PECAN TREE REHAB AND HEALTHCARE CENTER

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents in one of four medication carts for expired medications. <BR/>The facility failed to ensure expired medications were removed from stock in one out of four medication carts.<BR/>This failure could place residents at risk of not receiving the intended therapeutic benefit of their medications. <BR/>Findings included:<BR/>Observation on 07/20/22 at 10:24 a.m. of the 200-hallway medication cart revealed, a bottle of Aspirin 325 mg tablet with an expiration date of 6/22. This bottle was found in the 200-hall medication cart which means this medication was not for a specific resident.<BR/>Interview on 07/20/22 at 10: 24 a.m . with RN A revealed, it is my responsibility to remove expired medications. She stated, I just missed it. I am sorry. Anyone could have received this medication in the 200 hallway that had an order for Aspirin 325mg tablet. RN A stated that giving expired medications can decrease its effectiveness.<BR/>Interview on 07/21/22 08:58 a.m. with the DON revealed that he stated I go through medications every Sunday. He stated she got specialized glasses a week ago and maybe that was what caused her to miss that expired medication. DON stated that giving expired medications can decrease potency.<BR/>Review of the facility's policy on Medication Storage in the Facility dated January 2018, revealed, . G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents in one of four medication carts for expired medications. <BR/>The facility failed to ensure expired medications were removed from stock in one out of four medication carts.<BR/>This failure could place residents at risk of not receiving the intended therapeutic benefit of their medications. <BR/>Findings included:<BR/>Observation on 07/20/22 at 10:24 a.m. of the 200-hallway medication cart revealed, a bottle of Aspirin 325 mg tablet with an expiration date of 6/22. This bottle was found in the 200-hall medication cart which means this medication was not for a specific resident.<BR/>Interview on 07/20/22 at 10: 24 a.m . with RN A revealed, it is my responsibility to remove expired medications. She stated, I just missed it. I am sorry. Anyone could have received this medication in the 200 hallway that had an order for Aspirin 325mg tablet. RN A stated that giving expired medications can decrease its effectiveness.<BR/>Interview on 07/21/22 08:58 a.m. with the DON revealed that he stated I go through medications every Sunday. He stated she got specialized glasses a week ago and maybe that was what caused her to miss that expired medication. DON stated that giving expired medications can decrease potency.<BR/>Review of the facility's policy on Medication Storage in the Facility dated January 2018, revealed, . G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining .

Based on observation, interview, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 2 (Residents #48 and #63) of 15 residents reviewed for wheelchair maintenance.<BR/>The facility failed to properly maintain wheelchairs for Residents#48 and #63.<BR/>This failure placed residents by placing them at risk for skin tears and discomfort.<BR/>Findings included: <BR/>An observation of Resident #48's wheelchair on 07/19/22 9:30 am revealed both armrest vinyl pads were cracked with the foam exposed. The left pad wrapped with clear tape and the forward 1/3 of the armrest and the back half of the pad could be lifted from the armrest. <BR/>In an interview on 07/19/22 at 9:30 am with Resident #48, he stated the armrest had been like this a while and he would like for it to be repaired. He had already told the nurse before. <BR/>On 07/20/22 at 9:40 am observed Resident#63's wheelchair which had the right armrest missing and the left armrest vinyl is cracked with the foam beneath exposed. <BR/>In an interview on 07/20/22 at 12:15 pm, the Maintenance Director stated if a wheelchair needed repair, the staff let him know by the TELS systems which comes directly to his phone, and he repaired the wheelchair. He stated he was not aware of wheelchairs that needed repair.<BR/>In an interview on 07/20/22 at 12:28 pm with the Administrator , he stated if a wheelchair needed repair, the staff let maintenance know by entering it into the TELS systems which went to the Maintenance Director's personal cell phone to let maintenance know of the needed repairs.<BR/>In an interview on 07/20/22 at 12:35 pm , LVN B stated if a wheelchair needed repair, the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair. <BR/>In an interview on 07/20/22 at 12:37 pm with LVN C stated if a wheelchair needed repair the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair.<BR/>In an interview on 07/21/22 at 8:30 am with CNA D stated when a wheelchair needed repair the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair.<BR/>In an interview on 07/21/22 at 8:35 am with CNA E when a wheelchair needed repair the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair.<BR/>A review of May, June, and July 2022 revealed the messages sent through the TELS system to the maintenance department, reflected none had been for repair of residents' wheelchairs. <BR/>A review of the facility's policy entitled, 'Maintenance Service, dated 2002 , indicated The Maintenance Department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents in one of four medication carts for expired medications. <BR/>The facility failed to ensure expired medications were removed from stock in one out of four medication carts.<BR/>This failure could place residents at risk of not receiving the intended therapeutic benefit of their medications. <BR/>Findings included:<BR/>Observation on 07/20/22 at 10:24 a.m. of the 200-hallway medication cart revealed, a bottle of Aspirin 325 mg tablet with an expiration date of 6/22. This bottle was found in the 200-hall medication cart which means this medication was not for a specific resident.<BR/>Interview on 07/20/22 at 10: 24 a.m . with RN A revealed, it is my responsibility to remove expired medications. She stated, I just missed it. I am sorry. Anyone could have received this medication in the 200 hallway that had an order for Aspirin 325mg tablet. RN A stated that giving expired medications can decrease its effectiveness.<BR/>Interview on 07/21/22 08:58 a.m. with the DON revealed that he stated I go through medications every Sunday. He stated she got specialized glasses a week ago and maybe that was what caused her to miss that expired medication. DON stated that giving expired medications can decrease potency.<BR/>Review of the facility's policy on Medication Storage in the Facility dated January 2018, revealed, . G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had complete admission orders for the resident's immediate care for 1 of 3 residents (Resident #97) reviewed for physician orders. <BR/>The facility failed to ensure Resident #97 had dialysis orders in place when she was admitted . <BR/>This failure placed residents at risk of not receiving the care they required. <BR/>Findings included:<BR/>Review of Resident #97's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included end stage kidney disease requiring dialysis, diabetes, and heart failure. <BR/>Review of Resident #97's admission MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. Her Functional Status indicated she required limited assistance with her ADLs. <BR/>Review of Resident #97's admission care plan revealed she required hemodialysis for her kidney failure, with interventions of dialysis on Monday, Wednesday, and Friday every week. <BR/>Review of Resident #97's physician orders revealed no order for the resident to go to dialysis. <BR/>Interview on 09/17/23 at 11:32 AM, Resident #97 stated she was just admitted on [DATE] and the facility had done a good job of getting her to her dialysis appointments on time. They provided her with a snack to eat while at dialysis, as well as an extra blanket to keep her warm. She stated her dialysis days are Monday, Wednesday, and Friday. <BR/>Interview on 09/19/24 at 10:28 AM, the DON stated Resident #97 should have had her dialysis orders in place when the physician wrote her admission orders. The DON stated he was glad staff did not miss any of her dialysis days, but they should have noticed there was no order in place. <BR/>Review of the facility's Hemodialysis Access Care policy and procedure did not cover physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 2 residents (Resident #97) reviewed for dialysis. <BR/>The facility failed to ensure staff provided ongoing assessment of Resident #97's condition and monitoring for complications after dialysis treatments received at a certified dialysis facility.<BR/>This failure placed the residents at risk of undetected complications post-dialysis.<BR/>Findings included:<BR/>Review of Resident #97's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included end stage kidney disease requiring dialysis, diabetes, and heart failure. <BR/>Review of Resident #97's admission MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. Her Functional Status indicated she required limited assistance with her ADLs. <BR/>Review of Resident #97's admission care plan revealed she required hemodialysis for her kidney failure, with interventions of dialysis on Monday, Wednesday, and Friday every week. <BR/>Review of Resident #97's Dialysis Communication Sheets revealed she had been to dialysis three times since admission [DATE]) and had three communication sheets in her binder. The post dialysis assessments were not completed by the staff or 09/13/23 and 09/15/23. Review of nursing progress notes and daily assessments revealed no post dialysis assessments for either day as well. <BR/>Interview on 09/19/23 at 10:28 AM, the DON stated all post dialysis assessments were documented on the dialysis communication sheets located in each resident's dialysis binder. The DON stated if the assessments were not completed it placed the residents at risk of post dialysis problems going undetected. <BR/>Review on 09/19/23 of the facility policies reflected the facility did not have a policy addressing post dialysis assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure staff did not prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #24, #26, and #64) observed for infection control.<BR/>The facility failed to ensure LVN C sanitized her re-useable blood pressure cuff between resident uses. <BR/>This failure placed residents at risk of contracting or spreading infectious agents. <BR/>Findings included:<BR/>Review of Resident #24's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke affecting his right side, diabetes, and candidiasis (fungal) infection. <BR/>Review of Resident #24's quarterly MDS, dated [DATE], revealed a BIMS score of 13 indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. <BR/>Review of Resident #24's care plan revealed he was at risk of impaired psychosocial well-being related to Covid. <BR/>Review of Resident # 26's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included skin infection of his leg, emphysema, and morbid obesity. <BR/>Review of Resident #26's quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. <BR/>Review of Resident #26's care plan revealed he was at risk of impaired skin integrity related to poor nutrition and non-compliance with diet and hygiene. <BR/>Review of Resident #64's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pneumonia, emphysema, and respiratory failure. <BR/>Review of Resident #64's quarterly MDS, dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. His Functional Status revealed he required limited assistance with his ADLs.<BR/>Review of resident #64's care plan revealed he was at risk for impaired skin integrity related to fragile skin. <BR/>Observation on 09/18/23 from 7:57 AM-8:59 AM LVN C exited Resident #24's room with a reusable blood pressure cuff and returned it to her cart without sanitizing it. LVN-C then next used the blood pressure cuff on Resident #24 and returned it to her cart without sanitizing it. Resident #24 notified LVN C that he was having symptoms of sore throat, cough, and congestion. LVN C stated he would have to be tested for Covid. LVN C next used the blood pressure cuff on Resident #64 and again returned it to her cart without sanitizing it. <BR/>Observation and interview on 09/18/23 at 10:35 AM LVN C's cart had sanitizing wipes located in the bottom drawer. LVN C stated the wipes were used to wipe down the cart, the glucose monitor, and the pill crusher. LVN C was asked if the wipes were for the blood pressure cuff and she affirmed they were. LVN C was asked why she had not sanitized the cuff between Residents #24, #26, and #64, and she admitted to being nervous with the surveyor monitoring her. She stated the risk of not sanitizing the blood pressure cuff between uses was spreading an infection from one resident to another. <BR/>Interview on 09/19/23 at 10:28 AM, the DON stated all reusable medical equipment had to be sanitized between each resident in order to prevent spreading infectious agents from one resident to another. <BR/>Review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment, policy, dated July 2014, reflected:<BR/> .4. Reusable resident care equipment will be decontaminated and/or sterilized between residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #77) reviewed for reasonable accommodation of needs.<BR/>The facility failed to ensure the call light system was within reach of the Resident #77, who was sitting in a wheelchair by the foot of the bed.<BR/>This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers.<BR/>Findings included:<BR/>Record review of Resident #77's MDS assessment dated [DATE] reflected Resident #77 was an [AGE] year-old female with a BIMS score 03 of 15, indicating severe cognitive impairment. Resident #77 was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus (elevated blood sugar), Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and hypertension (elevated blood pressure). The review further reflected the resident was totally dependent on staff for the ADLs .<BR/>Record review of Resident #77's Comprehensive Care Plan dated 11/11/24 reflected Focus. Resident#77 has impaired cognitive function/dementia or impaired thought process related to .impaired decision making. Goal. The Resident#77 Will be able to communicate basic needs on a daily basis through the review date. Interventions. Keep the Resident's routine consistent . in order to decrease confusion. Record review revealed no intervention of keeping the call light within reach of the resident.<BR/>Observation on 11/13/24 at 08:43 AM revealed Resident#77 was sitting in her wheelchair by the foot of the bed, and the call light was lying by the head of the bed. Resident#77 stated she could not reach the call light. This state surveyor called LVN F inside the Resident#77's room and pointed to the call light by the head of the bed. LVN F stated the call light was not within reach of Resident#77. He took the call light and placed it closer to Resident#77 by the foot of the bed. Resident#77 took the call light and held it in her hand. <BR/>Interview on 11/13/24 at 08:53 AM LVN F stated the call light was not within reach of the Resident#77. LVN F stated the call light should be within residents' reach all the time. LVN F stated the risk to the resident was not getting help he/she needed. LVN F stated it was the responsibility of all the staff to make sure the call light was within resident reach before exiting the room.<BR/>Interview on 11/13/24 at 10:05 AM the DON stated his expectation was the call light should be always within resident reach. He stated it was the responsibility of all staff to make sure the call light is within resident reach. The DON stated the risk to residents, if the call light was not within resident reach or did not work properly, was the residents could not call for help.<BR/>Review of the facility policy titled Call Lights: Accessibility and Timely Response, revised 05/01/2024 revealed The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance .5. Staff will ensure the call light is within reach of resident and secured, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure staff did not prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #24, #26, and #64) observed for infection control.<BR/>The facility failed to ensure LVN C sanitized her re-useable blood pressure cuff between resident uses. <BR/>This failure placed residents at risk of contracting or spreading infectious agents. <BR/>Findings included:<BR/>Review of Resident #24's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke affecting his right side, diabetes, and candidiasis (fungal) infection. <BR/>Review of Resident #24's quarterly MDS, dated [DATE], revealed a BIMS score of 13 indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. <BR/>Review of Resident #24's care plan revealed he was at risk of impaired psychosocial well-being related to Covid. <BR/>Review of Resident # 26's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included skin infection of his leg, emphysema, and morbid obesity. <BR/>Review of Resident #26's quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. <BR/>Review of Resident #26's care plan revealed he was at risk of impaired skin integrity related to poor nutrition and non-compliance with diet and hygiene. <BR/>Review of Resident #64's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pneumonia, emphysema, and respiratory failure. <BR/>Review of Resident #64's quarterly MDS, dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. His Functional Status revealed he required limited assistance with his ADLs.<BR/>Review of resident #64's care plan revealed he was at risk for impaired skin integrity related to fragile skin. <BR/>Observation on 09/18/23 from 7:57 AM-8:59 AM LVN C exited Resident #24's room with a reusable blood pressure cuff and returned it to her cart without sanitizing it. LVN-C then next used the blood pressure cuff on Resident #24 and returned it to her cart without sanitizing it. Resident #24 notified LVN C that he was having symptoms of sore throat, cough, and congestion. LVN C stated he would have to be tested for Covid. LVN C next used the blood pressure cuff on Resident #64 and again returned it to her cart without sanitizing it. <BR/>Observation and interview on 09/18/23 at 10:35 AM LVN C's cart had sanitizing wipes located in the bottom drawer. LVN C stated the wipes were used to wipe down the cart, the glucose monitor, and the pill crusher. LVN C was asked if the wipes were for the blood pressure cuff and she affirmed they were. LVN C was asked why she had not sanitized the cuff between Residents #24, #26, and #64, and she admitted to being nervous with the surveyor monitoring her. She stated the risk of not sanitizing the blood pressure cuff between uses was spreading an infection from one resident to another. <BR/>Interview on 09/19/23 at 10:28 AM, the DON stated all reusable medical equipment had to be sanitized between each resident in order to prevent spreading infectious agents from one resident to another. <BR/>Review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment, policy, dated July 2014, reflected:<BR/> .4. Reusable resident care equipment will be decontaminated and/or sterilized between residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's physician and responsible party of a significant change in condition for one (Resident #1) of five residents reviewed for notification of changes. 1. The facility failed to notify Resident #1's responsible party when the resident's urinary catheter was found removed with the balloon intact, when the resident's antibiotic therapy was modified from being administered through a PICC line to oral and when the PICC line became clogged and was unable to be used.2. The facility failed to notify the physician of Resident #1's missed IV antibiotic doses and refused medications. This failure could place residents at risk for delayed medical evaluation, treatment, lack of timely involvement by the responsible party in resident care decisions and the potential for worsening of the resident's condition.Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year-old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction) and direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high-risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline (a long peripheral IV catheter inserted into a vein in the arm, with its tip terminating in the arm, not reaching the heart) upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas all initiated on 10/08/25: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously. Res frequently pulls wound vac off despite education. May use wet to moist dressing if dislodged; B. Focus: The resident is on anticoagulant therapy.D. Focus: The resident has Intravenous (IV) Access. Resident #1's care plan did not reflect the use of a catheter. Record review of pertinent nursing notes related to Resident #1's change of condition reflected:-A nursing progress note by LVN A on 09/24/25 at 9:45 PM reflected Resident #1 pulled her PICC line out on her own and it was found next to her bed with no active bleeding at insertion site. There was no documentation to reflect the RP was notified. -A nursing progress note by LVN D the next morning on 09/25/25 at 8:45 AM reflected Nurse called [RP] for consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-A nursing progress note by LVN A on 10/03/25 at 9:45 AM reflected Resident #1 pulled out her foley catheter (a thin, flexible tube inserted into the urethra to drain urine from the bladder) with the balloon (anchors the catheter in the bladder, preventing it from slipping out) intact and was found by the CNAs. Nurse assessment reflected there was no bleeding or obvious trauma noted. There was no documentation to reflect the RP was notified of the removal.-A nursing progress note by LVN A on 10/06/25 at 8:40 PM reflected, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line (An IV line is used to deliver medicines, fluids, blood products, or nutrition into a patient's bloodstream) and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders. There was no documentation to reflect the RP was notified of the PICC line issue.-A nursing progress note by LVN E dated 10/07/25 at 12:01 AM reflected, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. There was no documentation the RP was notified at the time of the new order implementation. An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed Resident #1 missed several IV antibiotic doses while at the facility. She said the nurses told her the pharmacy had not sent the medication yet. The RP said days later, the facility switched Resident #1 to oral antibiotic medication without notice to the RP. She stated, They just said, 'We're giving her pills now'. The RP also stated she was never informed that IV therapy had been discontinued or that doses were missed. The RP stated she was never notified of major changes in Resident #1's condition or treatment. The RP said no one told her the PICC line was no longer going to be used. The RP stated she learned about each incident only when she visited. The RP stated she was never told Resident #1 pulled out her catheter. She stated she remembered visiting the resident and did not see the catheter bag hanging on the side of her bed or wheelchair. The RP stated she did not recall any concerns being voiced by the hospital post-fall on 10/08/25 of any vaginal trauma. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 pulled at her catheter quite a bit and would itch around the area and LVN D felt it irritated the resident's skin, but she never saw her pull it out. She said at one point, Resident #1 did pull out her PICC line and it was replaced by the infusion company. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. She said she did contact [MD C] to get an oral antibiotic approved. LVN D stated Resident #1 would take oral medications much easier but she did not notify the RP of the order change. LVN D said the change of dose from IV to oral happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated the nurse who got the order change was responsible for calling the RP. She did not know who got the order change. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. An interview with LVN A on 10/15/25 at 3:55 PM revealed she provided antibiotics though Resident #1's IV but did not provide wound care. She stated the wound vac functioned as far as she knew and when she sent Resident #1 to the ER on her shift the day after her admission for vomiting, I accidentally let it (wound vac) go with her. But we got it back and everything was functioning properly. LVN A stated she was the charge nurse who did Resident #1's initial admission and sent her out on day two (09/25/25) and did her subsequent re-admission on [DATE]. LVN A stated Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP . LVN A did not recall any problems flushing the PICC line the first night, but on the second admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it but was unable to flush the line because it was clotted in the PICC line due to being exposed to air and she notified MD C and the RP. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated Resident #1 did have a catheter and pulled it out, but she was not sure when and thought it was night two of admission. LVN A stated a CNA notified her the catheter was found on the floor. When she went to assess, she saw the catheter with a 10-cc [NAME] intact (a flexible tube-foley catheter, that is inserted into the bladder to drain urine with the 10-cc referring to the balloon's capacity of 10 cubic centimeters or milliliters) had been removed. LVN A stated, She ripped it out. She said Resident #1 showed no pain and there was no blood. LVN A said she notified MD C and nursing administration, assessed and placed Resident #1 in a brief and got her cleaned up. LVN A stated the potential harm of pulling out a catheter, I mean anything pulled out the size of a straw there could be internal trauma. I think it was a 22 French (a large-diameter urinary catheter used in specific situations where a larger size is needed to prevent blockage. The 22 French refers to the catheter's external diameter, which is approximately 7.3 mm). She stated the catheter removal happened at the end of her shift, so it was turned over to the night shift. LVN A said she did not consider the catheter removal to be a change in condition. LVN A stated, In hindsight, [RP] should have been notified by the nursing staff. I gave report the next shift, it had just happened. LVN A said the event happened on her shift and she should have been the nurse to notify the RP about it. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall on 10/08/25 at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated when she called, she stated, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we had put a broken wound vac on her, clogged PICC line and she was not getting IV antibiotics and we let her fall and break her hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic and no doses were missed. The ADO said she did verify via Resident #1's chart that, She declined so much and I don't think it mattered what lines she had, she would have pulled on any of them due to her dementia and it was a sad situation. The ADO stated maybe Resident #1's RP was not contacted about the catheter removal because the nurse did not think there was a medical change of condition. She stated, If it happens on your shift, you own it. The oncoming nurse isn't responsible because they weren't there. An interview with the VPCO on 10/16/25 at 10:40 AM revealed when she reviewed Resident #1's nursing documentation and chart, she did not see where the RP was notified of the catheter removal. An interview with the DON on 10/16/25 at 1:00 PM revealed he had heard Resident #1's catheter had been pulled out and the RP should have been notified by the nurse on the hall at the time. He stated it was important because we always want to keep families up to date with any changes. Review of the facility's policy titled, Notifying the Physician of Change in Status (revised 03/11/2013) reflected, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilized the INTERACT tool, 'Change in Condition-When to Notify the MD/NP/PA' to review resident conditions and guide the nurse when to notify he physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work Day notification of the physician.5) The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 7) The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's order and the resident's status and response to interventions.

**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 regarding the resident's care and treatment for one (Resident #1) of five residents reviewed for care concerns. The facility failed to document a grievance, respond and follow through on Resident #1's RP concerns when she voiced them to multiple management staff about poor nursing care and issues with her PICC line, wound vac, antibiotic medication and falls. This failure could place residents at risk for harm by allowing ongoing care concerns-including missed medications, PICC line and wound care issues, to go unaddressed, delaying necessary interventions and oversight.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity (the parts of the body from the hips down to the feet, including the thighs, knees, legs, ankles, and toes). Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously (a treatment that uses suction to aid healing in chronic or non-healing wounds), B. Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25), C. Focus: The resident has Hip Fracture. (Date Initiated: 10/08/25), D. Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25) and E. Focus: The resident is risk for falls (Date Initiated: 10/08/25).Record review of Resident #1's medication order summary for September 2025 and October 2025 reflected she required extensive wound care and IV therapy following her readmission with a right hip infection and sepsis. Resident #1's physician orders directed that the surgical wound to the right hip be cleaned with normal saline, packed with gauze and draped daily with a negative pressure wound therapy vac (a medical device that uses suction to promote wound healing) to remain in place continuously at 125 mmHg. Resident #1 also had standing orders for IV antibiotics, including Cefazolin every eight hours and Bactrim DS for bacterial infection and Lovenox for prevention of blood clots. Additional physician instructions included daily saline flushes to maintain IV line patency (the state of being open or unobstructed, allowing for the free flow of fluids, air, or blood) and wet-to-moist dressing changes if the vac became dislodged.An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed she was not notified when the resident's PICC line was not able to be flushed and used to administer the IV medications. She stated when she saw the PICC line tubing, it appeared black and crusted, and she became aware of the issue only during a visit. The RP also stated staff did not contact her to inform her that Resident #1's IV antibiotic therapy had been stopped and change to oral medications until after the change was made. The RP stated the nursing staff told her she would be fine taking oral medications, but she was concerned Resident #1 would not be able to swallow them safety due to being on a pureed diet. The RP further stated she was not notified when the resident's urinary catheter immediately after it had been dislodged and not replaced. The RP stated she expected to be informed of any change to IV therapy or catheter status, as she was the responsible party for the resident's care decisions. Review of the facility's documented grievances from 09/25/25 through 10/18/25 revealed none for Resident #1. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated on the call she told the RP, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we had put a broken wound vac on her, clogged PICC line and she was not getting IV antibiotics and we let her fall and break her hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic and no doses were missed. The ADO then stated she notified the RP that an incident report to HHSC would be initiated for the fall with a major injury and the RP responded, 'You have plenty of time to falsify the chart. An interview with the VPCO on 10/16/25 at 10:40 AM revealed she was not aware about the issues with Resident #1's PICC line, wound vac or two falls until after Resident #1 was transferred to the hospital on [DATE] The VPCO said the ADO had notified her Resident #1's RP was upset after the second fall on 10/08/25 and the facility had initiated a self-reported incident to HHSC based upon the concern that she was upset with care. She thought the ADO also completed a grievance for the RP's care concerns and they were important because any concerns needed to be addressed appropriately and reported back to whoever made the concern.An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay if she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he did not complete a grievance form related to Resident #1's RP concerns but he told her he would talk to the insurance company about the coverage for oral versus IV medication. He also said the RP had concerns about the wound vac but when he saw it on Resident #1, it was working and told her it was on her now. The DON stated looking back, he probably could have done a grievance for the RP's concerns, but when he was talking to her, he thought they were on the same page and she was satisfied with their conversation. An interview with ADON G on 10/18/25 at 12:26 PM revealed she had recently learned that any staff member could enter a grievance into their e-charting system. She said once those were entered online, they were routed to the appropriate department for review. ADON G stated, It takes the burden off one person. Typically, our social worker did them before. ADON G added that when families made multiple or serious complaints, the determination whether it qualified as a formal grievance depended on the grievance and what was involved. If the issue was complex, ADON G said it could require additional resources and multiple department members. ADON G stated staff were expected to check with a supervisor or management before deciding not to initiate a grievance so they could ensure every concern was documented.A follow up interview with the ADO on 10/18/25 at 12:43 PM revealed when a resident had a concern or complaint, she expected anyone with PCC access (a cloud-based software platform for the senior and long-term care industry that helps manage electronic health records, billing, and resident engagement)-with the exception of CNAs-to open a grievance and start it. The ADO stated grievances were entered electronically and management reviewed them daily and during monthly QAPI meetings. The ADO stated her expectation was that any concern was documented, and If there's frustration, anger, or genuine concerns-it's a grievance. She said if a resident/family member were emotionally attached or anxious about a concern, that was when staff should recognize something is wrong and initiate a grievance. The ADO said when Resident #1's RP raised concerns about wound care and supervision, the ADO and the DON reviewed documentation and determined whether a grievance was warranted. The ADO stated, Looking through the chart, it looked like communication had been happening through the PICC line issue and staff were documenting. I didn't think a grievance was needed at that time, but I did a self-report for the fall with injury and the RP's concern that the facility was not caring for her [Resident #1]. The ADO confirmed that a self-report was submitted to the State and that she and a corporate clinical RN investigated it that same evening and discovered Resident #1's PICC line was clotted and that an oral antibiotic was subsequently obtained. She stated she saw that the resident's antibiotics were changed and the wound vac was replaced. When asked if the RP's concerns fit the definition of a grievance under the facility's policy, the ADO replied, Personally, I do not, because we addressed it with a self-report.Review of the facility's Provider Investigation Report to HHSC for Resident #1 dated 10/08/25 reflected the incident category listed was Other and the description of the allegation by the ADO who reported it was, Resident stood up at the nurses station and fell. The self-report did not indicate any concerns of abuse/neglect of Resident #1 or concerns that the RP felt the resident's care was a concern.Review of the facility's policy titled, Grievances (Revised 11/02/2016) reflected, The resident has a right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.Procedure:.2. The grievance official of this facility if the administrator or their designee. 3. The grievance official will: Oversee the grievance process, Receive and track grievances to their conclusion.Issue written grievance decisions to the resident.6. All written grievances decisions will include: 1) The date the grievance was received, 2) A summary statement of the resident's grievance, 3) The steps taken to investigate the grievance, 4) A summary of the pertinent findings or conclusions regarding the resident's concern(s), 5) A statement as to whether the grievance was confirmed or not confirmed, 6) Any corrective action taken or to be taken by the facility as a result of the grievance and 7) The date the written decision was issued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time-frames to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility failed to revise Resident #1's care plan after she fell on [DATE] to include updated fall prevention interventions and nursing management's identification of 1:1 supervision needs. The failure could place residents at risk for additional falls and injury by delaying the implementation and documentation of required supervision and safety interventions following a known fall event. Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity (the parts of the body from the hips down to the feet, including the thighs, knees, legs, ankles, and toes). Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Record review of Resident #1's Fall Risk Assessment completed dated 09/24/25 reflected a score of 11, which indicated she was a high-risk. Record review of a nursing progress note dated 10/07/25 at 12:15 PM by ADON G reflected Resident #1 had an unwitnessed fall in her room from a low bed and was discovered on the floor next to her bed. The progress note further reflected, Another resident alerted staff that resident was observed to be on the floor. Upon entering the room resident was next to bed already attempting to get back up and on knees next to w/c. Res unable to answer questions regarding intent. Res obs for injury, Neuro's (assesses the nervous system through a combination of tests on mental status, cranial nerves, motor and sensory function, coordination and balance, and reflexes) initiated, VS stable. Denies any c/o pain. Res assisted w/ 2 assist up to w/c No Pain. Interventions noted to be in place prior to fall were a floor mat and low bed. Interventions initiated in response to the fall were documented as, 1 on 1 supervision (involves a dedicated caregiver providing constant, undivided attention to prevent falls and ensure safety due to cognitive impairment). Record review of Resident #1's Transfer Notification nursing note dated 10/08/25 at 1:27 PM by ADON G reflected the resident had a fall at the nurses' station and hit her head. The fall caused an abrasion to the left side of the head. Resident #1 was noted to react to painful stimuli with any attempts to move her bilateral lower extremities and was bleeding. The nursing note further reflected, Resident was sitting in w/c at nurses' station when staff heard her scream. She was noted to be standing up and attempting to walk. She lost balance and hit her head against the nurses' station and landed on left side of body. No LOC noted and mentation (the overall mental activity of the mind, including thinking, memory, reasoning, perception, and consciousness) remained at baseline. VS assessed. Neuros assessed. Attempted to locate wounds/injury. EMS called. [RP] notified.Interventions in place prior to fall: 1 on 1 supervision. T Record review of Resident #1's care plan initiated 09/25/25 reflected a focus area/interventions for falls was initiated on 10/08/25 by the CCN and reflected, Focus: The resident is risk for falls (Date Initiated: 10/08/25)- Interventions/Tasks: 1) Anticipate and meet the resident's needs (Date Initiated: 10/08/25), 2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date Initiated: 10/08/25), 3) Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Date Initiated: 10/08/25), Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Date Initiated: 10/08/25), Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (Date Initiated: 10/08/25), Keep furniture in locked position (Date Initiated: 10/08/25), Keep needed items, water, etc, in reach (Date Initiated: 10/08/25), Pt evaluate and treat as ordered or PRN (Date Initiated: 10/08/25), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove [sic]any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Date Initiated: 10/08/25), Staff x 2 to assist with transfers (Date Initiated: 10/08/25), The resident needs a safe environment (Date Initiated: 10/08/25), The resident needs activities that minimize the potential for falls while providing diversion and distraction (Date Initiated: 10/08/25). An interview with CNA H on 10/15/25 at 1:02 PM revealed she worked with Resident #1 and assisted her with all ADLs including feeding, changing and transfers. CNA H stated Resident #1 could not stand or ambulate safely on her own and required hands-on help at all times. CNA H stated that staff had discussed Resident #1 needing a one-on-one person to be with her because she could not be left alone without risk of falling. She said the ADONs and charge nurses were aware Resident #1 needed constant monitoring and that she tried to keep the resident within sight while on duty, especially during meals and rounding the hall. CNA H stated Everyone knew she couldn't be left by herself. An interview with LVN D on 10/15/25 at 12:32 PM revealed she was aware Resident #1 was a high-risk for falls and that staff were expected to keep her within eyesight. She said she knew from change of shift report and staff discussion that Resident #1 required close monitoring and should not attempt to get up unassisted. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 required increased supervision following her initial fall. She said she kept Resident #1 near the nurses' station in her wheelchair, So I could keep an eye on her. LVN A stated Resident #1 was confused and impulsive but pleasant, and she understood that nursing staff were expected to monitor her closely even though no one-on-one supervision was formally ordered. An interview with ADON G on 10/16/25 at 1:20 PM revealed she knew Resident #1 was a high fall risk and that increased supervision had been discussed after the first fall. She said she believed staff were keeping the resident near the nurses' station to maintain visual supervision but admitted she did not know whether she updated the care plan to reflect the need for 1:1 supervision. An interview with the ADO on 10/17/25 at 9:26 AM revealed when she reviewed the 10/07/25 fall incident report, it reflected 1:1 supervision had been selected as the intervention. She said ADON G entered the intervention but was unsure whether it had been communicated clearly to all shifts. The ADON said she assumed staff were aware of the supervision expectation but acknowledged that it may not have been documented in the care plan. An interview with ADON G was conducted on 10/18/25 at 12:26 PM and revealed the facility's policy when a resident fell was to update the care plan at the time of the incident and new interventions were expected to be documented by the end of the shift. ADON G stated the charge nurse was responsible for those updates with the assistance of MDS staff if available. ADON G said that waiting 24-hours to update the care plan was too long because documentation should reflect current risks and care being provided. She stated, If we are adjusting interventions, we need to record that. ADON G stated the charge nurse was responsible for initiating the care plan revision following a fall and that CNAs were notified of new interventions verbally before the plan was formally updated. A follow-up interview with the ADO on 10/18/25 at 12:43 PM revealed her expectation was that care plans were to be reviewed and updated during the same shift when an event or change in condition occurred. The ADO stated, During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time. The care plan revision-we can do them then. That's the gold standard. She clarified that charge nurses were responsible for initiating revisions and could place immediate interventions after a fall or change in condition. The ADO stated, If I am the DON, you're calling me after a resident falls, and I expect you to intervene and make it right. I try to communicate to my nurses to put a plan in place. She said new interventions post falls should be communicated to CNAs by updating the Kardex (a online documentation system, originally a brand name for a paper-based system, used primarily by nurses to keep a quick, organized summary of essential patient information) and through verbal handoff. She said the Kardex was the CNAs' quick look for what residents needed. Review of the facility's policy titled, Fall Policy (not dated) reflected, The Fall risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history and functional status. Information may be obtained by reviewing current medical records, interview with resident/family or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care; reassessment will occur after each fall. Interventions will be resident centered. Record review of the facility's Comprehensive Care Plan Policy (not dated) reflected, Each person will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Interventions are the specific care and services that will be implemented.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS Assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 Residents (Resident #61) reviewed for quality of care.<BR/>The facility failed to ensure Resident #61 was wearing compression wraps (a specialized hosiery designed to help prevent the occurrence of and guard against further progression of venous disorders such as swelling/inflammation and blood clots) as ordered by the physician. <BR/>This failure placed residents at risk of not receiving appropriate care and worsening of their conditions. <BR/>Findings included: <BR/>Record review of Resident #61's face sheet revealed the resident was a [AGE] year-old male, admitted [DATE] and readmitted [DATE] with diagnosis of Type 2 Diabetes (high blood sugar), peripheral vascular disease (slow and progressive circulation disorder), cellulitis (bacterial infection), dermatitis (skin inflammation), edema (buildup of fluid), unsteadiness on feet, and high blood pressure. <BR/>Record review of Resident #61's quarterly MDS dated [DATE], revealed a BIMS score of 15 indicating the resident's cognition was intact. The assessment reflected Resident #61 required supervision with dressing, one-person physical assist. <BR/>Record review of Resident #61's undated care plan revealed the care plan did not address Resident #61's order for bilateral knee high 15 compression hose. <BR/>Record review of Resident #61's physician order dated 08/08/23 revealed Bilateral knee high 15 compression hose one time a day, apply in the morning Remove at bedtime remove per schedule. <BR/>Record review of Resident #61's clinical records did not reveal the resident had refused physician order for compression hose. <BR/>Observation and interview with Resident #61 on 09/17/23 beginning at 11:16 AM revealed the resident sitting on the side of the bed. The resident was observed with both feet swollen and with dry flaky skin. Resident #61 stated he has been having problems with both feet being swollen and hurting at times. When asked about his feet, Resident #61 stated he needed cream or lotion on them to prevent the dry skin. The resident stated he should be wearing compression hose everyday; however, he had not worn them in about a month. Resident #61 stated he required assistance to get them on because they are so tight, they were used to help prevent the swelling. Resident #61 stated staff had not asked or attempted to put them on in a long while. <BR/>Observation of Resident #61 on 09/18/23 at 9:15 AM revealed Resident #61 sitting on the side of the bed, Resident #61 was observed without compression hose, both feet swollen and dry with flaky skin. <BR/>Observation and interview with Resident #61 on 09/18/23 beginning at 3:00 PM without compression hose, Resident #61 stated staff did not assist or offer to place compressions hose today, the hose are in my armoire (pointing behind the door). <BR/>Observation of Resident #61 on 09/19/23 at 9:30 AM without his compression hose, feet were swollen with dry skin. <BR/>Interview on 09/18/23 at 10:36 AM with LVN E revealed Resident #61 will have compression hose put on and he will take them off or refuse to have them on. According to LVN E, the last time he attempted to put them on was yesterday morning, they could be in his top drawer, or he will put them in the laundry. LVN E stated he was not aware of the risk involved with not having on the socks. LVN E stated Resident #61 does frequently have swollen feet and takes 80 milligrams of Lasix. LVN E stated there was an active order in place to have the compression hose on daily and removed at bedtime. LVN E stated it was facility policy to follow doctor orders. LVN E stated nursing staff were responsible for ensuring to attempt to put the socks on daily. LVN E stated nursing staff were responsible to document and notify the doctor if residents refuse the order. <BR/>Interview on 09/19/23 at 3:35 PM with the DON revealed Resident #61's feet were usually swollen. The DON stated Resident #61 did have an active order to wear compression hose. According to the DON, Resident #61 did not always leave the compression hose on due to them feeling tight on his legs. The DON stated he was not sure of the last time nursing staff had put the compression hose on Resident #61. The DON stated he assisted Resident #61 at least two weeks ago to place on the hose. The DON stated he expected staff to assist Resident #61 with the compression hose daily and as stated in the order. The DON stated the charge nurse was responsible for initiating and administering the compression hose on a daily basis. The DON stated not using the compression hose could place Resident #61 at risk of complications of edema (swelling caused by excess fluid trapped in tissue). According to the DON, he expected staff to properly document in resident charts anytime a resident was administered treatment, resident refused treatment or a change in resident condition. The DON stated not accurately documenting resident treatment would affect resident treatment goals and outcomes. <BR/>A policy regarding Treatment orders was requested; however, it was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 6 residents (Residents #37 and #72) reviewed for accidents and supervision. <BR/>The facility failed to ensure Residents #37 and #72 were properly covered with a smoking apron while being supervised during smoking breaks. <BR/>These deficient practices could place residents at risk for burns causing injury or harm. <BR/>Findings included: <BR/>Record review of a Face Sheet for Resident #37 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included repeated falls, weakness, high blood pressure, acute upper respiratory infection, chronic obstructive pulmonary disease, lack of coordination, abnormal posture. <BR/>Record review of Resident #37's Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated a cognition level that was moderately impaired. <BR/>Record review of Resident #37 ' s's Smoking Evaluation dated 01/24/23 revealed resident was able to smoke independently but could not safely have smoking paraphernalia. <BR/>Record review of Resident #37's undated care plan revealed a focus that Resident #37 was a smoker and required staff supervision/adaptations when using smoking tobacco. Goals: I will follow tobacco policy of community without injuring myself or others. Interventions: I require facility to keep all tobacco and fire-starting materials for safety. Observe my clothing, skin, and environment for signs of cigarette burns. Staff will complete a smoking assessment to ensure my safety quarterly and as needed. <BR/>Record review of a Face Sheet for Resident #72 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (diseases that cause airflow blockage), lack of coordination, repeated falls, weakness, other fatigue, pneumonia, acute respiratory failure with hypoxia, high blood pressure, tobacco use. <BR/>Record review of Resident #72's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated a cognition level that was intact. <BR/>Record review of Resident #72's Smoking Evaluation dated 01/24/23 revealed resident was able to smoke independently but could not safely have smoking paraphernalia. <BR/>Record review of Resident #72's undated care plan revealed a focus that Resident #72 was a smoker and required staff supervision/adaptations when using smoking tobacco. Goals: I will follow tobacco policy of community without injuring myself or others. Interventions: I require facility to keep all tobacco and fire-starting materials for safety. Observe my clothing, skin, and environment for signs of cigarette burns. Staff will complete a smoking assessment to ensure my safety quarterly and as needed. <BR/>Observation on 09/18/23 1:30 PM revealed Residents #37 and #72 was observed outside smoking with Hospitality Aide M, Resident #37 was observed being handed a cigarette by Hospitality Aide M. Hospitality Aide M then reached over to light Resident #37's cigarette. Hospitality Aide M then passed Resident #72 a cigarette box which housed cigarettes, lighter, and smoking apron, then she sat down. Resident #72 lit her own cigarette. Hospitality Aide M was then told by residents that were outside smoking, in unison, they told Hospitality Aide M that Resident #37 also required an apron. Hospitality Aide M passed Resident #72 a smoking apron. During the smoking break, Resident #37 and Resident #72, were not properly wearing their smoking aprons to cover their entire body. Hospitality Aide M was observed sitting with residents, Hospitality Aide M was heard calling Resident #72 to wake up and finish cigarette. Hospitality Aide M was then observed to sit closer and engage with Resident #72 until she completed her smoke break. <BR/>During Interview on 09/18/23 at 1:47 PM with Hospitality Aide M revealed staff will pass out cigarettes to the smokers. Hospitality Aide M stated she would light cigarettes for residents that need a little more assistance, however most residents are able to light their own cigarettes on their own. Hospitality Aide M stated she was fairly new and was never told anything about the use of the aprons but there are two in the bag, residents told her who would use them. Hospitality Aide M stated she was responsible to make sure resident's aprons were fully covering their body for protection. Hospitality Aide M stated aprons are to be laid over the resident's lap and used to protect residents against fallen ashes. Hospitality Aide M stated, Resident #37 ad #72 did not have their smoking aprons on correctly because it did not cover their entire bodies, the aprons were only placed across their lap. <BR/>Observation on 09/18/23 03:33 PM Resident #37 and #72 were outside smoking with CNA L supervising. Resident #37 or Resident #72 were observed to have their smoking apron properly covering their body. Weekend Supervisor was observed to walk outside past Resident #37 and returned, instructing the CNA L to ensure smoking aprons are worn properly. Weekend Supervisor was observed in placing the strap around Resident #37's neck. <BR/>During interview with CNA L revealed certain hall assignments are responsible for taking residents outside for smoke break, staff are present to bring smoking products out and supervise residents to ensure they do not burn themselves. CNA L stated Resident #37 had the apron on his lap because he got upset when she attempted to strap it around his neck, he rather have it on his lap. CNA L stated Resident #72 does require one due to her ability to fall asleep. CNA L stated she was responsible for ensuring residents were properly wearing smoking aprons. CNA L stated hopefully there would not be any risk to residents because she was there to supervise otherwise residents could burn themselves. CNA L stated it was a state requirement to have the smoking apron worn properly to prevent injuries. <BR/>During interview on 09/19/23 at 2:51 PM with Weekend Supervisor revealed smoking products are kept by facility staff and are passed out during smoking breaks. Weekend Supervisor stated there are 2 residents that tend not to pay attention to the ashes falling on them, putting themselves at risk for burns or injury. Weekend Supervisor stated prior to Resident #37 and Resident #72 being handed a cigarette, staff are responsible to properly place a smoking apron to cover resident's entire body. Weekend Supervisor stated smoking risk assessments are completed and based on the score it would determine who would require the smoking aprons, reassessments are completed quarterly or as needed. Weekend Supervisor stated according to Resident #37's last assessment he did not require the use of a smoking apron. Resident #72's last assessment revealed she required supervision, and the assessment prior to that revealed Resident #72 required an apron. Weekend Supervisor stated he did not feel the assessments were completely accurate due to both requiring close supervision. <BR/>Record review of the facility Smoking Policy - Residents policy, revised December 2011, reflected: <BR/>This facility shall establish and maintain safe resident smoking practices prior to or upon admission residents shall be informed about any limitation on smoking, including designated smoking areas <BR/> .any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. <BR/> .any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking. <BR/> .the staff will review the status of a resident's smoking privileges periodically

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents are free of any significant medication errors for one (Resident #1) of five residents reviewed for pharmacy services. The facility did not administer Resident #1's prescribed IV antibiotics through her PICC line or her ordered Lovenox injections following a surgery for a right hip fracture sustained from a prior fall. This failure placed residents at risk of not receiving medications as prescribed in order to meet residents needs.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25)- Interventions/Tasks: Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (Date Initiated: 10/08/2025) Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25)-Interventions/Tasks: 1) Administer IV fluids as ordered (Date Initiated: 10/08/25), Administer IV medications as ordered (Date Initiated: 10/08/25), Check dressing at site daily. Monitor for signs and symptoms of infection, Drainage, Inflammation, Swelling, Redness, Warmth. if present notify the physician (Date Initiated: 10/08/25), Flush the ports/lines as ordered (Date Initiated: 10/08/25), If Tegaderm ( a transparent medical dressing used to cover and protect wound sites); change dressing every 7 days and prn-If gauze dressing change every 48 hours (Date Initiated: 10/08/2025), the resident has PICC line IV access (Date Initiated: 10/08/2025). Record review of a facility admission Alert-Communication Alert for Approved Admissions for Resident #1 dated 09/24/25 at 3:36 PM and signed by LVN Q reflected the resident's ETA was 6:00 PM and her special requirements included ADL assist, IV meds and wounds. Equipment needs included PICC line and wound vac. A copy of the hospital discharge orders were included in the alert and reflected Resident #1 had Cefazolin (Ancef) 2 grams intravenously every eight hours and Ertapenem one gram intravenously every day. Record review of Resident #1's order summary reflected the prescribing physician was MD C: -Cefazolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection, R hip (Start Date 09/25/25); -Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously every 24 hours for infection, R hip for 1 Day (start date 09/24/25) and Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for R hip fracture related to for 28 Days (Start Date 09/25/25. Record review of Resident #1's September 2025 MAR reflected she was not administered her three antibiotic doses of Cefazolin on 09/25/25, her second day of admission at 1:00 AM (refused) and 9:00 AM (refused). Record review of Resident #1's October 2025 medication administration record reflected that she was not administered her prescribed anticoagulant Lovenox or her IV antibiotic Cefazolin on 10/03/25. A nursing note by LVN D reflected, Resident refused, swatting at nurse. Further review reflected Lovenox was also not administered on 10/06/25, 10/07/25 and 10/08/25 with refusals again documented by LVN D on the MAR. Additionally, the oral antibiotic Bactrim, ordered by MD C on 10/06/25 was not administered until the morning of 10/07/25). Record review of a Resident #1's pertinent nursing progress notes reflected: -09/24/25 at 6:00 PM by LVN A (admission nursing note) documented she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered.-09/24/25 at 8:46 PM LVN A documented Ertapenem was not administered due to awaiting delivery from pharmacy.- 09/25/25 at 12:14 AM LVN E documented Cefazolin was not administered due to Awaiting med from pharmacy and PICC line to be replaced.-09/25/25 at 3:55 AM by LVN E documented the infusion company was contacted to schedule PICC replacement.-09/25/25 at 8:45 AM by LVN D documented, Nurse called [RP] or consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-09/25/25 at 9:15 AM by LVN D documented Resident #1's PICC line was in place and an x-ray confirmed placement.-09/25/25 at 10:06 AM by LVN D documented the Cefazolin was not administered due to Waiting on pharmacy.-09/25/25 by LVN A-Transfer Notification Progress Note by LVN A on reflected, [Resident #1] was transferred to a hospital on [DATE] 8:30 PM related to vomiting black, meaty smelling emesis x 2. This is intended to serve as notice of an emergency transfer. A nursing note dated 10/02/25 by LVN A reflected Resident #1 re-admitted with a diagnosis of an upper GI bleed, was non-mobile and bedfast, was not oriented or alert and had memory impairment and she had a foley catheter in place.-10/06/25 at 8:13 AM-e-MAR administration note by LVN D reflected the Lovenox injection was not administered due to Resident swatting at nurses hands and jumping.-10/06/25 at 8:40 PM LVN A documented, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders.-10/07/25 at 12:01 AM LVN E documented, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10 days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. All needs anticipated and met by staff. Resting in bed with eyes closed. No s/s of distress/discomfort noted. Bed low, call light in reach, fall mat in place.-10/07/25 at 9:43 AM by LVN D documented Lovenox was not administered because, Resident pushed nurse's hands away and refused injection.-10/08/25 at 8:59 AM by LVN D reflected the resident refused the medication administration for Lovenox. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 did pull out her PICC line and it was replaced by the infusion company during her stay. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it. She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her. She said she did contact [MD C] to get an oral antibiotic approved. She stated Resident #1 would take oral medications much easier but she said she did not notify the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the day of the second re-admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it was unable to flush the line because it was clotted in the PICC line due to being exposed to air. LVN A said Resident #1 had an arterial venous two port. She said she notified MD C and the RP but was not sure which infusion company to call due to recent contract changes and the recent facility company changeover. She said, They (unknown) were going to talk to administration and it was taken out of my hands. LVN A said she worked with Resident #1 the next evening and her PICC line was working. LVN A said she did not know what happened with the PICC line, I didn't get a good report on that, but it was functioning. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated there was no alternative when a when a resident pulled out a PICC line, and it wasn't until the second removal that MD C ordered an oral antibiotic to cover the resident until they tried to figure out what we were going to do. She further stated, We just didn't know what to do with her honestly. I don't think we were the right place for her, she needed memory care. An interview with the VPCO on 10/16/25 at 10:40 AM revealed Resident #1's IV antibiotic was changed to oral because she was pulling at other things and the thought process by the charge nurse was to change the order to po to make it easier to administer. She stated, I believe the physician obliged and switched to Bactrim. The VPCO stated there was one dose that the charge nurse was unable to administer for IV antibiotics from the 10/06/25 into 10/07/25 due to the line being clotted, so an oral order was obtained and the new antibiotic was administered the morning of 10/07/25. She said the facility had an e-kit and that was where Resident #1 got her initial dose of Bactrim. An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay it she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he was not notified when Resident #1's PICC line was clogged but was told the next day the nurse had to get an order to change it to oral antibiotic. The DON stated there was a way to get a PICC line going again, there was a company the facility used that came out and unclogged them. The DON stated, I don't believe they came out and unclogged it. I don't know why. It was already discontinued and pulled out by the time I got to work so I didn't assess it. The DON stated his expectation was it a PICC line was clogged, the charge nurse should have called the infusion company to get a new one placed. He did not know if the infusion company worked 24/7, but thought if the line came out at night, they would come out the next morning. If it could not get replaced quickly, the DON said the nurse would notify the doctor. He did not know what the charge nurse did that night the PICC line was clogged. An interview with ADON G on 10/16/25 at 1:20 PM revealed she did not know Resident #1's PICC line was clotted or the IV meds had been stopped until she got to work the morning after and got shift report. ADON G said she was told the night nurse had received an order from MD C for an oral antibiotic. She did not know if that nurse had contacted the infusion company to come and replace the line before requesting the route change and she did not know if the charge nurse assessed the PICC line post-removal. An interview with MD C was attempted and unsuccessful on 10/17/25 9:55 AM. An interview with the C-VP on 10/17/25 at 12:59 PM revealed Resident #1 was unable to receive one of her antibiotic medications three times via her PICC line and MD C was notified and the PICC line was removed. She did not know if MD C was told the IV antibiotic was unable to be administered per order. A follow up interview with LVN A on 10/17/25 at 2:05 PM revealed there was a pharmacy the facility used that did deliveries three times a day. She did not know the exact times, but thought one was at dinner time and one at midnight. LVN A said if a resident admitted in the later part of the afternoon, there may be some medications that would come in that night, but by the daytime next shift, they would all be coming in. She stated the latest she could order medications for a new admission from the pharmacy was around 5 or 6 pm for the midnight delivery. LVN A stated missing three doses of IV antibiotics, the facility should already be talking about a backup plan with the doctor. LVN A stated the problem with missing three doses of IV abx was you will not have a decrease in bacteria, there would be an increase and flora will start growing. LVN A stated she was open to oral antibiotics due to the problems with the PICC line and Resident #1 fiddling with the lines and unwrapping the bandaging. LVN A stated the facility tried long-sleeved shirts and [MD C] went with the flow of whatever we had to do. Regarding the Lovenox, LVN A stated she tried to contact the doctor and get a hold order which was done typically when residents refused it. She stated Lovenox was an anticoagulant and was prescribed because Resident #1 had a hip fracture and was prone to a DVT, which could travel to her lungs and give her a pulmonary embolism. She said anyone who had a surgery was prone to that, especially leg surgery. She stated she never administered Resident #1 Lovenox because it was a morning medication and she did not work that shift. If a resident refused a high risk medication, LVN A said the protocol was by the second refusal, she would notify the doctor. LVN A stated there was a problem the night she tried to fax MD C about Resident #1's PICC line being clotted and she did not start the oral Bactrim that night as a result. She stated the order would have been sent to the pharmacy and she felt like she probably gave it from the e-kit but could not remember. An interview with MD K on 10/17/25 at 1:00 PM revealed he was the medical director for the facility and he and MD C had the bulk of the residents as patients. He stated he did not know Resident #1 and had never seen her as she was not assigned as his patient. However, as the medical director, MD K stated if a resident had an IV antibiotic medication upon admission and the facility knew they would not be able to obtain and give the medication when it is to be given, they really did not have a choice but to send the resident back to the hospital. MD K stated, I've told them before to send them back and infuse as an outpatient in the emergency room at the hospital until we get the antibiotic delivered, then they can come back. He stated some residents were more critical than others, for example, if the resident admitted with sepsis, They certainly need to have it [IV abx] continued. MD K stated missing three doses of an antibiotic medication was too many and he thought that the facility's contracted pharmacy would have provisions to do stat deliveries. MD K stated Lovenox was an anticoagulant that was used to help prevent DVT for surgery and it should be readily available. He stated if a resident was refusing Lovenox, the simple solution would be to change the medication to Xarelto or Eliquis, both oral medications, But they need to call the doctor to consult us if the resident is refusing. MD K stated a lot depended on the patient and the shape they were in, if they were bedfast or had any peripheral edema. An interview with LVN L on 10/18/25 at 11:33 AM revealed when a new resident admitted with time-sensitive mediations, as the admission nurse he would write the order, enter it into the computer, call the pharmacy and verify if they received the order. Then if it was an antibiotic and the facility did not have it, he would check the e-kit to see if it was available and call the pharmacy to get the code. He stated if he needed a medication and it was not in the e-kit, he would call the pharmacy and let the doctor know the resident did not receive the dose and hope it came in the next day. LVN stated he did not administer Resident #1's Lovenox because it was a morning medication. He said Lovenox was quite important because it was a blood thinner, One degree lower than heparin. An interview with RN M on 10/18/25 at 11:49 AM revealed when a new resident admitted , the charge nurse who admitted the resident could always check the e-kit and see if the medication was available, if not, then call the pharmacy and see how soon they could get it to the facility. Then the physician should be contacted to see if he wanted an alternative medication or did he want to wait. RN M did not know what antibiotics were kept in the e-kit and said pharmacy usually came around 8-10 PM on her shift. RN M stated with the anticoagulant Lovenox, she did not work with Resident #1 but knew the medication was used to keep blood clots from forming and was usually used after surgeries. An interview with ADON G on 10/18/25 at 12:26 PM revealed when a resident was newly admitted , orders were to be entered timely and as ordered. For medications not in stock, ADON G said they worked with what they had in stock and usually did not get advanced notice of orders coming in with new admissions. She stated that the nursing management, which included herself and the DON, reviewed admissions, verified orders had been processed and the pharmacy had been contacted. ADON G stated there was no formalized tracking log showing timeliness for medication deliveries or stat medications. She said her expectation would be for the nurse to notify the physician immediately if a medication was unavailable or delayed, ADON G stated communication between nurses, pharmacy and provider was expected to be verbal and immediate for critical admissions and that if issues arose, They would be expected to call the pharmacy and discuss any issues. An interview on 10/18/25 at 12:43 PM with the ADO revealed that upon a resident's admission, nursing staff immediately entered new orders into e-MAR, which transmitted directly to the pharmacy. She stated, When they arrive to the facility, we enter meds into e-MAR which immediately sends the order to the pharmacy. She said the pharmacy delivered in the evenings, but if not, the facility had an extensive e-kit available to utilize. The ADO described that for time-sensitive medications, such as IV antibiotics or anticoagulants, if the item was not in stock and needed urgently, We can call pharmacy and they can STAT a med out. We also have contracts with local pharmacies so it can be 'hot-shotted' to the facility. The ADO said the administrative nurses (ADONs and DON) were supposed to verify admissions and ensure the pharmacy had been contacted. The ADO stated, It's a team effort to admit a resident, but med entry is a priority after initial assessment because we know we have to get them in-it's an immediate process. The ADO stated for monitoring missed or delayed medications, We review our dashboard. The DON and I review it during morning meeting, and if we see any missed meds, then we address it right then. She added that if a PICC line was dislodged or malfunctioned, nurses were expected to notify the physician immediately, obtain orders for replacement and if necessary, Call immediately to our PICC line vendor, and if it will delay to next dose, then get alternate med or hold if not critical for the resident. Review of the facility's e-Kit medication list provided by the ADO on 10/18/25 reflected there were two tablets available for Sulfamethoxazole/Trimethoprim (also known as Bactrim) . The e-kit inventory list also reflected the facility had emergency access in the kit to the blood thinners Eliquis, Xarelto and Warfarin as well as alternative oral antibiotics of Amoxicillin-Clavulanate, Ceftriaxone, Ciprofloxacin and Azithromycin. Review of the facility's policy titled, Medication Administration and General Guidelines (dated March 2025) reflected, Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time.Unless otherwise specified by the physician, routine medications are administered according to the established administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.The physician must be notified when a dose of medication has not been given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one (Resident #8) of 5 residents reviewed for PASARR . <BR/>The facility failed to refer Resident #8, who had an active diagnosis of Post Traumautic Stress Disorder (PTSD), to the appropriate state-designated authority for Level II PASARR evaluation.<BR/>This failure could affect residents with mental disorders, intellectual disabilities, or a related condition by placing them at risk for not receiving needed treatment and services that could enhance their quality of life.<BR/>Findings included:<BR/>Review of Resident #8's quarterly MDS assessment dated [DATE] revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses to include: hypertension (elevated blood pressure), diabetes Mellitus (elevated blood sugar), anxiety, depression, and PTSD. The resident had a BIMs score of 15, indicating her cognition was intact, and required substantial/maximal assistance with ADLs. There was not a diagnosis of dementia. <BR/>Review of Resident #8's Medical Diagnosis Report dated 10/22/19 revealed, Post Traumatic stress disorder. <BR/>Review of Resident #8's PASARR Level 1 screen dated 09/06/19 revealed Effective date: 09/06/2019, Resident#8. MI/ID/DD : N-N-N. admitted : yes. Status date: 09/06/2019. Status: Negative PASRR (sic) Eligibility. <BR/>Review of Resident#8's psychological evaluation dated 01/30/22 revealed Resident#8 was referred for psychological service in April of 2017 due to anxiety and picking at her skin, at which time she was diagnosed with adjustment disorder and PTSD. currently carries the diagnoses of F43.10 post-traumatic stress disorder .<BR/>Interview on 11/13/24 at 07:58 AM. with the Administrator revealed, he stated the Social Worker and the MDS coordinator were responsible for resident record review during the resident admission and with any changes in the resident status thereafter. <BR/>Interview on 11/13/24 at 08:24 AM with Social Worker revealed, she stated she was not responsible for completing the PASARR level 1. She stated the MDS coordinator was responsible for completing the PASARR level 1 and following with the residents. She stated her responsibility on admission was to do the resident code status and schedule the care plan meeting. <BR/>Interview on 11/13/24 at 09:34 AM with the MDS coordinator revealed she was responsible for the PASARR level 1. The MDS coordinator stated when a resident admits to the facility, she reviewed the resident's information documenting the admission information on the PASARR level 1. She stated if the resident had a diagnosis of Mental Illness Health, she would answer yes to the question asking if they had a diagnosis. MDS coordinator stated the LA would come to complete a PASARR level 2 to see if the resident qualifies for services. She stated Resident#8 had been living in the facility since 2016, and the PASARR level 1 done for Resident#8 on 09/06/19 was related to the facility change of ownership. She stated that the follow-up for the PASARR 1 was her responsibly, and the SW would notify her if she noticed some change in the resident diagnosis, and the MDS coordinator would report to the LA. The MDS coordinator gave examples of diagnosis that she would check yes for: Schizophrenia, bipolar disorder, psychosis, anxiety with psychosis. The MDS coordinator stated it could had been missed, because she did not know that PTSD was a diagnosis that will qualify the residents for PASARR level 2 evaluation. She stated that the follow-up for the PASARR 1 was her responsibly and the meetings were also her responsibility, if the residents qualified for services (specialized services) it would be the responsibility of the department manager to receive the orders and initiate the services. <BR/>Interview on 11/13/24 at 09:50 AM with Resident #8 revealed she did not know anything about PASARR or specialized services, no one had talked to her about that. The resident said if she was entitled to something, she wanted to be able to get it.<BR/>Interview on 11/13/24 at 10:05 AM with the DON revealed, he stated the MDS coordinator took care of the PASARR reports. The DON stated he did know that PTSD was a qualifying diagnosis for PASRR. The DON stated if the assessment was not completed properly, he thought the resident might not get services she needed.<BR/>Record review, no date, of facility's form, Active Residents with PASARR Positive PI , did not include Resident #8.<BR/>Review of the facility's policy and procedure Resident Assessment-Coordination with PASRR (sic) program implemented March 01, 2023, reflected, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .a. A resident who exhibits behavioral, psychiatric, . symptoms . (where dementia is not the primary diagnosis).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of four residents (Resident #13) reviewed for catheter and incontinence care. <BR/>1. The facility failed to ensure NA E and CNA D maintained the foley catheter drainage bag below Resident #13's bladder during a mechanical lift transfer. <BR/>2. The facility failed to ensure CNA C did not place the urine catheter bag on the bed while performing incontinence care for Resident #13. <BR/>These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. <BR/>Findings included:<BR/>1. Record review of Resident #13's quarterly MDS assessment, dated 10/02/24, reflected a [AGE] year-old male with an admission date of 01/13/11 and a re-admission date of 05/29/24. He had a BIMS of 9, which indicted he was moderately cognitively impaired. Resident #13 required substantial/maximum assist with ADLs and was dependent of 2 persons assist with transfers. He had an indwelling catheter and was always incontinent of bowel. Resident #13 had diagnoses which included obstructive uropathy (structural or functional hindrance of normal urine flow) and hemiplegia (paralysis that affects one side of the body). <BR/>Record review of Resident #13's care plan, with a revision date of 08/29/24, reflected, The resident has 18 French (measurement of the circumference of the outer catheter tube) indwelling catheter related to obstructive uropathy .Goal .The resident will show no signs or symptoms of urinary infection through the review period .Interventions .Catheter anchor in place .Change as needed .Monitor/record/report to MD for signs and symptoms of urinary tract infection <BR/>Record review of Resident #13's Order summary report, dated 11/13/24, reflected .Foley catheter care every shift and as needed . with a start date of 05/30/24.<BR/>In an observation on 11/12/24 at 11:15 a.m. CNA C entered Resident #13's room to provide catheter care. CNA C washed hands and put on gloves. CNA C placed a towel on the floor and placed a plastic container on the floor and emptied the foley catheter drainage bag which contained approximately 150 cc of dark amber urine. CNA C emptied the container of urine, removed her gloves, and performed hand hygiene and put on clean gloves and proceeded to provide catheter care and incontinence care. CNA C unfastened the catheter drainage bag and placed in on the bed between the resident's feet. Urine was observed in the tube flowing back toward the resident. CNA C then unfastened the brief and pulled the foreskin back revealing moderate amount of white drainage around the penis head. CNA C cleaned in circular motion and then cleaned the catheter tubing from tip downward. ADON A entered Resident #13's room and performed hand hygiene and put on gloves. ADON A immediately picked up the catheter bag lying on the bed and placed it back on the bed frame ADON A and CNA C completed the incontinence care and removed their gloves and performed hand hygiene. <BR/>In an interview with CNA C on 11/12/24 at 11:35 a.m. she stated the catheter bag was considered dirty and by placing it on the bed it was not below the bladder and urine could back up into the bladder. <BR/>In an interview with ADON A on 11/12/24 at 11:40 a.m. he stated he walked into the room and observed the catheter bag on the bed and knew it was not supposed to be on the bed, and he instinctively stepped in and placed it in the proper place to ensure the flow of urine was not backing up toward the resident. He stated the staff were taught to always keep the urinary drainage bag below the bladder. <BR/>In an observation with ADON A on 11/13/24 at 09:20 a.m. NA E and CNA D entered Resident #13's room with the Mechanical lift. Both staff washed their hands and put on gloves. Both staff maneuvered the lift around the resident's wheelchair and hooked the sling to the lift. NA E unhooked the catheter bag from the wheelchair and started to hook it to her pants legs when CNA D instructed her to hang it on the mechanical lift arm. NA E placed the catheter bag on the arm of the mechanical lift which was above the resident's bladder. The staff lifted the resident up with the catheter bag above the bladder and transferred him from the wheelchair to the bed. Staff then unhooked the urinary drainage bag and placed it on the bed frame. <BR/>In an interview with ADON A on 11/13/24 at 09:30 a.m. he stated the urinary drainage bag was not supposed to be hooked to the mechanical lift during the transfer because it placed it above the bladder which could increase the risk of the urine backing up into the bladder and causing urinary tract infections. He stated he realized after the observations he had seen the past two days they needed to be observing the staff more frequently while they were providing care. He stated they had developed some bad habits and he needed to address how they were training and reinforce that training through more one-on-one observations during resident care. <BR/>In an interview on 11/13/24 at 09:35 a.m. with CNA D she stated they were supposed to ensure the catheter tubing was over the resident's leg. She stated she was afraid if NA E had hooked the drainage bag to her pants it would pull the catheter too tight when they transferred Resident #13. She stated the catheter was supposed to be lower than the bladder but stated she really was not sure how they were supposed to keep it below the bladder during a mechanical lift transfer. She stated she guessed one of them should have held the catheter bag during the transfer. <BR/>In an interview on 11/13/24 at 09:40 a.m. with NA E she stated they were supposed to always keep the catheter bag below the bladder to prevent the urine from flowing back toward the resident's bladder. She stated one of them should have held it below the bladder. <BR/>In an interview with the DON on 11/13/24 at 01:00 p.m., he stated any resident with a foley catheter should always have the bag and tubing below the bladder and the bag should never be placed on the bed. He stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. He stated all the staff had been trained numerous times on the expectation. He stated to ensure staff were knowledgeable in the care of indwelling catheters and peri-care the facility did skills competency checks, but stated he and ADON A had discussed they were going to have to observe staff more frequently during resident care. <BR/>Record Review of CNA D's skills check off dated 10/09/24 reflected she was competent in the care of indwelling catheters and infection control. <BR/>Record Review of NA E's skills check off dated 10/08/24 reflected she was competent in the care of indwelling catheters and infection control. <BR/>Record review of the facility's policy titled, Perineal Care, dated May 2024, did not address foley catheter care.<BR/>Record review of the facility's undated skills assessment titled, Indwelling Catheter care, reflected, Ensure that the resident has a catheter secured in placed and a privacy bag for the urine collection bag. Never lift the catheter urine bag above the resident's bladder .

Based on observation, interview, and record review the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. <BR/>The facility failed to ensure various foods stored in the freezer were sealed, dated and labeled. <BR/>This failure could place all residents at risk for food contamination and food borne illness. <BR/>Findings included: <BR/>Observation of the freezer on 09/17/23 at beginning at 9:00 AM revealed a grey tub in the top of the freezer, 4 clear plastic bags one each of breaded rectangles measuring about 3 inches long and 1inch thick, white rectangles 3 inches long and 1 inch thick, potato wedges, diced potatoes, and a blue bag with circular noodles. The blue bag was not properly sealed, labeled or dated. The four clear bags were not properly labeled or dated. At the bottom of the freezer, it appeared to be spilled orange ice cream that was frozen at the bottom of the freezer. <BR/>Interview on 09/17/23 at 9:05 AM with [NAME] D revealed the grey tub in the freezer was used to hose leftover items that were cooked from a previous day or food items that were taken from their original box. [NAME] D revealed bagged items in the tub were breaded fish, baked fish, potato wedges and diced potatoes. [NAME] D stated the blue bag were cheese Cannoli and it was tied in a knot when placed in the freezer. [NAME] D stated she would usually go back to the tub first before opening a new box food item to see what was available or to add to the menu as an alternate. [NAME] D stated the cooks and Dietary Manager are responsible for ensuring foods placed in the freezer are properly sealed, labeled and dated. [NAME] D state cooks and Dietary Manager were responsible for completing a walk through on a weekly basis to ensure anything past 7 days are discarded. [NAME] D stated she was unsure of who placed the items in the tub, however it should have been properly labeled and dated. [NAME] D stated she did not do a walk-through this morning to review the items in the tub. [NAME] D stated not having foods properly sealed, labeled, or dated could led staff to cook foods that are expired or out of date causing residents to have food poisoning. <BR/>Interview on 09/17/23 at 12:30 PM with the Dietary Manager revealed the tub in the top of the freezer is where overflow foods are placed, when foods are low it is taken out the of the original box and in the tub. The Dietary Manager stated she was new back in the kitchen and recently had an in-service on how to properly seal, label, and date all food items by the dietician. The Dietary Manager stated it was the responsibility of all cooks and herself to ensure food items are sealed, labeled, and dated properly. The Dietary Manager stated she and the cooks complete a walkthrough at least weekly to discard old foods from each, the freezer, fridge, and the pantry. The Dietary Manager stated she was not aware of who placed the food items without labeling or dating them, but not doing so could cause food borne illnesses. The Dietary Manager stated she noticed the ice cream in the freezer, and it was cleaned. <BR/>Interview on 09/18/23 at 11:45 AM with the Administrator revealed he was aware food was to be properly sealed, labeled and dated, that the kitchen was in-serviced recently by the Dietitian. The Administrator stated the Dietary Manager was responsible for ensuring food was kept in a safe manner to prevent food borne illnesses. The Administrator stated not properly sealing, labeling, and dating food items could cause staff to use outdated food items. The Administrator stated he expects the kitchen to follow through with the in-service to properly store food items and to keep the storage equipment clean at all times. <BR/>Review of the facility's Food Receiving and Storage policy, dated July 2014, reflected: Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable environment, including but not limited to receiving treatments and supports for daily living for 1 of 5 residents (Resident #102) reviewed for quality of life.<BR/>Facility staff/Hospice Aide failed to provide Resident #102 with clean linens. <BR/>These failures could affect the residents by causing infections and skin issues. <BR/>Findings include:<BR/>A record review of Resident #102's MDS assessment dated [DATE] reflected Resident #102 was a [AGE] year-old male with a BIMS score of 00 of 15, indicating severe cognitive impairment. Resident #102 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), depression, and anxiety. The review further reflected the resident was on hospice services, and totally dependent on staff for the ADLs.<BR/>A record review of Resident #102's Comprehensive Care Plan initiated date 10/01/24 reflected Problem. Resident#102 has a terminal prognosis related to senile degenerative of the brain. Utilized: Hospice services. Goal. Resident#102's comfort Will be maintained through the review date. Interventions .Keep the environment quiet and calm, keep linens clean, dry, and wrinkle free . Work with the nursing staff to provide maximum comfort for the resident. <BR/>Observation on 11/13/24 at 07:55 AM of Resident #102 revealed that he was walking in the hall wearing daytime attire. Resident #102's linen (fitted sheet) was soiled with a feces smear at the middle of the bed, where Resident#102 would be if he was sitting at the edge of the bed. Resident#102 was unable to respond to interview.<BR/>Observation and interview on 11/13/24 at 01:27 PM revealed Resident #102's bed still had the same soiled fitted sheet. The state surveyor showed the soiled linen to NA K, and NA K responded the fitted sheet was dirty. NA K stated she was assigned to the Resident#102, but the hospice aide was responsible for giving Resident#102 a shower and changing his bed linen. She further stated she did not notice the dirty linen and did not know when the last time Resident#102's bed linen was changed. NA K stated the risk to Resident#102 was development of infection.<BR/>Observation and interview on 11/13/24 at 01:30 PM revealed LVN F entered Resident #102's room during the observation and interview with NA K. LVN F looked at Resident#102's bed linen fitted sheet, and stated it was dirty and need to be changed. LVN F stated the staff will change Resident#102's bed linen. LVN F stated the risk to Resident#102 was development of infection, and skin issues. <BR/>Interview on 11/13/24 at 01:57 PM with Hospice Aide, she stated she was responsible for changing the linen on the days of the resident showers. The hospice Aide stated she gave a shower to Resident #102 this morning, and did not change the bed linen, because she could not find clean linen, and she looked in other Halls linen carts. The hospice Aide stated she could not recall the staff she notified.<BR/>Interview on 11/13/24 at 02:05 PM with NA K and LVN F revealed, both denied been notified by the hospice Aide regarding Resident#102's bed linen not being changed after Resident#102's shower this morning.<BR/>Interview on 11/13/24 at 02:19 PM with the DON revealed, he stated the hospice aides were responsible for giving residents in hospice services showers and changing the resident's linen on the shower day. DON stated not changing Resident#102's bed linen because the hospice aide could not find clean linen was not acceptable, and the hospice aide was supposed to communicate the issue with the management. The DON stated the hospice aides get training on residents' care via their agency. DON stated the risk to residents was infection, and skin issues.<BR/>On 11/13/24 at 03:00 PM the facility administrator stated they do not have a policy for linen and safe clean comfortable home like.<BR/>The facility did not submit a policy for linen and safe clean comfortable home like policy by the date and time of exit.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 11 of 13 residents reviewed for activities.<BR/>The facility failed to ensure there were organized activities during the weekends according to 11 residents who attended the confidential group interview.<BR/>The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status.<BR/>Findings included:<BR/>Observation on 09/17/23 from 9:05 AM-3:00 PM residents were observed in their rooms either sleeping or watching television or in the lobby sitting. No activities were observed being provided.<BR/>Review of facility's current September 2023 Activities Calendar, revealed weekends activities scheduled were repetitive for every weekend 6am coffee bar & daily chronicles, 8am Sunday Morning Show, All day Activity Packets, 10am Shuffleboard, 2pm Resident Choice Movie, 4pm Yahtzee.<BR/>During the confidential resident group interview, on 09/18/23 at 9:48 AM, 11 of the 13 residents in attendance revealed during the weekends they had nothing to do. Residents revealed disliking the weekends because all they did was either stay in their rooms, sleep, watch television or find a place in the facility and sit all day. Residents stated they were aware of the activities that were schedule for them during the weekends; however, they did not like them. Residents stated they would like other options for activities. Residents stated they wanted to do activities other than coloring. Residents stated, Staff have more fun during the weekends than us (residents). Residents stated they had asked staff about other activities; however, nothing was being done. Residents stated the staff always wanted to provide them with drawings for them to color like if they were 2 years old. Residents stated the lack of activities had made them feel bored because they had nothing to do during the weekends.<BR/>Interview on 09/19/23 at 1:20 PM, the Activity Director revealed she had been employed since December 2022. She stated she worked Monday-Friday, but if a resident had a birthday during the weekend, she would come in to celebrate. She stated she completed the monthly activity schedules and during the weekends residents had activities like different coloring pages, crossword puzzles, movies and card games. The Activities Director stated the weekend staff were responsible for providing those activities to the residents. She stated residents could come in the activities rooms and do whatever they liked. She stated she had not had any residents complain about weekend activities. <BR/>Interview on 09/19/23 at 2:51 PM, RN G revealed he was the Weekend Supervisor and had been employed for about two weeks. He stated the Activities Director completed the monthly activities schedule. He stated during the weekends residents liked playing bingo. He stated they tried to encourage the residents to come to the activities room to watch a movie or find other things to do. He stated they did not have an assigned staff who did activities, it was whomever was available to do activities with the residents. He stated he had not had any residents complain about weekend activities. <BR/>Interview on 09/19/23 at 3:18 PM, Housekeeper J revealed she had been scheduled to work during the weekends. She stated when she worked during the weekends, she had not seen any activities being provided to the residents. She stated at times she would see residents coloring in the activity room, but no other activities were being provided. <BR/>Interview on 09/19/23 at 3:22 PM, LVN I stated she had been scheduled to work during the weekends. She stated since football season started residents watched football in their individual rooms. She stated they had an activities schedule planned for residents like puzzles, coloring pages, and movies. She stated some residents did attend but not all the time. She stated this past weekend she did not observe any activities being provided; she was not sure why. She stated she had offered residents to play dominos, but she was declined. She stated all the residents appeared content and were acquainted to their environment. <BR/>Interview via phone call on 09/19/23 at 3:27 PM, CNA H revealed he had been employed for three months and worked only the weekends. He stated residents did not have a lot of activities going on during the weekends. He stated they had an activities calendar with things to do with residents; however, they did not follow the schedule due to residents not wanting to participate. He stated residents mostly were sitting at the front area of the facility or would go outside and sit. He stated they tried to encourage residents to do activities like puzzles or bingo, but at times they do not want to. He stated this past Sunday 09/17/23 they had no activities provided to residents, and he was unsure why. He stated the weekend scheduled activities were repetitive. He stated the risk of not having weekend activities was that resident would be bored or depressed. <BR/>Interview on 09/19/23 at 3:52 PM, the DON revealed the Weekend Supervisor was responsible for ensuring weekend activities were being provided to the residents. He stated he has had conducted walk-ins during the weekends and had not had any residents mention any concerns regarding activities. He stated he had spoken to residents regarding weekend activities and no resident had mentioned any concerns. <BR/>Review of facility's current Quality of Life - Self Determination and Participation policy, dated December 2023, reflected the following: <BR/> .1. Each resident shall be allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including:<BR/>a. <BR/>Daily routine, such as sleeping, eating, exercise and bathing schedules; <BR/>b. <BR/>Personal care needs, such as bathing methods, grooming styles and dress; <BR/>c. <BR/>Health care scheduling, such as times of day for therapies and certain treatments; <BR/>d. <BR/>Activities, hobbies and interests; and <BR/>e. <BR/>Religious affiliation and worship preference

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 Residents (Resident #61) reviewed for quality of care.<BR/>The facility failed to ensure Resident #61 was wearing compression wraps (a specialized hosiery designed to help prevent the occurrence of and guard against further progression of venous disorders such as swelling/inflammation and blood clots) as ordered by the physician. <BR/>This failure placed residents at risk of not receiving appropriate care and worsening of their conditions. <BR/>Findings included: <BR/>Record review of Resident #61's face sheet revealed the resident was a [AGE] year-old male, admitted [DATE] and readmitted [DATE] with diagnosis of Type 2 Diabetes (high blood sugar), peripheral vascular disease (slow and progressive circulation disorder), cellulitis (bacterial infection), dermatitis (skin inflammation), edema (buildup of fluid), unsteadiness on feet, and high blood pressure. <BR/>Record review of Resident #61's quarterly MDS dated [DATE], revealed a BIMS score of 15 indicating the resident's cognition was intact. The assessment reflected Resident #61 required supervision with dressing, one-person physical assist. <BR/>Record review of Resident #61's undated care plan revealed the care plan did not address Resident #61's order for bilateral knee high 15 compression hose. <BR/>Record review of Resident #61's physician order dated 08/08/23 revealed Bilateral knee high 15 compression hose one time a day, apply in the morning Remove at bedtime remove per schedule. <BR/>Record review of Resident #61's clinical records did not reveal the resident had refused physician order for compression hose. <BR/>Observation and interview with Resident #61 on 09/17/23 beginning at 11:16 AM revealed the resident sitting on the side of the bed. The resident was observed with both feet swollen and with dry flaky skin. Resident #61 stated he has been having problems with both feet being swollen and hurting at times. When asked about his feet, Resident #61 stated he needed cream or lotion on them to prevent the dry skin. The resident stated he should be wearing compression hose everyday; however, he had not worn them in about a month. Resident #61 stated he required assistance to get them on because they are so tight, they were used to help prevent the swelling. Resident #61 stated staff had not asked or attempted to put them on in a long while. <BR/>Observation of Resident #61 on 09/18/23 at 9:15 AM revealed Resident #61 sitting on the side of the bed, Resident #61 was observed without compression hose, both feet swollen and dry with flaky skin. <BR/>Observation and interview with Resident #61 on 09/18/23 beginning at 3:00 PM without compression hose, Resident #61 stated staff did not assist or offer to place compressions hose today, the hose are in my armoire (pointing behind the door). <BR/>Observation of Resident #61 on 09/19/23 at 9:30 AM without his compression hose, feet were swollen with dry skin. <BR/>Interview on 09/18/23 at 10:36 AM with LVN E revealed Resident #61 will have compression hose put on and he will take them off or refuse to have them on. According to LVN E, the last time he attempted to put them on was yesterday morning, they could be in his top drawer, or he will put them in the laundry. LVN E stated he was not aware of the risk involved with not having on the socks. LVN E stated Resident #61 does frequently have swollen feet and takes 80 milligrams of Lasix. LVN E stated there was an active order in place to have the compression hose on daily and removed at bedtime. LVN E stated it was facility policy to follow doctor orders. LVN E stated nursing staff were responsible for ensuring to attempt to put the socks on daily. LVN E stated nursing staff were responsible to document and notify the doctor if residents refuse the order. <BR/>Interview on 09/19/23 at 3:35 PM with the DON revealed Resident #61's feet were usually swollen. The DON stated Resident #61 did have an active order to wear compression hose. According to the DON, Resident #61 did not always leave the compression hose on due to them feeling tight on his legs. The DON stated he was not sure of the last time nursing staff had put the compression hose on Resident #61. The DON stated he assisted Resident #61 at least two weeks ago to place on the hose. The DON stated he expected staff to assist Resident #61 with the compression hose daily and as stated in the order. The DON stated the charge nurse was responsible for initiating and administering the compression hose on a daily basis. The DON stated not using the compression hose could place Resident #61 at risk of complications of edema (swelling caused by excess fluid trapped in tissue). According to the DON, he expected staff to properly document in resident charts anytime a resident was administered treatment, resident refused treatment or a change in resident condition. The DON stated not accurately documenting resident treatment would affect resident treatment goals and outcomes. <BR/>A policy regarding Treatment orders was requested; however, it was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 6 residents (Residents #37 and #72) reviewed for accidents and supervision. <BR/>The facility failed to ensure Residents #37 and #72 were properly covered with a smoking apron while being supervised during smoking breaks. <BR/>These deficient practices could place residents at risk for burns causing injury or harm. <BR/>Findings included: <BR/>Record review of a Face Sheet for Resident #37 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included repeated falls, weakness, high blood pressure, acute upper respiratory infection, chronic obstructive pulmonary disease, lack of coordination, abnormal posture. <BR/>Record review of Resident #37's Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated a cognition level that was moderately impaired. <BR/>Record review of Resident #37 ' s's Smoking Evaluation dated 01/24/23 revealed resident was able to smoke independently but could not safely have smoking paraphernalia. <BR/>Record review of Resident #37's undated care plan revealed a focus that Resident #37 was a smoker and required staff supervision/adaptations when using smoking tobacco. Goals: I will follow tobacco policy of community without injuring myself or others. Interventions: I require facility to keep all tobacco and fire-starting materials for safety. Observe my clothing, skin, and environment for signs of cigarette burns. Staff will complete a smoking assessment to ensure my safety quarterly and as needed. <BR/>Record review of a Face Sheet for Resident #72 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (diseases that cause airflow blockage), lack of coordination, repeated falls, weakness, other fatigue, pneumonia, acute respiratory failure with hypoxia, high blood pressure, tobacco use. <BR/>Record review of Resident #72's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated a cognition level that was intact. <BR/>Record review of Resident #72's Smoking Evaluation dated 01/24/23 revealed resident was able to smoke independently but could not safely have smoking paraphernalia. <BR/>Record review of Resident #72's undated care plan revealed a focus that Resident #72 was a smoker and required staff supervision/adaptations when using smoking tobacco. Goals: I will follow tobacco policy of community without injuring myself or others. Interventions: I require facility to keep all tobacco and fire-starting materials for safety. Observe my clothing, skin, and environment for signs of cigarette burns. Staff will complete a smoking assessment to ensure my safety quarterly and as needed. <BR/>Observation on 09/18/23 1:30 PM revealed Residents #37 and #72 was observed outside smoking with Hospitality Aide M, Resident #37 was observed being handed a cigarette by Hospitality Aide M. Hospitality Aide M then reached over to light Resident #37's cigarette. Hospitality Aide M then passed Resident #72 a cigarette box which housed cigarettes, lighter, and smoking apron, then she sat down. Resident #72 lit her own cigarette. Hospitality Aide M was then told by residents that were outside smoking, in unison, they told Hospitality Aide M that Resident #37 also required an apron. Hospitality Aide M passed Resident #72 a smoking apron. During the smoking break, Resident #37 and Resident #72, were not properly wearing their smoking aprons to cover their entire body. Hospitality Aide M was observed sitting with residents, Hospitality Aide M was heard calling Resident #72 to wake up and finish cigarette. Hospitality Aide M was then observed to sit closer and engage with Resident #72 until she completed her smoke break. <BR/>During Interview on 09/18/23 at 1:47 PM with Hospitality Aide M revealed staff will pass out cigarettes to the smokers. Hospitality Aide M stated she would light cigarettes for residents that need a little more assistance, however most residents are able to light their own cigarettes on their own. Hospitality Aide M stated she was fairly new and was never told anything about the use of the aprons but there are two in the bag, residents told her who would use them. Hospitality Aide M stated she was responsible to make sure resident's aprons were fully covering their body for protection. Hospitality Aide M stated aprons are to be laid over the resident's lap and used to protect residents against fallen ashes. Hospitality Aide M stated, Resident #37 ad #72 did not have their smoking aprons on correctly because it did not cover their entire bodies, the aprons were only placed across their lap. <BR/>Observation on 09/18/23 03:33 PM Resident #37 and #72 were outside smoking with CNA L supervising. Resident #37 or Resident #72 were observed to have their smoking apron properly covering their body. Weekend Supervisor was observed to walk outside past Resident #37 and returned, instructing the CNA L to ensure smoking aprons are worn properly. Weekend Supervisor was observed in placing the strap around Resident #37's neck. <BR/>During interview with CNA L revealed certain hall assignments are responsible for taking residents outside for smoke break, staff are present to bring smoking products out and supervise residents to ensure they do not burn themselves. CNA L stated Resident #37 had the apron on his lap because he got upset when she attempted to strap it around his neck, he rather have it on his lap. CNA L stated Resident #72 does require one due to her ability to fall asleep. CNA L stated she was responsible for ensuring residents were properly wearing smoking aprons. CNA L stated hopefully there would not be any risk to residents because she was there to supervise otherwise residents could burn themselves. CNA L stated it was a state requirement to have the smoking apron worn properly to prevent injuries. <BR/>During interview on 09/19/23 at 2:51 PM with Weekend Supervisor revealed smoking products are kept by facility staff and are passed out during smoking breaks. Weekend Supervisor stated there are 2 residents that tend not to pay attention to the ashes falling on them, putting themselves at risk for burns or injury. Weekend Supervisor stated prior to Resident #37 and Resident #72 being handed a cigarette, staff are responsible to properly place a smoking apron to cover resident's entire body. Weekend Supervisor stated smoking risk assessments are completed and based on the score it would determine who would require the smoking aprons, reassessments are completed quarterly or as needed. Weekend Supervisor stated according to Resident #37's last assessment he did not require the use of a smoking apron. Resident #72's last assessment revealed she required supervision, and the assessment prior to that revealed Resident #72 required an apron. Weekend Supervisor stated he did not feel the assessments were completely accurate due to both requiring close supervision. <BR/>Record review of the facility Smoking Policy - Residents policy, revised December 2011, reflected: <BR/>This facility shall establish and maintain safe resident smoking practices prior to or upon admission residents shall be informed about any limitation on smoking, including designated smoking areas <BR/> .any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. <BR/> .any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking. <BR/> .the staff will review the status of a resident's smoking privileges periodically

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #51) reviewed for enteral nutrition.<BR/>The facility failed to follow Resident #51's physician orders for enteral feeding.<BR/>These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.<BR/>Findings included:<BR/>Record review of Resident #51's face sheet dated 09/19/23 revealed the resident was [AGE] year-old female admitted on [DATE] with a diagnosis that included cerebral infarction (stroke), and dysphagia (swallowing difficulties), <BR/>Record review of Resident #51's admission MDS dated [DATE] revealed the resident had moderate cognitive impairment with a BIMS score of 10. The assessment reflected Resident #51 required limited assistance with eating, one-person physical assist, and the resident received nutrition via a feeding tube.<BR/>Record review of Resident #51's care plan revised dated 09/07/23 revealed: Resident requires tube feeding r/t Swallowing problem. Goal: The resident will be free of aspiration through the review date. The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. The resident will remain free of side effects or complications related to tube feeding through review date.<BR/>Record review of Resident #51's physician order dated 08/27/23 revealed enteral Feed Order every 24 hours Isosource 1.5 at 55ml/hr continue x20hr. w/ water flushes 150mL q4h (off at 9am/on at 1pm). The order start date was 08/27/23. <BR/>Record review of Resident #51's physician order dated 08/27/23 revealed Tube Feeding off for 4hrs every 24 hours. The order start date was 08/27/23 9:00 AM. <BR/>Record review on 09/17/23 at 2:10 PM of Resident #51's September 2023 MAR revealed resident had been disconnected at 9:53 AM and was connected at 12:36 PM by LVN F. <BR/>Observation on 09/17/23 at 2:14 PM of Resident #51 lying in bed sleeping. Observed a feeding pump next to Resident #51 bed not infusing. A bag of enteral feeding was hanging from the pole of the feeding pump with a date of 09/17/23, time 5:30 AM, rate of 55 ml/hr x 20 hours. <BR/>Observation on 09/17/23 at 2:48 PM of Resident #51 lying in bed sleeping. Observed a feeding pump next to Resident #51 bed infusing. A bag of enteral feeding was hanging from the pole of the feeding pump with a date of 09/17/23, time 5:30 AM, rate of 55 ml/hr x 20 hours.<BR/>Interview on 09/17/23 at 2:54 PM LVN F revealed she was the nurse assigned for Resident #51. LVN F stated she disconnected Resident #51 at 11:00 AM. LVN F reviewed Resident #51 orders and stated resident had an order to be disconnected at 9:00 AM, be off for 4 hours and be reconnected at 1:00 PM. LVN F stated when she came in today (09/17/23) between the times of 8:00 AM-9:00 AM Resident #51 g-tube machine was beeping due feeding tube was clamped by Resident #51's upper extremities. LVN F stated Resident #51 did not received her full feeding amount and she decided to keep her on the g-tube longer. When LVN F was asked if she had documented in the Resident #51's MAR prior to stopping Resident #51 formula feeding, LVN F stated she made a mistake by clicking on Resident #51's MAR at 9:53 AM. LVN F stated she did not disconnect Resident #51 at 9:53 AM. She stated she disconnected her at 11:00 AM, and she did not reconnect her at 12:36 PM but at around 2:45 PM. LVN F was asked if she notified the physician, she stated she did and the Weekend Supervisor RN G was in the room with her when she disconnected Resident #51 at 11:00 AM. LVN F stated the risk of not following physician orders was that it could cause weight loss and residents not receiving the correct amount of formula.<BR/>Interview on 09/17/23 at 3:00 PM RN G revealed he was the Weekend Supervisor. He stated he had observed LVN F flush Resident #51 g-tube earlier this morning, unknown of the time. He stated he did not observe LVN F disconnect Resident #51, he stated he left the room. RN G stated he was unsure of Resident #51 physician orders; observed RN G review Resident #51's physician orders and stated Resident #51 had an order to be disconnected for 4 hours from 9:00 AM-1:00 PM. During the interview with RN G, LVN F intervened and stated to RN G remember you were in the room when I flushed her g-tube and I told you about [Resident #51] feeding machine beeping, that is why I disconnected her at 11AM. RN G stated he recalled LVN F had inform him about Resident #51's feeding machine beeping but did not observe when LVN F disconnected the resident. RN G stated his expectation was for the nurses to follow physician orders. If there was a problem, nurses should contact the physician for further instruction. RN G stated the risk of not following physician orders was that it could cause weight loss.<BR/>Record review of Resident #51's Progress Notes dated 09/17//23 at 15:39 [3:59 PM] by LVN F revealed: Effective Date: 09/17/23 at 9:30 AM Upon entering residents' room at beginning of shift residents gtube machine was clamped by residents' upper extremities which caused machine to alarm. Supervisor notified. Discussed Let feeding run overtime because the feeding was unknown to be adequately flowing through tubing r/t delayed feeding r/t equipment. Tubing residual checked and in normal range.<BR/>Record review of Resident #51's Progress Notes dated 09/17//23 at 15:56 [3:56 PM] by LVN F revealed: Effective Date: 09/17/23 at 14:54 [2:54 PM] Resumed feeding after 4 hrs of being stopped, residual within normal limits, Pain medications given for comfort. Will notify MD and hospice of Situation<BR/>Interview on 09/19/23 at 3:47 PM with the DON revealed his expectation were for his staff to follow physician orders. He stated he was made aware by RN G who is also the weekend supervisor about a problem that had occurred with Resident #51's g-tube. He stated he was informed LVN G had disconnected Resident #51 after 9AM. The DON was notified Resident #51's MAR indicated Resident #51 was disconnected at 9:53 AM and was provided with her feeding at 12:36 PM; however, the resident was not connected until around 3:00 PM. The DON stated the best practice was for staff to follow physician orders and then document after the procedure was completed. The DON stated the risk of not following physician order would be weight loss. <BR/>Interview via phone call on 09/19/23 at 4:24 PM with Resident #51's Physician revealed he had received a call from the facility on Sunday 09/17/23; however, he could not recall the conversation. <BR/>Record review of the facility's Enteral Nutrition policy, revised January 2014, reflected: Adequate nutritional support through enteral feeding will be provided to residents as ordered.

Based on observation, interview, and record review the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. <BR/>The facility failed to ensure various foods stored in the freezer were sealed, dated and labeled. <BR/>This failure could place all residents at risk for food contamination and food borne illness. <BR/>Findings included: <BR/>Observation of the freezer on 09/17/23 at beginning at 9:00 AM revealed a grey tub in the top of the freezer, 4 clear plastic bags one each of breaded rectangles measuring about 3 inches long and 1inch thick, white rectangles 3 inches long and 1 inch thick, potato wedges, diced potatoes, and a blue bag with circular noodles. The blue bag was not properly sealed, labeled or dated. The four clear bags were not properly labeled or dated. At the bottom of the freezer, it appeared to be spilled orange ice cream that was frozen at the bottom of the freezer. <BR/>Interview on 09/17/23 at 9:05 AM with [NAME] D revealed the grey tub in the freezer was used to hose leftover items that were cooked from a previous day or food items that were taken from their original box. [NAME] D revealed bagged items in the tub were breaded fish, baked fish, potato wedges and diced potatoes. [NAME] D stated the blue bag were cheese Cannoli and it was tied in a knot when placed in the freezer. [NAME] D stated she would usually go back to the tub first before opening a new box food item to see what was available or to add to the menu as an alternate. [NAME] D stated the cooks and Dietary Manager are responsible for ensuring foods placed in the freezer are properly sealed, labeled and dated. [NAME] D state cooks and Dietary Manager were responsible for completing a walk through on a weekly basis to ensure anything past 7 days are discarded. [NAME] D stated she was unsure of who placed the items in the tub, however it should have been properly labeled and dated. [NAME] D stated she did not do a walk-through this morning to review the items in the tub. [NAME] D stated not having foods properly sealed, labeled, or dated could led staff to cook foods that are expired or out of date causing residents to have food poisoning. <BR/>Interview on 09/17/23 at 12:30 PM with the Dietary Manager revealed the tub in the top of the freezer is where overflow foods are placed, when foods are low it is taken out the of the original box and in the tub. The Dietary Manager stated she was new back in the kitchen and recently had an in-service on how to properly seal, label, and date all food items by the dietician. The Dietary Manager stated it was the responsibility of all cooks and herself to ensure food items are sealed, labeled, and dated properly. The Dietary Manager stated she and the cooks complete a walkthrough at least weekly to discard old foods from each, the freezer, fridge, and the pantry. The Dietary Manager stated she was not aware of who placed the food items without labeling or dating them, but not doing so could cause food borne illnesses. The Dietary Manager stated she noticed the ice cream in the freezer, and it was cleaned. <BR/>Interview on 09/18/23 at 11:45 AM with the Administrator revealed he was aware food was to be properly sealed, labeled and dated, that the kitchen was in-serviced recently by the Dietitian. The Administrator stated the Dietary Manager was responsible for ensuring food was kept in a safe manner to prevent food borne illnesses. The Administrator stated not properly sealing, labeling, and dating food items could cause staff to use outdated food items. The Administrator stated he expects the kitchen to follow through with the in-service to properly store food items and to keep the storage equipment clean at all times. <BR/>Review of the facility's Food Receiving and Storage policy, dated July 2014, reflected: Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 2 of 18 residents (Resident #61 ad Resident #51) records reviewed for treatment documentation.<BR/>1. LVN E documented Resident #61 had been provided with his compression hose, but observation revealed resident was not provided with the care of compression hose.<BR/>2. LVN F documented Resident #51 had been connected to her g-tube feedings at 12:36 PM, but the resident was not connected to her g-tube feedings until 2:45 PM.<BR/>These failures could affect the residents medical record not being an accurate representation of the residents medical condition or medical needs. <BR/>Findings included:<BR/>1. Record review of Resident #61's face sheet revealed the resident was a [AGE] year-old male, admitted [DATE] and readmitted [DATE] with diagnosis of Type 2 Diabetes (high blood sugar), peripheral vascular disease (slow and progressive circulation disorder), cellulitis (bacterial infection), dermatitis (skin inflammation), edema (buildup of fluid), unsteadiness on feet, high blood pressure. <BR/>Record review of Resident #61's quarterly MDS dated [DATE], revealed a BIMS score of 15 indicating the resident's cognition was intact. The assessment reflected Resident #61 required supervision with dressing, one-person physical assist. <BR/>Record review of Resident #61's undated care plan revealed the care plan did not address Resident #61's order for Bilateral knee high 15-20mmHg compression hose. <BR/>Record review of Resident #61s physician order dated 08/08/23 revealed Bilateral knee high 15-20mmHg compression hose one time a day, Apply in the AM Remove at bedtime remove per schedule.<BR/>Record review of Resident #61's September 2023 MAR, revealed resident was provided with compression hose for the day of 09/17, 09/18 and 09/19/23 by LVN E. Applied at 0800 [8:00AM] and removed at 2000 [8:00PM]. <BR/>Observation and interview with Resident #61 on 09/17/23 beginning at 11:16 AM revealed resident sitting on the side of the bed, resident was observed with both feet swollen and with dry flaky skin. Resident #61 stated he has been having problems with both feet being swollen and hurting at times. When asked about his feet, Resident #61 stated he needed cream or lotion on them to prevent the dry skin, Resident stated he should be wearing compression hose everyday however he had not worn them in about a month. Resident #61 stated he required assistance to get them on because they are so tight, they are used to help prevent the swelling. Resident #61 stated staff had not asked or attempted to put them on in a long while. <BR/>Observation and interview with Resident #61 on 09/18/23 beginning at 9:15 AM revealed resident #61 sitting on the side of the bed, Resident #61 was observed without compression hose, both feet swollen and dry with flaky skin. Resident was observed on 09/18/23 at 3:00 PM without compression hose, Resident #61 stated staff did not assist or offer to place compressions hose today, the hose are in my armoire (pointing behind the door). <BR/>Observation of Resident #61 on 09/18/23 at 9:30 AM without his compression hose on, feet were swollen with dry skin. <BR/>Interview on 09/18/23 at 10:36 AM with LVN E revealed Resident #61 will have compression hose put on and he will take them off or refuse to have them on. According to LVN E, the last time he attempted to put them on was yesterday morning, they could be in his top drawer, or he will put them in the laundry. LVN E stated he was not aware of the risk involved with not having on the socks. LVN E stated Resident #61 does frequently have swollen feet and takes 80 milligrams of Lasix. LVN E stated there was an active order in place to have the compression hose on daily and removed at bedtime. LVN E stated it was facility policy to follow doctor orders. LVN E stated nursing staff were responsible for ensuring to attempt to put the socks on daily. LVN E stated nursing staff were responsible to document and notify the doctor if residents refuse the order. <BR/>Interview on 09/19/23 at 3:35 PM with the DON revealed Resident #61's feet are usually swollen; Resident #61 does have an active order to wear compression hose. According to the DON Resident #61 does not always leave the compressions hose on due to them feeling tight on his legs. The DON stated he was not sure of the last time nursing staff had put the compression hose on Resident #61. The DON stated he assisted Resident #61 at least 2 weeks ago to place the on the hose. The DON stated he expects staff to assist Resident #61 with the compression hose daily and as stated in the order. DON stated the charge nurse was responsible for initiating and administering the compression hose on a daily basis. The DON stated not using the compression hose could place Resident #61 at risk of complications of Edema (swelling caused by excess fluid trapped in tissue). According to the DON he expected staff to properly document in resident charts anytime a resident was administered treatment, resident refused treatment or a change in resident condition. The DON stated not accurately documenting resident treatment would affect resident treatment goals and outcomes.<BR/>2. Record review of Resident #51's face sheet dated 09/19/23 revealed the resident was [AGE] year-old female admitted on [DATE] with a diagnosis that included cerebral infarction (stroke), and dysphagia (swallowing difficulties).<BR/>Record review of Resident #51's admission MDS dated [DATE] revealed the resident had moderate cognitive impairment with a BIMS score of 10. The assessment reflected Resident #51 required limited assistance with eating, one-person physical assist, and the resident received nutrition via a feeding tube.<BR/>Record review of Resident #51's care plan revised dated 09/07/23 revealed: Resident requires tube feeding r/t Swallowing problem. Goal: The resident will be free of aspiration through the review date. The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. The resident will remain free of side effects or complications related to tube feeding through review date.<BR/>Record review of Resident #51's physician order dated 08/27/23 revealed enteral Feed Order every 24 hours Isosource 1.5 at 55ml/hr continue x20hr. w/ water flushes 150mL q4h (off at 9am/on at 1pm). The order start date was 08/27/23. <BR/>Record review of Resident #51's physician order dated 08/27/23 revealed Tube Feeding off for 4hrs every 24 hours. The order start date was 08/27/23 0900AM. <BR/>Record review on 09/17/23 at 2:10 PM of Resident #51's September 2023 MAR revealed resident had been disconnected at 9:53AM and was connected at 12:36 PM by LVN F. <BR/>Observation on 09/17/23 at 2:14 PM of Resident #51 lying in bed sleeping. Observed a feeding pump next to Resident #51 bed not infusing. A bag of enteral feeding was hanging from the pole of the feeding pump with a date of 09/17/23, time 5:30AM, rate of 55 ml/hr X 20 hours. <BR/>Observation on 09/17/23 at 2:48 PM of Resident #51 lying in bed sleeping. Observed a feeding pump next to Resident #51 bed infusing. A bag of enteral feeding was hanging from the pole of the feeding pump with a date of 09/17/23, time 5:30AM, rate of 55 ml/hr X 20 hours.<BR/>Interview on 09/17/23 at 2:54 PM LVN F revealed she was the nurse assigned for Resident #51. LVN F stated she disconnected Resident #51 at 11AM. LVN F reviewed Resident #51 orders and stated resident had an order to be disconnected at 9 AM, be off for 4 hours and be reconnected at 1PM. LVN F stated when she came in today (09/17/23) between the times of 8AM-9AM Resident #51 g-tube machine was beeping due feeding tube was clamped by Resident #51's upper extremities. LVN F stated Resident #51 did not received her full feeding amount and she decided to keep her on the g-tube longer. State Surveyor asked LVN F if she had documented in the Resident #51's MAR prior to stopping Resident #51 formula feeding, LVN F stated she made a mistake by clicking on Resident #51's MAR at 9:53AM. LVN F stated she did not disconnect Resident #51 at 9:53AM, she disconnected her at 11AM and she did not reconnect her at 12:36PM but at around 2:45PM. LVN F was asked if she notified the physician, she stated she did and the Weekend Supervisor RN G was in the room with her when she disconnected Resident #51 at 11AM. LVN F stated the risk of not documenting correctly could cause resident not receiving the correct amount of formula. <BR/>Interview on 09/17/23 at 3:00 PM RN G revealed he was the weekend supervisor. He stated he had observed LVN F flush Resident #51 g-tube earlier this morning, unknown of the time. He stated he did not observe LVN F disconnect Resident #51, he stated he left the room. RN G stated he was unsure of Resident #51 physician orders; observed RN G review Resident #51's physician orders and stated Resident #51 had an order to be disconnected for 4 hours from 9AM-1PM. While in interview with RN G, LVN F intervene and stated to RN G remember you were in the room when I flushed her g-tube and I told you about Resident #51 feeding machine beeping, that is why I disconnected her at 11AM. RN G stated he recalls LVN F informed him about Resident #51's feeding machine beeping but did not observed when LVN F disconnected the resident. RN G stated his expectation are for the nurses to follow physician orders and if there was a problem nurses should contact the physician for further instruction. RN G stated nurses should document after they finished providing the care. <BR/>Record review of Resident #51's Progress notes dated 09/17//23 at 15:39 [3:59 PM] by LVN F revealed: Effective Date: 09/17/23 at 9:30 AM Upon entering residents' room at beginning of shift residents gtube machine was clamped by residents upper extremities which caused machine to alarm. supervisor notified. discussed Let feeding run overtime because the feeding was unknown to be adequately flowing through tubing r/t delayed feeding r/t equipment. tubing residual checked and in normal range.<BR/>Record review of Resident #51's Progress notes dated 09/17//23 at 15:56 [3:56 PM] by LVN F revealed: Effective Date: 09/17/23 at 14:54 [2:54 PM] Resumed feeding after 4 hrs of being stopped, residual within normal limits , Pain medications given for comfort. Will notify MD and hospice of Situation<BR/>Interview on 09/19/23 at 3:47 PM with the DON revealed his expectation were for his staff to follow physician orders. He stated he was made aware by RN G who is also the weekend supervisor about a problem that had occurred with Resident #51's g-tube. He stated he was informed LVN G had disconnected Resident #51 after 9:00 AM. The DON was notified Resident #51's MAR indicated Resident #51 was disconnected at 9:53 AM and was provided with her feeding at 12:36 PM; however, the resident was not connected until around 3:00 PM. The DON stated the best practice was for staff to follow physician orders and then document after the procedure was completed. The DON stated not accurately documenting resident treatment would affect resident treatment goals and outcomes. <BR/>Interview via phone call on 09/19/23 at 4:24 PM with Resident #51's Physician revealed he had received a call from the facility on Sunday 09/17/23; however, he could not recall the conversation.<BR/>A policy regarding Charting/Documentation was requested; however, it was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents reviewed for pest control. <BR/>The facility failed to keep an effective pest control program to ensure resident dining rooms, facility kitchen and resident rooms were free of gnats and flies.<BR/>This failure could place residents at risk for a reduced quality of life.<BR/>Findings include:<BR/>Observation on 07/19/22 at 9:25 AM revealed two flying insects in facility's kitchen preparation on steamtable. <BR/>Observation and Interview on 07/19/22 at 9:40 AM with Resident #7, in her room, revealed the facility had flies and stated she has been told they can't use bug spray and won't find her a fly swatter. Observation of two flies and one gnat was made in her room, One fly and one gnat were observed in the window sill. She tells anyone who comes into her room about it and they say they can't use bug spray at the facility. She asked for fly swatter from staff, but they leave and don't hear from them again. <BR/>Observations on 07/19/22 during lunch time: <BR/>- At 12:09 PM, Resident #60 had a fly lay on his water glass.<BR/>- At 12:11 PM, A facility staff member swatted a fly away from Resident #62's food with her hand. <BR/>- At 12:16 PM, Resident #56 had a fly land on her coffee mug and she swatted it away with her hand. <BR/>- At12:17 PM Resident #80 had a fly land on his hand while he was eating his lunch.<BR/>Observation on 07/19/22 at 12:15 PM revealed Administrator gave LVN C a fly swatter while in the dining room to take care of the flies. <BR/>Observation and interview on 07/19/22 at 12:22 PM revealed Resident # 49 had a flying insect landing on her lunch plate. Resident #49 swatted it away. Resident #49 on 12:26 PM stated the flies were bothering her today, especially during meal times when she was eating. She was observed swatting at a fly. <BR/>Interview on 07/20/22 at 8:50 AM with Resident # 80 revealed he saw flies in the dining room a long time during meal times, as regular occurrence.<BR/>Observation on 07/20/22 at 2:09 PM in facility kitchen revealed two flies. One landed on the steam table and the other one landed on the stove.<BR/>Interview on 07/20/22 at 2:10 PM with Dietary Aide O revealed she noticed flies in the kitchen recently especially when people enter from the outside door the flies come in.<BR/>During a resident confidential group interview with 11 residents, all 11 residents stated they have flies and gnats in their facility and see them everywhere for a long time. They stated it started with gnats and then it had gotten worse with the larger flies. They stated at that time, the facility had both. <BR/>Interview on 07/20/22 at 9:10 AM with LVN F revealed the facility did have an issue with pests including flies and gnats especially in the dining rooms during meal times. She stated the flies have been in the facility for at least a few weeks and it started with the smaller flies (gnats). She stated the facility treated the smaller flies but then the regular flies started showing up. <BR/>Interview on 07/21/22 at 9:08 AM with the Maintenance Director revealed pest control came out and treated pests. He was not sure when; prior to yesterday, the facility treated flies . He stated they came out recently to treat for ants. <BR/>Interview on 07/21/22 at 9:10 AM with Administrator revealed pest control came out twice a month and yesterday they came out due to the flies. He stated they treated the drains in the kitchen. They have ordered fly traps as of yesterday but were not aware could have these before yesterday. They will come back the 07/26/22 to treat drains again and it will be regular. He stated going forward from now on each time pest control comes out to facility they will treat the drains in the kitchen where the flies are coming in from.<BR/>Interview on 07/21/22 at 9:30 AM with Dietary Manager revealed she had noticed flies in kitchen and dining room recently. <BR/>Record Review of facility's Pest Control Log from April to July 2022 did not reflect any flies or gnats. <BR/>Review of May to July 2022 pest control visits reflected the following:<BR/>-Dated 05/16/22 reflected pest control inspected and treated in these areas; interior and exterior restrooms, kitchen area, dining area, treated hallway 300 and exterior serviced all devices . Target pests treated were drain flies/fruit flies/vinegar flies, house flies.<BR/>-Dated 06/10/22 reflected pest control inspected and treated kitchen. Pest control granulated building for ants. <BR/>-Dated 06/28/22 reflected pest control inspected and treated interior and exterior restrooms, kitchen area, hallways and serviced bait boxes for rodent control. Targeted pests were rodents and crawling insects. There was no treatment completed for flies or gnats.<BR/>-Dated 07/14/22 reflected pest control inspected and treated interior and exterior hallways, office, kitchen area, dining area rooms and exterior windows. There was no treatment completed for flies or gnats.<BR/>-Dated 07/20/22 reflected pest control treated interior for flies and drain flies. It reflected invade foam application to help control the drain flies and that included kitchen, showers, laundry room and sprayed exterior dining room . Pest control hung up 3 fly glue traps in the dining area and recommended fly lights in ever hallway to control the situation. <BR/>Review of the facility's policy Pest Control, revised May 2008, reflected the facility should maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . Maintenance serves assist , when appropriate and necessary, in providing pest control services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 2 of 3 residents (Residents #2 and #67) reviewed for resident rights.<BR/>The facility failed to ensure Hospitality Aide A treated Residents #2 and #67 with respect and dignity in her interactions with them in April 2023. <BR/>This failure led to the residents having feelings of decreased self-worth. <BR/>Findings included: <BR/>Review of Resident #2's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia falls, anxiety, and depression. <BR/>Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 5 indicating severe cognitive impairment. Her Functions Status revealed she required extensive assistance with most of her ADLs. <BR/>Review of Resident #2's care plan, dated 09/07/23, revealed she required the assistance of staff for her ADLs, with interventions of providing a mechanical lift for transfers. <BR/>Review of Resident #67's admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, diabetes, non-pressure related chronic ulcer, and muscle weakness<BR/>Review of Resident #67's quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating intact cognition. Her Functional Status indicated she required extensive assistance with most of her ADLs. <BR/>Review of Resident #67's care plan, dated 08/03/23, revealed she required the use of a mechanical lift to transfer, and an electric wheelchair to move about, with intervention of physical help for the resident. <BR/>Interview on 09/17/23 at 11:29 AM, Resident #2 stated she had an incident in April 2023 that she reported to the nurse and the Administrator. Hospitality Aide A was putting her back to bed, using the Hoyer Lift, when she struck Resident #2's leg against the TV stand. Resident #2 stated when she told the aide that it hurt, the aide was very rude and cursed at her. Resident #2 stated it was not the first time this had happened, but this time there was a witness to confirm it. Resident #2 stated the situation made her feel bad about herself because she knew she was fat and did not need to be reminded of it.<BR/>Interview on 09/17/23 at 11:40 AM, Resident #67 stated the Social Worker had come around asking if any staff had been abusive towards her, and she reported that in April of 2023 Hospitality Aide A had caught her foot under the bed while using the Hoyer lift to transfer her. When Resident #67 told Hospitality Aide A her foot was stuck under the bed, Hospitality Aide A just pulled the Hoyer lift back, scraping the top of Resident #67's foot on the underside of the bed. When Resident #67 mentioned that it hurt, Hospitality Aide A just continued about her business as if nothing had happened and never apologized for it. Resident #67 stated she felt frustrated and upset afterwards that the aide just acted like nothing had happened. <BR/>Interview on 09/19/23 at 10:28 AM, the DON stated he had been made aware of the accusation of Hospitality Aide A being verbally abusive towards Resident #2 on 04/18/23 and began his investigation. Based on his interviews with Hospitality Aide B, Resident #2, and the results of the Safety Surveys, Hospitality Aide A was terminated in April 2023. <BR/>Interview on 09/19/23 at 11:20 AM, Hospitality Aide B stated she had been working with Hospitality Aide A in April of 2023 when they entered Resident #2's room to put her back to bed. Hospitality Aide A had lifted Resident #2 out of her wheelchair and in the process of moving her to the bed she accidentally hit the resident's foot on the furniture. When Resident #2 said something about it hurting Hospitality Aide A stated, If you don't quit fucking bitching so much, I'm going to just leave your fat ass in the bed all day. Hospitality Aide B stated she knew this was wrong and reported it to the nurse as soon as she could. <BR/>Phone interview on 09/19/23 at 3:26 PM, Hospitality Aide A stated she had no recall of the event in April 2023, and she terminated the interview. <BR/>Review of the facility's Prohibiting and Preventing Abuse, Neglect, Exploitation, and Misappropriation of Property policy and procedure, dated 2022, described verbal abuse as:<BR/> .including but not limited to the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents .Examples include cursing, yelling, name calling, threatening or saying things to frighten a resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents (Residents #2 and Resident #67) reviewed for abuse. <BR/>The facility failed to ensure Hospitality Aide A did not abuse Residents #2 and #67 in April 2023. <BR/>This failure left the residents feeling unsafe around Hospitality Aide A.<BR/>Findings included:<BR/>Review of Resident #2's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia falls, anxiety, and depression. <BR/>Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 5 indicating severe cognitive impairment. Her Functions Status revealed she required extensive assistance with most of her ADLs. <BR/>Review of Resident #2's care plan, dated 09/07/23, revealed she required the assistance of staff for her ADLs, with interventions of providing a mechanical lift for transfers. <BR/>Review of Resident #67's admission Record revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, diabetes, non-pressure related chronic ulcer, and muscle weakness<BR/>Review of Resident #67's quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating intact cognition. Her Functional Status indicated she required extensive assistance with most of her ADLs. <BR/>Review of Resident #67's care plan, dated 08/03/23, revealed she required the use of a mechanical lift to transfer, and an electric wheelchair to move about, with intervention of physical help for the resident. <BR/>Interview on 09/17/23 at 11:29 AM, Resident #2 stated she had an incident in April 2023 that she reported to the nurse and the Administrator. Hospitality Aide A was putting her back to bed, using the Hoyer Lift, when she struck Resident #2's leg against the TV stand. Resident #2 stated when she told the aide that it hurt, the aide was very rude and cursed at her. Resident #2 stated it was not the first time this had happened, but this time there was a witness to confirm it. Resident #2 stated the situation made her feel unsafe around Hospitality Aide A as she was known to be verbally abusive towards the residents. <BR/>Interview on 09/17/23 at 11:40 AM, Resident #67 stated the Social Worker had come around asking if any staff had been abusive towards her and she reported that in April of 2023 the Hospitality Aide A had caught her foot under the bed while using the Hoyer lift to transfer her. When Resident #67 told Hospitality Aide A her foot was stuck under the bed, Hospitality Aide A just pulled the Hoyer lift back, scraping the top of Resident #67's foot on the underside of the bed. When Resident #67 mentioned that it hurt, Hospitality Aide A just continued about her business as if nothing had happened and never apologized for it. Resident #67 stated she felt frustrated because she would tell staff about things Hospitality Aide A would say and do but no one would do anything about it. <BR/>Interview on 09/19/23 at 10:28 AM, the DON stated he had been made aware of the accusation of Hospitality Aide A being verbally abusive towards Resident #2 on 04/18/23 and began his investigation. Based on his interviews with Hospitality Aide B, Resident #2, and the results of the Safety Surveys, Hospitality Aide A was terminated. The DON stated any form of abuse was not tolerated at the facility and reports of abuse were taken seriously. <BR/>Interview on 09/19/23 at 11:20 AM, Hospitality Aide B stated she had been working with Hospitality Aide A in April of 2023 when they entered Resident #2's room to put her back to bed. Hospitality Aide A had lifted Resident #2 out of her wheelchair and in the process of moving her to the bed she accidentally hit the resident's foot on the furniture. When Resident #2 said something about it hurting Hospitality Aide-A stated, If you don't quit fucking bitching so much, I'm going to just leave your fat ass in the bed all day. Hospitality Aide B stated she knew this was wrong and reported it to the nurse as soon as she could. <BR/>Phone interview on 09/19/23 at 3:26 PM, Hospitality Aide A stated she had no recall of the event in April, and she terminated the interview. <BR/>Review of the facility's Prohibiting and Preventing Abuse, Neglect, Exploitation, and Misappropriation of Property policy and procedure, dated 2022, described verbal abuse as:<BR/> .including but not limited to the use of oral, written, or gestured language that wilfully includes disparaging or derogatory terms to residents .Examples include cursing, yelling, name calling, threatening or saying things to frighten a resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident the most recent hospice plan of care specific to each patient, the physician certification and recertification of the terminal illness specific to each patient, hospice election form and hospice medication information specific to each patient for two (Residents #15 and #79) of three residents reviewed for hospice services.<BR/>The facility failed to obtain the most recent hospice plan of care, the physician certification and recertification of the terminal illness, hospice election form and hospice medication information from Hospice M for Resident #15 and Hospice N for Resident #79. <BR/>This failure could result in services and treatments for end-of-life care not being properly coordinated.<BR/>Findings included:<BR/>1. Record Review of Resident #15's face sheet dated 07/20/22 reflected Resident #15 was admitted to the facility on [DATE] with diagnoses of liver failure, low back pain, dysphagia and heart failure . She was receiving hospice services through Hospice.<BR/>Record Review of Resident #15's Annual MDS assessment dated [DATE] reflected she had a BIMS of 15 indicating she was cognitively intact. She was on hospice services while at the facility. <BR/>Record Review of Resident #15's Comprehensive Care Plan, last revised on 07/19/22, reflected the date initiated for hospice services was on 11/17/20with Hospice M due to hepatic failure.<BR/>Record Review of Resident #15's electronic clinical record revealed no hospice documentation for Resident #15.<BR/>Interview on 07/19/22 at 10:19 AM with Resident #15 revealed she was on hospice services with Hospice M and the hospice aide came to facility three times a week to bathe her.<BR/>Interview on 07/20/22 at 10:18 AM with the DON revealed he could not locate Resident #15's hospice book and stated they do not scan hospice documentation into the electronic record. He stated he did not know where any of Hospice M's books were at that time for the hospice residents. <BR/>In a follow up interview on 07/20/22 at 12:55 PM with the DON revealed they could not find any hospice documentation from Hospice M on Resident #15. He stated Hospice M was contacted today after being unable to find hospice documentation for Resident #15 and state the nurse will bring it today. He was not aware of what required hospice documentation the facility needed for hospice residents. He stated they should have a hospice binder for each resident which should include the required hospice documentation. Hospice is in charge of ensuring required hospice documentation is on file. <BR/>Interview on 07/20/22 at 2:32 PM with Hospice RN G revealed she has not been providing the facility with up-to-date hospice documentation on residents including Resident #15. She stated she took Hospice M binders for her patients with her last week but did not tell anyone at the facility. She stated the hospice binders were not up-to-date until today and she had gotten behind in making sure facility had required hospice documentation. She stated the facility had not discussed hospice documentation with her. <BR/>2. Record Review of Resident #79's face sheet dated 07/20/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of local infection of the skin, Alzheimer's disease, dysphagia, hypertension. <BR/>Review of Resident #79's Significant change MDS assessment dated [DATE] reflected she had a BIMS of 5 indicating she was severely cognitively impaired. She was on hospice services while in the facility.<BR/>Review of Resident #79's current physician orders dated 06/25/22 reflected Resident #79 was admitted to Hospice N for diagnosis of Alzheimer's disease.<BR/>Interview on 07/20/22 at 10:18 AM with the DON revealed he could not locate Resident #79's hospice book and stated they did not scan hospice documentation into the electronic record. <BR/>In a follow up interview on 07/20/22 at 12:55 PM with the DON revealed the facility requested Hospice N's documentation for Resident #79 after not being able to find any on file. He was not aware of what was the required documentation the facility needed for residents on hospice services. <BR/>Review of facility's policy Hospice Program undated reflected 3. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family should be developed and should include directives for managing pain and other uncomfortable symptoms. The policy did not reflect other required hospice documentation.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents reviewed for pest control. <BR/>The facility failed to keep an effective pest control program to ensure resident dining rooms, facility kitchen and resident rooms were free of gnats and flies.<BR/>This failure could place residents at risk for a reduced quality of life.<BR/>Findings include:<BR/>Observation on 07/19/22 at 9:25 AM revealed two flying insects in facility's kitchen preparation on steamtable. <BR/>Observation and Interview on 07/19/22 at 9:40 AM with Resident #7, in her room, revealed the facility had flies and stated she has been told they can't use bug spray and won't find her a fly swatter. Observation of two flies and one gnat was made in her room, One fly and one gnat were observed in the window sill. She tells anyone who comes into her room about it and they say they can't use bug spray at the facility. She asked for fly swatter from staff, but they leave and don't hear from them again. <BR/>Observations on 07/19/22 during lunch time: <BR/>- At 12:09 PM, Resident #60 had a fly lay on his water glass.<BR/>- At 12:11 PM, A facility staff member swatted a fly away from Resident #62's food with her hand. <BR/>- At 12:16 PM, Resident #56 had a fly land on her coffee mug and she swatted it away with her hand. <BR/>- At12:17 PM Resident #80 had a fly land on his hand while he was eating his lunch.<BR/>Observation on 07/19/22 at 12:15 PM revealed Administrator gave LVN C a fly swatter while in the dining room to take care of the flies. <BR/>Observation and interview on 07/19/22 at 12:22 PM revealed Resident # 49 had a flying insect landing on her lunch plate. Resident #49 swatted it away. Resident #49 on 12:26 PM stated the flies were bothering her today, especially during meal times when she was eating. She was observed swatting at a fly. <BR/>Interview on 07/20/22 at 8:50 AM with Resident # 80 revealed he saw flies in the dining room a long time during meal times, as regular occurrence.<BR/>Observation on 07/20/22 at 2:09 PM in facility kitchen revealed two flies. One landed on the steam table and the other one landed on the stove.<BR/>Interview on 07/20/22 at 2:10 PM with Dietary Aide O revealed she noticed flies in the kitchen recently especially when people enter from the outside door the flies come in.<BR/>During a resident confidential group interview with 11 residents, all 11 residents stated they have flies and gnats in their facility and see them everywhere for a long time. They stated it started with gnats and then it had gotten worse with the larger flies. They stated at that time, the facility had both. <BR/>Interview on 07/20/22 at 9:10 AM with LVN F revealed the facility did have an issue with pests including flies and gnats especially in the dining rooms during meal times. She stated the flies have been in the facility for at least a few weeks and it started with the smaller flies (gnats). She stated the facility treated the smaller flies but then the regular flies started showing up. <BR/>Interview on 07/21/22 at 9:08 AM with the Maintenance Director revealed pest control came out and treated pests. He was not sure when; prior to yesterday, the facility treated flies . He stated they came out recently to treat for ants. <BR/>Interview on 07/21/22 at 9:10 AM with Administrator revealed pest control came out twice a month and yesterday they came out due to the flies. He stated they treated the drains in the kitchen. They have ordered fly traps as of yesterday but were not aware could have these before yesterday. They will come back the 07/26/22 to treat drains again and it will be regular. He stated going forward from now on each time pest control comes out to facility they will treat the drains in the kitchen where the flies are coming in from.<BR/>Interview on 07/21/22 at 9:30 AM with Dietary Manager revealed she had noticed flies in kitchen and dining room recently. <BR/>Record Review of facility's Pest Control Log from April to July 2022 did not reflect any flies or gnats. <BR/>Review of May to July 2022 pest control visits reflected the following:<BR/>-Dated 05/16/22 reflected pest control inspected and treated in these areas; interior and exterior restrooms, kitchen area, dining area, treated hallway 300 and exterior serviced all devices . Target pests treated were drain flies/fruit flies/vinegar flies, house flies.<BR/>-Dated 06/10/22 reflected pest control inspected and treated kitchen. Pest control granulated building for ants. <BR/>-Dated 06/28/22 reflected pest control inspected and treated interior and exterior restrooms, kitchen area, hallways and serviced bait boxes for rodent control. Targeted pests were rodents and crawling insects. There was no treatment completed for flies or gnats.<BR/>-Dated 07/14/22 reflected pest control inspected and treated interior and exterior hallways, office, kitchen area, dining area rooms and exterior windows. There was no treatment completed for flies or gnats.<BR/>-Dated 07/20/22 reflected pest control treated interior for flies and drain flies. It reflected invade foam application to help control the drain flies and that included kitchen, showers, laundry room and sprayed exterior dining room . Pest control hung up 3 fly glue traps in the dining area and recommended fly lights in ever hallway to control the situation. <BR/>Review of the facility's policy Pest Control, revised May 2008, reflected the facility should maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . Maintenance serves assist , when appropriate and necessary, in providing pest control services.