/23. <BR/>- Interventions: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Date initiated: 03/25/23.<BR/>- Focus: The resident is high risk for falls related to dementia Date Initiated: 05/28/23 and revised on 06/05/23<BR/>- Goal: The resident will be free of falls through the review date. - Date Initiated: 03/25/23 Target Date: 12/24/23 <BR/>- Interventions: Anticipate and meet the resident's needs; Date Initiated: 05/28/23; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Date initiated: 05/28/23.<BR/>- Focus: 8/9/23 Resident had an actual unwitnessed fall with no injury noted Date Initiated: 08/09/23 <BR/>- Goal: Resident will remain free from injury through review date Date Initiated: 09/09/23 with Target Date: 12/24/23 <BR/>- Interventions: Assist resident from floor to w/c X 2; Educate on call light usage for assistance; Head to toe assessment; Notify MD, RP and ADON; Obtain vitals; Perform ROM Date Initiated 09/09/23<BR/>- Focus: The resident had an actual fall 08/29/23 unwitnessed fall no injuries Date Initiated: 08/30/23<BR/>- Goal: Resident will resume usual activities without further incident through the review date Date Initiated: 08/30/23 with a Target Date of 12/24/23.<BR/> - Interventions: Monitor/document report PRN x 72 h to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation; Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound Date Initiated: 08/30/23<BR/>- Focus: Resident had an actual witnessed fall with no injury Date Initiated: 10/15/23<BR/> - Goal: Resident will resume usual activities without further incident through the review date Date Initiated: 10/18/23 with a Target Date of 12/24/23<BR/> - Interventions: Continue interventions on the at-risk plan; Monitor/document report PRN x 72 h to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation; Take BP lying/sitting/standing x 1 in first 24 hr. Date Initiated: 10/16/23<BR/>-Focus: 05/15/23 Resident had injury to right hand due to propelling w/c and hand got <BR/>caught between wheel and chair. Dated Initiated: 05/17/23<BR/>-Goal: The resident will have no complications from right hand incident through the review date. Revision on: 05/17/23 Target Date: 12/24/23<BR/>-Interventions: Seek medical attention if resident complains of uncontrollable pain. Date Initiated: 05/17/23<BR/>Observation and interview on 10/19/23 at 2:25 PM, Resident #3's fall mats were observed on both sides of the bed and the bed was in the low position. Resident #3 stated she felt safe and said the care staff were fine. <BR/>2. <BR/>Record review of Resident #7's Face Sheet dated 10/17/23 documented resident initially admitted to facility 03/28/23 with the latest admission of 03/28/23. Resident #7's diagnoses included difficulty walking, muscle wasting and atrophy, unspecified dementia (impaired ability to remember, think or make decisions that interferes with everyday activities), unspecified lack of coordination, encounter for other orthopedic aftercare, and other specified disorders of bone density and structure. <BR/>Record review of Resident #7's Quarterly MDS dated [DATE] documented a BIMS score of 0 indicating severe cognitive impairment. <BR/>Record review of Resident #7's Care Plan revealed:<BR/>- Focus: 8/18/23- The resident has had an actual fall with no injury Date Initiated: 08/18/23 <BR/> - Goal: The resident will resume usual activities without further incident through the review date. Date Initiated: 09/05/23 Target Date: 12/06/23 <BR/>- Interventions: Monitor/document/report PRN x72h to MD for s/sx: Pain, bruises. Change in mental status. New onset: confusion, sleepiness, inability to maintain posture, agitation; Perform head to toe assessment; prn pain med as ordered Date initiated: 08/18/23<BR/>- Focus: 8/24/23- The resident has had an actual fall with no injury Date Initiated: 08/24/23 <BR/>- Goal: The resident will resume usual activities without further incident through the review date. Date Initiated: 09/05/23 Target Date: 12/06/23 <BR/>- Interventions: Monitor/document/report PRN x72h to MD for s/sx: Pain, bruises. Change in mental status. New onset: confusion, sleepiness, inability to maintain posture, agitation; Perform head to toe assessment; PRN PAIN MED AS ORDERED Date initiated: 08/24/23<BR/>During an observation with Resident #7 on 10/18/23 at 11:30 am, resident's bed was in the lowest position. Resident was not able to conversate at this time. Resident #7's RP was present. During an interview with Resident #7's RP on 10/18/23 at 11:30 am, resident was ambulatory prior to 07/31/23. Resident #7's RP revealed that resident had a history of falls. After resident changed rooms, RP reported that resident had received more care. <BR/>Interview on 10/20/23 at 9:46 AM, the MDS Nurse stated that when care plan meetings were held, the team discussed how they could prevent a fall and injury from happening again such as implementing fall mats. The MDS Nurse stated the DON and ADON wrote Acute Care Plans and that chronic conditions were her own responsibility. The MDS Nurse stated If we see an intervention is not working then we discuss what else can be implemented. The purpose of an intervention is what we do to keep it from happening again. The MDS Nurse further stated that falls and changes in condition were discussed in their morning meeting with the department managers and licensed nurses at shift change. The MDS Nurse further stated that the charge nurses were trained about how to access the care plan and stated, it would be important to have interventions in the care plan to make sure everyone knows the situation - if everyone is not aware of the situation, then they won't know what to do.<BR/>Interview on 10/20/23 at 11:32 AM, the CCO and DON were interviewed about the lack of measurable interventions in the care plans. The CCO stated the purpose of care plans was to make sure the facility is meeting the resident's needs and was a source of information for nurses. The CCO stated After a fall, we want to make sure of the cause and if needed, to do an SBAR . There should also be interventions and we should be updating interventions. It is important since this is the guide for the plan of care. The CCO further stated a PIP on care plans was completed on 10/19/2023. The CCO stated We make sure staff is following policy and ensuring the residents are safe. Interventions should include doing different things like use of fall mats, check medications, etc and when we exhaust all interventions, we should put we will try to prevent further falls. <BR/>Interview on 10/20/23 at 1:24 PM, the ADM stated the purpose of care plans was to identify the resident and indicate behaviors. The ADM stated the team gets together with the resident and family to discuss possible interventions and what may work for each resident. The ADM stated the current care plan interventions are more reactive than proactive and do not indicate actions being taken to keep the resident safe. <BR/>The care plan policy, titled Comprehensive Assessments and the Care Delivery Process, dated as revised December 2016 reflected: Comprehensive assessments will be conducted to assist in developing person centered care plans. Comprehensive Assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Monitoring results and adjusting interventions includes: Periodically reviewing progress and adjusting treatments; Continue to define or refine the objectives of specific treatments as well as overall care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 7 Residents (Resident #77 ) whose rooms were observed for safety hazards.<BR/>Two bottles of cleansers were found in Resident #77's bathroom on top of the safety grab bar by the toilet.<BR/>This deficient practice could affect residents in the women's secured unit and could place them at risk of having serious avoidable accidents.<BR/>The findings were:<BR/>Review of Resident #77's face sheet, dated 9/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included unspecified Dementia with behavior disturbance, Anxiety disorder, unspecified Psychosis not due to a known substance or known physiological condition and Schizophrenia (a serious mental disorder in which people interpret reality abnormally).<BR/>Review of Resident #77's admission MDS, dated [DATE] revealed her BIMS score was 00 indicating severe cognitive impairment. Further review revealed Resident #77 required supervision, oversight or cueing by 1 person physical assist for locomotion on the unit and set up help only for toileting . Further review revealed Resident #77 did not use any devices for mobility. <BR/>Review of Resident #77's Care Plan, dated 7/30/22, revealed Resident #77 required ADL assistance related to confusion, Dementia, history of wandering and impaired cognition. Further review revealed Resident #77 required assistance with toileting by 1 to 2 staff. <BR/>Observation on 09/21/22 at 12:28 PM in Resident 77's bathroom revealed two plastic bottles with cleaning chemicals in them on top of the safety grab bar by the toilet. One of the labels on the plastic bottle read in part: Odor Couteractant Concentrate for Professional Use: Warning Harmful if swallowed. Keep out of the reach of children. The label on the second plastic bottled read in part: Crew Clinging Toilet Bowl Cleaner. Keep out of Reach of Children Danger: If swallowed call Poison Control Center immediately and doctor. <BR/>Interview on 09/21/22 at 12:30 PM with LVN G revealed Resident #77 was very confused. She stated the cleansers could be a safety hazard and harmful to the Resident if ingested. LVN G further stated most of the resident's in the women's secured unit including Resident #77 wandered in and out of each other's rooms. She stated the chemicals presented a potential safety hazard for any resident who wandered into Resident #77's room. LVN G stated the housekeeper must have left them because she had just left the unit. LVN G further stated that although staff closely supervised the residents in the unit they could not guarantee supervision at all times.<BR/>Interview on 09/21/22 at 1:30 PM with the DON revealed she was aware about the two plastic bottles of cleaning chemicals left in Resident 77's bathroom. She stated the chemicals could harm the residents if ingested and it could potentially be fatal. The DON stated nursing staff knew they should be vigilant about safety hazards in the secured unit.<BR/>Review of facility policy, Secured Memory Care Neighborhood undated read in part: Policy: To provide a safe environment for all residents living in the secure memory care unit. To prevent accidents related to wandering and cognitive disability.<BR/>Review of facility policy, Safety and Supervision of Residents revised July 2017 read in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. 2. Safety risks and environmental hazards are identified on an on-going basis through a combination of employee training, employee monitoring and reporting processes. 4. Employees shall demonstrate competency on how to identify and and report accident hazards and try to prevent avoidable accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 1 Resident (Resident #78) whose records were reviewed for grievances.<BR/>The SW failed to write and follow up on Resident #78's grievance when he reported an expensive gold ring was missing.<BR/>This deficient practice could affect residents and place them at risk of their concerns being left unresolved and lead to misappropriations's of resident property.<BR/>The findings were:<BR/>Review of Resident #78's face sheet, dated 9/22/22, revealed he was admitted to the facility on [DATE] with diagnosis which included Cerebrovascular Disease.<BR/>Review of Resident #78's quarterly MDS, dated [DATE], revealed his BIMS score was an 8 indicating he had moderate cognitive impairment.<BR/>Review of Resident grievances from June 2022 to September 2022 did not reveal any grievances provided by Resident #78.<BR/>Interview on 09/19/22 at 02:02 PM, during a confidential group meeting with 9 residents in attendance, including Resident #78 revealed they were familiar with the grievance process but the residents reported the problem was sometimes there was no follow up only if it was taken up to the ADM. <BR/>Interview on 09/19/22 at 3:10 PM with Resident #78 revealed he reported a missing gold ring to the SW months ago and she stated they would replace the ring but he had not heard anything back from the SW. Resident #78 stated the ring was a big chunk of gold and he wanted it back. <BR/>Interview on 09/22/22 at 02:41 PM with the SW revealed she was responsible for ensuring grievance forms were completed per resident/family request and that staff followed up on resident concerns. The SW stated she would talk with unit manager in question and the resident to ensure the grievance was resolved. The SW stated Resident #78 reported a gold ring was missing several months back. She stated she did not write a grievance report and stated I guess I just didn't. The SW also confirmed telling Resident #78 the facility would replace the ring but they had not replaced it. The SW stated she thought she told the ADM but did not remember having any conversations about replacing the ring.<BR/>Interview on 09/22/22 at 04:13 PM with the ADM revealed he had not heard of Resident #78 missing a gold ring. He stated the SW stated she knew about it and she thought she told him. The ADM further stated it was never reported as stolen but as missing. The ADM stated he talked with a family member who told him Resident #78's other family members had gifted him the ring and it meant a lot to the Resident.<BR/>Review of facility policy, Grievances/Complaints - Staff Responsibility, revised October 2017, read in part: Staff members are encouraged to guide residents about where and how to file a grievance and or complaint when the resident believes that his/her rights have been violated. 4. Any alleged abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported to the administrator immediately, but not later than 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement written policies and procedures that, establish policies and procedures to investigate any such allegations for 1 of 1 reportable incident reviewed for reporting, in that:<BR/>The DON did not report a fall with fracture for Resident #98 within 2 hours per the facility policy.<BR/>This could affect residents and could result in residents decrease in care. <BR/>The Findings include:<BR/>Record review of the facility Abuse Prevention Program dated December 2016 revealed Reporting, 2. An alleged violation of abuse, neglect, exploiting or mistreatment (including injury of unknown source) and will be reported immediately, nut not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury, <BR/>Record review of Resident #98's face sheet dated 9/22/2022 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of nasal fracture, Parkinson's disease, and neurocognitive disorder with Lewy Bodies. (Google internet dated 10/4/2022- is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood.<BR/>Record review of Resident #98's MDS dated [DATE] revealed his BIMS score was 3 of15 (severely cognitively impaired)., ADLs was extensive assistance with one person assistance, Mobility he required use of a wheelchair, ROM was no limitations, and falls indicated he had a history of falls, had a fall before entering facility and had a fracture in the last 6 months. <BR/>Record review of Resident # 98's care plan dated 8/30/2022 revealed he was at risk for falls, history of falls, us of psychotropic medications; he was diagnosed with Parkinson's disease intervention was to monitor for falls; and had a fracture as a diagnoses with fall risk interventions in place. <BR/>Record review of the provider investigation report for Resident #98 indicated the incident occurred on 9/16/2022 at 5:40 PM, this was reported to HHSC on 9/20/2022 at 4:27 PM by the DON. <BR/>Record review of Resident # 98's progress note dated 9/16/2022 at 7:40 AM written by LVN A noted at 5:40am CNA B on station 2 reported to this nurse that patient fell, upon arrival at resident room resident was on the floor sitting down facing his bed. Nurse asked what happened, but he was unable to tell the nurse. The resident was bleeding from his left side of face. The nurse cleaned and applied pressure. A resident head to toe assessment was completed with a cut noted on the left eyebrow no swelling noted. The resident was alert and oriented. The resident denies pain and states I did not fall patient was assisted from floor to his bed. Resident #98's family member notified and on call RN for MD was also notified with order to start neuro check and also to monitor patient for any changes. I will continue to assess.<BR/>Record review of Resident #98's progress note dated 9/16/2022 at 9:47 PM written by (LVN D) revealed the nurse followed up with neuros checks & skull series results: question of interval fractures of the Left mandibular ramus/neck and possibly of the left zygomatic arch. Nurse notified family & MD, new orders to send to ER for CT scan. Nurse asked resident what happened? Resident stated, I fell. Nurse asked resident if he had any pain, resident denies pain or discomfort. Resident returned with CT results with facial fracture and contusion this day. Resident to start Augmenting 875 x10days, and Tylenol 500mg 1-2 tabs prn. Nurse did a head-to-toe assessment, bruising above the Left eyebrow, denies pain. -SBAR assessment was completed, he was ordered anticoagulants, sent to ER for CT scan. <BR/>Record review of Resident #98's incident report dated 9/16/2022 at 7 am by LVN A was documented at 5:40 AM Can B on station 2 reported to Nurse A that Resident #98 fell, upon arrival at resident room resident #98 was on the floor sitting sown facing his bed. Nurse asked wat happened, but he was unable to tell Nurse A. <BR/>Observation on 9/22/2022 at 11:32 AM Resident # 98 was sitting down at the table getting ready for lunch, he had a bruise on his left eye. <BR/>Observation of Resident #98's room on 9/22/2022 at 11:43 AM revealed he had a low bed, fall mat, and his fall interventions were in place.<BR/>Interview on 9/22/2022 at 11:55 AM, the DON stated Resident # 98 was not gone for 24 hours and his fracture was to the jaw area. The DON stated Resident #98's skull series 9/16/22 was completed at the facility and was questionable fracture. The DON stated Resident #98 was sent out to emergency room for CT scan via order from MD on he had a facial fracture and did not have surgery, he was placed on antibiotics for urinary tract infection. The DON stated she called the HHS after 2 hours due to resident was able to say he fell. <BR/>Interview on 9/22/2022 at 1:30 PM , LVN A stated Resident #98 was in the memory care and fall occurred on the night shift. The LVN A stated the CNA B reported to her she found Resident # 98 on the floor, face on bed, his face was bleeding, and LVN A stated Resident #98 was not able to tell her what happened at the time of incident. LVN A stated she assessed Resident #98 and treated for bleeding. LVN A stated she notified the family, NP, DON, ADON, did incidents/assessment, <BR/>Interview on 9/22/2022 at 1:40 PM, CNA B stated she was working on the memory care unit when she found Resident #98 on the floor and was not able to explain what happened, she reported to LVN A nurse assessed and cleaned wound, they both picked him up off the floor, put dressing on his face above the eyebrow on left side, nurse notified family, MD, etc.<BR/>Interview on at 9/22/2022 at 3:01 PM, LVN C stated she assessed Resident # 98 on 9/16/2022 at 3:15pm, he was sent out to emergency room and came back from hospital on 9/16/22 about 8:30/9 PM. LVN C had the results of bruising and facial fracture was faxed on 9/16/2022 at 9:10 PM, she notified the DON on 9/16/2022 at 9:10 PM via text. The LVN C stated Resident #98 sated he fell but was not able to tell her what had happened to cause fall due to dementia diagnoses. LVN C stated Resident #98 only answers in short phrases, he does not explain or describe what occurred. <BR/>Interview on 9/22/2022 at 2:41 PM with the Administrator and DON stated LVN A text her on 9/16/22 at 8:35pm about Resident #98's facial fracture. The DON stated she did not report Resident #98's fall with fracture because LVN C stated Resident #98 told her he fell, and no Abuse/Neglect occurred. SO, the DON did report to STATED as required due to no Abuse/Neglect. The Administrator stated he followed the ANE protocol form STATE on reporting allegations of Abuse/Neglect/Exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure that all alleged violations including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) for 1 of 1 (#98) facility incidents reviewed for reporting in that:<BR/>The DON did not report a fall with fracture for Resident #98 within 2 hours.<BR/>This could affect residents and result in abuse, neglect, and decrease in care. <BR/>The Findings include:<BR/>Based on observation, interview, and record review the facility failed to implement written policies and procedures that, establish policies and procedures to investigate any such allegations for 1 of 1 reportable incident reviewed for reporting, in that:<BR/>The DON did not report a fall with fracture for Resident #98 within 2 hours per the facility policy.<BR/>This could affect residents and could result in residents decrease in care. <BR/>The Findings include:<BR/>Record review of the facility Abuse Prevention Program dated December 2016 revealed Reporting, 2. An alleged violation of abuse, neglect, exploiting or mistreatment (including injury of unknown source) and will be reported immediately, nut not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury, <BR/>Record review of Resident #98's face sheet dated 9/22/2022 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of nasal fracture, Parkinson's disease, and neurocognitive disorder with Lewy Bodies. (Google internet dated 10/4/2022- is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood.<BR/>Record review of Resident #98's MDS dated [DATE] revealed his BIMS score was 3 of15 (severely cognitively impaired)., ADLs was extensive assistance with one person assistance, Mobility he required use of a wheelchair, ROM was no limitations, and falls indicated he had a history of falls, had a fall before entering facility and had a fracture in the last 6 months. <BR/>Record review of Resident # 98's care plan dated 8/30/2022 revealed he was at risk for falls, history of falls, us of psychotropic medications; he was diagnosed with Parkinson's disease intervention was to monitor for falls; and had a fracture as a diagnoses with fall risk interventions in place. <BR/>Record review of the provider investigation report for Resident #98 indicated the incident occurred on 9/16/2022 at 5:40 PM, this was reported to HHSC on 9/20/2022 at 4:27 PM by the DON. <BR/>Record review of Resident # 98's progress note dated 9/16/2022 at 7:40 AM written by LVN A noted at 5:40am CNA B on station 2 reported to this nurse that patient fell, upon arrival at resident room resident was on the floor sitting down facing his bed. Nurse asked what happened, but he was unable to tell the nurse. The resident was bleeding from his left side of face. The nurse cleaned and applied pressure. A resident head to toe assessment was completed with a cut noted on the left eyebrow no swelling noted. The resident was alert and oriented. The resident denies pain and states I did not fall patient was assisted from floor to his bed. Resident #98's family member notified and on call RN for MD was also notified with order to start neuro check and also to monitor patient for any changes. I will continue to assess.<BR/>Record review of Resident #98's progress note dated 9/16/2022 at 9:47 PM written by (LVN D) revealed the nurse followed up with neuros checks & skull series results: question of interval fractures of the Left mandibular ramus/neck and possibly of the left zygomatic arch. Nurse notified family & MD, new orders to send to ER for CT scan. Nurse asked resident what happened? Resident stated, I fell. Nurse asked resident if he had any pain, resident denies pain or discomfort. Resident returned with CT results with facial fracture and contusion this day. Resident to start Augmenting 875 x10days, and Tylenol 500mg 1-2 tabs prn. Nurse did a head-to-toe assessment, bruising above the Left eyebrow, denies pain. -SBAR assessment was completed, he was ordered anticoagulants, sent to ER for CT scan. <BR/>Record review of Resident #98's incident report dated 9/16/2022 at 7 am by LVN A was documented at 5:40 AM Can B on station 2 reported to Nurse A that Resident #98 fell, upon arrival at resident room resident #98 was on the floor sitting sown facing his bed. Nurse asked wat happened, but he was unable to tell Nurse A. <BR/>Observation on 9/22/2022 at 11:32 AM Resident # 98 was sitting down at the table getting ready for lunch, he had a bruise on his left eye. <BR/>Observation of Resident #98's room on 9/22/2022 at 11:43 AM revealed he had a low bed, fall mat, and his fall interventions were in place.<BR/>Interview on 9/22/2022 at 11:55 AM, the DON stated Resident # 98 was not gone for 24 hours and his fracture was to the jaw area. The DON stated Resident #98's skull series 9/16/22 was completed at the facility and was questionable fracture. The DON stated Resident #98 was sent out to emergency room for CT scan via order from MD on he had a facial fracture and did not have surgery, he was placed on antibiotics for urinary tract infection. The DON stated she called the HHS after 2 hours due to resident was able to say he fell. <BR/>Interview on 9/22/2022 at 1:30 PM, LVN A stated Resident #98 was in the memory care and fall occurred on the night shift. The LVN A stated the CNA B reported to her she found Resident # 98 on the floor, face on bed, his face was bleeding, and LVN A stated Resident #98 was not able to tell her what happened at the time of incident. LVN A stated she assessed Resident #98 and treated for bleeding. LVN A stated she notified the family, NP, DON, ADON, did incidents/assessment, <BR/>Interview on 9/22/2022 at 1:40 PM, CNA B stated she was working on the memory care unit when she found Resident #98 on the floor and was not able to explain what happened, she reported to LVN A nurse assessed and cleaned wound, they both picked him up off the floor, put dressing on his face above the eyebrow on left side, nurse notified family, MD, etc.<BR/>Interview on at 9/22/2022 at 3:01 PM, LVN C stated she assessed Resident # 98 on 9/16/2022 at 3:15pm, he was sent out to emergency room and came back from hospital on 9/16/22 about 8:30/9 PM. LVN C had the results of bruising and facial fracture was faxed on 9/16/2022 at 9:10 PM, she notified the DON on 9/16/2022 at 9:10 PM via text. The LVN C stated Resident #98 sated he fell but was not able to tell her what had happened to cause fall due to dementia diagnoses. LVN C stated Resident #98 only answers in short phrases, he does not explain or describe what occurred. <BR/>Interview on 9/22/2022 at 2:41 PM with the Administrator and DON stated LVN A text her on 9/16/22 at 8:35pm about Resident #98's facial fracture. The DON stated she did not report Resident #98's fall with fracture because LVN C stated Resident #98 told her he fell, and no Abuse/Neglect occurred. SO, the DON did report to STATED as required due to no Abuse/Neglect. The Administrator stated he followed the ANE protocol form STATE on reporting allegations of Abuse/Neglect/Exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 7 Residents (Resident #77 ) whose rooms were observed for safety hazards.<BR/>Two bottles of cleansers were found in Resident #77's bathroom on top of the safety grab bar by the toilet.<BR/>This deficient practice could affect residents in the women's secured unit and could place them at risk of having serious avoidable accidents.<BR/>The findings were:<BR/>Review of Resident #77's face sheet, dated 9/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included unspecified Dementia with behavior disturbance, Anxiety disorder, unspecified Psychosis not due to a known substance or known physiological condition and Schizophrenia (a serious mental disorder in which people interpret reality abnormally).<BR/>Review of Resident #77's admission MDS, dated [DATE] revealed her BIMS score was 00 indicating severe cognitive impairment. Further review revealed Resident #77 required supervision, oversight or cueing by 1 person physical assist for locomotion on the unit and set up help only for toileting . Further review revealed Resident #77 did not use any devices for mobility. <BR/>Review of Resident #77's Care Plan, dated 7/30/22, revealed Resident #77 required ADL assistance related to confusion, Dementia, history of wandering and impaired cognition. Further review revealed Resident #77 required assistance with toileting by 1 to 2 staff. <BR/>Observation on 09/21/22 at 12:28 PM in Resident 77's bathroom revealed two plastic bottles with cleaning chemicals in them on top of the safety grab bar by the toilet. One of the labels on the plastic bottle read in part: Odor Couteractant Concentrate for Professional Use: Warning Harmful if swallowed. Keep out of the reach of children. The label on the second plastic bottled read in part: Crew Clinging Toilet Bowl Cleaner. Keep out of Reach of Children Danger: If swallowed call Poison Control Center immediately and doctor. <BR/>Interview on 09/21/22 at 12:30 PM with LVN G revealed Resident #77 was very confused. She stated the cleansers could be a safety hazard and harmful to the Resident if ingested. LVN G further stated most of the resident's in the women's secured unit including Resident #77 wandered in and out of each other's rooms. She stated the chemicals presented a potential safety hazard for any resident who wandered into Resident #77's room. LVN G stated the housekeeper must have left them because she had just left the unit. LVN G further stated that although staff closely supervised the residents in the unit they could not guarantee supervision at all times.<BR/>Interview on 09/21/22 at 1:30 PM with the DON revealed she was aware about the two plastic bottles of cleaning chemicals left in Resident 77's bathroom. She stated the chemicals could harm the residents if ingested and it could potentially be fatal. The DON stated nursing staff knew they should be vigilant about safety hazards in the secured unit.<BR/>Review of facility policy, Secured Memory Care Neighborhood undated read in part: Policy: To provide a safe environment for all residents living in the secure memory care unit. To prevent accidents related to wandering and cognitive disability.<BR/>Review of facility policy, Safety and Supervision of Residents revised July 2017 read in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. 2. Safety risks and environmental hazards are identified on an on-going basis through a combination of employee training, employee monitoring and reporting processes. 4. Employees shall demonstrate competency on how to identify and and report accident hazards and try to prevent avoidable accidents.

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 the facility's only kitchen.<BR/>The 3-compartment sink was not maintained in working condition.<BR/>Undercooked eggs were served to residents.<BR/>These deficient practices could affect residents who ate from the kitchen and could contribute to food-borne illnesses.<BR/>The findings include:<BR/>In an observation on 09/19/22 at 9:43 AM, the 3-compartment sink was revealed to be draining shortly after being filled.<BR/>In an observation and interview on 09/19/22 at 1:02 PM revealed when [NAME] B added water to the first compartment of the 3-compartment sink, the water started to drain out. [NAME] B stated when he filled the first compartment up, the water will drain down to being half full in a short while. He showed the surveyor the water coming out of the drainpipe underneath the 3-compartment sink.<BR/>In an interview on 09/19/22 at 01:12 PM, the DM stated he would provide a work order for the 3-compartment sink.<BR/>Record review of a maintenance work order titled sink drain leaking revealed the order was created on 09/18/2022 3:53 PM by the Maintenance Director and the order was fulfilled on 09/20/2022 at 9:17 AM by the Maintenance Director. Additionally revealed was the request was submitted by the DM with work order #9546 with a priority setting of Medium.<BR/>In an interview on 09/19/22 at 2:29 PM, the Maintenance Director stated he was told by the kitchen the 3-compartment sink was not operating and proceeded to create a work order and then fix the equipment.<BR/>In an observation of the kitchen on 09/20/22 at 02:04 PM, the following was noted: The 3-compartment sink was observed to be operating, with a small stream of water draining from the first compartment. Eggs within the walk-in refrigerator had white, unmarked eggshells within a container that stated, Fresh Shell Eggs, USDA AA Grade, Wholesome Farms, and 9/17 on the box. Within the container, approximately 9 of 48 eggs were observed to have broken shells and atop a wet paper egg tray.<BR/>In an interview on 09/20/22 at 02:26 PM the DM stated he had never had concern with using unpasteurized eggs. He stated he had instructed his staff to make only eggs that will be completely cooked both ways with a mechanism that will cook both sides, describing a hard egg.<BR/>In an interview on 09/20/22 at 04:06 PM, the Dietician stated the facility ordered pasteurized eggs, but recently since they're being sent unpasteurized eggs, they are not to use them whatsoever. The Dietitian stated that if the facility received unpasteurized eggs, the kitchen was not to use the eggs even indirectly. She stated there was at least 1 resident who had requested over-easy eggs.<BR/>In an interview on 9/21/2022 at 8:25 AM, Resident #41 stated she understood fried eggs or sunny side up eggs to mean eggs with a liquid yoke. Resident #41 stated she had asked for sunny side eggs but received scrambled eggs this morning. Resident #41 stated she had sunny side eggs the day prior [9/20/2022]. Resident #41 stated she had sunny side up eggs approximately once or twice a week.<BR/>In an interview on 9/21/2022 at 8:50 AM, Resident #51 stated eggs sunny side up meant an egg where one would use toast to soak up the liquid yoke. Resident #51 stated that he received sunny side up eggs yesterday [9/20/2022] to the best of his recollection. Resident # 51 stated he was not sure, but thought he had sunny side up eggs a few times in the last month but also stated that he had memory problems. Resident #51 stated he would not ever turn down eggs with a runny yoke. Resident #51 stated he received scrambled eggs for breakfast this morning, but he preferred eggs sunny side up.<BR/>In an interview on 09/21/22 at 9:30 AM, Resident #308 stated she gets her eggs as over-easy and sunny side up where the yolk is runny.<BR/>In an interview on 09/21/22 at 9:36 AM, Resident #310 stated he gets his eggs over easy, but the yolk is firm and hard<BR/>In an interview on 09/21/22 at AM, Resident #312 stated he gets his eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 9:42 AM, Resident #314 stated she gets her eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 9:45 AM, Resident #413 stated he gets his eggs scrambled, but will also like his eggs over easy and that the yolk is runny.<BR/>In an interview on 9/21/2022 at 9:45 AM, Resident #25 stated he liked sunny side up eggs with a runny [liquid] yoke. Resident # 25 stated he had sunny side up eggs for breakfast the day prior [9/20/2022]. Resident #25 stated he had sunny side up eggs a few times in the past month.<BR/>In an interview on 09/21/22 at 9:57 AM R#421A stated she gets her eggs over easy, and the yolk is runny<BR/>In an interview on 09/21/22 at 10:02 AM R#123A stated she gets her eggs scrambled but sometimes over easy but the eggs are firm and hard<BR/>In an interview on 09/21/22 at 10:19 AM R#127A stated he gets his eggs scrambled but if it's not scrambled, it's firm all the way through<BR/>In an interview on 09/21/22 at 03:18 PM, the DM stated the 3-compartment sink was reported to him on 09/17/2022 by [NAME] A, and that same day the DM reported the work order request to the Maintenance Director verbally. The DM stated the protocol for equipment that was not operating to manufacturer specifications would be to stop using the equipment immediately and to report the malfunctioning equipment immediately.<BR/>In an interview on 09/21/22 at 03:22 PM, The DM stated the fried egg that is made is cooked both sides. The DM stated that an over-easy egg is one where it is runny. He stated the last time R#314-B had an over-easy egg was 10-15 days ago. The DM stated that R#128-A told him a month and a half ago, he was told that the resident was telling her she does not like hard eggs. The DM stated that the Dietician has not stated he cannot use unpasteurized eggs.<BR/>In an interview on 09/22/22 at 11:20 AM, the DON stated she is unaware if the kitchen has made undercooked eggs<BR/>In an interview on 09/22/22 at 11:21 AM, the DON stated she was not aware of the risks associated with using unpasteurized eggs. The DON stated the risks associated with undercooked eggs would be salmonella, or other foodborne illness. The DON stated that nausea or vomiting would be to call the physician, and such a CoC would be completed.<BR/>In an interview on 09/22/22 at 11:34 AM, the Admin stated he was unaware if the residents have requested undercooked eggs for meals. The Admin stated he was aware that the kitchen has received unpasteurized eggs and has ordered them. The Admin stated his expectation for the kitchen once received a substitution for eggs, they are to decline it. The Admin stated the policy for having only unpasteurized eggs would be to cook the eggs thoroughly.<BR/>In an interview on 09/22/22 at 11:37 AM, the Admin stated that he was unaware of a previous deficiency related to the 3-compartment sink. The Admin stated his expectation when equipment was malfunctioning was for the DM to report the equipment as not operating and was to do so either verbally, in paper, or online in the electronic work order system. The Admin stated the risk associated with the 3-compartment sink not operating would be the that the potential for disinfecting not being completed properly. The Admin stated the facility does not have policy for the 3 compartment sink or kitchen equipment.<BR/>Record review of dietary order submitted on 09/20/2022 revealed a line item described as EGG SHELL LARGE GR AA USDA WHT from brand name WHLFCLS.<BR/>Record review of the facility's policy, undated, titled [The Facility] Egg Safety revealed that if a [facility] has a resident who prefers undercooked eggs . [The Facility] will use pasteurized eggs when available but if the facility uses unpasteurized eggs eggshells for individual resident consumption, those eggs must be cooked until both the yolk and white are completed firm and served immediately.<BR/>Record review of the United Stated Food & Drug Administration Food Code dated 01/01/2017 revealed only pasteurized eggs are used in recipes if eggs are undercooked and if eggs are combined, unless there is a cook step or HACCP plan to control Salmonella enteriditis within the section titled Highly Susceptible Population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure they maintained an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 Residents (Resident #207) who was observed for COVID-19 precautions.<BR/>Resident #207 whose vaccinated status was unknown for COVID-19 upon admission was not placed on isolation precautions.<BR/>This deficient practice could affect residents in the women's secured unit and could lead to the spread of infections.<BR/>The findings were:<BR/>Review of Resident #207's face sheet, dated 9/22/22, revealed he was admitted to the facility on [DATE] with diagnosis, unvaccinated for COVID-19.<BR/>Review of Resident #207's initial Baseline Advanced Care Plan, dated 9/15/22, revealed the Resident was not on transmission based precautions.<BR/>Review of a progress note, dated 9/15/22, did not address Resident #207's isolation status.<BR/>Review of Resident #207's physician orders for September 2022 revealed an order dated 9/19/22 for: Rapid COVID-19 test x 1 Now due to unvaccinated status.<BR/>Observation on 09/18/22 at 10:05 AM revealed #207 was in the common area along with 7 other residents in the women's secured unit. <BR/>Interview on 09/18/22 at 10:08 AM with LVN G revealed Resident #207 remained in the women's unit because he was not vaccinated or his vaccination status was unknown. She stated he was most recently admitted to the facility from the hospital and to her knowledge the Resident was named as his own responsible party. LVN G further stated Resident #207 was not transferred to the men's secured unit because at least one of the Resident's was diagnosed with COVID-19 and they did not want to place him at risk for exposure. However, LVN G stated it did not make any sense because he could be placing the women in the secured unit at risk for exposure due to his unknown vaccination status.<BR/>Observation and interview on 9/19/22 at 12:15 PM with ADON F revealed Resident #207 was still on the unit and was on isolation based on facility protocol. ADON F stated all new and unvaccinated admissions were placed on isolation. ADON F stated Resident #207's family member reported he was vaccinated but they had to secure his immunization record before releasing him from isolation. ADON F stated he added the PPE cart upon reporting to work this morning and stated Resident #207 was also supposed to be on 1 to 1 supervision in his room so that he did not wander out of his room. He stated the Resident was non-complaint about staying in his room. Observation, at this same time, revealed Resident #207's door to his room was closed. There was a sign to see the nurse before entering the room and a PPE cart was outside of his room. ADON F stated he understood staff was not following protocol yesterday (9/18/22) per administrative report and was aware Resident #207 was mingling with other residents in the women's secured unit and could place them at risk of potentially being exposed to COVID-19.<BR/>Interview on 09/19/22 at 05:05 PM with the ADM revealed Resident #207 was admitted from the hospital and stated he was placed on isolation and his isolation status should have been included on the nursing admission assessment. The ADM stated he learned staff did not place the Resident on isolation but stated that was the plan for Resident #207 upon admission. He stated a PPE cart should have been posted outside his door for nursing staff to access upon entering his room.<BR/>Interview on 09/19/22 at 05:23 PM with the DON revealed she talked with Resident #207's family member who told her the Resident had received both COVID vaccinations at two different facilities. She stated she called and spoke with a representative at both of facilities and a representative stated Resident #207 received a COVID vaccination at their facility. However, Resident #207's immunization record had not been secured. The DON stated Corporate Office instructed her to place the Resident on isolation until she received his immunization records and could ensure he was fully vaccinated. The DON stated Resident #207 was supposed to be placed on 1 to 1 supervision until his vaccination status was confirmed. <BR/>Interview on 09/20/22 at 02:29 PM with LVN G revealed Resident #207 was admitted on Thursday, 9/15/22, and was supposed to be placed on isolation precautions. She stated the admission nurse did not document the Resident's isolation status on a nurse's progress note or on the 24 hour report which she should have done. LVN G stated she was not sure why Resident #207 was in the women's secured unit and she inquired about it. She was informed it was because his COVID vaccination status was unknown. LVN G stated after the last interview with Surveyor, she read Resident #207's hospital records and talked with the DON. The DON stated he was supposed to be on isolation and on 1 to 1 supervision in his room. LVN G stated they Made him 1 to 1 supervision as best as they could but did not have the extra person to supervise him. LVN G stated she reached out to a family member, listed in Resident #207's hospital records, who said he had been vaccinated at two different facilities. LVN G stated Resident #207 was sent back out to the hospital on 9/19/22 related to abdominal pain. Further interview with LVN G revealed Resident #207's vaccination status was unknown at the time she talked with the DON.<BR/>Review of facility policy, Policies and Practices - Infection Control revised on October 2018 read in part: This facilities policies and practices are intended to manage transmission of diseases and infections. 2. The objectives of our infection control policies and practices are to a. prevent, detect, investigate and control infections in the facility. c. establish guidelines for implementing isolation precautions including standard and transmission based precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed the facility failed to ensure that residents had the right to a safe, clean, and comfortable homelike environment for 2 of 7 Residents (Resident #67 and Resident #103) whose rooms and equipment were checked.<BR/>1. The MS failed to repair Resident #67's room door and the bathroom door so they did not stick making it difficult to open; and failed to clean the air vent in the Resident's bathroom.<BR/>2. The MS failed to ensure Resident #103's wheelchair armrests were replaced and the wheelchair was free of debris and build up.<BR/>These deficient practices could affect residents in the women's and men's secured unit and could place them at risk of dissatisfaction of their environment.<BR/>The findings were:<BR/>1. Review of Resident #67's face sheet, dated 9/18/22, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia with behavior disturbance, unspecified Psychosis not due to a substance or known physiological condition and Bipolar disorder.<BR/>Observation and interview on 09/20/22 at 11:15 AM in Resident #67's room revealed the entry door would get stuck and was hard to open and the bathroom door was also difficult to open. Further observation revealed a vent on the wall by the ceiling in the right hand side of the bathroom was black inside and along the outer edges on the wall. Resident #67's family member stated she told the MS about the doors sticking and the dirty air vent last week. She stated nothing had been done.<BR/>Interview on 09/22/22 at 09:10 AM with the MS revealed he made daily rounds of resident rooms and would make notes of anything needing repair; anything residents or staff brought to his attention. He stated he also had an automated program in place that he used as a guide for rotating maintenance of facility equipment. The MS stated Resident #67's family member told him last week about the door to the room and the bathroom door sticking and they were hard to open. He stated he did not remember her saying anything about a dirty air vent. The MS stated he had a to do list and made repairs in the order they were reported or according to priority. The MS stated he should have given the doors a higher priority because they could be a safety hazard to Resident #67 who was in the women's secured unit. <BR/>Interview on 09/22/22 at 04:10 PM with the MS revealed he stated the inside of the air vent in Resident #67's bathroom was black inside and along the outer edges on the wall. He stated the air vent was dirty he had not noticed it during rounds but cleaned it earlier on this date. <BR/>2. Review of Resident #103's face sheet, dated 9/22/22, revealed he was admitted to the facility on [DATE] with diagnoses including other specified disorders of the brain, Cerebral vascular disease and unspecified Dementia, unspecified severity w/o behavior disturbance, psychotic disturbance, mood disturbance and anxiety disturbance.<BR/>Review of Resident #103's quarterly MDS, dated [DATE], revealed his BIMS score was 01 indicating severe cognitive impairment.<BR/>Observation and interview on 09/20/22 at 04:46 PM revealed Resident #103 sitting in his wheelchair in the dining room in the men's secured unit. The right armrest did not have a cushion and the left armrest was peeling off around the edges. The wheelchair frame and wheels had built up residue. Resident #103 presented as being very confused and did not answer any questions. CNA H stated she started working at the NF 1 month ago and the wheelchair looked cleaner then. CNA H stated the cushion to the right armrest was missing and the left armrest was peeling around the edges. She stated the wheelchair looked very dirty. CNA H stated she thought the MS power washed the wheelchairs once a month but was not sure. She stated Resident #103 often spilled his food while eating. <BR/>Observation and interview on 09/21/22 at 4:30 PM revealed Resident #103 sitting in his wheelchair in the dining room in the men's secured unit. The right armrest did not have a cushion and the left armrest was peeling off around the edges. The wheelchair frame and wheels had built up residue. LVN C stated the wheelchair was filthy and the right armrest was missing. LVN C also stated the MS was responsible for ensuring all resident wheelchairs were power washed. LVN further stated she had not noticed the condition of the wheelchair.<BR/>Interview on 09/22/22 at 09:10 AM with the MS revealed he made daily rounds of resident rooms and would make notes of anything needing repair; anything residents or staff brought to his attention. He stated he also had an automated program in place that he used as a guide for rotating maintenance of facility equipment. He stated nursing staff told him about Resident #103's wheelchair on 9/21/22. He believed the wheelchair belonged to Hospice but stated Resident #103 was not on Hospice. The MS stated he was not sure where the wheelchair came from but confirmed the wheelchair had a missing armrest and it was dirty. The MS stated resident's wheelchairs were power washed on a rotating and monthly basis. He stated he had an assistant and they checked the wheelchair in the men's secured unit at the beginning of the month (September 2022) and did not notice the condition of Resident #103's wheelchair. The MS also stated he would replace the armrests as needed. <BR/>Review of facility policy, Cleaning and Disinfecting of Resident Care Items and Equipment, revised August 2019, read in part: Resident care equipment including reusable items and durable medication equipment will be cleaned and disinfected according to CDC recommendations for disinfection. c. Non-critical items are those that come in contact with intact skin but not mucous membrane.

Based on observation and interview the facility failed to post a notice of availability to the results of the most recent survey for 4 of 5 (9/18/22, 9/19/22, 9/20/22 and 9/21/22) survey days.<BR/>The facility failed to post a sign letting the residents know the location of the most recent survey results.<BR/>This deficient practice could place residents at risk and could result in the residents not being informed of the facility's survey citation history.<BR/>The findings were:<BR/>Interview during a confidential group meeting on 09/19/22 at 02:02 PM with residents revealed the survey results were not posted and they did not know where to find them. <BR/>Observation of the lobby area on 09/19/22 at 4:00 PM during facility tour revealed there was no posting indicating the location of the survey results. <BR/>Observation on 09/20/22 at 05:20 PM during a facility tour revealed there was no posting indicating the location of the of the survey results.<BR/>Observation and interview on 09/21/22 at 4:45 PM revealed the ADM stated the binder with the survey results was on the bottom shelf of a console table in the lobby area. He stated he made sure it was there every day upon walking into the NF. He stated there should be a posting providing Residents with the location of the survey results. Upon further observation the ADM stated he did not see the posting anywhere.<BR/>Review of a facility policy, Resident Rights, revised December 2016 read in part: Employees shall treat all residents with kindness, respect and dignity. 1. w. examine survey results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 7 Residents (Resident #1) whose records were reviewed for care plans. The facility failed to ensure Resident #1's care plan was revised to reflect the use of oxygen. This deficient practice could place Residents at risk of not receiving the care and services they needed.Findings included: Record review of Resident # 1's face sheet, dated 11/5/25 revealed a 74 - year old male admitted on [DATE] with diagnosis included : Unspecified Dementia (a condition where the cause of cognitive decline is unknown), respiratory failure with hypoxia (a condition where the body does not receive enough oxygen), and general anxiety disorder (a mental health condition marked by persistent worry about everyday life events) Record review of Resident # 1's quarterly MDS, dated [DATE], revealed a BIMS score of 2 which indicated a severe cognitive deficit. Record review of Resident #1's physician orders dated 11/5/25 revealed an order for oxygen dated on 9/26/25 at 2-4 liters as needed. Record review of Resident #1's care plan which was dated 7/25/25 revealed there was not a care plan update to include the resident's use of oxygen. During an observation on 11/05/2025 at 8:30 a.m., Resident #1 was sleeping with an oxygen concentrator set up on the floor besides the resident's bed; the resident was not interviewed due to his overall cognitive status. During an interview on 11/5/25 at 8:35am C.N.A.-A stated Resident #1 used oxygen on an as needed basis sometimes in the a.m. hours. During an interview on 11/5/25 at 9:00am ADON-B stated Resident #1's current care plan did not include the use of oxygen. ADON-B stated he thought only a resident's use of oxygen on a full-time basis was care planned. During an interview on 11/5/25 at 9:20am with DON stated that Resident #1's oxygen use was not included in the current care plan. The DON stated oxygen use on an as needed basis needed to be care planned to reflect the resident's total treatment. Record review of the facility's policy named Care Plans, Comprehensive Person-Centered dated 12-2016 revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on interview and record review, the facility failed to provide notice to residents of the change as soon as was reasonably possible when changes in coverage were made to items and services covered by the Medicare and/or Medicaid state plan for 2 of 3 residents [Resident #95, Resident #001] reviewed for Medicaid and Medicare Coverage Liability Notices. <BR/>The facility failed to ensure Resident # 95 and Resident #001 were provided a Skilled Nursing Facility Advance Beneficiary Notice of non-coverage Form CMS-10055 [SNF ABN] that informs a Medicare beneficiary that Medicare will no longer pay for skilled services when discharged from skilled services at the facility prior to completion of covered stay or covered days being exhausted when he/she was discharged from Medicare Part A skilled nursing services. <BR/>This failure placed residents, or their representatives, at risk for not being fully informed about services covered by Medicare Part A and not being aware of changes to provided services. <BR/>Findings included: <BR/>Record review of the facility Beneficiary Notice Worksheet (undated) revealed Resident #95 and #001 had been discharged from a Medicare covered Part A stay with benefits remaining within the six months prior to survey. <BR/>Record review of the entrance conference worksheet for the Advanced Benificiary notice for Resident #001 completed a Part A skilled stay on 8/31/24.<BR/>Record review of the entrance conference worksheet for the Advanced Benificiary notice for Resident #95 completed a Part A skilled stay on 9/30/24. <BR/>Record Review from June 2024 to December 2024 revealed no documentation of SNF ABN notice isseued for Resident #001.<BR/>Record Review from June 2024 to December 2024 revealed no documentation of SNF ABN notice isseued for Resident #95.<BR/>Interview with ADM on 12/19/24 at 2:00 PM revealed that Resident #001 completed his Medicare Part A stay on 8/31/24 and remained in the facility. Resident #001 did not utilize the full 100 days of Medicare part A, so he had days remaining. Resident # 001 should have received a SNF ABN. The facility failed to provide Resident #001 a SNF ABN. ADM confirmed facility is expected to follow the rules of Medicare Part A and the Medicare Claims Processing Manual for financial liability protections. The failure for the SNF ABN having not been provided was human error. Resident #001 was never placed in any harm or at risk for denial to participate in Medicare Part A moving forward. <BR/>Interview with ADMIN on 12/19/24 2:00 PM revealed that Resident #95 completed her Medicare Part A stay on 9/30/24 and remained in the facility. Resident #95 did not utilize the full 100 days of Medicare part A, so she had days remaining. Resident #95 should have received a SNF ABN. The facility failed to provide Resident #95 a SNF ABN. ADM confirmed facility is expected to follow the rules of Medicare Part A and the Medicare Claims Processing Manual for financial liability protections. The failure for the SNF ABN having not been provided was human error. Resident #95 was never placed in any harm or at risk for denial to participate in Medicare Part A moving forward. <BR/>Interview with ADMIN on 12/19/24 2:00 PM confirmed facility's guidelines for determination to issue a SNF ABN according to Section 20.2 of the Medicare Claims Processing Manual, Chapter 30 and CMS requirements to issue an ABN when a Medicare service is not reasonable and necessary under program standards, when providing custodial care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 residents (Resident #38) whose assessments were reviewed, in that:<BR/>Resident #38's quarterly MDS incorrectly documented the resident as receiving an anticoagulant medication.<BR/>This failure could place residents at-risk for inadequate care due to an inaccurate assessments. <BR/>The findings were:<BR/>1. Record review of Resident #38's face sheet, dated 11/15/2023, revealed an admission date of 07/08/2014 and, a readmission date of 05/08/2023 with diagnoses that included: Dementia(decline in cognitive abilities), Seizures (uncontrolled shaking movements), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure) and, Malformation of coronary vessels (Heart artery is in the wrong spot or it started in the wrong spot).<BR/>Record review of Resident #38's Physician orders and Medication administration record for November 2023 revealed orders for: Clopidogrel Bisulfate (used to prevent heart attack and stroke) Tablet 75 MG Give 1 tablet by mouth one time a day. <BR/>Record review of Resident #38's Medication Administration Record for the month of November 2023 revealed Resident #38 received Clopidogrel Bisulfate Tablet 75 MG everyday, as per order, between 11/01/2023 and 11/07/2023. <BR/>Record review of Resident #38's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #38 received an anticoagulant. <BR/>Record review of Resident #38's Physician orders and Medication administration record for August 2023 revealed orders for: Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day. <BR/>Record review of Resident #38's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #38 received an anticoagulant. <BR/>During an interview with the MDS nurse on 11/17/23 at 4:30 p.m., the MDS nurse verbally confirmed she had completed the MDS. The MDS nurse confirmed Resident #38's quarterly MDS was coded as the resident having received an anticoagulant when Resident #38 had received Clopidogrel (an antiplatelet) . The MDS nurse revealed she did not know why she had coded Clopidogrel as an anticoagulant. She verbally confirmed Clopidogrel was an antiplatelet and should not have been coded as an anticoagulant. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. <BR/>Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.18.11, October 2023, revealed, N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 4 dining rooms (Station 4 dining room) observed for resident rights.<BR/>The facility failed to ensure CNA W and CNA X were not using their personal phones while in the dining room, sitting with residents on 12/18/24. <BR/>This failure could place residents at risk of not being treated with dignity and respect. <BR/>Findings included:<BR/>Record review of Resident #62's admission Record, dated 12/16/2024, reflected Resident #62 was initially admitted on [DATE] and readmitted on [DATE]. Resident #62 was noted to be [AGE] years old. Resident #62 was diagnosed with mononeuropathy (damage that happens to a single nerve which can cause pain, loss of movement and/or numbness).<BR/>Record review of Resident #62's Annual MDS assessment, dated 09/30/2024, reflected Resident #62 had a BIMS of 15, indicating intact cognition. <BR/>Interview and observation on 12/18/24 at 12:26 PM revealed CNA W and CNA X were on their respective personal cell phones while sitting at a dining table with 2 unidentified residents present. CNA X revealed she was not supposed to be on her phone. <BR/>Attempted interview on 12/18/24 at 12:30PM. The residents did not respond. <BR/>Interview on 12/18/24 at 12:52 PM with the DON revealed CNAs were not allowed on their phones in the dining room because they were to help the residents with what the residents needed. <BR/>Interview on 12/19/24 at 04:25 PM with Resident #62 revealed nursing staff stay on their phones. He had seen them answering calls and making calls in the dining room. He had not seen them on their phones while feeding residents but had seen them make phone calls while they were waiting for meal trays. Resident #62 revealed the nursing staff do not seem to care. <BR/>Record review of the facility's policy Quality of Life-Dignity, revised August 2009, reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 4 resident hallways (Hallway 100/300/400) reviewed for physical environment. 1. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a yellow stain around the toilet bowl with missing caulking 2. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a black stain mark on the lower bathroom door measuring 2x1 ft. 3. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 300 had repaired a chipped piece of bathroom tile which measured approximately 2x2 inches and a broken piece of floor molding which measured approximately 2x2 inches on the right side wall adjacent to the bathroom. 4. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 300 had repaired a missing section of the lower door jam on the left side entry of the bathroom which measured approximately 1x1 inches. 5-On the 300 hallway ceiling adjacent to room [ROOM NUMBER] there was a 2x2 ft water stain mark and a section of peeling paint. 6-The facility failed to ensure resident room [ROOM NUMBER] located on hallway 400 had repaired a door penetration which measured approximately 2x1 inches. near the bathroom door handle. 7. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 400 had repaired a broken bathroom ceiling light which did not turn on. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe. Findings included: During an observation in the facility's conference room on 11/5/25 at 9:30 a.m. revealed a posted list of the facility's pending work orders for completion. During observation rounds with the Maintenance Director and Administrator on 11/5/25 from 10:00am-10:20am revealed the following:a. In room [ROOM NUMBER] on hallway 100 there was a yellow stain around the parameter of the toilet bowl that had missing caulking.b. In room [ROOM NUMBER] on hallway 100 there was a black stain mark on the lower bathroom door which measured approximately 2x1 ft. c. In room [ROOM NUMBER] on hallway 300 there was a chipped piece of bathroom tile which measured approximately 2x2 inches and a broken piece of floor molding which measured 2x2 inches on the right side of the wall adjacent to the bathroom. d. In room [ROOM NUMBER] on hallway 300 there was a missing section of the lower door jam entry to the bathroom which measured approximately 1x1 inches.e. On the 300-hallway adjacent to room [ROOM NUMBER] there was a section of the ceiling with a 2x2 ft water stain that had a section of paint which was peeling.f. In room [ROOM NUMBER] on hallway 400 there was a door penetration which measured approximately 2x1 inches near the bathroom door handle.g. In room [ROOM NUMBER] on hallway 400 there was a broken bathroom ceiling light that did not engage when turned on. During an interview with the Maintenance Director and Administrator on 11/5/25 at 10:25 a.m. the Maintenance Director and Administrator stated the observed areas which needed repair were scheduled for repair on the work order process named TELS. The Maintenance Director and Administrator stated completing the repairs would improve the resident's home environment. Record review of the facility policy titled Work Orders, Maintenance dated 04/2010 stated The Maintenance Director will review work orders, assessing priority, and ensure appropriate follow-up and completion.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 (lunch meal) observed for planned menus, in that:<BR/>1. <BR/>The facility failed to ensure all residents received roasted red potatoes with their lunch meal on 11/14/2023.<BR/>2. <BR/>The facility failed to ensure carrot cake was served with their lunch meal on 11/14/2023.<BR/>These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.<BR/>The findings included:<BR/>Record review of the facility's, Fall/Winter 2023, Week 1 Day 3, menu revealed Onion Sage Chicken, Roasted Red Potatoes, Spinach, and Carrot Cake w/Cream Cheese Frosting were to be served with the lunch meal on 11/14/2023. Record review of the November substitution log revealed that substitutions did not include mashed potatoes for roasted red potatoes and chocolate cake for carrot cake w/cream cheese frosting. <BR/>1. During an observation and interview on 11/14/23 at 12:47 PM in the 400-hall dining room, the LVN H revealed Resident #9 had a regular diet and had mashed potatoes instead of roasted red potatoes. When compared to Resident #228's lunch meal tray card (regular diet), the LVN H reported that Resident #9 should've received roasted red potatoes instead of mashed potatoes. <BR/>During an interview on 11/14/23 at 1:40 PM, the DM stated the last few trays in the 400-hall received mashed potatoes instead of roasted red potatoes. The DM was unable to quantify how many trays that this affected. The DM further stated the kitchen sometimes ran out of food because they have about 18 people that had double portions for their meals. The DM revealed that the substitution log was not filled out for the month of November yet, so the mashed potato substitution was not documented and not signed by the RD. <BR/>During an interview on 11/16/23 at 10:14 AM, [NAME] K revealed during 11/14/23 lunch, the kitchen ran out of roasted red potatoes at the end of lunch service and the kitchen switched to serving mashed potatoes in place of the roasted red potatoes.<BR/>2. Record review of the posted 11/14/23 lunch daily menu revealed that chocolate cake was served instead of carrot cake w/cream cheese frosting. <BR/>During an interview on 11/14/23 at 1:40 PM, the DM reported that the kitchen was not able to serve chocolate cake because the kitchen did not have yellow cake mix. The DM revealed that the substitution log was not filled out for the month of November yet, so the carrot cake substitution was not documented and not signed by the RD.<BR/>During an interview on 11/14/23 at 1:40 PM, the DM stated Resident #11's 11/14/23 lunch meal tray ticket revealed that Resident #11 did not like chocolate.<BR/>During a combined interview on 11/17/23 at 4:58 PM, the DON and the ADM revealed that the tray aides and nurses should have checked tray tickets before meals get delivered to the residents. <BR/>Record review of the facility's policy titled, Standardized Recipes, revised April 2007, Standardized recipes shall be developed and used in the preparation of foods 2. Standardized recipes will be adjusted to the number of portions required for a meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 8 Residents (Resident #64) reviewed for the ability to call for staff, in that:<BR/>The facility failed to ensure that Resident #64 had a functional call light system. <BR/>This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance. <BR/>The findings included:<BR/>A record review of Resident #64's electronic face sheet, dated 11/14/23, revealed an admission date of 4/28/23, re-admitted [DATE], with diagnoses which included difficulty in walking, lack of coordination, and mild cognitive impairment.<BR/>A record review of Resident #64's care plan revealed focus of [Resident #64] is high risk for falls r/t mild cognitive impairment with intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Focus of Mrs. [NAME] has had an actual unwitnessed fall with no injury with intervention of Encourage pt to use call light for help.<BR/>A record review of Resident #64's quarterly MDS assessment, dated 10/23/23, revealed Resident #64 had a BIMS score of 15, cognitively intact. Resident #64 needs set up or clean-up assistance for toileting hygiene. Resident #64 needs supervision or touching assistance for toilet transfer.<BR/>During an observation and interview on 11/14/23 at 2:34 PM, Resident #64 needed help turning on the television (TV). Resident revealed not having a remote and pressed the call light to get help from staff. Resident revealed that the staff had not responded to her call light in the past, and the staff may not respond to this call light now. No staff appeared to answer the call light. Resident pressed the call light for a second time on 11/14/23 at 2:48 PM. It was observed that the light in the hallway that was triggered by the resident's call light was not turning on, revealing the call light was not turning working properly. <BR/>During an observation and interview on 11/14/23 at 2:52 PM, LVN O checked to see if Resident #64's call light was working, revealing that Resident #64's call light was not working. LVN O further revealed that Resident #64 needed a functioning call light due to Resident #64 being a fall risk. <BR/>During an interview on 11/14/23 starting at 6:26 PM, the ADM revealed that every shift call lights were to be checked that they functioned and that they were within reach of the residents to ensure the safety of the residents. <BR/>A record review of facility's policy, Call System, Resident, dated September 2022, revealed 1. Each resident is provided with a means to call staff directly for assistance from his/her bed .3. The resident call system remains functional at all times . 5. The resident call system is routinely maintained and tested by the maintenance department.<BR/>A record review of facility's policy, Answering the Call Light, revised September 2022, revealed 4. Be sure that the call light is plugged in and functioning at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments in 1 of 10 medication storage carts (Nurses' Treatment Cart) observed for drug security in that:<BR/>Nurses' Treatment Cart was left unattended and unlocked in the corridor outside room [ROOM NUMBER]. <BR/>This deficient practice could affect residents at risk of lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications.<BR/>The findings included:<BR/>In an observation on 9/21/2022 at 9:03 AM, the Nurses' Treatment Cart was observed unlocked and unattended with the keys in the lock mechanism in the corridor outside of room [ROOM NUMBER]. The cart did not contain narcotic medications. The cart included over the counter and prescription medications. Staff and visitors were observed in the immediate vicinity. The Nurses' Treatment Cart had multiple over the counter medications for wound care and one Urea Cream, prescription strength medication. <BR/>In an interview on 9/21/2022 at 9:05 AM, LVN E stated the Nurses' Treatment Cart was his responsibility. LVN E stated the Nurses' Treatment Cart had been left unattended for less than 2 minutes while he disposed of trash from a dressing change he just performed on one of the residents in room [ROOM NUMBER]. LVN E stated he knew he should not have left the keys in the cart. <BR/>In an interview on 9/21/2022 at 9:08 AM, the DON stated medication carts are to be secured when not in use. The DON stated she would initiate staff In-Servicing immediately. <BR/>In an interview on 9/21/2022 at 12:21 PM, the DON stated residents could have been negatively impacted if one had obtained a medication from the unattended nurses treatment cart and used it inappropriately. Additionally, the DON stated if a medication were to be stolen from the cart by an unknown person, it might not be available for the residents' immediate use. <BR/>Record review of the facility's policy, Storage of Medications, revised November 2020, revealed in step 1. Drugs and biologicals .stored in locked compartments .In step 3. Nursing staff is responsible for maintaining medication storage .in a clean safe, sanitary manner. In step 6. Compartments .are locked when not in use. Unlocked medication carts are not left unattended. <BR/>Record Review of In-Service Attendance dated 9/21/2021 with the Subject of Lock Carts When Unattended revealed staff were trained to lock an unlocked cart no matter who you are. 11 Staff signatures included.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 1 (Resident#84) resident observed for catheter care. <BR/>Resident #84's indwelling catheter tubing and bag were touching the floor. <BR/>This failure could place residents at risk of infections.<BR/>The Findings include:<BR/>Record review of Resident #84's face sheet dated 9/21/2022 revealed he was admitted on [DATE] with a diagnosis of metabolic encephalopathy, dysphagia due to cerebral vascular disease, major depression disorder, benign prostatic hyperplasia without lower urinary tract symptoms, , and obstructive and reflux uropathy. <BR/>Record review of Resident #84's consolidated physician orders dated September 2022 revealed he had orders for Foley: change 16f 30 cc catheter and drainage bag based on clinical indications, such as infections as needed related to obstructive and reflux uropathy. <BR/>Record review of Resident #84's Quarterly MDS dated [DATE] revealed under section Bowel/Bladder revealed he had an indwelling catheter and his BIMS score was 15/15 (cognitively intact), <BR/>Record review of Resident #84's care plan dated 9/1/2022 revealed he had an indwelling catheter related to obstructive uropathy and interventions were to change catheter and drainage bag as needed. <BR/>Observation on 9/18/2022 at 4:04 PM revealed Resident #48's indwelling catheter tubing was on the floor while he was lying in bed.<BR/>Observation on 9/21/2022 a t 11:49 AM revealed Resident #48 was sitting in his wheelchair wheeling himself down the hall to his room, revealed his indwelling catheter tubing was hanging on the floor.<BR/>Interview on 9/1/2022 at 11:50 AM with Resident #48 was not able to answer questions at the time due to preoccupation with other things related the depression. <BR/>Interview on 9/21/2022 at 11:51 AM with LVN D stated Resident #48's indwelling catheter tubing was on the floor hanging from his wheelchair. LVN D stated the tubing on the floor could cause infection. <BR/>Interview on 9/22/2022 at 9:22 AM with the MDS nurse stated if a catheter tubing was on the floor, it's a tripping hazard and infection control issue.<BR/>Interview on 9/22/2022 at 2:41 PM with the Administrator and DON acknowledged finding and no other comments. <BR/>Record review of the policy for indwelling catheter provided did not indicate any issues with catheter tubing on the floor and the cause for infection. <BR/>Record review of the policy on Infection Control dated October 2018 was documented The facility 's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure labratory services were provided to meet the needs of the resident in accordance with professional standards of practice, and for 1 of 30 residents (Resident #31) reviewed for labratory service.<BR/>The facility failed to ensure Resident #31's HgA1c lab (a blood test that measure the average blood sugar level of the past 3 months) was drawn every 3 months as per physician order.<BR/>These failures could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health.<BR/>Findings included:<BR/>Record review of Resident #31's face sheet dated 12/18/2024, revealed she was a [AGE] year-old woman initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included: cerebral infarction (stroke), quadriplegia (paralysis which affects all 4 limbs), and type 1 diabetes mellitus without complications (lifelong condition where the pancreas makes little or no insulin, leading to high blood sugar levels). <BR/>Record review of Resident #31's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment and active diagnosis of Diabetes Mellitus.<BR/>Record review of Resident #31's care plan initiated on 08/17/2021 reflected a focus area of Diabetes Mellitus with goal of will have no complications related to diabetes .<BR/>Record review of Resident #31's Physician Order Summary dated 12/19/2024 revealed an order dated 07/29/2024 for: HgA1C Q 3 months<BR/>Record review of Resident #31's lab results in her clinical record reveal her only HgA1C lab was drawn 07/27/2024.<BR/>During an interview with the DON on 12/19/2024 at 10:50 a.m., the DON confirmed the last HgA1C lab for Resident #31 was drawn on 07/27/2024, and that per physician orders, another HgA1C should have been drawn 3 months later in October 2024. She stated she contacted the Doctor, who changed the order effective today to HgA1C every 6 months, however, she confirmed that per existing orders at the time, Resident #31's HgA1C lab was due in October and was not done. The DON stated she did not know why the lab was not drawn but will look into it. The DON further stated that it was important to draw labs as ordered by the Physician to monitor Resident #31's diabetic status.

Based on observations, interviews and record reviews the facility failed to post the following information on a daily basis for nurse staffing data Resident census and facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 1 of 1 facility in that:<BR/>The posted nurse staffing data sheet was missing the census. The facility was missing census on from July 20 , 2022 to Septmeber 28, 2022, August 30, 202022 and September 19, 2022.<BR/>This could and result in resident and cenus not knowing the census for days missing. <BR/>The Findings were:<BR/>Interview on 9/19/2022 at 9:21 AM with staffing coordinator I stated sherecently took over being responsible for the nurse staffing data and stated she usually added the census after the morning meeting, The staffing coordinator I stated the census was missing from July 20 , 2022 to Septmeber 28, 2022, and August 30, 2022 and and September 19, 2022.<BR/>Observtion on 9/20/2202 at 11:51 AM revealed no census on nurse staffing posting for 1 day .(Spetember 19, 2022).<BR/>Recored review of the posted nurse staffing data sheet from July 20 , 2022 to Septmeber 28, 2022, August 30, 202022 and September 19, 2022 was missing census.<BR/>Record review of the policy Department of Duty , Nursing Services dated May 2019 revealed the cenus was not mentioned in the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 4 resident hallways (Hallway 100/300/400) reviewed for physical environment. 1. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a yellow stain around the toilet bowl with missing caulking 2. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a black stain mark on the lower bathroom door measuring 2x1 ft. 3. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 300 had repaired a chipped piece of bathroom tile which measured approximately 2x2 inches and a broken piece of floor molding which measured approximately 2x2 inches on the right side wall adjacent to the bathroom. 4. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 300 had repaired a missing section of the lower door jam on the left side entry of the bathroom which measured approximately 1x1 inches. 5-On the 300 hallway ceiling adjacent to room [ROOM NUMBER] there was a 2x2 ft water stain mark and a section of peeling paint. 6-The facility failed to ensure resident room [ROOM NUMBER] located on hallway 400 had repaired a door penetration which measured approximately 2x1 inches. near the bathroom door handle. 7. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 400 had repaired a broken bathroom ceiling light which did not turn on. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe. Findings included: During an observation in the facility's conference room on 11/5/25 at 9:30 a.m. revealed a posted list of the facility's pending work orders for completion. During observation rounds with the Maintenance Director and Administrator on 11/5/25 from 10:00am-10:20am revealed the following:a. In room [ROOM NUMBER] on hallway 100 there was a yellow stain around the parameter of the toilet bowl that had missing caulking.b. In room [ROOM NUMBER] on hallway 100 there was a black stain mark on the lower bathroom door which measured approximately 2x1 ft. c. In room [ROOM NUMBER] on hallway 300 there was a chipped piece of bathroom tile which measured approximately 2x2 inches and a broken piece of floor molding which measured 2x2 inches on the right side of the wall adjacent to the bathroom. d. In room [ROOM NUMBER] on hallway 300 there was a missing section of the lower door jam entry to the bathroom which measured approximately 1x1 inches.e. On the 300-hallway adjacent to room [ROOM NUMBER] there was a section of the ceiling with a 2x2 ft water stain that had a section of paint which was peeling.f. In room [ROOM NUMBER] on hallway 400 there was a door penetration which measured approximately 2x1 inches near the bathroom door handle.g. In room [ROOM NUMBER] on hallway 400 there was a broken bathroom ceiling light that did not engage when turned on. During an interview with the Maintenance Director and Administrator on 11/5/25 at 10:25 a.m. the Maintenance Director and Administrator stated the observed areas which needed repair were scheduled for repair on the work order process named TELS. The Maintenance Director and Administrator stated completing the repairs would improve the resident's home environment. Record review of the facility policy titled Work Orders, Maintenance dated 04/2010 stated The Maintenance Director will review work orders, assessing priority, and ensure appropriate follow-up and completion.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 (lunch meal) observed for planned menus, in that:<BR/>1. <BR/>The facility failed to ensure all residents received roasted red potatoes with their lunch meal on 11/14/2023.<BR/>2. <BR/>The facility failed to ensure carrot cake was served with their lunch meal on 11/14/2023.<BR/>These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.<BR/>The findings included:<BR/>Record review of the facility's, Fall/Winter 2023, Week 1 Day 3, menu revealed Onion Sage Chicken, Roasted Red Potatoes, Spinach, and Carrot Cake w/Cream Cheese Frosting were to be served with the lunch meal on 11/14/2023. Record review of the November substitution log revealed that substitutions did not include mashed potatoes for roasted red potatoes and chocolate cake for carrot cake w/cream cheese frosting. <BR/>1. During an observation and interview on 11/14/23 at 12:47 PM in the 400-hall dining room, the LVN H revealed Resident #9 had a regular diet and had mashed potatoes instead of roasted red potatoes. When compared to Resident #228's lunch meal tray card (regular diet), the LVN H reported that Resident #9 should've received roasted red potatoes instead of mashed potatoes. <BR/>During an interview on 11/14/23 at 1:40 PM, the DM stated the last few trays in the 400-hall received mashed potatoes instead of roasted red potatoes. The DM was unable to quantify how many trays that this affected. The DM further stated the kitchen sometimes ran out of food because they have about 18 people that had double portions for their meals. The DM revealed that the substitution log was not filled out for the month of November yet, so the mashed potato substitution was not documented and not signed by the RD. <BR/>During an interview on 11/16/23 at 10:14 AM, [NAME] K revealed during 11/14/23 lunch, the kitchen ran out of roasted red potatoes at the end of lunch service and the kitchen switched to serving mashed potatoes in place of the roasted red potatoes.<BR/>2. Record review of the posted 11/14/23 lunch daily menu revealed that chocolate cake was served instead of carrot cake w/cream cheese frosting. <BR/>During an interview on 11/14/23 at 1:40 PM, the DM reported that the kitchen was not able to serve chocolate cake because the kitchen did not have yellow cake mix. The DM revealed that the substitution log was not filled out for the month of November yet, so the carrot cake substitution was not documented and not signed by the RD.<BR/>During an interview on 11/14/23 at 1:40 PM, the DM stated Resident #11's 11/14/23 lunch meal tray ticket revealed that Resident #11 did not like chocolate.<BR/>During a combined interview on 11/17/23 at 4:58 PM, the DON and the ADM revealed that the tray aides and nurses should have checked tray tickets before meals get delivered to the residents. <BR/>Record review of the facility's policy titled, Standardized Recipes, revised April 2007, Standardized recipes shall be developed and used in the preparation of foods 2. Standardized recipes will be adjusted to the number of portions required for a meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments in 1 of 10 medication storage carts (Nurses' Treatment Cart) observed for drug security in that:<BR/>Nurses' Treatment Cart was left unattended and unlocked in the corridor outside room [ROOM NUMBER]. <BR/>This deficient practice could affect residents at risk of lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications.<BR/>The findings included:<BR/>In an observation on 9/21/2022 at 9:03 AM, the Nurses' Treatment Cart was observed unlocked and unattended with the keys in the lock mechanism in the corridor outside of room [ROOM NUMBER]. The cart did not contain narcotic medications. The cart included over the counter and prescription medications. Staff and visitors were observed in the immediate vicinity. The Nurses' Treatment Cart had multiple over the counter medications for wound care and one Urea Cream, prescription strength medication. <BR/>In an interview on 9/21/2022 at 9:05 AM, LVN E stated the Nurses' Treatment Cart was his responsibility. LVN E stated the Nurses' Treatment Cart had been left unattended for less than 2 minutes while he disposed of trash from a dressing change he just performed on one of the residents in room [ROOM NUMBER]. LVN E stated he knew he should not have left the keys in the cart. <BR/>In an interview on 9/21/2022 at 9:08 AM, the DON stated medication carts are to be secured when not in use. The DON stated she would initiate staff In-Servicing immediately. <BR/>In an interview on 9/21/2022 at 12:21 PM, the DON stated residents could have been negatively impacted if one had obtained a medication from the unattended nurses treatment cart and used it inappropriately. Additionally, the DON stated if a medication were to be stolen from the cart by an unknown person, it might not be available for the residents' immediate use. <BR/>Record review of the facility's policy, Storage of Medications, revised November 2020, revealed in step 1. Drugs and biologicals .stored in locked compartments .In step 3. Nursing staff is responsible for maintaining medication storage .in a clean safe, sanitary manner. In step 6. Compartments .are locked when not in use. Unlocked medication carts are not left unattended. <BR/>Record Review of In-Service Attendance dated 9/21/2021 with the Subject of Lock Carts When Unattended revealed staff were trained to lock an unlocked cart no matter who you are. 11 Staff signatures included.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 residents (Resident #38) whose assessments were reviewed, in that:<BR/>Resident #38's quarterly MDS incorrectly documented the resident as receiving an anticoagulant medication.<BR/>This failure could place residents at-risk for inadequate care due to an inaccurate assessments. <BR/>The findings were:<BR/>1. Record review of Resident #38's face sheet, dated 11/15/2023, revealed an admission date of 07/08/2014 and, a readmission date of 05/08/2023 with diagnoses that included: Dementia(decline in cognitive abilities), Seizures (uncontrolled shaking movements), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure) and, Malformation of coronary vessels (Heart artery is in the wrong spot or it started in the wrong spot).<BR/>Record review of Resident #38's Physician orders and Medication administration record for November 2023 revealed orders for: Clopidogrel Bisulfate (used to prevent heart attack and stroke) Tablet 75 MG Give 1 tablet by mouth one time a day. <BR/>Record review of Resident #38's Medication Administration Record for the month of November 2023 revealed Resident #38 received Clopidogrel Bisulfate Tablet 75 MG everyday, as per order, between 11/01/2023 and 11/07/2023. <BR/>Record review of Resident #38's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #38 received an anticoagulant. <BR/>Record review of Resident #38's Physician orders and Medication administration record for August 2023 revealed orders for: Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day. <BR/>Record review of Resident #38's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #38 received an anticoagulant. <BR/>During an interview with the MDS nurse on 11/17/23 at 4:30 p.m., the MDS nurse verbally confirmed she had completed the MDS. The MDS nurse confirmed Resident #38's quarterly MDS was coded as the resident having received an anticoagulant when Resident #38 had received Clopidogrel (an antiplatelet) . The MDS nurse revealed she did not know why she had coded Clopidogrel as an anticoagulant. She verbally confirmed Clopidogrel was an antiplatelet and should not have been coded as an anticoagulant. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. <BR/>Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.18.11, October 2023, revealed, N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Based on observations, interviews and record reviews failed to accommodate residents' food preferences for 1 of 8 (Resident #11) residents reviewed for food preferences, in that:<BR/>Resident #11's lunch meal tray on 11/14/23 did not follow her dislike of chocolate. <BR/>This could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. <BR/>The Findings were:<BR/>Record review and observation of Resident #11's 11/14/23 lunch meal revealed that Resident #11's tray ticket included a dislike of chocolate, but Resident #11 still received chocolate cake. <BR/>During an observation and interview on 11/14/23 at 12:56 PM in the 300-hall dining room, the CMA J stated Resident #11's meal tray ticket said that Resident #11 disliked chocolate. CMA J revealed that Resident #11 received chocolate cake for 11/14/23 lunch. Resident #11 stated she did not like chocolate and was not going to eat the chocolate cake. <BR/>During an interview on 11/14/23 at 1:40 PM, the DM stated Resident #11's 11/14/23 lunch meal tray ticket revealed that Resident #11 did not like chocolate. The DM stated that the kitchen staff made sure that the residents' meal preferences on their meal tray tickets were followed before being sent out to the residents. <BR/>During a combined interview on 11/17/23 at 4:58 PM, the DON and the ADM revealed that the tray aides and nurses should have checked tray tickets before meals get delivered to the residents. <BR/>Record review of the facility's policy titled, Food and Nutrition Service, revised October 2017, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident 1. The multidisciplinary staff, including nursing staff, the attending physician, and the dietitian will assess each resident' nutritional needs, food likes, dislikes, and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and the physician documented what, if any, action has been taken to address them, for 1 of 6 residents (Residents #2) whose records were reviewed for pharmacy services.<BR/>After 11/18/24 medication review for Resident #2, the facility failed to add a doctor's order as was recommended by the pharmacist and approved by MD D. <BR/>This failure could place residents at risk for significant health status declines. <BR/>The findings included:<BR/>Record review of Resident #2's admission record, dated 12/19/24, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis to include type 2 diabetes, hypertension (high blood pressure), chronic kidney disease. <BR/>Record review of Resident #2's quarterly MDS Assessment, dated 12/06/24, reflected Resident #2 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. <BR/>Record review of Resident #2's Consultant Pharmacist/Physician Communication, signed by MD D on 11/18/24, reflected Resident has an order for Bumetanide and Glipizide. Please consider BMP and [HgbA1c] every 6 months.<BR/>Record review of Resident #2's doctor's orders as of 12/19/24 reflected no orders of BMP or HgbA1c. Resident #2's doctor's orders reflected Bumetanide Oral Tablet 1 MG and glipizide oral tablet 5 MG. <BR/>During an interview on 12/18/24 at 06:12 PM, ADON A revealed not updating Resident #2's doctor's orders as was recommended by the pharmacist and approved by MD D was an oversight and they will change Resident #2's doctor's orders immediately. <BR/>During an interview on 12/19/24 at 11:15 AM, the DON revealed it was important to follow an order to check a resident's A1c to monitor the A1C for the resident's health. <BR/>During an interview on 12/19/24 at 04:00 PM, the DON revealed she was going to implement audits of various things like the pharmacy reviews to ensure the facility was not overlooking pharmacy and doctor recommendations. <BR/>Requested policy for pharmacy reviews on 12/23/24 at 12:18 PM. No policy received.<BR/>Requested policy for following doctor's orders on 12/19/24 at 03:09 PM, 12/19/24 at 04:14 PM, and 12/23/24 at 12:18 PM. No policy received.